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EDITORIAL
Welcome aboard . . .
ladies and gentlemen. This is your You might wonder what planes,
captain speaking. My name is Mr boats, and trains have to do with
Smith. My first officer, Mr Meyer, the World Journal of Orthodontics?
and I invite you to sit back and Well, this journal is also in a sense
enjoy your flight. a system of transportation: It
We usually hear something moves knowledge that impacts
along these lines after settling our minds and ultimately drives
into our seats on a plane. Such an our clinical activities. This means
announcement makes us feel that the knowledge thus delivered
comfortable because we subcon- will determine in part how well we
sciously realize that if the senior treat our patients, indeed how well
pilot had a problem, the second in we fulfill the oath of Hippocrates.
command could take over and the Oh, Hippocrates is a good key-
plane would still arrive at its final word. The responsibility this jour-
destination without any notice- nal demands has led us to invite
able difference. someone else from Greece to help
Not only do planes have this us maintain the high standards of
backup safety scheme, but so do World Journal of Orthodontics.
cruise boats, trains, and other modes of transportation. This person is Dr Moschos Papadopoulos, whom we in-
What we can learn from this model is that demanding troduce by way of a short biography below. Or would
transport systems, such as those with high responsibil- that mean to carry owls to Athens, as they say in my
ity requirements, regularly have two individuals to guar- home country? Anyway, we are glad that you have
antee a smooth delivery. joined our team,

. . . Dr Mike Papadopoulos

Moschos A. Papadopoulos, DDS, Dr Med Dent is associate professor and post-


graduate program coordinator at the Department of Orthodontics, School of Den-
tistry, Aristotle University of Thessaloniki, Greece. He received his dental degree
from the same university in 1986 and his doctorate degree (1988) and certificate
in orthodontics (1990) from the University of Freiburg, Germany. Dr Papadopoulos
has also served as research collaborator at the Department of Experimental Rainer-Reggie Miethke
Surgery, Swiss Research Institute, Davos, Switzerland. Editor-in-Chief
Dr Papadopoulos is editor of the Hellenic Orthodontic Review and associate
editor of Stoma. He is a member of the editorial board and serves as referee for
many journals. He is also an active member of nine Greek and six international
societies, federations, and unions. He is the recipient of several awards, including
the A. Tsoukanelis Award of the Aristotle University of Thessaloniki (1993), the
Annual Scientific Award of the German Association of Plastic Surgeons (2004),
and the Joseph E. Johnson Clinical Award of the American Association of Ortho-
dontists (2009).
Dr Papadopoulos’ main clinical and research interests include noncompliance
orthodontic treatment, mini-implants as temporary anchorage devices, and
evidence-based orthodontics. He is the author of the book Orthodontic Treatment
for the Class II Non-compliant Patient: Current Principles and Techniques, has
published more than 120 scientific articles, and has presented more than 200
lectures, courses, and papers.

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MAXILLARY ARCH WIDTH CHANGES Simona Tecco, DDS1

DURING ORTHODONTIC TREATMENT Stefano Tetè, MD, DDS2

Letizia Perillo, MD, DDS3


WITH FIXED SELF-LIGATING AND
Claudio Chimenti, MD,
TRADITIONAL STRAIGHT-WIRE DDS4

APPLIANCES Felice Festa, MD, DDS5

Aim: To evaluate the transverse dimensions of the maxillary arch


induced by fixed self-ligating and traditional straight-wire appliances
during orthodontic therapy. Patients and Methods: Forty consecutive
patients (age range 14 to 30 years) with normal or low mandibular
plane angle, normal overbite, and mild crowding were included. The
traditional appliance was composed of Victory Series MBT brackets
(3M Unitek), and the self-ligating appliance of Damon-3MX brackets
(Ormco). The leveling and aligning phase with round archwires lasted
6 months and was followed by another 6 months of rectangular arch-
wires. The archwire sequence with the MBT appliance was 0.016-inch
and 0.019 ⫻ 0.025-inch Ni-Ti form II (3M Unitek), while in the Damon-
3MX, it was 0.014-inch and 0.016-inch followed by 0.016 ⫻ 0.025-inch
copper nickel-titanium (Ormco). Intercanine, first and second interpre-
molar, and intermolar widths in the maxilla were recorded before
treatment (T0) and 12 months later (T1). Results: In both groups, a sig-
nificant increase from T0 to T1 was recorded for all transverse mea-
surements, but no significant difference was observed between groups.
Conclusion: Within 12 months of treatment, both appliances increased
maxillary dentoalveolar widths. World J Orthod 2009;10:290–294.

Key words: arch width, dentoalveolar width, maxillary expansion, MBT


brackets, self-ligating brackets
1PhD Student, Department of Oral
Science, University G. D’Annunzio,
Chieti/Pescara, Italy.
2Associate Professor, Department of

onextraction treatment is of ten and 2.96 mm2 (as reported by Franchi et Oral Science, University G. D’Annun-
N accompanied by dentoalveolar
expansion.1–5 Dental arch width plays an
al8 and Bennet and McLaughlin9).
New low-friction self-ligating brackets
zio, Chieti/Pescara, Italy.
3Full Professor, Department of Oral

Science, University of Naples, Fed-


impor tant role in smile esthetics 1 are reported to induce (a significant) erico II, Naples, Italy.
because a small dental arch is typically maxillary arch expansion during the ini- 4Full Professor, Department of Oral

associated with an increase of blind buc- tial therapy phase when superelastic Science, University of L’Aquila, Italy.
5Full Professor, Department of Oral
cal corridors.6 In addition, dental arch nickel-titanium archwires are used.8,10–12
Science, University G.D’Annunzio,
width seems to be an important aspect Generally, three hypotheses exist in con- Chieti/Pescara, Italy.
of posttreatment stability.7 nection with bracket systems and arch
During fixed orthodontic treatment, expansion: (1) light wires produce an CORRESPONDENCE
intercanine width increases between efficient expansion of the dental arch, Dr Simona Tecco
Via Le Mainarde 26
0.55 mm1 and 2.13 mm,2 the interpre- (2) with less buccal tipping, and (3) less
65121 Pescara
molar width (at the second premolars) incisor protrusion because the light Italy
between 2.10 mm1 and 4.94 mm,2 and forces cannot overrule the labial/buccal Email: simtecc@tin.it,
the intermolar width between 1.53 mm1 musculature. simtecc@unich.it

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VOLUME 10, NUMBER 4, 2009 Tecco et al

Fig 1 Maxillary occlusal view of a patient Fig 2 Maxillary occlusal view of a patient
in group 1 (MBT brackets) with a 0.019 ⫻ in group 1 (Damon-3MX brackets) with a
0.025-inch Ni-Ti form II archwire after 0.016 ⫻ 0.025-inch copper Ni-Ti archwire
12 months of treatment. after 12 months of treatment.

In the Franchi et al8 study, low-friction


ligatures were evaluated so it seemed
reasonable to conduct a similar investi-
gation with self-ligating brackets that also
produce low friction. According to Harra-
dine,13 compared to conventional ones,
self-ligating brackets have a lower friction
coefficient, which leads to a more rapid
tooth alignment, and better anchorage
management.10,14–17
The aim of this study was to investi- Fig 3 The reference points used to mea-
gate the changes of the maxillary trans- sure intercanine, interpremolar (at the first
verse dimensions produced by self- and second premolar), and intermolar
ligating and traditional preadjusted widths. Actual measurements were per-
formed on study casts (compare to Fig 4).
brackets with conventional elastic liga-
tures after using rectangular archwires.

PATIENTS AND METHODS


The sample consisted of 40 nonextraction superelastic nickel-titanium archwires
patients (23 females, 17 males) with a (Nitinol archwire, 3M Unitek), followed by
mean age of 15 years 8 months (age 0.019 ⫻ 0.025-inch Nitinol (Orthoform II,
range 14 to 30 years), consecutively archform selection, 3M Unitek, Fig 1).
treated at the Department of Oral Sci- The 20 patients in group 2 received
ence, University G. D’Annunzio, Chieti/ self-ligating brackets (Damon-3MX, Ormco)
Pescara, Italy. and copper nickel-titanium 0.014-inch
The inclusion criteria were permanent archwires (copper Ni-Ti, Ormco) followed by
dentition, normal or low mandibular 0.016-inch and 0.016 ⫻ 0.025-inch cop-
plane angle, normal or increased over- per Ni-Ti archwires (Fig 2).
bite, straight or concave profile, and at Leveling and aligning with the respec-
least 2-mm crowding in the maxillary tive round wires lasted an average of
arch. All subjects gave informed consent 6 months. Thereafter, the round wires
to participate in this study. were replaced by rectangular ones. Dental
According to the treatment protocol, the casts were produced at T0 (immediately
20 patients of group 1 wore preadjusted before treatment) and T1 (after 1 year).
brackets (MBT Victory Series, 3M Unitek) The following measurements were made
with conventional ligatures (Alastik, on the maxillary casts at both time points
3M Unitek) coupled with 0.016-inch (Fig 3):

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Tecco et al WORLD JOURNAL OF ORTHODONTICS

Fig 4 Width measurement on a dental


cast using a fine-pointed digital calliper;
approximation of all readings was made to
the second decimal place.

Table 1 Descriptive statistics and comparison of maxillary measurements at T0 and T1


MBT (n = 20) Damon-3MX (n = 20)
T0 T1 ⌬T (T1–T0) T0 T1 ⌬T (T1–T0)
Measurements Mean ± ⌬T Paired t test, Mean ± ⌬T Paired t test,
(mm) Mean SD Mean SD SD (T1–T0) significance Mean SD Mean SD SD (T1–T0) significance

Intercanine 32.3 2.0 34.3 1.5 2.6 ± 2.4 6.2% t = 2.6, P < .05 31.1 2.3 34.1 1.4 3.3 ± 2.6 10.0% t = 2.6, P < .05
Interpremolar (first) 31.2 1.8 35.6 1.6 4.3 ± 2.1 14.1% t = 5.8, P < .05 30.8 1.9 35.2 0.5 4.4 ± 2.5 14.3% t = 5.9, P < .05
Interpremolar (second) 36.4 1.4 40.5 2.1 4.1 ± 2.1 11.3% t = 5.0, P < .05 36.2 1.9 40.4 0.5 4.2 ± 1.8 11.6% t = 6.8, P < .05
Intermolar 43.9 2.3 46.0 1.8 2.4 ± 2.0 4.8% t = 2.2, P < .05 42.9 1.5 44.8 0.9 2.3 ± 1.5 4.4% t = 3.2, P < .05

There was no significance in the unpaired t test MBT vs Damon at T0 or unpaired t test MBT vs Damon at T1 for any measurement.

• Intercanine width: distance between were performed on 10 randomly selected


the maxillary canine tips or between dental casts. The data sets were com-
the centers of the surfaces in case of pared using Dahlberg’s formula21:
worn cusps
• First interpremolar width: distance ␦ = √(⌺d2/2N)
between the central fossae on the
occlusal surfaces of the maxillary first in which ␦ is the difference between the
premolars two measurements and N is the number
• Second interpremolar width: distance of double registrations.
between the central fossae on the
occlusal surfaces of the maxillary sec-
ond premolars Statistical analysis
• Intermolar width: distance between
the mesial ends of the central fissures All statistical computations were per-
on the occlusal surfaces of the maxil- formed with SPSS 12 software (SPSS).
lary first molars Descriptive statistics were calculated for
the measurements at T0 and T1 and for
The individual reference points on the the T0-T1 comparisons (Table 1). The Kol-
dental casts were digitized in accordance mogorov-Smirnov test showed a normal
with other researchers,18–20 using a fine- data distribution at T0 and T1. Conse-
pointed digital calliper (Tresna, Guilin quently, the means and standard devia-
Guanglu Measuring Instrument); the tions were computed.
measurements were approximated to the The paired student t test was used to
second decimal place (Fig 4). identify significant differences (P < .05)
To avoid interoperator error, all mea- between T0 and T1, and the unpaired stu-
surements were carried out by a single dent t test was used to compare the data
investigator. To assess error due to land- between the groups at both T0 and T1.
mark identification, double measurements

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VOLUME 10, NUMBER 4, 2009 Tecco et al

RESULTS Still, caution is indicated because Franchi


et al8 worked with low-friction elastic liga-
The variance of the intraoperator method tures (slide ligatures).
error for the double measurements was The aforementioned three hypotheses
less than 5% of the observed variance in could not be confirmed by this study
the whole sample. Thus, all measure- because it did not consider buccal tip-
ments were accepted. ping or incisor protrusion. Instead, its
From T0 to T1, the intercanine width emphasis was on whether rectangular
showed a significant increase of 2.6 ± 2.4 archwires (after light round archwires)
mm (6.2%) and 3.3 ± 2.6 mm (10.0%) in play a role in the final width of the maxil-
the MBT and Damon-3MX groups, respec- lary dental arch. But even after the inser-
tively. tion of rectangular archwires, tipping and
The first interpremolar width increased protrusion between the two systems
significantly by 4.3 ± 2.1 mm (14.1%) and could not be compared due to their dif-
4.4 ± 2.5 mm (14.3%) in the MBT and ferent inclination prescriptions.
Damon-3MX groups, respectively. The two samples of the present inves-
Similarly, the second interpremolar width tigation consisted of only patients with
increased significantly by 4.1 ± 2.1 mm mild crowding. However, the amount of
(11.3%) and 4.2 ± 1.8 mm (11.6%) in the crowding could play an important role in
MBT and Damon-3MX groups, respectively. the determination of the final arch width.
The changes in intermolar width were In this study, the greatest expansions
2.4 ± 2.0 mm (4.8%) and 2.3 ± 1.5 mm were recorded for the premolars (14.1%
(4.4%) in the MBT and Damon-3MX and 14.3% for the first premolars; 11.3%
groups, respectively. and 11.6% for the second premolars).
No significant difference between the They were followed by the canines (6.2%
two groups was observed at either time and 10.0%), whereas the smallest
point. increase was found for the first molars
(4.8% and 4.4%). This is in accordance
with Franchi et al,8 who explained this as
DISCUSSION a possible result of the archwire form
(Tru-Arch form), which is especially wide
In this study, the transverse dimensional in the canine and first premolar region. It
changes of the maxillary arch produced can be assumed that the form II arch-
by conventional and self-ligating brackets wires used in this study caused the same
during orthodontic therapy were evaluated. outcome.
Damon observed a posterior expan-
sion of the dental arch with self-ligating
brackets and superelastic nickel-titanium CONCLUSIONS
0.014-inch archwires.10 The present find-
ings showed significant increases in max- The findings of this study indicate that a
illary arch widths with no difference low-friction system consisting of self-ligat-
between the groups with conventional ing brackets produces a significant
and self-ligating brackets when coupled increase of maxillary transverse den-
with rectangular archwires. Obviously, toalveolar width. When rectangular arch-
expansion with round archwires can be wires are used, conventional brackets
achieved only when low-friction brackets produce an arch width increase compara-
are used as demonstrated by Franchi et ble to that of self-ligating brackets.
al. 8 These authors further noted that
after using round archwires, the arch
widths were in the same range as after
the entire orthodontic treatment,1–5 con-
firming that low-friction systems obtain
expansion during just the aligning phase.
Conventional systems do the same only
after rectangular archwires are used.

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Tecco et al WORLD JOURNAL OF ORTHODONTICS

REFERENCES 11. Fortini A, Lupoli M, Cacciafesta V. A new low-


friction ligation system. J Clin Orthod 2005;39:
464–470.
1. Kim E, Gianelly AA. Extraction vs nonextraction:
12. Baccetti T, Franchi L, Fortini A. Orthodontic
Arch widths and smile esthetics. Angle Orthod
treatment with preadjusted appliances and
2003;73:354–358.
low-friction ligatures: Experimental evidence
2. BeGole EA, Fox DL, Sadowsky C. Analysis of
and clinical observations. World J Orthod
change in arch form with premolar expansion.
2008;9:7–13.
Am J Orthod Dentofacial Orthop 1998;113:
13. Harradine NW. Self-ligating brackets: Where are
307–315.
we now? J Orthod 2003;30:262–273.
3. Bishara SE, Cummins DM, Zaher AR. Treatment
14. Koenig HA, Burstone CJ. Force systems from an
and posttreatment changes in patients with
ideal arch—Large deflection considerations.
Class II, Division 1 malocclusion after extrac-
Angle Orthod 1989;59:11–16.
tion and nonextraction treatment. Am J Orthod
15. Damon DH. The rationale, evolution, and clini-
Dentofacial Orthop 1997;111:18–27.
cal application of the self-ligating bracket. Clin
4. Isık F, Sayınsu K, Nalbantgil D, Arun T. A com-
Orthod Res 1998;1:52–61.
parative study of dental arch widths: Extraction
16. Voudouris JC. Interactive edgewise mecha-
and non-extraction treatment. Eur J Orthod
nisms: Form and function comparison with con-
2005;27:585–589.
ventional edgewise brackets. Am J Orthod
5. Paquette DE, Beattie JR, Johnston LE Jr. A long-
Dentofacial Orthop 1997;111:119–140.
term comparison of nonextraction and premo-
17. Tecco S, Di Iorio D, Cordasco G, Verrocchi I,
lar extraction edgewise therapy in “borderline”
Festa F. An in vitro investigation of the influ-
Class II patients. Am J Orthod Dentofacial
ence of self-ligating brackets, low friction liga-
Orthop 1992;102:1–14.
tures, and archwire on frictional resistance.
6. Braun S, Hnat WP, Fender DE, Legan HL. The
Eur J Orthod 2007;29:390-397.
form of the human dental arch. Angle Orthod
18. Walkow TM, Peck S. Dental arch width in Class
1998;68:29–36.
II Division 2 deep-bite malocclusion. Am J
7. Nojima K, McLaughlin RP, Isshiki Y, Sinclair PM.
Orthod Dentofacial Orthop 2002;122:608-613.
A comparative study of Caucasian and Japan-
19. Buschang PH, Stroud J, Alexander RG. Differ-
ese mandibular clinical arch forms. Angle
ences in dental arch morphology among adult
Orthod 2001;71:195–200.
females with untreated Class I and Class II mal-
8. Franchi L, Baccetti T, Camporesi M, Lupoli M.
occlusion. Eur J Orthod 1994;16:47-52.
Maxillary arch changes during leveling and
20. Bishara SE, Jakobsen JR, Treder J, Nowak A.
aligning with fixed appliances and low-friction
Arch width changes from 6 weeks to 45 years
ligatures. Am J Orthod Dentofacial Orthop
of age. Am J Orthod Dentofacial Orthop 1997;
2006;130:88–91.
111:401-409.
9. Bennet JC, McLaughlin RP. Orthodontic Treat-
21. Dahlberg G. Statistical Methods for Medical
ment Mechanics and the Preadjusted Appli-
and Biological Students. London: George Allen
ance. London: Mosby Wolfe, 1993.
and Unwin, 1940.
10. Damon DH. The Damon low-friction bracket: A
biologically compatible straight-wire system.
J Clin Orthod 1998;32:670–680.

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A. Hamid Zafarmand,
DDS, MSD, PhD1 EVALUATION OF THE PERIODONTAL
G. Ali Gholami, DDS, MS2 STATUS OF PALATALLY IMPACTED
MAXILLARY CANINES AFTER EXPOSURE
USING A MODIFIED WINDOW
TECHNIQUE
Aim: To evaluate the periodontal status of surgically exposed maxil-
lary canines after their alignment. Patients and Methods: Twenty con-
secutive patients with one palatally impacted maxillary canine and
one fully erupted synergist were selected. The impacted canines were
surgically exposed with a modified window technique, an attachment
was bonded, and the teeth were extruded and aligned. Six months
after therapy, the periodontal status of both canines was evaluated by
registering the following parameters: (1) keratinized gingiva level,
(2) attached gingiva level, (3) sulcus probing depth, (4) length of clini-
cal crown, (5) quality of marginal tissue, (6) bleeding on probing, and
(7) height of alveolar bone. The data were analyzed with the Mann-
Whitney test. Results: There was no significant difference between the
periodontal status of the two canine groups concerning the keratinized
gingival level, the attached gingival level, the sulcus probing depth,
and the length of the clinical crown. The quality of marginal tissue and
bleeding on probing were acceptable. However, the level of alveolar
bone was significantly lower in the surgically exposed group. Conclu-
sion: The periodontal health of impacted maxillary canines that were
exposed using a modified window technique and subsequently ortho-
dontically aligned is acceptable. The only concern is a somewhat
reduced alveolar bone level. World J Orthod 2009;10:295–300.

Key words: alveolar bone level, canine exposure, impacted canines,


keratinized gingiva, marginal tissue

1Associate Professor, Department of


Orthodontics, M.C. School of Den-
he canine is vital for esthetics, continu- After the third molar, the maxillary
tistry, Shahid Beheshti University
M.C., Tehran, Iran.
2Associate Professor, Department of
T ity within the dental arch, and function.
Palatally impacted maxillary canines are
canine is the most frequently impacted
tooth.11 Nearly 2% of the patients who
Periodontics, M.C. School of Den- a dilemma for the patient, as well as for are referred for orthodontic treatment
tistry, Shahid Beheshti University the orthodontist. To expose them, the oral have an impacted canine.6,12–14 Maxillary
M.C., Tehran, Iran.
surgeon, orthodontist, and periodontist canines are impacted 10 times as often
CORRESPONDENCE should choose a safe procedure that as their mandibular counterparts. It also
Dr A. Hamid Zafarmand results in a healthy periodontium. If not appears that females face with this prob-
Department of Orthodontics aligned, an impacted canine can cause lem more frequently than males.5,11,15–17
School of Dentistry root resorption of adjacent teeth, a com- The general consensus is that maxillary
Shahid Beheshti University M.C.
Evin Tehran promised occlusion, and an unpleasant canines are 2 to 12 times more palatally
I.R. of Iran 19839 appearance.1–9 Rarely, the crown of the impacted than buccally.11,18
Email: zafarmand@alum.bu.edu impacted canine itself may be resorbed.10

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Zafarmand/Gholami WORLD JOURNAL OF ORTHODONTICS

The etiology of maxillar y canine relevant literature.40 Originally, banding


impaction is obscure.5 However, at least of the impacted tooth was recom-
16 factors are reported as potential mended. 24,41 Other outdated methods
causes. 3,5,16,17,19–25 A few of these are include lasso ligation, cementing a pin
heredity, insufficient space, ankylosis, into the crown, and ligating or cementing
trauma, cysts, and supernumerary teeth. a custom-cast gold cap onto the tooth.
In case of space deficiency, it must be These procedures are replaced by bond-
determined whether any teeth (first pre- ing buttons or others onto the respective
molars) should be removed.19,24 tooth.11,24,41,42 According to Boyd,42 direct
Early diagnosis (between 9 and 10 bonding guarantees the best success for
years of age) is possible by palpating the the orthodontic management of palatally
maxilla palatally. According to Ericson and exposed canines. Despite all efforts, the
Kurol,26 5% of 10- to 11-year-old children prognosis of impacted canines is some-
have nonpalpable unerupted canines. The times poor, meaning they must be
impaction site can be localized radio- removed. 49
graphically with Clark’s principle. 6,27 It is of fundamental importance at the
Recently, Faber et al 28 recommended completion of treatment that the origi-
computed tomography with rapid prototyp- nally impacted canine is periodontally
ing to improve diagnosis and treatment healthy compared to a normally erupted
planning. Even more highly recommended canine. This investigation was designed
is digital volumetric tomography.25 It must to find a response to this issue.
be mentioned that the prognosis of
impacted canines worsens with age.29 The
duration of treatment is influenced by fac- PATIENTS AND METHODS
tors such as depth of impaction, patient
age, and angle of the tooth’s long axis to Twenty patients, 10 males (mean age 16.4
the occlusal plane.30 Because of possible ± 2.5 years, range 13 to 20 years) and 10
complications, timely diagnosis and treat- females (mean age 17.0 ± 1.2 years, range
ment is strongly recommended. 15 to 18 years) (total mean age 16.7 ± 1.9
years) were included in this study. All had
unilaterally a palatally impacted maxillary
Treatment canine and a normally erupted synergistic
canine. Palatal impaction was verified
Generally, four treatment options exist for using Clark’s principle. Inclusion criteria
impacted teeth: observation, intervention, were no history of orofacial trauma, no sys-
relocation, or extraction.31 Occasionally, temic diseases, no congenital disorders,
impacted canines erupt spontaneously. no prepubertal periodontitis, no mental
More often, however, surgery is required. If retardation, and no consumption of any
intervention is indicated, surgical exposure gingival hyperplasia (inducing medications
and orthodontic treatment are two viable such as carbamezapines, phenitoines, and
choices.13,32–34 The type of surgical proce- cyclosporine A).
dure is particularly decisive for periodontal Prior to surgery, all patients were
health after treatment completion. The bracketed and banded. If the patient pre-
surgery is not simple and increases the sented with insufficient space in the den-
length of treatment. 16,21,35,36 Surgery tal arch, expansion or premolar extraction
becomes even more complicated if the was initiated. Surgical crown exposure of
patient is missing any permanent teeth or if the impacted tooth was performed with a
he has an Angle Class III.37,38 modified window technique (Fig 1). It was
Boyd 39 introduced the window tech- limited to expose only 4 to 5 mm of the
nique for labially impacted canines. In its crown to preserve the gingival tissue and
modified form, it involves the least possi- supporting bone. An advantage of this
ble tissue excision to provide enough approach is that it results in less postop-
access for bonding an attachment. erative discomfort for the patient.
Various methods for ligation and The modified window technique begins
orthodontic extrusion are proposed in the with the use of a no. 15 scalpel to excise

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Fig 1 (left) Intraoral situation


after dressing removal. Note
minimum crown exposure
with almost no inflammation.
Molars were previously
banded.

Fig 2 (right) Situation after


completed bonding proce-
dure.

Fig 3 (a) Initial distal trac-


tion with power chain—the
crown of the previously
impacted canine is close to
the lateral incisor; (b) situa-
tion 4 months later.

a b

Fig 4 Panoramic radiograph of a 16-year-old


patient with a palatally impacted maxillary left
canine. Note the distally tipped crown of the
lateral incisor due to the anteriorly positioned
canine crown.

the soft tissue covering the crown of the tion for 2 weeks following surgery. After
palatally impacted canine. The incision is 1 week, the dressing is removed and the
limited to the area needed to attach a but- site professionally cleaned with physiologic
ton or cleat. Any bone is removed with a saline. The patient is also instructed to
chisel or no. 2 round diamond bur. The in- gently clean the exposed location with a
cised gingival edges are beveled to prevent soft brush. During the second week, the
their proliferation into the exposure site, patient is referred for bonding an attach-
which is then compressed with wet gauze ment to the exposed enamel (Fig 2).
for 10 minutes to control bleeding. The pro- At the same time, the remaining teeth
cedure concludes with a Co-Pack surgical are bracketed. If the canine is close to
dressing stabilized with a few sutures. the lateral incisor root, it will initially be
Occasionally bleeding may be controlled pulled distally with a power chain before
with electrosurgical coagulation. In case of it is tied with elastic thread to the arch-
postsurgical discomfort, over-the-counter wire (Fig 3).16,18,24,33,49 Panoramic radi-
analgesic medication can help. Patients ographs will help define the direction of
should rinse with 0.2% chlorhexidine solu- traction (Fig 4). During active orthodontic

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Zafarmand/Gholami WORLD JOURNAL OF ORTHODONTICS

Table 1 Periodontal status of the two groups of teeth (in mm)


Parameter Normal (mean ± SD) Impacted (mean ± SD) P

Gingival sulcus (DB) 2.3 ± 0.7 2.3 ± 0.5 ≤ .9


Gingival sulcus (MB) 2.5 ± 1.2 2.7 ± 1.3 ≤ .7
Gingival sulcus (midB) 1.9 ± 1.2 1.8 ± 0.9 ≤ 1.0
Gingival sulcus (L) 2.4 ± 0.7 2.5 ± 0.9 ≤ .8
Length of clinical crown 9.3 ± 1.7 9.9 ± 1.6 ≤ .5
Keratinized gingiva level 5.0 ± 1.4 4.5 ± 1.4 ≤ .4
Attached gingiva level 3.2 ± 1.1 2.6 ± 0.7 ≤ .2
SD = standard deviation; DB = distobuccal; MB = mesiobuccal; midB = midbuccal; L= lingual.

therapy, the patient is recalled every 3 to RESULTS


5 months for professional periodontal
maintenance therapy.43 The quality of the gingival margin was
The periodontal status of both maxil- acceptable in 16 patients but unaccept-
lary canines was evaluated 6 months able in the remaining four. The Bleeding In-
after therapy. The evaluation included dex was 0 in 12 and 1 in eight individuals.
registration of (1) keratinized gingiva The remaining results are listed in
level, (2) attached gingiva level, (3) sul- Table 1. The clinical crown length ranged
cus probing depth, (4) length of clinical between 5.4 and 12.0 mm in the control
crown, (5) quality of marginal tissue, (6) group (9.3 ± 1.7 mm) and from 6.7 to
bleeding on probing, and (7) height of the 12.0 mm (9.9 ± 1.6 mm) in the study
alveolar bone.44 group (P ≤ .5). The range of the kera-
All examinations were performed with tinized gingiva in the control group was
a Williams periodontal probe by one den- from 4.0 to 8.0 mm (5.0 ± 1.4 mm) and
tist under the supervision of a periodon- from 3.0 to 7.0 mm (4.5 ± 1.4 mm) in the
tist. To evaluate the bone level, the study group (P ≤ .4). For the level of the
distance between the cementoenamel attached gingiva the respective values
junction and the alveolar bone crest was were 2.0 to 5.0 mm (3.2 ± 1.1 mm) in
measured. The length of the clinical the control group and 2.0 to 4.0 mm
crown was computed buccally with a (2.6 ± 0.7 mm) in the study group
Vernier digital caliper as the distance (P ≤ .2).
between the deepest curvature of the The range of the bone level in the con-
gingival margin and the canine cusp tip. trol group varied between 0 and 1.0 mm
Bleeding on probing is categorized in (0.1 ± 0.3 mm) and between 0 and
six levels44: 2.0 mm (1.0 ± 0.5 mm) in the study
group (P ≤ .006).
0 Healthy gingiva, no bleeding on probing
1 Healthy gingiva, but bleeding on prob-
ing DISCUSSION
2 Altered gingiva color and bleeding on
probing In 1987, Gaulis and Joho46 studied the
3 Altered gingiva color, slightly edema- periodontal condition of surgically
tous, and bleeding on probing exposed teeth. They found mucogingival
4 Altered gingiva color, greatly edema- problems in the surgically treated teeth,
tous, and bleeding on probing especially when they were impacted
5 Altered gingiva color, greatly edema- vestibularly. A Swedish study concluded
tous, and self-bleeding similar periodontal conditions on both
sides.9 But even if the periodontal condi-
The Mann-Whitney test was used to tion of the exposed tooth is unfavorable,
compare the two groups of teeth (nor- it should not be forgotten that the
mally erupted vs orthodontically erupted) adverse condition can gradually reverse
for their periodontal condition. to some degree. 47

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VOLUME 10, NUMBER 4, 2009 Zafarmand/Gholami

Boyd39 used a window approach for CONCLUSION


labially impacted canines, during which
the entire crown was exposed. Subse- Based upon the results of this study, the
quently, the periodontal condition of the periodontal status of impacted maxillary
respective teeth after orthodontic treat- canines that are orthodontically aligned
ment was characterized by gingival reces- into the dental arch is comparable to rou-
sions, inflammation, and attachment tinely treated canines. A modified window
loss. These consequences possibly relate technique is superior to surgically expose
to the fact that the entire crown was impacted canines.
exposed. Thus, this technique was modi-
fied for the present study. Here, a window
was created by removing only a very ACKNOWLEDGMENT
small part of the soft and hard tissue
over the crown. The authors would like to thank Dr Azadeh Sharif-
In this investigation, no significant dif- Zadeh for her sincere assistance in collecting the
data of this study.
ference was found for the measurements
of the keratinized gingiva level, attached
gingiva level, sulcus probing depth,
length of clinical crown, quality of mar-
REFERENCES
ginal tissue, and bleeding on probing. 1. Erikson BE. Impaction and pseudo-impactions
If the height of the alveolar bone was of teeth. Am J Orthod 1938;24:1090–1096.
0.9 mm less in the previously impacted 2. Erickson S, Kurol J. Resorption of maxillary lat-
teeth, it should be taken into considera- eral incisors caused by ectopic eruption of the
tion that this deficiency could be substi- canines. A clinical and radiographic analysis of
predisposing factors. Am J Orthod Dentofacial
tuted with synthetic bone.35 Orthop 1988;94:503–513.
The results of this research could only 3. Proffitt WR. The etiology of orthodontic prob-
partially be compared to other publica- lems. In: Contemporary Orthodontics. St Louis:
tions because none evaluated all seven Mosby, 1986:95–102.
of the aforementioned periodontal fac- 4. DiSalvo NA. Evaluation of unerupted teeth:
Orthodontic viewpoint. J Am Dent Assoc 1971;
tors. D’Amico et al9 found in their study of 82:829–834.
unilaterally impacted canines similar peri- 5. Fastlicht S. Treatment of impacted canines. Am
odontal conditions as in normally erupted J Orthod 1954;40:891–905.
canines with the exception of sulcus 6. Jarjoura K, Crespo P, Fine JB. Maxillary canine
probing depth. According to Kohavi et impactions: Orthodontic and surgical manage-
ment. Compend Contin Educ Dent 2002;23:
al, 36 the surgical exposure technique 23–26.
plays an important role to achieve an 7. Becker A, Chaushu S. Long-term follow-up of
acceptable alignment with minimal peri- severely resorbed maxillary incisors after reso-
odontal complications. Their study also lution of an etiologically associated impacted
indicated that no difference was found canine. Am J Orthod Dentofacial Orthop 2005;
127:650–654.
between the exposed and control side, 8. Otto RL. Early and unusual incisor resorption
except for the loss of bony support. due to impacted maxillary canines. Am J Orthod
It should be realized that not all Dentofacial Orthop 2003;124:446–449.
unerupted teeth can be salvaged and 9. D’Amico RM, Bjerklin K, Kurol J, Falahat B.
that they must be removed in certain sit- Long-term results of orthodontic treatment of
impacted maxillary canines. Angle Orthod
uations.49 In those cases, restorative pro- 2003;73:231–238.
cedures are an alternative to orthodontic 10. Azaz B, Shteyer A. Resorption of the crown in
treatment.50 impacted maxillary canine. A clinical, radio-
The combination of the described sur- graphic and histologic study. Int J Oral Surg
gical technique and orthodontic therapy 1978;7:167–171.
11. Shapira Y, Kuftinec MM. Early diagnosis and
leads to a successful alignment of interpretation of potential maxillary canine
impacted canines with sound periodontal impaction. J Am Dent Assoc 1998;129:
conditions. 1450–1454.
12. Olive RJ. Orthodontic treatment of palatally im-
pacted maxillary canines. Aust Orthod J 2002;
18:64–70.

299

© 2009 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE
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295_Zafarmand.qxd 11/6/09 2:30 PM Page 300

Zafarmand/Gholami WORLD JOURNAL OF ORTHODONTICS

13. Sunil S, Avinash BS, Prasad D, Jagadish L. A 33. Council on Communications. “Orthodontic Dia-
modified double pedicle graft technique and logue.” The Management of unerupted maxil-
other mucogingival interceptive surgeries for lary cuspid. Am Assoc Orthodontists
the management of impacted teeth: A case Publications, 4(2) spring 1992.
series. Indian J Dent Res 2006;17:35–39. 34. Lin JJ. Do teeth want to be straight? A nonsurgi-
14. McDonald F, Yap WL. The surgical exposure cal approach to unerupted teeth. World J
and application of direct traction of unerupted Orthod 2005;6:248–257.
teeth. Am J Orthod 1986;89:331–340. 35. Caranza F, Newman M. Clinical Periodontology,
15. Rohrer A. Displaced and impacted canines. Int ed 8. Philadelphia: Saunders, 1996.
J Orthod 1929;15:1003–1020. 36. Kohavi D, Becker A, Zilberman Y. Surgical expo-
16. Lappin MM. Practical management of the sure, orthodontic movement, and final tooth
impacted maxillary cuspid. Am J Orthod 1951; position as factors in periodontal breakdown of
37:769–778. treated palatally impacted canines. Am J
17. Gensior AM, Strauss RE. The direct bonding Orthod 1984;85:72–77.
technique applied to the management of the 37. Arslan SG, Kama JD, Baran S. Correction of a
maxillary impacted canine. J Am Dent Assoc severe Class III malocclusion. Am J Orthod
1974;89:1332–1337. Dentofacial Orthop 2004;126:237–244.
18. Jacoby H. The etiology of maxillary canine 38. Saiar M, Rebellato J. Maxillary impacted canine
impactions. Am J Orthod 1983;84:125–132. with congenitally absent premolars. Angle
19. Bishara SE, Kommer DD, McNeil MH, Mon- Orthod 2004;74:568–575.
tagano LN, Oesterle LJ, Youngquist HW. Man- 39. Boyd RL. Clinical assessment of injuries in ortho-
agement of impacted canines. Am J Orthod dontic movement of impacted teeth. II. Surgical
1976;69:371–387. recommendations. Am J Orthod 1984;86:
20. Ericson S, Kurol J. Radiographic examination of 407–418.
ectopically erupting maxillary canines. Am J 40. Johnston WD. Treatment of palatally impacted
Orthod Dentofacial Orthop 1987;91:483–492. canine teeth. Am J Orthod 1969;56:589–596.
21. Ziegler TF. A modified technique for ligating 41. von der Heydt K. The surgical uncovering and
impacted canines. Am J Orthod 1977;72: orthodontic positioning of unerupted maxillary
665–670. canines. Am J Orthod 1975;68:256–276.
22. Levin MP, D’Amico RA. Flap design in exposing 42. Boyd RL. Clinical assessment of injuries in ortho-
unerupted teeth. Am J Orthod 1974;65:419–422. dontic movement of impacted teeth. I. Methods
23. Ericson S, Kurol J. Early treatment of palatally of attachment. Am J Orthod 1982;82:478–486.
erupting maxillary canines by extraction of the pri- 43. Hammerle CHF, Joss A, Lang NP. Short-term
mary canines. Eur J Orthod 1988;10:283–295. effects of initial periodontal therapy (hygienic
24. Lewis PD. Preorthodontic surgery in the treat- phase). J Clin Periodontol 1991;18:233–239.
ment of impacted canines. Am J Orthod 1971; 44. Stewart JA, Heo G, Glover KE, Williamson PC,
60:382–397. Lam EW, Major PW. Factors that relate to treat-
25. Becher A. Palatally impacted canine. In: The ment duration for patients with palatally
Orthodontic Treatment of Impacted Teeth, ed 2. impacted maxillary canines. Am J Orthod
Thieme: UK, 2007:93–150. Dentofacial Orthop 2001;119:216–225.
26. Ericson S, Kurol J. Longitudinal study and analy- 45. Zachrisson BV, Alnaes L. Periodontal condition
sis of clinical supervision of maxillary canine in orthodontically treated and unerupted indi-
eruption. Community Dent Oral Epidemiol viduals. 1. Loss of attachment, gingival pocket
1986;14:172–176. depth, and clinical crown height. Angle Orthod
27. Ferguson JW. Management of the unerupted 1973;43:402–411.
maxillary canine. Br Dent J 1990;169:11–17. 46. Gaulis R, Joho JP. The marginal periodontium of
28. Faber J, Berto PM, Quaresma M. Rapid prototyp- impacted upper canines. Evaluation of following
ing as a tool for diagnosis and treatment plan- various methods of surgical approach and ortho-
ning for maxillary canine impaction. Am J dontic procedures [in French]. SSO Schweiz
Orthod Dentofacial Orthop 2006;129:583–589. Monatsschr Zahnheilkd 1978;88:1249–1261.
29. Becker A, Chaushu S. Success rate and dura- 47. Boyd RL, Leggott PJ, Quinn RS, Eakle WS, Cham-
tion of orthodontic treatment for adult patients bers D. Periodontal implications of orthodontic
with palatally impacted maxillary canines. Am J treatment in adults with reduced or normal peri-
Orthod Dentofacial Orthop 2003;124:509–514. odontal tissues versus those of adolescents. Am
30. Zuccati G, Ghobadlu J, Nieri M, Clauser C. Fac- J Orthod Dentofacial Orthop 1989;96:191–198.
tors associated with the duration of forced 48. Danan M, Zenou S, Bouaziz-Attal AS, Dridi SM.
eruption of impacted maxillary canines: A retro- Orthodontic traction of an impacted canine
spective study. Am J Orthod Dentofacial Orthop through a synthetic bone substitute. J Clin
2006;130:349–356. Orthod 2004;38:39–44.
31. Frank CA. Treatment options for impacted 49. Vanarsdall RL, Corn H. Soft-tissue management
teeth. J Am Dent Assoc 2000;131:623–632. of labially positioned unerupted teeth. Am J
32. Frank CA, Long M. Periodontal concerns associ- Orthod 1977;72:53–64.
ated with the orthodontic treatment of 50. Magheri P, Cambi S, Grandini R. Restorative
impacted teeth. Am J Orthod Dentofacial alternatives for the treatment of an impacted
Orthop 2002;121:639–649. canine: Surgical and prosthetic considerations.
Pract Proced Aesthet Dent 2002;14:659–664.

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301_Seliem.qxd 11/6/09 2:31 PM Page 301

Essam Nassef Seliem, BDS,


MSc, PhD1 SOFT TISSUE CEPHALOMETRICS:
Khaled Hazem Attia, BDS, AN OVERDUE EVALUATION
MSc, PhD1

Saba Al-Hadithiy, BDS, The purpose of this study was to compare the accuracy of cephalo-
MSc, MOrth (RCSEd)2 metric soft tissue linear measurements obtained from conventionally
traced cephalograms with those taken directly on patients. This study
Yehya Ahmed Mostafa, was conducted on 11 orthodontic patients. Small pieces of orthodon-
BDS, FDSRCS(Ed), MS, tic wire were fixed on five soft tissue landmarks in the midline of the
PhD3 face of each patient. Five linear measurements were taken directly on
each patient’s face using an electronic Boley gauge reading to the
nearest 0.05 mm. Also, a lateral cephalogram was taken of each
patient with the aforementioned wires still in place. Using the same
gauge, the same linear measurements were taken from the tracings of
all cephalograms. The two sets of readings were statistically analyzed
using the concordance correlation coefficient and Pearson correlation
coefficient. The study concluded that soft tissue measurements on lat-
eral cephalometric radiographs do not give reliable values. A single
magnification factor cannot be applied for lateral cephalometric soft
tissue measurements in all patients, nor within the same patient.
World J Orthod 2009;10:301–304.

Key words: lateral cephalometry, soft tissue, linear measurements,


profile

ephalometric radiography is important method limitations do not allow an accu-


C for both clinicians and researchers,
especially those studying craniofacial
rate assessment of craniofacial abnor-
malities and facial asymmetries.6
1Assistant Professor, Orthodontic
Department, Faculty of Oral and growth.1 Over the years, a variety of meth- Another important factor in this issue
Dental Medicine, Cairo University, ods have been established for the analy- is the significant amount of external
Cairo, Egypt. sis of lateral cephalograms. 2–5 A error, known as radiographic projection
2Visiting Resident, Orthodontic
cephalogram is a 2D representation of a error, which is associated with image
Department, Faculty of Oral and
Dental Medicine, Cairo University,
3D object. Thus, due to the laws of projec- acquisition. These errors comprise mag-
Cairo, Egypt. tion, the images are displaced vertically nification, incorrect positioning, as well
3Professor and Head, Orthodontic and horizontally. The amount of displace- as projective distortion. 7 In addition,
Department, Faculty of Oral and ment is proportional to the focus/object/ manual data collection and processing
Dental Medicine, Cairo University, film or recording plane distance.6 in cephalometrics have been shown to
Cairo, Egypt.
Moreover, cephalometric analyses are have low accuracy.7 Despite these limita-
CORRESPONDENCE based on the hypothesis that accurate tions, countless cephalometric analyses
Dr Yehya Ahmed Mostafa superimposition of the right and left have been developed to help diagnose
Orthodontic Department sides occurs on the midsagittal plane. skeletal malocclusions and dentofacial
Faculty of Oral and Dental Medicine
Per fect superimposition is seldom deformities.
Cairo University
52 Arab League Street observed because facial symmetry is The aim of this study was to evaluate
Mohandesseen, Giza, Egypt rare, but more so because of relative the accuracy of cephalometric soft tis-
Email: mangoury@usa.net image displacement. These inherent sue measurements.

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Seliem et al WORLD JOURNAL OF ORTHODONTICS

Fig 1 Patient on whom short Fig 2 Direct linear measure- Fig 3 Linear measure-
sections of orthodontic wire were ment on the patient’s face using ment on a cephalometric
fixed with clear adhesive tape on an electronic Boley gauge. radiograph using the
five soft tissue landmarks. same electronic Boley
gauge.

MATERIAL AND METHODS observer. His reliability was also tested by


repeating all measurements 1 day after the
Small pieces of orthodontic wire (Ormco) first set of measurements was attained.
(0.016 ⫻ 0.022-inch stainless steel, The data were collected, tabulated,
3-mm long) were fixed with clear surgical and analyzed with a reproducibility index,
tape horizontally to the floor in the mid- called the concordance correlation coeffi-
line of the faces of 11 randomly selected cient (CCC), introduced by Lin.8 It evalu-
orthodontics patients on five soft tissue ates the agreement between two readings
landmarks in the midsagittal plane (Fig (from the same sample) by measuring the
1). These landmarks were: variation for the 45-degree line through
the origin (the concordance line).9,10 The
• G, glabella = most anterior point of the CCC contains the measurements of accu-
forehead racy and precision. It was used to evalu-
• N, soft tissue nasion = deepest point ate the equivalence and association
of the concavity between the forehead between the direct and cephalometric
and the nose measurements. Also, the reproducibility
• SLS, superior labial sulcus = deepest of all measurements was assessed with
point of the concavity of the upper lip the CCC statistical test.
between subnasale and labrale
superius
• ILS, inferior labial sulcus = deepest RESULTS
point of the concavity of the lower lip
between labrale inferius and soft tis- The results and consequent comparison
sue pogonion between the direct and cephalometric
• Me, soft tissue menton = lowest point measurements are represented in Table
on the contour of the soft tissue chin 1 and Fig 4.
The CCC showed that of the five linear
Five linear measurements (G-N, N-SLS, measurements, three agreed poorly and
N-ILS, N-Me, and SLS-Me) were taken two fairly between the two modalities.
directly on each patient’s face and on Error assessment between repeated mea-
each cephalometric radiograph using an surements, as represented in Table 2 and
electronic Boley gauge, which was read Fig 5, depicted an excellent correlation.
to the nearest 0.05 mm (Figs 2 and 3). The percentage of magnification was
To ensure measurement reliability, all not constant among patients, nor within
measurements were made by the same the same patient (Table 3).

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VOLUME 10, NUMBER 4, 2009 Seliem et al

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


44 correlation coefficient (CCC) test for the direct clinical (DC)
and cephalometric (CEPH) measurements (mm)
42
Mean SD CCC
40
G-N
DC 34.931 4.103 0.633**
38
Ceph

CEPH 39.148 5.197


N-SLS
36
DC 56.715 4.009 0.306***
34 CEPH 65.132 4.750
N-ILS
32 DC 90.425 6.616 0.342***
CEPH 102.713 7.214
30 N-Me
30 32 34 36 38 40 42 44 DC 112.283 7.948 0.108***
Direct CEPH 120.895 18.054
SLS-Me
DC 58.360 5.223 0.486**
Fig 4 Graphic representation of the CCC for the direct (clini- CEPH 64.656 4.981
cal) and cephalometric (ceph) linear measurements.
** = .40 > P < .75 (fair agreement).
*** = P < .40 (poor agreement).

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


44 correlation coefficient (CCC) test of intraobserver
difference between the first (Obs 1) and second (Obs 2)
42 measurement (mm)
40 Mean SD CCC

G-N
38
Osb 2

Obs 1 34.93 4.103 0.995*


36 Obs 2 35.07 3.999
N-SLS
34 Obs 1 56.71 4.009 0.978*
Obs 2 56.74 3.919
32 N-ILS
Obs 1 90.42 6.616 0.998*
30 Obs 2 90.43 6.595
30 32 34 36 38 40 42 44 N-Me
Obs 1 Obs 1 112.28 7.948 0.992*
Obs 2 112.37 7.717
SLS-Me
Fig 5 Graphic representation of the CCC for the intraob- Obs 1 58.36 5.223 0.986*
server error assessment between the first (Obs 1) and sec- Obs 2 58.15 5.322
ond (Obs 2) measurement of both direct and cephalometric
linear parameters. *= P > .75 (excellent agreement).

Table 3 Percentage of magnification between the direct


and cephalometric measurements (mm)
Subject G-N N-SLS N-ILS N-Me SLS-Me

1 14.21 8.20 10.69 12.33 10.52


2 3.03 15.78 10.27 8.79 2.88
3 9.98 12.98 13.23 10.94 10.45
4 9.54 14.79 13.93 13.47 10.10
5 14.43 14.79 13.92 14.19 13.64
6 10.66 11.19 12.52 12.01 10.62
7 11.61 11.53 6.92 7.79 3.26
8 13.3 14.34 11.80 10.90 13.07
9 11.19 12.94 13.20 12.47 10.64
10 14.78 11.05 10.91 11.10 9.96
11 3.39 14.15 14.13 12.53 12.14

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DISCUSSION REFERENCES

In contemporary orthodontics, systematic 1. Broadbent BH Sr. A new x-ray technique and its
application to orthodontia. Angle Orthod
quantitative measurements based on
1931;1:45–66.
hard and soft tissue landmarks deter- 2. Tweed CH. The Frankfort-mandibular plane
mined on cephalometric films are used angle in orthodontics. Am J Orthod 1946;32:
on a daily basis. Precision and repro- 175–230.
ducibility in data obtained from cephalo- 3. Downs WB. Variations in facial relationship:
Their significance in treatment and prognosis.
grams are important for the orthodontist.
Am J Orthod 1948;34:812–840.
Errors in conventional methods arise 4. Graber TM. New horizons in case analysis—
from image acquisition, landmark identi- Clinical cephalometrics. Am J Orthod 1952;38:
fication, and measurement method.11–13 603–624.
In cephalometry, the validity of the 5. Ricketts RM. Cephalometric synthesis. Am J
measurements must be ascertained by Orthod 1966;46:647–673.
6. Athanasiou AE. Orthodontic Cephalometry. Lon-
comparing the measurements from don: Mosby-Wolfe, 1997.
cephalograms with measurements made 7. Adams GL, Gansky SA, Miller AJ, Harrell WE Jr,
directly on the same skull in the case of Hatcher DC. Comparison between traditional 2-
hard tissue measurements and directly on dimensional cephalometry and a 3-dimensional
the same face in the case of soft tissue approach on human dry skulls. Am J Orthod
Dentofacial Orthop 2004;126:397–409.
measurements.14 In this study, the accu- 8. Lin LI. A concordance correlation coefficient to
racy was tested by comparing the linear evaluate reproducibility. Biometrics 1989;45:
measurements obtained on cephalograms 255–268.
and directly on the same patients’ faces. 9. Lin LI. Assay validation using the concordance
All five selected soft tissue landmarks correlation coefficient. Biometrics 1992;48:
599–604.
were in the midline of the face so as to 10. Lin L, Torbeck LD. Coefficient of accuracy and
avoid superimpositions. Moreover, only lin- concordance correlation coefficient: New statis-
ear measurements were tested because tics for methods comparison. PDA J Pharm Sci
angular measurements would be more dif- Technol 1998;52:55–59.
ficult to acquire and should be relatively 11. Houston WJB, Maher RE, McElroy D, Sherriff M.
Sources of error in measurements from
independent of the measurement method. cephalometric radiographs. Eur J Orthod
Magnification, inherent to radiographic 1986;8:149–151.
projection, must be considered when 12. Forsyth DB, Shaw WC, Richmond S. Digital
comparing cephalometric data from vari- imaging of cephalometric radiography, Part 1:
ous sources. This applies to only linear Advantages and limitations of digital imaging.
Angle Orthod 1996;66:37–42.
dimensions, because angular values 13. Forsyth DB, Shaw WC, Richmond S, Roberts CT.
would not be affected. Digital imaging of cephalometric radiographs,
Although the number of individuals Part 2: Image quality. Angle Orthod 1996;66:
was limited to 11, the results obviate the 43–50.
need to expand the sample size. 14. Potter JW, Meredith HV. A comparison of two
methods of obtaining biparietal and bigonal
measurements. J Dent Res 1948;27:459–466.

CONCLUSIONS
From this study, the following conclusions
could be drawn:

• Soft tissue analysis showed that linear


soft tissue measurements extracted
from lateral cephalometric radiographs
do not represent the true values to be
found in a particular patient.
• A single magnification factor cannot
be applied as a correction factor for
the lateral cephalometric soft tissue
measurements.

304

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José Augusto Mendes
Miguel, MSc, PhD1 ORTHODONTIC TREATMENT NEEDS
Daniela Feu, Esp2 OF BRAZILIAN 12-YEAR-OLD
Rogéria Mendes Brêtas,
MSc3
SCHOOLCHILDREN
Aim: To assess the orthodontic treatment need of 12-year-old Brazil-
Cristiane Canavarro, MSc4
ian school children using the Index of Orthodontic Treatment Need
(IOTN). Methods: One experienced examiner evaluated the IOTN’s
Marco Antonio de Oliveira
dental health component (DHC) and its esthetic component (EC) in
Almeida, MSc, PhD5
1,182 individuals from 50 randomly selected state schools of Rio de
Janeiro. He also requested that these students score their own EC
(self-perception). Results: The DHC showed that 51.1% of the children
had no/little need, while 26.7% had a need/high need/priority for
orthodontic treatment. There was no significant difference between
the two sexes (P = .156). According to the EC, esthetics were good in
59.1% of the children, borderline in 32.7%, and unattractive in 8.1%.
The self-perception of the EC showed that 89.0% judged themselves
as having good esthetics, with girls significantly more critical than
boys (P = .035). The statistical correlation between EC (examiner) and
EC (children) was low (kappa coefficient = .13). Conclusions: About
half of the scored Brazilian 12-year-old schoolchildren had no/little
need for treatment. Orthodontists were more critical in their esthetic
evaluation than the children themselves, with girls being more critical
in self-perception than boys. World J Orthod 2009;10:305–310.

Key words: dental health component, esthetic component, IOTN, occlusal


indices, treatment need

1Adjunct Professor, Department of or many years, occlusal indices have five progressive levels of occlusal irregu-
Orthodontics, Rio de Janeiro State
University, Rio de Janeiro, Brazil.
2Specialist in Orthodontics and MSc
F been widely used to uniformly evalu-
ate orthodontic treatment need.1,2 Sev-
larities, and an esthetic component (EC),
which grades dental attractiveness
Student, Rio de Janeiro State Uni- eral indices have been developed to based on a set of 10 color photographs.
versity, Rio de Janeiro, Brazil. categorize malocclusions into groups Grade 1 represents the most attractive
3Pedodontics Master, State University
that reflect the level of treatment need. and grade 10 the least attractive appear-
of Rio de Janeiro, Rio De Janeiro,
Assessing treatment need is indispens- ance.6 Since its introduction, the IOTN
Brazil.
4PhD Student, State University of Rio able for public health purposes and spe- has been widely applied by orthodontists
de Janeiro, Rio de Janeiro, Brazil. cialist-training programs.3 Such data is the world over.7,8 The reproducibility and
5Chair, Department of Orthodontics,
limited for the Brazilian population. 4 validity of the IOTN is approved, which
Rio de Janeiro State University, Rio Most of the published data deal with enforces its use.1,9,10
de Janeiro, Brazil.
specific occlusal traits, which makes Although dissatisfaction with dental
CORRESPONDENCE comparisons difficult and provides little appearance is related to the severity
Daniela Feu Rosa Kroeff de Souza information about treatment need. of occlusal irregularities,11,12 there are
Moacir Ávidos Street, n° 156 / The Index of Orthodontic Treatment differences in the recognition and evalua-
apartment 804 Need (IOTN) incorporates two compo- tion of dental features.13 Previous inves-
Praia do Canto – Vitória – E.S.
Cep: 29055-350
nents: a dental health component (DHC), tigations have suggested that dental
Brazil based on the recommendations of the professionals have a more critical view of
Email: danifeutz@yahoo.com.br Swedish Medical Board, 5 which ranks malocclusions than laypersons, when

305

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Miguel et al WORLD JOURNAL OF ORTHODONTICS

considering treatment in conditions scored separately on an individual form.


acceptable to laypersons.7,11,12,14–18 Addi- The DHC grade was then determined
tionally, ranking dental attractiveness is according to the highest scoring anomaly.
subjective and may be related to the The EC score was evaluated by both the
judge’s background, with differences investigator and each individual.
among patients’ self-perception usually For the DHC, 10 malocclusions/symp-
related to sex,12,19–21 age,22–24 ethnicity, toms were considered: overjet, anterior
and cultural conditions.25 crossbite, overbite, open bite, lateral cross-
The aims of this study were to evaluate bite, displacement of teeth, clefts of lip or
the orthodontic and esthetic treatment palate, Class II, Class III buccal occlusion,
need, as well as the self-perception, of and hypodontia. The EC complements the
12-year-old schoolchildren from Rio de DHC by assessing the appearance of the
Janeiro. anterior tooth alignment.2
The DHC of the IOTN has five grades,
while the EC has 10. DHC grades 1 to 2
METHODS and EC grades 1 to 4 represent no/little
need for treatment, DHC grade 3 and EC
One thousand two hundred and fifty 12- grades 5 to 7 correspond to a moderate
year-old schoolchildren from 50 state or borderline need for treatment, and
schools in Rio de Janeiro were evaluated. DHC grades 4 to 5 and EC grades 8 to 10
These schools were randomly selected represent a high need/priority for treat-
from all 390 Rio de Janeiro schools in ment.2
this age group, respecting the city’s Data analysis was performed using
regions’ ratios. Twenty-five children were SPSS 9.0, SPSS. The chi-square test was
chosen from each class independent of used to analyze qualitative data and
their sex. Sixty-eight (5.4%) were under- determine differences in treatment need
going or had undergone orthodontic among subgroups. The significance level
treatment. Subsequently, they were was set at .05. The agreement evaluation
excluded from the sample, bringing the between the examiner scores and stan-
final number to 1,182. Of these, 550 dard scores (gold standard) and intra-
(46.5%) were male and 632 (53.5%) examiner reliability were analyzed with
female, with no significant difference kappa statistics.
between sexes (P = .93).
Permission to undergo the survey was
obtained from the city of Rio de Janeiro’s RESULTS
education department, each school, and
each child’s parent. Each party was In the examiner gold-standard evaluation,
asked to consent to their child’s coopera- good agreement was found for DHC
tion in the study through an informative (kappa = .73) and EC (kappa =.72). Intra-
letter including a consent form that was examiner reliability had a kappa of .92,
approved by the Ethics Research Commit- indicating a substantial agreement.5
tee of the authors’ university. According to the IOTN-DHC, 51.1% of
One examiner (who had been previ- the children had no/little need for treat-
ously trained in the use of the IOTN index ment, 22.2% had a moderate/borderline
at the University of Manchester) carried need, and 26.7% a high need/priority
out the screening. He was evaluated on for treatment (Fig 1). There was no signifi-
a set of 30 plaster casts previously exam- cant dif ference between the sexes
ined (gold standard). To test his (intraex- (P = .156).
aminer) reliability, these casts were According to the IOTN-EC (examiner),
re-examined after 7 days. 59.2% of the children had no/little need
The complete investigation was car- for treatment, 32.7% had a moderate/bor-
ried out in natural light using a mouth derline need, and 8.1% a high need/prior-
mirror. No radiographs, study casts, or ity for treatment (Fig 2). Again, there was
written records were used. All occlusal no significant difference between the
anomalies of the DHC were recorded and sexes (P = .279, Table 1).

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VOLUME 10, NUMBER 4, 2009 Miguel et al

25
45
40.6
40 20
35 17.3 17.4 17.1

Frequency (%)
Frequency (%)

30 15
25 22.2 11.7 11.4
20.2
20 10 9.6
15 7.3
10.5
10 6.5 5 3.6 4.1
5
0.5
0 0
1 2 3 4 5 1 2 3 4 5 6 7 8 9 10
DHC score EC score

Fig 1 Perceptual frequency of the five DHC scores. Fig 2 Perceptual frequency of the 10 ECs (examiner).

Table 1 IOTN-EC examiner categorization according to sex


Female Male Total
EC n % n % n %

1–4 (No/little need) 386 61.1 313 56.9 699 59.1


5–7 (Moderate/borderline need) 200 31.6 187 34.0 387 32.7
8–10 (High need/priority for treatment) 46 7.3 50 9.1 96 8.1
Total 632 100.0 550 100.0 1,182 100.0

n = number of individuals.

35 32.7

30

25 22.8
Frequency (%)

21.6
20

15 12.0
10
6.1
5 2.2 1.3
0.9 0.4 0.1
0
1 2 3 4 5 6 7 8 9 10
EC score

Fig 3 Perceptual frequency of the 10 ECs (children).

Table 2 IOTN-EC children categorization according to sex


Female Male Total
EC n % n % n %

1–4 (No/little need) 575 91.0 477 86.7 1052 89.0


5–7 (Moderate/borderline need) 48 7.6 65 11.8 113 9.6
8–10 (High need/priority for treatment 9 1.4 8 1.5 17 1.4
Total 632 100.0 550 100.0 1,182 100.0

n = number of individuals.

According to the IOTN-EC (children) ment (Fig 3). A significant difference was
89.0% had no/little need for treatment, identified between the sexes (P = .035,
9.6% had a moderate/borderline need, Table 2), revealing that girls were more criti-
and 1.4% a high need/priority for treat- cal in their esthetic self-perception.

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Miguel et al WORLD JOURNAL OF ORTHODONTICS

Table 3 Relationship between examiner-assessed EC and DHC scores


EC score
1–4 (No/ 5–7 (Moderate/ 8–10 (High need/
DHC score little need) borderline need) priority for treatment) Total

1–2 (No/little need) 560 43 1 604


3 (Moderate/borderline need) 106 146 10 262
4–5 (High need/priority for treatment) 33 198 85 316
Total 699 387 96 1,182

Table 4 Relationship between children-assessed EC and DHC scores


EC score
1–4 (No/ 5–7 (Moderate/ 8–10 (High need/
DHC score little need) borderline need) priority for treatment) Total

1–2 (No/little need) 567 35 2 604


3 (Moderate/borderline need) 238 22 2 262
4–5 (High need/priority for treatment) 247 56 13 316
Total 1,052 113 17 1,182

In this study, the two most frequent Tanzanian 9 to 18 year olds,25 the 22.0%
occlusal features responsible for the DHC of the Arabian 12 to 18 year olds,26 and
categorization were overjet (32.9%) and the 21.0% to 24.0% for British 11 to 12
crowding (30.4%). The most common fea- year olds.9
ture responsible for a DHC grade 5 was However, the percentage for high treat-
nonerupted teeth. ment need in this study was lower than
Cross-tabulation between DHC and EC the 32.7% and 32.0% found for 11- to
(examiner) scores showed moderate reli- 12-year-old British children in the Brook
ability (kappa = 0.45, Table 3). The corre- and Shaw 1 and Holmes 14 studies,
lation of DHC and EC (children) scores respectively. It was also lower than the
was found to be very low (kappa = .056, 38.8% reported for 11- to 14-year-old
Table 4). The correlation between EC Turkish children in Uçüncü and Eturgay’s8
(examiner) and EC (children) was again study, the 37.0% for 12- to 13-year-old
low (kappa: .13). This disagreement indi- Swedish children in the study of Josefs-
cates a less critical evaluation of the son et al,11 and the 42.6% for 12- to 13-
affected children. year-old Senegalese children in Ngom’s
et al25 study.
Hamdan19 reported that 71.0% of the
DISCUSSION children in Jordan with a mean age of
15.3 years had an objective need for
The present cross-sectional study is one orthodontic treatment. In another study of
of the few Brazilian surveys using the 12- to 14-year-old Jordanian individuals,
IOTN to evaluate the treatment need and Abu Alhaija et al27 found that only 34.0%
perception of dental attractiveness in had an objective treatment need. This dif-
Brazilian children. The sample does not ference in treatment need between chil-
represent the entire Brazilian 12-year-old dren of similar age shows the impact of
population but rather gives an overview sample selection because the individuals
of the potential request for orthodontic of the first survey sought orthodontic or
therapy in the studied area. orthognathic surgery treatment at the
The 26.7% who, according to the DHC, Jordan University Hospital, whereas the
had an objective need for orthodontic second sample was schoolchildren.
treatment (with a DHC of 4 to 5) are simi- In the IOTN-DHC index, only the most
lar to the 21.3% of the 9- to 12-year-old severe occlusal trait is considered for cat-
French schoolchildren, 3 the 22.0% of egorization, despite the fact that other

308

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VOLUME 10, NUMBER 4, 2009 Miguel et al

severe symptoms may be present. In this On the other hand, when Hunt et al15
study, the two most common occlusal asked 19-year-old British individuals to
traits responsible for the final DHC cate- rank other person’s and their own dental
gorization were increased overjet and esthetics, they did not find any sex differ-
crowding. Similarly, Souames et al 28 ences. Similarly, Locker and Slade, 30
recorded crowding as the most common Locker, 23 and Dolan and Gooch 22
trait, followed by increased overjet. Again, reported that age directly influences
Ngom et al 25 and Abu Alhaija et al 27 esthetic self-perception. These authors
found crowding as the most common concluded that the level of criticism
occlusal trait. These authors thought that increases in laypersons as they grow
this finding should have implications on older, independent of their sex.
public dental health, because crowding is
most commonly associated with poor
periodontal condition. CONCLUSIONS
According to the EC of the IOTN, Brazil-
ian children had exactly the same fre- From this study, the following conclusions
quency of a high need/priority for were drawn:
treatment (examiner EC = 8 to 10) as Tan-
zanian children (8.1%).24 Similar results • More than half of the 12-year-old
were found for French,28 Arabian,16 and Brazilian schoolchildren who took part
Senegalese children. 25 However, in in this study had a DHC score indicat-
British and Turkish children, the EC val- ing no/little need for treatment, where-
ues were much lower.8,9 as a quarter had a high need/priority
In Brazil, Frazão and Narvai29 evalu- for treatment.
ated 13,801 12 to 18 year olds in São • According to the EC, as evaluated by
Paulo state using the Dental Esthetic an orthodontist, 8.1% of the children
Index (DEI). They concluded that 16.5% had a high need/priority for treatment.
of the sample had severe or very severe • The examiner was more critical in his
malocclusions. In 12-year-old children, esthetic evaluation than were the chil-
these authors did not find a significant dren. Girls, though, were more critical
sex differences in dental appearance in their esthetic self-perception than
perception, corroborating the present boys.
study’s findings. • Increased overjet and crowding were
According to the EC, 89.0% of the chil- the most common occlusal features
dren of this study perceived themselves as defining the DHC categorization.
not to have an esthetic need for treatment,
which is in contrast to this examiner’s
view as to that of dental professionals like ACKNOWLEDGMENTS
Shaw et al,12 Prahl-Anderson,20 Holmes,14
Hunt et al,15 Josefsson et al,11 and Ngom The authors would like to thank Drs Kevin O’Brien
et al.25 The low correlation between EC and William Shaw for their help with IOTN calibration.
score (children) and DHC score and
between EC (children) and EC (examiner)
scores in this study is in agreement with REFERENCES
Ngom et al,25 Josefsson et al,11 and Ham-
1. Brook PH, Shaw WC. The development of an
dan.19 The EC scores (examiner) showed a
index of orthodontic treatment priority. Eur J
moderate correlation with the DHC scores, Orthod 1989;11:309–320.
while Souames et al28 found a higher cor- 2. Richmond S, Shaw WC, O’Brien, KD, et al. The
relation for the same comparison. relationship between the index of orthodontic
The statistical analysis of this study treatment need and consensus opinion of a
panel of 74 dentists. Br Dent J 1995;178:
revealed that girls were more critical in
370–374.
their esthetic evaluation than boys. This 3. Tung AW, Kiyak HA. Psychological influences on
is in agreement with the findings of oth- the timing of orthodontic treatment. Am J
ers.12,17,21,29 Orthod Dentofacial Orthop 1998;113:29–39.

309

© 2009 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE
MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Miguel et al WORLD JOURNAL OF ORTHODONTICS

4. Frazao P, Narvai PC. Socio-environmental factors 18. Proffit WR, Fields HW Jr, Moray LJ. Prevalence
associated with dental occlusion in adolescents. of malocclusion and orthodontic treatment
Am J Orthod Dentofacial Orthop 2006;129: need in the United States: Estimates from the
809–816. NHANES III survey. Int J Adult Orthodon Orthog-
5. Linder-Aronson JS. Orthodontics in the Swedish nath Surg 1998;13:97–106.
Public Dental Health Service. Trans Eur Orthod 19. Hamdan AM. The relationship between patient,
Soc 1974;233–240. parent and clinician perceived need and nor-
6. Evans R, Shaw W. Preliminary evaluation of an mative orthodontic treatment need. Eur J
illustrated scale for rating dental attractiveness. Orthod 2004;26:265–271.
Eur J Orthod 1987;9:314–318. 20. Prahl-Andersen B. The need for orthodontic
7. Tomita NE, Sheiham A, Bijella VT. Relação entre treatment. Angle Orthod 1978;48:1–9.
determinantes socioeconômicos e hábitos 21. Shaw WC, Lewis HG, Robertson NR. Perception
bucais de risco para más oclusões em pré-esco- of malocclusion. Br Dent J 1975;138:211–216.
lares. Pesquisa Odontológica Brasileira 2000; 22. Dolan TA, Gooch BF. Dental health questions
14:169–175. from the rand health insurance study. In: Slade
8. Ucuncu N, Ertugay E. The use of the Index of GD (ed). Measuring Oral Health and Quality of
Orthodontic Treatment need (IOTN) in a school Life. Chapel Hill: University of North Carolina
population and referred population. J Orthod Press, 1997.
2001;28:45–52. 23. Locker D. Concepts of oral health, disease, and
9. Burden DJ. Need for orthodontic treatment in the quality of life. In: Slade GD (ed). Measuring
Northern Ireland. Community Dent Oral Epi- Oral Health and Quality of Life. Chapel Hill: Uni-
demiol 1995;23:62–63. versity of North Carolina, 1997.
10. Shaw WC. Factors influencing the desire for 24. Mugonzibwa EA, Kuijpers-Jagtman AM, Van’t
orthodontic treatment. Eur J Orthod 1981;3: Hof MA, Kikwilu EN. Perceptions of dental
151–162. attractiveness and orthodontic treatment need
11. Josefsson E, Bjerklin K, Lindersten R. Malocclu- among Tanzanian children. Am J Orthod Dento-
sion frequency in Swedish and immigrant ado- facial Orthop 2004;125:426–434.
lescents—influence of origin on orthodontic 25. Ngom PI, Diagne F, Dieye F, Diop-Ba K, Thiam F.
treatment need. Eur J Orthod 2007;29:79–87. Orthodontic treatment need and demand in
12. Shaw WC, Rees G, Dawe M, Carles CR. The Senegalese school children aged 12–13 years.
influence of dentofacial appearance on the Angle Orthod 2007;77:323–330.
social attractiveness of young adults. Am J 26. Kiyak HA. Cultural and psychologic influences
Orthod 1985;87:21–26. on treatment demand. Semin Orthod 2000;6:
13. Landis JR, Kock GG. The measurement of 242–248.
observer agreement for categorical data. 27. Abu Alhaija ES, Al-Nimri KS, Al-Khateeb SN.
Biomet 1977;33:159–174. Orthodontic treatment need and demand in
14. Holmes A. The prevalence of orthodontic treat- 12-14-year-old north Jordanian school children.
ment need. Br J Orthod 1992;19:177–182. Eur J Orthod 2004;26:261–263.
15. Hunt O. The Aesthetic Component of the Index 28. Souames M, Bassigny F, Zenati N, Riordan PJ,
of Orthodontic Treatment Need validated against Boy-Lefevre ML. Orthodontic treatment need in
lay opinion. Eur J Orthod 2002;24:53–59. French schoolchildren: An epidemiological
16. Kerosuo H, Enezi SA, Kerosuo E, Abdulkarim E. study using the Index of Orthodontic Treatment
Association between normative and self-per- Need. Eur J Orthod 2006;28:605–609.
ceived orthodontic treatment need among Arab 29. Gravely JF. A study of need and demand for
high school students. Am J Orthod Dentofacial orthodontic treatment in two contrasting
Orthop 2004;125:373–378. National Health Service Regions. Br J Orthod
17. de Oliveira CM, Sheiham A. Orthodontic treat- 1990;17:287–292.
ment and its impact on oral health-related qual- 30. Locker D, Slade G. Oral health and the quality of
ity of life in Brazilian adolescents. J Orthod life among older adults: the oral health impact
2004;31:20–27. profile. J Can Dent Assoc 1993;59:830–833.

310

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311_Sharma.qxd 11/6/09 2:32 PM Page 311

Jagan Nath Sharma, BDS,


MDS (Orthodontics)1 EPIDEMIOLOGY OF MALOCCLUSIONS
AND ASSESSMENT OF ORTHODONTIC
TREATMENT NEED FOR THE POPULATION
OF EASTERN NEPAL
Aim: To evaluate the prevalence of malocclusions in eastern Nepal,
estimate the treatment need, and compare the findings with those of
other populations. Methods: Seven hundred patients between 7 and
48 years of age were evaluated. Their orthodontic treatment need was
assessed subjectively and via the Index of Orthodontic Treatment
Need (IOTN) (dental health component [DHC]). Dependency of the
subjective assessment grades and those of the IOTN (DHC) on sex
were checked with the chi-square test. Age and Angle class were
cross-tabulated to test for relationships using analysis of variance
(ANOVA). Results: The prevalence of Class I, II, and III were 67.5%,
28.8%, and 3.7%, respectively. The most common age group was 12 to
24 years. The female to male ratio was 2:1. The subjective assessment
indicated that treatment was indicated in 66.9%, urgently indicated in
30.9%, and not indicated in 2.2%. The IOTN (DHC) showed that 62.0%
had a severe/extreme need of treatment, 28.1% a moderate/border-
line need, and 9.9% little/no need. The mean age was not related to
any specific malocclusion. Also, there was no relationship among
sex, IOTN, and the subjective assessment grades (except for IOTN
grade 4, which was found significantly more frequently in females).
Conclusion: Class I malaoolusion is the most common, while Class III is
the least prevalent in eastern Nepal. The most prevalent age group
seeking treatment was that of 12 to 24 years of age, with more females
than males. The majority of those visiting the orthodontic department
actually needed treatment. World J Orthod 2009;10:311–316.

Key words: IOTN, DHC, epidemiology, treatment need, subjective


assessment

pidemiology of malocclusions and Malocclusions can be assessed with

1Associate
E assessment of orthodontic treatment
need is of national importance in many
various methods,20–25 but not one has
gained universal acceptance. The Index
Professor and Head,
Department Of Orthodontics, BP countries and were thus included in of Orthodontic Treatment Need (IOTN)
Koirala Institute of Health Sciences, numerous national-level health sur- was developed to grade malocclusions
Dharan, Nepal.
veys.1–16 These assessments are neces- on the basis of the significance of vari-
CORRESPONDENCE sar y to plan suf ficient treatment ous occlusal traits for dental health and
Dr Jagan Nath Sharma facilities and develop adequate training esthetic impairment.25 The IOTN incorpo-
Deparment of Orthodontics programs for respective specialists. rates a dental health component (DHC)
College Of Dental Surgery
Many studies reported on the general based on the recommendation of the
BP Koirala Institute of Health
Sciences prevalence of malocclusions in popula- Swedish Medical Board 24 and an
Dharan, Nepal tions, but only a few evaluated it in a esthetic component. 26 Being widely
Email: dr.jnsharma@yahoo.com referred population.17–19 accepted, the IOTN (DHC) was used in

311

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Sharma WORLD JOURNAL OF ORTHODONTICS

Table 1 Age (in years) and sex


distribution 80
70 67.5
Sex n % Mean age SD 60
50
Males 253 36.1 18.5 5.7

%
40 28.8
Females 447 63.9 19.9 5.7 30
Total 700 100.0 19.5 5.8 20
10 3.7
n = number of patients; SD = standard deviation. 0
Class I Class II Class III

Fig 1 Distribution of the malocclusion


according to the Angle classification.

this study to identify the treatment need All data were analyzed with SPSS soft-
of the eastern Nepalese population. Fur- ware (SPSS). The level of significance was
ther, the aims of this study were to esti- set at .05. To test the intraexaminer agree-
mate the respective orthodontic treatment ment, the records of 150 patients were
need and compare these data with that of reexamined 1 month after the initial exam-
other populations. ination and checked with kappa statistics.
The dependency of sex and IOTN (DHC) on
the subjective assessment grades were
MATERIAL AND METHODS tested with the chi-square test. Mean age
and the various Angle classes were cross-
This study was conducted after approval tabulated, so they could be compared with
by the Research Committee, BP Koirala analysis of variance (ANOVA) for any signif-
Institute of Health Sciences, Dharan, icant relationship.
Nepal. Consent was obtained from all
patients before recording their data. The
sample comprised 700 patients (447 RESULTS
females, 253 males) who were referred
from district and zonal hospitals of east- The mean age of the population was
ern Nepal to the Department of Ortho- 18.5 ± 5.7 years for males and 19.9 ± 5.7
dontics at BP Koirala Institute of Health years for females (Table 1). The age was
Sciences. Their ages ranged from 7 to 48 categorized in four groups: younger than
years. All were permanent inhabitants of 12 years (10.5%), 12 to 24 years (76.7%),
Nepal. None had previously undergone 24 to 36 years (11.7%), and older than
orthodontic treatment or suffered from 36 years (1.1%).
any systemic disease. A standard form As demonstrated in Fig 1, 28.8% had
was prepared to record all relevant data. a Class II relationship, of which 22.0%
Alginate impressions were taken and (154) were classified as Class II, Division
plaster casts prepared to define Angle 1, 4.1% (28) as Class II, Division 1 subdi-
classes, other occlusal traits, and the vision, 2.7% (19) as Class II, Division 2,
IOTN. The IOTN (DHC) was used to assess and 3.7% (26) as Class III.
orthodontic treatment need. The treat- Three hundred four (43.4%) of the
ment need was also appraised subjec- 67.5% (473) Class I patients had a
tively in three grades: grade 1, treatment crowded dentition, 17.1% (120) an
not required; grade 2, treatment incisor protrusion, 4.9% (34) an anterior
required; and grade 3, treatment urgently crossbite, 1.7% (12) a posterior crossbite,
required. and 0.4% (3) a mesial migration of their
posterior teeth.

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VOLUME 10, NUMBER 4, 2009 Sharma

60
53.1
50
40.7
40 35.7

30
%

27.0

20 16.4
12.0 10.7
10
3.7 4.4
2.0
0
Absent Super- Ectopic Midline Incisor Anterior Malformations Increased Deep Anterior
numerary eruption diastema crowding spacing overjet bite open bite

Fig 2 Distribution of various occlusal traits.

Table 2 Relationship between mean age


47.0
and malocclusions
50
40 Age (y) SD P
30 28.1
Class I (n = 473) 19.5 5.8 .79
%

20 15.0 Class II, Division 1 (n = 182) 19.3 5.3 .77


8.9 Class II, Division 2 (n = 19) 19.8 8.8 .80
10 Class III (n = 26) 4.3 0.2 .26
1.0
0 n = number of patients; SD = standard deviation.
Grade 1 Grade 2 Grade 3 Grade 4 Grade 5
No Little Moderate/ Severe Extreme
need of need of borderline treatment treatment
treatment treatment need of need need
treatment

Fig 3 Treatment need as per IOTN (DHC).

Other occlusal traits were absent 8.9% (62); grade 3, 28.1% (197); grade 4,
teeth 12% (84), supernumerary teeth 47.0% (329); and grade 5, 15.0% (105)
3.7% (26), ectopic eruption 10.7% (75), (Fig 3). Subjective assessment of ortho-
midline diastema 16.4% (115), maxillary/ dontic treatment need showed that treat-
mandibular incisor crowding 53.1% (372), ment was required in 66.9% (468),
anterior spacing 27.0% (189), malforma- urgently required in 30.9% (216), and not
tions 2.0% (14), increased overjet (> 4 mm) required in 2.2% (16).
40.7% (285), anterior open bite 4.4% There was no significant relationship
(31), and deep bite (> 4 mm) 35.7% (250) between age and the various Angle
(Fig 2). classes (Table 2). The same was true for
The IOTN (DHC) showed the following the relationship between sex and the IOTN
distribution: grade 1, 1.0% (7); grade 2, (DHC) and the subjective assessment

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Table 3 Relationship between the IOTN (DHC) grades Table 4 Relationship between the grades of
and both sexes subjectively assessed treatment need and sexes
Grade Females Males Total % P
P (chi-
square 1 (Treatment not required) 10 6 16 2.2 .42
IOTN (DHC) Females Males Total % test) 2 (Treatment required) 300 168 468 66.9 .46
3 (Treatment urgently required) 137 79 216 30.9 .51
Grade 1: no need of treatment 5 2 7 1.0 .51
Total 447 253 700 100.0
Grade 2: little need of treatment 41 21 62 8.9 .41
Grade 3: moderate/borderline need 133 64 197 28.1 .12
Grade 4: severe treatment need 198 131 329 47.0 .03*
Grade 5: extreme treatment need 70 35 105 15.0 .30
Total 447 253 700 100

* = significant.

grades except for IOTN grade 4, which was Class I, in 19.0% a Class II, and in 12% a
significantly (.03) more frequent in Class III. The difference in the frequency
females (Tables 3 and 4). of the various Angle classes in all these
The kappa value for the intraexaminer studies can mainly be explained by differ-
variability was 0.90, indicating a high ences in sample size and ethnicity.
agreement among repeated observations. In this study, congenitally missing
teeth mainly involved lateral incisors.
Supernumerary teeth occurred mostly in
DISCUSSION the form of mesiodens. Ectopic eruption
was most often observed in maxillary
The distribution of malocclusions among canines and lateral incisors but also in
patients living in eastern Nepal who were mandibular premolars. Midline diastemas
referred for orthodontic treatment had were typically associated with fibrous
not yet been reported in the literature. frenum. Malformed teeth were usually
Sari18 evaluated 1,602 Turkish patients peg-shaped lateral incisors.
and showed that 61.7% of them had a Ucuncu et al27 pointed out that 4.8% of
Class I; 25.1% a Class II, Division 1; 3.2% referred Turkish patients had a slight or
a Class II Division 2; and 10.2% a Class no need for treatment, 12.0% a moderate
III. Thus, the frequency of Class I occlu- need, and 83.2% a great need of treat-
sions was lower than in the present ment. Brook and Shaw25 studied the IOTN
study, whereas that of Class IIIs was con- (DHC) in 222 individuals and found the
siderably higher. Proffit et al1 reported following distribution for treatment need:
that 30.0% of their sample had a normal no need 5.9%, moderate need 19.7%,
occlusion 50.0% a Class I, 15.0% a Class and great need 74.4%. In a study of
II, and 1.0% a Class III. Lew et al16 evalu- 1,025 patients by Richmond et al, 28
ated 1,050 Chinese children and stated the respective numbers were 3.0%,
that 7.1% had a normal occlusion; 58.8% 19.0%, and 78.0%. A similar distribution
a Class I malocclusion; 18.8% a Class II, was observed by Firestone et al29 in 95
Division 1; 2.7% a Class II, Division 2; persons (4.1%, 14.3%, and 81.6%). Over-
and 12.6% a Class III. Sayin et al 17 stud- all, the results of this investigation are
ied 1,356 patients and found in 64.0% a quite comparable with those of previous

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VOLUME 10, NUMBER 4, 2009 Sharma

Table 5 Treatment need according to the IOTN (DHC)


in referred populations studied by various authors
No/little Moderate Great
Author Country n need (%) need (%) need (%)

Brook and Shaw25 England 222 5.9 19.7 74.4


Richmond et al28 England 1,025 3.0 19.0 78.0
Firestone et al29 Switzerland 95 4.1 14.3 81.6
Ucuncu et al27 Turkey 250 4.8 12.0 83.2
Present study Nepal 700 9.9 28.1 62.0

n = number of patients.

publications, though the number of sub- more interest than males for orthodontic
jects urgently requiring treatment was treatment. The IOTN (DHC) showed that
somewhat lower (Table 5). 62.0% had a great need for treatment,
The subjective assessment of treat- 28.1% had a borderline need, and 9.9%
ment need in this study by categorizing little or no need of treatment. Subjective
three grades was felt to be a more realistic assessment showed that most of the
approach to assess the severity of existing patients who visited the orthodontic
malocclusions and to determine treatment department required treatment. Subjec-
priority. Besides this, the results of the tive assessment seems to be a more
subjective assessment and the IOTN realistic and easy approach to determine
(DHC) ratings are very comparable. treatment necessity. The percentage of
The age group of 12 to 24 years was individuals with a high need for orthodon-
the most frequent, which seems to be a tic treatment in eastern Nepal draws spe-
consequence of a high self-consciousness cial attention to the arrangement of
for esthetics, ie, the motivation of these treatment facilities and trained orthodon-
individuals for seeking orthodontic treat- tists in this region.
ment was the greatest. The same motiva-
tion might apply when females sought for
orthodontic treatment approximately two ACKNOWLEDGMENTS
times more frequently than males. Also,
parental motivation due to social reasons The author thanks his teacher Prof R.K. Singh for
might explain this difference. helping to approve this study; Mr D.D. Baral for his
statistical analysis; and Drs Mamta Dali, Dilip Das,
and Kundan Singh and Mr Youbaraj Bajgain and
departmental staff for their valuable support. The
CONCLUSION author would also like to express his sincere grati-
tude to the Research Committee, BP Koirala Insti-
tute of Health Sciences, Dharan, Nepal, for
Angle Class I was the most prevalent and
approval and funding of this research project (no.
Class III the least common occlusal trait Aca.667/061/062, dated March 21, 2005,
in this study. The most prevalent age research code 15/13).
group seeking orthodontic treatment was
that of 12 to 24 years. Females showed

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REFERENCES 15. Thilander B, Myrberg N. The prevalence of mal-


occlusion in Swedish schoolchildren. Scand J
Dent Res 1973;81:12–21.
1. Proffit WR, Fields HW Jr, Moray LJ. Prevalence
16. Lew KK, Foong WC, Loh E. Malocclusion preva-
of malocclusion and orthodontic treatment
lence in an ethnic Chinese population. Aust
need in the United States: Estimates from the
Dent J 1993;38:442–449.
NHANES III survey. Int J Adult Orthodon Orthog-
17. Sayin MO, Turkkahraman H. Malocclusion and
nath Surg 1998;13:97–106.
crowding in an orthodontically referred Turkish
2. Burgersdijk R, Truin GJ, Frankenmolen F, Kals-
population. Angle Orthod 2004;74:635–639.
beek H, van’t Hof M, Mulder J. Malocclusion
18. Sari Z. Orthodontic malocclusions and evalua-
and orthodontic treatment need of 15 74-year-
tion of treatment alternatives: An epidemiologic
old Dutch adults. Community Dent Oral Epi-
study. Turk J Orthod 2003;16:119–126.
demiol 1991;19:64–67.
19. Jones WB. Malocclusion and facial types in a
3. Foster TD, Day AJ. A survey of malocclusion and
group of Saudi Arabian patients referred for
the need for orthodontic treatment in a Shrop-
orthodontic treatment: A preliminary study. Br J
shire school population. Br J Orthod 1974;1:
Orthod 1987;14:143–146.
73–78.
20. Draker HL. Handicapping labio-lingual devia-
4. al-Emran S, Wisth PJ, Boe OE. Prevalence of
tions: A proposed index for public health pur-
malocclusion and need for orthodontic treat-
poses. Am J Orthod 1960;46:295–305.
ment in Saudi Arabia. Community Dent Oral
21. Grainger RM. Orthodontic treatment Priority
Epidemiol 1990;18:253–255.
Index. Public Health Service Publication No.
5. de Muniz BR. Epidemiology of malocclusion in
1000. Series 2, no. 25. Government Printing
Argentine children. Community Dent Oral Epi-
Office, Washington DC, 1967.
demiol 1986;14:221–224.
22. Saltzmann JA. Handicapping malocclusion
6. Helm S, Kreiborg S, Barlebo J, et al. Estimates
assessment to establish treatment priority. Am
of orthodontic treatment need in Danish school-
J Orthod 1968;54:749–765.
children. Community Dent Oral Epidemiol 1975;
23. Summers CJ. The occlusal index: A system for
3:136–142.
identifying and scoring occlusal disorders. Am J
7. Ansai T, Miyazaki H, Katoh Y, et al. Prevalence of
Orthod 1971;59:552–567.
malocclusion in high school students in Japan
24. Linder-Aronson S. Orthodontics in the Swedish
according to the Dental Aesthetic Index. Commu-
Public Dental Health Service. Trans Eur Orthod
nity Dent Oral Epidemiol 1993;21:303–305.
Soc 1974;233–240.
8. Ghabrial E, Wiltshire WA, Zietsman ST, Viljoen E.
25. Brook PH, Shaw WC. The development of an
The epidemiology of malocclusion in Zambian
index orthodontic treatment priority. Eur J
urban school children. SADJ 1998;53:405–408.
Orthod 1989;11:309–320.
9. Haynes S. Orthodontic treatment needs in Eng-
26. Evans R, Shaw W. Preliminary evaluation of an
lish children aged 11–12 years. Br J Orthod
illustrated scale for rating dental attractive-
1973;1:9–12.
ness. Eur J Orthod 1987;9:314–318.
10. Hill PA. The prevalence and severity of maloc-
27. Ucuncu N, Ertugay E. The use of the index of
clusion and the need for orthodontic treatment
treatment need (IOTN) in a school population
in 9-, 12-, and 15-year-old Glasgow schoolchild-
and referred population. J Orthod 2001;28:
ren. Br J Orthod 1992;19:87–96.
45–52.
11. Ingervall B, Mohlin B, Thilander B. Prevalence
28. Richmond S, Roberts CT, Andrews M. Use of
and awareness of malocclusion in Swedish
Index of Orthodontic treatment need (IOTN) in
men. Community Dental Oral Epidemiol 1978;
assessing the need for Orthodontic treatment
6:308–314.
prepost appliance therapy. Br J Orthod 1994;
12. Luffingham JK, Campbell HM. The need for
21:175–184.
orthodontic treatment. A pilot survey of 14-
29. Firestone AR, Hasler RU, Ingervall B. Treatment
year-old school children in Paisley, Scotland.
results in dental school orthodontic patients in
Trans Eur Orthod Soc;1974:259–267.
1983 and 1993. Angle Orthod 1999;69:19–26.
13. Prahl-Andersen B. The need for orthodontic
treatment. Angle Orthod 1978;48:1–9.
14. Salonen L, Mohlin B, Gotzlinger B, Hellden L.
Need and demand for orthodontic treatment in
an adult Swedish population. Eur J Orthod
1992;14:359–368.

316

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Özge Uslu, DDS, PhD1


LONG-TERM FOLLOW-UP OF PATIENTS
M. Okan Akcam, DDS,
PhD2 WITH A SKELETAL ANGLE CLASS III
RELATIONSHIP TREATED WITH CHIN CAPS
Aim: To evaluate the long-term result of chin-cap treatment in
patients with a skeletal Angle Class III relationship due to mandibular
prognathism. Material and Methods: Records of nine patients (five
girls and four boys) with a mean age of 10.8 ± 1.6 years at the start of
treatment were retrieved from the archives. The records comprised
lateral cephalograms, intra- and extraoral photographs, and dental
casts. The subjects were recalled at 6.1 ± 1.5 years after the comple-
tion of active orthodontic treatment. Cephalometric measurements
from the treatment’s beginning (T1), end (T2), and follow-up (T3)
were calculated by using PorDios software. Subjects with a positive
overjet at T3 were grouped as stable, and those with a negative over-
jet were grouped as relapse. Differences between the two groups
were analyzed by repeated measures analysis of variance (ANOVA)
and the Duncan test. Results: Five individuals maintained a positive
overjet at T3, while four relapsed as indicated by a negative overjet.
SNA increased in the stable group between T2 and T3 but not in the
relapse group. Conclusion: About half of the young individuals with a
mandibular prognathism treated with a chin cap relapsed over time.
The relapse seemed to originate from skeletal rather than dentoalve-
olar changes. World J Orthod 2009;10:317–322.

Key words: chin cap, follow-up, long-term observation, skeletal Angle


Class III relationship

or many years after its introduction Consequently, the aim of this study
F by Amos Westcott in the 1840s,1–11
chin-cap therapy was one treatment
was to evaluate the long-term results of
treatment with chin caps in patients with
alternative in patients with mandibular a skeletal Angle Class III relationship
prognathism. Age and related skeletal due to mandibular prognathism.
growth are important factors for suc-
1Research Assistant, Department of
cessful treatment with a chin cap.
Orthodontics, School of Dentistry, Another influencing factor is patient MATERIALS AND METHODS
Ankara University, Ankara, Turkey. cooperation, as are the direction and
2Associate Professor, Department of
amount of the applied force. Fifty-five individuals with a skeletal Angle
Orthodontics, School of Dentistry, Mitani and Sakamoto5 showed that if Class III were randomly selected from
Ankara University, Ankara, Turkey.
used properly, chin-cap therapy can be the archives of the orthodontic depart-
CORRESPONDENCE effective within certain limits. Decisive ment of the Ankara University and
Dr Özge Uslu are the long-term results from an ortho- invited for a follow-up visit. Only nine per-
Department of Orthodontics pedic correction of skeletal Class IIIs, sons (five girls, four boys) responded
School of Dentistry about which repor ts are still fairly and agreed to be involved in this study.
Ankara University
Besevler 06500 sparse.2,3,6,8-12 Uner at al13 found that The mean age of these subjects was
Ankara, Turkey even after 4 years of chin-cap therapy, 10.8 ± 1.6 years at the beginning of
Email: osgeuslu@gmail.com relapse is still a possibility. treatment. They all were treated with

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Fig 1 Patient from the stable group; (left) pretreatment, (center) posttreatment, and (right) long-term follow-up extra- and
intraoral photographs.

chin caps and comprehensive fixed appli- those with a negative overjet as relapse.
ances. The mean treatment duration was Changes between the groups were ana-
3.3 ± 1.1 years. The applied chin caps lyzed by repeated measures analysis of
exerted a force of 500 cN and were to be variance (ANOVA) and the Duncan test.
used at least 16 hours per day. For reten-
tion, Hawley-type retainers were worn full-
time in both arches with a chin cap at RESULTS
night for at least 1 year.
From all participating individuals of Five individuals maintained a positive
this follow-up, lateral cephalograms, overjet (Fig 1), while four showed relapse
intra- and extraoral photographs, and (Fig 2). Changes of their cephalometric
dental casts were obtained. This variables are shown in Fig 3 and Table 1.
occurred on average 6.1 ± 1.5 years after SNA showed an increase in both
orthodontic treatment. The respective groups from T1 to T3 (P < .05). It
records were taken according to the prin- increased further in the stable group
ciples outlined in the Declaration of from T2 to T3 but not in the group with
Helsinki, and an informed consent form relapse. SNB showed a slight increase in
was signed by each person. both groups from T2 to T3. However, it
Cephalometric parameters from the was larger in the relapse (76.8 degrees to
beginning (T1) and end (T2) of treatment, 79.3 degrees) than in the stable group
as well as the follow-up (T3), were calcu- (79.8 degrees to 80.4 degrees). From T2
lated using PorDios software (Purpose on to T3, ANB showed a decrease in the
Request Digitizer Input Output System). relapse group (1.5 degrees to –1.3
The study casts were inspected for pre- degrees), in contrast to the stable group
sent overjet. Patients who had a positive (1.6 degrees to 2.3 degrees). SND
overjet were classified as stable and showed a significant difference (P < .001)

318

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VOLUME 10, NUMBER 4, 2009 Uslu/Akcam

Fig 2 Patient from the relapse group; (left) pretreatment, (center) posttreatment, and (right) long-term follow-up extra- and
intraoral photographs.

from T1 to T3 with a larger increase in


the relapse than in the stable group.
From T2 to T3, SN-GoGn decreased in
the stable group, but it did not change in
the relapse group. SN-OcP decreased in
both groups from T2 to T3 (P < .01). N
S
UI-NA increased significantly (P < .01)
in both groups from T1 to T2. LI-NB was
similar between T1 and T2 in the stable
group, whereas it increased significantly
A
(P < .05) from 3.0 mm to 4.9 mm in the
group with relapse. Go LI
UI
Lower lip-soft tissue line measurement
decreased from T1 to T3 in both groups B
D
and in the total study sample (P < .05).
Gn

Fig 3 Cephalometric landmarks used in


DISCUSSION this study: S = sella, N = nasion, A = A
point, UI = upper incisor tip, LI = lower
incisor tip, B = B point, D = geometrical
The major variable that determines long- midpoint of symphysis, Go = gonion, Gn =
term success with chin-cap therapy is the gnathion.
amount and direction of mandibular
growth during and after adolescence.
According to many authors, 14–18 the
length of the mandible is fundamental
for long-term success or failure.

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Table 1 Cephalometric measurements (means and standard deviations), ANOVA,


and Duncan test for the three time points
T1 T2 T3 P

SNA (degrees)
Stable 80.2 ± 3.4 81.4 ± 3.8 82.7 ±3.3 **
Relapse 76.6 ± 2.1 78.3 ± 1.5 78.0 ± 3.2
Total b 78.6 ± 3.3 a 79.8 ± 3.2 a 80.6 ± 3.9

SNB (degrees)
Stable 79.3 ± 4.6 79.8 ± 4.3 80.4 ± 3.5 NS
Relapse 77.8 ± 3.5 76.8 ± 2.8 79.3 ± 3.6
Total 78.6 ± 4.0 78.4 ± 3.8 79.9 ± 3.4
ANB (degrees)
Stable 0.9 ± 1.9 1.6 ± 2.5 2.3 ± 2.0 NS
Relapse –1.1 ± 2.6 1.5 ± 2.1 –1.3 ± 2.6
Total –0.1 ± 2.4 1.6 ± 2.2 0.7 ± 2.8
SND (degrees)
Stable 75.3 ± 4.0 76.2 ± 3.3 77.4 ± 3.8 ***
Relapse 74.3 ± 4.1 75.5 ± 3.1 77.5 ± 3.4
Total c 74.8 ± 3.8 b 75.8 ± 3.0 a 77.4 ± 3.4

SN-OcP (degrees)
Stable 21.4 ± 7.2 18.0 ± 6.8 15.8 ± 3.3 *
Relapse 19.0 ± 4.0 17.5 ± 1.7 16.5 ± 2.4
Total a 20.3 ± 5.8 b 17.8 ± 4.9 b 16.1 ± 2.8

SN-GoGn (degrees)
Stable 37.2 ± 5.3 35.8 ± 8.0 34.4 ± 8.6 NS
Relapse 38.0 ± 7.0 39.2 ± 7.0 39.2 ± 6.9
Total 37.5 ± 5.7 37.3 ± 7.3 36.6 ± 7.8
UI-NA (mm)
Stable 2.3 ± 1.9 5.0 ± 2.0 4.1 ± 1.6 **
Relapse 3.0 ± 1.2 6.3 ± 1.7 6.1 ± 2.9
Total b 2.7 ± 1.5 a 5.6 ± 1.9 a 5.1 ± 2.3

UI-NA (degrees)
Stable 24.0 ± 6.4 23.0 ± 3.9 24.8 ± 5.5 NS
Relapse 23.5 ± 5.7 28.5 ± 2.9 26.5 ± 5.2
Total 23.8 ± 5.7 25.4 ± 4.3 25.5 ± 5.1
LI-NB (mm)
Stable a 4.9 ± 1.9 a 4.1 ± 2.6 a 4.4 ± 3.2 **
Relapse b 3.0 ± 2.4 a 4.9 ± 3.1 ab 3.9 ± 3.6
Total 4.0 ± 2.2 4.4 ± 2.7 4.2 ± 3.1
LI-NB (degrees)
Stable 25.2 ± 5.8 25.0 ± 6.3 22.8 ± 8.0 NS
Relapse 18.7 ± 4.6 22.2 ± 2.9 18.0 ± 5.8
Total 22.3 ± 6.0 23.8 ± 5.0 20.7 ± 7.1
Pg-NB (mm)
Stable 0.3 ± 0.7 1.2 ± 1.0 0.4 ± 1.8 NS
Relapse 1.4 ± 2.3 2.4 ± 2.1 2.9 ± 2.9
Total 0.8 ± 1.6 1.7 ± 1.6 1.5 ± 2.5
UI-LI (degrees)
Stable 126.3 ± 10.1 128.8 ± 7.7 130.0 ± 10.3 NS
Relapse 137.5 ± 8.9 129.2 ± 9.8 137.0 ± 11.4
Total 131.3 ± 10.8 129.0 ± 8.0 133.1 ± 10.8
Holdaway difference (mm)
Stable 4.6 ± 2.1 2.9 ± 3.5 4.0 ± 4.7 NS
Relapse 1.6 ± 4.5 2.5 ± 4.9 1.0 ± 6.4
Total 3.3 ± 3.5 2.7 ± 3.9 2.7 ± 5.4
Upper lip-soft tissue line (mm)
Stable –1.4 ± 1.3 –0.5 ± 1.6 –0,8 ± 1.3 NS
Relapse –2.9 ± 3.5 –1.8 ± 2.5 –3.0 ± 2.4
Total –2.1 ± 2.5 –1.1 ± 2.0 –1.8 ± 2.1
Lower lip-soft tissue line (mm)
Stable 1.2 ± 0.8 0.7 ± 1.1 –0.4 ± 1.1 **
Relapse 0.1 ± 2.3 1.5 ± 3.0 –0.5 ± 2.9
Total a 0.7 ± 1.6 a 1.1 ± 2.0 b –0.4 ± 1.9

NS = not significant; *P < .01; **P < .05; ***P < .001. Groups (T1-T2-T3) with different letters are signifi-
cantly different from one another.

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VOLUME 10, NUMBER 4, 2009 Uslu/Akcam

In their study, Uner et al 13 saw the start quite early relative to most other
return of the original skeletal pattern skeletal problems. Baccetti et al 16
after chin-cap removal. Somewhat in con- reported that maxillary skeletal changes
trast to this, Ferro et al12 observed that are most likely in children younger than
on average, 9 years after treatment, only 8 years of age.
six of 52 patients had a clinical relapse In the current study, SNA, ie, maxillary
(overjet ≤ 0). This is a significantly lower protrusion, increased in only the stable
rate than in the current study. Ferro et al group. Therefore, it can be speculated
noted that Wits appraisal, ANB, SNB, and that the stimulation of forward maxillary
overbite were the best predictors of development could be meffective in pre-
relapse. They suggested that long-term venting long-term relapse.
stability can be enhanced by a deep over- The results of this study should be
bite and an optimal skeletal correction. interpreted with caution because of the
Other authors also feel that the degree of relatively small sample. However, all fol-
overbite is an important factor when pre- low-up investigations are difficult, espe-
dicting relapse.3,9–10 cially as the time after orthodontic treat-
According to Baccetti et al, the cranial ment increases.
base angle is central.15 An acute angle
could project the mandible forward and
thus favor treatment failure. Other para- CONCLUSION
meters of the discriminant function of
Baccetti et al are mandibular length and Half of the individuals with mandibular
ramus height. Their equation success- prognathism treated with a chin cap
fully identified 83% of the sample from showed relapse at a follow-up investiga-
which it was derived. The discriminant tion. This relapse seems to originate from
function derived by Ghiz et al18 identified skeletal rather than from dentoalveolar
the sagittal position of the mandible rela- changes. It can be hypothesized that
tive to the cranial base, mandibular stimulation of maxillary forward growth is
length, ramus height, and gonial angle as important to prevent relapse in skeletal
key indicators. Class III patients.
Patient age has also to be considered
because significant skeletal corrections
can only be achieved in young patients. REFERENCES
That is why some suggest19 starting chin
cap therapy before the age of 9 years. 1. Wahl N. Orthodontics in 3 millennia. Chapter 2:
Entering the modern era. Am J Orthod Dentofa-
Age could explain the relatively high cial Orthop 2005;127:510–515.
relapse rate in the current study in which 2. Deguchi T, Kuroda T, Minoshima Y, Graber TM.
the mean patient age at the start of treat- Craniofacial features of patients with Class III
ment was 10.8 years. However, others20 abnormalities: Growth-related changes and
observed no significant difference in the effects of short-term and long-term chincup
therapy. Am J Orthod Dentofacial Orthop 2002;
skeletal profiles after chin-cap applica- 121:84–92.
tion at the age of 7 and 11 years. 3. Battagel JM. Predictors of relapse in orthodon-
Wells et al 14 investigated the long- tically-treated Class III malocclusions. Br J
term result of reverse-pull headgear in Orthod 1994;21:1–13.
prognathic children (early mixed dentition 4. Moon YM, Ahn SJ, Chang YI. Cephalometric pre-
dictors of long-term stability in the early treat-
stage) with an anterior crossbite. They ment of Class III malocclusion. Angle Orthod
reported 25% to 30% relapse in overjet 2005;75:747–753.
after at least 5 years posttreatment. Late 5. Mitani H, Sakamoto T. Chin cap force to a grow-
horizontal mandibular growth was sug- ing mandible. Long-term clinical reports. Angle
gested as a reason for relapse. They fur- Orthod 1984;54:93–122.
6. Sugawara J, Mitani H. Facial growth of skeletal
ther concluded that up to an age of 10 Class III malocclusion and the effects, limita-
years, the time at which reverse-pull tions, and long-term dentofacial adaptations
headgear treatment begins is not a major to chincap therapy. Semin Orthod 1997;3:
factor in maintaining a positive overjet in 244–254.
the long term. Still, treatment should

321

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Uslu/Akcam WORLD JOURNAL OF ORTHODONTICS

7. Danaie SM, Salehi P. Cephalometric evaluation 16. Baccetti T, McGill JS, Franchi L, McNamara JA
of class-III patients with chin cap and tongue Jr, Tollaro I. Skeletal effects of early treatment
guard. J Indian Soc Pedod Prev Dent 2005;23: of Class III malocclusion with maxillary expan-
63–66. sion and face-mask therapy. Am J Orthod
8. Arat ZM, Akçam MO, Gökalp H. Long-term effects Dentofacial Orthop 1998;113:333–343.
of chin-cap therapy on the temporomandibular 17. Westwood PV, McNamara JA Jr, Baccetti T,
joints. Eur J Orthod 2003;25:471–475. Franchi L, Sarver DM. Long-term effects of
9. Abu Alhaija ES, Richardson A. Long-term effect Class III treatment with rapid maxillary expan-
of the chincap on hard and soft tissues. Eur J sion and facemask therapy followed by fixed
Orthod 1999;21:291–298. appliances. Am J Orthod Dentofacial Orthop
10. Wendell PD, Nanda R, Sakamoto T, Nakamura 2003;123:306–320.
S. The effects of chin cup therapy on the 18. Ghiz MA, Ngan P, Gunel E. Cephalometric vari-
mandible: A longitudinal study. Am J Orthod ables to predict future success of early ortho-
1985;87:265–274. pedic Class III treatment. Am J Orthod Dentofa-
11. Ritucci R, Nanda R. The effect of chin cup ther- cial Orthop 2005;127:301–306.
apy on the growth and development of the cra- 19. Neuman D. Treatment of true progenua in the
nial base and midface. Am J Orthod Dentofa- decidious dentition. Transactions of the Euro-
cial Orthop 1986;90:475–483. pean Orthodontic Society 1970;213–223.
12. Ferro A, Nucci LP, Ferro F, Gallo C. Long-term sta- 20. Ülgen M. Ortodontik Tedavi Prensipleri (Ortho-
bility of skeletal Class III patients treated with dontic treatment principles) [thesis]. Ankara:
splints, Class III elastics, and chincup. Am J Ankara Üniversitesi Basımevi, 1983.
Orthod Dentofacial Orthop 2003;123:423–434. 21. Sakamoto T. Effective timing for the application
13. Uner O, Yuksel S, Ucuncu N. Long-term evalua- of orthopedic force in the skeletal class III mal-
tion after chincap treatment. Eur J Orthod occlusion. Am J Orthod 1981;80:411–416.
1995;17:135–141. 22. Sugawara J, Asano T, Endo N, Mitani H. Long-
14. Wells AP, Sarver DM, Proffit WR. Long-term effi- term effects of chincap therapy on skeletal pro-
cacy of reverse pull headgear therapy. Angle file in mandibular prognathism. Am J Orthod
Orthod 2006;76:915–922. Dentofacial Orthop 1990;98:127–133.
15. Baccetti T, Franchi L, McNamara JA Jr. Cephalo-
metric variables predicting the long-term suc-
cess or failure of combined rapid maxillary
expansion and facial mask therapy. Am J
Orthod Dentofacial Orthop 2004;126:16–22.

322

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Milton M.B. Farret, DDS,


MSD1 STRATEGIES TO FINISH ORTHODONTIC
Marcel M. Farret, DDS, TREATMENT WITH A CLASS III MOLAR
MSD2

Alessandro M. Farret, DDS3


RELATIONSHIP: THREE PATIENT REPORTS
The purpose of this article is to review treatment concepts for
patients with congenitally missing teeth in the mandible, for patients
in whom teeth in only the mandibular arch were extracted, or for
patients with Class III camouflage treatment. The therapy result in
these situations is a Class III molar relationship. With this type of
intercuspation, esthetic and functional aspects must be observed.
World J Orthod 2009;10:323–333.

Key words: Class III molar relationship, camouflage treatment, intercus-


pation, uniarch extraction, orthodontic finalization

he existing concept of normal occlu- The extraction of two mandibular premo-


T sion in orthodontics calls for the first
molars occluding in a Class I relation-
lars could lead to a Class III molar rela-
tionship at the end of treatment, ie, the
ship, which ensures ideal intercuspation mandibular first molar will occlude with
of all posterior teeth. However, nearly two maxillary premolars, leading to a
45% of patients who seek orthodontic somewhat awkward intercuspation due to
treatment demonstrate a Class II or III the dissimilar cusp configuration. Thus,
molar relationship.1 These malocclusions the involved teeth have to be reshaped by
can be of dental or skeletal origin. If they either grinding or restoration.6
are of skeletal origin and the patient still Camouflaging with extractions in the
has some potential for growth, he can be mandible can be indicated for certain
treated with orthopedic appliances, patients with a Class III, but a similar sit-
which will influence the development of uation will evolve in patients with tooth
the basal bones, as well as dentoalveolar agenesis in only the mandibular arch.
remodeling, simultaneously leading to a Agenesis of mandibular premolars
dental Class I relationship. However, in occurs in about 3% of the population.7 If
1Professor and Chair, Department of adult patients, mainly those with Class III a patient with missing mandibular teeth
Orthodontics, Universidade Federal occlusions, the involvement of orthodon- presents with a convex profile, a Class II
de Santa Maria—RS; PhD Student, tics and orthognathic surgery is often relationship, excessive incisor protrusion,
Pontifícia Universidade Católica, RS; necessary to accomplish a satisfactory and increased overjet, the orthodontist
Santa Maria, Brazil.
2PhD Student, Department of Ortho- treatment outcome. If, on the other may consider extracting two maxillary
dontics, Pontifícia Universidade hand, the skeletal deformity is only mod- premolars to compensate for the missing
Católica—RS, Porto Alegre, Brazil. erate or the malocclusion is solely of ones in the mandible, thus ending with a
3MSD Student, Department of Oral
dentoalveolar origin, the possibility of Class I relationship. However, if the afore-
and Maxillofacial Surgery, Pontifícia camouflage exists.2–4 mentioned situation is not present,
Universidade Católica—RS, Porto
Alegre, RS, Brazil.
In a patient with a Class II relation- extraction of maxillary premolars is con-
ship, extraction of two maxillary teeth, traindicated and treatment will finish
CORRESPONDENCE generally the first premolars, is often the with the molars in a Class III relationship.
Dr Marcel Marchiori Farret therapy of choice because it reduces Subsequently, three patients are
1000/113 Floriano Peixoto St.
treatment time and allows for an excel- presented in whom the mandibular pre-
Downtown, Santa Maria,
Rio Grande do Sul lent esthetic and functional finish. 5 molars were extracted or genetically
Brazil 97015-370 When dealing with a Class III occlusion, missing, leading at the end of therapy to
Email: marcelfarret@yahoo.com.br orthodontists become more cautious: a Class III molar relationship.

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Farret et al WORLD JOURNAL OF ORTHODONTICS

CLINICAL EXAMPLES ficult to establish a correct overjet and


overbite, as well as resulting in less
Patient CG reduction of the lower lip projection.
At the end of treatment, the profile
Patient CG was a 13-year-old male who was considerably improved due to retrac-
had congenitally missing mandibular sec- tion of the incisors and the subsequent
ond premolars. His facial appearance uprighting of the lower lip. The intraoral
was very agreeable. He presented with a photographs document an optimal inter-
Class I molar relationship and excellent cuspation with the canines in Class I and
maxillary incisor inclination (Figs 1 and the molars in Class III occlusion (Fig 8).
2). The patient was treated using a stan- The final panoramic radiograph reveals
dard edgewise technique, no extraction root parallelism, and the lateral cephalo-
of maxillary premolars, and space clo- gram exhibits the repositioning of the
sure in the mandibular arch by moving mandibular incisors as a remodeling of
the mandibular molars mesially. the mandibular symphysis (Fig 9).
Treatment with extraction of the first or
second maxillary premolars was con-
traindicated because it would have nega- Patient RL
tively affected the incisor inclination and
the patient’s facial profile. Patient RL was a 14-year-old male in
With the aforementioned approach, the whom the mandibular right second pre-
patient’s facial profile was maintained, molar was absent. This patient shows a
even though his chin showed accentuated straight profile with pleasant facial fea-
growth. At the completion of therapy, the tures. The molar relation was Class I on
patient had an excellent Class I canine the left and Class III on the right side. The
and a Class III molar relationship (Fig 3) canines were Class I on the right and
with parallel roots of all his posterior teeth slightly Class II on the left side due to a
(Fig 4). Figure 5 shows the patient deviation of the mandibular midline to the
13 years posttreatment. The treatment left. Besides an agenesis of the mandibu-
result was stable and all tissue healthy. lar right second premolar, the patient pre-
sented with a retention cyst of his
mandibular left second premolar (Figs 10
Patient MT and 11). The patient was again treated
with the standard edgewise technique.
Patient MT was a 17-year-old male whose The cyst of the left second premolar was
mandibular first premolars were surgically removed and the tooth aligned
extracted. The patient showed an exces- within the arch, establishing a Class I
sive projection of the lower lip. The molar molar relationship on this side. The space
and canine relationships were Class III of the right second premolar was closed
with an edge-to-edge incisal relationship by mesial movement of the posterior seg-
(Figs 6 and 7). The treatment plan fore- ment, resulting in a Class III molar rela-
saw the extraction of the mandibular first tionship.
premolars to retract the mandibular Nowadays, a viable alternative treat-
incisors without anchorage loss, thus ment for this patient would be the place-
improving the profile, establishing a cor- ment of an implant. However, this patient
rect incisor relationship, and finishing was treated about 15 years ago when
with the canines in a Class I and the implant use was still arguable. The final
molars in a Class III relationship. result of this treatment is shown in Fig
An alternative would have been to 12. The panoramic radiograph reveals
extract the mandibular second premolars. correct root parallelism (Fig 13). Figure
However, this approach would have cer- 14 depicts the patient 14 years posttreat-
tainly resulted in a greater loss of anchor- ment with excellent stability and optimal
age and therefore in less retraction of the tissue health.
incisors. It would have also been more dif-

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VOLUME 10, NUMBER 4, 2009 Farret et al

Fig 1 Patient CG. A 13-year-old male


with persisting primary second molars,
agreeable facial appearance, Class I
molar relationship, and physiologic max-
illary incisor inclination.

Fig 2 Patient CG. Cephalogram and panoramic radiograph at the beginning of treatment revealing normal maxillary incisor
inclination and congenitally missing mandibular second premolars.

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Farret et al WORLD JOURNAL OF ORTHODONTICS

Fig 3 Patient CG. Extra- and intraoral


appearance of patient at the end of
treatment. The profile was maintained
despite some remarkable chin growth;
excellent Class I canine and a Class III
molar relationship are visible.

Fig 4 Patient CG. Cephalogram and panoramic radiograph at the end of treatment revealing normal maxillary incisor inclination
and good root parallelism of all posterior teeth.

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VOLUME 10, NUMBER 4, 2009 Farret et al

Fig 5 Patient CG. Thirteen years post-


treatment showing a stable result and
healthy tissue.

DISCUSSION all three patients, the mandibular first


molars were positioned more lingually
Angle 8 advocated that all treatments than usual, ie, without an offset, as
should finish with a Class I molar relation- when finished in a Class I relationship. In
ship. Since extractions were introduced in addition, the maxillary premolars and
orthodontics, principally by Tweed,9 the molars received accentuate offsets with
sagittal relationship of the molars has no toe-in for the first molar. To further
lost importance. Today, professionals improve the occlusal contacts, special
emphasize the canine relationship more, care should be taken vis a vis the incli-
which is considered fundamental for func- nation of the posterior teeth. The
tion. This gives orthodontists increased mandibular molars may receive accentu-
therapy options. ated lingual crown inclination, whereas
In a Class III relationship, the man- the palatal inclination of the maxillary
dibular first molar occludes with both molars and premolars can be reduced.
maxillary premolars. The anatomy of Even then, intercuspation is some-
these teeth can hamper occlusion, and times compromised and some recontour-
adjustments with first and third order ing is indicated. This includes reducing
bends should therefore take place.6,10 In the palatal cusps of the maxillary premo-

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Farret et al WORLD JOURNAL OF ORTHODONTICS

Fig 6 Patient MT. A 17-year-old male


with excessive lower lip projection,
Class III occlusion, and edge-to-edge
incisor relationship. Situation prior to
extraction of mandibular first premolars
to maximally retract mandibular incisors
for improvement of profile and incisor
relationship.

Fig 7 Patient MT. Cephalogram and panoramic radiograph at the beginning of treatment revealing bimaxillary protrusion and
congenitally missing maxillary third molars.

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VOLUME 10, NUMBER 4, 2009 Farret et al

Fig 8 Patient MT. Extra- and intraoral


appearance of patient at the end of
treatment. Considerable profile
improvement due to incisor retraction
and subsequent uprighting of the lower
lip. Optimal intercuspation with canines
in Class I occlusion and molars in Class
III occlusion.

Fig 9 Patient MT. Cephalogram and panoramic radiograph at the end of treatment revealing repositioning of the mandibular
incisors, remodeling of the mandibular symphysis, and good root parallelism.

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Farret et al WORLD JOURNAL OF ORTHODONTICS

Fig 10 Patient RL. A 14-year-old male


with large spaces between the
mandibular first premolars and first
molars, straight profile with pleasant
facial features, Class I molar relation-
ship on the left side and Class III on the
right side, and Class I canines on the
right and slightly Class II on the left side
due to mandibular midline deviation to
the left.

Fig 11 Patient RL. Cephalogram and


periapical radiograph at the beginning of
treatment revealing agenesis of the
mandibular right second premolar and
retention cyst of the mandibular left
second premolar.

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VOLUME 10, NUMBER 4, 2009 Farret et al

Fig 12 Patient RL. Extra- and intraoral


appearance of patient at the end of
treatment showing a straight profile,
Class I canine and a Class III molar rela-
tionship, as well as midline correction.

Fig 13 Patient RL. Panoramic radi-


ograph at the end of treatment reveal-
ing good root parallelism of posterior
teeth.

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Farret et al WORLD JOURNAL OF ORTHODONTICS

Fig 14 Patient RL. Patient 14 years


posttreatment with excellent stability of
occlusion (third molars have erupted)
and optimal tissue health.

lars and molars or the augmentation of • They are blocked out and severely lin-
the buccal cusps of the mandibular gually tipped
molars with restorative material.6,10 • Anterior crowding is absent or less
According to Hisano and Soma, 11 than moderate
masticatory efficiency is not severely • The patient has a straight or concave
reduced in a Class III molar relationship. profile
In addition, Bakke 12 ascribes the • The mandibular incisors are posi-
occlusal force more to the number and tioned upright or even slightly lingually
quality of occlusal contacts than to the inclined, ie, when retraction require-
sagittal relationship between the poste- ments are not preponderant and
rior teeth. Therefore, regardless of the some anchorage loss is acceptable
molar relationship at the end of treat-
ment, orthodontists should always strive The first premolar should be extracted
for an excellent intercuspation. in situations in which greater anchorage
In camouflage therapy of patients with is needed, which is when:
a Class III occlusion, orthodontists can
opt for extraction of the mandibular first • Anterior crowding is severe
or the second premolars. Second premo- • Mandibular incisors are excessively
lars should be the chosen when: tipped labially

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VOLUME 10, NUMBER 4, 2009 Farret et al

• The sagittal discrepancy between the during diagnosis, treatment planning,


arches is pronounced and execution have to be observed.
• The facial profile is compromised by a
projection of the lower lip, as in
patient MT REFERENCES
According to Janson et al,13 bone re- 1. Silva Filho OG, Freitas SF, Cavassan AO. Preva-
lence of normal occlusion and malocclusion in
modeling of the symphysis will occur with
the mixed dentition on schoolars in Bauru (Säo
a controlled retraction of the mandibular Paulo). Rev Assoc Paul Cir Dent
incisors, as documented by all patients 1989;43:287–290.
presented here. 2. Costa Pinto TM, Ustrell Torrent JM, Correira
In patients with agenesis or extraction Pinto JG. Orthodontic camouflage in the case
of a skeletal Class III malocclusion. World J
of mandibular premolars, the extraction
Orthod 2004;5:213–223.
of maxillary teeth should always be con- 3. Hamanci N, Basaran G, Sahin S. Nonsurgical
sidered. Extraction should especially be correction of an adult skeletal class III and
taken into account when the patient: open-bite malocclusion. Angle Orthod
2006;76:527–532.
• Shows a convex profile 4. Moullas AT, Palomo JM, Gass JR, Amberman
BD, White J, Gustovich D. Nonsurgical treat-
• Presents with severely inverted lips ment of a patient with a Class III malocclusion.
• Demonstrates excessive maxillary Am J Orthod Dentofacial Orthop 2006;129(4
incisor protrusion suppl):S111–118.
• Suffers from severe crowding and 5. Mailankody J, Janson G. Enigma of Class II
increased overbite5 molar finishing. Reader’s forum. Am J Orthod
Dentofacial Orthop 2004;126:15A–17A.
6. Popp TW, Gooris CGM, Schur JA. Nonsurgical
None of the patients presented here treatment for a Class III dental relationship: A
fulfilled these characteristics, which is case report. Am J Orthod Dentofacial Orthop
why no maxillary teeth were extracted 1993;103:203–211.
7. Pinzan A, Pinzan CRM, Santos JAZ. Abordagem
Nowadays, replacing missing teeth
alternativa para o tratamento precoce da
with implants is often the first choice. In Classe II, 1 divisao associada a agenesia dos
this situation, the orthodontist mainly segundos pre-molares inferiores. J Bras Ortod
reestablishes the necessary space for the Ortop Facial 2002;7:361–369.
implant. Because the first and third 8. Angle EH. Classification of malocclusion. Dent
Cosmos 1899;248–264.
patient were treated in the early ‘90s, this
9. Tweed CH. Indications for the extraction of
treatment alternative was not considered. teeth in orthodontic procedures. Am J Orthod
At that time, space closure was the most Oral Surg 1944;30:405–428.
viable option. This option should never be 10. Gelgör IE, Karaman AI. Non-surgical treatment
overlooked as there are always patients of Class III malocclusion in adults: Two case
reports. J Orthod 2005;32:89–97.
who object to implant placement.
11. Hisano M, Soma K. Energy-based re-evaluation
When finishing with a Class III molar of Angle’s Class I molar relationship. J Oral
relationship, mandibular third molars Rehabil 1999;26:830–835.
should have erupted so that the maxillary 12. Bakke M. Bite force and occlusion. Semin
second molars have an antagonist. Also, Orthod 2006;12:120–126.
13. Janson G, de Souza JE, Alves Fde A, et al.
any present maxillary third molars should
Extreme dentoalveolar compensation in the
be extracted or splinted to the adjacent treatment of Class III malocclusion. Am J
teeth to prevent supraeruption.13,14 Orthod Dentofacial Orthop 2005;128:
787–794.
14. Lin J, Gu Y. Lower second molar extraction in
correction of severe skeletal class III malocclu-
CONCLUSION sion. Angle Orthod 2006;76:217–225.

Based upon the related literature and the


clinical examples presented here, the
establishment of a Class III molar rela-
tionship to compensate for congenitally
missing or extracted mandibular premo-
lars is viable. However, specific details

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SURGICALLY ASSISTED RAPID Susana M. Deon Rizzatto,


DDS, MSD1

MAXILLARY EXPANSION COMBINED Luciane Macedo de


Menezes, DDS, MSD,
WITH MAXILLARY PROTRACTION PhD1

IN AN ADULT: A PATIENT REPORT Marcel M. Farret, DDS,


MSD2
The aim of this article is to discuss an alternative treatment for adult Eduardo Martinelli S. de
patients who have a dental or skeletal Class III relationship. A 20-year- Lima, DDS, MSD, PhD2
old woman presented with a dental and skeletal Class III relationship
and a transverse maxillary deficiency. Surgically assisted rapid maxil- Rogério Belle, DDS, MSD,
lary expansion was followed by maxillary protraction with a face PhD3
mask and orthodontic treatment with standard edgewise technique.
At the end of treatment, a Class I molar and canine relationship was Michel A. Lanes, DDS,
attained with an adequate transverse intercuspation and improve- MSD4
ment of the patient’s facial profile. World J Orthod 2009;10:334–344.

Key words: Class III, maxillary deficiency, rapid maxillary expansion,


protraction, SARME

he treatment of a skeletal Class III this situation, a surgically assisted rapid


T relationship in a young (growing)
patient can consist of rapid maxillary
maxillary expansion (SARME) with a total
Le Fort I osteotomy is the therapy of
expansion (RME) and maxillary protrac- choice. If, at the same time, the sagittal
tion with a face mask because RME dis- skeletal and dentoalveolar relationships
ar ticulates the sutures and allows are not severe, SARME can be combined
orthopedic changes. 1–19 Because this with maxillary protraction by a face
approach is not promising in adults, mask, as one would use in a growing
1Professor, Department of Orthodon-
camouflage or orthognathic surgery are patient. Similar procedures are de-
options, depending on the severity of the scribed in the literature.3,24–26 tics, Pontifical Catholic University,
Rio Grande do Sul, Brazil.
anteroposterior discrepancy and the This case report describes a 20-year- 2Graduate PhD Student, Department
patient’s preference. old woman who sought orthodontic of Orthodontics, Pontifical Catholic
When the sagittal discrepancy between treatment at the School of Dentistry at University, Rio Grande do Sul, Brazil.
3Professor, Department of Oral and
maxilla and mandible is not severe, a sat- Pontifical Catholic University of Rio
isfactory facial profile and a correct dental Grande do Sul, Brazil. The patient’s chief Maxillofacial Surgery, Pontifical
Catholic University, Rio Grande do
relation with camouflage treatment can complaint was the unesthetic position of Sul, Brazil.
be achieved. This approach often includes her maxillary right canine and facial 4Department of Orthodontics, Pontifi-

protrusion of the maxillary and retrusion esthetics. cal Catholic University, Rio Grande
of the mandibular anterior teeth or extrac- do Sul, Brazil.
tion of mandibular premolars.20–22 If the
CORRESPONDENCE
skeletal discrepancy is severe, the only DIAGNOSIS Dr Marcel Marchiori Farret
way to achieve a proper sagittal relation- Department of Orthodontics
ship is orthognathic surgery, in addition to Facial analysis showed a mandibular Pontifícia Universidade Católica
maxillary advancement or mandibular set- deviation to the right and an increased Av. Ipiranga 6061/6/410,
Porto Alegre
back (or a combination of the two).23 lower facial third (Figs 1a to 1c). The
Rio Grande do Sul, Brazil
Many adult patients exhibiting a patient’s facial profile was concave with Email: marcelfarret@yahoo.com.br,
skeletal Class III relationship also pre- retrusive lips. Her smile was unesthetic smdr@uol.com.br (Dra Susana M.D.
sent a transverse maxillary deficiency. In due to 6.5-mm crowding in the maxillary Rizzatto)

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VOLUME 10, NUMBER 4, 2009 Rizzatto et al

a b c

d e f

Fig 1 (a to c) Initial facial photographs


showing a concave profile with retru-
sive lips, a mandibular deviation to the
right, and an increased lower facial
third. (d to h) Initial intraoral pho-
tographs showing 6.5 mm of crowding
in the maxillary and 3 mm of crowding
in the mandibular arch, a Class III molar
relationship, an edge-to-edge incisor
relationship, a maxillary transverse defi-
ciency, a posterior crossbite, an open g h
bite between the lateral incisors and the
premolars on both sides, and a devia-
tion of the maxillary midline to the right.

arch, a deviation of the maxillary midline Pretreatment panoramic radiographs


to the right, a maxillary transverse defi- revealed that the third molars were pre-
ciency, and a posterior crossbite (Figs 1d sent partially with cystic extensions of
to 1h). Crowding in the mandibular arch their pericoronal space; further, a fourth
amounted to 3 mm. Further, she had a molar was detected on the maxillary left
Class III molar relationship, an edge-to- side (Fig 2a). The respective measure-
edge incisor relationship, and an open ments for the lateral cephalogram (Fig
bite between the lateral incisors and pre- 2b) are in Table 1. On the frontal cephalo-
molars on both sides. gram, the deviation of the mandible to
the right became evident as there was an
insinuation of the maxillary transverse
deficiency (Fig 2c).

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Rizzatto et al WORLD JOURNAL OF ORTHODONTICS

Fig 2a Initial panoramic radiograph.


All third molars are present, partially
with cystic extensions of their pericoro-
nal space; further, a fourth molar is visi-
ble on the maxillary left side.

Fig 2b Initial lateral cephalogram.

Fig 2c Initial frontal cephalogram


showing a deviation of the mandible to
the right and hinting at a transverse
maxillary deficiency.

b c

TREATMENT OBJECTIVES patient had a straight to concave profile,


this option would have compromised her
The treatment objectives were to align all facial esthetics even further and was
teeth, establish a normal overbite and consequently rejected.
overjet, attain a stable occlusion, correct The second option was a slow expan-
the posterior crossbite, match the dental sion of the maxilla and interproximal
midlines to each other and the facial mid- enamel reduction (IPR) to align all teeth
line, and improve the patient’s facial and in both arches. This option was also dis-
dental appearance. regarded because of the patient’s chief
complaint of facial esthetics and the risk
of increasing the maxillary posterior teeth
TREATMENT OPTIONS recession via expansion.
Based on the patient’s concern about
Three treatment options were consid- esthetics, SARME followed by maxillary
ered. The first called for extraction of all protraction with a face mask and IPR of
second premolars with the intent of elimi- the mandibular posterior teeth, as well as
nating the crowding without much retru- protrusion of the maxillary and mandibu-
sion of the incisors, avoiding a flattening lar incisors, was the optimal option.
of the facial profile. However, as the

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VOLUME 10, NUMBER 4, 2009 Rizzatto et al

Fig 3 Extra- and intraoral views at the


beginning of treatment, starting with
leveling and aligning in the mandibular
arch followed by insertion of a Hyrax
appliance, which was cemented on the
maxillary first premolars and first
molars.

TREATMENT INITIATION the orthopedic expansion were observed


and face mask protraction was initiated.
Treatment started in the mandibular arch Elastics producing a force of 350 cN per
with IPR, leveling and aligning with a side and running at a 15-degree angle
slight protrusion of the incisors, and downward to the palatal plane were
uprighting the lingually tipped posterior applied 14 hours per day. The Hyrax appli-
teeth to allow a larger expansion of the ance was activated for 3 weeks, until
maxillary arch. Subsequently, a Hyrax there was a transverse overcorrection.
appliance was cemented to the first pre- Figure 4 depicts the patient after expan-
molars and first molars and the patient sion with an 11-mm diastema, revealing a
underwent surgery (Fig 3). After a week, considerable improvement in the volume
the Hyrax appliance was activated twice of the middle face; the respective radi-
daily. One week later, the first effects of ographs are shown in Fig 5.

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Rizzatto et al WORLD JOURNAL OF ORTHODONTICS

Fig 4 Extra- and intraoral views after


3 weeks of expansion with an 11-mm
diastema; a considerable improvement in
the volume of the middle face is visible.

Fig 5 Panoramic radiograph and lat-


eral and frontal cephalogram taken at
the same time as photographs in Fig 4.

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VOLUME 10, NUMBER 4, 2009 Rizzatto et al

a b c

d e f

Fig 6 (a to c) Extraoral view after


3.5 months of maxillary protraction,
considerably improved facial esthetics
due to the increased volume in the mid-
dle facial third, and an increased con-
vexity in facial profile. (d to h) Intraoral
view with a reduced diastema and
improved sagittal relationship between
maxilla and mandible.

g h

TREATMENT PROGRESS

After 3.5 months of maxillary protraction,


the facial esthetics had improved consid-
erably due to an increased volume in the
middle facial third and an increased con-
vexity in the facial profile (Figs 6a to 6c).
Intraorally, the diastema was reduced,
and the sagittal relation between the two
arches improved (Figs 6d to 6g).

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Rizzatto et al WORLD JOURNAL OF ORTHODONTICS

Fig 7 Extraoral and intraoral views


after 6 months of retention; a trans-
palatal arch substituted the Hyrax
expander, all maxillary teeth except the
maxillary right lateral incisor and canine
received brackets, and an open-coil
spring was placed between the central
incisor and first premolar to create
space to align the two teeth.

After 6 months of retention, a trans- there was adequate overjet and overbite.
palatal arch replaced the Hyrax expander An open-coil spring was positioned
and brackets were attached to all maxil- between the maxillary right central incisor
lary teeth (with the exception of maxillary and first premolar to create space. Soon
right lateral incisor and canine) (Fig 7). after, the lateral incisor was included into
The facial aspect was similar to the previ- the appliance, whereas the canine was
ous appearance. The molars and the left slowly drawn toward the archwire so as to
canine presented a Class I relationship avoid a gingival recession.
with a good intercuspation of most poste-
rior teeth, both midlines coincided, and

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VOLUME 10, NUMBER 4, 2009 Rizzatto et al

a b c

d e f

Fig 8 (a to c) Extraoral view at the


end of treatment. Improved profile con-
vexity is visible. (d to h) Intraoral view
at the end of treatment showing good
transverse relationship between both
arches, normal overbite and overjet, and
a Class I molar and canine relationship.

g h

RESULTS shows no root resorption but good root


parallelism (Fig 9a). The final cephalo-
At the end of treatment, the profile grams and the superimposition are
convexity was improved (Figs 8a to 8c). depicted in Figs 9b and 9c; the respec-
Intraorally, there was a good transverse tive measurements are listed in Table 1.
relationship between the arches, a nor- The frontal cephalogram reveals an ade-
mal overbite and overjet, and a Class I quate transverse relationship between
molar and canine relationship (Figs 8d to maxilla and mandible (Fig 9d).
8h). The final panoramic radiograph

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Rizzatto et al WORLD JOURNAL OF ORTHODONTICS

Fig 9 (a) Final panoramic radiograph


revealing no root resorption and good
root parallelism. (b and c) Final lateral
cephalogram and superimposition of
tracings from the initial (solid line) and
final (dotted line) cephalogram. (d) Final
frontal cephalogram revealing an ade-
quate transverse relationship between
maxilla and mandible.

b c d

Table 1 Results of cephalometric analysis before, during, and at the end


of treatment
Norm Pretreatment Postexpansion Posttreatment

SNA (degrees) 82 76 75 75
SNB (degrees) 80 76 76 75
ANB (degrees) 2 0 –1 0
SN-GoGn (degrees) 32 39 40 40
U1-NA (degrees) 22 18 22 26
U1-NA (mm) 4 7 910 9
L1-NB (degrees) 25 22 32 23
L1-NB (mm) 4 4 6 6
U1-L1 (degrees) 131 140 128 134
IMPA (degrees) 93 85 92 87
FMA (degrees) 25 29 28 27
FMIA (degrees) 62 66 60 66

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VOLUME 10, NUMBER 4, 2009 Rizzatto et al

DISCUSSION SARME and maxillary dentoalveolar pro-


traction is a viable treatment alternative.
A Class III malocclusion may be charac- This allows dissolving the existing crowd-
terized by maxillary retrognathism, pre- ing, avoiding extractions, correcting cross-
sent in about 60% of the af fected bites, and improving facial appearance.
patients; mandibular prognathism, found
in 20%; or a combination of the
two.2,4,6–9,11 In patients who have exces- CONCLUSION
sive mandibular length, the prognosis in
growing individuals is especially unfavor- In patients with a mild Class III discrep-
able because it is very difficult to foresee ancy, camouflage treatment with only
and control mandibular growth. However, maxillary osteotomy and protraction is
with maxillary retrognathism, the progno- feasible. The accomplished results are
sis in growing patients is quite favorable esthetically and functionally satisfying
because excellent stable results can be and also help to prevent extractions and
obtained with RME followed by protrac- orthognathic surgery.
tion with a face mask.2,6–9,11,12,16,27
In patients with primary or mixed den-
titions, RME promotes the disarticulation ACKNOWLEDGMENTS
of the sutures around the maxillary
region and an intensification of cellular The authors would like to thank colleagues Guil-
herme Thiesen, Janara Feldens, and Maira Massua
activity.1,6,15,19 However, in adult patients,
for their contribution in diagnosis, planning, and
suture release is no longer possible and treatment of this patient.
protraction also becomes unviable.
In such a situation, it is difficult to
determine whether camouflage is still REFERENCES
indicated or if orthognathic surgery is
preferable. The patient presented here 1. Hata S, Itoh T, Nakagawa M, et al. Biomechani-
was in this borderline range because she cal effects of maxillary protraction on the cran-
had a Class III molar/canine relationship iofacial complex. Am J Orthod Dentofacial
Orthop 1987;91:305–311.
and a concave facial profile. According to
2. Turley PK. Orthopedic correction of Class III
the Wits appraisal, she was skeletally malocclusion with palatal expansion and cus-
Class III, though the Steiner analysis indi- tom protraction headgear. J Clin Orthod
cated a Class I relationship. Most of her 1988;22:314–325.
findings spoke in favor of orthognathic 3. Roberts CA, Subtelny JD. An American Board of
surgery. On the other hand, this patient Orthodontics case report. Use of the face mask
in the treatment of maxillary skeletal retrusion.
also had a transverse maxillary defi- Am J Orthod Dentofacial Orthop 1988;93:
ciency, which required an expansion. In 388–394.
adults, such an expansion usually 4. Mermigos J, Full CA, Andreasen G. Protraction
requires a total Le Fort I osteotomy by of the maxillofacial complex. Am J Orthod
which the entire maxilla is released to Dentofacial Orthop 1990;98:47–55.
5. Popp TW, Gooris CGM, Schur JA. Nonsurgical
make protraction with a face mask possi- treatment for a Class III dental relationship: A
ble. However, in this patient, an antero- case report. Am J Orthod Dentofacial Orthop
posterior change of the maxillary region 1993;103:203–211.
was not evident. The esthetic improve- 6. Ngan P, Hägg U, Yiu C, Merwim D, Wei S. Soft
ment of the profile had to be attributed to tissue and dentoskeletal profile changes asso-
ciated with maxillary expansion and protraction
the protrusion and extrusion of the maxil- headgear treatment. Am J Orthod Dentofacial
lary anterior teeth as to a general protrac- Orthop 1996;109:38–49.
tion of the maxillary dentition. A long 7. Shanker S, Ngan P, Wade D, et al. Cephalomet-
period of retention was necessary to ric A point changes during and after maxillary
protraction and expansion. Am J Orthod Dento-
avoid relapse.
facial Orthop 1996;110;423–430.
The results obtained in this individual
prove that in situations with minor dental
and skeletal discrepancies but transverse
and anteroposterior maxillary deficiencies,

343

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334_Rizzatto.qxd 11/6/09 2:36 PM Page 344

Rizzatto et al WORLD JOURNAL OF ORTHODONTICS

8. Williams MD, Sarver DM, Sadowsky PL, Bradley 17. Keles A, Tokmak EÇ, Erverdi N, Nanda R. Effect
E. Combined rapid maxillary expansion and of varying the force direction on maxillary
protraction facemask in the treatment of Class orthopedic protraction. Angle Orthod
III maloclusions in growing children: A prospec- 2002;72:387–396.
tive long-term study. Semin Orthod 1997; 18. Ngan P. Biomechanics of maxillary expansion
3:265–274. and protraction in Class III patients. Am J
9. Ngan P, Hägg U, Yiu C, Wei SHY. Treatment Orthod Dentofacial Orthop 2002;121:
response and long-term dentofacial adapta- 582–583.
tions to maxillary expansion and protraction. 19. Cha KS. Skeletal changes of maxillary protraction
Semin Orthod 1997;3:255–264. in patients exhibiting skeletal Class III maloclu-
10. Merwin D, Ngan P, Hägg D, Yiu C, Wei SHY. Tim- sion: A comparison of three skeletal maturation
ing for effective application of anteriorly groups. Angle Orthod 2003;73:26–35.
directed orthopedic force to the maxilla. Am J 20. Costa Pinho TM, Ustrell Torrent JM, Correia
Orthod Dentofacial Orthop 1997;112:292–299. Pinto JGR. Orthodontic camouflage in the case
11. Pangrazio-Kulbersh V, Berger J, Kersten G. of a skeletal Class III maloclusion. World J
Effects of protraction mechanics on the mid- Orthod 2004;5:213–223.
face. Am J Orthod Dentofacial Orthop 1998; 21. Proffit WR, White RP. Surgical-Orthodontic
114:484–491. Treatment. St Louis: Mosby, 1991.
12. Ngan P. Yiu C, Hu A, Hägg U, Wei SHY, Gunel E. 22. Litton SF, Ackermann LV, Isaacson RJ, Shapiro
Cephalometric and occlusal changes following BL. A genetic study of Class 3 malocclusion.
maxillary expansion and protraction. Eur J Am J Orthod 1970;58:565–577.
Orthod 1998;20:237–254. 23. Gelgör IE, Karaman AI. Non-surgical treatment
13. da Silva Filho OG, Magro AC, Capelozza Filho L. of Class III maloclusion in adults: Two case
Early treatment of the Class III malocclusion reports. J Orthod 2005;32:89–97.
with rapid maxillary expansion and maxillary 24. Ahn JG, Figueroa AA, Braun S, Polley JW. Biome-
protraction. Am J Orthod Dentofacial Orthop chanical considerations in distraction of the
1998;113:196–203. osteotomized dentomaxillary complex. Am J
14. Suda N, Ishii-Suzuki M, Hirose K, Hiyama S, Orthod Dentofacial Orthop 1999;116:264–270.
Suzuki S, Kuroda T. Effective treatment plan for 25. Figureroa AA, Polley JW. Management of severe
maxillary protraction: Is the bone age useful to cleft maxillary deficiency with distraction osteo-
determine the treatment plan? Am J Orthod genesis: Procedure and results. Am J Orthod
Dentofacial Orthop 2000;118:55–62. Dentofacial Orthop 1999;115:1–12.
15. Saadia M, Torres E. Sagittal changes after max- 26. Polley JW, Figueroa AA. Management of severe
illary protraction with expansion in Class III maxillary deficiency in childhood and adoles-
patients in the primary, mixed, and late mixed cence through distraction osteogenesis with an
dentitions: A longitudinal retrospective study. external, adjustable, rigid external distraction. J
Am J Orthod Dentofacial Orthop 2000;117: Craniofac Surg 1997;8:181–185.
669–680. 27. Franchi L, Baccetti T, McNamara JA. Postpuber-
16. Ngan P, Yiu C. Evaluation of treatment and tal assessment of treatment timing for maxil-
posttreatment changes of protraction face- lary expansion and protraction therapy followed
mask treatment using the PAR index. Am J by fixed appliances. Am J Orthod Dentofacial
Orthod Dentofacial Orthop 2000;118: Orthop 2004;126:555–568.
414–420.

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Rhita C. Almeida, MsD1


ORTHODONTIC MANAGEMENT
Felipe A.R. Carvalho,
MsD1 OF A PATIENT WITH IMPACTED AND
Marco A.O. Almeida, TRANSPOSED MANDIBULAR CANINES
PhD2
This patient report describes the treatment of a 10-year-old female
Jonas Capelli Júnior, PhD2
with complete transposition of her impacted mandibular canines and
lateral incisors. The patient had a Class I occlusion, and her mandibu-
lar lateral incisors were in crossbite with the maxillary central
incisors. The treatment objectives were to create space for the
impacted canines and align them with the incisors, one of which was
extracted. After treatment, the appearance of the patient’s teeth was
improved, the occlusion was preserved, and overjet and overbite
were corrected. World J Orthod 2009;10:345–349.

Key words: ectopic eruption, impacted mandibular canines, impaction,


transposed mandibular canines

n ectopic position of a (permanent) canines were absent and her mandibu-


A tooth bud can lead to ectopic erup-
tion. It occurs most often in the maxillary
lar right primary second molar was still
present.
first molars and mandibular incisors.1,2 The panoramic radiograph revealed a
Ectopic eruption of mandibular lateral complete transposition of the mandibu-
incisors may lead to transposition of lar lateral incisors and impacted
them and the canines. Due to an incor- canines. The cephalogram showed a
rect path of eruption or lack of space, skeletal Class II (ANB = 5 degrees) with
eruption of the canines is frequently im- protruded mandibular incisors and a
peded, oftentimes resulting in impaction. convex profile (Fig 2).
Even when there is adequate space, The treatment objectives were to
canines can erupt ectopically and improve the patient’s dental appearance
become transposed with a premolar or by creating space for the mandibular
lateral incisor.3 canines and aligning them with the
This article describes the treatment incisors.
of a young patient who had impacted
mandibular canines that transposed
1PhD Student, Department of Ortho- with her lateral incisors. Treatment progress
dontics, State University of Rio de
Janeiro, Rio de Janeiro, Brazil. The 0.022 ⫻ 0.028-inch Roth prescrip-
2Professor, Department of Orthodon-
DIAGNOSIS AND tion brackets were bonded, and a lingual
tics, State University of Rio de
Janeiro, Rio de Janeiro, Brazil.
TREATMENT PLAN arch appliance was inser ted in the
mandibular arch to maintain enough
CORRESPONDENCE A 10-year-old female presented with a space to correct the rotation of the left
Dr Rhita Almeida convex profile but good facial proportions. second premolar and allow the eruption
Av. das Américas
Clinical examination showed a Class I of the right second premolar. After this
3434 bl.5 sala 223. Barra da Tijuca
Rio de Janeiro, RJ Brasil occlusion with a crossbite of her man- tooth (which was peg-shaped) had
Cep. 22640-102 dibular lateral incisors with the maxillary erupted, the lingual arch appliance was
Email: rhita.almeida@gmail.com central incisors (Fig 1). Her mandibular removed. The treatment plan for the

345

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Almeida et al WORLD JOURNAL OF ORTHODONTICS

a b c

d e f

Fig 1 (a to c) A 10-year-old girl prior to


treatment exhibiting a convex profile
but good facial proportions; (d to f)
mesially tipped mandibular incisors; (g)
relatively well-aligned maxillary arch; (h)
and missing mandibular canines,
retained mandibular right primary sec-
ond molar, and rotated mandibular left
second premolar.

g h

maxillary arch foresaw conventional level- space proper alignment. Because the
ing and alignment of all teeth. In the patient’s mandibular incisors were
mandibular arch, a 0.016-inch stainless already protruded, the left lateral incisor
steel archwire with a coil spring between was extracted. The lingual arch appliance
the lateral incisors was used to move was preventing the canines’ eruption, so
these two teeth distally, thus making it was removed, as well. With adequate
space for the canines (Fig 3). space, both canines erupted sponta-
When the right canine started to erupt neously. Nickel-titanium and stainless
in the lateral incisor position, it became steel archwires were used to align these
apparent that there was insufficient two teeth (Fig 4).

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VOLUME 10, NUMBER 4, 2009 Almeida et al

a b
Fig 2 (a) Panoramic radiograph revealing a complete transposition of the impacted canines and mandibular lateral incisors.
(b) Cephalogram before treatment showing a skeletal Class II with protruded mandibular incisors and a convex profile.

a a
Fig 3 Occlusal view of the mandibular Fig 4 (a and b) Occlusal view of both arches toward the completion of treatment;
arch with inserted lingual arch appliance (b) with the canines aligned.
for space preservation and distal move-
ment of lateral incisors with an open
coil spring.

In the maxillary arch, some interproxi- preserved. In spite of the uniarch extrac-
mal enamel reduction was performed to tion, treatment concluded with a correct
solve the Bolton discrepancy created by overjet and overbite; the maxillary mid-
the extraction of the mandibular left lat- line coincided with the middle of the
eral incisor. mandibular right central incisor (Fig 5).
The patient’s oral hygiene was unfortu-
nately very poor, and multiple demineral-
Treatment outcome izations had established. Radiographs
taken at the end of treatment revealed
The patient’s dental appearance was that the roots were parallel, especially in
improved, and the molar relationship was the mandibular anterior area (Fig 6).

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Almeida et al WORLD JOURNAL OF ORTHODONTICS

a b c

d e f

Fig 5 Patient at the completion of


treatment (a to c) with improved dental
appearance; (d to f) preserved molar
relationship, correct overjet and over-
bite, maxillary midline coinciding with
the middle of the mandibular right cen-
tral incisor; (g) well-aligned teeth in the
maxillary arch; and (h) tooth sequence
in the mandibular arch is left canine, left
central incisor, right central incisor, right
g h canine, and right lateral incisor. Multiple
demineralizations due to insufficient
oral hygiene are visible throughout.

a b
Fig 6 (a) Panoramic radiograph revealing good root parallelism, especially in the mandibular anterior area. (b) Cephalogram
showing an almost identical situation as that at the beginning of therapy.

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VOLUME 10, NUMBER 4, 2009 Almeida et al

DISCUSSION REFERENCES

In situations of tooth transpositions, treat- 1. Bjerklin K, Kurol J. Ectopic eruption of the max-
illary first permanent molar: Etiologic factors.
ment options include extractions, align-
Am J Orthod 1983;84:147–155.
ment in the transposed position,4–7 or 2. Shapira Y, Kuftinec MM. The ectopically
orthodontic relocation. 5,8–10 When the erupted mandibular lateral incisor. Am J Orthod
respective teeth are aligned in their trans- 1982;82:426–429.
posed position, they should be recon- 3. Proffit W, Fields HW Jr. Contemporary Ortho-
dontics, ed 2. St Louis: Mosby, 1993:113.
toured with composite.4,5 It is often said
4. Shapira Y, Kuftinec MM. Orthodontic manage-
that moving transposed teeth into their ment of mandibular canine-incisor transposi-
normal position provides a more esthetic tion. Am J Orthod 1983;83:271–276.
result. However, this does not always prove 5. Shapira Y, Kuftinec MM, Storm D. Maxillary ca-
possible or true. Treatment planning must nine-lateral incisor transposition—Orthodontic
management. Am J Orthod Dentofacial Orthop
include an assessment of the root apex
1989;95:439–444.
position, the amount of available bone at 6. Kreia TB, Tanaka O. Transposição dentária. Rev
the relocation site,11 esthetics, periodontal Dent Press Ortod Ortop Facial 2004;9:129–136.
support,12 the anticipated occlusion, and 7. Peck S, Peck L. Classification of maxillary tooth
the patient’s expected cooperation during transpositions. Am J Orthod Dentofacial Orthop
a prolonged treatment.5,8,9 1995;107:505–517.
8. Shapira Y, Kuftinec MM. A unique treatment
In the mandible, a transposition would approach for maxillary canine-lateral incisor
require moving the canine around the lat- transposition. Am J Orthod Dentofacial Orthop
eral incisor, which would lead to bone loss 2001;119:540–545.
and gingival recession. For the sake of 9. Schott K, Capelli J Jr. Transposição de canino
esthetics and safety, it was decided to superior com incisivo lateral: Relato de caso e
revisão da literatura. Rev Bras Odont 1997;
leave the canine in its transposed position 54:359–361.
in this patient. 10. Mucha JN. Transposição de canino e primeiro
pré-molar com ausência congênita de incisivos
laterais superiores- conduta ortodôntica. Rev
CONCLUSION Soc Bras Ortod 1989;1:54–61.
11. Parker WS. Transposed premolars, canines,
and lateral incisors. Am J Orthod Dentofacial
This case report shows that a satisfactory Orthop 1990;97:431–448.
result can be obtained by maintaining 12. Sato K, Yokozeki M, Takagi T, Moriyama K. An
the transposition and that correction, orthodontic case of transposition of the upper
even when possible, is not always advis- right canine and first premolar. Angle Orthod
2002;72:275–278.
able from a cost-benefit viewpoint.

349

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TREATMENT OF A PERIODONTALLY Eduardo Yugo Suzuki,


DDS, PhD1

COMPROMISED PATIENT WITH Boonsiva Suzuki, DDS,


PhD2
MINI-IMPLANT ANCHORAGE
Background: Advanced periodontal disease and its sequelae are char-
acterized by severe attachment loss, tooth mobility, and migration.
This pathology often leads to compromised function and esthetics. A
multidisciplinary approach combining orthodontic, periodontic, and
restorative treatment is necessary to provide complete rehabilitation
both in terms of function and esthetics with a satisfactory long-term
prognosis. Methods: A simple and effective treatment of an adult
patient with periodontally migrated teeth using mini-implants in the
maxilla and mandible is described. Mini-implant placement was
aided by a 3D surgical guide, which made the procedure exceedingly
safe. Results: Gradual intrusion of the maxillary and mandibular
anterior teeth was achieved with a relatively simple orthodontic force
system. A significant profile improvement was observed during the
18 months of treatment due to the retraction and intrusion of the
incisors in both arches. This intrusion was accomplished without any
sign of apical root resorption. The mandibular incisors were uprighted
6.5 degrees, and their maxillary counterparts were uprighted 13.4
degrees. The 2-year follow-up examination revealed a stable result
with an increase in periodontal attachment as well as esthetics and
function. Conclusion: A combined orthodontic, periodontic, and
restorative treatment approach with adequate patient motivation can
lead to improved masticatory function, esthetics, and periodontal
conditions. World J Orthod 2009;10:350–360.

Key words: mini-implant anchorage, periodontally compromised patient,


adult orthodontics

dvanced periodontal disease and its inflammation is controlled and the peri-
A sequelae are characterized by severe
attachment loss, reduction of alveolar
odontium is healthy.8,9 To obtain a signif-
icant intrusion, either J-hook headgear
1Lecturer, Department of Orthodon-
tics, Faculty of Dentistry, Chiang Mai
University, Chiang Mai, Thailand.
bone, marginal gingival recession, or intrusion wires are necessary. How- 2Associate Professor, Department of

increased tooth mobility, and tooth ever, J-hook headgear is not an esthetic Orthodontics, Faculty of Dentistry,
migration. 1,2 This condition will often appliance and requires patient compli- Chiang Mai University, Chiang Mai,
lead to compromised function and ance; intrusion wire mechanics will often Thailand.
esthetics.3 A combined orthodontic, peri- lead to a reactive extrusion, as well.10 CORRESPONDENCE
odontic, and restorative treatment Recently, mini-implants have become Dr Boonsiva Suzuki
approach can completely rehabilitate an important in obtaining absolute ortho- Department of Orthodontics, Faculty
affected patient both in terms of func- dontic anchorage.11–17 Mini-implants are of Dentistry, Chiang Mai University
Suthep Road
tion and esthetics with a satisfactory relatively inexpensive, easy to handle,
Amphur Muang
long-term prognosis.4–7 and permit immediate loading.14–17 Ini- Chiang Mai 50200
Periodontally migrated teeth can be tially, they were used to treat patients Thailand
orthodontically realigned after existing who were unwilling to wear extraoral Email: boonsiva@chiangmai.ac.th

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VOLUME 10, NUMBER 4, 2009 Suzuki/Suzuki

Fig 1 Pretreatment facial and intraoral


photographs of a 42-year-old female
Class I patient with bimaxillary protru-
sion.

anchorage. Because these implants are Thailand. She presented with a severely
small in diameter, they can be implanted periodontally compromised dentition and
between the roots of adjacent teeth, pathologic migration of her anterior teeth.
which makes the force system relatively This resulted in a severe diastema of her
simple.18,19 maxillary and mandibular anterior teeth.
This article describes a simple and Her chief complaint was the unfavorable
effective approach to manage periodon- appearance of her teeth, caused by their
tally migrated teeth using orthodontic excessive extrusion. This led to a lack of
mini-implants. self-confidence and a fear of smiling and
talking to friends (Fig 1).
Initially, the patient was treated peri-
PATIENT REPORT odontally at the University Hospital. This
included instruction in oral hygiene and a
A 42-year-old woman was referred for 6-month recall for professional scaling,
treatment to the orthodontic clinic of the root planing, and curettage. After the
Faculty of Dentistry, Chiang Mai University, inflammation was adequately controlled

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Suzuki/Suzuki WORLD JOURNAL OF ORTHODONTICS

Fig 2 Initial panoramic and periapical


radiographs and intraoral view of the
incisor relationship.

and the periodontal tissue had recov- the patient’s masticatory function was
ered, the patient was referred to the also compromised.
orthodontic clinic for complementary Radiographic examination demon-
treatment. strated significant bone loss of the maxil-
Pretreatment facial photographs lary and mandibular anterior area (Fig 2).
showed a symmetric face with mild Cephalometric analysis showed that the
bimaxillary protrusion. Intraorally, the maxilla and mandible were normally posi-
diastema in the maxillary and mandibu- tioned relative to Thai standards (Fig 3).
lar anterior regions were most prominent. However, all incisors were protruded; the
Clinical examination revealed severe ver- overjet and overbite were 6.5 mm and
tical bone loss in the anterior dentoalveo- 4.0 mm, respectively.
lar areas of both arches, which was
accompanied by excessive dental extru-
sion. All teeth were severely mobile, but
pocket-probing depths were not greater
than 3 mm. Because of the mobile teeth,

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VOLUME 10, NUMBER 4, 2009 Suzuki/Suzuki

Fig 3 Lateral cephalometric analysis. (a) Pre- and


(b) posttreatment cephalometric values relative to Mean SD a b
adult Thai female standards. Facial angle 89.1 2.7 86.4 85.9
Convexity 8.8 4.1 6.5 6.5
A-B plane –4.2 2.3 –9.5 –7.1
Mandibular plane 22.0 4.6 30.2 28.0
Y-axis 63.2 9.5 64.0 64.5

Occlusal plane 6.8 3.6 13.2 9.2


Interincisal angle 121.3 7.1 95.5 122.3
LI to OP 29.7 7.9 42.1 28.2
LI to MP 96.8 5.1 99.6 93.1
UI to A-P plane 3.0 0.7 6.5 3.3
FMIA 61.2 4.5 50.2 58.8
FH to SN 7.7 2.1 9.5 9.6

SNA 85.0 3.5 83.1 82.6


SNB 81.2 2.8 78.4 78.9
ANB 3.8 1.8 4.7 3.6
UI to N-P plane 9.7 2.7 15.8 10.1

UI to FH 116.9 5.3 127.4 114.1


UI to SN 109.2 5.4 117.9 104.5

Gonial angle 114.6 5.0 119.6 117.8


Ramus inclination 6.0 3.8 1.6 2.1

TREATMENT PLAN alveolar bone between the maxillary and


mandibular central incisors. This was
The treatment plan was to realign aided by a 3D surgical guide (Y&B Prod-
(intrude) the migrated teeth using light ucts)19 to avoid root damage to the adja-
continuous orthodontic forces. Mini- cent teeth (Fig 4). The extruded teeth
implants were inserted in the maxilla and were intruded with elastomeric ligatures
mandible to provide absolute anchorage (50 cN), which ran between the mini-
for this intrusion. Intensive control of the implants and the incisors (Fig 5). At the
patient’s oral hygiene and a strict peri- same time, the maxillary anterior teeth
odontal care regimen were planned were retracted with Ni-Ti coil springs,
throughout orthodontic treatment. For which again delivered a force of 50 cN.
retention, an intracoronal splint connect- Following the original plan, the teeth
ing all maxillary incisors was planned. were stabilized for 3 months after treat-
ment with an intracoronal splint to allow a
preliminary remodeling of the underlying
TREATMENT PROGRESS bone.

Orthodontic treatment was performed


with a 0.018 ⫻ 0.025-inch preadjusted IMPLANT PROCEDURE
appliance. Leveling was initiated with
0.016-inch Sentalloy archwires for 2 The 3D surgical guide was connected to
months, followed by a 0.016 ⫻ 0.022- the orthodontic wire and positioned as
inch improved superelastic nickel-titanium accurately as possible at the preselected
(L&H Titan) archwire. After 3 months, mini-implant site (Fig 4). A periapical radi-
mini-implants (diameter 1.6 mm, length ograph of this area was taken with the
8.0 mm) were inserted into the buccal long-cone paralleling technique aided by

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Suzuki/Suzuki WORLD JOURNAL OF ORTHODONTICS

Fig 4 Mini-implants inserted into the


buccal alveolar bone with the aid of a
3D surgical guide.

Fig 5 Elastomeric ligatures between the mini-implants and anterior incisors.

a film holder (Rinn XCP film holding sys- implant placement procedure. The long-
tem, Dentsply).15,16 During exposure, the cone technique reduced the distortion
patient bit into a bite registration made and standardized the film–x-ray tube dis-
from conventional elastomeric impres- tance (Fig 6). 15,16 Radiographs were
sion material. Thus, a standardized taken until a possible implant position
series of radiographs of the implant site was found that would not violate the
could be obtained throughout the neighboring tooth roots.

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VOLUME 10, NUMBER 4, 2009 Suzuki/Suzuki

Fig 6 Film holder used to


ensure precise mapping of the
optimum implant site.

Minor adjustments of the position of RESULTS


the 3D surgical guide allow varying the
recommended implant angulation to the Significant profile improvement was
long axes of the teeth. These angulation observed during the first 6 months of treat-
changes produce an increased surface ment. After 18 months, the patient showed
contact between the implant and the an acceptable occlusion with a Class I
bone.17,20,21 molar relationship (Fig 7). Although the
After the optimum implant position maxillary and mandibular incisors were
was determined, a pilot hole was pre- retracted and intruded, there was no sign of
pared with a manual drill under normal apical root resorption. The ANB angle was
saline irrigation to avoid excessive heat reduced from 4.7 degrees to 3.6 degrees.
and remove bone debris (see Fig 4). The proclined incisors were uprighted by
The mini-implant was inserted into the 6.5 degrees and 13.4 degrees in the man-
pilot hole through the 3D surgical guide dible and maxilla, respectively. Cephalomet-
tube with a manual screwdriver to reduce ric superimposition demonstrated a bodily
the risk of a deviation during insertion retraction of the maxillary anterior teeth
and to assure the precise 3D placement with an intrusion of the incisors in both
into the preoperatively planned position. arches. The maxillary posterior teeth were
After insertion, an additional radiograph uprighted, but no other significant move-
with the custom-made film holder was ment was observed. The mandibular
taken to confirm the proper position. molars moved slightly mesially (Fig 8).

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Fig 7 The patient’s profile was signifi-


cantly improved after 18 months of
active treatment with retraction and
intrusion of the maxillary and mandibu-
lar incisors.

Fig 8 Superimposition of
cephalometric tracings
(black) before and (red)
after treatment showing
controlled bodily retraction
of maxillary anterior teeth
without anchorage loss.

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VOLUME 10, NUMBER 4, 2009 Suzuki/Suzuki

Fig 9 Final panoramic and periapical


radiographs reveal gain of periodontal
attachment. Frontal view and incisor
relationship show good tooth alignment.

Fig 10 An intracoronal splint connects


all maxillary incisors to avoid relapse
and to improve esthetics.

General radiographic examination re- Following active orthodontic treatment,


vealed an increase of periodontal attach- instead of the orignally planned bridge, an
ment and bony support of the maxillary intracoronal splint for the four maxillary
and mandibular anterior teeth (Fig 9). incisors was inserted to prevent relapse
and improve esthetics and function (Fig 10).

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Fig 11 Two-year follow-up pho-


tographs showing a successful esthetic
and functional result.

A 2-year follow -up examination and a disfiguring migration of her incisors


revealed no current tooth migration, that resulted in severe diastemata in both
more gain of periodontal attachment, dental arches. To provide complete re-
and good esthetics and function (Fig 11). habilitation in terms of both esthetics and
function with a satisfactory long-term
prognosis, a multidisciplinary approach
DISCUSSION combining or thodontic-periodontic-
restorative was essential.4–7
Periodontal disease and its sequelae, This treatment involved initial peri-
such as pathologic tooth migration, odontal intervention to control the inflam-
diastema, and gingival recessions, often mation of the periodontium, followed by
lead to compromised function and orthodontic treatment to realign and
esthetics.1–8 intrude the migrated teeth. Thus, all
This article describes the treatment of a diastemas were closed, and an appropri-
patient with a severe periodontal disease ate occlusal relationship re-established.

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VOLUME 10, NUMBER 4, 2009 Suzuki/Suzuki

Several techniques have been out that prior to orthodontic treatment,


described how to intrude periodontally the gingival inflammation must be elimi-
migrated teeth.1–8 These include the use nated, which includes adequate scaling of
of extra- and intraoral devices, such as the root surfaces.
J-hook headgear or specific archwire The radiographic images suggest a
mechanics. However, these are not with- reconstruction of the periodontal liga-
out limitations. Although J-hook headgear ment space. This is in accordance with
can provide an intrusive force to the den- Melsen et al9 who found in monkeys with
tition, it is not esthetically well-accepted controlled oral hygiene formation of new
and requires patient compliance. This cementum and new collagen attachment
could become a problem, especially for after periodontal treatment and orthodon-
adult patients. On the other hand, the tic intrusion.
use of intraoral archwire mechanics to
obtain true intrusion is again not without
any problems. To obtain a true intrusion CONCLUSION
of the incisors, an archwire with an
accentuated curve of Spee in the maxilla With a multidisciplinary approach, com-
and a reversed one in the mandible is bining orthodontic, periodontic, and
combined with intermaxillary elastics to restorative treatment together with ade-
prevent an undesirable labial tipping. quate patient motivation and cooperation,
However, these elastics may cause again masticatory function, esthetics, and the
an extrusion of the incisors. Moreover, condition of the periodontium can be
such mechanics will likely extrude the improved.
posterior teeth.10
Mini-implants are employed to treat
complex malocclusions, in which conven- ACKNOWLEDGMENTS
tional anchorage would not be sufficient
to obtain satisfactory results.22–24 The authors acknowledge the assistance of Dr M.
Kevin O’Carroll, professor emeritus of the University
In this patient, a relatively simple force
of Mississippi School of Dentistry and faculty con-
system was used to deliver light and con- sultant at Chiang Mai University Faculty of Den-
tinuous intrusive forces to the anterior tistry, in the preparation of the manuscript. Part of
teeth. Because skeletal anchorage was this study was supported by grant MRG5080347
used, undesirable dental effects were from Thailand Research Funding.
avoided. Instead, the light and continu-
ous forces delivered by the springs and
wires stimulated the formation of new REFERENCES
bone attachment.
Previous reports have demonstrated 1. Rabie AM, Gildenhuys R, Boisson M. Manage-
ment of patients with severe bone loss: Bone
that with adequate plaque control, teeth induction and orthodontics. World J Orthod
with reduced periodontal support can be 2001;2:142–153.
successfully moved without compromis- 2. Ong MMA, Wang HL. Periodontic and orthodon-
ing their periodontal condition.1–8 In the tic treatment in adults. Am J Orthod Dentofacial
present patient, the initial periodontal Orthop 2002;122:420–428.
3. Melsen B, Agerbaek N, Markenstam G. Intru-
status was improved by scaling and root sion of incisors in adult patients with marginal
planing. The obtained result including the bone loss. Am J Orthod Dentofacial Orthop
use of the mini-implants was similar to 1989;96:232–241.
that presented by Melsen et al. 8 How- 4. Feng X, Oba T, Oba Y, Moriyama K. An interdis-
ever, Melsen et al needed complex ortho- ciplinary approach for improved functional and
esthetic results in a periodontally compromised
dontic mechanics to obtain an adequate adult patient. Angle Orthod 2005;75:
intrusion of the migrated teeth. 1061–1070.
According to Melsen et al8 the gradual 5. Claman L, Alfaro MA, Mercado A. An interdisci-
intrusion of periodontally involved teeth in plinary approach for improved esthetic results
adults with marginal bone loss is benefi- in the anterior maxilla. J Prosthet Dent 2003;
89:1–5.
cial because new attachment is gener-
ated. However, these authors also pointed

359

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350_Suzuki.qxd 11/6/09 2:39 PM Page 360

Suzuki/Suzuki WORLD JOURNAL OF ORTHODONTICS

6. Cirelli JA, Cirelli CC, Holzhausen M, Martins LP, 15. Suzuki EY, Suzuki B. Accuracy of miniscrew
Brandao CH. Combined periodontal, orthodon- implant placement with a 3-D surgical guide.
tic, and restorative treatment of pathologic J Oral Maxillofac Surg 2009;67:2245–2253.
migration of anterior teeth: A case report. Int J 16. Biggerstaff RH, Phillips JR. A quantitative com-
Periodontics Restorative Dent 2006;26: parison of paralleling long-cone and bisection-
501–506. of-angle periapical radiography. Oral Surg Oral
7. Re S, Corrente G, Abundo R, Cardaropoli D. The Med Oral Pathol 1976;62:673–677.
use of orthodontic intrusive movement to 17. Lin JC, Liou EJ. A new bone screw for orthodon-
reduce infrabony pockets in adult periodontal tic anchorage. J Clin Orthod 2003;37:676–681.
patients: A case report. Int J Periodontics 18. Carano A, Velo S, Leone P, Siciliani G. Clinical
Restorative Dent 2002;22:365–371. applications of the Miniscrew Anchorage Sys-
8. Melsen B, Agerbaek N, Eriksen J, Terp S. New tem. J Clin Orthod 2005;39:9–24.
attachment through periodontal treatment and 19. Suzuki EY, Suzuki B. Adjustable traction hooks
orthodontic intrusion. Am J Orthod Dentofacial for anterior torque control with miniscrew
Orthop 1988;94:104–116. anchorage. J Clin Orthod 2007;41:14–19.
9. Melsen B. Tissue reaction following application 20. Suzuki EY, Buranastidporn B. An adjustable
of extrusive and intrusive forces to teeth in adult surgical guide for miniscrew placement. J Clin
monkeys. Am J Orthod 1986;89:469–475. Orthod 2005;39:588–590.
10. Creekmore TD, Eklund MK. The possibility of 21. Weiland FJ, Bantleon H, Droschl H. Evaluation
skeletal anchorage. J Clin Orthod 1983;17: of continuous arch and segmented arch level-
266–269. ing techniques in adult patients—A clinical
11. Kanomi R. Mini-implant for orthodontic anchor- study. Am J Orthod Dentofacial Orthop 1996;
age. J Clin Orthod 1997;31:763–767. 110:647–652.
12. Costa A, Raffainl M, Melsen B. Miniscrews as 22. Paik CH, Woo YJ, Boyd RL. Treatment of an
orthodontic anchorage: A preliminary report. adult patient with vertical maxillary excess
Int J Adult Orthodon Orthognath Surg 1998;13: using miniscrew fixation. J Clin Orthod 2003;
201–209. 37:423–428.
13. Bae SM, Park HS, Kyung HM, Kwon OW, Sung 23. Park HS, Kwon OW, Sung JH. Micro-implant
JH. Clinical application of micro-implant anchor- anchorage for forced eruption of impacted
age. J Clin Orthod 2002;36:298–302. canines. J Clin Orthod 2004;38:297–302.
14. Kyung HM, Park HS, Bae SM, Sung JH, Kim IB. 24. Park HS, Bae SM, Kyung HM, Sung JH. Micro-
Development of orthodontic micro-implants for implant anchorage for treatment of skeletal
intraoral anchorage. J Clin Orthod 2003;37: Class I bialveolar protrusion. J Clin Orthod
321–328. 2001;35:417–422.

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361_Siqueira.qxd 11/10/09 4:15 PM Page 361

Danilo Furquim Siqueira,


PhD, MSc1 THE IMPORTANCE OF THE FACIAL
Marinês Vieira da Silva PROFILE IN ORTHODONTIC DIAGNOSIS
Sousa, MSC2

Paulo Eduardo Guedes


AND TREATMENT PLANNING:
Carvalho, PhD, MSc1 A PATIENT REPORT
Karyna Martins do Valle-
Corotti, PhD, MSc1 Orthodontic treatment to improve not only tooth alignment but also
facial esthetics is a given in modern society. This paper illustrates this
assumption with a report of a patient with a Class I, maxillary retrusion,
concave profile, and retrusion of the upper and lower lips. Maxillary
expansion was followed by face mask therapy and orthodontic treat-
ment, which significantly improved the soft tissue profile by projecting
the upper lip. World J Orthod 2009;10:361–370.

Key words: esthetics, diagnosis, orthodontic profile, lips

he concept of facial beauty and har- analyses. Subsequently, numerous angu-


T mony has changed over the cen-
turies. Facial beauty can be defined as
lar and linear measurements with
respective norm values were presented.
harmony and balance among facial pro- With Ricketts’ esthetic plane,10 the
portions, established by skeletal struc- position of the lower lip in relation to line
tures, teeth, and soft tissue. 1,2 The E (soft tissue pogonion—nose tip) is eval-
desire to improve one’s dentofacial uated. Ideally, the upper and lower lips
esthetics is one of the main reasons should be positioned about 2.0 mm
patients seek orthodontic treatment.3 behind the E line. Steiner11 suggested to
Changes in the soft tissue profile are use line S (a tangent from soft tissue
closely related to dental and skeletal chin to S = intersection of nasal col-
changes, caused by either orthodontic umella and upper lip). If the lips touch
treatment or growth.4 the S line, the profile is straight. It is con-
In 1907, Angle emphasized the impor- vex if the lips are positioned in front of
tance of soft tissues and facial esthetics this line and concave if positioned
in orthodontics. He believed that, to a behind. In 1967, Burstone12 suggested a
1Associate Professor, Department of
great extent, facial harmony and balance line through subnasale and soft tissue
Orthodontics, University of São depend on the shape and beauty of the pogonion to verify the ideal position of
Paulo City (UNICID), São Paulo, mouth.5 Therefore, the main goal of any the upper and lower lips in thranteropos-
Brazil. orthodontic treatment had to be a per- terior direction. On average, the upper
2Graduate Student, Postgraduate
fect dental relationship. 6 In 1924, lip should be 3.5 ± 1.4 mm in front of
Dentistry, Area of Concentration in
Carrea7 conducted the first investigation this line, whereas the lower lip should be
Orthodontics, Methodist University,
São Paulo, Brazil. on facial profile on radiographs; in 1944, 2.2 ± 1.6 mm behind it. In 1983, Hold-
Tweed emphasized that ideal positioning away13 defined line H, which connects
CORRESPONDENCE of the mandibular incisors is imperative the upper lip and soft tissue pogonion
Dr Danilo Furquim Siqueira
for facial balance and harmony. Ortho- (Ls-Pg). Line H and line NB determine
Rua Costa Aguiar, 875, apto 111
CEP: 04204-000 dontists such as as Downs8 and Hold- the angle H, which according to Hold-
Ipiranga, São Paulo, SP, Brazil away9 included soft tissue profile mea- away, should ideally range between 7.0
Email: danilofurquim@uol.com.br surements in their cephalometric degrees and 15.0 degrees.

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Fig 1 Initial frontal and lateral facial


views showing maxillary retrusion, a
slightly concave profile, obtuse
nasolabial angle, and some facial asym-
metry.

Another important factor for facial face should routinely be considered. In


analysis is the nasolabial angle, which is view of the importance of facial evalua-
formed by Sn-Co (columella) and Sn-Ls tion at the onset of orthodontic/orthope-
(upper lip).14,15 This angle was suggested dic therapy, the following patient report
by Scheideman et al16 in 1980. According will demonstrate that the profile improve-
to McNamara,17 it should be the main ment was predominant for orthodontic
guide for defining the sagittal position of treatment planning.
the maxilla. The ideal value of the naso-
labial angle ranges from 90.0 degrees to
110.0 degrees, indicating maxillary retru- PATIENT REPORT
sion if greater 110.0 degrees and protru-
sion if less than 90.0 degrees. A 14-year-old white female, presenting a
Since physical appearance became Class I molar and canine relationship and
ever more important to society, analyses an anterior crossbite of her maxillary left
such as the ones of Arnett et al18 and lateral incisor, requested orthodontic
Bergman 19 became more and more treatment with the chief complaint of
complex comprising a big number of refer- buccally ectopic canines (Figs 1 and 2).
ence soft tissue points. Today, the analy- Frontal and lateral facial analysis
sis of the profile on lateral photographs revealed a deficiency in zygomatic projec-
and cephalograms is a substantial part of tion, indicating a maxillary retrusion. Fur-
orthodontic diagnosis and treatment ther, a slightly concave profile and facial
planning.20–24 Still, according to Suguino,25 asymmetry were obvious.
it is a challenge to convert the results of In agreement with the subjective facial
any analysis into a well-defined, objective evaluation, the soft tissue analysis indi-
therapeutic goal. If orthodontic treatment cated a concave profile, maxillary retru-
aims at overcoming psychosocial difficul- sion, and retrusion of the upper and
ties related to facial and dental appear- lower lips (Table 1).
ance, the evaluation of esthetics becomes Intraoral and dental cast analysis
increasingly more important.26 revealed a slight maxillary constriction
State-of-the-art orthodontic diagnosis with increased lingual inclination of the
and treatment planning aims at a balance mandibular posterior teeth, a buccally
and harmony among facial dimensions ectopic maxillary left canine, a reverse
and proportions, primarily considering the overbite of the maxillary left lateral
soft tissue profile. Thus, the esthetic incisor, and a maxillary midline deviation
impact of dental correction on a patient’s to the left (Figs 2 and 3).

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VOLUME 10, NUMBER 4, 2009 Siqueira et al

Fig 2 Initial intraoral photographs


revealing buccally ectopic maxillary left
canine, reverse overbite of the maxillary
left lateral incisor, maxillary midline
deviation to the left, and slight maxillary
constriction with lingual inclination of
the mandibular posterior teeth.

Table 1 Soft tissue profile analysis with initial values, ideal values,
and interpretation
Parameter Initial values Ideal values Interpretation

Ricketts’ esthetic plane LL 5.0 mm behind E-line LL 2.0 mm behind E-line Retrusion of lower lip
Steiner’s S line UL and LL behind S-line UL and LL touch S-line Concave profile
Burstone’s line UL 0 mm; LL 1.0 mm in UL 3.5 ± 1.4 mm in UL retruded,
front front, LL 2.2 ± 1.6 mm LL protruded
behind Burstone’s line
Nasolabial angle 133 degrees 90 degrees to 110 degrees Maxillary retrusion
H angle 8 degrees 7 degrees to 15 degrees Normal

LL = lower lip; UL = upper lip.

Fig 3 Initial photographs of dental


casts (compare with Fig 2).

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Table 2 Initial and final cephalometric


measurements
Cephalometric
measurements Initial Final

NAP (degrees) –4.0 0.0


SNA (degrees) 81.5 85.0
SNB (degrees) 82.0 83.0
ANB (degrees) –0.5 2.0
SN-Gn (degrees) 67.0 68.0
SN-Po (degrees) 11.0 11.0
IMPA (degrees) 85.0 86.0
FMA (degrees) 18.0 25.0
SN-GoMe (degrees) 32.0 30.0
UI-NA (degrees) 32.0 25.0
UI-NA (mm) 6.5 5.0
LI-NB (degrees) 16.0 22.0
LI-NB (mm) 1.8 5.0
H-NB (degrees) 7.0 8.0
H-nose (mm) 13.0 14.0

Fig 4 Initial lateral cephalogram and panoramic radiograph showing concave profile, slight maxillary retrusion, and reduced
facial height. Protruded maxillary and retruded mandibular incisors compensate the Class III configuration.

Initial cephalometric measurements lip.15,18 Rapid maxillary expansion (RME)


(Table 2) also confirmed a concave pro- alone was not indicated either because it
file, slight maxillary retrusion, reduced would not have improved the profile.
facial height, and protruded maxillary and However, it would have provided space
retruded mandibular incisors compensat- for the maxillary left canine and allowed
ing the skeletal Class III. The analysis of for the correction of the maxillary midline
the initial panoramic radiograph did not deviation. All in all, RME with a face
reveal any significant findings (Fig 4). mask followed by leveling and aligning all
teeth seemed to be the most reasonable
option.
TREATMENT OPTIONS
Tooth extraction to gain space for the TREATMENT SEQUENCE
maxillary left canine and correct the mid-
line had to be excluded because this After placement of elastic separators,
treatment would have directly worsened bands were adapted on the maxillary first
the profile due to a retrusion of the upper molars and first premolars and an

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VOLUME 10, NUMBER 4, 2009 Siqueira et al

Fig 5 (a) Intraoral situation after place-


ment of elastic separators; (b) fabri-
cated Haas appliance on the patient’s
dental cast.

a b

Fig 6 (a) Intraoral situation after Haas


appliance insertion; (b) characteristic
diastema after expansion.

a b

Fig 7 (a and b) Right and left lateral


views showing hooks welded to the
premolar bands (c and d) for application
of face mask elastics.

a b

c d

impression was taken for the fabrication After RME, a face mask for maxillary
of a Haas appliance (Figs 5 and 6). protraction (600 cN per side) was applied
RME was performed by daily activa- to hooks on the Haas expander (Fig 7).
tions of the expander screw for 8 subse- The face mask was used for 5 months
quent days. and then removed due to a lack of

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Siqueira et al WORLD JOURNAL OF ORTHODONTICS

Fig 8 Intraoral view after


insertion of postexpansion
retention plate.

Fig 10 Bite plate with


spring to move left lateral
Fig 9 Creating space with an open coil incisor mesially;at the same Fig 11 Intraoral situation after insertion
spring. time, it is moved labially of superelastic Ni-Ti archwire.
with a power chain.

a b c
Fig 12 (a) Frontal and (b and c) lateral intraoral views after repositioning of the maxillary
left canine bracket and placement of the fixed appliance in the mandible.

patient compliance. At this time, a reten- After the crossbite correction, the
tion plate was placed for 6 months (Fig bracket on the maxillary left canine was
8). Also, a fixed appliance (Roth prescrip- rebonded to accomplish a better angula-
tion) was inserted in the maxillary arch. tion. At the same time, the plate was
All teeth were leveled and aligned with removed and a fixed appliance was
nickel-titanium archwires, followed by inserted in the mandibular arch (Fig 12).
stainless steel wires.
After expansion with an open coil
spring, sufficient space for the labial RESULTS
movement of the maxillary left lateral
incisor was created (Fig 9). A bite plate After active treatment, a removable
with coil springs was placed to move this retainer was placed in the maxilla and a
tooth mesially. Simultaneously, a ligature bonded 3-to-3 retainer in the mandible
between the bracket on the maxillary left (Fig 13).
lateral incisor and the archwire inclined it The facial profile was significantly
buccally (Fig 10). improved by moving the upper lip for-
This bite plate was used for 2 months; ward, as seen in Figs 14 and 15 and
after the first month, the stainless steel confirmed by the final cephalometric
wire was replaced by a Ni-Ti wire and the analysis in Tables 2 and 3. The naso-
maxillary left lateral incisor and canine labial angle was reduced, the NAP and
were included in the appliance, as SNA angle increased, and the ANB angle
demonstrated in Fig 11. changed to a positive reading.

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VOLUME 10, NUMBER 4, 2009 Siqueira et al

Fig 13 (a and b) Extraoral frontal and


(c to e) intraoral photographs after com-
pletion of treatment.

a b

c d e

Fig 14 (a) Initial and (b) final extraoral


lateral photographs.

Fig 15 (below) Final lateral cephalo-


gram and panoramic radiograph. a b

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Siqueira et al WORLD JOURNAL OF ORTHODONTICS

Table 3 Inital and final soft tissue profile analysis values


Parameter Initial values Final values

Ricketts’ esthetic plane LL 5 mm behind E-line LL 5 mm behind E-line


Steiner’s S line Concave profile Concave profile
Burstone’s line UL 0 mm LL 1mm in front
UL 0 mm LL 1mm in front
Nasolabial angle 133 degrees 128 degrees
H angle 8 degrees 8 degrees

Figure 16 demonstrates satisfactory at treatment onset was 133.0 degrees,


stability at the 4-year follow-up. which is far from the ideal of 90.0
Figure 17 shows the superimpositions degrees to 110.0 degrees. Subjective
of the cephalometric tracings at the facial analysis was fundamental in con-
beginning, and at the end of treatment firming this deviation because the profile
as seen at the 4-year follow-up. The evaluation revealed a soft tissue defi-
superimpositions reveal the improvement ciency of this region. The vermillion of the
of the incisor position and the soft tissue upper lip was reduced in thickness, even
profile as the treatment stability. though the U1-NA (degrees and mm) val-
ues increased, thus favoring some projec-
tion of the upper lip.
DISCUSSION Initial analysis in this patient revealed
a facial convexity angle of –4.0 degrees,
Cephalometric analysis is routinely used indicating a concave skeletal profile and
for orthodontic diagnosis because it is an thereby confirming the need for maxillary
effective method to evaluate faciodental protraction to improve the profile.
features. At the same time, it used to be Because the nose grows forward and
thought that the achievement of estab- downward (more intensely during adoles-
lished cephalometric standards would cence and slower throughout life)4 and
assure a satisfactory esthetic outcome the chin grows forward, the lips are pro-
with regard to the soft tissue profile.6,23,25 gressively retruded.10 However, not to rely
However, this proved not to be true, on growth, which is difficult to predict,
because a good occlusal relationship seemed to be the best therapeutic option
does not necessarily imply facial harmony for this patient.
or vice versa. The increasing esthetic con- Even though the patient initially pre-
cern of modern societies and the advent sented with a Class I molar relationship,
of better therapeutic resources (advances a face mask was used after maxillary
in orthognathic surgery) led to an evolu- expansion to improve her facial esthetics.
tion of cephalometrics by establishing This is justified by the improvement of
soft tissue measurements that might indi- the nasolabial angle (133.0 degrees to
cate facial beauty and harmony. Beside 128.0 degrees) and the facial convexity
cephalometric analyses, standardized angle (–4.0 degrees to 0 degrees).
photographs provide even more reliable Notwithstanding the lack of her compli-
parameters for treatment planning. ance, the face mask also helped to cor-
The nasolabial angle is of ten rect the patient’s crossbite.
employed for the evaluation of the facial All treatment goals were fully achieved
profile even though it is influenced by in this patient because her chief com-
nasal morphology.14,15,17 That is why Fitz- plaint (buccally ectopic canines) was
gerald et al6 stated that the nasolabial eliminated. At the same time, a harmo-
angle may not reliably describe variations nious profile was established.
in the soft tissue profile. This highlights
the importance of evaluating nasal mor-
phology during orthodontic diagnosis. In
the present report, the nasolabial angle

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VOLUME 10, NUMBER 4, 2009 Siqueira et al

Fig 16 (a and b) Extraoral and (c to g)


intraoral photographs at 4-year follow-
up.

a b

c d e

Fig 16 (a and b) Extraoral and (c to g)


intraoral photographs at 4-year follow-
up.

f g

a b c
Fig 17 Superimpositions of cephalometric tracings on point S (S). (a) Superimposition of initial (blue) and final (red) tracing,
(b) superimposition of initial (blue) and follow-up (red) tracing, and (c) superimposition of final (red) and follow-up (blue) tracing.

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Siqueira et al WORLD JOURNAL OF ORTHODONTICS

CONCLUSION 13. Holdaway RAA. A soft-tissue cephalometric


analysis and its use in orthodontic planning.
Part I. Am J Orthod 1983;84:1–28.
The search for balance and harmony of 14. Brandão AMB. Avaliação da correlação entre
facial proportions for esthetics, especially as características dentárias esqueléticas e
in respect to the soft tissue profile, is fun- tegumentares em portadores de má oclusão cl.
damental for sound orthodontic treat- II div. 1a, obtidas pela cefalometria e análise
facial numérica. R Dental Press Ortodon e
ment planning. RME with a face mask
Ortop Facial 2002;7:27–35.
was effective for this patient who exhib- 15. Salgado JAP, Moraes LC, Castilho, JCM,
ited a maxillary deficiency in both antero- Moraes, MEL. Avaliação do ângulo nasolabial,
posterior and transverse dimension. em radiografias cefalométricas laterais, divi-
Furthermore, this treatment was stable dido em ângulo superior e inferior, por uma
linha paralela ao plano de Frankfort, em indiví-
4 years after therapy.
duos portadores de má-oclusão classe II e
classe III de angle. Cienc Odontol Bras 2003;
6:40–49.
REFERENCES 16. Scheideman GB, Bell WH, Legan HL, Finn RA,
Reisch JS. Cephalometric analysis of dentofa-
1. Langlade M. Diagnóstico Ortodôntico, ed 3. cial normals. Am J Orthod Dentofacial Orthop
São Paulo: Ed Santos, 1993:129–159. 1980;78:404–420.
2. Hambleton RS. The soft-tissue covering of the 17. McNamara JAA Jr. Method of cephalometric
skeletal face as related to orthodontic prob- evaluation. Am J Orthod 1984;86:449–469.
lems. Am J Orthod 1964;50:405–420. 18. Arnett GW, Jelic JS, Kim J, et al. Soft tissue
3. Burstone CJ. Integumental contour and exten- cephalometric analysis: Diagnosis and treat-
sion patterns. Angle Orthod 1959;29:93–104. ment planning of dentofacial deformity. Am J
4. Subtelny JD. The soft tissue profile, growth, and Orthod Dentofacial Orthop 1999;116:239–253.
treatment changes. Angle Orthod 1961;31: 19. Bergman RT. Cephalometric soft tissue facial
105–122. analysis. Am J Orthod Dentofacial Orthop
5. Erbay EF, Caniklioglu CM, Erbay SK. Soft tissue 1999;116:373–389.
profile in Anatolian Turkish adults: Part I. Evalu- 20. Riveiro PF, Quintanilla DS, Chamosa ES, Cun-
ation of horizontal lip position using different queiro MS. Linear photogrammetric analysis of
soft tissue analyses. Am J Orthod Dentofacial the soft tissue facial profile. Am J Orthod
Orthop 2002;121:57–64. Dentofacial Orthop 2002;122:59–66.
6. Fitzgerald JP, Nanda RS, Currier GF. An evalua- 21. Scavone H Jr, Trevisan JH Jr, Garib DG, Ferreira
tion of the nasolabial angle and the relative FV. Facial profile evaluation in Japanese-Brazil-
inclinations of the nose and upper lip. Am J ian adults with normal occlusions and well-bal-
Orthod Dentofacial Orthop 1992;102: anced faces. Am J Orthod Dentofacial Orthop
328–334. 2006;129:721.e1–721.e5.
7. Carrea CS. Les radiofaces a profile delinee en 22. Halazonetis DJ. Morphometric evaluation of
orthodontometrie. Semaine Dent 1924;6: soft-tissue profile shape. Am J Orthod Dentofa-
16–19. cial Orthop 2007;131:481–489.
8. Downs WB. Analysis of the dentofacial profile. 23. Lundström A, Forsberg CM, Peck S, McWilliam
Angle Orthod 1956;26:191–212. J. A proportional analysis of soft tissue facial
9. Holdaway RA. Changes in relationship of points profile in young adults with normal occlusion.
A and B during orthodontic treatment. Am J Angle Orthod 1992;62:127–133.
Orthod Dentofacial Orthop 1956;42:176–193. 24. Chen, K. So, L. L. Soft tissue profile changes of
10. Ricketts RM. Planning treatment on the casis reverse headgear treatment in Chinese boys
of the facial pattern and an estimate of its with complete unilateral cleft lip and palate.
growth. Angle Orthod 1957;27:14–37. Angle Orthod 1997;67:31–38.
11. Steiner CC. Cephalometric as clinical tool. In: 25. Suguino R, Ramos AL, Terada HH, Furquim LZ,
Kraus B, Riedel RA, eds. Vistas in Orthodontics, Maeda L, Silva Filho OG. Análise Facial. R Dental
ed 1. Philadelphia: Leandro & Febiger, 1962: Press Ortodon e Ortop Facial 1996;1:86–107.
131–161. 26. Proffit W, Fields H. Contemporary Orthodontics,
12. Burstone CJ. Lip posture and its significance in ed 3. St Louis: Mosby, 2000:742– 2000.
treatment planning. Am J Orthod 1967;53:
262–284.

370

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371_Koidis.qxp 11/6/09 2:43 PM Page 371

Petros T. Koidis,
DDS, MS, PhD1 ANKYLOSING SPONDYLITIS ASSOCIATED
Ioanna Basli, DDS2 WITH CRANIOMANDIBULAR DISORDER—
Nikos Topouzelis,
DDS, PhD3
A COMBINED ORTHODONTIC AND
PROSTHODONTIC THERAPEUTIC
APPROACH
Ankylosing spondylitis is a disease that causes inflammatory changes
of the involved joints. Although the initial clinical signs are pain and
discomfort, synovial changes progressively involve all the axial
joints, including the temporomandibular joint (TMJ). Eventually, bony
alterations develop (condylar erosions, flattening, sclerosis) that
affect the position of the condyle, the superior joint space, and the
range of movements. These symptoms correlate with the severity of
the disease. Besides physiotherapy and surgery, no dental rehabilita-
tion has been reported for these patients. This report of a female
patient with ankylosing spondylitis and a TMJ disorder emphasizes
dental rehabilitation. The aim of the splint, orthodontic, and prostho-
dontic treatment was to relieve the subjective symptoms through
establishing a stable optimum occlusion. Anamnestic, laboratory, and
clinical findings including pre- and postradiographic examination
records are presented. World J Orthod 2009;10:371–377.

Key words: ankylosing spondylitis, craniomandibular disorders,


rehabilitation

nkylosing spondylitis is a chronic environmental agents.5 A familial cluster-


A inflammatory disorder of the axial
skeleton, sacroiliac, and large peripheral
ing exists, with Class I HLA-B27 antigen
of the major histocompatibility complex
joints.1 The clinical signs vary from mild (MHC) being the major allele in 95% of
1Professor, Department of Fixed Pros- mobility limitation to total ankylosis and affected persons. Many candidate gene
thesis & Implant Prosthodontics, can be compounded by extra-articular loci for the susceptibility of this disease
School of Dentistry, Aristotle Univer- manifestations.2 have been suggested, but no evidence of
sity of Thessaloniki, Thessaloniki,
Greece.
Ankylosing spondylitis has a strong linkage is yet confirmed.6 The cytokine
2Private Practice, London, England. association with psoriatic arthritis, a sub- tumor necrosis factor alpha (TNF-␣) may
3Associate Professor, Department of set of reactive arthritis, and arthritis/ also be involved.7 Trauma and bacterial
Orthodontics, School of Dentistry, sacroiliitis in inflammatory bowel dis- infections act as triggering factors, which
Aristotle University of Thessaloniki, eases.3 It occurs in 0.2% of the popula- disturb the immune system.8 The 60kDa
Thessaloniki, Greece.
tion with a male/female ratio of 2.5 to heat shock protein of Klebsiella Pneumo-
CORRESPONDENCE 5.0:1.0. Ankylosing spondylitis typically niae plus its homology in sequence with
Dr Nikos Topouzelis presents in young adulthood, but symp- other enterobacteria indicate their
Department of Orthodontics toms may arise in adolescence or involvement in ankylosing spondylitis.9
School of Dentistry earlier.4 As for HLA-B27–negative families, a
Aristotle University of Thessaloniki
54124 Thessaloniki The etiology of ankylosing spondylitis hypothesis is that genes for psoriasis or
Greece is suspected to be an interrelation other alleles of the MHC may be etiologi-
Email: ntopouz@dent.auth.gr between HLA genes, sex factors, and cally important.6,10

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Koidis et al WORLD JOURNAL OF ORTHODONTICS

Table 1 Laboratory findings in patients with ankylosing spondylitis showing which


components are elevated, present, or absent
Elevated Present Absent

ESR HLA-B27 RA factor


CRP Normochromic normocytic anemia Autoantibodies
Akaline phosphatase Leukocytosis
IgA, IgG

The inflammatory process begins at Laboratory findings support the inflamma-


the ligament, tendon, and joint capsule tory nature of the disease (Table 1).3,20
attachments to bone—the entheses. This Diagnosis of ankylosing spondylitis is
comprises an agglomeration of chronic based on a patient’s symptoms: a family
inflammatory cells and bone erosion. history of iritis, psoriasis, or spondy-
Later, features of healing by fibrosis, scle- loarthropathies; and physical examina-
rosis of the underlying bone, and new tion that demonstrates a decreased
bone formation in the adjacent ligaments range of spinal motion in all directions.14
can be observed.11 In case of the verte- Laboratory findings verify the diagnosis;
bral column, the new bone, termed syn- however, radiographic examination is
desmophyte, forms bridges both laterally helpful. The main laboratory finding that
and anteriorly to vertebral bodies. This characterizes ankylosing spondylitis is
leads to a fusion of the spine, thus con- the presence of HLA-B27, which is pre-
verting it into a rigid structure, which is sent in 40% to 95% of all patients.21 The
vulnerable to fracture.12 radiologic findings of ankylosing spondyli-
The onset of this disease is insidious, tis usually include symmetric sacroiliac
often beginning in the sacroiliac region joint space narrowing and blurring of joint
and spreading upward to the thoracic margins, subchondral sclerosis, squaring
and cervical spine. A suspicious symp- of vertebral bodies with paravertebral
tom of ankylosing spondylitis is lower syndesmophytes, general erosions, and
back pain that persists longer than 3 sclerosis of ligamentous attachments.
months, worsening by inactivity but These pathologic findings progressively
improving with exercise. In time, flexion lead to the characteristic ankylosed
and rotation are inhibited, rigidity “bamboo spine.”22,23
becomes extreme (ankylosis), and the Treatment relies on daily physical ther-
cervical spine is curved while chest apy, including stretching, back extension,
expansion is limited and respiration and breathing exercises. Medications
impaired.13,14 Additional symptoms are such as NSAIDs suppress ar ticular
low-grade fever, fatigue, tachycardia, and inflammation, pain, and muscle spasms;
anorexia responsible for loss of weight new NSAIDs, known as COX-2, have even
and muscle.15 fewer adverse effects. Sulfasalazine, glu-
Peripheral asymmetric oligoarthropa- cocorticoids, narcotics, analgesics, or
thy16 and joint synovitis is seen in 30% of muscle relaxants are also beneficial.24–27
patients. Systemic manifestations also Anti-TNF-␣ agents, such as infliximab28,29
include ocular lesions (anterior uveitis and radium-224 in intravenous injec-
and iridocyclitis) and cardiovascular affec- tions, 25 seem promising. If ankylosing
tions (aortitis, mitral valve involvement, spondylitis leads to immobility, surgical
and pericarditis). Rare complications are treatment can be indicated. Radiotherapy
pulmonary fibrosis, neurologic disorders, is recommended as a last resort due to
and secondary amyloidosis. 17–19 The the risk of developing acute myelogenous
progress of ankylosing spondylitis can be leukemia.30,31
relentless or can cease at any stage.15

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VOLUME 10, NUMBER 4, 2009 Koidis et al

Fig 1 Patient’s initial intraoral situation: Increased overbite, crowding, and buccal nonocclusion of the maxillary left first and
second premolars.

TMJ INVOLVEMENT fatigue during speech. She reported an


earlier diagnosis of scoliosis, iritis, and
Ankylosing spondylitis has a tendency to an operation on the right inner ear due to
affect fibrocartilaginous structures such an angiotumor of the tympanon. General
as the TMJ. In fact, TMJ affections occur in symptoms such as malaise or pain
11% to 35% of all ankylosing spondylitis throughout all joints, especially with
patients. The variation in frequency can be humid weather, were also present. The
explained by the type of study, the exam- clinical examination revealed tenderness
ined population, and the tools used to to palpation of the right TMJ as of her
assess TMJ affection.32–35 The most com- right sternocleidomastoid and posterior
mon subjective symptoms are difficulties belly of digastric muscles. In addition,
in wide mouth-opening, TMJ crepitus, pain, swelling of the ankle joints with persis-
stiffness, swelling, and headaches.36,37 tent depression upon pressure and pain
Computed tomography (CT) and magnetic upon pressure on the distal and proximal
resonance imaging (MRI) images show interphalangeal joints were noticed. Maxi-
temporal flattening, abnormal condylar mum mouth-opening amounted to
shape, erosions, sclerosis, disc alter- 49 mm, right/left lateral excursion to
ations, osteophytes and even total ankylo- 12 mm/13 mm, and protrusion to 12 mm.
sis of the joint. 38,39 TMJ treatment She had an Angle Class I molar and
includes physiotherapy and occasionally canine relationship and a deep curve of
moist heat and ultrasound application.40 Spee on her left side (Fig 1). The maxil-
In acute phases of TMJ arthritis, glucocor- lary and mandibular anterior teeth were
ticoid injections are indicated. To prevent crowded, and the overbite increased so
muscle hyperactivity and articular strain that the crown of the mandibular left cen-
due to bruxism, occlusal splints can be tral incisor was covered by its antagonist
inserted, but in cases of obvious occlusal by 110%. The mandibular left first and
interferences, occlusal adjustment or second premolars were severely lingually
prosthetic reconstruction could be neces- inclined, thus leading to a buccal nonoc-
sary. Orofacial pain can be treated with clusion of their antagonists.
transcutaneous nerve simulation. When Laboratory findings revealed that
the TMJ is ankylosed, surgical interven- rheumatoid factor was negative, while
tions such as arthroplasty and synovec- the HLA-B27 antigen was positive (Table
tomy with discectomy are indicated. If not, 1). The diagnosis of ankylosing spondyli-
a joint prosthesis becomes necessary.37,41 tis was verified by a rheumatologist. The
specific differential diagnosis was based
primarily on the laboratory findings and
PATIENT REPORT only secondarily on the rheumatologic
symptoms.
A 36-year-old female presented with bilat- The aim of the dental rehabilitation
eral pain in her masticatory muscles and was to relieve the subjective symptoms by
both TMJs, headaches localized in the aligning all teeth optimally and establish-
temporal and iliac region, and a feeling of ing an ideal stable occlusion. This was

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Koidis et al WORLD JOURNAL OF ORTHODONTICS

Fig 2 Intraoral situation with a mandibular stabilization splint in place at the initiation of orthodontic treatment.

Fig 3 Introaral situation after placement of an anterior repositioning splint.

Fig 4 Patient’s final occlusion after orthodontic therapy with reduced overbite, eliminated crowding, and corrected nonocclu-
sion of the mandibular left first and second premolars.

Fig 5 Clinical try in of the cast copings, including the maxillary right first premolar
and a cantilever for the maxillary right canine; porcelain-fused-to-metal crowns with
metal surfaces restored the posterior teeth.

Fig 6 Intraoral situation at the completion of the prosthetic reconstruction.

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VOLUME 10, NUMBER 4, 2009 Koidis et al

a c

Fig 7 (a) Pretreatment and (b) post-


treatment panoramic radiographs and
(c) 1-year posttreatment orthopantomo-
graphic sectional images of both joints.

achieved by a combination of kinesio- and a prosthetic rehabilitation of her poste-


splint therapy, followed by orthodontic rior teeth (Fig 5). The prosthetic rehabili-
and prosthodontic treatment. Kinesiother- tation was thought to further stabilize the
apy for the head and neck was initiated to patient’s occlusion, developing almost
diminish the chance of TMJ ankylosis and pure canine guidance (the maxillary right
relax the masticatory muscles. first premolar was included because the
The full-coverage stabilization man- maxillary right canine was a cantilever).
dibular splint aimed at a load reduction of Also, occlusal interferences were elimi-
the TMJ, especially during mastication, nated, masticatory function improved,
thus reducing the sensitivity of the joints and esthetics enhanced by replacing the
and masticatory muscles (Fig 2). At the unattractive prosthetic work (Fig 6).
same time, the splint raised the bite, The combined orthodontic and pros-
which helped to correct the lingual non- thetic therapy was succeeded by periodi-
occlusion of the mandibular left first and cal examinations for a period of 2 years.
second premolars. Subsequently, to relo- These follow-ups included both clinical
cate both condyles in a more physiologic and radiologic examinations.
position and further unload the TMJ, an All therapeutic efforts resulted in the
anterior repositioning splint with a signifi- elimination of the clinical symptoms in-
cant increase of the vertical dimension (8 cluding reduction of the patient’s head-
to 9 mm) was inserted (Fig 3). With the aches and fatigue during speech. The
accompanying orthodontic treatment, the relocated condyles maintained their posi-
buccal nonocclusion was corrected and tion without any evidence of deterioration
the crowding alleviated, which led to 2 years posttreatment as revealed radio-
desensitization of both the joints and graphically (Fig 7). With minor occlusal
muscles. refinements, the patient remained asymp-
Finally, upon completion of orthodon- tomatic 8 years after the completion of
tic treatment (Fig 4), the patient received treatment.

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Koidis et al WORLD JOURNAL OF ORTHODONTICS

CONCLUSION 15. Boyd W. A Textbook of Pathology—Structure


and Function in Diseases. Philadelphia: Lea &
Febiger, 1961: 1282.
In a case of ankylosing spondylitis, it was 16. Lee JH, Jun JB, Jung S, et al. Higher prevalence
possible by combined orthodontic and of peripheral arthritis among ankylosing
prosthodontic treatment to relieve sub- spondylitis patients. J Korean Med Sci 2002;
jective symptoms through realignment of 17:669–673.
17. Goldmann L, Benett JC. Cecil Textbook of Medi-
elements of the stomatognathic system,
cine, ed 21. Philadelphia: Saunders, 2000:
to achieve optimum tooth and arch posi- 1499–1506.
tions and relationships, and to develp a 18. Gregersen PK, Gallerstein P, Jaffe W, Enlow RW.
permanently functional and stable Valvular heart disease associated with juvenile
occlusal scheme. onset ankylosing spondylitis: A case report and
review of the literature. Bull Hosp Jt Dis Orthop
Inst 1982;42:103–114.
19. Kovacsonics-Bankowski M, Juffery P, So AK,
REFERENCES Gerster JC. Secondary amyloidosis: A severe
complication of ankylosing spondylitis. Two case
1. Fauci AS, Braunwald E, Kasper DS, et al. Harri- reports. Joint Bone Spine 2000;67:129–133.
son’s Principles of Internal Medicine, ed 14. 20. Eastham DR. A Laboratory Guide to Clinical Diag-
New York: McGraw Hill Health Professions Divi- nosis. Bristol: John Wright & Sons, 1976:263.
sion, 1998:2363–2367. 21. Calin A. Ankylosing spondylitis. Medicine
2. Kamarkar US, Chaudhari LS, Hosalkar H, Budhi 2006;34:396–400.
M, Venkataraghavan D. Difficult intubation in a 22. Utsinger DP, Zvaifler JN, Ehrlich EG. Rheumatoid
case of ankylosing spondylitis: A case report. Arthritis. Philadelphia; JB Lippincot, 1985: 174.
J Postgrad Med 1998;44:43–46. 23. Fishman CM, Hoffman RA, Klausner DR, Thaler
3. Sieper J, Braun J. Pathogenesis of spondy- SM. Medicine, ed 2. Philadelphia: JB Lippincott,
larthropathies. Persistent bacterial antigen, 1985: 347–348.
autoimmunity, or both? Arthritis Rheum 1995; 24. Leirisalo-Repo M. Prognosis, course of disease,
38:1547–1554. and treatment of the spondyloarthropathies.
4. Goldman L, Ausiello D. Cecil Textbook of Medi- Rheum Dis Clin North Am 1998;24:737–751.
cine, ed 22. Philadelphia: Saunders, 2004: 25. Braun J, Zochling J, Baraliakos X, et al. Efficacy
1655–1657. of sulphasalazine in patients with inflammatory
5. Stein HJ. Internal Medicine, ed 2. Boston: Little back pain due to undifferentiated spondy-
Brown and Company, 1987: 1300–1303. loarhritis and early ankylosing spondylitis: A
6. Djouadi K, Nedelec B, Tamouza R, et al. Inter- multicentre randomised controlled trial. Ann
leukin 1 gene cluster polymorphisms in multi- Rheum Dis 2006;65:1147–1153.
plex families with spondylarthropathies. 26. Ferraz M, Tugwell P, Goldsmith CH, Atra E.
Cytokine 2001;13:98–103. Meta-analysis of sulfasalazine in ankylosing
7. Dougados M. Treatment of spondyloarthro- spondylitis. J Reumatol 1990;17:1482–1486.
pathies. Recent advances and prospects in 27. Lee CK, Lee EY, Cho YS, Moon KA, Yoo B, Moon
2001. Joint Bone Spine 2001;68:557–563. HB. Increased expression of glycorticoid recep-
8. Moll HMJ. Rheumatology in Clinical Practice. tor beta messenger RNA in patients with anky-
Oxford: Blackwell Scientific Publications, 1987: losing spondylitis. Korean J Intern Med 2005;
349–355. 20:146–151.
9. Cancino-Diaz M, Curiel-Quesada E, Garcia- 28. Breban M, Vignon E, Claudepierre P, et al. Effi-
Latorre E, Jimenez-Zamudio L. Cloning and cacy of infliximab in refractory ankylosing
sequencing of the gene that codes for the Kleb- spondylitis. Results of a 6-month open-label
siella pneumoniae, GroEL-like protein associ- study. Rheumatol (Oxford). 2002;41:
ated with ankylosing spondylitis. Microb Pathog 1280–1285.
1998;25:23–32. 29. Braun J, Brandt J, Listing J, et al. Treatment of
10. Eastmond CJ, Woodrow JC. The HLA system active ankylosing spondylitis with infliximab: A
and the arthropathies associated with psoria- randomised controlled multicentre trial. Lancet
sis. Ann Rheum Dis 1977;36:112–120. 2002;359:1187-1193.
11. Underwood ECJ. General and Systematic 30. Tiepolt C, Gruning T, Franke WG. Renaissance
Pathology, ed 2. Edinburgh: Churchill Living- of 224 Ra for the treatment of ankylosing
stone, 1996:811–812. spondylitis: Clinical experiences. Nucl Med
12. Forrester DM, Brown JC. The Radiology of Joint Commun 2002;23:61–66.
Disease, ed 3. Philadelphia: WB Saunders, 31. Walter BJ, Hamilton CM, Israel SM. Principles
1987:430–432. of Pathology for Dental Students. Edinburg:
13. Scully C, Cawson AR. Medical Problems in Den- Churchill Livingstone, 1974: 304.
tistry. Bristol: Wright-PSG, 1982: 260. 32. Kelley WN, Harris ED, Ruddy S, Sledge CB. Text-
14. Klippel JH. Primer on the Rheumatic Diseases, book of Rheumatology ed 3. Philadelphia: WB
ed 12. Atlanta: Arthritis Foundation, 2001: Saunders, 1989:1021–1034.
250–255.

376

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371_Koidis.qxp 11/6/09 2:43 PM Page 377

VOLUME 10, NUMBER 4, 2009 Koidis et al

33. Wenneberg B, Könönen M, Kallenberg A. Radio- 37. Zarb AG, Carlson EG, Sessle JB, Mohl DN. Tem-
graphic changes in the temporomandibular joint poromandibular Joint and Masticatory Muscle
of patients rheumatoid arthritis, psoriatic arthri- Disorders. Copenhagen: Munksgaard, 1994:
tis and ankylosing spondylitis. J Craniomandib 367–372.
Disord 1990;4:35–39. 38. Ramos-Remus C, Major P, Gomez-Vargas A, et
34. Könönen M, Wenneberg B, Kallenberg A. Cran- al. Temporomandibular joint osseous morphol-
iomandibular disorders in rheumatoid arthritis, ogy in a consecutive sample of ankylosing
psoriatic arthritis, and ankylosing spondylitis. spondylitis patients. Ann Rheum Dis 1997;56:
A clinical study. Acta Odontol Scand 1992;50: 103–107.
281–287. 39. Ramos-Remus C, Perez-Rocha O, Ludwig RN, et
35. Helenius LMJ, Tervahartiala P, Helenius I, et al. al. Magnetic resonance changes in the tem-
Clinical, radiographic, and MRI findings of the poromandibular joint in ankylosing spondylitis.
temporomandibular joint in patients with differ- J Rheumatol 1997;24:123–127.
ent rheumatic diseases. Int J Oral Maxillofac 40. Okeson PJ. Management of Temporomandibu-
Surg 2006;35:983–989. lar Disorders and Occlusion. St Louis: Mosby,
36. Major P, Ramos Remus C, Suarez-Almazor ME, 1989.
Hatcher D, Parfitt M, Russell AS. Magnetic reso- 41. Wolford ML, Mehra P. Custom-made total joint
nance imaging and clinical assessment of tem- protheses for TMJ recontruction. BUMC Pro-
poromandibular joint pathology in ankylosing ceedings 2000;13:135–138.
spodylitis. J Rheumatol 1999;26:3:616–621.

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378_Coelho.qxd 11/6/09 2:44 PM Page 378

TREATMENT OF A MUTILATED Carlos M. Coelho, DDS,


MSD1

DENTITION WITH THE MANDIBULAR Fabio Coelho, DDS, MSD2

PROTRACTION APPLIANCE: Larry W. White, DDS, MSD3

A PATIENT REPORT
A 35-year-old female presented missing her maxillary right first pre-
molar, left central and lateral incisors, and left second premolar and
mandibular left first molar. The referring dentist had requested that
only the maxillary left first molar be intruded to facilitate the prostho-
dontic replacement of the missing mandibular left first molar. After
clinical examination and consultation with her dentist, it was decided
to protract the mandibular left second and third molars, intrude the
maxillary left first molar, replace the missing incisors with a tempo-
rary partial denture, and restore the missing maxillary right first pre-
molar with an implant. World J Orthod 2009;10:378–382.

Key words: MPA, missing teeth, partial denture

dult patients offer challenges for the INTRAORAL FINDINGS


A orthodontist seldom seen in adoles-
cents: Because of their age and dental After a clinical examination, the follow-
history, they often present with missing ing symptom list was compiled (Fig 1):
teeth, restorations, and compromised
1Private
periodontal conditions. This 35-year-old • Class I occlusion Practice of Orthodontics; for-
female with a Class I occlusion was • Deep anterior overbite with moderate merly, Professor, Department of
Orthodontics, Federal University of
missing multiple teeth, had an extruded anterior overjet Maranhao, Brazil.
maxillary left first molar and mesially • Slight midline shift 2Private Practice of Orthodontics,

tipped mandibular left first and second • Multiple missing teeth Associate Professor, Brazilian Den-
molars, and displayed isolated periodon- • Extruded and periodontally compro- tal Society/Maranhao, Brazil.
3Private Practice of Orthodontics,
tal problems. Her general dentist had mised maxillary left first molar
Dallas, Texas, USA.
referred her for intrusion of the maxillary • Generalized attachment loss
left first molar to facilitate a prosthodon- • Mesially tipped mandibular left first CORRESPONDENCE
tic replacement of the missing mandibu- and second molars Dr Carlos Martins Coelho Filho
lar left first molar. The missing maxillary • Root canal filling of the mandibular Rua Prof. Luis Pinho Rodrigues 20
Sala 204
left incisors created a big esthetic prob- left second premolar
Renascenca II Ed QUARTZ
lem for orthodontic therapy. • Straight profile 65075-740 San Luis, Maranhao
• Frequently locked temporomandibular Brazil
joints (TMJs) upon awakening Email: carlosm@elo.com.br

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VOLUME 10, NUMBER 4, 2009 Coelho et al

Fig 1 Patient before therapy (a and b)


with a straight profile; (c to g) a deep
anterior overbite with a moderate ante-
rior overjet, a slight midline shift, multi-
ple missing teeth, an extruded and
periodontally compromised maxillary
left first molar; and (h) a generalized
attachment loss, mesially tipped
mandibular left first and second molars,
and a root canal filling of the mandibular
left second premolar.
a b

c d e

f g

TREATMENT OBJECTIVES closure is described in the literature.1–3


The maxillary left first molar had to be
A prime task prior to orthodontic therapy intruded, and the maxillary right second
was to establish normal periodontal con- premolar was to be moved mesially into
ditions. Rather than uprighting and the area of the first premolar so an
retracting the mandibular left first and implant could replace the second premo-
second molars, these teeth were pro- lar. The missing maxillary left central and
tracted using a closing arch and a man- lateral incisors were to be replaced by a
dibular protraction appliance (MPA). This partial denture with brackets.
procedure for successful posterior space

379

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Coelho et al WORLD JOURNAL OF ORTHODONTICS

Fig 2 Intraoral situation after place-


ment of a standard 0.022-inch twin
bracket system. Figure 2a shows the
situation after the brackets were placed
on the archwire, while Fig 2b shows
the situation after they were bonded to
a b the denture.

c d

a b c
Fig 3 Intraoral situation after leveling and aligning. Placement of an archwire with a closing loop on the left side to protract
both molars and insertion of an MPA on the right side to reinforce anchorage in the mandible.

Fig 4 Intraoral situation after protrac-


tion of the mandibular left molars and
moving the maxillary right second pre-
molar into the first premolar’s position.

a b

TREATMENT ALTERNATIVES TREATMENT PROGRESS

One alternative would have been to Standard 0.022-inch twin brackets were
remove the maxillary left first molar so placed on all teeth except for the molars,
the second and third molars could move which received bands. Brackets for the
forward. However, the periodontist coun- denture were initially attached to the
seled against this approach because of archwire; after insertion of the partial
the poor osseous condition in that area. denture, they were bonded to the artifi-
Also, the missing maxillary right first pre- cial teeth (Fig 2).
molar could have been replaced by an After leveling and aligning, an archwire
implant, but as treatment progressed, the with only one closing loop on the left side
periodontist decided to move the second was placed in the mandible (Fig 3). At the
premolar mesially with a compressed coil same time, an MPA was inserted on the
spring. Thus, a better implant site was right side to reinforce the anchorage in
accomplished in the original position of the mandible. Figure 4 shows the situa-
the second premolar. tion after the mandibular left molars were
protracted and the maxillary right second
premolar moved into the first premolar’s
position.

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VOLUME 10, NUMBER 4, 2009 Coelho et al

Fig 5 Situation at the end of treat-


ment. (a and b) Unchanged profile. (c
to g) Bilateral Class I canine occlusion
with a Class I molar occlusion on the
right and a Class II occlusion on the left
side, good overbite and overjet, and
midline correction. The maxillary right
second premolar was replaced by an
implant with a crown, and the partial
denture was still in place. (h) The
panoramic radiograph reveals parallel
root orientation and no pathologies. a b

c d e

f g

RESULTS (Fig 5). The maxillary right second premo-


lar was replaced by an implant with a
At the conclusion of treatment, the patient crown. The patient was to keep the par-
displayed an unchanged profile, a bilat- tial denture until her dentist determined
eral Class I canine occlusion with a Class what the optimal final restoration of this
I molar occlusion on the right and a Class area would entail. The patient no longer
II occlusion on the left side, good over- suffers from TMJ symptoms.
bite and overjet, and a midline correction

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Coelho et al WORLD JOURNAL OF ORTHODONTICS

DISCUSSION REFERENCES

Protracting mandibular posterior teeth is 1. Coelho Filho CM, White LW. Treating adults with
mandibular protraction appliance. Orthod Cyber
complicated because the anterior teeth
J. 2003: http://www.oc-j.com/jan03/MPA2.htm.
may move too far distally. The MPA is 2. Coelho Filho CM. Emprego do aparelho de pro-
proven to prevent this and therefore tração mandibular. In: Grupo Brasileiro de Pro-
became an integral part of this patient’s fessores de Ortodontia e Odontopediatria. 9º
treatment plan. Herbst appliances, Livro Anual do Grupo Brasileiro de Professores
de Ortodontia e Odontopediatria, ed 1. São
Jasper jumpers, or Forsus springs could
Paulo: IMC - Image Maker Comunicações,
provide the same stability for the 1997:122–129.
mandibular anterior teeth. The many den- 3. Coelho Filho CM. Mandibular protraction appli-
tal deficits of this patient necessitated a ance IV. J Clin Orthod 2001;35:18–24.
multidisciplinary approach (periodontist,
restorative dentist, and orthodontist).

CONCLUSION

After 20 years of author use that


demonstrates high levels of efficiency in
the treatment of several orthodontic
problems, the MPA shows once again
how versatile a tool it can be as a part of
the orthodontic armamentarium.

382

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Tancan Uysal, DDS, PhD1
DENTAL MATURATION IN PATIENTS
Ahmet Yagci, DDS2
WITH UNILATERAL POSTERIOR CROSSBITE
Sabri Ilhan Ramoglu,
DDS, PhD3 Aim: To investigate whether there is a difference in dental maturation
between patients with a skeletal unilateral crossbite and a control
sample (individuals with an Angle Class I and no crossbite) and to
compare the dental maturation on the right and left posterior seg-
ments in both samples. Materials and Methods: The sample consisted
of 101 Turkish individuals (53 boys and 48 girls, 8 to 13 years of age,
mean age 10.90 ± 1.62 years). These subjects were divided into two
groups: unilateral posterior crossbite (23 boys and 28 girls, mean age
10.87 ± 2.01 years) and control (25 boys and 25 girls, mean age 10.93 ±
1.14 years). Each subject’s dental age (according to Demirjian’s dental
maturity score) was determined with an orthopantomogram. A differ-
ence of 6 months at a significance level of P < .05 was considered clini-
cally significant, so the power of the statistical test was 85%. Results:
No sexual dimorphism was detected for the chronological or dental
age in either group. In both groups, the dental ages determined from
Demirjian and Goldstein’s tables were more advanced than the chrono-
logical ages. Dental age did not differ significantly between sides. Sub-
jects with a posterior crossbite had a tendency for a delayed dental
maturation compared to the control individuals. A difference of about
1 month was observed between the right and left sides in the crossbite
and control groups. Conclusion: The difference in dental age between
the crossbite and control groups was big enough to be clinically rele-
vant. No significant side differences in either group were detected.
World J Orthod 2009;10:383–388.

Key words: crossbite, dental age, dental maturation

xamining the formation and eruption Tooth maturation is a multifactorial


E of the teeth in periapical or panoramic
radiographs can be used to assess the
phenomenon. Although Garn et al 11
thought that genes, hormones, and calo-
1Associate Professor and Chair, physiologic maturity of an individual with- ries play a role in dental development,
Department of Orthodontics, Faculty out resorting to hand-wrist radiographs.1 Demirjian12 indicated that dental matura-
of Dentistry, Erciyes University, Kay-
Dental maturity can be determined via tion is largely environmentally influenced.
seri, Turkey.
2Research Assistant, Department of the various stages of tooth formation and Differences in the dental development
Orthodontics, Faculty of Dentistry, eruption.1–9 Dental eruption is influenced between various Angle Classes have not
Erciyes University, Kayseri, Turkey. by various factors such as crowding, yet been investigated. Only Janson et al13
3Assistant Professor, Department of
extractions, ankylosis, ectopic positions, and Jamroz et al14 evaluated the dental
Orthodontics, Faculty of Dentistry,
and persistence of primary teeth. Emer- maturation in patients with short and
Erciyes University, Kayseri, Turkey.
gence into the oral cavity usually occurs long faces. These studies were based on
CORRESPONDENCE when 75% of the root formation is com- the fact that Nanda15 evidenced a differ-
Dr Tancan Uysal plete. Tooth formation is thought to be a ence in the timing of the adolescent
Erciyes Üniversitesi more reliable criterion for determining growth spurt when comparing subjects
Dis Hekimligi Fak. Ortodonti AD
Melikgazi, Kayseri 38039 dental maturation than tooth eruption.3,4 with either a skeletal open or deep bite.
Turkey As such, the Demirjian et al10 analysis is Janson et al13 showed that subjects with
Email: tancanuysal@yahoo.com based on tooth mineralization. a long face have in principle a dental

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Uysal et al WORLD JOURNAL OF ORTHODONTICS

maturation advanced by 6 months in • No previous orthodontic treatment


comparison to short-face subjects. How- • No signs or symptoms of TMD (tem-
ever, according to Jamroz et al,14 the dif- poromandibular disorder)
ference in dental age between patients • No missing teeth (excluding third
with long and short facial configurations molars)
is not enough to be clinically significant. • No caries lesions, extensive restora-
In patients with a unilateral posterior tions, or pathologic periodontal status
crossbite, the buccal cusps of the maxil- • Pretreatment records taken between
lary teeth occlude lingually to the buccal 2004 and 2007
cusps of the corresponding mandibular
teeth.16 Crossbites are associated with
asymmetric muscular function, ie, the Control group
muscle activity level in maximum occlu-
sion and during chewing on the crossbite Fifty subjects (25 boys, 25 girls) met the
side is lower compared to the noncross- following selection criteria:
bite side and the controls.17 In children
with unilateral posterior crossbites, the • Normal transversal posterior occlusion
two condyles occupy a different position • Caucasian
in their fossae.18 This asymmetric mor- • Angle Class I, normal overjet and over-
phology and function reflects a dissimilar bite, and coincidence of both dental
development of the mandible. The back- midlines
ground of this investigation is that this • Good facial symmetry
asymmetric development and bite force • No missing teeth (excluding third
might affect the dental development and molars)
tooth eruption. • No significant medical history
• No previous trauma or orthodontic,
prosthodontic, or surgical treatment
MATERIALS AND METHODS • Pretreatment records taken between
2004 and 2007
This investigation was designed as a
cross-sectional study. The material con- All orthopantomograms were assessed
sisted of 101 patients (53 boys, 48 girls) in a dark room with a radiographic illumi-
of the Orthodontic Department, Faculty nator to ensure contrast enhancement.
of Dentistry, Erciyes University. Their age Tooth mineralization was rated according
ranged from 8 years to 13 years with a to the method described by Demirjian et
mean age of 10.90 ± 1.62 years (boys al10 (eight stages, Table 1).
10.93 ± 1.40 years, girls 10.87 ± 1.81
years).
Determination of dental maturity
scores and dental age
Unilateral posterior prossbite
proup In children, dental age is defined accord-
ing to scores of tooth mineralization.19
Fifty-one patients (23 boys, 28 girls) met These scores were recorded for all seven
the following selection criteria: teeth on the left and right side of both
jaws separately for boys and girls.20 The
• Unilateral posterior crossbite involving total score of all teeth constitutes the
at least two posterior teeth dental maturity of each segment. This
• Caucasian score can be converted directly into a
• Mandibular dental midline deviation specific dental age by using the standard
of at least 1 mm to the crossbite side table for boys and girls.
• No functional deviation of the mandible
• No systemic disease or developmental
or acquired craniofacial or neuromus-
cular deformity

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VOLUME 10, NUMBER 4, 2009 Uysal et al

Table 1 The eight stages of tooth development according to Demirjian et al10


Stage A Mineralization of single occlusal points without fusion.
Stage B Fusion of mineralization points; the contour of the occlusal surface is recognizable.
Stage C Enamel formation has been completed at the occlusal surface, and dentin formation has
commenced. The pulp chamber is curved, and no pulp horns are visible.
Stage D Crown formation has been completed to the level of the amelocemental junction. Root forma-
tion has commenced. The pulp horns are beginning to differentiate, but the walls of the pulp
chamber remain curved.
Stage E The root length remains shorter than the crown height. The walls of the pulp chamber are
straight, and the pulp horns have become more differentiated than in the previous stage. In
molars, the radicular bifurcation has commenced to mineralize.
Stage F The walls of the pulp chamber form an isosceles triangle, and the root length is equal to or
greater than the crown height. In molars, the bifurcation has developed sufficiently to give the
roots a distinct form.
Stage G The walls of the root canal are parallel, and the apex is partially open. In molars, only the dis-
tal root is rated.
Stage H The root apex is completely closed (distal root in molars). The periodontal membrane sur-
rounding the root and apex is uniform in width throughout.

Table 2 Descriptive statistic values of the chronological and dental age of patients
for investigated groups
Chronological age (y) Dental age (y)
Groups n Mean SD SE Min Max Mean SD SE Min Max

Unilateral cross bite


Male 23 10.88 1.76 0.37 8.00 13.92 11.38 2.55 0.53 7.40 16.00
Female 28 10.87 2.22 0.42 7.25 14.50 11.44 2.78 0.53 6.70 15.80
Total 51 10.87 2.01 0.28 7.25 14.50 11.42 2.65 0.37 6.70 16.00
Control sample
Male 25 10.99 1.02 0.20 7.92 12.50 14.06 4.00 0.80 8.63 26.93
Female 25 10.88 1.27 0.25 8.08 12.92 13.89 1.67 0.33 10.03 15.80
Total 50 10.93 1.14 0.16 7.92 12.92 13.97 3.03 0.43 8.63 26.93

n = sample size; SD = standard deviation; SE = standard error; Min = minimum; Max = maximum.

Statistical analysis pared with the independent sample t test.


From a clinical research–planning per-
All statistical analyses were performed spective, a dif ference of at least
using SPSS software (Statistical Package 6 months between two variables was
for Social Sciences for Windows 10.1). considered significant. Taking 6 months
Means, standard deviations, and errors of as clinically significant at a level of
chronological and dental age were calcu- P < .05 with a sample size of 50, the
lated for each segment in the crossbite power of the statistical test was 85%.21
and control group separately for each sex. A single investigator (A.Y.) assessed all
A paired-sample t test was used to com- dental maturity scores and ages. Dental
pare the dental age values of the left and maturity was reassessed in 15 randomly
right sides in the control group and the selected individuals after a 30-day inter-
crossbite and noncrossbite side in the val. The reliability in dental age assess-
crossbite group. Dental age between ment was r = .94.
crossbite and control patients was com-

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Uysal et al WORLD JOURNAL OF ORTHODONTICS

Table 3 Descriptive statistic values and statistical comparisons of the variations of


the dental age (in years) from one side to the other
Unilateral crossbite Control
Crossbite side Control side Right side Left side
Groups Mean SD SE Mean SD SE P Mean SD SE Mean SD SE P

Maxilla 11.41 2.92 0.41 11.34 2.80 0.39 NS 13.39 2.22 0.31 13.29 2.15 0.33 NS
Mandible 11.41 2.63 0.37 11.50 2.59 0.36 NS 13.28 1.74 0.25 13.25 1.80 0.25 NS

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

Table 4 Statistical comparison of the dental age (in years) in the two
studied groups
Maxilla Mandible
Groups n Mean SD SE P Mean SD SE P

Crossbite 51 11.32 2.83 0.40 *** 11.49 2.62 0.37 ***


Control 50 13.36 2.20 0.31 13.25 1.73 0.24
n = sample size, SD = standard deviation, SE = standard error, ***P < .001.

RESULTS jaws (P < .001) in both groups. Tooth mat-


uration was delayed 2.04 years in the
Table 2 shows the descriptive statistics of maxilla and 1.77 years in the mandible in
the chronological and dental age for both the crossbite group as compared to the
groups and sexes, separately and com- control group. This finding is statistically
bined. The dental age had a tendency to and clinically significant.
be more advanced in both sexes of the
control group as compared with the cross-
bite group. No sexual dimorphism was DISCUSSION
detected for chronological and dental age
in the investigated groups. When the com- Age estimation by means of tooth devel-
bined groups are evaluated, the mean opment has long been used. After all,
dental age of the control and the cross- tooth development corresponds well with
bite group was 13.97 ± 3.03 years and chronological age because it is only
11.42 ± 2.65 years, respectively. In both slightly affected by exogenic factors such
groups, the dental age as determined by as malnutrition or systematic dis-
Demirjian and Goldstein’s20 tables was eases.22,23
slightly advanced as compared to the The differences among populations,
chronological age. methods, and observers are important
The mean, standard deviation, stan- shortcomings of research related to matu-
dard error, and the statistical results are rity indicators. To overcome some of these
presented in Table 3. There were no sig- limitations, all subjects in the present
nificant differences in the dental age study were Turkish Caucasians and all
between sides or jaws of both groups. orthopantomograms were evaluated by
Table 4 shows the statistical compar- one skilled observer. In their study, Jam-
isons of the dental age between the roz et al14 included only individuals who
crossbite and control group. Significant were seen between 1990 and 2000 to
differences were determined for both avoid any possible influence of a secular

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VOLUME 10, NUMBER 4, 2009 Uysal et al

trend. 24 Similarly, here, only patients The significant difference in dental


whose orthopantomograms were taken development between individuals of the
between 2004 and 2007 were evaluated. crossbite and control group could be
In the literature, a range of classifica- explained with their individual genetic
tions for evaluating tooth mineralization background,34 which mutually influences
is found. Such classifications were pre- facial and dental development.
sented by Nolla,4 Kullman et al,22 Gleiser The present sample ranged in age
and Hunt,25 and Moorrees et al.26 How- from 8 to 13 years with a mean age of
ever, some of these identify a large num- 10.90 ± 1.62 years. Hagg and Matsson29
ber of stages that are difficult to delimit indicated that Demirjian’s method was
from one another. The Demirjian et al10 highly accurate for younger age groups
classification distinguishes only four but was inaccurate in older children.
stages of crown development (stages A to Thus, it cannot be excluded that the
D) and four stages of root development somewhat older children in the present
(stages E to H). This system uses no evaluation have obscured possible differ-
numeric identification so as to not imply ences in the dental maturity.
that the dif ferent stages represent
processes of the same duration. All the
stages are defined by changes of shape. CONCLUSION
In their study, Dhanjal et al27 concluded
that the Demirjian et al 10 method per- From this study, the following conclusions
formed best not only for intra- and inter- were drawn:
examiner agreement but also for the
correlation between chronological and • No significant differences in the den-
developmental age. Because of all these tal age on either side were present
reasons, this classification was selected between crossbite patients and con-
for this study. trol individuals.
Table 2 allows a more detailed compar- • The crossbite patients presented a ten-
ison of the sample. The boy control group dency for a delayed dental maturation
was on average chronologically 1 month as compared to the control individuals.
older than the boy crossbite group; simi-
larly, the dental age was higher. Liversidge
et al 28 (British), Hagg and Matsson 29 REFERENCES
(Swedish), Loevy and Goldberg30 (Cau-
casian American), Nystrom et al 31 1. Coutinho S, Buschang PH, Miranda F. Relation-
ships between mandibular canine calcification
(Finnish), and Leurs et al 32 (Dutch) stages and skeletal maturity. Am J Orthod
showed that the French–Canadian dental Dentofacial Orthop 1993;104:262–268.
age standards derived by Demirjian et 2. Krailassiri S, Anuwongnukroh N, Dechkunakorn
al10 could not be considered suitable for S. Relationships between dental calcification
the respective populations. This was also stages and skeletal maturity indicators in Thai
individuals. Angle Orthod 2002;72:155–166.
true for the present study. Therefore, pop- 3. Fanning EA. Effect of extraction of deciduous
ulation-specific dental age standards in a molars on the formation and eruption of their
big sample with the methodology of successors. Angle Orthod 1962;32:44–53.
Demirjian et al10 must be developed. 4. Nolla CM. The development of the permanent
Proffit and Fields33 indicated that devi- teeth. J Dent Child 1960;27:254–263.
5. Lewis AB, Garn SM. The relationship between
ations of tooth maturation or eruption on tooth formation and other maturational factors.
the two sides of a dental arch are fre- Angle Orthod 1960;30:70–77.
quent. They claimed that the difference 6. Green LJ. Interrelationship among height,
normally amounts to only a few months. weight and chronological, dental and skeletal
In this study, no significant side differ- age. Angle Orthod 1961;31:189–193.
7. Garn SM, Lewis AB, Bonne B. Third molar for-
ences in the crossbite and control group mation and its developmental course. Angle
were observed (Table 3). An approximate Orthod 1962;44:270–276.
1-month variation between both sides in
the crossbite and control group became
apparent.

387

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Uysal et al WORLD JOURNAL OF ORTHODONTICS

8. Chertkow S, Fatti P. The relationship between 22. Kullman L. Accuracy of two dental and one
tooth mineralization and early radiographic evi- skeletal age estimation method in Swedish ado-
dence of the ulnar sesamoid. Angle Orthod lescents. Forensic Sci Int 1995;75:225–236.
1979;49:282–288. 23. Melsen B, Wenzel A, Miletic T, Andreasen J,
9. Uysal T, Sari Z, Ramoglu SI, Basciftci FA. Rela- Vagn-Hansen PL, Terp S. Dental and skeletal
tionships between dental and skeletal maturity maturity in adoptive children: Assessments at
in Turkish subjects. Angle Orthod 2004;74: arrival and after one year in the admitting
657–664. country. Ann Hum Biol 1986;13:153–159.
10. Demirjian A, Goldstein H, Tanner JM. A new sys- 24. Nadler GL. Earlier dental maturation: Fact or
tem of dental age assessment. Hum Biol 1973; fiction? Angle Orthod 1998;68:535–538.
45:211–227. 25. Gleiser I, Hunt EE. The permanent mandibular
11. Garn SM, Lewis AB, Kerewsky RS. Genetic, nutri- first molar: Its calcification, eruption and decay.
tional, and maturational correlates of dental Am J Phys Anthropol 1955;13:253–283.
development. J Dent Res 1965;44:228–242. 26. Moorrees CFA, Fanning EA, Hunt EE Jr. Age vari-
12. Demirjian A. Dentition. In: Falkner F, Tanner JM ation of formation stages for ten permanent
(eds). Human Growth, vol 2. New York: Plenum teeth. J Dent Res 1963;42:1490–1502.
Publishers, 1978:413–444. 27. Dhanjal KS, Bhardwaj MK, Liversidge HM.
13. Janson GRP, Martins DR, Tavano O, Dainesi EA. Reproducibility of radiographic stage assess-
Dental maturation in subjects with extreme ver- ment of third molars. Forensic Sci Int 2006;159
tical facial types. Eur J Orthod 1998;20:73–78. (suppl 1):S74–77.
14. Jamroz GMB, Kuijpers-Jagtman AM, van’t Hof 28. Liversidge H, Speechly T, Hector MP. Dental
MA, Katsaros C. Dental maturation in short and maturity in British children: Are Demirjian’s
long facial types. Is there a difference? Angle standards applicable? Int J Paediatr Dent
Orthod 2006;76:768–772. 1999;9:263–269.
15. Nanda SK. Patterns of vertical growth in the 29. Hagg U, Matsson L. Dental maturity as an indi-
face. Am J Orthod Dentofacial Orthop 1988;93: cator of chronological age: The accuracy and
103–116. precision of three methods. Eur J Orthod
16. Kiki A, Kilic N, Oktay H. Condylar asymmetry in 1985;7:25–34.
bilateral posterior crossbite patients. Angle 30. Loevy HT, Goldberg AF. Shifts in tooth matura-
Orthod 2007;77:77–81. tion patterns in non-French Canadian boys.
17. Sonnesen L, Bakke M, Solow B. Bite force in Int J Paediatr Dent 1999;9:105–110.
pre-orthodontic children with unilateral cross- 31. Nystrom M, Ranta R, Kataja M, Silvola H. Com-
bite. Eur J Orthod 2001;23:741–749. parisons of dental maturity between the rural
18. Hesse KL, Artun J, Joondeph DR, Kennedy DB. community of Kuhmo in northeastern Finland
Changes in condylar position and occlusion and the city of Helsinki. Community Dent Oral
associated with maxillary expansion for correc- Epidemiol 1988;16:215–217.
tion of functional unilateral posterior crossbite. 32. Leurs IH, Wattel E, Aartman IH, Etty E, Prahl-
Am J Orthod Dentofacial Orthop 1997;111: Andersen B. Dental age in Dutch children. Eur J
410–418. Orthod 2005;27:309–314.
19. Gustafson G, Koch G. Age estimation up to 16 33. Proffit WR, Fields HW. Contemporary Orthodon-
years of age based on dental development. tics, ed 3. St Louis: Mosby, 2000.
Odontol Rev 1974;25:297–306. 34. Garn SM, Lewis AB, Polacheck DL. Sibling simi-
20. Demirjian A, Goldstein H. New systems for den- larities in dental development. J Dent Res
tal maturity based on seven and four teeth. 1960;39:170–175.
Ann Hum Biol 1976;3:411–421.
21. Marks RG. Design of Research Projects. The
Basics of Biomedical Research Methodology.
New York: Van Nostrand Reinhold Company,
1985.

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WORLD NEWS

7th International Orthodontic Congress to offer


global perspective on the specialty of orthodontics
Registration deadline is January 31, 2010; onsite registrations Clinician’s Delight – The Aesthetics and Performance of Ortho-
will be taken after this date dontic Appliances.” Both of these workshops will be held Friday,
The 7th International Orthodontic Congress (IOC) and the February 5.
4th Meeting of the World Federation of Orthodontists (WFO) will A distinguished group of leaders in the orthodontic specialty
draw the world of orthodontics together February 6 to 9, 2010, at will give the course on temporary anchorage devices (TADs) and
the Sydney Convention & Exhibition Centre in Sydney, Australia. microimplants. The speakers will feature doctors from northern
Be part of this historic event that occurs only once every 5 years. Asia and many other parts of the world. Dr Junji Sugawara of
Orthodontists, allied dental health professionals, and ortho- Japan and Dr Young-Cheol Park of Korea, two of the pioneers in
dontic staff may register for the conference through January 31, the field, will each chair a session, along with Dr Hee-Moon
2010. After this date, registrations will be taken onsite. Register Kyung of Korea and Dr John Jin-Jong Lin of Taiwan. At the end of
online at www.wfosydney.com. This Web site offers complete the day, Dr Jason Cope of the United States will offer a summary
details on the 7th IOC, as well as information on tour opportuni- of the factors important to the success of TADs.
ties and general information about Sydney. At the end of the The second workshop embraces the recent history of remov-
early registration period in October, more than 2,200 individuals able appliances (conventional and sequential), fixed lingual and
from 85 countries had registered for the congress. buccal appliances (metallic and ceramic), and retention appli-
The WFO, the Australian Society of Orthodontists (ASO), and ances. Dr Anmol Kalha of India will offer an evidence-based sum-
the Asian Pacific Orthodontic Conference are the official hosts of mary at the close of the workshop. Most of the speakers for this
the 7th IOC. These organizations look forward to welcoming workshop have commercial allegiances.
orthodontists and their staff members to Australia. “I sincerely believe that no delegate should miss attending a
“Everyone should visit Sydney once in their lifetime,” said precongress workshop,” Dr Watson said. “The greatest difficulty
Dr B. Ian Watson, chair of the 7th IOC Scientific Programme. “As will be in deciding which one to attend, as delegates will not be
orthodontists, this is a great time to do so and to bring the fam- able to move from one to the other unless fees have been paid
ily. We believe the Scientific Programme is absolutely excellent, for both. These courses represent extraordinary value for the
the Social Programme will delight, and Sydney is one of the material being presented. These events will set the stage for the
world’s truly great cities. Our country is safe, and it is beautiful. next four days and should not be missed. Where else can one
Hence, there are many good opportunities for additional touring. witness such an array of talented speakers? Nowhere—only in
The Australian Society of Orthodontists’ members are ready to Sydney.”
host you for a great experience.” Scientific Programme Highlights
Dr Rick Olive, chair of the Sydney International Orthodontic Dr William R. Proffit, Kenan Professor of Orthodontics at the Uni-
Congress Committee (SIOCC), hopes each delegate leaves the versity of North Carolina at Chapel Hill, is the principal speaker
7th IOC with great knowledge and fond memories. for the 7th IOC. He will deliver his lecture “New Approaches, New
“If every delegate leaves Sydney with an enhanced sense of Technologies in Modern Orthodontics” Saturday, February 6.
the strength of the scholarship, science, and commitment to “Dr Proffit is a very, very worthy selection as the principal
excellence of orthodontists, wherever they live in the world, then speaker,” Dr Watson said. “He has made an outstanding contri-
the 7th IOC will have been worthwhile, and the WFO will bene- bution to the specialty of orthodontics, and there is no doubt
fit,” Dr Olive said. “If they take away some special memories of that he will offer a wonderful presentation that will inform and
Sydney and Australia to match mine from San Francisco, Chicago, challenge delegates and, in particular, inspire all presenters to
and Paris, then the aura of the IOCs will be enhanced, too.” raise the bar.”
The SIOCC urges orthodontists to make an early decision to This lecture will kick off the Scientific Programme for the 7th
participate in the 7th IOC and to book travel, accommodations, IOC, which will feature many keynote speakers and invited
and tours now. Those who are coming into Australia from over- speakers. Go to www.wfosydney.com to review the extensive list
seas should also apply for visas. of speakers.
Precongress Workshops “Across all of the Scientific Programme, including the pre-
The 7th IOC will feature two precongress workshops: “Temporary congress workshops and the World Village Day, more than one-
Anchorage Devices/Microimplants in Orthodontics” and “The third of the speakers will be drawn from the Asian region,”

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VOLUME 10, NUMBER 4, 2009 World News

Dr Olive said. “This appropriately reflects the growing importance opened the opportunity to regional associations from all conti-
of Asian orthodontists and their strong contribution to research. nents. The Village Day is on the third day, Monday, so it should
Western orthodontists’ appreciation of the strength of Asian be recognized as an integral part of the Scientific Programme,
orthodontic research has been growing, and the exposure of so with every lecture open to all delegates.”
many Asian orthodontic academics on the 7th IOC Scientific Pro- Allied Dental Health Professionals and Staff Programme
gramme will strengthen the scientific content of the congress The Allied Dental Health Professionals and Staff Programme,
and fairly showcase the achievements of our Asian colleagues.” featuring many respected Australian and international speakers,
In addition to the lectures, attendees can view 76 oral has been structured to improve the depth of clinical and profes-
abstract presentations covering 38 topics. More than 600 indi- sional knowledge of all members of the orthodontic team.
viduals from 63 countries submitted abstracts to the SIOCC. In addition, 10 orthodontic nurses or clerical staff will compete
“The quality and diversity of the abstracts ensured that we were in the World Champion Orthodontic Nurses and Clerical Staff
able to select two excellent oral presentations for every one of Competition Monday, February 8. All attendees are welcome to
the 38 topics in the main Scientific Programme,” Dr Olive said. watch this competition.
Poster presentations are also part of the Scientific Pro- To learn more about the Allied Dental Health Professionals
gramme. The majority of the posters will be presented electroni- and Staff Programme, go to www.wfosydney.com.
cally. “We have been thrilled that almost all the presenters have
chosen to make electronic presentations,” Dr Watson said. “We Social Programme
are very excited about this innovative switch to electronic format, The Welcome Reception Saturday, February 6, at the Sydney
and we are sure it will end the (traditional) poster era. We will Convention & Exhibition Centre is complimentary and will feature
have numerous pods, or minitheaters, where delegates can view “unusual Aussie entertainment,” Dr Olive said.
the presentations on screens. Delegates will be able to down- The Stanley Wilkinson Memorial Oration and International
load the presentations, if the presenters agree—and most have. Reception will celebrate one of the founders of the ASO, Dr Stan-
So they (delegates) will be able to take them (the poster presen- ley Wilkinson, who also funded the original corpus of the ASO
tations) home on a ‘stick’. This is a very exciting development Foundation for Research and Education. The event will be held
and should win virtual universal acceptance from presenters and Sunday, February 7 at the Sydney Opera House Concert Hall.
delegates alike.” “This function is a fixture of the Australian Orthodontic Con-
gresses and will give delegates an opportunity to attend and
World Village Day enjoy the Sydney Opera House,” Dr Olive said.
A unique aspect of the 7th IOC is the World Village Day on Mon- The Presidents’ Reception on Sydney Harbour will be held
day, February 8. This day will feature the 22nd Australian Ortho- Monday evening, February 8. Participants will enjoy an evening
dontic Congress, lectures offered by the Arab Orthodontic Soci- cruise on board the Captain Cook “MV2000.”
ety, the 7th Asian Pacific Orthodontic Conference, lectures The final social event will be the Gala Dinner Tuesday
offered by the British Orthodontic Society, the European Village evening, February 9. This event at the Sydney Convention & Exhi-
Day, and the South American Village Day. All of the sessions are bition Centre will feature dinner, drinks, and music.
open to congress attendees. To learn more about these events and ticket prices, go to
“I have been most impressed by the engagement of all parts www.wfosydney.com.
of the world in the World Village Day,” Dr Olive said. “The SIOCC
copied the concept from the 6th IOC European Village Day, but

The famous Sydney Opera House will be the site of the Stanley Wilkin- The Blue Mountains border Sydney’s metropolitan area. The mountain-
son Memorial Oration and International Reception February 7, 2010, ous region consists mainly of a sandstone plateau, and the area is dis-
during the 7th International Orthodontic Congress and 4th Meeting of sected by gorges.
the World Federation of Orthodontists. Photo credit: Hamilton Lund. Courtesy Tourism New South Wales.
Photo credit: David Druce. Courtesy Tourism New South Wales.

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WFO announces representatives to


serve on the 2010–2015 WFO Council
To date, the majority of the World Federation of Orthodontists (WFO) affiliate organizations have informed the WFO of their
representatives who will serve on the WFO Council for the next 5 years. The WFO Council will convene February 4, 2010, in conjunction
with the 7th International Orthodontic Congress and the 4th Meeting of the WFO in Sydney, Australia.
Organizations that have not selected their representatives should do so as soon as possible. Please contact Ms Terri Wise of the
WFO Secretariat. Her email address is wfo@wfo.org.

Africa and the Middle East Central and South America


• Egyptian Orthodontic Society – Dr Yehya A. Mostafa • Academia Costarricense de Ortodoncia –
• Emirates Society of Orthodontists – Dr Moza Tehwara Dr Ana Lilia Dobles Jimenez
• Iranian Association of Orthodontists – Representative not • Asociación de Ortodoncistas de Nicaragua –
known at this time Dr Esteban Bendana
• Iraqi Orthodontic Society – Dr Akram Faisal Al-Huwaizi • Asociación Salvadorena de Ortodoncia –
• Israel Orthodontic Society – Dr Silvia Geron and Dr Armando Gutierrez-Oriani
Dr Orna Kaufman • Associaçao Brasileira de Ortodontia e Ortopedia Facial –
• Jordan Orthodontic Society – Dr Sami Sh. B. Samawi Dr Eustaquio A. Araujo
• Kenya Association of Orthodontists – Dr Mohamed Hanif Butt • Guatemalan Association of Orthodontists – Representative
• Kuwait Orthodontic Society – Dr Rasha Hamad Al-Mubarak not known at this time
• Lebanese Orthodontic Association – Dr Ali Fahs • Peruvian Orthodontic Society – Dr Lawrence R. Koenig
• Namibian Society of Orthodontists – Representative not • Sociedad Argentina de Ortodoncia – Dr José C. Elgoyhen and
known at this time Dr Lia Jaquelina Sokolowicz
• Nigerian Association of Orthodontists – Representative not • Sociedad Boliviana de Ortodoncia – Representative not
known at this time known at this time
• Palestinian Orthodontic Society – Representative not known • Sociedad Colombiana de Ortodoncia –
at this time Dr Julio R. Saldarriaga M.
• Saudi Orthodontic Society – Dr Khalid Ibraheem Albadr • Sociedad de Ortodoncia de Chile – Dr Octavio M. Del Real and
• Societe Marocaine d’Orthopedie Dento-Faciale – Dr Hernan Palomino M.
Representative not known at this time • Sociedad de Ortodoncia de Honduras – Representative not
• South African Society of Orthodontists – known at this time
Dr Haydn Harry Bellardie • Sociedad Dominicana de Ortodoncia Inc. – Dr Saqib Khan
• Sudanese Orthodontic Society – • Sociedad Ecuatoriana de Ortodoncia – Dr Gerson Cabezas B.
Dr Omer Elfarouk A. Abuelgasim • Sociedad Panamena de Ortodoncistas – Dr Francisco Lee
• Syrian Orthodontic Society – Dr Jihad Al Chaar • Sociedad Paraguaya de Ortodoncia – Representative not
• Tunisian Orthodontic Society – Representative not known at known at this time
this time • Sociedad Venezolana de Ortodoncia – Representative not
known at this time
Central and East Asia
• Sociedade Brasileira de Ortodontia – Dr Flavia Artese and
• Bangladesh Orthodontic Society – Dr Md. Zakir Hossain Dr Slamad Fernandes Rodrigues
• Chinese Orthodontic Society – Dr Jiu-Xiang Lin,
Dr Tian-Min Xu and Dr Yan-Heng Zhou Europe
• Hong Kong Society of Orthodontists – Dr Ricky W. K. Wong • Asociatia Nationala Romana de Ortodontie –
• Indian Orthodontic Society – Dr Om Prakash Kharbanda and Dr Dragos Stanciu
Dr E. T. Roy • Associazione Specialisti Italiana Ortodonzia –
• Japanese Orthodontic Society – Dr Yasuhiko Asai, Dr Antonio Gracco
Dr Shigemi Goto, Dr Keiji Moriyama and Dr Kazuo Tanne • Azerbaijanian Professional Orthodontic Society –
• Korean Association of Orthodontists – Dr Chung Ju Hwang, Dr Ziba Gasimova
Dr Sang-Cheol Kim and Dr Young Guk Park • Belgian Union of Orthodontists Societies (BUOS) –
• Macau Association of Orthodontics – Dr Wei Lin Dr Bart Maurice Vande-Vannet
• Orthodontic and Dentofacial Orthopaedic Association of • Berufsverband der Deutschen Kieferorthopaden –
Nepal - Representative not known at this time Dr Gundi M. Mindermann
• Pakistan Association of Orthodontists – Dr Amjad Mahmood • British Orthodontic Society – Dr Leslie Joffe and
• Sri Lanka Orthodontic Society – Dr Alison M. Murray
Dr Kasinathar Paranthamalingam • Bulgarian Orthodontic Society – Dr Laura Andreeva
• Taiwan Association of Orthodontists – Dr Ching-Huei Horng • Croatian Orthodontic Society – Dr Mladen Slaj
and Dr Yeong-Charng Yen • Cyprus Orthodontic Society – Dr Abraham Kyriakides
• Thai Association of Orthodontists – Dr Tanan Jaruprakorn • Czech Orthodontic Society – Dr Ivo Marek

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VOLUME 10, NUMBER 4, 2009 World News

• Danish Society of Orthodontic Specialists – Representative • Syndicat des Spécialistes Français en Orthopédie Dento-
not known at this time Faciale – Dr Claude Bourdillat-Mikol
• Dutch Association of Orthodontists – • Turkish Orthodontic Society – Dr Selma T. Elekdag-Turk and
Dr Anne Marie Kuijpers-Jagtman and Dr Yijin Ren Dr Tamer Turk
• German Association of Orthodontists – Dr Christian Scherer • Ukrainian Association of Orthodontists – Representative not
• German Orthodontic Society – Dr Barbel Kahl-Nieke known at this time
• Greek Association for Orthodontic Study and Research – North America
Dr Evangelia E. Stamou
• Academia Mexicana de Ortodoncia – Dr Adan A. Casasa
• Greek Orthodontic Society – Dr Michail Kalavritinos
• American Association of Orthodontists – Dr Robert J. Bray,
• Hungarian Association of Pediatric Dentistry and Orthodontics
Dr John F. Buzzatto, Dr Gayle Glenn, Dr Lee W. Graber,
– Dr Andras Vegh
Dr Brent E. Larson, Dr Morris N. Poole, Dr Michael B. Rogers,
• Icelandic Orthodontic Society – Dr Teitur Jonsson
and Dr Robert E. Varner
• Latvian Orthodontists Association – Representative not
• Asociación Mexicana de Ortodoncia – Dr Roberto Carrillo and
known at this time
Dr Jesus J. Rea
• Lithuanian Orthodontic Society – Dr Antanas Sidlauskas
• Canadian Association of Orthodontists – Dr Robert H. Cram
• Moldavian Association of Dentofacial Orthopedics –
and Dr Ritchie Mah
Representative not known at this time
• Norwegian Association of Orthodontists – Dr Bjorn Kvaran Australia, Indonesia, Malaysia, New Zealand, Philippines, and
• Orthodontic Section of the Finnish Dental Society – Singapore
Dr Pertti Pirttiniemi • Association of Orthodontists, Singapore – Dr Bryce Lee
• Orthodontic Society of Ireland – Dr Georges Takla • Association of Philippine Orthodontists –
• Polish Orthodontic Society – Representative not known at this Dr Ermelinda L. Sabater-Galang
time • Australian Society of Orthodontists – Dr Frederic Shane Fryer
• Professional Society of Orthodontists Russia – and Dr John Michele Razza
Dr Olga Arsenina • Indonesian Association of Orthodontists – Dr Himawan Halim
• Serbian Orthodontic Society – Dr Mirjana Sasic • Malaysian Association of Orthodontists –
• Slovak Orthodontic Society – Representative not known at Dr Noraini Binti Hj. Alwi
this time • New Zealand Association of Orthodontists – Dr Peter V. Fowler
• Slovenian Orthodontic Society – Representative not known at
Regional Affiliate Organizations
this time
• Sociedad Española de Ortodoncia – Representative not • Arab Orthodontic Society – Dr Sami Sh. B. Samawi
known at this time • Asian Pacific Orthodontic Society – Dr Crisanta C. Santayana
• Sociedade Portuguesa de Ortopedia Dento Facial – • Asociación Ibero-Americana de Ortodoncistas –
Dr Americo R. Ribeiro Ferraz Dr Pablo Echarri Lobiondo
• Societa Italiana di Ortodonzia – Dr Carmela Savastano • Asociación Latinoamericana de Ortodoncia –
• Societe Belge d’Orthodontie – Dr Danny G. Op Heij Dr Augusto J. Urena
• Société Française d’Orthopédie Dento-Faciale – • Caribbean Society of Orthodontists –
Dr Jean-Jacques Aknin Dr Sastri Edward Harnarayan
• Societe Luxembourgeoise d’Orthodontie – Dr Germain Becker • European Federation of Orthodontic Specialists Associations –
• Swedish Association of Orthodontists – Dr Heidrun Kjellberg Dr Lars Medin
• Swiss Orthodontic Society – Dr Christos Katsaros • European Federation of Orthodontics – Dr Olivier P. Mauchamp
• European Orthodontic Society – Dr Maja Ovsenik

New voluntary self-assessment system


for European orthodontists takes off
Charged with the responsibility to promote quality orthodontic EFOSA encourages European orthodontists to use ESAS, which
care throughout Europe, the European Federation of Orthodontic provides a controlled comparison of patient data and does not
Specialists Associations (EFOSA) has developed a voluntary self- reveal the identity of the doctors or patients. Orthodontists who
assessment system that allows orthodontists to evaluate their are members of an organization that belongs to EFOSA may regis-
daily clinical practices to determine which factors lead to the ter to use this free evaluation tool at www.esas.nu. (To determine
best patient service. While the EFOSA Self-Assessment System if your professional orthodontic organization belongs to EFOSA, go
(ESAS) has been online since 2008, EFOSA officially announced to www.efosa.eu.)
its availability to orthodontists during the European Orthodontic As of late September, at least 400 practicing orthodontists
Society’s 85th Congress in June in Helsinki, Finland. had registered to use the site. In addition, EFOSA recently began

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World News WORLD JOURNAL OF ORTHODONTICS

offering this resource to postgraduate orthodontic students. dontists, such as those in a particular area or country or those
Orthodontists can also invite their patients to participate in ESAS, who are best-scoring. The orthodontist will also be able to review
which collects their feedback through an online questionnaire. his average per question per questionnaire in comparison to the
Patients’ identities are not revealed to the ESAS users. As the database. “This may help stimulate orthodontists even more to
number of orthodontists using the system increases, the system improve their quality of care,” Dr de Winter said. “Since treat-
will be able to provide more sophisticated statistical comparisons. ment outcome, for the large part, is based on the treatment
Dr Frank de Winter, chair of the EFOSA Quality Committee, processes, this is where the ESAS user should go to study the
which developed ESAS, said ESAS is based on the EURO-QUAL pro- differences per question.”
ject. This project, which was twice funded by the European Union in Entering data into ESAS is not time-consuming, he said.
1993 and 1996, led to the development of a philosophy and com- “Once an orthodontist is a bit familiar with the ESAS Web site,
mon language for quality development in orthodontics. The second it will take him or her just over 5 minutes per case to enter all
phase of the project resulted in the development of the European data into the questionnaires on treatment outcome and on all
Orthodontic Quality Manual, which assists individual orthodontists five phases of treatment processes,” Dr. de Winter said. “Since
in their efforts to develop their own quality system. using outcome indices is made very easy in ESAS, entering all
“ESAS seemed to be a logical initiative for EFOSA, and it also data in PAR takes only 2 minutes, in ICON 1.5 minutes, and IOTN
seemed to be a logical continuation of EURO-QUAL,” said Dr de 30 seconds. A series that is widely used—TO-TP-ICON—takes a
Winter, who contributed to the EURO-QUAL project and practiced total of less than seven minutes. The American Board of Ortho-
orthodontics for 30 years in Heemstede, The Netherlands. “Once dontics Objective Grading System is not yet available in ESAS,
one has set up a quality system in the practice, it would be nice but hopefully will be soon.”
to find out what the end results look like when compared to Dr de Winter encourages orthodontists to enter 20 to 50 con-
other practices, which hopefully helps find ways for continuous secutively finished cases each year.
further improvement of orthodontic care.” “We hope that ESAS will not only be used by the orthodontists
He stresses that ESAS is strictly a voluntary self-assessment who do everything already to provide the best possible care, but
resource. ESAS measures treatment results with the help of a that using ESAS will be so normal to the orthodontic profession
treatment outcome (TO) questionnaire and occlusal indices that it will be used widely and become a basis for continuous
(PAR, ICON and IOTN). The treatment process (TP) questionnaire development of care. In this respect, a quality system like ESAS
then evaluates the total orthodontic process and practice rou- must be in continuous development; there is no indicator of
tines. Once orthodontists enter patient data, they can give the quality that has an eternal value. So we hope and expect that in
patient a login code. The patient can then enter data into the the future the ESAS users will have great input in further devel-
system through the patient satisfaction (PS) questionnaire. opment of the system.”
ESAS will show the orthodontist an outcome as a percentage EFOSA will promote ESAS during the upcoming 7th Interna-
for each item (index, TO, TP and PS) compared to the average of tional Orthodontic Congress and 4th Meeting of the World Feder-
the database. Once the database increases in size, it will be pos- ation of Orthodontists in Sydney, Australia.
sible to compare certain types of treatment and/or certain ortho-

WFO offers guidelines for Postgraduate Orthodontic Education


Review the guidelines at www.wfo.org. sponsoring institution and institutional commitments; program
The Executive Committee of the World Federation of Orthodon- evaluation; resident evaluation; and outcome assessment. The
tists (WFO) received and recently approved the Guidelines for guidelines also include the following appendices: Clinical Care,
Postgraduate Orthodontic Education, which were prepared and Study, and Research Facilities; and Educational Topics.
submitted by a task force that was appointed in 2006. These The WFO Task Force on Guidelines for Postgraduate Ortho-
guidelines may assist countries, associations, and educational dontic Education was chaired by Dr Athanasios E. Athanasiou,
institutions in need in the development or improvement of such president of the WFO. The other members of the task force
specialty programs. It is also anticipated that these detailed rec- included Dr M. Ali Darendeliler (Australia), Dr Theodore Eliades
ommendations will be used by postgraduate program directors (Greece), Dr Urban Hägg (Hong Kong), Dr Brent Larson (United
worldwide and by related educational, scientific, and administra- States), Dr Pertti Pirttiniemi (Finland), Dr Stephen Richmond
tive institutions at all levels of sophistication to measure their (United Kingdom), Dr Kunimichi Soma (Japan), Dr Alexander
respective curriculum against a worldwide standard. Vardimon (Israel), and Dr William Wiltshire (Canada).
These guidelines are now available at http://wfo.org/ These guidelines reflect the WFO’s efforts to offer support to
Guidelines-for-Postgraduate-Orthodontic-Education.cfm. The guide- recognized orthodontic training programs in every region of the
lines were also published in the World Journal of Orthodontics world.
(Volume 10, Number 2).
The guidelines cover 10 elements of postgraduate programs:
program goals and objectives; program duration; residents; faculty;
clinical care, study, and research facilities; required curriculum;

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VOLUME 10, NUMBER 4, 2009 World News

Slovenia to welcome the 86th EOS Congress in 2010


In 2010, the European Orthodontic Society (EOS) will host its Dr Wichelhaus is the featured speaker for Pre-Congress
86th Congress June 15 to 19 at the St Bernardin Adriatic Resort Course I: “Biomechanical Aspects in Orthodontic Treatment.”
and Convention Centre in Portorož , Slovenia. Located in the Dr Bagden and Dr Byloff will deliver Pre-Congress Course II:
heart of Europe, Slovenia is surrounded by the Adriatic Sea and “Active and Passive Self-Ligation: Clarification from Controversy.”
the Alps. This unique geography draws tourists to this European A panel discussion will follow the precongress course on active
Union country throughout the year. The coastal city of Portorož, and passive self-ligation.
also known as the Port of Roses, is a beautiful destination that The postgraduate course is “Time: The Fourth Dimension in
offers a rich history to all who visit. Orthodontics and Dentofacial Orthopaedics.” Dr Baccetti is the
The Scientific Program of the EOS Congress will be as speaker for this session.
dynamic as the country. Scientific topics include biotechnology The Post-Congress Course I is “Role of High-precision Three-
and its future in orthodontics, contemporary diagnostics and dimensional Surface Images in Understanding Facial Morpholo-
treatment approaches, Class III malocclusion, and free topics. gies and Planning Virtual Treatment.” Dr Chung How Kau is the
Dr Urban Hägg will deliver the Sheldon Friel Memorial Lec- speaker. The Post-Congress Course II, a two-day session, is titled
ture. His topic will focus on the facial profile and changes with “The Incognito System in Lingual Orthodontics.” Dr Wiechmann
and without treatment. Keynote speakers include Dr Tiziano Bac- will present this course.
cetti, Dr Alan Bagden, Dr Friedrich Byloff, Dr Renato Cocconi, To learn more about the EOS Congress Scientific Program
Dr Nataša Ihan Hren, Dr Fraser McDonald, Dr Peter Ngan, and special events, go to www.eos2010.si. Register by March
Dr Stephen Richmond, Dr Jože Trontelj, Dr David Turpin, Dr Frank 31, 2010, to qualify for the lowest registration fees. Visit
Weiland, Dr Andrea Wichelhaus, and Dr Dirk Wiechmann. www.slovenia-tourism.si to learn more about Slovenia.

WFO participates in the Graduate Orthodontic Residents Program


to encourage membership among orthodontic residents
For the second year, the World Federation of Orthodontists (WFO) sporting events designed to allow for maximum student interac-
participated in the Graduate Orthodontic Residents Program tion. The schedule also allows the participants to meet with repre-
(GORP) for US and Canadian orthodontic residents/students in an sentatives from the American Association of Orthodontists (AAO),
effort to introduce future orthodontists to the WFO and its mis- the Canadian Association of Orthodontists, and AAO-affiliated
sion. The WFO has accepted student memberships since 2005. organizations.
GORP, which began in 1989 at the University of Michigan, Dr Larson Keso, a member of the WFO Executive Committee,
provides an annual opportunity for future orthodontists to grow represented the WFO at the 2009 and 2008 meetings. This year,
professionally and to create interpersonal relationships among Dr Keso met approximately 200 students and distributed the
colleagues and representatives from orthodontic manufacturers. new WFO information brochure, student membership applica-
The program’s venue alternates between Ann Arbor, Michigan, USA, tion, and registration form for the 7th International Orthodontic
and other university cities. In 2009, the event was held in August Congress (IOC) in Sydney, Australia. Dr Keso also thanked ven-
at the University of Minnesota in Minneapolis, Minnesota, USA. dors who are under contract to exhibit at the 7th IOC. These ven-
The meeting, which is coordinated by the orthodontic resi- dors received a flyer promoting travel and tour options. He
dents/students, attracts between 350 and 400 attendees each invited other vendors who market products and services interna-
year. In addition to the scientific program presented by prominent tionally to consider exhibiting at the 7th IOC. He distributed the
lecturers, orthodontic residents/students participate in social and exhibitor prospectus and travel brochure to these vendors.

News & Announcements


The Canadian Association of Orthodontists (CAO) has elected its new officers. Dr Gerald Zeit of Toronto, Ontario, is
president; Dr Howard Steinman of Ajax, Ontario, is president-elect; Dr Ritchie Mah of Vancouver, British Columbia,
is 1st vice president; Dr Paul Major of Edmonton, Alberta, is 2nd vice president; and Dr Garry Solomon of Belleville,
Ontario, is secretary/treasurer. The CAO elected its officers during its 61st Annual Scientific Session in September
in Kelowna, British Columbia.

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Taiwan Association of AAO, WFO leaders


Orthodontists supports the greet Chinese Orthodontic
Thomas M. Graber Society delegation
WFO Memorial Fund in May

The Taiwan Association of Orthodontists (TAO) presented a Members of the American Association of Orthodontists (AAO)
$500 check to representatives of the World Federation of Board of Trustees and members of the World Federation of
Orthodontists (WFO) in May during the 109th American Associa- Orthodontists (WFO) Executive Committee formally welcomed
tion of Orthodontists Annual Session in Boston, Massachusetts, the Chinese Orthodontic Society (COS) delegation that
USA. The TAO designated the money for the Thomas M. Graber attended the 109th AAO Annual Session in Boston, Massachu-
WFO Memorial Fund. All monies in this fund are used to pur- setts, USA, in May. The Chinese Orthodontic Society became
chase subscriptions to the World Journal of Orthodontics for an affiliate organization of the WFO in 2008.
deserving, qualified academic institutions or deserving individu- Pictured here, from left, are Dr Bin Yan of Nanjing Medical
als, including orthodontic students in need. From left are University School of Stomatology; Dr Xiao-Tong Li, associate
Dr William DeKock, secretary-general of the WFO; Dr Chia Tze professor at Peking University School of Stomatology; Dr Bing-
Kao, past president of the TAO; Dr Athanasios E. Athanasiou, Shuang Zou, associate professor of Peking University School of
president of the WFO; Dr Ching Huei Horng, president of the Stomatology; Dr Zhen Wang of the Huizhou Dental Hospital;
TAO; and Dr Lee Graber, past president of the WFO and the son Dr Shan Wang of the Nanjing Medical University School of
of Dr Thomas M. Graber. Stomatology; Dr Wei-Jie Zhong of the Shanghai Stomatological
This is the second year that the TAO has made this dona- Disease Center; Dr Ai-Ping Huang of a hospital in the Xin Jiang
tion. “All TAO members support the WFO’s efforts to contribute Province; Dr A-Ying Ding, a private practitioner in Beijing;
to world orthodontics,” Dr Kao said. “Dr T.M. Graber was an Dr Yan-Heng Zhou, vice president of the COS; Dr Lee Graber,
honorary member of the TAO. We respect his contributions, AAO president-elect; Dr Tian-Min Xu, president of the COS;
too. It is hoped that the memorial fund can exist forever to help Dr Roberto Justus, president-elect of the WFO; Dr Raymond
those who need it. Although the (TAO’s) donation is small, the George Sr, immediate past president of the AAO; Dr Lin Wang,
TAO will continue doing it as long as the TAO can financially vice president of the COS; Dr Athanasios E. Athanasiou, presi-
support it,” Dr Kao said. dent of the WFO; Dr William DeKock, secretary-general of the
Others who wish to donate to the Thomas M. Graber WFO WFO; Dr Jiu-Xiang Lin, immediate past president of the COS;
Memorial Fund may do so by sending a check in US funds or Dr Rong-Dang Hu, vice dean of the Affiliated Hospital of Wen-
credit card number to the WFO, c/o Ms Terri Wise, executive zhou Medical College; Dr Robert James Bray, president of the
secretary, 401 N. Lindbergh Boulevard, St Louis, MO 63141- AAO; Dr Li-Li Chen, associate professor at Union Hospital, Tongji
7816, USA. If you prefer, a credit card number indicating the Medical College, Huazhong Science and Technology University;
amount of the donation may be faxed to Ms Wise at +1-314- Dr Yan Yan, clinical professor at the 1st Affiliated Dental Hospi-
993-5208. A contribution to this fund is not deductible as a tal of Peking University School of Stomatology; Dr Xin-Hua Sun,
charitable contribution, but may be deductible as a business a professor at Jilin University School of Stomatology; Dr Yan-
expense. Please consult your financial advisor. Ping Zuo, an associate professor at the 1st Affiliated Hospital of
He Bei Medical University; Dr Jian-Yong Wu, vice dean of the
Affiliated Dental Hospital, Nanchang University Jiangxi Medical
College; and Dr Xing Zhong Zhang, a former associate profes-
sor at Peking University School of Stomatology and current
third-year resident at Case Western Reserve University.
Photo credit: Fadi Kheir

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