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Orthodontics Vol 12 No 1 Romano
 

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    Orthodontics Vol 12 No 1 Romano Orthodontics Vol 12 No 1 Romano Document Transcript

    • Volume 12 • Number 1ORTHODONTICS T e A n P a ce f D nto cia E ancemen Formerly World Journal of Orthodontics
    • NEW TITLES FROM Quintessence Biomechanics Orthodontics Eiichiro Nakajima Manual of Biomechanics Wire Bending Orthodontics IN Techniques PRINCIPLES AND PRACTICE IN PRINCIPLES AND PRACTICEManual of Wire Bending Biomechanics in Orthodontics: Lingual Orthodontics: A NewTechniques Principles and Practice Approach Using STb Light LingualEiichiro Nakajima Ram S. Nanda and Yahya Tosun System and Lingual Straight WireThe authors of this step-by-step manual detail the Correct application of the principles of biomechanics Giuseppe Scuzzo and Kyoto Takemotoessential components and techniques of customized leads to highly efficient orthodontic treatment. This The authors detail the latest improvements in thewire bending, including the first-, second-, third-, book introduces students of orthodontics to the evo- STb light lingual system, such as improved patientand fourth-order bends; selection and proper manip- lution of orthodontic technology and the properties comfort, increased predictability of results, short-ulation of pliers; and optimal methods of adjustment of orthodontic materials and outlines the essential ened treatment times, and decreased laboratoryto be used during orthodontic treatment. mechanical principles behind successful orthodontic work. The biomechanical benefits of the STb system96 pp (spiral binding); 288 illus (117 color); treatment. are also explained in full, including comprehensiveISBN 978-0-86715-495-5 (B4955); US $85 168 pp; 350 illus (two-color); chapters on extractive and nonextractive mechanics, ISBN 978-0-86715-505-1 (B5051); US $98 absolute anchorage control, low frictional force, and the lingual straight-wire method. 264 pp; 885 illus (mostly color); 978-1-85097-192-4 (B8846); US $230Pediatric Laser Dentistry: A User’s Guide Invisalign Orthodontic Treatment Handbook of CephalometricGiovanni Olivi, Fred A. Margolis, Richard Bouchez Superimpositionand Maria Daniela Genovese Herman S. Duterloo and Pierre-Georges Planché Esthetics, Growth, and Orthopedics ofLingual and Esthetic Orthodontics the Face: Facial Development andEdited by Rafi Romano Transformation in the Eye of the The Alexander Discipline, Volume 2: Orthodontist and Other Beholders Building Facial Harmony and Stability Joseph G. Ghafari R. G. “Wick” Alexander Available Winter 2012 CALL: (800) 621-0387 (toll free within US & Canada) • (630) 736-3600 (elsewhere) TO ORDER FAX: (630) 736-3633 • EMAIL: service@quintbook.com • WEB: www.quintpub.com QUINTESSENCE PUBLISHING CO INC, 4350 Chandler Drive, Hanover Park, IL 60133 04/11
    • ORTHODONTICS SPRING • 2011 TableofContentsT e A n P a ce f Volume 12 • Number 1D nto cia E ancemen ISSN 2160-2999 (print) ISSN 2160-3006 (online)Editorial 52 52 5 The relevance of orthodontic articles Rafi RomanoForewords 9 Ronald Goldstein/Michael CohenScientific Innovation10 Modification of the bidimensional system 62 Daniel J. Rinchuse/Donald J. Rinchuse22 Posttreatment compliance with removable maxillary retention in a teenage population: A short-term randomized clinical trial Marc Bernard Ackerman/Barry ThorntonTechnology28 AUSOM: A 3D placement guide for orthodontic mini-implants Mahmoud Al-Suleiman/Manal ShehadahControversy 7438 Phantom bite: A survey of US orthodontists Bozena B. Ligas/Maria Therese S. Galang/Ellen A. BeGole/ Carla A. Evans/Gary D. Klasser/Charles S. GreeneInterdisciplinary48 A multidisciplinary approach to the treatment of a horizontally impacted mandibular second premolar: 10-year follow-up Dror Aizenbud/Liran Levin/Shaul Lin/Eli E. MachteiCase Reports60 Orthodontic management of an originally surgically planned treatment of an open bite: A case report Chadi Kassir/Samar Bou AssiPractice Pearls70 Dental amalgam corrosion in vacuum-formed retainers Joseph R. Karam/Daniel J. RinchuseTreatment Planning Challenge75 Missing maxillary lateral incisors: To close or to open?Management78 The dentist as a manager: Building effective relationships and networks for personal and professional advancement Hilla DotanVignettes82 Marc Bernard Ackerman
    • ORTHODONTICST e A n P a ce f PublisherD nto cia E ancemen H. W. Haase Executive Vice President William G. Hartman Director, Journal Publications Lori A. Bateman Managing Editor ISSN 2160-2999 (print) • ISSN 2160-3006 (online) Sally Curran Production Manager Diane Curran Formerly World Journal of Orthodontics Director, Advertising Sales William G. Hartman EDItor-In-ChIEF For advertising and subscription information contact: Quintessence Publishing Co, Inc, 4350 Chandler Drive, rafi romano, DMD, MSc Hanover Park, IL 60133 • Telephone: (630) 736-3600 Toll Free: (800) 621-0387 • Fax: (630) 736-3633 Private Practice of Orthodontics Email: service@quintbook.com • Web site: www.quintpub.com. Tel Aviv, Israel Subscription rates (includes online version): Regular rate for North America is $150 per year; $310 institutional (Canadian subscribers add applicable GST). International rate (outside North America) is $180; $340 institutional. International sub- scribers add $30 to international rate for air mail. Student rate ASSoCIAtE EDItor $50 per year ($80 international); verification should accompany order. Single issue $40. Subscription may begin at any time. Marc Bernard Ackerman, DMD, MBA Claims for missing issues will be serviced only within 6 months of Director of Orthodontics, Children’s Hospital Boston publication date. Otherwise, single-copy price will be charged on missing issues. Subscription orders and changes of address Boston, Massachusetts, USA should be sent to the nearest subscription office. Please allow 6 weeks for any change of address notification to be processed. Copyright © 2011 by Quintessence Publishing Co, Inc. All rights reserved. No part of this journal may be reproduced or EDItorIAL BoArD transmitted in any form or by any means, electronic or mechani- cal, including photocopying, recording, or any information and S. Jay Bowman, DMD, MSD retrieval system, without permission in writing from the publish- Portage, Michigan, USA er. The views expressed herein are those of the individual au- thors and are not necessarily those of the publisher. Information Vittorio Cacciafesta, DDS, MSc, PhD included herein is not professional advice and is not intended to replace the judgment of a practitioner with respect to particu- Milan, Italy lar patients, procedures, or practices. To the extent permissible under applicable laws, the publisher disclaims responsibility for Pablo Echarri, DDS any injury and/or damage to persons or property as a result of Barcelona, Spain any actual or alleged libelous statements, infringement of intel- lectual property or other proprietary or privacy rights, or from the use or operation of any ideas, instructions, procedures, Kurt Faltin Jr, DDS, PhD products, or methods contained in the material therein. São Paulo, Brazil Permission to photocopy items solely for internal or personal use, and for the internal or personal use of specific clients, is nigel harradine, BDS London, granted by Quintessence Publishing Co, Inc, for libraries and FDS rCSEd, FDS Morth, rSCEng, MSc other users registered with the Copyright Clearance Center (CCC) Transaction Reporting Service, provided that the base fee Bristol, United Kingdom of $5 per article plus $.10 per page is paid directly to the CCC, 222 Rosewood Drive, Danvers, MA 01923 (www.copyright.com). John C. Kois, DMD, MSD Identify this publication by including with your payment the fee Seattle, Washington, USA code: ISSN 2160-2999/11 $5 + $.10. Advertising Policy: All advertising appearing in Orthodontics hee-Moon Kyung, DDS, MS, PhD must be approved by the editorial staff. The editorial staff re- Daegu, Korea tains the right to reject advertising. The publication of an ad- vertisement does not constitute on the part of the journal, or publisher a guaranty or endorsement of the quality or value of Stephen rimer, DDS the advertised products or services or of any of the representa- Boca Raton, Florida, USA tions or the claims made by the advertisers. Manuscript submission information can be found on the Maurice A. Salama, DMD ORTHO website (www.quintpub.com). Submit manuscripts at Atlanta, Georgia, USA www.manuscriptmanager.com/ortho. The publisher assumes no responsibility for unsolicited manuscripts. David Sarver, DMD, MS ORTHO (ISSN 2160-2999 [print]; ISSN 2160-3006 [online]) Birmingham, Alabama, USA is published quarterly by Quintessence Publishing Co, Inc, 4350 Chandler Drive, Hanover Park, Illinois 60133. Printed in USA. Postmaster: Send address changes to Quintessence Publishing Co, Inc, 4350 Chandler Drive, Hanover Park, IL 60133.
    • Editorial The relevance of orthodontic articles I n recent years, orthodontic treatment has become extremely common among and accessible to a wide patient base. In 1997, the World Federation of Orthodontists commissioned a study of its affiliated organizationsfor the purpose of gathering information about the global orthodontic com-munity. The countries surveyed covered 54% of the world’s population, ac-counting for nearly 3.3 billion people. The number of orthodontists was 31,000.The highest ratios of orthodontists in relation to population (per 100,000inhabitants) were found in North America, Central and South America, andEurope (1.4 to 2.6).1 Today, with more than 70 accredited orthodontic postgraduate programs inthe United States and Canada, 12 in the United Kingdom, and many more in Asia(in India, for example, about 300 new specialists in orthodontics graduate everyyear), there is a growing number of faculty members (lecturers and professors) atuniversities. The academic component for tenure and promotion compels theseorthodontists to write articles to be published in Medline-indexed journals, pref-erably those with high impact factors. As a result, thousands of articles are sub-mitted to orthodontic journals each year. Orthodontics receives about five newsubmissions each week, or approximately 260 articles per year (meaning thatonly one of every six submitted manuscripts will eventually be published). Most of the articles are rejected, but many of those that are eventually pub-lished have very little clinical significance. In vitro research with poor statis-tics, clinical studies with minimal sample sizes, and conclusions that are notevidence-based are part of every journal. At the same time, journal subscriber-ship constantly decreases. In addition, the variety of free scientific and clinicalinformation online threatens the profitability of printed journals that are notaffiliated with professional societies or study clubs. Our mission is to find a common denominator that will attract clinicians,researchers, and postgraduate students. We have a commitment to stayrelevant, despite today’s tendency for instant messages and 140-character“tweets.” Evidence-based information is the essence of scientific and clini-cal articles. Even in countries where dental awareness is low, there is risinginterest in evidence-based dentistry (EBD).2 For EBD to become part ofdecision making in practice, the most current and comprehensive researchfindings must be translated into practice.3 We should focus on the take-home message rather than satisfying the deans of faculties who quantifythe number of articles published as the essential requirement for academicpromotion. Barriers for implementation of research into practice primarilyinclude lack of interest, lack of involvement, lack of time, and lack of re-muneration.4 As stated by David Turpin, the former editor of the AmericanJournal of Orthodontics and Dentofacial Orthopedics, as journal editors,we have the tools and the responsibility to help readers identify the EBDapproach in each article.5 Volume 12, Number 1, 2011 5
    • Editorial Along with my associate editor, Marc Bernard Ackerman, we have divided the journal into 10 different sections, including the most innovative scientific research, daily clinical pearls, updated technology, patient management tips, “The 10,” interdisciplinary case presentations, and treatment planning challenges, where each orthodontist will find tips for more efficient and esthetic treatment results. Our editorial board members, were carefully selected from all around the world. They have a variety of clinical and scientific backgrounds and are from private and university practices to ensure the relevance of Orthodontics to 21st century demands. I do hope you will enjoy the new concept and encourage your feedback and submission of relevant articles. Together, we can make this journal an essential clinical tool for the contemporary, evidence-based orthodontist. Rafi Romano, DMD, MSc Editor-in-Chief rafi@drromano.com RefeReNCeS 1. Waldman HB, Perlman SP, Schindel R. Update on the imbalanced distribution of orthodontists, 1995–2006. Am J Orthod Dentofacial Orthop 2009;135:704–708. 2. Oladimeji Adeniyi A, Wasiu Lanre A. Evidence-based dentistry in a developing economy—The Nigerian example. Open Dent J 2010;4:51–54. 3. Frantsve-Hawley J, Meyer DM. The evidence-based dentistry champions: A grassroots approach to the implemen- tation of EBD. J Evid Based Dent Pract 2008;8:64–69. 4. Clarkson JE. Getting research into clinical practice—Barriers and solutions. Caries Res 2004;38:321–324. 5. Turpin DL. Consensus builds for evidence- based methods. Am J Orthod Dentofacial Orthop 2004;125:1–2. 6 ORTHODONTICS The Art and Practice of Dentofacial Enhancement
    • ORTHODONTICS T e A n P a ce f D nto cia E ancemen Editor-in-ChiEf AssoCiAtE Editor rafi romano Marc Bernard Ackerman Private Practice of Director of Orthodontics Orthodontics Children’s Hospital Boston Tel Aviv, Israel Boston, Massachusetts, USA EditoriAL BoArd “The 10”s. Jay Bowman Vittorio Cacciafesta Pablo Echarri Kurt faltin Jr nigel harradinePrivate Practice Private Practice Private Practice Professor and Chair Consultant OrthodontistPortage, Michigan Milan, Italy Barcelona, Spain Department of Bristol Dental HospitalUSA Orthodontics and School University Paulista Bristol São Paulo, Brazil United KingdomJohn C. Kois hee-Moon Kyung stephen rimer Maurice A. salama david sarverDirector and Founder Chair Private Practice Clinical Assistant Professor Private PracticeKois Center Department of Boca Raton, Florida of Periodontics Birmingham, AlabamaSeattle, Washington Orthodontics USA University of Pennsylvania USAUSA Kyungpook National Philadelphia, Pennsylvania University Medical College of Georgia Daegu, Korea Augusta, Georgia, USA Private Practice Atlanta, Georgia, USA
    • ORTHODONTICST e A n P a ce f • Abstract/key words. Abstracts should • Original articles are considered for include a maximum of 250 words. publication on the condition they haveD nto cia E ancemen Abstracts for Scientific Innovations not been published or submitted for articles must be structured: Purpose, publication elsewhere. Materials and Methods, Results, and • Manuscripts that are not prepared in Conclusions. Abstracts for all other accordance with these guidelines will beGuidelines For Authors types of articles that require one (see returned to the author before review. description of 10 article categories) need • The editor and publisher reserve the rightORTHODONTICS The Art and Practice of not be structured; these articles should to edit all manuscripts to fit the spaceDentofacial Enhancement (ORTHO) will also include up to 6 key words. available and to ensure conciseness,consider for publication original articles on • Article text. See page limits for the 10 clarity, and stylistic consistency.dentofacial enhancement that fall under the types of articles.following 10 categories: • Acknowledgments. Persons who have ARTICLE ACCEPTANCE made substantive contributions to the Article acceptance is pending receipt of 1. Editorial [Upon request only.] study can be acknowledged at the end images judged to be of sufficient quality 2. Technology [Latest innovation in of the article. Also specify grant or other for publication (see the guidelines below). technology related to orthodontics. financial support, citing the name of Once a manuscript is accepted, authors Abstract mandatory.] the supporting organization and grant should submit high-resolution digital image 3. Controversy [Controversial topics in number. files (on disk) to: orthodontics. Pros and cons should be • Legends. Figure legends should discussed. Abstract mandatory.] be typed as group at the end of the Managing Editor 4. Treatment Planning Challenge [Upon manuscript. Detailed legends are ORTHODONTICS request only. No abstract required.] encouraged. For photomicrographs, Quintessence Publishing Co, Inc 5. Case Reports [Must include high- specify original magnification and stain. 4350 Chandler Drive quality before and after photographs • Tables. Each table should be logically Hanover Park, IL 60133 with full description of treatment organized, typed on a separate page at sequence. No abstract required.] the end of the manuscript, and numbered The disk/package should be labeled with 6. Scientific Innovations [Scientific consecutively. Table title and footnotes the first author’s name, shortened article updates, research—in vivo and in vitro. should be typed on the same page as the title, and code number assigned upon Abstract, discussion, and conclusions table. acceptance. are mandatory.] • Abbreviations. The full term for which an 7. Practice Pearls [Tips and tricks for abbreviation stands should precede its DIGITAL IMAGE FORMAT orthodontists’ daily work. Limit 4 first use in the text unless it is a standard When preparing final images to send, pages. No abstract required.] unit of measurement. consider the following points: 8. Management [Practice management, • Trade names. Generic terms are to • Resolution must be at least 300 dpi when marketing, and psychological aspects be used whenever possible, but trade the image is 3 inches wide. of orthodontic treatment. Limit 6 names and manufacturer name, city, • Images saved in TIFF format are pages. Abstract mandatory.] state, and country should be included preferred, but JPG or EPS files are 9. Interdisciplinary Advances [Cases parenthetically at first mention. acceptable. and/or research with interdisciplinary • Images grouped together must be saved orientation. All disciplines should REFERENCES as individual files. be well presented in the article. No • All references must be cited in the text, • Images containing type should either be abstract required.] numbered in order of appearance. saved as a layered file or provided along10. Vignettes [Stories from the history of • The reference list should appear at the with a second file with type removed. orthodontics, appliance invention, etc. end of the article in numeric sequence. • Line art (graphs, charts, line drawings) Limit 4 pages. No abstract required.] • Do not include unpublished data should be provided as vector art or personal communications in the (Illustrator or EPS files) MANUSCRIPT SUBMISSION reference list. Cite such references • Please do not embed images into other Submit manuscripts via ORTHO’s online parenthetically in the text and include a types of documents (eg, Word, Excel, submission service: date. PowerPoint, etc). www.manuscriptmanager.com/ortho • Avoid using abstracts as references. Follow the simple step-by-step • Provide complete information for each MANDATORY SUBMISSION FORM instructions. As the last step, you will reference, including names of all authors The Mandatory Submission Form upload your manuscript, which should be a (up to six). If the reference is to part of a (accessible at www.quintpub.com) must PC Word (doc) file with tables and figures book, also include title of the chapter and be signed by all authors and can be included at the end of the document. names of the book’s editor(s). uploaded as a separate document with the article submission, or it can be mailedMANUSCRIPT PREPARATION Journal reference style: (see address above) or faxed (630-736-• The journal will follow as much as 1. Pancherz H, Knapp V, Erbe C, Heis 3634) to the ORTHO Managing Editor. possible the recommendations of the AM. Divine proportions in attractive International Committee of Medical and nonattractive faces. World J PERMISSIONS AND WAIVERS Journal Editors (Vancouver Group) in Orthod 2010;11:27–42. • Permission of author and publisher must regard to preparation of manuscripts be obtained for the direct use of material and authorship (Uniform requirements Book reference style: (text, photos, drawings) under copyright for manuscripts submitted to biomedical 1. Sarver DM, Ackerman MB. Dynamic that does not belong to the author. journals: http://www.icmje.org). smile visualization and quantification • Waivers must be obtained for• Manuscripts should be typed in a and its impact on orthodontic diagnosis photographs showing persons. 12-point font and double-spaced. Pages and treatment planning. In: Romano R • Permissions and waivers should be faxed should be numbered. (ed): The Art of the Smile. Chicago: along with the Mandatory Submission• The first page(s) should include the title Quintessence, 2005:99–139. Form to the ORTHO Managing Editor of the article and the complete names, (630-736-3634). academic degrees, titles, professional REVIEW/EDITING PROCESS affiliations, full addresses, faxes, and • Manuscripts will be reviewed by the REPRINTS emails of all authors. The corresponding editors and reviewers with expertise in Reprints can be ordered from the author should be clearly noted; if it is not, the field that encompasses the article. publisher. Authors receive a 40% discount the first author will be assumed to be the • Reviews will be completed within 45 days on quantities of 100 or 200. corresponding author. of article submission.
    • F F wo ds“ or the past several decades, our society has been preoccupied with the subject of beauty and especially ways to make us all look and feel better about ourselves. So I applaud the entrance of anew journal devoted to the scienti c and artistic modalities to help patientslook and feel their best. Orthodontics has once again taken the lead inconvincing both the dental profession and the public of rst thinking of themost ideal and long-lasting treatment to improve facial esthetics. I was strongly in uenced by my uncle, Dr Marvin C. Goldstein, a brilliantorthodontist who wrote one of the very rst extensive papers on treating theadult patient. So my entire career has consisted of interdisciplinary consulta-tions and treatment plans. Unfortunately, over the past decade, the subjectof esthetic compromise using porcelain laminates and other restorative so-lutions has created many ongoing problems, resulting in esthetic failuresseen more and more throughout the world, when orthodontic treatmentwould have been the ideal and most ef cient treatment plan. Therefore, ”I welcome the new journal Orthodontics: The Art and Practice of DentofacialTEnhancement and especially the most quali ed team of Ra and Marc at itshelm. —Ronald Goldstein, DDS“ he world of orthodontics has changed dramatically over the past decade. The concept and practice of interdisciplinary team treatment has opened up more opportunities for orthodontiststo participate in comprehensive case planning than ever before. However, as both treatment planning and treatment have become increas-ingly sophisticated, so too have the demands placed on orthodontists by pa-tients and referring clinicians. Tooth position is only the starting point. In thisexciting new world of orthodontic possibilities, orthodontists by necessity musthave an even greater understanding of the various disciplines of dentistry. When I became aware of the new direction that the World Journal ofOrthodontics was taking, I felt con dent that this new endeavor would bet-ter meet the daily challenges that orthodontists face and, at the same time,more effectively serve all dental disciplines. With new journal sections ad-dressing topics such as clinical controversies, treatment planning challeng-es, practice pearls, and management, I envision a publication which willgenerate great appeal for clinical collaboration in the interdisciplinary team,between study club members, and among dental colleagues. I would like to congratulate Drs Ra Romano and Marc Ackerman for their ”foresight, courage, and energy in introducing this highly relevant publica-tion, Orthodontics: The Art and Practice of Dentofacial Enhancement, to ourprofession. —Michael Cohen, DDS, MSD Volume 12, Number 1, 2011 9
    • Scientific Innovation Modification of the bidimensional system Daniel J. Rinchuse, DMD, MS, MDS, PhD1 Donald J. Rinchuse, DMD, MS, MDS, PhD2 In the mid 1970s, Schudy and Schudy developed and described an edgewise bimetric system in which there were brackets with 0.016-inch slots on the incisors and canines and brackets with 0.022-inch slots on the premolars and molars. Modeling after Schudy and Schudy, Gianelly devised a similar, preadjusted system called the bidimensional system, in which the incisor brackets have 0.018-inch slots while the remaining teeth have brackets with 0.022-inch slots. We have further modified the bidimensional system and developed a dual-slot system. Hence, this article compares the bidimensional and dual-slot systems and provides justification for both. The main concerns regarding the bidimensional and dual-slot systems are posterior “play” and lack of three-dimensional control. We rationalize both as well as the self-ligating hybrid and dual-slot system. ORTHO 2011;12:10–21. Key words: bidimensional, bimetric, self-ligating, dual slot 1Professor and Associate Director, Graduate E Program in Orthodontics, ven though straight-wire, or preadjusted, edgewise appliances have Seton Hill University, Greensburg, Pennsylvania, achieved universal acceptance, there has been little discussion of their USA. clinical advantages in regard to treatment time, chair time, comfort, hy- 2Professor and Program giene, or treatment results. As Harradine noted: “No study ever demonstrat- Director, Graduate Program in Orthodontics, ed that preadjusted edgewise appliances were superior to plain edgewise, Seton Hill University, but the former are overwhelming preferred for reasons that are regarded by Greensburg, Pennsylvania, clinicians as being self-evident and in no need of the highest order of scien- USA. tific proof.”1 In a retrospective study comparing the treatment results of Roth CORRESPONDENCE (straight-wire) and standard edgewise appliances using two occlusal indices, Dr Dan Rinchuse there were no significant differences found between the two appliances.2 In 510 Pellis Road Greensburg, PA 15601 fact, despite using the Roth appliance, experienced orthodontists still found Email: drinchuse@aol.com it difficult to obtain all six keys to normal occlusion. 10 ORTHODONTICS The Art and Practice of Dentofacial Enhancement
    • To this juncture, the purpose of this article is not to demonstrate superior-ity of a modified bidimensional system over other edgewise appliances, butrather to justify our adaptations of Gianelly’s bidimensional system from a ra-tionale viewpoint with the best available evidence.bIMETRIC SySTEMIn the mid 1970s, Schudy and Schudy3 described and rationalized a fixed orth-odontic appliance system that incorporated two bracket slot sizes, which theycalled the bimetric system. It was a standard edgewise appliance system (zerobase) in which the incisors and canines had brackets with 0.016-inch slots andthe premolars and molars had brackets with 0.022-inch slots (Fig 1). They alsoargued for what they called the precision-fit principle, meaning that in the fin-ishing stages, the wires should fully engage the bracket slots, thus eliminatingor significantly reducing “play.” To fully engage and fill the dual-slot brackets,a 0.016 × 0.022-inch stainless steel wire is twisted and torqued 90 degreesdistal to the canines. As a result, a ribbon archwire, 0.022 × 0.016-inch, is cre-ated in the posterior segments.bIDIMENSIONal SySTEMModeling after Schudy and Schudy, Gianelly4 developed a preadjusted, edge-wise bidimensional system that had brackets with 0.018-inch slots on the inci-sors and 0.022-inch slots on the canines, premolars, and molars (Fig 2).Gianelly placed 0.022-inch slots on the canines, whereas Schudy and Schudyhad 0.016-inch slots on the canines. Gianelly made cogent arguments forsmaller bracket slots on the incisors (0.018 × 0.025-inch) for three-dimensionalcontrol and a tight fit as well as for larger bracket slots (0.022 × 0.028-inch) on Volume 12, Number 1, 2011 11
    • Scientific Innovation Modification of the bidimensional system Schudy and Schudy Gianelly 0.016-inch 0.018-inch 0.022-inch 0.022-inch 0.022-inch 0.022-inch 0.022-inch 0.022-inch 0.022-inch 0.022-inch 0.016-inch 0.018-inch Fig 1 (Left) Schudy and Schudy3 advocated brackets with 0.016-inch slots for the incisors and canines (red) and brackets with 0.022-inch slots for the premolars and molars (green). Fig 2 (Right) Gianelly’s bidimensional system4 uses brackets with 0.018-inch slots for the incisors (blue) and brackets with 0.022-inch slots for the canines, premolars, and molars (green). the posterior teeth and a loose fit for sliding mechanics and space closure (Fig 3). (The terms tight fit and loose fit were descriptions used by Gianelly.) Gianelly gave the following justifications for his bidimensional system: “The reason I did this was to combine precision with practicality. For example, one movement that requires torque control is the retraction of the maxillary incisors. In the edgewise technique, full engagement of the wire in the incisor brack- ets is generally necessary to control the axial inclination of the incisors during retraction. I use a 0.018 × 0.025-inch vertically slotted, programmed bracket on the central and lateral incisors and a 0.022 × 0.028-inch vertically slotted bracket posteriorly. For retraction, I simply insert a 0.018 × 0.022-inch wire for full engagement of the incisor brackets and retract the incisors bodily by means of sliding mechanics, because the wire is ’undersized‘ in the buccal segments. According to a New York University study, only 7% of wires ’fill the slots.’ My percentage during incisor retraction approaches 100%. The undersized poste- rior part of the wire also relieves me of the technical burden of adjusting the torque to the posterior brackets. My chair time is reduced, and I dont have to contend with loops that may impinge on the tissues.”5 Gianelly pointed out that few orthodontists fill the edgewise slots, especially for 0.022-inch slot users, so this is support for at least full 3D control of the inci- sors with 0.018 × 0.022-inch or 0.018 × 0.025-inch stainless steel archwires. For space closure, by sliding, Gianelly’s working wires are 0.016 × 0.022-inch 12 ORTHODONTICS The Art and Practice of Dentofacial Enhancement
    • Scientific InnovationRinchuse and Rinchuse 0.018 0.018 0.022-inch 0.018-inch Fig 3 Brackets with (right) 0.018 × 0.025-inch incisor slots and (left) 0.022 × 0.028-inch posterior slots. With a 0.018 × 0.022-inch stainless steel working wire for sliding space closure, the incisor brackets are filled, while in the posterior brackets, the wire is un- dersized for reduced resistance to sliding.stainless steel or 0.018 × 0.022-inch stainless steel with crimp-on hooks distalto the lateral incisor brackets and closed nickel-titanium (Ni-Ti) coils attachedto the crimp-on and molar hooks. He made an important point that for spaceclosure, 0.017 × 0.025-inch or 0.018 × 0.025-inch stainless steel wires are not “ Resistance to sliding is simply a combination of classical friction and a coefficient of binding. ”viable substitutes for the 0.016 × 0.022-inch or 0.018 × 0.022-inch stainlesssteel wires because the horizontal dimension of 0.025 inches creates too muchresistance to sliding for space closure. Resistance to sliding is simply a combi-nation of classical friction and a coefficient of binding. In fact, Gianelly typicallyadvocated using rectangular wires throughout treatment. Nonetheless, a criticism of the bidimensional system is a lack of 3D controlwith full-sized 0.018 × 0.025-inch wires in the incisors but undersized in theposterior teeth due to the 0.022-inch slot. Gianelly’s counter was the same asSchudy and Schudy: To fill the posterior bracket slots, twist a 0.018 × 0.022-inchstainless steel wire 90 degrees distal to the lateral incisors and create a rib-bon arch with 0.022 × 0.018-inch stainless steel wire in the posterior. However,twisting or torquing a wire 90 degrees is cumbersome and unconventional formost orthodontists. Another option is to bend custom torque into rectangulararchwires, as is traditionally done. Be that as it may, these solutions for lack of3D control has never impressed orthodontists enough to adequately justify thebidimensional system. This in part may account for why only 4.7% of respondingorthodontists reported routinely using the bidimensional system.6 Volume 12, Number 1, 2011 13
    • Scientific Innovation Modification of the bidimensional system Table 1 Comparison of the various slot sizes from a perspective of space closure (assuming sliding mechanics) and torque control Slot size advantages Disadvantages 0.018-inch slot Anterior torque control: Full 3D control with Space closure: Lighter undersized stainless steel 0.018 × 0.025-inch archwires wires more prone to deformation and notching 0.022-inch slot Space closure: Larger, stiffer undersized stain- Torque control: Full-sized 0.022 × 0.028-inch less steel wires, less deformation and notching archwires are too stiff to be used so undersized finishing wires must be used Bidimensional Space closure: Larger, stiffer undersized (dual-slot) 0.018- and rectangular wires (0.016 × 0.022- or 0.018 × 0.022-inch slots 0.022-inch), less deformation and notching with 0.022-inch slots in posterior teeth, and effective 3D control of incisors during space closure with 0.018-inch slot in the anterior. Anterior torque control: Full 3D control with Possible loss of posterior 3D control with 0.018 × 0.025-inch archwires full-sized 0.018 × 0.025-inch archwires (counterarguments made in this article) MODIFICaTION OF THE bIDIMENSIONal SySTEM: THE Dual-SlOT SySTEM Having worked with Gianelly’s bidimensional system for over 20 years, we have developed some conceptual and mechanical alterations, which, for communi- cation purposes, we will call the dual-slot system. It must be noted, however, that Gianelly deserves the credit for providing the foundation and framework for our modification of the bidimensional system. Proffit et al7 argued the advantages and disadvantages of the 0.018-inch slot vs the 0.022-inch slot from the perspective of sliding mechanics and torque control (Table 1). For instance, Proffit et al7 stated that sliding teeth along an archwire necessitates at least 2 mil (0.002-inch) of clearance— 4 mil (0.004-inch) of clearance is desirable. So, with this principle, the ad- vantage of a 0.022-inch slot would be that larger 18 mil (0.018-inch) wires could be used (compared to 16 mil [0.016-inch] wires in an 0.018-inch slot). Therefore, larger, stiffer wires would have fewer tendencies for notching and deformation. So, specifically for space closure by sliding, it would be advantageous to have brackets with 0.022-inch slots posterior to the ex- traction spaces for a looser fit, reduced resistance to sliding, and the use of stiffer wires. However, for torque control in the incisors, it is better to have brackets with 0.018-inch slots because full-sized wires can be engaged if full 3D control is necessary. A 0.022-inch slot would not be advantageous for torque control since full-sized 0.022 × 0.028-inch wires are too stiff to be engaged into the bracket slots. Therefore, using Proffit et al’s7 rationalization, a bidimensional system would integrate the best of both the 0.018-inch and 0.022-inch slot systems: a tight fit in the incisors for full 3D control and a loose fit elsewhere for space closure by sliding. As an aside, various studies have shown that treat- ment times are shorter8–10 and outcomes may be better with a 0.018-inch slot compared to a 0.022-inch slot.8 14 ORTHODONTICS The Art and Practice of Dentofacial Enhancement
    • Scientific InnovationRinchuse and Rinchuse In regard to criticism of play or lack of 3D control in the posterior segmentswith the bidimensional or dual-slot system, as a conceptual difference, wehave never twisted a 0.018 × 0.022-inch stainless steel wire distal to the lateralincisors in an attempt to enhance 3D control in the posterior, as advocated byGianelly and Schudy and Schudy. If most orthodontists using a 0.022-inch slotfinish with 0.019 × 0.025-inch wires,11 a full-sized 0.018 × 0.025-inch wire ina bidimensional or dual-slot system is not much different. Customized torquecan still be used in the posterior segments if necessary. Furthermore, it has been shown that there is tremendous morphologic vari-ability in the facial surfaces of teeth.12–15 Specifically, Germane et al12 reportedthe greatest variability in the posterior teeth. Even a very slight difference inbracket height placement, as little as 1 mm, could alter tooth inclination asmuch as 10 degrees.12 Creekmore and Kunik16 elaborated on this argumentand showed that variations in tooth structure, such as variable facial surfaces,crown-root angulations, and atypical crown shape, warrant variations in tip,torque, rotation, and height parameters to obtain optimal results for each tooth. In reference to a recent article by Mulligan,17 which differentiated the mo-ments created with full vs partial appliances, Keim18 noted that “one of themost common mistakes that arises as a result of standardized treatment proto-cols is the tendency to place full appliances in every case. Not only is this un-necessary in many patients, but if we analyze the resulting force systems, it mayactually be contraindicated.” Furthermore, Mulligan19 often avoided bracket-ing the premolars and sometimes canines so that these teeth could be used togauge whether the arches are expanding or constricting. Some have called thisthe neutral zone: equilibrium between lips, cheeks, tongue, and muscle forcesexerted on teeth, particularly in the buccal segments, and the preexisting buc-cal segments may be in their most stable functional environment. In reference to the “equilibrium effects on the dentition,” Proffit et al20 stat-ed that although masticatory forces are much stronger, the lighter pressuresof the lips, cheeks, and tongue are much greater in duration, and these pres-sures, even at rest, are sustained most of the time and affect tooth position. Todemonstrate this, they described the case of a woman who has tremendousunilateral splaying of the left posterior and anterior teeth subsequent to lossof lip and cheek pressure due to an infection and paralysis, with resulting pro- “nounced tongue pressure. Arguing for a new soft tissue paradigm over the old“Angle ideal dental occlusion” paradigm, Profitt et al20 showed evidence forthe new model. For instance, in regard to stability of results, the old model wasrelated primarily to dental occlusion, whereas the new model relates stability Some have calledprimarily to soft tissue pressure and equilibrium effects. Therefore, soft tissue this the neutral zone:balance and equilibrium even after teeth are moved orthodontically will influ-ence tooth position. So, even if you have a prescription in your appliance that equilibrium betweenresults in a certain 3D position of the teeth, the patient’s oral environment may lips, cheeks, tongue,provide the ultimate stable position of the dentition. and muscle forces For these reasons and others, in the finishing stage of treatment, some or-thodontists use lighter wires, anterior segmental archwires and no posterior exerted on teeth,archwires with or without vertical elastics, circumferential retainers, and canine- particularly in theto-canine vacuum-formed retainers to permit posterior settling. Again, the 3D buccal segments,control of the posterior segments that the orthodontist strived to obtain maybe altered with settling and equilibrium of soft tissue on the teeth. Interesting- and the preexistingly, Lyotard et al21 demonstrated the results of removing final archwires at the buccal segmentsend of active orthodontic treatment for 4 weeks. Mandibular crowding, over- may be in their most ”jet, and interproximal contacts worsened; however, marginal ridges, occlusalcontacts, and total American Board of Orthodontics scores improved. Assum- stable functionaling that anterior segmental archwires are left intact, the authors concluded that environment. Volume 12, Number 1, 2011 15
    • Scientific Innovation Modification of the bidimensional system their study supports the practice of removing the archwires from the posterior teeth a few weeks prior to debonding for settling and improved occlusion. If orthodontists using 0.022-inch slot appliances finish with 0.019 × 0.025-inch stainless steel wires,11 it may be argued that these orthodontists have play throughout their system, whereas the dual-slot system has play only in the pos- terior and complete control of anterior teeth with full-sized 0.018 × 0.025-inch finishing wires. With play in the posterior and complete control in the anterior, teeth may level and align faster and space closure may be enhanced because of reduced resistance to sliding in the posterior segments. If inclination/torque is dynamic and changes in the posterior, particu- larly the molars, over time as Marshall et al22 demonstrated, one might consider two possibilities: custom torque for each patient or to simply use the same for each patient. With normal, transverse growth of the max- illary and mandibular first molars from age 7.5 to 26.4 years, the maxillary molars upright lingually 3.3 degrees. Maxillary intermolar width increases 2.8 mm, and the mandibular molars upright 5.0 degrees and mandibular inter- molar width increases by 2.2 mm. Therefore, an attempt to prescribe a static facial torque in the buccal segments may ultimately be altered by growth or settling of the occlusion over time. So one may facetiously ask whether varying posterior 3D prescriptions for patients depending on their age is necessary. Another critical question is whether specific, ideal torque values are any healthier than others. Is there morbidity generally associated with malocclusion? Ackerman and Proffit stated, “Although the concept of ideal occlusion has taken precedence as the ultimate goal in clinical orthodontics for some 110 years and serves well as an adopted arbitrary convention and a clinical gold standard, it has no verifiable scientific validity. No one has yet demonstrated that ideal occlu- sion provides significant benefits in oral or general health or that it significantly improves oral function.”23 Research seems to support Ackerman and Proffit’s po- sition. For instance, malocclusion is generally not associated with temporoman- dibular disorders (TMD), and orthodontics cannot lessen or prevent the future development of TMD.24–28 Contrary to what may seem reasonable, a recent sys- tematic review29 identified an absence of reliable evidence describing the posi- tive effects of orthodontic treatment on periodontal health. In fact, orthodontic therapy results in small detrimental effects to the periodontium: alveolar bone loss, gingival recession, and increased periodontal pocket depth. Another point is related to the issue of expansion. Interestingly, many advo- cates of arch development and upright mandibular posterior teeth have inclination (lingual crown torque) prescriptions of –25 or –30 degrees, not –12 or –15, for the mandibular first molars. It is possible that expanded archwires may override the built-in prescription of –25 or –30 degrees and produce upright molars.30 Another difference in biomechanics between our system and Gianelly’s is that for space closure, Gianelly4 generally advocated separately retracting ca- nines and then the four incisors. On the contrary, our system employs en masse“ retraction for the the six anterior teeth, except for cases of anterior arch-length discrepancies or crowded anterior teeth, such as lingually blocked lateral inci-. . . an attempt to sors. Then, we separately retract the canines only to relieve crowding. This treat-prescribe a static ment philosophy is also held by Burstone, who said: “Since relatively low forces are capable of retracting six teeth, there is little logic to separate retraction offacial torque in the canines followed by retraction of the four incisors. For that reason, only patientsbuccal segments may who have anterior arch-length problems with anterior crowding require separateultimately be altered canine retraction.”31 This would prevent round-tripping teeth. ” This is supported by Heo et al,32 who found no significant difference inby growth or settling of posterior anchorage loss between en masse retraction of the six anterior teeththe occlusion over time. and separate, two-step retraction of the canines followed by the four incisors; 16 ORTHODONTICS The Art and Practice of Dentofacial Enhancement
    • Scientific InnovationRinchuse and Rinchuse Table 2 Comparison of the differences between Gianelly’s bidimensional technique and the dual-slot system Comparisons bidimensional technique Dual-slot system Canine vs en masse Canine retraction En masse retraction except for anterior retractions arch-length discrepancies Initial wires Generally rectangular Generally round Vertical slots Yes, for auxiliaries, and uprighting springs in No canines for anterior labial forces in the mandibu- lar arch in Class II extraction cases to prevent an overjet with intra-arch mechanics Ball hooks No Yes, on most teeth Bracket torque No posterior torque More torque on anteriors and posterior torque Rationalization for Twist a 0.018 × 0.022-inch stainless steel wire Can place conventional torque in archwires lack of 3D control in 90 degrees distal to the lateral incisors to create a More variability of facial surfaces in the posterior teeth ribbon arch posterior teeth Mulligan Mechanics —generally premolars and sometimes canines are not bracketed, especially with use of V-bends Neutral zone With growth, molars tend to upright Self-ligation model No Propose dual-slot self-ligating and hybrid self-ligating modelstwo-step retraction took longer. Likewise, Xu et al,33 in a randomized clinicaltrial comparing en masse and two-step retraction in 64 growing boys and girlswith Angle Class I and II malocclusions requiring maxillary premolar extractionsand maximum anchorage using an MBT prescription and 0.022 × 0.028-inchbracket slots, headgear, and some transpalatal appliances, found that contraryto what some clinicians believe, two-step retraction is not more effective thanen masse retraction in preventing clinically meaningful anchorage loss. And,again, two-step retraction lengthens treatment time. As an example, if you want to close maxillary first premolar extraction spacesby 8 mm, assume that you can close the space 1 mm per month for a total of 8months to retract the canines and then another 8 months to retract the incisors.However, if you retract the six anterior teeth en masse, you can close the spacein 8 months, saving 8 months of treatment. Moreover, a recent study concludedthat there should be no expected difference in external apical root resportionbetween two-step and en masse space closure procedures.34 As mentioned previously, Gianelly routinely used rectangular wires throughouttreatment, whereas our initial wires are generally round Ni-Ti wires, as advocatedby Proffit. For instance, Proffit et al7 state that, “A tightly fitting resilient rect-angular archwire for initial alignment is almost always undesirable because notonly is frictional resistance to sliding likely to be problematic, the wire producesback-and-forth movement of the root apices as the teeth move into alignment.” With moderate to severely rotated teeth, resilient round wires would offeranother advantage because they have flexibility in both the horizontal and ver-tical dimensions, whereas resilient rectangular wires have more flexion in thevertical dimension and limited flexion in the horizontal dimension. Table 2 isan overall comparison of differences between the Gianelly bidimensional tech-nique and the dual-slot system. Volume 12, Number 1, 2011 17
    • Scientific Innovation Modification of the bidimensional system Table 3 Summary of the possible hybrid or dual-slot self-ligating systems adapted after Rinchuse and Miles35 bracket system Slot size (inches) active Passive Hybrid self-ligating 0.018-inch 0.018 Anterior Posterior Hybrid self-ligating 0.022-inch 0.022 Anterior Posterior Dual-slot self-ligating 0.018 Anterior 0.022 Posterior Dual-slot self-ligating active 0.018 Anterior 0.022 Posterior Dual-slot self-ligating passive 0.018 Anterior 0.022 Posterior SElF-lIGaTION: FuTuRE HybRID aND Dual-SlOT SElF-lIGaTING SySTEMS Rinchuse and Miles35 described a hybrid self-ligating bracket systems in either entirely 0.018-inch slots or entirely 0.022-inch slots in which the anterior brack- ets are active with a spring clip and the posterior brackets have a passive slide, very similar to a bimetric, bidimensional, or dual-slot system. Since the gingival horizontal wall is compromised by an obliquely inclined spring clip, the ac- tive self-ligating brackets are smaller than their conventional counterparts and not truly 0.018 × 0.025- or 0.022 × 0.028-inch. Therefore, this hybrid system“ would have so-called reduced bracket slots in the anterior for a tighter fit and enhanced 3D control, especially with undersized 0.019 × 0.025-inch stainless steel finishing wires in 0.022-inch slots, and a looser fit with possibly reducedWith moderate to resistance to sliding with passive brackets36–38 in the posterior for leveling,severely rotated teeth, alignment, and space closure.resilient round wires In an in vitro study, Badawi et al39 found that active self-ligating brackets are more effective in torque expression than passive self-ligating brackets inwould offer another 0.022-inch slots and 0.019 × 0.025-inch stainless steel wire. Likewise, if manyadvantage because orthodontists use a 0.022-inch slot and only finish with 0.019 × 0.025-inch stain-they have flexibility in less steel wire,11 it might be desirable to use an active self-ligating system since there may be more enhanced 3D control and dental esthetics of the incisors.both the horizontal and However, if a clinician is filling the 0.018-inch bracket slots with 0.018 × 0.025-vertical dimensions, or 0.0175 × 0.025-inch finishing wires, a passive self-ligating system might bewhereas resilient advantageous, possibly reducing resistance to sliding in the initial stages of treatment. However, this is controversial, with notching and binding as variablesrectangular wires have affecting resistance to sliding.40more flexion in the To obtain excellent 3D control in the anterior teeth and at the same timevertical dimension and have even more reduced resistance to sliding in the posterior, a dual-slot self- ” ligating system can be used with active 0.018-inch slot anterior brackets andlimited flexion in the passive 0.022-inch slot posterior brackets. Other self-ligating permutations arehorizontal dimension. all-active or all-passive dual-slot systems. Table 3 codifies the possible hybrid 18 ORTHODONTICS The Art and Practice of Dentofacial Enhancement
    • Scientific InnovationRinchuse and Rinchuse Dual-slot system (different slot sizes, but same self-ligating brackets) • 0.018-inch slots on the anterior teeth and 0.022-inch slots on the posterior teeth • Conventional • Active self-ligating • Passive self-ligating Hybrid system (same slot size, but different self-ligating brackets) • Mimics a bidimensional or dual-slot system • Active anterior and passive posterior self-ligating brackets • Stays in the same slot size (0.018- or 0.022-inch) Dual-slot–hybrid system (different slots and different self-ligating brackets [active and passive]) • 0.018-inch slot anterior brackets and 0.022-slot posterior brackets • Active anterior brackets and passive posterior bracketsFig 4 The various permutations of self-ligating systems.and dual-slot self-ligating systems. Figure 4 shows the permutations of ma-nipulating slot size, active or passive self-ligating brackets, and a hybrid system(same slot size but active anterior and passive posterior brackets). Paik et al41 applied the principles that Rinchuse and Miles35 developed todescribe a hybrid bracket-tube system called the hybrid sliding mechanics oflow friction, which is a combination of passive self-ligating brackets on the pre-molars, conventional tubes on the molars, and conventional twin brackets onthe anterior teeth. However, much of the rationale for this system is based onin vitro data regarding friction and passive self-ligating brackets.CONCluSIONWe have presented a cursory review of the bimetric and bidimensional systemsjuxtaposed with a dual-slot system that offers an alternative to Gianelly’s sys-tem. Furthermore, we codified Rinchuse and Miles’35 thoughts on hybrid anddual-slot self-ligating systems.aCKNOWlEDGMENTSSince we were orthodontic residents at the University of Pittsburgh in 1974, we have beenimpressed with Dr Anthony Gianelly’s (1936–2009) research, articles, and particularly his bi-dimensionsal system. He was a very unassuming and humble man. We have used a bidimen-sional prescription that we have modified for over two decades, which this paper addresses.However, without Tony’s concepts and principles, this paper would not have been possible. Volume 12, Number 1, 2011 19
    • Scientific Innovation Modification of the bidimensional system REFERENCES 17. Mulligan TF. The advantages of differen- tial moments. J Clin Orthod 2009;43: 1. Harradine N. Northcroft Memorial Lecture 379–386. self-ligation: Past, present and future. 18. Keim RG. Common sense revisited. J Clin J Orthod 2009;36:260–271. Orthod 2009;43:357–358. 2. Kattner FP, Schneider BJ. Comparsion of 19. Mulligan TF. Common Sense Mechanics the Roth appliance and standard edge- in Everyday Orthodontics. Phoenix: CSM, wise appliances treatment results. Am J 1998. Orthod Dentofacial Orthop 1993; 20. Proffit WR, Fields Jr HW, Sarver DM. Con- 103:24–32. temporary Orthodontics, ed 4. St Louis: 3. Schudy FF, Schudy GF. The bimetric sys- Mosby, 2007:6, 145–147. tem. Am J Orthod 1975;67:57–91. 21. Lyotard N, Hans M, Nelson S, Valiathan 4. Gianelly AA. Bidimensional Technique: M. Short-term postorthodontic changes Theory and Practice. New York: GAC in the absence of retention. Angle Orthod International, 2000. 2010;80:1045–1050. 5. White L. JCO interviews Dr Anthony 22. Marshall S, Dawson D, Southard KA, Lee Gianelly on current issues in orthodontics. AN, Casko JS, Southard TE. Transverse J Clin Orthod 1996;30:439–445. molar movement during growth. Am J 6. Keim RG, Gottlieb EL, Nelson AH, Vogels Orthod Dentofacial Orthop 2003; DS 3rd. 2008 JCO study of orthodontic 124:615–624. diagnosis and treatment procedures, 23. Ackerman JL, Proffit WR. Guest editorial. part 1: Results and trends. J Clin Orthod A not-so tender trap. Am J Orthod Dento- 2008;42:625–640. facial Orthop 2009;136:619–620. 7. Proffit WR, Fields Jr HW, Sarver DM. Con- 24. Rinchuse DJ, Rinchuse DJ. Orthodontics temporary Orthodontics, ed 4. St Louis: justified as a profession. Am J Orthod Mosby, 2007:376, 553. Dentofacial Orthop 2002;121:93–96. 8. Detterline DA, Isikbay SC, Brizendine EJ, 25. American Academy of Pediatric Dentistry Kula KS. Clinical outcomes of 0.018-inch Conference. Treatment of temporoman- and 0.022-inch bracket slot using ABO dibular disorders in children: Summary objective grading system. Angle Orthod statement and recommendations. J Am 2010;80:528–532. Dent Assoc 1990;120:265–269. 9. Vu C, Roberts WE, Hartsfield JK Jr, Ofner 26. Gesch D, Bernhardt O, Kirbschus A. Asso- S. Treatment complexity index for assess- ciation of malocclusion and functional oc- ing the relationship of treatment duration clusion with temporomandibular disorders and outcomes in a graduate orthodontics (TMD) in adults: A systematic review of clinic. Am J Orthod Dentofacial Orthod population-based studies. Quintessence 2008;133:9.e1–9.e13. Int 2004;35:211–221. 10. Amditis C, Smith LF. The duration of fixed 27. Mohl ND. Temporomandibular disorders: orthodontic treatment: A comparison Role of occlusion, TMJ imaging, and elec- of two groups of patients treated using tronic devices. A diagnostic update. J Am edgewise brackets with 0.018” and 0.022” Coll Dent 1991;58:4–10. slots. Aust Orthod J 2000;16:34–39. 28. McNeill C, Mohl ND, Rugh JD, Tanaka TT. 11. Sheridan JJ. The reader’s corner. J Clin Temporomandibular disorders: Diagnosis, Orthod 2003;37:27–29. management, education, and research. 12. Germane N, Bentley BE Jr, Isaacson J Am Dent Assoc 1990;120:253–257. RJ. Three biologic variables modifying 29. Bollen AM, Cunha-Cruz J, Bakko DW, faciolingual tooth angulation by straight- Huang GJ, Hujoel PP. The effects of orth- wire appliances. Am J Orthod Dentofacial odontic therapy on periodontal health: A Orthop 1989;96:312–319. systematic review of controlled evidence. 13. Dellinger EL. A scientific assessment of J Am Dent Assoc 2008;139:413–422. the straight-wire appliance. Am J Orthod 30. Rinchuse DJ, Kandasamy S. Implications of 1978;73:290–299. the inclination of mandibular first molars 14. Vardimon AD, Lambertz W. Statistical in the extractionist versus expansionist evaluation of torque angles in reference debate. World J Orthod 2008;9:383–390. to straight-wire appliance (SWA) theories. 31. Burstone CJ. The segmented arch ap- Am J Orthod 1986;89:56–66. proach to space closure. Am J Orthod 15. Miethke RR, Melsen B. Effect of variation 1982;82:361–378. in tooth morphology and bracket position 32. Heo W, Nahm DS, Baek SH. En masse on first and third order correction with retraction and two-step retraction of preadjusted appliances. Am J Orthod maxillary anterior teeth in adult Class I Dentofacial Orthop 1999;116:329–335. women. A comparison of anchorage loss. 16. Creekmore TD, Kunik RL. Straight wire: Angle Orthod 2007;77:973–978. The next generation. Am J Orthod Den- tofacial Orthop 1993;104:8–20 [erratum 1993;104:20]. 20 ORTHODONTICS The Art and Practice of Dentofacial Enhancement
    • Scientific InnovationRinchuse and Rinchuse33. Xu TM, Zhang X, Oh HS, Boyd RL, Korn 38. Matarese G, Nucera R, Militi A, et al. EL, Baumrind S. Randomized clinical trial Evaluation of frictional forces during comparing control of maxillary anchorage dental alignment: An experimental model with 2 retraction techniques. Am J Orthod with 3 nonlevel brackets. Am J Orthod Dentofacial Orthop 2010;138:544. Dentofacial Orthop 2008;133:708–715. e1–544.e9. 39. Badawi H, Toogood RW, Carey JPR, Heo34. Huang Y, Wang XX, Zhang J, Liu C. G, Major PW. Torque expression of self- Root shortening in patients treated with ligating brackets. Am J Orthod Dentofa- two-step and en masse space closure cial Orthop 2008;133;721–728. procedures with sliding mechanics. Angle 40. Shoaf S. JCO Interviews Dr William Proffit Orthod 2010;80:492–497. on the present and future of orthodontics.35. Rinchuse DJ, Miles P. Self-ligating brack- J Clin Orthod 2009;42:711–717. ets: Present and future. Am J Orthod 41. Paik CH, Ahn HW, Yang IH, Baek SH. Dentofacial Orthop 2007;132:216–222. Low-friction space closure with a hybrid36. Henao SP, Kusy RP. Evaluation of the bracket-tube system. J Clin Orthod frictional resistance of conventional and 2010;44:623–627. self-ligating bracket designs using stan- dardized archwires and dental typodonts. Angle Orthod 2004;74:202–211.37. Kim TK, Kim KD, Baek SH. Comparison of frictional forces during the initial leveling stage in various combinations of self- ligating brackets and archwires with a custom-designed typodont system. Am J Orthod Dentofacial Orthop 2008;133:187. e15–187.e24. Volume 12, Number 1, 2011 21
    • Scientific Innovation Posttreatment compliance with removable maxillary retention in a teenage population: A short-term randomized clinical trial Marc Bernard Ackerman, DMD, MBA1 Barry Thornton, EdD2 Removable retainer wear is most related to patient comfort and acceptance. Patient compliance is essential for retention and maintenance of the orthodontic treatment results. Even though patients are educated about the need for prolonged retention after active treatment and asked to sign informed consent regarding the risk of noncompliance (relapse) prior to treatment, most orthodontists would estimate that at least half of their teenage patients do not comply at optimal levels. The aim of the present study was to quantify teenage patient compliance with removable maxillary retention and compare actual usage vs prescribed usage between subjects who knew they were being monitored via an implanted microsensor in the retainer and those subjects who were unaware of any monitoring. The final sample consisted of 9 subjects in the test group (5 males and 4 females) and 10 subjects in the control group (4 males and 6 females). The evidence suggests that individuals who were made aware of the orthodontist’s ability to monitor compliance wore the device for a significantly larger number of hours per day than those who were unaware of this fact. Patients reporting full usage of the retainer wore the appliance a mean of 4.3 hours more per day than those reporting less than full usage, holding all other variables constant. Patients who misrepresented their retainer use (reported full usage but wore the device less than 19 hours per day) wore the appliance a mean 12.4 hours less than the more honest patients who participated in the study. ORTHO 2011;12:22–27. 1Formerly, Chair and Program Director, Jacksonville University School of Orthodontics, Key words: orthodontic retention, compliance, microsensor Jacksonville, Florida, O USA; currently, Director of rthodontics is concerned with variations in dentofacial traits that may Orthodontics, Children’s Hospital Boston, Boston, affect an individual’s overall well-being. Dentofacial traits are defined Massachusetts, USA. as hard or soft tissue characteristics or combinations of characteristics 2Professor, Department of that distinguish an individual’s facial appearance and determine their level Economics, Jacksonville University, Jacksonville, of oral and social function. Orthodontic intervention includes therapies that Florida, USA. enhance dentofacial traits, thus improving a person’s health.1 Contemporary orthodontic treatment is a two-step process: active treatment and retention. CORRESPONDENCE Dr Marc Bernard Ackerman Active treatment involves modification of tooth position via fixed applianc- Children’s Hospital Boston es or removable clear aligners. Retention refers to the period of supervised 300 Longwood Ave maintenance of the teeth in their corrected positions via retainers after active Boston, MA 02115 Email: marc.ackerman@ treatment. Of all the dentofacial traits, tooth alignment is most affected by a childrens.harvard.edu patient’s compliance with retention. 22 ORTHODONTICS The Art and Practice of Dentofacial Enhancement
    • Nearly a century ago, Norman Kingsley stated, “The success of orthodontiaas a science and an art now lies in the retainer.”2 To date, there is little con-sensus in the orthodontic literature on the most effective retention strategy inclinical practice.3 However, many orthodontists concur that retention is abso-lutely necessary for three principal reasons: (1) gingival and periodontal tissuesare affected by orthodontic tooth movement and require time for reorganiza-tion when active appliances are removed4; (2) teeth may be in an inherently un-stable position after active treatment, such that soft tissue pressure constantlyproduces a relapse tendency; and (3) changes produced by growth may altertreatment results in growing subjects.5 Reorganization of the periodontal liga-ment (PDL) occurs over a 3- to 4-month period after active appliance removal.4Reorganization of the collagenous and elastic fibers in gingivae occurs moreslowly than that of the PDL.6 The collagenous fiber networks within gingivaecomplete their reorganization within 4 to 6 months after removal of activeappliances. The elastic supracrestal fibers remodel very slowly and can exertforces capable of tooth movement even 1 year after active appliance removal. There is tremendous variation in retention protocols used in contemporaryorthodontic practice. However, there is general agreement among orthodon-tists that regardless of the length of the supervised retention period or theprescribed daily schedule of retainer wear, patients must have some type ofretention following active treatment to maintain treatment results. Althoughdata in the scientific literature are scant, some authors have suggested thatretention appliances be placed immediately after the active appliances areremoved,4 worn full-time (except during meals) for the first 3 to 4 months afteractive appliance removal, and then worn part-time for 1 or 2 years thereafter.5In practice, most orthodontists develop their own retention protocol basedeither on what they were taught in residency or their clinical experience aftersome years of practice. Removable retainer wear is most related to patient comfort and acceptance.7Patient compliance in retention is essential for maintenance of the orthodonticresult. Although subjects are educated about the need for prolonged retentionafter active treatment and are asked to sign an informed consent form regard-ing the risk of noncompliance (relapse) prior to treatment, most orthodontistsestimate that at least half of their teenage patients comply below optimal lev-els. Noncompliant patients experience a relapse of tooth crowding or spacingwithin the first few months of retention. Patients who do not comply properlyin the initial retention period are at risk for significant relapse in the long term.With no way of determining whether patients follow the prescribed plan ofretention, orthodontists have been unable to assess whether changes in toothposition are a result of poor retainer compliance or ineffective retainer design. Volume 12, Number 1, 2011 23
    • Scientific Innovation Posttreatment compliance with removable maxillary retention in a teenage population Table 1 Study criteria Inclusion criteria Exclusion citeria • Subjects aged between 13 and 19 years • Phase I–treated patients • Treatment plan includes maxillary Hawley • Craniofacial syndromes retainer use • Poor compliance during active orthodontic • No history of retainer wear treatment (such as multiple missed • No missing anterior teeth requiring appointments or excessive appliance pontic teeth on the retainer breakage) • Ideal alignment of maxillary anterior teeth at debonding “ There is tremendous variation in retention protocols used in contemporary orthodontic practice. However, there is general agreement among orthodontists that regardless of the length of the supervised retention period or the prescribed daily schedule of retainer wear, patients must have some type of retention ” following active treatment to maintain treatment results. This inability to accurately monitor or police patient retainer compliance has also negatively affected patient motivation during this important phase of treat- ment. A new methodology for incorporating a microsensor to quantify patient compliance was published in the orthodontic literature.8 The aim of the present study was to quantify teenage patient compliance with removable maxillary retention and compare actual vs prescribed usage between subjects who knew they were being monitored via a microsensor in the retainer and those subjects who were unaware of any monitoring. The null hypothesis was that there was no difference in retainer usage between those subjects who knew they were being monitored and those subjects who were unaware of it. METHODS Once study approval from the Jacksonville University Institutional Review Board was granted, patients approaching the end of fixed appliance ther- apy who met the inclusion and exclusion criteria (Table 1) were invited to participate in the study. Written informed consent was obtained from each patient or patient’s parent or guardian prior to the initiation of retention, and subjects were free to withdraw at any time during the study. 24 ORTHODONTICS The Art and Practice of Dentofacial Enhancement
    • Scientific InnovationAckerman and Thornton Fig 1 The USB-powered sensor reader with a study retainer in the reading position. Twenty-three subjects were recruited. Subjects were randomly assigned tothe test (aware of monitoring) or control group (unaware of monitoring). Thetest group initially consisted of 11 subjects (5 males and 6 females) with amean age of 15.4 years; the control group initially consisted of 12 subjects(5 males and 7 females) with a mean age of 15.6 years. Each subject received amaxillary Hawley retainer constructed of wire and pink orthodontic acrylic witha blue microsensor embedded in the middle of the palatal acrylic. The word“smart” was stamped on the sensor and visible through the acrylic (Fig 1). Allsubjects were asked to wear the appliance at all times, with the exception ofduring meals and contact sports (approximately 20 hours per day) for the firstmonth after fixed appliance therapy. Subjects were recalled 1 month after debonding. Retainer compliance wascalculated using the methodology described in a previous publication.8 Sub-jects were asked to subjectively rate their compliance with the prescribed hoursof retainer wear. Three options were given: (1) worn as prescribed, (2) moder-ately worn (at least half of the time), and (3) poorly worn (less than half of thetime). Four subjects dropped out of the study: Three subjects lost their retain-ers in the first month after debonding, and one patient’s microsensor malfunc-tioned. The final sample consisted of 9 subjects in the test group (5 male and4 female) and 10 subjects in the control group (4 male and 6 female). Volume 12, Number 1, 2011 25
    • Scientific Innovation Posttreatment compliance with removable maxillary retention in a teenage population Table 2 Multiple regression results Predictor Estimated coefficient T ratio P Constant 17.5 16.9 .000 Day –0.2 –8.1 .000 Aware 2.3 4.9 .000 Report 4.3 5.7 .000 Lie –12.4 –24.2 .000 F = 236.77, P = .000, adj R2 = 62.4%. RESulTS Multiple regression was employed to determine whether a patient’s retainer usage was influenced by the knowledge that his or her use of the device was being monitored. The dependent variable was the number of hours that the patient actually wore the retainer each day. The total number of observations on the dependent variable was 570, based on a 30-day trial for 19 patients. The dependent variable was regressed on four independent variables. The first independent variable, ranging from 1 to 30, was the day of the trial. The second independent variable was a binary variable that was set equal to 1 if the patient was aware of monitoring and 0 if he or she was unaware. The third independent variable was a binary variable that was set equal to 1 if the pa- tient reported full usage of the appliance and 0 if he or she did not. The fourth independent variable in the model was a binary variable that was set equal to 1 if the patient misrepresented retainer usage and 0 if he or she was truthful. An example of a misrepresentation would be if the patient wore the appliance for less than 19 hours and reported full usage. The determination of 19 hours as the minimum value for full usage was based on an analysis of the sample data. The third quartile for the number of hours per day patients used the appliance was 19 hours. Patients who reported wearing the retainer for 19 hours or more per day were considered to have achieved full usage, while those patients wearing the retainer less than19 hours per day were classified as having less than full usage. The overall evaluation of the model confirms that it has significant explanatory power (computed F = 236.77, with an associated P value of .000) (Table 2). This model explains 62.4% of the variation in the actual number of hours patients wore their retainers. All of the independent variables selected in the model were significant at less than .01. DISCuSSION The primary issue to be investigated was whether the actual amount of time a patient wore the retainer during the 30-day trial was impacted by their knowl- edge of the researcher’s ability to monitor compliance. The sample evidence suggests that individuals who were made aware of the ability to monitor com- pliance wore the device for a significantly larger number of hours per day than those who were unaware of this fact. The results of the analysis indicate that patients made aware of the presence of the ability to monitor compliance wore the device 2.3 hours more per day than the unaware patients, holding every- thing else constant. 26 ORTHODONTICS The Art and Practice of Dentofacial Enhancement
    • Scientific InnovationAckerman and Thornton “ There was a tendency for subjects in the study to reduce their use of theappliance over time. The estimated coefficient on the variable for the day of … it would appear thatthe trial shows that with each passing day, patients wore the retainer a mean0.2 hours (12 minutes) less. Over the life of the study (30 days), this is 6 hours there is a significantper day. disparity between the In addition, patients reporting full usage of the retainer wore the appliance amount of actual and ”a mean 4.3 hours more per day than those reporting less than full usage, hold-ing all other variables constant. Those who misrepresented their retainer us- prescribed retainerage wore the appliance an average of 12.4 hours less than the more honest usage…patients that participated in the study.CONCluSIONFrom the results of this clinical trial, it would appear that there is a significantdisparity between the amount of actual and prescribed retainer usage in thissample of teenage orthodontic patients. Specifically, patients who knew thattheir orthodontist was actively monitoring hours of retainer wear clearly ex-hibited better compliance than those who were unaware of the monitoring.However, very few patients in the test group demonstrated full-time retainerwear. It would appear that in this teenage sample, asking patients to wear theirremovable maxillary retainers half-time (12 hours per day) would have been amore reasonable prescription for compliance. Future research utilizing micro-sensor technology will permit orthodontists to correlate the extent of toothalignment relapse with retainer compliance.ACKNOwlEDgMENTSDr Ackerman wishes to thank the orthodontic residents at Jacksonville Uni-versity for their assistance with the execution of this study. This study wasfunded by Scientific Compliance. Neither author has financial interest in Scien-tific Compliance. Dr Ackerman is the former chief scientific officer of ScientificCompliance.REFERENCES 5. Proffit WR, Fields HW, Sarver DL. Con- temporary Orthodontics, ed 4. St Louis: Mosby, 2007:623.1. Ackerman MB. Enhancement Orthodon- 6. Reitan K. Tissue rearrangement during tics: Theory and Practice. Ames, Iowa: the retention of orthodontically rotated Blackwell, 2007. teeth. Angle Orthod 1959;29:105–113.2. Kingsley NW. A letter to the Alumni Soci- 7. Wong P, Freer TJ. Patients’ attitudes to- ety of the Angle School of Orthodontia. wards compliance with retainer wear. Aust Am Orthod 1908,125. Orthod J 2005;21:45–53.3. Littlewood SJ, Millett DT, Doubleday B, 8. Ackerman MB, McRae MS, Longley WH. Bearn DR, Worthington HV. Retention Microsensor technology to help monitor procedures for stabilizing tooth position removable appliance wear. Am J Orthod after treatment with orthodontic braces. Dentofacial Orthop 2009;135:549–551. Cochrane Database Syst Rev 2006;1: CD002283.4. Reitan K. Principles of retention and avoidance of posttreatment relapse. Am J Orthod 1969;55:776–790. Volume 12, Number 1, 2011 27
    • Technology AUSOM: A 3D placement guide for orthodontic mini-implants Mahmoud Al-Suleiman, DDS, COS, PhD1 Manal Shehadah, DDS, MSc2 Aim: Anchorage management is an important issue in orthodontic treatment and plays a big role in the success or failure of orthodontic treatment. Using a mini-implant system as skeletal anchorage is a suitable solution if maximum or absolute anchorage control is required. Applying mini-implants requires pinpointing their optimal position to prevent damaging adjacent anatomical structures. There are three considerations in locating proper mini-implant position: the point of implant insertion, the angle of implant insertion in the anterior- posterior direction, and the angulation of implant insertion in the vertical plane. Here, we illustrate a new three-dimensional mini-implant guide (Aleppo University Surgical Orthodontic Miniscrew Guide [AUSOM]) developed for determination of ideal mini-implant placement and demonstrate AUSOM’s role in mini-implant success. Methods: After reviewing of articles about mini-implants in orthodontic 1Professor, treatment, we determined the characteristics of an ideal orthodontic implant guide Department of Orthodontics, Dental (IOIG). We invented a new instrument, AUSOM, that consists of four components: Faculty, University of a horizontal part, a vertical part, a graduation guide, and film-holding part. Forty Aleppo, Aleppo, Syria. 2Lecturer, Department mini-implants were inserted for orthodontic treatment purposes; AUSOM and of Orthodontics, Dental Faculty, University of wire guides were used to insert the mini-implants. Conclusion: We found AUSOM Aleppo, Aleppo, Syria. to be a practical and accurate device. It works as a radiographic-locating device CORRESPONDENCE and a mini-implant surgical placement guide. The failure rate of mini-implants Dr Mahmoud Al-Suleiman placed by AUSOM was lower than that of those placed by simple metallic Department of Orthodontics guides. Clinical randomized studies must be carried out to prove AUSOM’s role Dental Faculty in improving the success rate of mini-implant placement. ORTHO 2011;12:28–37. University of Aleppo Al-Fateh St Aleppo, Syria Email: Key words: AUSOM, mini-implant, mini-implant guide, optimal screw implant, sulieman@scs-net.org position, skeletal anchorage28 ORTHODONTICS The Art and Practice of Dentofacial Enhancement
    • A nchorage is an important issue in orthodontics, and it plays a vital role in successful treatment results.1–3 It can been defined as the nature and degree of resistance to displacement provided by anatomical units orintra- or extraoral devices used for the purpose of performing tooth move-ment.1–3 Undesired movements were a clinical complication caused by insuf-ficient resistance values of anchoring teeth.1,2 Anchorage loss can be causedby a low level of patient cooperation and cannot be considered stable anchor-age.1,2 To overcome these problems, skeletal anchorage has been increasinglyincorporated into orthodontic treatment.4–12 The need for absolute anchoragebegan with conventional dental,13 retromolar,14 and palatal implants.13–15 How-ever, space limitations, implant costs, and difficult connections to orthodonticappliances encouraged the rapid development of smaller devices that can beplaced in various locations in the dental arch. Mini-implants and miniplatesspecifically designed for orthodontic use satisfy some of these requirementsand are being progressively adopted in clinical practice.7,16,17 Skeletal anchorage systems include all devices that are fixed to bone for thepurpose of enhancing orthodontic anchorage either by supporting the teeth ofthe reactive unit or altogether obviating the need for the reactive unit.18 Tem-porary anchorage devices (TADs) refer to devices placed specifically to provideorthodontic anchorage and are removed upon completion of biomechanicaltherapy; examples include onplants, zygoma wires, mini-implants, and mini-plates.3,7,11,16,17,19,20 On the other hand, stationary anchorage, such as inten-tionally ankylosed teeth and conventional dental implants, refers to devicesthat can be used to provide skeletal orthodontic anchorage and do not needto be removed after the completion of orthodontic treatment.18 Mini-implants have been introduced into orthodontics for various purposes,such as canine and anterior teeth retraction, en masse anterior retraction, molaruprighting, distalization, and protraction.9,20–23 They have the advantages ofsmall size; more implant sites and indications; simplicity of placement; short Volume 12, Number 1, 2011 29
    • Technology AUSOM: A 3D placement guide for orthodontic mini-implants or even no waiting period before loading; no need for laboratory work; easy removal after treatment; and lower cost than implants, onplants, and mini- plates.24 Two types of mini-implants have been used in orthodontics: predrilled and self-drilling.25 In an experimental study, it was reported that self-drilling mini-implants have less mobility and more bone-to-metal contact than their predrilled counterparts.25 The implant site should have good bone density and thickness to provide enough bone around the screw.8,22,26 Improper positioning may result in inter- ference with required tooth movement and limit the effectiveness of the skeletal anchorage.16 Several factors might influence the stability and failure rates of mini-implants, including vertical or sagittal placement27 and the proximity to a root.28 Insertion techniques should maximize the available bone volume while avoiding adjacent anatomical structures, such as dental roots, nasomaxillary cavities, and neurovascular tissues.29–32 Placing a mini-implant without a surgical guide increases the risk of prob- lems.4,12,27 Therefore, to determine the optimal position and suitable inser- tion direction of mini-implants, different methods have been used, including radiographs,26,33,34 computed tomography (CT), cone beam CT, and dental CT scans.26,31,33–36 Mini-implants placed manually can penetrate the root den- tin.27 The type of surgical procedure was the most significant predictor for failure, followed by mini-implant placement at a high level (in nonkeratinized mucosa).37 There are three considerations when determining ideal mini-implant posi- tioning: 1. The point of implant insertion 2. Ensuring the angle of implant insertion is anterior-posterior to prevent harm to the adjacent dental roots 3. The recommended angulations of insertion in the vertical plane (20 to 30 degrees in the mandible and 30 to 40 degrees in the maxilla8,22,26) Wu et al reported that screw placement without an accurate surgical guide results in 20% of injuries during positioning.38 Accidental impingement of mini-implants into the dental root and periodontium is a possible complica- tion, especially in the interradicular areas. However, histologic studies have shown that repair of the periodontal tissue is possible in cases of accidental contact of dental roots.39,40 Cementum can be significantly damaged when mini-implants are screwed against the root surface. In these cases, the screw should be immediately removed,41 and the tooth should not be moved for 3 to 4 months to reduce root resorption risks.39,42 Screws placed in the periodontal ligament have a greater failure rate.28,38,39 The aim of this article is to describe a three-dimensional universal guide designed to determine the ideal position and placement of orthodontic mini- implants. “ Insertion techniques should maximize the available bone volume while avoiding adjacent anatomical structures, such as ” dental roots, nasomaxillary cavities, and neurovascular tissues.30 ORTHODONTICS The Art and Practice of Dentofacial Enhancement
    • Al-Suleiman and Shehadah TechnologyMATERIAlSAfter reviewing articles written about mini-implant usage in orthodontic treat-ment, it was concluded that are many devices are used in locating implantplacement. These methods can be lumped into three categories: wire or me-tallic guides, surgical templates, and other devices and methods.26,43Wire and metallic guidesA wire guide is a practical radiopaque marker formed from a brass or stainlesssteel wire.22,32,44,45 It is inexpensive, simple to fabricate, and easy use, but it pro-vides limited, two-dimensional information on the implant site. Because rela-tive positions may be inconsistent in different radiographic views, the wire andmetallic guides are not always accurate.43 Furthermore, because guides do notprevent deviation of the pilot drill, they do not eliminate the risk of root dam-age.34 A Kim stent is a 3D method for positioning mini-implants that preventsroot damage and improves the insertion success rate.43 The wire guide (0.0215× 0.028-inch wire) consists of two parts: a positioning gauge, which is attachedto the tooth distally to the mini-implant placement site, and a directional guide,which is attached to the tooth mesially to the mini-implant.43Surgical templatesSurgical stents, guides, and templates can transfer a radiographically planned,3D implant position to the surgical site more accurately than wire or metal-lic guides.26 Kyung et al used vertical and mesiodistal measurements from alateral cephalogram to construct an acrylic marker, but this provides only a2D location.9 Kitai et al described a technique requiring several complicatedand expensive steps: a CT scan of a template in the appropriate position, adigital surface scan of the working cast and template, production of a stereo-lithographic model, and fabrication of an acrylic or prefabricated removablestent.36 Morea et al designed an acrylic stent with a metal sleeve to guide thepilot drill for nondrilling mini-implants, but the initial wax fixation of the sleeveto the working cast seems fragile, there appears to be no access for externalirrigation, and retention of the acrylic stent may be problematic.32 Cousley andParberry modified the 3D stent.26 The design and fabrication are simple, andthe stent provides reliable guidance for either the pilot drill or the self-drillingmini-implant in terms of both location and angulation. The stent allows accessfor both visual monitoring and saline irrigation, but this takes time and effortfor the laboratory work, and fine adjustments cannot be made.Other devices and methodsThese devices do not have standard forms and were fabricated to overcomeproblems found with the two categores previously mentioned. Suzuki 3D guide. The Suzuki guide consists of a vertical arm (available in5, 7, and 9 mm). One end is attached to the main orthodontic archwire witha Gurin lock, and the other is connected to a stainless steel tube 5-mm longand 3 mm in diameter. The tube is used to identify the optimal implant site onbitewing radiographs and guide the drilling of the pilot hole and placementof the mini-implant. The Suzuki guide has a simple design, is adjustable in thehorizontal dimension, and is comfortable for the patient.46 3D radiographic surgical guide. This consists of two items. The first is a0.045-inch stainless steel telescopic tube soldered to the end of a verticalarm, which is attached to a horizontal arm by a Gurin lock. Both arms aremade of 0.021 × 0.025-inch stainless steel wire, allowing the guide to beinserted into the fixed orthodontic appliance. The second is a modified radio-graphic positioner.33 Volume 12, Number 1, 2011 31
    • Technology AUSOM: A 3D placement guide for orthodontic mini-implants Periapical radiograph film Vertical part Placement guide Horizontal Rinn XCP part Film holding part a b Fig 1 AUSOM parts. (a) Vertical and horizontal parts as well as placement guide. (b) Diagram of how vertical part is fixed to the archwire and how the film-holding part connects between the molar tube and periapical radiograph film holder. METHOD From previous critical reviews of guides and methods used to determine op- timal position and correct placement of orthodontic mini-implants, it can be concluded that the ideal orthodontic implant guide (IOIG) must have the fol- lowing characteristics: • Versatile (allows the localization of the ideal mini-implant position by using periapical radiographs and at the same time be used to apply the orthodon- tic mini-implant33) • 3D adjustable (can be adjust to locate the point of implant insertion,8,22,26 the angle of implant insertion in the anterior-posterior direction to avoid hurting the adjacent dental roots,8,22,26 and the recommended angulations of implant insertion in the vertical plane8,22,26) • Universal (can be used for both arches and both sides [right and left] to save time and money and with both self- and non–self-drilling mini-implants46) • Comfortable (does not bother or annoy patients during use) • Simple design (easy to use, does not waste time, and inexpensive) • Sterilizeable (can be used on other patients) Taking all this into account, we invented a 3D placement guide for orth- odontic mini-implants—the Aleppo University Surgical Orthodontic Miniscrew (AUSOM). It is used to determine the ideal position and to place mini-implants in the optimal recommended position. The AUSOM consists of four pieces (Fig 1). 1. The vertical part is a graduated stainless steel round cogged wire 1.2 mm in diameter that acts as a millimeteric guide to locate the position of mini- implants in the vertical direction. It has a lock that will be fixed to a rectan- gular orthodontic wire connected to the fixed appliance (adjacent bracket slots and molar band tubes).32 ORTHODONTICS The Art and Practice of Dentofacial Enhancement
    • Al-Suleiman and Shehadah TechnologyTable 1 Failure and success rates of placed mini-implants AUSOM Wire guide Total n (%) n (%) n (%)Failures 1 (5.0) 5 (25.0) 6 (15.0)Successes 19 (95.0) 15 (75.0) 34 (85.0)Total 20 (100.0) 20 (100.0) 40 (100.0)Table 2 Comparison between mini-implant placement methodaccording to failure rate based on Wilcoxon signed rank test Mean Sum of n rank ranks Z PNegative ranks 4 2.50 10.00 –2.000(a) .046wire guide failure < AUSOM failurePositive ranks 0 0.00 0.00wire guide failure > AUSOM failureTies 16wire guide failure = AUSOM failure(a), based on postive rank.2. The horizontal part is a graduated stainless steel round cogged wire 1.2 mm in diameter that acts as a millimeteric guide to locate the position of mini-implants in the horizontal direction and has a cylinder with a lock. It is movable in the vertical direction by sliding the vertical part. Once the desired height is reached, the lock can be closed. The horizontal part also holds the placement guide.3. The placement guide is a vertical round wire 1 mm in diameter. It has a cylinder on the end, which works as a guide to place the mini-implant. The angle between the cylinder axis and the vertical wire is adjustable. The other end has two perpendicular cylinders, which makes it able to rotate around its axis and move horizontally.4. The film-holding part is a wire that extends from the facebow tube of the molar band and inserts into the perapical radiograph holder, which is a part of the Rinn XCP film-holding system that depends on paralleling technique for dental radiography. To evaluate the efficiency of AUSOM in the placement of mini-implants, a pre-liminary study was carried out. Twenty patients (13 male and 7 female) whoseorthodontic treatment plans included mini-implants were selected. Each patientreceived two mini-implants in symmetric positions between the maxillary secondpremolar and first molar. One of the mini-implants was placed with AUSOM, whilethe other was placed with a traditional wire guide. To detect mini-implant position,periapical radiographs were taken before implantation with the guide in its placeand after mini-implant placement. To assess mini-implant position in regard to toothroots in periapical radiographs, a scale of four degrees was created: (1) unaccept-able position, (2) acceptable position, (3) good position, and (4) very good position. One week after insertion, mini-implants were loaded and stability of the mini-implants was examined. The results showed that the success rate of the mini-implants placed with AUSOM was 95%, while the success rate of those placedwith the wire guide was 75% (Table 1). The significant deference in failure rate ofmini-implants was P = .046 (Table 2). Tables 3 and 4 show the significant differ-ence in the positions of mini-implants placed with AUSOM and traditional wireguides (P = .009). Volume 12, Number 1, 2011 33
    • Technology“ AUSOM: A 3D placement guide for orthodontic mini-implantsThe radiographic Table 3 Mini-implant position in periapical radiographssurgical guide orients AUSOM (n = 20) Wire guide (n = 20) Total (n = 40)both the radiographic n (%) n (%) n (%)and surgical procedures Not acceptable 1 (5.0) 5 (25.0) 6 (15.0)to ensure a coincident Acceptable 2 (10.0) 6 (30.0) 8 (20.0)path for the x-ray and Good 9 (45.0) 6 (30.0) 15 (40.0) Very good 8 (40.0) 3 (15.0) 11 (27.5)drill, which minimizes ”the risk of damage to Table 4 Comparison between mini-implant placement method accordinganatomical structures … to periapical radiograph results based on Wilcoxon signed rank test Mean Sum of n rank ranks Z P Negative ranks 15 9.53 143.00 –2.600(a) .009 wire guide < AUSOM Positive ranks 3 9.33 28.00 wire guide failure > AUSOM failure Ties 2 wire guide failure = AUSOM failure (a), based on postive rank. DISCUSSION All metallic and surgical wires guides need to be individually fabricated for every patient. All surgical templates have the same disadvantages; fabrica- tion is complicated and time-consuming, requires laboratory equipment, and is expensive. Moreover, such devices do not allow the orthodontist to perform the clinical adjustments. Wire guides do not prevent deviation of the pilot drill. Using a tube in the Suzuki 3D guide with an internal diameter of 3 mm allows drill deviation; it is also limited to three lengths and is difficult to adjust in the anterior-posterior or vertical angulations necessary for optimal implantation. The radiographic surgical guide orients both the radiographic and surgical procedures to ensure a coincident path for the x-ray and drill, which minimizes the risk of damage to anatomical structures, and can be used for predrilled implants. The AUSOM may have several advantages. One, it works as a radiographic locator as well as a 3D surgical placement guide for mini-implants. Since it is a 3D adjustable guide, it can determine the point of implant insertion. The AUSOM’s simple design (Fig 2) is easy to use. Its design allows easy and rapid attachment at any position along a maxillary or mandibular archwire, with ei- ther labial or lingual appliances. It saves time; there is no need to repeat ra- diographs to determe if the new position is acceptable. It is less expensive: There is no need for laboratory fabrication, and it can be reused after steriliza- tion. The AUSOM can be used with self-drilling and predrilling mini-implants. Patient discomfort is minimal, and the guide can easily be removed from the archwire after mini-implant placement and reused on the opposite side, saving chair time and expense. 34 ORTHODONTICS The Art and Practice of Dentofacial Enhancement
    • Al-Suleiman and Shehadah Technology a b c d e f g h i j k lFig 2 Clinical procedures with AUSOM for mini-implant placement in the maxilla. (a) PuttingAUSOM in the position thought to be suitable for mini-implant placement between the secondpremolar and first molar. AUSOM was fixed in place by a 0.16 × 0.22-inch archwire attachedto the fixed appliance. (b and c) Applying the film-holding part after inserting film into the filmholder. (d) Taking a periapical radiograph of the region. (e) Periapical radiograph with AUSOMshowing that adjustments should be made (distalization of 1 mm and mesial palatal rotation ofthe placement guide). (f and g) Inserting the mini-implant into the interradicular septum via theplacement guide cylinder. (h) Removing the archwire and AUSOM. (i and j) Mini-implant in place.(k) Periapical radiograph of the region after mini-implant insertion showing mini-implant wasinserted perfectly. (l) Pre- and postinsertion radiographs. Volume 12, Number 1, 2011 35
    • Technology AUSOM: A 3D placement guide for orthodontic mini-implants CONClUSION After using AUSOM on several patients and evaluating its efficiency, we find it to be a reasonable and practical method to guide and place mini-implants. The failure rate of mini-implants placed by AUSOM was lower than those placed by simple metallic guides. Clinical randomized studies must be carried out to prove AUSOM’s role in improving the success rate of mini-implant placement. ACKNOWlEDGMENT The device described in this article (AUSOM) received a national patent license with the follow- ing patent number, 1393, which was registered by INPI (National Institute for Industrial Property) in the Syrian Arab Republic. REFERENCES 13. Higuchi KW, Slack JM. The use of titanium fixtures for intraoral anchorage to facili- tate orthodontic tooth movement. Int J 1. Graber TM, Vanarsdall RL. Orthodontics: Oral Maxillofac Implants 1991;6:338–344. Current Principles and Techniques. St Louis, 14. Roberts WE, Marshall KJ, Mozsary PG. Mosby: 2000. Rigid endosseous implant utilized as 2. Proffit WR, Fields HW. Contemporary anchorage to protract molars and close Orthodontics. St Louis: Mosby, 2000: an atrophic extraction site. Angle Orthod 308–311. 1990;60:135–152. 3. Block MS, Hoffman DR. A new device 15. Wehrbein H, Merz BR, Diedrich P, Glatz- for absolute anchorage for orthodon- maier J. The use of palatal implants for tics. Am J Orthod Dentofacial Orthop orthodontic anchorage. Design and clini- 1995;107:251–258. cal application of the orthosystem. Clin 4. Chen Y, Kyung HM, Zhao WT, Yu WJ. Criti- Oral Implants Res 1996;7:410–416. cal factors for the success of orthodontic 16. Kanomi R. Mini-implant for orthodontic mini-implants: A systematic review. Am J anchorage. J Clin Orthod 1997;31:763–767. Orthod Dentofacial Orthop 2009; 17. Cornelis MA, Scheffler NR, Nyssen-Behets 135:284–291. C, De Clerck HJ, Tulloch JF. Patients and 5. Costa A, Raffainl M, Melsen B. Miniscrews orthodontists perceptions of miniplates as orthodontic anchorage: A preliminary used for temporary skeletal anchorage: report. Int J Adult Orthodon Orthognath A prospective study. Am J Orthod Dento- Surg 1998;13:201–209. facial Orthop 2008;133:18–24. 6. Creekmore TD, Eklund MK. The possibil- 18. Prabhu J, Cousley RR. Current products ity of skeletal anchorage. J Clin Orthod and practice: Bone anchorage devices in 1983;17:266–269. orthodontics. J Orthod 2006;33:288–307. 7. Jenner JD, Fitzpatrick BN. Skeletal 19. Melsen B, Petersen JK, Costa A. Zygoma anchorage utilising bone plates. Aust ligatures: An alternative form of maxillary Orthod J 1985;9:231–233. anchorage. J Clin Orthod 1998;32:154– 8. Kyung HM, Park HS, Bae SM, Sung JH, 158. Kim IB. Development of orthodontic 20. Chung KR, Nelson G, Kim SH, Kook YA. micro-implants for intraoral anchorage. Severe bidentoalveolar protrusion treated J Clin Orthod 2003;37:321–328. with orthodontic microimplant-dependent 9. Kyung SH, Choi JH, Park YC. Miniscrew en-masse retraction. Am J Orthod Dento- anchorage used to protract lower second facial Orthop 2007;132:105–115. molars into first molar extraction sites. 21. Gelgor IE, Karaman AI, Buyukyilmaz T. J Clin Orthod 2003;37:575–579. Comparison of 2 distalization systems 10. Lin JC, Liou EJ. A new bone screw for supported by intraosseous screws. Am J orthodontic anchorage. J Clin Orthod Orthod Dentofacial Orthop 2007;131: 2003;37:676–681. 161.e1–161.e8. 11. Melsen B. Mini-implants: Where are we? 22. Park HS, Kwon OW, Sung JH. Uprighting J Clin Orthod 2005;39:539–547. second molars with micro-implant anchor- 12. Reynders R, Ronchi L, Bipat S. Mini- age. J Clin Orthod 2004;38:100–103. implants in orthodontics: A systematic review of the literature. Am J Orthod Den- tofacial Orthop 2009;135:564.e1–564.e19.36 ORTHODONTICS The Art and Practice of Dentofacial Enhancement
    • Al-Suleiman and Shehadah Technology23. Thiruvenkatachari B, Pavithranand A, Ra- 35. Kim SH, Choi YS, Hwang EH, Chung KR, jasigamani K, Kyung HM. Comparison and Kook YA, Nelson G. Surgical position- measurement of the amount of anchorage ing of orthodontic mini-implants with loss of the molars with and without the guides fabricated on models replicated use of implant anchorage during canine with cone-beam computed tomogra- retraction. Am J Orthod Dentofacial phy. Am J Orthod Dentofacial Orthop Orthop 2006;129:551–554. 2007;131(suppl):S82–89.24. Wang YC, Liou EJ. Comparison of the 36. Kitai N, Yasuda Y, Takada K. A stent loading behavior of self-drilling and pre- fabricated on a selectively colored drilled miniscrews throughout orthodontic stereolithographic model for placement loading. Am J Orthod Dentofacial Orthop of orthodontic mini-implants. Int J Adult 2008;133:38–43. Orthodon Orthognath Surg 2002;17:25. Kim JW, Ahn SJ, Chang YI. Histomorpho- 264–266. metric and mechanical analyses of the 37. Viwattanatipa N, Thanakitcharu S, Uttr- drill-free screw as orthodontic anchorage. aravichien A, Pitiphat W. Survival analyses Am J Orthod Dentofacial Orthop 2005; of surgical miniscrews as orthodontic 128:190–194. anchorage. Am J Orthod Dentofacial26. Cousley RR, Parberry DJ. Surgical stents Orthop 2009;136:29–36. for accurate miniscrew insertion. J Clin 38. Wu JC, Huang JN, Zhao SF, Xu XJ, Xie Orthod 2006;40:412–417. ZJ. Radiographic and surgical template27. Antoszewska J, Papadopoulos MA, Park HS, for placement of orthodontic microim- Ludwig B. Five-year experience with orth- plants in interradicular areas: A techni- odontic miniscrew implants: A retrospective cal note. Int J Oral Maxillofac Implants investigation of factors influencing success 2006;21:629–634. rates. Am J Orthod Dentofacial Orthop 39. Asscherickx K, Vannet BV, Wehrbein H, 2009;136:158.e1–158.e10. Sabzevar MM. Root repair after injury28. Kuroda S, Yamada K, Deguchi T, Hashi- from mini-screw. Clin Oral Implants Res moto T, Kyung HM, Takano-Yamamoto 2005;16:575–578. T. Root proximity is a major factor for 40. Roberts WE, Helm FR, Marshall KJ, Gon- screw failure in orthodontic anchor- gloff RK. Rigid endosseous implants for age. Am J Orthod Dentofacial Orthop orthodontic and orthopedic anchorage. 2007;131(suppl):S68–73. Angle Orthod 1989;59:247–256.29. Cousley R. Critical aspects in the use of 41. Melsen B, Verna C. Miniscrew implants: orthodontic palatal implants. Am J Orthod The Aarhus anchorage system. Semin Dentofacial Orthop 2005;127:723–729. Orthod 2005;11:24–31.30. Cousley RR, Parberry DJ. Combined 42. Kravitz ND, Kusnoto B. Risks and cephalometric and stent planning for complications of orthodontic minis- palatal implants. J Orthod 2005;32:20–25. crews. Am J Orthod Dentofacial Orthop31. Ishii T, Nojima K, Nishii Y, Takaki T, Yama- 2007;131(suppl):S43–S51. guchi H. Evaluation of the implantation 43. Choi HJ, Kim TW, Kim HW. A precise wire position of mini-screws for orthodontic guide for positioning interradicular mini- treatment in the maxillary molar area by a screws. J Clin Orthod 2007;41:258–261. micro CT. Bull Tokyo Dent Coll 2004; 44. Bae SM, Park HS, Kyung HM, Kwon OW, 45:165–172. Sung JH. Clinical application of micro-32. Morea C, Dominguez GC, Wuo Ado V, implant anchorage. J Clin Orthod 2002; Tortamano A. Surgical guide for optimal 36:298–302. positioning of mini-implants. J Clin Or- 45. Suzuki EY, Buranastidporn B. An adjust- thod 2005;39:317–321. able surgical guide for miniscrew place-33. Estelita Cavalcante Barros S, Janson G, ment. J Clin Orthod 2005;39:588–590. Chiqueto K, de Freitas MR, Henriques JF, 46. Suzuki EY, Suzuki B. A simple three-di- Pinzan A. A three-dimensional radiograph- mensional guide for safe miniscrew place- ic-surgical guide for mini-implant place- ment. J Clin Orthod 2007;41:342–346. ment. J Clin Orthod 2006;40:548–554.34. Suzuki EY, Suzuki B. Accuracy of miniscrew implant placement with a 3-dimensional surgical guide. J Oral Maxillofac Surg 2008;66:1245–1252. Volume 12, Number 1, 2011 37
    • Controversy Phantom bite: A survey of US orthodontists Bozena B. Ligas, DMD, MS1 Maria Therese S. Galang, DMD, MS2 Ellen A. BeGole, PhD3 Carla A. Evans, DDS, DMSc4 Gary D. Klasser, DMD5 Charles S. Greene, DDS6 Aim: In 1976, Marbach described the term phantom bite as a patient’s perception of an irregular bite when the clinician could identify no evidence of a discrepancy. Typically, the patient presents with a history of bite-altering procedures, hyperawareness of occlusion, and a persistent complaint of an uncomfortable bite, usually with an absence of pain. Patients with phantom 1Former Resident, bite complaints often undergo lengthy, expensive, irreversible, invasive, and Department of Orthodontics, University unnecessary treatments in search of a resolution of their symptoms. The of Illinois at Chicago, objectives of the study were: (1) to gauge orthodontists’ awareness of phantom Chicago, Illinois, USA; currently, Private Practice, bite and its associated signs and symptoms, (2) to identify the most common Chicago, Illinois, USA. types of treatments rendered for this phenomenon, (3) to determine if regional 2Assistant Professor, Department of differences or length of practice experience affected the aforementioned Orthodontics, University factors, and (4) to determine sex characteristics of patients with phantom bite. of Illinois at Chicago, Chicago, Illinois, USA. Methods: The study consisted of a 14-item survey administered electronically 3Associate Professor, Department of using SurveyMonkey software. Using the American Association of Orthodontists Orthodontics, University (AAO) directory, 4,124 orthodontists were recruited to participate via email; of Illinois at Chicago, Chicago, Illinois, USA. 337 completed the survey. Results: Approximately 50% of the responding 4Professor and Head, orthodontists were unfamiliar with the term “phantom bite”; however, many Department of Orthodontics, University reported seeing patients with phantom bite complaints. Demographic of Illinois at Chicago, differences, such as geographic region of practice or years in practice, did not Chicago, Illinois, USA. 5Assistant Professor, affect familiarity with this condition or its treatment. Conclusion: The results Department of Oral suggest a need for increasing awareness of this condition among orthodontic Medicine and Diagnostic Sciences, University practitioners to provide patients with appropriate care. ORTHO 2011;12:38–47. of Illinois at Chicago, Chicago, Illinois, USA. 6Clinical Professor, Key words: phantom bite, occlusion, occlusal dysthesia, occlusal hyperawareness Department of Orthodontics, University of Illinois at Chicago, D Chicago, Illinois, USA. entists often encounter patients who have unusual oral complaints CORRESPONDENCE that do not fit into ordinary and customary categories (ie, toothache, Dr Maria Therese S. Galang gingival bleeding, or oral sores). One particular phenomenon in den- Department of tistry, commonly referred to as phantom bite, exemplifies this type of clinical Orthodontics University of Illinois at problem. Patients may present with a variety of subjective occlusion-related Chicago complaints; upon examination, however, the dentist can find no evidence of a 801 S Paulina St, Room 131 problem. Most often, the patients verbalize that their bite is off, meaning that M/C 841 Chicago, IL 60612 it is uncomfortable or abnormal in some way.1,2 They are extremely preoc- Email: mgalang@uic.edu cupied and focused with how their teeth come together, appearing virtually38 ORTHODONTICS The Art and Practice of Dentofacial Enhancement
    • relief toothache e q u i l i b R aT i O n clinical problem frustrationphantom bite CHRONIC anxiety complaints obsessed abnormal a wa re n e s sobsessed. The onset of such complaints almost always begins after some typeof bite-changing procedure involving major dental restorations or orthodon-tic treatment has occurred. Over time, it could become a chronic condition.These patients often travel from clinician to clinician in search of a “cure,”acquiring along the way treatments ranging from removable splints and oc-clusal equilibration to orthodontic therapy and complete full-mouth prostheticreconstruction, none of which provide relief or satisfaction. Since orthodontists routinely perform treatment that alters the occlusion, atsome point in their careers, they may encounter patients with phantom bite com-plaints. When general dentists are faced with the dilemma of a patient seekingtreatment for such a problem, they frequently refer patients to a specialist. Or-thodontists, being specialists in managing occlusal relationships, will thereforebe likely to have these patients referred to them. Alternatively, some patientsmay identify orthodontists as specialists from whom to seek help. The orthodon-tist’s own patients may develop this problem as well, since they are undergoingmajor bite-changing treatment. Early identification of such patients is vital be-cause it will minimize the patients’ frustration and anxiety over the condition aswell as the likelihood of unnecessary, time-consuming, and costly treament. The purpose of this survey study was to determine whether US orthodontistswere aware of the existence of phantom bite, and if so, how they dealt with thepatients who presented with such problems. To get a more complete picture,orthodontists were also asked how frequently they saw patients with the typi-cal complaints of this condition, even if they did not label it as such. Anothergoal was to identify the most common types of treatments rendered by ortho-dontists for this phenomenon as well as to determine if regional differences orlength of practice experience affected their approach to those patients. In ad-dition, this study aimed to determine the sex distribution of patients who pre-sented to orthodontists with phantom bite. The authors did not try to ascertainthe prevalence of phantom bite among the general population, because thatwould require a systematic epidemiologic approach.Etiologic theories for phantom biteA psychologic disorder. The term “phantom bite” was coined by Dr JosephMarbach in 1976.1 At that time, Marbach proposed that this was a psycho-logic condition, comparing patients with phantom bite complaints to paranoidschizophrenics with obsessive-compulsive tendencies. He described the typi-cal manifestation of this condition beginning in late adolescence, commonlyfollowing orthodontic treatment. Although orthodontic changes normallyoccur slowly, allowing most patients to adapt over time, Marbach believed somepatients fail to do so, and for them, the treatment could become a “catalyst . . .in the nascent schizophrenic.” The initial sign is the development of a preoc-cupation with the details of treatment. Marbach explained that these patientsexperience proprioceptive changes in their occlusion at the conscious leveland begin a quest to collect dental casts, radiographs, and treatment notes Volume 12, Number 1, 2011 39
    • Controversy Phantom bite: A survey of US orthodontists in an attempt to remember their original occlusion. These patients will often invest much time, money, and energy traveling from clinician to clinician with these items and requesting treatment that will allow them to regain their origi- nal bite. Over time, the recollection of their original bite often becomes very distorted and unreasonable. Marbach noted that there was neither a way to screen for the potential for this problem, nor any method to prevent it. He also believed that once the problem is observed, a psychiatric referral should be made. No tooth-altering treatment should be rendered; in fact, he suggested the best treatment was no treatment at all.1 In later publications, Marbach et al3 and Marbach4 altered the classification of phantom bite as possibly falling under the category of monosymptomatic hypochondriacal psychosis, defined by Munro5 as having an unshakeable belief in a distorted body image (as with anorexia nervosa patients). A second possi- ble label Marbach proposed was dysmorphophobia, which is when the patient has a delusion about a cosmetic defect. Both of these classifications still regard phantom bite as a psychologic disorder, and the authors’ recommendation for treatment remained unchanged. A nervous system disorder. Melzack discussed brain signaling and the neuro- matrix theory, stating that physical sensations can be felt without actual input from the body.6 They are generated by the brain, and although peripheral stim- uli almost always precede the sensations, they do not directly produce them. As research grew on the topic of phantom limb pain, discussions about phantom bite began appearing in this category. Marbach7 published an article on three types of orofacial phantom phenomena: phantom tooth pain follow- ing extraction or root canal therapy, stump pain in the edentulous patient, and phantom bite. Although Marbach admits that patients exhibiting symptoms of phantom bite rarely complain of any pain, he advocates that the pathophysi- ology of this altered perception may be similar to that of the phantom limb phenomenon, in which the patients’ painful symptoms appear to be due to changes not only in the peripheral nervous system but also the central nervous system. There may be neuroma formation or nociceptor sensitization in the peripheral area, in addition to processing changes in the brain regarding how the input signals are now processed, interpreted, and stored.6 Another proposed physical etiology for phantom bite during this time hy- pothesized that the complaints generated by these patients were actually due to their preexisting heightened occlusal awareness. Baba et al8 tested this the- ory by comparing a group of phantom bite patients with a control group. Thick- ness discrimination and mouth opening reproducibility tests were administered to the two groups, but no significant differences were found. The authors con- cluded that these patients did not differ from healthy subjects in their sensory, perceptive, or discriminative abilities. A combination disorder. In 1997, Clark et al9 noted that a more appropriate term for phantom bite would be occlusal dysesthesia (OD), meaning an altered or abnormal sensation in regard to the bite. In a later paper,10 Clark and Sim- mons suggested two possible explanations for this disorder: (1) an impaired “oral kinesthetic ability” that they define as a person’s ability to differentiate the position of the mandibular jaw; or (2) a psychiatric disorder, particularly somato- form disorder. These authors believe that a psychologic diagnosis should be considered only after all physical sources are ruled out. This article also attempt- ed to answer whether occlusal dysesthesia was linked to temporomandibular disorders (TMDs). The conclusions were that TMD changes of the involved joint and muscles could initiate OD, but that OD can indeed develop independently.9 Besides a psychiatric consultation, if warranted, they recommended the use of an occlusal splint, with gradual usage reduced over time as well as patient edu- cation as the treatment of choice.40 ORTHODONTICS The Art and Practice of Dentofacial Enhancement
    • Ligas et al Controversy Phantom bite patients referred for a psychologic evaluation may be diag-nosed with comorbid depression, obsessive-compulsive tendencies, or somato-form disorder. Somatoform disorder inclusion criteria, as listed by the Diagnosticand Statistical Manual of Mental Disorders IV,11 consist of one or more physicalcomplaints that cannot be fully explained by a medical condition. They causeclinically significant distress with a duration of at least 6 months and are not partof another mental disorder or intentionally produced. The medical expenses ofthese patients are estimated to be six to 14 times higher than average and havenegative effects due to lost work and productivity.12,13 Reeves and Merrill14 noted that it is imperative for dentists to consult psy-chologists upon observing this disorder, so that cognitive-behavioral therapymay be initiated. This therapy includes education, relaxation and stretching ex-ercises, positive feedback, and possibly psychopharmacologic management.Treatment could be rendered by any dentist or psychologist familiar with thiscondition and its course of treatment. These authors believe that continueddental treatment will not only fail in relieving the patients’ symptoms, but alsolikely make the problem worse. Further dental treatment or even a referral toanother dental specialist for a second opinion will only reinforce the patients’“illness conviction” and raise their preoccupation with their symptoms. Etiology conclusions. The most likely conclusion that can be drawn from thecurrent literature suggests that phantom bite has neurologic and psychologic eti-ologic components. Therefore, clinicians should appreciate that patients with thiscondition are experiencing a combination of neurosensory hyperawareness andpsychologic impact. Because these patients can present to both general dentistsand specialists, all dentists should be educated about this diagnosis, not onlyso that reasonable advice and treatment can be given, but also to minimize thedistress experienced by both the patient and clinician rendering treatment.METHODSThis study was based on a 14-item questionnaire directed at practicing ortho-dontists. To the authors’ knowledge, no other similar study has been reported;therefore, a new set of questions was formulated based upon the expertise ofthe investigators. The survey questions were meant to determine whether US or-thodontists are aware of phantom bite, what common signs and symptoms ofphantom bite they are encountering in their practices, how many of these typesof cases they have encountered, and what types of treatment they are providing.The survey also included demographic questions for orthodontists, such as thestate in which they practice and how many years they have been practicing ortho-dontics. The final question allowed for an open-ended comment on the subject. The study sample consisted of licensed US orthodontists whose email ad- “dresses were collected from every other page of the 2005 American Associationof Orthodontists (AAO) directory. Duplicate email addresses were discarded;4,124 usable email addresses were obtained. The software used to design the survey and collect the responses was Survey- . . . clinicians shouldMonkey (SurveyMonkey.com). Using this software, a link to the survey webpage appreciate that patientswas created and emailed to the participants. Recipients were given 2 weeks with this conditionto complete the survey. After the initial data-collection period, two reminderemails were sent, at 2-week intervals. SurveyMonkey sent the reminder emails are experiencingonly to those who had not responded at the 2-week time point. Data collection a combinationwas complete 6 weeks after the initial survey was distributed. of neurosensory ” After the initial 4,124 emails were sent, 899 failed to be delivered due to in-valid addresses. Forty-eight orthodontists replied via email that they could not hyperawareness andtake the survey because they were retired. Twenty-six participants chose to opt psychologic impact. Volume 12, Number 1, 2011 41
    • Controversy Phantom bite: A survey of US orthodontists 4,124 Email addresses 48 899 Responded Invalid addresses as retired 3,177 Possible respondents 26 337 2,814 Opted out (0.01%) Completed survey (10.61%) No response (88.57%) Fig 1 Survey response flow chart. out, removing their email address from any further correspondence, and 2,814 failed to respond. In the end, 337 responses were collected, which represents 10.61% of possible respondents (Fig 1). RESULTS The answers to the first survey question revealed that 50.3% of the respon- dents were familiar with the term “phantom bite.” The second question in- vestigated the signs and symptoms associated with phantom bite. More than 75% of the respondents encountered one or more patients with the following symptoms or complaints: (1) excessive bite concerns; (2) statements such as “my bite is off” or “I lost my bite and am unable to find it” as a consequence of previous dental procedures; (3) detailed accounts of previous dental experi- ences, often expressing dissatisfaction; (4) complaints of bite irregularity not present upon careful examination; (5) unrealistic and excessive awareness of minute tooth alignment details and how they affect occlusion; and (6) history of various bite-altering procedures such as occlusal equilibration, multiple res- torations, or repeated orthodontic treatments. More than 50% of respondents had encountered patients who brought duplicate dental records from previous dentists as well as previously prescribed oral appliances; most of these patients reported an absence of pain but a persistent chief complaint of discomfort due to the bite. Finally, 36% of respondents saw patients who presented diagnostic casts with explanations regarding occlusal conditions. Eighty-five percent of the respondents reported that these patients were pre- dominantly female. The number of years the respondents have been practicing orthodontics ranged from 1 to 60 years. The majority of respondents reported not holding a faculty position in an orthodontic residency program; 70 (21.3%) of the 329 who answered the question confirmed having faculty status. From those who identified themselves as faculty members, 75% reported seeing these phantom bite patients mostly in private practice. The highest numbers of surveys were collected from respondents in the west- ern and southern regions of the United States, while the fewest were collected from the northeast region. A Pearson chi-square test found no statistically signifi- cant relationships between familiarity with the term phantom bite and the four US42 ORTHODONTICS The Art and Practice of Dentofacial Enhancement
    • Ligas et al Controversy No No 120 Yes 100 Yes No. of respondents No. of respondents 100 80 80 45 52 58 60 53 35 27 60 26 40 40 23 20 52 40 50 20 38 35 47 43 23 0 0 West Midwest South Northeast 1–10 11–20 21–30 >31 US region Length of practice (y)Fig 2 Distribution of familiarity with the term “phantom bite” Fig 3 Distribution of famil-according to US region. iarity with the term “phantom bite“ according to years in practice.regions. Figure 2 displays the distribution of respondents who were familiar withthe term vs those who were not. The Pearson chi-square test found no statisticallysignificant relationships between respondents’ familiarity with the term phantombite and their time in practice. Figure 3 displays the distribution of respondentsfamiliar with the term vs those who were not, according to years in practice. Due to the low number of respondents in each answer category of question 7,which was an eight-part question dealing with different management approach-es for phantom bite patients, the responses were pooled to obtain a larger num-ber of responses per answer category. For each treatment rendered, the always,almost always, and sometimes responses were grouped into a yes category; like-wise, the never and almost never responses were grouped into a no category.Table 1 shows the pooled responses for question 7. A majority of respondentsanswered yes to referred to another specialist; sent back to the referring doctor;and started orthodontic treatment. However, a majority answered no to referredto a prosthodontist; referred to another orthodontist; referred for psychologicevaluation; and mounted models, did occlusal analysis, and started orthodontictreatment. The Pearson chi-square test was completed to establish relationshipsbetween each of the seven treatments with the region of practice. No statisticallysignificant relationships were found between the respondents in the four US re-gions and the treatment rendered. Only 3% of the respondent orthodontists reported always resolving the case suc-cessfully. Fifty-two percent reported sometimes, and another 3% reported neverresolving the patient’s chief complaint. Eighty-five percent claimed that no readingmaterial or published literature was helpful in diagnosing or treating these patients.DISCUSSIONSurvey sampleIn general, response rates to emailed surveys have been steadily decliningfrom a high at 61.5% in 1986 to 24.0% in 2000.15 Some of the reasons for thisare an increase in unsolicited emails, email filtering, and the threat of viruses.In spite of the drawbacks of email surveys, this method is still a valuable re-search tool due to the many benefits, including speed and cost efficiency.Using an email survey is fast and relatively easy, therefore making it a valuable Volume 12, Number 1, 2011 43
    • Controversy Phantom bite: A survey of US orthodontists table 1 Management of patients presenting with symptoms related to phantom bite: Pooled responses for question 7 (“how did you manage the case/s that you did encounter?”) Yes No Total count per question Referred to a prosthodontist 107 129 236 Referred to another orthodontist 32 187 219 Referred for a psychologic evaluation 43 178 221 Referred to another specialist 187 53 240 Sent back to the referring doctor 166 70 236 Started orthodontic treatment 170 79 249 Mounted models, did occlusal analysis, 120 125 245 then started orthodontic treatment Other (please specify) 75 Answered question 289 Skipped question 48 pilot study instrument to obtain baseline data for further investigation if the results indicate a need for subsequent research. It is important to keep the relatively low response rate in mind when at- tempting to interpret the results of this survey. In addition, because the email addresses were taken from every other page of the AAO directory, this survey included participants from every US state. Therefore, when looking at the re- spondent demographics, particularly the uneven distribution across the four US regions, it may be explained by the fact that an uneven number of partici- pants were contacted in each region. Familiarity with phantom bite Marbach4 stated, “The best approach to the care and treatment of the patient with phantom bite lies in the dentist’s familiarity with the signs and symptoms of these syndromes.” The current study indicates that approximately half the ortho- dontists who responded to this survey were not familiar with this condition. This may be an underestimate of the actual percentage for several reasons. One is that the survey questions exclusively used the term “phantom bite,” while other synon- ymous terms such as “occlusal dysesthesia,” “persistent uncomfortable bite,” or “occlusal neurosis” are frequently used in the dental literature. Although the invita- tion email did include these terms, participants who did not read it prior to starting the survey may have answered no to being familiar with the term “phantom bite,” whereas they may have been familiar with one of the abovementioned terms. Alternatively, this percentage may be an overestimate of the actual familiar- ity rate. As with any survey study, the ultimate sample selection is not random because each respondent self-selects whether to participate. Several studies on survey research report that topic salience is a key factor influencing re- sponse rate.16,17 It is understandable that someone who regards a subject as meaningful and significant is more likely to participate in sharing opinions and experience. It follows that an orthodontist familiar with phantom bite, particu- larly someone who has encountered the difficulty of treating a patient with this condition, would be more likely to complete the present survey than an ortho- dontist who is unaware of it. If the invitation specifically stated that the survey aimed to gauge orthodontists’ awareness of the subject, those unfamiliar with it may have been more likely to participate.44 ORTHODONTICS The Art and Practice of Dentofacial Enhancement
    • Ligas et al ControversyEncounters with phantom bite complaintsAlthough approximately only half of the survey respondents reported being fa-miliar with the term “phantom bite,” a high percentage (86%) reported seeingone or more patients with unrealistic and excessive awareness of minute toothalignment details and complaints about their occlusion. More than half of therespondents (60.6%) reported that during the time they have practiced ortho-dontics, they have encountered five or more of these types of patients; 21.2%indicated that they have seen 15 or more. Eighty-three percent have heard apatient state that her “bite is off” or “I lost my bite and am unable to find it” asa consequence of previous dental procedures. Seventy-five percent have hada patient complain of bite irregularity that was not visibly present upon carefulexamination. Sixty-three percent had a patient present without pain but witha persistent chief complaint of bite discomfort. The combination of low famil-iarity with the term phantom bite, yet relatively high occurrence of patientspresenting with symptoms of the same, may indicate a potential problem withmisdiagnosis and inappropriate treatment of these patients. This in turn wouldindicate a need for increasing awareness of this problem and how to manage it. There was a wide range of answers to the question asking participants to quan-tify what percentage of patients who presented to them with such occlusal com-plaints would receive a phantom bite diagnosis. The answers ranged from 0% to100%, with a large standard deviation of 33.8, suggesting that respondents areeither using different criteria for this diagnosis or do not know what the criteria are. The results suggest that there are no differences among orthodontists in fa-miliarity with phantom bite across the US regions, and this did not significantlyvary from region to region. It also did not vary when comparing the respon-dents according to length of practice, meaning that those practicing for 10, 20,or 30 years were equally likely to be familiar with this condition. These resultsalso indicate that there may be no differences in schools of thought in vari-ous areas of the country that would predispose certain graduates to be moreaware of phantom bite. Furthermore, the results do not show that increasedpractice experience increases the likelihood of the orthodontist being familiarwith this condition or that those who more recently completed a training pro-gram are more likely to recognize the term.Treatment of phantom biteThe most recent literature describes phantom bite or occlusal dysesthesia as a “form of somatoform disorder, for which the appropriate treatment is cognitivebehavioral therapy. When the diagnosis is suspected, many experts suggestthat a psychologic referral should be made.2,14 However, 80.5% of the respon- The combination ofdents in this study reported never or almost never referring to a psychologist. low familiarity withWhen presented with a patient exhibiting signs and symptoms of phantombite, 9.2% of responding orthodontists said they would always or almost al- the term “phantomways start orthodontic treatment, while 59% said they sometimes do that; only bite,” yet relatively31.7% of the respondents said they would never or almost never start orth- high occurrence ofodontic treatment. Attempting to treat these patients occlusally is contrary toevery expert’s recommendations about how to deal with these hyperaware- patients presentingness complaints. The lack of psychologic consideration, combined with the with symptoms of thewillingness to treat these patients orthodontically, implies a need for educating same, may indicateorthodontic practitioners about this diagnosis. Overwhelmingly, respondents to this survey stated that females (81.5%) were a potential problemthe predominant sex among patients who presented with signs and symptoms with misdiagnosisof phantom bite. This agrees with a study by Yamaguchi et al,18 in which their and inappropriate ”sample consisted of four males and 35 females. These authors retrospectivelyexamined the features of patients with phantom bite, which they referred to as treatment of thesepersistent uncomfortable occlusion, who presented to a Japanese clinic over a patients. Volume 12, Number 1, 2011 45
    • Controversy Phantom bite: A survey of US orthodontists period of 4.5 years. Their data also showed that 22 (56.4%) of the 39 persistent uncomfortable occlusion patients did not improve with time or with various types of treatments. In this study, however, only 15.1% of the respondents reported that the patient’s chief complaint was never or almost never resolved successfully. One possibility for this difference is that the sample populations are differ- ent, reflecting ethnic or cultural differences. Another possibility is that different criteria were used to diagnose persistent uncomfortable occlusion patients, resulting in different treatment success rates. In addition, the Japanese clinic specifically diagnosed and treated these patients, while the surveyed ortho- dontists were only randomly encountering them. Finally, the orthodontists in the present study may not have realized that some of their unimproved pa- tients simply sought treatment from another clinician with the same complaint, thereby inflating their perceived success rates. It is noteworthy that 85.4% of the respondents stated that no reading material or published literature was helpful in diagnosing or treating these cases. This is not surprising, since the only published article in an orthodontic journal on the topic of phantom bite is Marbach’s 1976 paper in which he introduced the term.1 Of the more recently published articles that discuss the topic of phantom bite, three2,8,18 were in non-US journals, while only two10,14 were published in US-based dental journals. Hopefully, the current study may serve as an important stimulus for this discussion and for further research within the orthodontic community. The most current literature on the subject describes a model that includes both neurologic and psychologic components of phantom bite. Reeves and Merrill14 provided a hypothesis for the etiology of this condition that combined occlusal hyperawareness in a patient prone to somatization. In such a case, mental and emotional stresses can manifest in the form of psychosomatic illnesses. Accord- ing to these authors, cognitive behavioral therapy is the appropriate treatment. They warn that continued dental therapy will most likely not improve the condi- tion, but may in fact worsen it by reinforcing the patients’ illness conviction and increasing their somatic preoccupation. Treatment should focus on patient edu- cation and improved overall well-being and functioning, rather than complete symptom eradication. One may draw a parallel to chronic pain patients when attempting to understand the interplay of neurologic and psychologic compo- nents involved in phantom bite. Also, clinicians can draw on current concepts of chronic pain treatment to understand why further dental manipulation of the phantom bite patient is not recommended. Failure to recognize this paradoxic situation may lead to lengthy, expensive, unnecessary, invasive, and unsuccessful mechanical treatment of these patients, resulting in frustration for both the pa- tient and the treating clinician as well as possible litigation. Therefore, awareness of this condition and its proper treatment is important. Respondent comments Several respondents said that they have “never read or heard of this condition” or were unaware “that anyone had put a ‘name’ on this problem.” Many com- ments suggested that dentists rarely see this condition: “It is a nonentity,” and “Your cause is of minor concern to most practitioners and patients.” Others re- lated in detail their encounters and frustrations with such patients and stated that “research addressing this issue is long overdue.” Comments on the treatment provided for these patients varied the most. Some orthodontists attempt to do as little as possible, choosing a noninvolvement approach, while others provide pa- tient education along with a lot of handholding. However, many said they strongly believe that there usually is an occlusal discrepancy and that proper diagnos- tic procedures (ie, articulator mountings or recognizing CR to CO discrepancies) will reveal the occlusal problem and point to the correct treatment. There were46 ORTHODONTICS The Art and Practice of Dentofacial Enhancement
    • Ligas et al Controversy “also many comments that categorized this condition along with TMD and recom-mended the same approach to treating these patients as TMD patients. There did . . . awareness ofnot appear to be any general consistency to the respondent comments, either in this condition and ”their level of understanding or in the treatment provided for these patients, sug-gesting a need for increasing orthodontists’ knowledge of phantom bite, how to its proper treatmentdiagnose it, and the appropriate treatment for this condition. is important.CONCLUSIONApproximately 50% of the orthodontists who responded to the survey were notfamiliar with the term “phantom bite,” although a majority reported encounter-ing patients with signs and symptoms of that condition. Most orthodontists donot even consider making a psychologic referral, and many start orthodontictreatment in an attempt to resolve these complaints. These factors, combinedwith the reported lack of literature on the subject, indicate a need for further re-search and education of orthodontists on this topic, so that they may themselvesprovide the appropriate advice and treatment or make the appropriate referral.ACKNOWLEDGMENTSThe authors wish to thank Dr Nishant Patel and Dr Hoi-Jeong Lim for their assistance in data col-lection and statistical analysis, respectively.REFERENCES 11. American Psychiatric Association. Diag- nostic and Statistical Manual of Mental Disorders DSM-IV. New York: American 1. Marbach JJ. Phantom bite. Am J Orthod Psychiatric Association, 1994. 1976;70:190–199. 12. Smith GR Jr, Monson RA, Ray DC. 2. Jagger RG, Korszun A. Phantom bite Psychiatric consultation in somatization revisited. Br Dent J 2004;197:241–243. disorder: A randomized controlled study. 3. Marbach JJ, Varoscak JR, Blank RT, Lund N Engl J Med 1986;314:1407–1413. P. Phantom bite: Classification and treat- 13. Katon W, Lin E, Von Korff M, Russo J, ment. J Prosthet Dent 1983;49:556–559. Lipscomb P, Bush T. Somatization: A spec- 4. Marbach JJ. Psychosocial factors for fail- trum of severity. Am J Psychiatry 1991;148: ure to adapt to dental prostheses. Dent 34–40. Clin North Am 1985;29:215–233. 14. Reeves JL II, Merrill RL. Diagnostic and 5. Munro A. Monosymptomatic hypochon- treatment challenges in occlusal dysesthe- driacal psychosis. Br J Hosp Med 1980; sia. J Calif Dent Assoc 2007;35:198–207. 24:34–38. 15. Sheehan KB. E-mail survey response 6. Melzack R. Pain: Past, present, and future. rates: A review. J Comput Mediat Com- Can J Exp Psychol 1993;47:615–629. mun [serial online] 2001;6(2). Available at: 7. Marbach JJ. Orofacial phantom pain: http://jcmc.indiana.edu/vol6/issue2 Theory and phenomenology. J Am Dent /sheehan.html. Accessed 9 February 2011. Assoc 1996;127:221–229. 16. Sheehan KB, McMillan SJ. Response varia- 8. Baba K, Aridome K, Haketa T, Kino K, tion in e-mail surveys: An exploration. Ohyama T. Sensory perceptive and dis- J Advert Res 1999;3:45-54. criminative abilities of patients with occlusal 17. Heberlein TA, Baumgartner R. Factors dysesthesia [in Japanese]. Nihon Hotetsu affecting response rates to mailed ques- Shika Gakkai Zasshi 2005;49:599–607. tionnaires: A quantitative analysis of the 9. Clark G, Tsukiyama Y, Baba K, Simmons published literature. Am Sociol Rev 1978; M. The validity and utility of disease de- 43:447–462. tection methods and of occlusal therapy 18. Yamaguchi T, Mikami S, Okada K, et al. A for temporomandibular disorders. Oral clinical study on persistent uncomfortable Surg Oral Med Oral Pathol Oral Radiol occlusion. Prosthodont Res Pract 2007;6: Endod 1997;83:101–106. 173–180.10. Clark G, Simmons M. Occlusal dysesthesia and temporomandibular disorders: Is there a link? Alpha Omegan 2003;96:33–39. Volume 12, Number 1, 2011 47
    • Interdisciplinary A multidisciplinary approach to the treatment of a horizontally impacted mandibular second premolar: 10-year follow-up Dror Aizenbud, DMD, MSc1 Liran Levin, DMD2 Shaul Lin, DMD3 Eli E. Machtei, DMD2 This report presents a multidisciplinary approach to the treatment of a rare case of a distally impacted mandibular second premolar indicating a 90-degree tilt 1Orthodontics of the long axis in a healthy, 15-year-old girl. It also describes the clinical and and Craniofacial Department, radiologic findings after a 10-year longitudinal follow-up period. The horizontally Graduate School of Dentistry, Rambam impacted mandibular second premolar was positioned behind the roots of the Health Care Campus first molar and in close proximity to the root of the second molar, toward the and Bruce Rappaport Faculty of Medicine— lingual cortex of the mandibular body. Treatment methods required 2 years Technion, Israel Institute of of cooperation among an orthodontist, an oral and maxillofacial surgeon, a Technology, Haifa, Israel. 2Department of periodontist, and an endodontist to achieve a leveled and aligned position Periodontology, Graduate in a properly healed condition. Finally, the horizontally impacted mandibular School of Dentistry, Rambam Health Care second premolar was correctly positioned in the arch surrounded by healed Campus and Bruce periodontal ligament tissue. Root resorption of the adjacent orthodontic Rappaport Faculty of Medicine—Technion, anchorage units was recorded. The 10-year postoperative follow-up presented Israel Institute of Technology, Haifa, Israel. a stable, functional, and symptom-free permanent mandibular second 3Unit of Endodontics premolar. The multidisciplinary dental team’s considerations and cooperation and Dental Trauma, Department of Oral account for the successful repositioning of the compromised mandibular and Dental Sciences, second premolar with minimal damage to the surrounding hard and soft Graduate School of Dentistry, Rambam tissue following 10 years of longitudinal follow-up. ORTHO 2011;12:48–59. Health Care Campus and Bruce Rappaport Faculty of Medicine— Key words: bone regeneration, combined lesion, endodontic treatment, Technion, Israel Institute of impacted premolar, orthodontic traction, periodontal surgery Technology, Haifa, Israel. CORRESPONDENCE I Dr Dror Aizenbud mpeded eruption or impaction of permanent teeth occurs in 5.6% to 18.8% Orthodontic and of the population.1–4 The mandibular second premolar is typically among Craniofacial Department Rambam Health Care the last to develop and erupt, showing great variation in its development Campus pattern.5–12 It is therefore not surprising that impacted mandibular second PO Box 9602 premolars have been found to constitute approximately 24% of all impact- Haifa 31096 Israel ed teeth, excluding third molars.13 Furthermore, the frequency of unerupted Email: aizenbud@ortho.co.il mandibular second premolars in 15-year-old children is as high as 9.7%.14 48 ORTHODONTICS The Art and Practice of Dentofacial Enhancement
    • The germ of the mandibular second premolar is ideally positioned betweenthe two roots of the primary second premolar.15 Normally, the path of erup-tion follows the resorption of the roots of the primary second molar, with nomajor deviations. However, abnormal tooth germ position and consequentdeviated angular changes during tooth development and eruption seem to befrequent.16,17 Left untreated, the tooth will remain impacted,5,9,11,18–23 with therisk of damaging neighboring teeth and loss of arch integrity.24,25 Conservative management with exposure of the crown has been advocat-ed.12,22,26–28 The majority of reported cases involve distally impacted premo-lars in which the long axis of the teeth were inclined in such a way that favorsspontaneous or minimally assisted eruption if exposed. Surgical exposure isunpredictable and best limited to cases with no more than a 45-degree tilt ofthe long axis from its normal position.22 This report presents the rare case of a distally impacted mandibular secondpremolar with a 90-degree angulation from the long axis in a healthy 15-year-old girl. This horizontally impacted mandibular second premolar was posi-tioned behind the roots of the first molar and in close proximity to the root ofthe second molar, toward the lingual cortex of the mandibular body. The con-siderations and treatment approach of a multidisciplinary dental team involvingthe management of the complicated malposed tooth are discussed and the10-year postoperative long-term clinical and radiologic findings are described.CASE REPORTA 15-year-old girl was referred to our clinic by her family dentist due to thedelayed eruption of her mandibular right second premolar and overretainedprimary mandibular right second premolar. The patient had no relevant medical history. Upon clinical examination, allpermanent teeth had erupted except for the mandibular right second premo-lar and all third molars. The primary mandibular right second premolar was stillin place, and both arches were well aligned with a Class I canine and molarrelationship (Figs 1a to 1c). A normal incisor relationship, including overjet Volume 12, Number 1, 2011 49
    • Interdisciplinary Treatment of a horizontally impacted mandibular second premolar a b c e d Fig 1 Pretreatment clinical and radiographic records. (a) Intraoral frontal view, (b) intraoral right lateral view, (c) intraoral mandibular occlusal view, (d) pretreatment lateral cephalometric radio- graph, and (e) pretreatment panoramic radiograph. and overbite and a normal growth pattern of the skeletal jaws, was recorded (Fig 1d). Cephalometric (Fig 1d) and panoramic (Fig 1e) radiographs revealed that the mandibular right second premolar was horizontally orientated and impacted distally behind the roots of the first and second molars toward the compact lingual cortex of the right lingual border of the mandibular body. The upper border of the unerupted distoangular inclined premolar was level with the apices of the adjacent teeth, and the crown could be palpated from the lingual aspect of the vestibule. The patient was further examined by a multidisciplinary team—an ortho- dontist, oral and maxillofacial surgeon, periodontist, endodontist, and pedo- dontist—at the Rambam Health Care Campus–Graduate School of Dentistry. Following clinical and radiographic examination, a conservative treatment plan consisting of extraction of the primary mandibular right second premolar and surgical exposure and orthodontic extrusion of the impacted tooth was out- lined for the patient and her parents. 50 ORTHODONTICS The Art and Practice of Dentofacial Enhancement
    • Aizenbud et al Interdisciplinary A 0.022 × 0.025-inch preadjusted fixed orthodontic appliance was attachedto the buccal aspects of the mandibular dentition immediately after extractionof the primary second premolar. A passive open-coil spring was placed on thelabial archwire of the orthodontic appliance to maintain appropriate space forthe permanent second premolar until it was moved into its proper place. After 4 months of mandibular orthodontic leveling and alignment, surgicalexposure was performed. The most superficial labial surface of the impactedmandibular second premolar’s clinical crown was minimally exposed at the lin-gual side of the mandible behind the distal root of the permanent mandibularright first molar. A lingual button was attached with a 0.012-inch soft ligaturewire (Fig 2a), which was twisted lightly around the lingual button prior to thebonding procedure. The surgical flap was sutured back, leaving the free endof the ligature, which was rolled into a small pigtail loop, near the palatal mu-cosa. A 0.014-inch auxiliary traction spring26 was prepared and applied in apiggyback fashion over the main 0.017 × 0.025-inch stainless steel mandibu-lar archwire. It was activated by tying the auxiliary spring loop to the ligaturepigtail loop with elastic thread (Figs 2a and 2b), thus exerting gentle tractionforces on the unerupted mandibular right second premolar in the occlusal-lingual direction. In this manner, and as time passed, the loop of the springauxiliary progressively moved farther from the occlusal surface and interferedwith normal oral function. The patient needed to be seen at 2-week intervalsto roll the 0.012-inch ligature pigtail around the spring auxiliary loop and againdraw it closer to the lingual mucosa. This produced added activation and sup-plemented the range even farther. It also improved patient comfort. During the14-month phase of orthodontic traction, the mandibular right second premolarmoved from the roots of the first and second molars and lingually erupted intothe oral cavity while the dominant direction of the force was vertical. In its approach toward the mandibular dental arch, the tooth was still locatedtoo lingually to be directly tied to the base archwire presented in the brackets.Hence, the lingual button was replaced by an orthodontic bracket bonded in anideal position onto the labial surface of the mandibular right second premolar.A 0.015-inch twist flex multistranded wire was then attached to the tooth in apiggyback fashion, replacing the auxiliary spring and exerting a dominant hori-zontal force in the buccal direction (Fig 2c). Later, when the long axis of the man-dibular right second premolar was better oriented, elastic thread was appliedand tied to the mandibular archwire at the incisor site, enhancing the buccal di- “rection of the force (Fig 2d). Lingual brackets were then attached to the man-dibular molars and premolars for final aligning and torquing. After 2 years oftreatment, the mandibular right second premolar was properly leveled and Cephalometric andaligned in the mandibular arch (Figs 3a to 3c). Nonetheless, a perfect Class I panoramic radiographsocclusal relationship had not yet been achieved, and the mandibular right sec-ond premolar was therefore apparent in tooth-to-tooth relationships. However, revealed that theperiapical radiographs taken at the time (Figs 4a and 4b) revealed an asymptom- mandibular rightatic periapical radiolucent lesion that had developed in the mandibular right second premolar wassecond premolar as well as angular alveolar bone loss diagnosed as an infrabonydefect. Following a negative pulp vitality test, root canal treatment was initiated. horizontally orientatedThe canal was dressed with calcium hydroxide for 1 month. At that point, the and impacted distallydecision was made to cease orthodontic treatment in an effort to prevent further behind the roots of thedamage of the mandibular right second premolar and its adjacent teeth. Thefixed orthodontic appliance was removed, and a removable maxillary clear re- first and second molarstainer was prepared in addition to a fixed orthodontic twist-flex retainer that was toward the compactbonded to the lingual aspects of the mandibular canines and incisors. An addi- lingual cortex of the ”tional 0.017 × 0.025-inch stainless steel wire splint was bonded to the buccal andlingual crown surfaces of the mandibular right segment (molars and premolars) right lingual border ofdue to increased mobility of the mandibular right second premolar. the mandibular body. Volume 12, Number 1, 2011 51
    • Interdisciplinary Treatment of a horizontally impacted mandibular second premolar a b c d Fig 2 Surgical orthodontic traction stages of the mandibular right second premolar. (a) Periapical radiograph taken immediately after surgical exposure, with the lingual button bonded and the spring auxiliary tied to the mandibular right second premolar; (b) 0.014-inch auxiliary traction spring applied in a piggyback fashion; (c) 0.015-inch twist flex multistranded wire attached to the mandibular right second premolar in a piggyback fashion, replacing the auxiliary spring; (d) elastic thread applied and tied to the mandibular archwire at the site of the incisors. a b c Fig 3 Mandibular right second premolar properly leveled and aligned in its correct position in the arch. (a) Intraoral frontal view, (b) intraoral right lateral view, (c) intraoral mandibular occlusal view. “ …the decision was made to cease orthodontic treatment in an effort to prevent further damage ” of the mandibular right second premolar and its adjacent teeth. 52 ORTHODONTICS The Art and Practice of Dentofacial Enhancement
    • Aizenbud et al Interdisciplinary a b c dFig 4 Periapical radiographs of the mandibular right second premolar orthodontic traction. (a) Dur-ing traction, revealing loss of alveolar bone support; (b) radiolucent lesion detected when the toothwas in its final position; (c) root canal treatment performed and the crown filled with glass ionomer;(d) follow-up radiograph 8 months later showing partial resolution of the periapical lesion and someimprovement in the infrabony defect. During the second appointment with the endodontist, following 1 month ofroot canal dressing with calcium hydroxide, the canal was sealed with gutta-percha and AH-26 (Dentsply) and the crown was filled with glass ionomer (Fig4c). Eight months later, a follow-up radiograph showed partial resolution ofthe periapical lesion and some improvement in the infrabony defect (Fig 4d). The periodontal evaluation of the defect revealed a pocket depth of 9 mm onthe mesiobuccal and mesiolingual aspects of the mandibular right second pre-molar, indicating a regenerative approach. Full-thickness mucoperiostal flapswere raised and two- to three-walled infrabony defects 7 mm in depth were re-vealed on the mesial aspect of this tooth (Fig 5a). The roots were thoroughlyplaned and decalcified using 24% ethylenediaminetetraacetic acid (EDTA). Eachdefect was then filled with bone-derived xenograft (BDX) (Bio-Oss, Geistlich)(Fig 5b) and covered with resorbable collagen membrane (Bio-Gide, Geistlich),which was thoroughly adapted in the proximal area between the mandibularright first and second premolars (Fig 5c). The flaps were repositioned and adapt-ed to completely cover the membrane. The healing process was uneventful, and the patient was put on a mainte-nance program that included scaling and deplaquing every 3 months. Periapi-cal radiographs taken 2 years later revealed bone fill in the infrabony defect onthe mesial aspect of the mandibular right second premolar. Some of the BDXparticles were still evident; however, the radiolucent lesion decreased and anarrow space of the periodontal ligament was evident through the newly re-stored alveolar bone (Fig 5d). The orthodontic stainless steel wire splint wasthen removed, as increased stability was recorded for the mandibular rightsecond premolar. Root resorption of the adjacent orthodontic anchorage units(the mandibular right molars and first premolar) was diagnosed. At the 10-year postoperative examination, the mandibular right second pre-molar was found to be stable, functional, and symptom-free (Fig 6). Volume 12, Number 1, 2011 53
    • Interdisciplinary Treatment of a horizontally impacted mandibular second premolar a b c d Fig 5 (a) Full-thickness mucoperiostal flaps and two- to three-walled infrabony defects 7-mm deep on the mesial aspect of this tooth. (b) The roots thoroughly planed and decalcified using EDTA 24%. The defect filled with bone-derived xenograft and (c) covered with resorbable collagen membrane (Bio-Gide) thoroughly adapted in the proximal area between the mandibular right first and second premolar. (d) Periapical radiograph taken 2 years later revealed bone fill in the infrabony defect on the mesial aspect of the mandibular right second premolar. Some of the BDX particles are still evident; however, the radiolucent lesion decreased and a narrow space of the periodontal ligament is evident through the newly restored alveolar bone. DISCuSSION The dental team had three treatment options: (1) a wait-and-see approach, (2) surgical exposure and orthodontic extrusion,17,22,23 and (3) extraction of the horizontally impacted mandibular right second premolar.29 Each of these treatment options had several disadvantages, thus none could be considered as having only advantages (Table 1). The first treatment option considered the asymptomatic primary mandibu- lar right second premolar and the balanced occlusion, despite the overretained tooth, and no distinct functional or esthetic complaints from the patient or her parents as advantages. However, it was obvious that this treatment modality would postpone the prosthetic treatment plan, which would be required soon after exfoliation of the primary mandibular right second premolar. Complete resorption of its roots would have left the mandibular right second premolar impacted in the lingual portion of the right mandibular body. At the same time, the impacted second premolar could have caused damage to the nearby molar roots. Thus, the restorative option (Table 2) for the missing mandibular right sec- ond premolar would probably have been a fixed partial denture with the mandib- ular right first premolar and first molar serving as abutments and a pontic serving as the second premolar. With this option, the prognosis for completely healthy 54 ORTHODONTICS The Art and Practice of Dentofacial Enhancement
    • Aizenbud et al Interdisciplinary “Each of these treatment options had several disadvantages, thus none could be ” considered as having only advantages.Fig 6 Periapical radiographs of the mandibular right second premolar taken at the 10-year post-operative examination. The permanent mandibular right second premolar is stable, functional, andsymptom-free. Table 1 Treatment options and procedures Treatment Advantages Disadvantages Wait-and-see approach • Conservative approach • Chronologic age of the patient (15 years) with mandibular • Balanced occlusion right second premolar roots already completed and complete • No functional or esthetic resorption of primary mandibular right second premolar roots complaints • Postponed prosthetic treatment • Impacted mandibular right second premolar may damage molar roots Surgical exposure • Restore the unerupted • Requires risky surgical exposure and bonding for mandibular right second pre- • Compromised mandibular right second premolar position orthodontic traction molar with the natural resulted in technical demands of bonding and tooth itself orthodontic traction • Extreme cases are best not to expose Surgical extraction • Prevents prolonged, risky, • Limited surgical approach compromising, and • Excessive damage to hard and soft tissue, nerve tissue, and unpredictable surgical teeth exposure and orthodontic • Risk of infection treatment procedure • Loss of alveolar bone mass for future implantationabutment teeth would be slim. Removable partial dentures are not applicablefor young patients. Dental implants would have been impossible in light of themandibular right second premolar’s unusually long horizontal axis, which wouldhave served as an obstacle. Thus, with this scenario, extraction of the mandibularright second premolar would have required dental implantation. Surgical extrac-tion of the mandibular right second premolar was not free of complication or risk. The second option included surgical exposure and bonding for orthodontictraction. This type of treatment can be technically demanding since it compro-mises the position of the mandibular right second premolar. According to the lit-erature, extreme cases do not respond well to exposure.23 Becker discussed twocases of surgical exposure followed by bonding of an attachment for traction.17One of these cases was a failed attempt of bonding and traction, underscoringthe difficulty of access for the bonding approach. Andreassen illustrated suc-cessful and unsuccessful cases of exposure of horizontally inclined premolars.22The majority of reported cases involved distally impacted premolars in which thelong axis was inclined to favor eruption if exposed.12,22,30–32 Jacobs documentedsix cases of successful exposure and eruption.31 In all six cases, the axial rootinclination favored eruption. Forty-five degrees from the normal eruptive posi-tion has been considered the limit at which spontaneous eruption is no longer Volume 12, Number 1, 2011 55
    • Interdisciplinary Treatment of a horizontally impacted mandibular second premolar Table 2 Prosthetic treatment options available for the unerupted mandibular right second premolar Treatment Advantages Disadvantages Fixed partial denture • Leave impacted mandibular right second premolar • Risk of severely compromising completely in place, thus preventing surgical procedure healthy abutment teeth • Restore esthetics and function with relative minimal damage to periodontal and dental tissue Removable partial • Restore esthetics and function with minimal damage • Is not applicable for a young patient denture to dental tissue • Potential damage to periodontal tissue with long-term use Dental implant • Minimal damage to surrounding dental and • Impacted mandibular right second premolar periodontal tissue serves as an obstacle, and a surgical procedure for its extraction is required for dental implantation possible.22,30 In our case, the impacted mandibular right second premolar’s long axis presented an inclination of 90 degrees from the normal eruptive position. The third treatment option included surgical extraction of the impacted premolar. This involved even more complications and risks compared to the second option of surgical exposure limited to the tooth bud. Complications include mental nerve damage; mucosal trauma; infection; damage to the sur- rounding teeth; and periodontal, restorative, and orthodontic difficulties cre- ated by extensive bone removal with subsequent loss of alveolar bone height and contour.33,34 Furthermore, since the impacted mandibular right second premolar was lingually palpated and oriented deep in the lingual vestibulum, the surgical approach would have been limited and compromised. There- fore, lingual nerve injury is also a possible adverse effect that must be con- sidered.35,36 The compromised approach and location of the mandibular right second premolar (which was in close proximity to and behind the first and second molar roots) might have caused damage to the roots during surgical extraction with massive loss of bone attachment. Ultimately, this could have resulted in loss of the first and second molars. The second option of orthodontic maneuver was considered the treatment of choice for this challenging mandibular right second premolar. It could have brought about speedy and effective eruption and moved the mandibular right second premolar from the roots of the mandibular molars. Since adequate space was already available in the arch as a result of the retained primary mandibular right second premolar, a minimal leveling procedure was required before surgical exposure and extrusion of the permanent mandibular right second premolar began. An occlusally directed vector of traction may have brought the mandibular right second premolar into contact with the molar roots, which would have damaged them. Accordingly, the method used in this case was to first move the impacted mandibular right second premolar in an occlusal (vertical download) and lingual direction to circumvent the obstacle in its path and only then move it bucally toward its final location. A spring auxil- iary26 incorporating a single vertical loop with a small helix at its extremity was used. This device was modified by making the vertical loop longer, thus intro- ducing a more horizontal than vertical traction vector. This was done to move the impacted mandibular right second premolar more lingually (toward the midline) while the spring was drawn inferiorly. Though the dominant direction of movement was vertical, the tooth moved noticeably away (and became dis- 56 ORTHODONTICS The Art and Practice of Dentofacial Enhancement
    • Aizenbud et al Interdisciplinaryimpacted) from the roots of the molars. The activation of the spring produceda very wide range of actions, and even the most deeply buried portions ofthe tooth responded to the force applied. However, it is important that undueforce be avoided, since in the event of excessive forces, the socket walls wouldresist by producing undermining resorption.37 On the other hand, extrusionis the only orthodontic movement in which the walls of the tooth socket donot provide some form of protection against heavy pressure. Consequently,reduced forces should be applied. A force of 24 cN per cm2 of root surfaceis generally considered optimal for tipping a tooth.38,39 We can conclude thatforce levels of less than 24 cN should be used when pure extrusive force is ap-plied through the long axis of an erupted tooth.26 In this case, where the toothwas completely buried, soft tissue resistance increased the amount of forceneeded, but did not exceed 30 to 35 cN.26 The presented method describes the ability to apply measured forces in oc-clusal, lingual, and anterior directions, which allowed complete control to beexercised in the efficient resolution of the impaction. Even successfully aligned teeth can have dwarfed roots, pulpal obliteration,and nonvitality,29 which in turn requires root canal therapy and restoration.Excessive tooth movement increases the risk of pulpal changes, with pulpalobliteration occurring in more than 20% of previously impacted canines.40 Ex-perimental studies have suggested that extreme types of tooth movement maycause changes in pulpal blood flow.41–43 The periodontal ligament and rootcanal systems have a common developmental, anatomical, and functional rela-tionship.44–50 Theoretically, changes in one tissue affect the other and are con-nected both anatomically and physiologically. The main connection betweenthe periodontal support system and the root canal through which bacteria andtheir products pass and cause pathology is the apical foramen. The major pas-sage is from the root canal to the periapical tissue, which leads to a local inflam-matory response that manifests in the bone or in root absorption.51 In this case, the orthodontic treatment was terminated before final torqueand perfect occlusion of the mandibular right second premolar was achieved.The apparent periodontal-endodontic lesion that developed around the man-dibular right second premolar root seemed to cause root resorption and en-danger the adjacent permanent roots. According to the literature, cessation oforthodontic treatment was indicated: The final occlusion should be compro-mised to prevent further worsening of the patients teeth.52 Maintaining adequate plaque control around the lingually exposed man-dibular right second premolar may be difficult due to the combination of itscompromised position and irritation from orthodontic attachments. Therefore, “surgical exposure and orthodontic alignment of palatally impacted canines isassociated with a loss of periodontal support.53–55 Furthermore, Becker et alclaimed that more profound periodontal consequences may reflect a moreaggressive surgical exposure.56 The loss of periodontal attachment was associ- The presented methodated with pocket formation rather than recession of the gingival margin.57 The describes the ability toadjacent teeth, serving as anchorage units, are exposed to intrusive forces androot torque during the alignment of the impacted mandibular right second apply measured forcespremolar. An association has been found between root shortening and tooth in occlusal, lingual,intrusion.57,58 Linge and Linge59 reported that alignment of impacted maxillary and anterior directions,canines is a risk factor for root resorption. However, longitudinal clinical andradiologic follow-up along the 10-year follow-up period demonstrated that which allowedthe permanent mandibular right second premolar is stable with no additional complete control tosplinting required, functions normally, and is symptom-free. This may be attrib- be exercised in the ”uted to the conservative, minimally invasive treatment method chosen for sucha complex case and the reduced orthodontic forces that were applied during efficient resolution ofthe traction of the impacted mandibular right second premolar. the impaction. Volume 12, Number 1, 2011 57
    • Interdisciplinary Treatment of a horizontally impacted mandibular second premolar“The multidisciplinary dental team’s considerations and cooperation account for the successful repositioning of CONCluSION This report presents a rare case of a distally impacted mandibular second pre- molar indicating a 90-degree tilt of the long axis. This horizontally impacted mandibular right second premolar was positioned in a very complicated and compromised position behind the molars roots and in close proximity to the lingual and mental nerves, toward the lingual cortex of the mandibular body. The multidisciplinary dental teams considerations and cooperation account the compromised for the successful repositioning of the compromised mandibular right second mandibular right premolar into its proper position with minimal damage to the surrounding hard and soft tissue. A 10-year postoperative follow-up showed that the mandibular second premolar into right second premolar is stable, functional, and symptom-free. its proper position with minimal damage to the ” REFERENCES 15. Rose JS. Atypical paths of eruption: Some surrounding hard and causes and effects. Dent Pract 1958;9: 69–75. soft tissue. 1. Kramer RM, Williams AC. The incidence 16. Stemm RM. The frequency of malposed of impacted teeth. A survey at Harlem unerupted lower premolar teeth. Angle hospital. Oral Surg Oral Med Oral Pathol Orthod 1971;41:157–158. 1970;29:237–241. 17. Becker A. The Orthodontic Treatment of 2. Grover PS, Lorton L. The incidence of Impacted Teeth. London: Martin Dunitz, unerupted permanent teeth and related 1998. clinical cases. Oral Surg Oral Med Oral 18. Joshi MR. Atypical eruption of mandibular Pathol 1985;59:420–425. second premolars. Oral Surg Oral Med 3. Thilander B, Myrberg N. The prevalence Oral Pathol 1970;29:223. of malocclusion in Swedish schoolchil- 19. Loh HS, Ho KH. Unerupted and ectopic dren. Scand J Dent Res 1973;81:12–21. mandibular premolars. Oral Surg Oral 4. Shah RM, Boyd MA, Vakil TF. Studies Med Oral Pathol 1986;62:358. of permanent tooth anomalies in 7,886 20. Steelman R, Tinkler D, Kerr V, Jordan C. Canadian individuals. I: Impacted teeth. Ectopic developing mandibular pre- Dent J 1978;44:262–264. molar. Oral Surg Oral Med Oral Pathol 5. Shapira Y, Borell G, Kuftinec MM, Stom D, 1986;62:738. Nahlieli O. Bringing impacted mandibular 21. Lehman R. A deviate eruption pat- second premolars into occlusion. J Am tern. Am J Orthod Dentofacial Orthop Dent Assoc 1996;127:1075–1078. 1987;91:427–428. 6. Burch J, Ngan P, Hackman A. Diagnosis 22. Andreassen JO. The impacted premolar. and treatment planning for unerupted In: Andreassen JO, Petersen JK, Laskin premolars. Pediatr Dent 1994;16:89–95. DM (eds). Textbook and Color Atlas of 7. Alexander-Abt J. Apparent hypodontia: Tooth Impactions. Diagnosis, Treatment A case of misdiagnosis. Am J Orthod and Prevention. Copenhagen: Munks- Dentofacial Orthop 1999;116:321–323. gaard, 1997:177–195. 8. Posen AL. The effect of premature loss of 23. Collett AR. Conservative management of deciduous molars on premolar eruption. lower second premolar impaction. Aust Angle Orthod 1965;35:249–252. Dent J 2000;45:279–281. 9. Kuba Y, Taniguchi K, Kuboyama H, Moto- 24. Tracey C, Lee RT. Root resorption: The kawa W, Braham RL. Inverted impaction of aggressive, unerupted second premolar. second premolar: Two case reports. J Clin Br J Orthod 1985;12:97–101. Pediatr Dent 1995;19:205–209. 25. Brezniak N. Lower first molar mesio- 10. Tores JS. Late development of second buccal root resorption. J Clin Orthod premolar. Oral Surg Oral Med Oral Pathol 1990;24:25–28. 1972;34:350. 26. Kornhauser S, Abed Y, Harari D, Becker 11. Harary D, Zilberman Y. Eruption of A. The resolution of palatally impacted mandibular second premolar. J Pedod canines using palatal-occlusal force from a 1983;7:337–342. buccal auxiliary. Am J Orthod Dentofacial 12. Cryer B. The unpredictable lower second Orthop 1996;110:528–534. molar? Dent Pract 1965;15:458–464. 27. Wasserstein A, Shalish M. Adequacy of 13. Thilander H, Thilander B, Persson G. mandibular premolar position despite Treatment of impacted teeth by surgical early loss of its deciduous molar. ASDC J exposure. A survey study. Sven Tandlak Dent Child 2002;69:254–258, 233–234. Tidskr 1973;66:519–525. 14. Hitchin AD. The unerupted mandibular premolar. Br Dent J 1966;120:117–126. 58 ORTHODONTICS The Art and Practice of Dentofacial Enhancement
    • Aizenbud et al Interdisciplinary28. Wasserstein A, Brezniak N, Shalish M, 45. Orban B. Oral Histology and Embryology, Heller M, Rakocz M. Angular changes and ed 5. St Louis: Mosby, 1962. their rates in concurrence to develop- 46. De Deus QD. Frequency, location, and mental stages of the mandibular second direction of the lateral, secondary, and ac- premolar. Angle Orthod 2004;74:332–336. cessory canals. J Endod 1975;1:361–366.29. Frank CA. Treatment options for im- 47. Simon JH, Glick DH, Frank AL. The pacted teeth. J Am Dent Assoc 2000;131: relationship of endodontic-periodontic 623–632. lesions. J Periodontol 1972;43:202–208.30. Azaz B, Steiman Z, Koyoumdjisky-Kaye E, 48. Baumgartner JC, Picket AB, Muller JT. Mi- Lewin-Epstein J. The sequelae of surgical croscopic examination of oral sinus tracts exposure of unerupted teeth. J Oral Surg and their associated periapical lesions. 1980;38:121–127. J Endod 1984;10:146–152.31. Jacobs SG. The surgical exposure of 49. Langeland K, Rodrigues H, Dowden W. teeth—Simplest, safest and best? Aust Periodontal disease, bacteria, and pulpal Orthod J 1987;10:5–11. histopathology. Oral Surg Oral Med Oral32. Ohman I, Ohman A. The eruption tenden- Pathol 1974;37:257–270. cy and changes of direction of impacted 50. Meng HX. Periodontic-endodontic le- teeth following surgical exposure. Oral sions. Ann Periodontol 1999;4:84–90. Surg Oral Med Oral Pathol 1980;49: 51. Rotstein I, Simon JH. Diagnosis, prognosis 383–389. and decision-making in the treatment of33. Frank CA, Long M. Periodontal concerns combined periodontal-endodontic le- associated with the orthodontic treatment sions. Periodontol 2000 2004;34:165–203. of impacted teeth. Am J Orthod Dento- 52. Brezniak N, Wasserstein A. Orthodontical- facial Orthop 2002;121:639–649. ly induced inflammatory root resorption.34. Jones J, Robinson PD. Submerging pri- Part II: The clinical aspects. Angle Orthod mary molars—An extraction in time! Dent 2002;72:180–184. Update 2001;28:309–311. 53. Hansson C, Linder-Aronson S. Gingival35. Loescher AR, Smith KG, Robinson PP. status after orthodontic treatment of im- Nerve damage and third molar removal. pacted upper canines. Trans Eur Orthod Dent Update 2003;30:375–382. Soc 1972:433–441.36. Tolstunov L. Lingual nerve vulnerability: 54. Wisth PJ, Norderval K, Boe OE. Periodon- Risk analysis and case report. Compend tal status of orthodontically treated im- Contin Educ Dent 2007;28:28–31. pacted maxillary canines. Angle Orthod37. Strr N, Becker A. Forced eruption: 1976;46:69–76. Biological and clinical considerations. 55. Boyd RL. Clinical assessment of injuries in J Oral Rehabil 1980;7:395–402. orthodontic movement of impacted teeth.38. Schwartz AM. Tissue changes incident I. Methods of attachment. Am J Orthod to orthodontic movement. Int J Orthod 1982;82:478–486. 1932;18:331–352. 56. Becker A, Kohavi D, Zilberman Y. Peri-39. Steigman S, Michaeli Y. Experimental odontal status following the alignment intrusion of rat incisors with continuous of palatally impacted canine teeth. Am J loads of varying magnitude. Am J Orthod Orthod 1983;84:332–336. 1981;80:429–436. 57. McFadden WM, Engstrom C, Engstrom40. Woloshyn H, Artun J, Kennedy DB, H, Anholm JM. A study of the relationship Joondeph DR. Pulpal and periodontal between incisor intrusion and root short- reactions to orthodontic alignment of ening. Am J Orthod Dentofacial Orthop palatally impacted canines. Angle 1989;96:390–396. Orthod 1994;64:257–264. 58. Dermaut LR, De Munck A. Apical root41. Butcher EO, Taylor AC. The vascularity resorption of upper incisors caused by of the incisor pulp of the monkey and its intrusive tooth movement: A radiographic alteration by tooth retraction. J Dent Res study. Am J Orthod Dentofacial Orthop 1952;31:239–247. 1986;90:321–326.42. Stenvik A. Pulp and dentine reactions to 59. Linge L, Linge BO. Patient characteristics experimental tooth intrusion. (A histologic and treatment variables associated with study—Long-term effects). Rep Congr Eur apical root resorption during orthodon- Orthod Soc 1969:449–464. tic treatment. Am J Orthod Dentofacial43. Marshall JA. A study of bone and tooth Orthop 1991;99:35–43. changes incident to experimental tooth movement and its application to orth- odontic practice. Int J Orthod Dent for Children 1933;19:1–17.]44. Mandel E, Machtou P, Torabinejad M. Clinical diagnosis and treatment of endo- dontic and periodontal lesions. Quintes- sence Int 1993;24:135–139. Volume 12, Number 1, 2011 59
    • Case Reports Orthodontic management of an originally surgically planned treatment of an open bite: A case report Chadi Kassir, DDS, DEA, DESSO1 Samar Bou Assi, DDS, MS2 The treatment of open bite malocclusion is generally considered a challenge due to its multifactorial etiology. Many treatment modalities to correct open bites, including orthognathic surgery and dental compensation, have been proposed. Dental compensation (intruding the posterior teeth and uprighting and extruding the anterior teeth with elastics) is a treatment option for borderline patients and those who are reluctant to undergo surgery. This report documents the treatment of a patient with a severe skeletal open bite malocclusion whose treatment plan originally included fixed appliance therapy as well as orthognathic surgery. He was subsequently treated with only fixed appliances. The patient, a male 17 years, 7 months of age, presented with a Class II, Division 1 malocclusion, 5 mm anterior open bite, and an increased anterior facial height. He was treated with extraction of the maxillary and mandibular premolars, full fixed appliances, and anterior vertical elastics. After 30 months of active treatment, a Class I occlusion with improved overjet and overbite was achieved. ORTHO 2011;12:60–69. Key words: open bite, surgical treatment, hyperdivergent pattern 1Private Practice, Beirut, Lebanon. 2Clinical Associate, A Department of n anterior open bite can be defined as the presence of negative over- Orthodontics, American bite between the incisal edges of the maxillary and mandibular teeth, University of Beirut, Beirut, Lebanon; Associate with the posterior teeth in occlusion.1–4 The cause of an anterior open Professor, Department of bite is generally multifactorial and can be due to a combination of skeletal, Orthodontics, Lebanese dental, and soft tissue effects. Many potential etiologic factors, including un- University, Beirut, Lebanon. favorable growth patterns,5,6 digit-sucking habits,7–9 enlarged lymphatic tis- sue,7,10 heredity,8,11 and oral functional matrices,12 have been considered. The CORRESPONDENCE characteristics of individuals with anterior open bites include one or more of Dr Chadi Antoine Kassir Massoud Centre Main the following: excessive gonial, mandibular, and occlusal plane angles; short Road, first floor mandibular body and ramus; increased lower anterior facial height and de- Bikfaya, El Metn creased lower posterior facial height; decreased upper anterior facial height; Lebanon Email: chadikassir489@ retrusive mandible; Class II tendency; divergent cephalometric planes; steep hotmail.com anterior cranial base13; and inadequate lip seal.560 ORTHODONTICS The Art and Practice of Dentofacial Enhancement
    • Some studies have found a correlation between orofacial musculature andfacial structure, suggesting a relationship between weak musculature and along face–anterior open bite pattern.14,15 Due to the variety of causes, many treatment options have been suggestedfor correcting anterior open bites. Among the treatments used are habit-break-ing appliances; bite blocks; high-pull headgear therapy; and molar intrusionwith temporary anchorage devices, vertical-pull chin cups, vertical elastics,multiloop edgewise archwire therapy, and surgical correction. The following case report illustrates the treatment of a Class II malocclusionwith superimposed severe crowding in both arches, an anterior open bite of5 mm, and severe hyperdivergence.CASE REPORTA male, 17 years, 7 months of age, presented to the Department of Ortho-dontics Lebanese University seeking treatment. The patient’s chief complaintswere the high position of his maxillary left canine and his anterior open bite. Pretreatment facial photographs (Fig 1) show a straight profile, an averagenasolabial angle, an increased lower facial height, lip incompetency at rest,and slight chin deviation to the left. When he smiled, the full crowns of themaxillary incisors was shown as well as 4 to 6 mm of gingival display. Pretreat-ment intraoral photographs (Fig 1) reveal an anterior open bite of 5 mm withan overjet of 3 mm. In addition, two distinct occlusal planes were present inthe maxillary arch. Severe crowding was present: constricted arch form and thecomplete blockage of the left canine in the maxillary arch and the completelingual blockage of the mandibular right second premolar in the mandibulararch. The upper dental midline was deviated 2 mm to the left and the lowermidline 1 mm to the right. Transversally, a unilateral crossbite on the left sidewas present, starting from the lateral incisor to the second molar. Sagittally, themaxillary right first molar was in a full Class III relationship with the mandibularright first molar and in a Class II relationship end on on the left side; the canineson both sides were in an end-on Class II relationship. Radiography showed restorations at the mandibular right second molar leveland that the mandibular left first molar had been treated endodontically (Fig 2). Volume 12, Number 1, 2011 61
    • Case Reports Orthodontic management of an originally surgically planned treatment of an open bite Fig 1 Pretreatment extra- and intraoral photographs. Initial cephalometric analysis (T1) showed a skeletal Class I relationship (ANB 0 degree) with bimaxillary retrusion (SNASNB 76 degrees). The mandib- ular plane angle was very steep, and the gonial angle was severely increased (MP/FH, GoA), but the mandibular body length and ramus height were with- in the normal range. The maxillary incisors were well positioned (U1SN 103 degrees), and the mandibular incisors were severely retroclined (L1MP 74) (Table 1).62 ORTHODONTICS The Art and Practice of Dentofacial Enhancement
    • Kassir and Bou Assi Case ReportsFig 2 Pretreatment panoramic radiograph and lateral cephalogram. Table 1 Pre- and posttreatment cephalometric measurements Measurement Norm Before treatment (T1) After treatment (T2) Skeletal SNA angle (degrees) 82 76 75 SNB angle (degrees) 80 76 75 ANB angle (degrees) 2 0 0 FH-NA (degrees) 90 86 86 FH-NP (degrees) 87 86 86 Witts (mm) 1 –10 –8 SN-MPA(degrees) 32 51 51 FMA (degrees) 25 42 41 Dental UI-SN (degrees 103 104 95 UI-NA (degrees) 22 28 20 UI-NA (mm) 4 10 5 LI-NB (degrees) 25 21 17 LI-NB (mm) 4 5 3 LI-MP (degrees) 87 74 70 LI- APO (mm) 1 5 2.5 UI-LI (degrees) 131 131 143 Soft tissue Holdaway line (mm) Tip of nose (mm) 9 10 11 Subnasal (mm) 5 5 5 Upper lip (mm) 0 0 0 Lower lip (mm) 0 1 0 Supramentale (mm) 5 3 6 Pogonion (mm) 0 0 0 Volume 12, Number 1, 2011 63
    • Case Reports Orthodontic management of an originally surgically planned treatment of an open bite The patient was a mouth breather and had a tongue thrust at rest. He also lisped with the “s” sound. Temporomandibular joint (TMJ) examination re- vealed clicking on both sides with no pain. Ideal treatment objectives were as follows. Extraorally, the objective was to decrease the lower facial height, correct the excessive gingival display upon smiling, widen the maxilla to minimize the buccal corridors, and correct the chin deviation. Intraorally, we hoped to achieve a Class I relationship with ideal overjet and overbite, relieve the crowding, correct the crossbite on the left side, and correct the midlines. Three treatment alternatives were presented to the patient. The first option consisted of orthodontic treatment with the extraction of the four first premo- lars to correct maxillary and mandibular crowding as well as midlines deviations and to decompensate and prepare for orthognatic surgery (surgically assisted expansion if the suture did not open with rapid palatal expansion as well as maxillary impaction and mandibular autorotation or genioplasty to correct chin deviation). The second option was nonsurgical and would have entailed differ- ential extraction of the maxillary and mandibular second premolars to maintain vertical control and close the anterior openbite with vertical elastics. The third option included the use of mini-implants to intrude the molars to rotate the mandible counterclockwise. This would be followed by extraction of the mandibular and maxillary second premolars to relieve the crowding and correct the midlines. Clinicians recommended and the patient subsequently chose the first treat- ment plan, which consisted of extracting the first premolars to correct crowd- ing and midlines followed by orthognatic surgery to correct the gummy smile. After caries control and oral hygiene instruction, a Hyrax appliance with bands attached to the first premolars and the first molars was used for rapid maxillary expansion. The appliance was activated twice a day for 14 days, re-“ sulting in approximately 7 mm of arch widening at the level of the first mo- lars and 4 mm of diastema between central incisors with suture opening. TheExtraorally, the crossbite was slightly overcorrected on the left side, and no reverse crossbiteobjective was to occurred on the right side. The screw was then locked with a brass wire, and the expander served as a stabilizer.decrease the lower Preadjusted edgewise appliances (Roth prescription, 0.022 × 0.028-inchfacial height, correct slot) were placed in both arches. The arches were leveled and aligned with athe excessive progression of archwires, starting with 0.014-inch nickel-titanium (Ni-Ti) wires. The four first premolars were extracted when a 0.018-inch stainless steel wiregingival display upon was reached. The Hyrax appliance was left in place during canine retractionsmiling, widen the after cutting the arms off the premolars. The maxillary and mandibular caninesmaxilla to minimize were distalized with elastic chains. (Some Class II correction was to be expect- ed after maxillary impaction and mandibular autorotation; therefore, the casethe buccal corridors, was to be prepared presurgically with a Class II molar and canine relationship.)and correct the chin The maxillary left canine was aligned at first with an overlay and was then en-deviation. Intraorally, gaged into the main archwire and distalized. While preparing for orthognatic surgery and closing extraction spaces, the pa-we hoped to achieve tient decided not to undergo surgery. An in-progress lateral cephalometric radio-a Class I relationship graph was taken, and the revised objectives were to achieve a Class I relationshipwith ideal overjet on both sides with proper overbite and overjet while maintaining vertical control. Class II elastics to correct the Class II malocclusion, as well as anterior verticaland overbite, relieve elastics at the lateral incisors in combination with a step down on the maxillarythe crowding, correct incisors, were used to achieve a normal overbite. Once the desired overbite wasthe crossbite on the attained, the patient was asked to stop the vertical elastics after 2 months of ” stabilization. No relapse was noticed. The fixed appliances were removed, andleft side, and correct a maxillary Hawley retainer was delivered (some acrylic was removed anterioralythe midlines. as a tongue position reminder), and a mandibular 3–3 retainer was bonded. Total64 ORTHODONTICS The Art and Practice of Dentofacial Enhancement
    • Kassir and Bou Assi Case ReportsFig 3 Posttreatment extra- and intraoral photographs.treatment time was 30 months. Retention was mainly directed toward preventingrelapse in the transverse dimension. The patient was instructed to wear his maxil-lary Hawley retainer full-time for 6 months, then for 6 months only at night, andthen 3 times a week at night. The mandibular retainer consisted of a 0.7-mm wirebonded to the lingual surfaces of the canines. The lingual retainer could be keptpermanently to enhance the long-term stability of the results.RESulTSThe treatment objectives were achieved, thanks in part to perfect patient co-operation with intraoral elastics and oral hygiene. Extraorally, facial harmony and lip closure were achieved. When the patientsmiled, no increase in the gingival display was visible, and maxillary arch ex-pansion was noted. Intraorally, bilateral Class I molars and canines relation-ships were evident. Both dental midlines were aligned with the facial midline,and optimal overjet and overbite relationships were achieved (Fig 3). Volume 12, Number 1, 2011 65
    • Case Reports Orthodontic management of an originally surgically planned treatment of an open bite Fig 4 Posttreatment panoramic radiograph and lateral cephalogram. Fig 5 Superimpositions: ini- tial (solid line) and final (dashed line). The posttreatment cephalometric tracing and superimposition analysis re- vealed a similar ANB angle as T1 (Figs 4 and 5, Table 1). No changes in the verti- cal measurements were noted, indicating that the mechanics used controlled the vertical movement of the posterior teeth. The maxillary and mandibular incisors were extruded and retroclined. Soft tissue analysis showed slight retraction of the upper and lower lips by 1 mm, which maintained a normal relationship to the Holdaway line of the chin, lips, and nose and improved the lip closure at rest. The posttreatment panoramic radiograph showed that the roots of the teeth were fairly parallel. Supporting tissues appeared healthy and only minimal apical blunting occurred (especially at the level of the maxillary incisors). Photographs 2 years 3 months after debonding show no relapse of the an- terior open bite or crowding but some mandibular extraction space opening (Fig 6).66 ORTHODONTICS The Art and Practice of Dentofacial Enhancement
    • Kassir and Bou Assi Case ReportsFig 6 Extra- and intraoral photographs 2 years 3 months after debonding.DISCuSSIONKnowing the limitations of orthodontic treatment, most orthodontists would agreethat skeletal open bites are ideally treated with a combination of orthodontics andorthognathic surgery.16 The advantages of the surgical option are that the overbitecan be overcorrected and the gummy smile corrected, so posttreatment stability isbetter than that with a nonsurgical option.17 In a nonsurgical plan, orthodontic treat-ment consists of camouflaging the skeletal discrepancies to an extent that overcor-rection, esthetics, and functional concerns can be addressed to the greatest extentthe case will allow. According to Hiller,16 nonsurgical correction usually requires alonger treatment time and is more difficult, especially for stability and retention. When orthognathic surgery is planned and orthodontic treatment is initi-ated to prepare for decompensation, it is very troublesome to revise treatmentobjectives and finish the case properly without surgery. This case report docu-ments the successful orthodontic treatment of an adult patient; with a severe Volume 12, Number 1, 2011 67
    • Case Reports Orthodontic management of an originally surgically planned treatment of an open bite hyperdivergent pattern characterized by an open bite and gummy smile, it was originally intended to be treated with surgery, but the patient refused surgery while orthodontic preparation was in progress. The premolars were extacted to relieve crowding and allow some incisor ret- roclination and step down on the maxillary incisors and step up on the mandib- ular incisors. Anterior vertical elastics were used to extrude the anterior teeth. Anterior vertical elastics can create a vertical extruding force on the anterior teeth; as a result, the incisors tend to upright, which happened in this case.13,18 Simple extrusion of anterior teeth to correct open bite has been criticized as being unstable, and Ellis and McNamara19 even reported that the vertical height of the anterior maxilla was already increased in the open bite group. However, in the patient, no pre- or postoperative changes occurred in the amount of gingival display upon smiling. Sarver and Weissman20 proposed some useful guidelines for the nonsurgi- cal treatment of adult patients with open bite who have no potential for growth modification. They discussed clinical results using extraction and retraction for dental open bite correction. It is emphasized that there are a limited number of open bites amenable to this type of treatment. Patients who are candidates for this type of therapy should meet the following criteria: (1) proclined or procum- bent maxillary or mandibular incisors, (2) little or no gingival display upon smil- ing, (3) normal craniofacial pattern, and (4) no more than 2 to 3 mm of maxillary incisor exposure at rest. According to those criteria, this case did not qualify for nonsurgical treatment. Stability is a particular concern with open bite malocclusions. Studies of long-term results of open bite orthodontic treatment by Lopez-Gavito et al13 and surgically treated cases by Denison et al17 indicate that the relapse rate can range from 35% to 42.9%. The data from the Denison et al17 study suggested that relapse was caused by dentoalveolar changes, not skeletal changes. This is an indication of the importance of retainer wear. It is especially important to prevent labial flaring of the incisors. Placing retainers with occlusal coverage may be helpful in preventing further molar eruption, especially in patients with remaining growth. The first requirement to enhance stability is to eliminate the cause of the open bite. If tongue posture and aberrant function can cause an open bite, it is possible they may have a significant role in posttreatment relapse often observed in patients with open bite. Placement of a tongue crib may improve stability in patients with pretreatment open bites. In selected cases in which tongue posture or function is an apparent factor, some form of crib therapy during or after treatment may offer enhanced stability.21,22 Pro-“ longed retention with fixed or removable retainers is advisable and necessary in most cases of anterior open bite treatment. The findings reported by Lopez-Gavito et al13 and Denison et al17 indicateAlthough correction a rather high rate of relapse in patients treated for open bite. Whereas theseof an open bite numbers may appear discouraging, it should be noted that the relapse rate in-cannot always cludes some patients who experienced a reduction of posttreatment overbite but did not progress to an open bite. Although correction of an open bite can-be perfectly not always be perfectly maintained, there are many patients who will benefitmaintained, there considerably from treatment with only orthodontic appliances. Prudent selec-are many patients tion of patients and adherence to sound orthodontic principles can producewho will benefit very acceptable and, at times, outstanding treatment results. Chang et al23 reported that there is a difference in stability between openconsiderably from bite treatments that involve nonextraction vs extraction approaches. The ex-treatment with traction approach seems to be more stable. ”only orthodontic Treating this case nonsurgically did not allow for the correction of the exces- sive gingival display or for optimal positioning of the incisors in the basal bone.appliances. Enhanced stability could also have been achieved with orthognathic surgery.68 ORTHODONTICS The Art and Practice of Dentofacial Enhancement
    • Kassir and Bou Assi Case ReportsCONCluSIONThe treatment outcome of this severely hyperdivergent phenotype with ananterior open bite was a great improvement in both function and esthetics,although the stability of the open bite closure is questionable. The main rea-son this patient could be successfully treated nonsurgically was the posteriorvertical control while the occlusal planes were anteriorly brought toward eachother in addition to the patient’s excellent treatment compliance.ACKNOwlEDgMENTThe authors would like to acknowledge Dr Maria Haydar for her contribution to the article.REFERENCES 13. Lopez-Gavito G, Wallen TR, Little RM, Joondeph DR. Anterior open-bite maloc- clusion: A longitudinal 10-year postreten- 1. Almeida RR, Almeida-Pedrin RR, Almeida tion evaluation of orthodontically treated MR, Ferreira FPC, Pinzan A, Insabralde patients. Am J Orthod 1985;87:175–186. CMB. Displasias verticais: Mordida aberta 14. Proffit WR, Fields HW. Occlusal forces in anterior—Tratamento e estabilidade. Rev normal- and long-face children. J Dent Dent Press Orthodon Ortop Facial 2003; Res 1983;62:571–574. 8:91–119. 15. Straub W. Malfunctions of the tongue. Am 2. Almeida RR, Ursi W. Anterior open-bite, J Orthod 1960;46:404–424. etiology and treatment. Oral Health 1990; 16. Hiller ME. Nonsurgical correction of Class II 80:27–31. open bite malocclusion in an adult patient. 3. Pedrin F, Almeida MR, Almeida RR, Al- Am J Orthod Dentofacial Orthop 2002; meida-Pedrin RR, Torres F. A prospective 122:210–216. study of the treatment effects of a remov- 17. Denison TF, Kokich VG, Shapiro PA. able appliance with palatal crib combined Stability of maxillary surgery in open bite with high-pull chincup therapy in anterior versus non-open bite malocclusions. open-bite patients. Am J Orthod Dento- Angle Orthod 1989;59:5–10. facial Orthop 2006;129:418–423. 18. Gehring D, Greeseman M, Frazier M, 4. Torres F, Almeida RR, de Almeida MR, Southard K. Extraction treatment of a Almeida-Pedrin RR, Pedrin F, Henriques Class II, Division 1 malocclusion with ante- JFC. Anterior open-bite treated with rior open bite with headgear and vertical a palatal crib and high-pull chin cup elastics. Am J Orthod Dentofacial Orthop therapy. A prospective randomized study. 1998;113:431–436. Eur J Orthod 2006;28:610–617. 19. Ellis E, McNamara JA. Components of 5. Bell WH. Correction of skeletal type of ante- adult Class III open-bite malocclusion. Am rior open bite. J Oral Surg 1971;29:706–714. J Orthod 1984;86:277–290. 6. Nahoum HI. Vertical proportions: A guide 20. Sarver DM, Weissman SM. Nonsurgical for prognosis and treatment in anterior treatment of open bite in nongrowing pa- open bite. Am J Orthod 1977;72:128–146. tients. Am J Orthod Dentofacial Orthop 7. Atkinson SR. “Open-bite” malocclusion. 1995;108:651–659. Am J Orthod 1966;52:877–886. 21. Huang GJ, Justus R, Kennedy DB, Kokich 8. Mizrahi E. A review of anterior open bite. VG. Stability of anterior open bite treated Br J Orthod 1978;5:21–27. with crib therapy. Angle Orthod 1990;60: 9. Subtelny JE, Sakuda M. Open bite diag- 17–26. nosis and treatment. Am J Orthod 1964; 22. De Cuebas JO. Nonsurgical treatment 50:337–358. of a skeletal vertical discrepancy with a10. Linder-Aronson S. Adenoids. Their effect significant open bite. Am J Orthod Dento- on mode of breathing and nasal airway facial Orthop 1997;112:124–131. and their relationship to characteristics of 23. Chang Y, Moon SC. Cephalometric evalu- the facial skeleton and the dentition. Acta ation of the anterior open bite treatment. Otolaryngol Suppl 1970;265:1–132. Am J Orthod Dentofacial Orthop 1999;11. Sassouni V. A classification of skeletal fa- 115:29–38. cial types. Am J Orthod 1969;55:109–123.12. Moss ML, Salentijn L. Differences between functional matrices in anterior open-bite and deep overbite. Am J Orthod 1971; 60:264–280. Volume 12, Number 1, 2011 69
    • Practice Pearls Dental amalgam corrosion in vacuum-formed retainers Joseph R. Karam1 Daniel J. Rinchuse2 Aim: To report and evaluate the confinement of metal ions released by dental amalgam restorations in vacuum-formed thermoplastic retainers (VFRs). Methods: VFR samples that contained corrosion tarnish corresponding with dental amalgam restorations were collected from patients, and replacement retainers were fabricated. The stained retainers were tested for trace metals utilizing inductively coupled plasma-atomic emission spectrometry (ICP-AES) and for mercury utilizing cold-vapor atomic absorption (CVAA). The results were compared to a control piece of VRF material from the manufacturer. Results: The tarnished sections of the VFRs contained mercury (61.00 ppm), calcium (205.00 ppm), and zinc (3.05 ppm). The control sample results were below qualitative limits for metal ion and mercury testing and can be considered, for our purposes, to be uncontaminated. Conclusion: VFRs that cover surfaces of teeth restored with dental amalgam become tarnished and confine amalgam corrosion products, including mercury and zinc. ORTHO 2011;12:70–74. Key words: aligners, staining, thermoplastic V acuum-formed thermoplastic retainers (VFRs) are widely used in ortho- dontics in part because they are highly esthetic. VFRs are commonly composed of polyester, polypropylene, polyethylene, or copolymer blends as well as stabilizers.1 Several patients from a private practice (D.R.) pre- sented with concerns about tarnished areas in their retainers (Fig 1). Rinchuse et al first reported VFR staining in 2007.2 Clinical examinations revealed that the tarnish marks correspond with amalgam dental restorations. Studies have evaluated the physical durability and environmental adsorption of some of these plastics when used as retainers or aligners3,4; however, no studies have evaluated the interaction between VFR and amalgam dental restorations, spe- 1Private cifically the staining of VFR associated with dental amalgam corrosion prod- Practice, Scranton, Pennsylvania, USA. ucts. The aim of this article is to discuss the potential interaction between VFR 2ClinicalProfessor, and amalgam dental restorations and to chemically identify what components Department of of amalgam restorations stain VFRs. Orthodontics, University of Pittsburgh School Metal ions including zinc, copper, and silver are released as corrosion prod- of Dental Medicine, ucts from dental amalgam. It is well documented that elemental mercury vapor Pittsburgh, Pennsylvania, is released from dental amalgam and that mercury vapor release increases USA. upon mastication.5 Elemental mercury exists as a vapor at oral temperature CORRESPONDENCE and as a volatile liquid at room temperature. Elemental mercury can adsorb Dr Joseph R. Karam into and pass through many plastics.6 Mercury spills or waste from laboratory 600 Lackawanna, Suite 200 Scranton, PA 18503 use or commercial use (ie, light bulbs or thermometers) contained in plastic Email: drjkaram@gmail.com bags or containers can adsorb into or permeate the plastic. Researchers at 70 ORTHODONTICS The Art and Practice of Dentofacial Enhancement
    • Brown University recently developed nanomaterial sorbents in plastic packag-ing capable of capturing mercury vapor release from broken compact fluores-cent lamps, thereby decreasing the risk of mercury vapor release.7 There havebeen reports of mercury-based preservatives metabolizing and escaping fromplastic containers and decreasing the shelf life of some pharmaceuticals.8 From what is known about elemental mercury and its interaction with plas-tic, including polypropylene and polyethylene, it can be suggested that mer-cury released from dental amalgam restorations adsorbs into and permeatesthrough the plastics in VFRs. Mercury in dental amalgam is a topic of debate. Two prominent randomizedcontrolled trials have concluded that the low level of mercury released fromdental amalgams has no neurobehavioral or renal adverse effects in children,establishing justification for the continued use of dental amalgam as a restor-ative material.8,9 Any further discussion of the use of mercury in dental amal-gam is beyond the scope of this paper.METHODSSample collectionSeven VFR samples (Fig 1) collected from a private practice (D.R.) containing atotal of 11 tarnished areas corresponding with 11 dental amalgam restorationswere collected from patients; replacement retainers were fabricated. TheseVFRs show modest staining. The authors have observed other patients whoseVFRs exhibit extreme staining as shown in Fig 2. Since the authors did notanticipate reporting these findings, the samples were initially stored in plasticbags in a dark storage area for about 2 months prior to testing. However, whenwe decided to carry out this investigation, approximately 2 weeks before actualtesting, the samples were stored in a glass jar, restricted from light, and refrig-erated at 4°C. The type of thermoplastic material used in the tested VFRs wasnot originally documented; possibilities are Neoform, Duraforce, and Essix C+(all Dentsply, GAC International). Amalgam corrosion staining has been notedin VFRs made of each of these materials.Sample analysisTarnished sections of the VFRs corresponding to amalgam dental fillings werecut out and digested accordingly. The samples were tested for mercury utilizingcold-vapor atomic adsorption (CVAA) (EPA method 7471, Lancaster Laborato-ries), which is based on the absorption of radiation (wavelength of 253.7 nm) bymercury vapor. Mercury vapor extracted from a sample passes through a cell inthe light path of an atomic absorption spectrophotometer, and peak heightabsorbance is measured as a function of mercury concentration. The sampleswere tested for trace metals utilizing inductively coupled plasma-atomic emis-sion spectrometry (ICP-AES) (EPA method 6010B, Lancaster Laboratories) in Volume 12, Number 1, 2011 71
    • Practice Pearls Dental amalgam corrosion in vacuum-formed retainers Fig 1 (Left) Tested VFR sam- ples containing corrosion cor- responding to dental amalgam restorations. Fig 2 (Right) An example of extreme dental amal- gam staining on a VFR. which the digested samples are nebulized and the aerosol transported to a plas- ma torch. Individual element specific emission spectra are produced by radio- frequency inductively coupled plasma. Photosensitive devices monitor the intensity of the emissions, which are categorized by element. For comparison and as a control, an unstained, unused sample of Duraforce was also tested. RESULTS Table 1 displays results from CVAA and ICP-AES sample testing. The tarnished sec- tions of the VFR contained mercury (61.00 ppm), calcium (205.00 ppm), and zinc (3.05 ppm). The control sample results were below qualitative limits for metal ion and mercury testing; therefore, any contaminants can be considered negligible. DISCUSSION AND CONCLUSION The results indicate that corrosion products from dental amalgam, including mercury and zinc, are confined by VFR material. Future studies need more rigorous documentation and identification of the types of VFR materials that develop corrosion staining and in what time frame. 72 ORTHODONTICS The Art and Practice of Dentofacial Enhancement
    • Karam and Rinchuse Practice Pearls Table 1 Results of CVAA and ICP-AES sample testing Element Mercury Control sample (unstained VFR; in ppm) < quantitative limit (0.06) Experimental sample (stained VFR; in ppm) 61.00 “ Mercury released from dental amalgam restorations adsorbs into and permeates ” Aluminum < quantitative limit (20.00) < quantitative limit (20.00) Calcium < quantitative limit (20.00) 205.00 through the plastics Iron < quantitative limit (20.00) < quantitative limit (20.00) in VFRs. Magnesium < quantitative limit (10.00) < quantitative limit (10.00) Potassium < quantitative limit (50.00) < quantitative limit (50.00) Sodium < quantitative limit (100.00) < quantitative limit (100.00) Thallium < quantitative limit (3.00) < quantitative limit (3.00) Arsenic < quantitative limit (2.00) < quantitative limit (2.00) Selenium < quantitative limit (2.00) < quantitative limit (2.00) Antimony < quantitative limit (2.00) < quantitative limit (2.00) Barium < quantitative limit (0.50) < quantitative limit (0.50) Beryllium < quantitative limit (0.50) < quantitative limit (0.50) Cadmium < quantitative limit (0.50) < quantitative limit (0.50) Chromium < quantitative limit (1.50) < quantitative limit (1.50) Cobalt < quantitative limit (0.50) < quantitative limit (0.50) Copper < quantitative limit (1.00) < quantitative limit (1.00) Lead < quantitative limit (1.50) < quantitative limit (1.50) Manganese < quantitative limit (0.50) < quantitative limit (0.50) Nickel < quantitative limit (1.00) < quantitative limit (1.00) Silver < quantitative limit (0.50) < quantitative limit (0.50) Vanadium < quantitative limit (0.50) < quantitative limit (0.50) Zinc < quantitative limit (2.00) 3.05 Bolded items were greater than the quantitative limit. Inquiry about potential morbidity from mercury being retained in VFRs isunderstandable. It is the opinion of the authors that due to the diminutive totalamount of mercury in the retainer, there should be little associated morbidity.However, the type of mercury must be considered when discussing potentialmorbidity. Currently, the authors have not tested for type of mercury confinedin the VFR, but it is likely to be either elemental or inorganic mercury. Somedata suggest that oral bacteria can metabolize elemental mercury releasedfrom dental restorations into very toxic forms of organic mercury, includingmethyl mercury; however, no reports of morbidity associated with this phe-nomena have been found.11 The presence of zinc in the stained VFR samples suggests that either smallportions of the restoration are embedded in the retainer containing both mer-cury and zinc or that a potential inorganic mercury salt containing zinc is form-ing in the retainer. In the case that the type of mercury found in the VFRs is inthe elemental form, the concentration of mercury reported in Table 1 may beundervalued. This study was conducted a priori, and as such, the samples werestored longer than ideal prior to testing. Due to the volatile nature of elemen-tal mercury, the mercury concentration found in the VFR samples at the time oftesting (61 ppm) may be significantly lower than the concentration of mercuryin the VFRs at the time the samples were originally collected. Also, the stainedVFR samples tested in this study were modestly stained. Other cases that had Volume 12, Number 1, 2011 73
    • Practice Pearls Dental amalgam corrosion in vacuum-formed retainers more extreme staining would have obviously shown more mercury adsorption. Further studies focusing on the type of mercury in VFRs, total mercury volume contained in VFRs in vivo, and potential metabolism or chemical conversion of mercury adsorbed into the VFR need to be conducted. Although corrosion materials from dental amalgam end up confined in VFRs, variables that increase or decrease the concentration of these materials need to be evaluated, including VFR prescription (full-time wear vs part-time wear), VFR age, mechanical interaction between the VFR plastic and amalgam resto- ration, chemical or electrochemical interaction between the VFR plastic (and its stabilizing agents) and the amalgam restoration, eating or drinking habits (eg, drinking hot beverages or eating with the retainers seated), and oral hygiene habits (eg, hydrogen peroxide usage). Amalgam corrosion staining may be less of an esthetic issue for patients utilizing thermoplastic materials as align- ers, such as Invisalign (Align Technology), since patients often switch to the next aligner in a series prior to staining. Some immediate remedies for amalgam corrosion in VFRs are as follows. Rinchuse et al advocated in a recent publication2 wearing VFRs canine-to-canine only at night, except in open-bite or extraction cases, because this would allow the posterior and buccal segments to settle after orthodontic treatment. Also, canine-to-canine VFRs offer greater flexibility than full-coverage VFRs, so mov- ing teeth is easier. Another obvious solution is to use Hawley or fixed retainers in place of VFRs. Corrosion products from dental amalgam including mercury and zinc can be confined by VFR material. Further studies are needed to evaluate the amalgam staining characteristics of different VFR plastics; the type and concentration of mercury in VFRs; and the possible mechanical, chemical, and electrochemical interactions between VFRs and amalgam restorations. REFERENCES 7. Johnson N, Manchester S, Sarin L, Gao Y, Kulaots I, Hurt R. Mercury vapor release from broken compact fluorescent lamps 1. Sheridan JJ, Hilliard K, Armbruster P. Es- and in situ capture by new nanomaterial six Appliance Technology: Applications, sorbents. Environ Sci Technol 2008;42: Fabrication and Rationale. Bohemia, NY: 5772–5778. GAC International, 2003. 8. Reader M, Lines CB. Decomposition of 2. Rinchuse DJ, Miles P, Sheridan JJ. Orth- thimerosal in aqueous solution and its odontic retention and stability: A clinical determination by high-performance liquid perspective. J Clin Orthod 2007;41: chromatography. J Pharm Sci 1983;72: 125–132. 1406–1409. 3. Lindauer SJ, Shoff RC. Comparison of“ 9. Bellinger DC, Trachtenberg F, Barregard L, Essix and Hawley retainers. J Clin Orthod et al. Neuropsychological and renal 1998;32:95–97. effects of dental amalgam in children: 4. Schuster S, Eliades G, Zinelis S, Eliades T, A randomized clinical trial. JAMA 2006; Amalgam corrosion Bradley TG. Structural conformation and 295:1775–1783. leaching from in vitro aged and retrieved staining may be Invisalign appliances. Am J Orthod Den- 10. DeRouen TA, Martin MD, Leroux BG, et al. Neurobehavioral effects of dental amal- less of an esthetic tofacial Orthop 2004;126:725–728. gam in children: A randomized clinical 5. Mackert JR Jr, Berglund A. Mercury issue for patients trial. JAMA 2006;295:1784–1792. exposure from dental amalgam fillings: 11. Heintze U, Edwardsson S, Derand T, Absorbed dose and the potential for utilizing thermoplastic adverse health effects. Crit Rev Oral Biol Birkhed D. Methylation of mercury from dental amalgam and mercuric chloride by materials as aligners Med 1997;8:410–436. oral streptococci in vitro. Scand J Dent 6. Parker JL, Bloom NS. Preservation and . . . since patients storage techniques for low-level aque- Res 1983;91:150–152. often switch to the ous mercury speciation. Sci Total Environ ” 2005;337:253–263. next aligner in a series prior to staining. 74 ORTHODONTICS The Art and Practice of Dentofacial Enhancement
    • Treatment PlanningS CHALLENGE 1 o often, our peers can teach us far more than any book: The Treatment Planning Challenge is designed to be a forum for readers to learn from one another. In each issue, we will present a complexcase, complete with intra- and extraoral photographs, panoramic andcephalometric radiographs, and cephalometric data as well as any essentialanamnestic details. After reviewing the case, readers are encouraged to detail their own treat-ment plan (in no more than 250 words) and provide answers to the accom-panying questionaire. In the next issue, we will outline with photographs,radiographs, and data how the clinician actually treated this case and its out-come, as well as some of the most interesting reader responses and the statisti-cal distribution of the questionaire answers. Tell us your treatment plan for this case (answers will edited for clarity, lan-guage, and length) at http://www.quintpub.com. Click the Journals link at thetop of the page and then the Orthodontics cover. Please submit your plan for thiscase by June 1, 2011, and note that it is for Treatment Planning Challenge no. 1. Send us your completed challenging case for a future issue: Provide all pre-and posttreatment records as well as a short of explanation of why you chosethe treatment plan you did at http://www.manuscriptmanager.com/ortho. SelectTPC (new case) from the Manuscript Type drop-down menu. Low-resolutionimages are acceptable for the review process; however, if your case is chosenfor publication, keep in mind that you will need to provide images that are atleast 300 dpi at 3.5 inches wide. You must also have signed patient consent forpublication of the photographs.Missing maxillary lateral incisors:To close or to open?In the case of an 11-year-old girl with missing maxillary lateralincisors:• Would you close or open the space of the missing maxillary lateral incisors?• If you chose to close the space, would you reshape the canines upon completion of treatment?• Would you start treatment immediately or wait ____ years? 75
    • Treatment Planning Missing maxillary lateral incisors: To close or to open? CHALLENGE 1 76 ORTHODONTICS The Art and Practice of Dentofacial Enhancement
    • TreatmentCephalometric data Planning Norms Patient CHALLENGE 1Maxillary skeletalSNA (degrees) 80 < 82 < 84 78NVertA (mm) –2 < 0 < 2 –3Nasiolabial angle (degrees) 113 > 105 > 97 108Upper lip–subnasale (mm) 1>2>3 0Maxillary dentalU1 to SN (degrees) 100 < 104 < 108 93U1 to PAL/PL (degrees) 105 < 110 < 115 108U1 to NA (degrees) 18 < 22 < 26 15U1 to NA (mm) 2<4<6 0Upper lip drape (degrees) 92 < 97 < 102 91Mandibular dentalIMPA 90 < 95 < 100 88Incisor to NB (degrees) 21 < 25 < 29 19Incisor to NB (mm) 2 <4<6 3Incisor to AP (mm) 0<2<4 –2Half Steiner (mm) –5 < 0 < 5 –1Mandibular skeletalSNB (degrees) 78 < 80 < 82 73Facial angle (Downs) 86 < 89 < 92 85(degrees)NaVertPo (mm) –9 < –6 < –3 –10E angle (degrees) 68 < 72 < 76 64VerticalGoGn–SN (degrees) 28 < 32 < 36 37OM angle (degrees) 15 < 20 < 25 17Y-axis 64 < 67 < 70 68Jarabak SGo:NMe (%) 62 < 64 < 66 60Anterior facial height (%) 55 ± 2 51Tell us your treatment plan for this case athttp://www.quintpub.com. Volume 12, Number 1, 2011 77
    • Management The dentist as a manager: Building effective relationships and networks for personal and professional advancement Hilla Dotan, PhD1 ORTHO 2011;12:78–81. M any skilled and highly specialized professionals such as dentists, surgeons, scientists, and musicians invest a great deal of time and resources obtaining the required technical skills and certification, as- suming that these will help them reach their professional goals. Unfortunately, only a limited amount of top talent also invests in gaining practical, manage- rial, and relational skills to accompany their technical expertise. Consequently, many accomplished professionals do not attain their full career potential. Many struggle to build their own businesses and lack basic knowledge with regard to hiring and product pricing. They also have difficulty determining where and if to open a private clinic; how to gain market share; how to reach a patient; and how to build long-term, effective relationships with clients, distributers, and dental staff. One of the main reasons for this lack of critical knowledge is that many professional schools do not offer basic business courses as part of their curricu- lum. Is it because they assume their graduates will succeed regardless of such schooling? Is there no need? What percentage of professional school gradu- ates succeed in building their own practices? Who are the most successful den- tists? Are they the ones who are the top experts in their field? We often find that it is not always the most capable and skilled professionals who build the most successful practices. What is unique about those who do? What does it take to become a leader in a specialized profession? Findings from interviews with executives and research conducted in the United States over the last decade1 suggest that the most successful leaders and professionals are those who know how to build the right relationships and manage and maintain their social networks. In today’s business world, relationships are the new bottom line. The qual- ity and impact of one’s work and the profitability of a business depend on relationships: relationships with coworkers, patients, competitors, distributors, 1Department investors, and others. Relationships offer opportunities for mutual growth, col- of Organizational Behavior, laboration, innovation, information sharing, and new business development, Faculty of Management, but they also pose challenges in these respects. The distinguishing factor be- Recanati Graduate School tween a successful manager and an ineffective leader is the ability to effec- of Management, Tel Aviv University, Tel Aviv, Isreal. tively manage relationships. Nonetheless, most of us do not receive formal training on relational man- CORRESPONDENCE agement. When we enter a new organization, no one tells us with whom we Dr Hilla Dotan Faculty of Management should connect and whom to avoid. An organizational chart does not tell us Tel Aviv University anything about the informal side of the organization, for example, its cliques Tel Aviv 69978 or internal politics. No one provides a manual that shows whom it is good to Israel Email: hdotan@ befriend, how to build a good relationship with a patient, or how to manage post.tau.ac.il relationships with our colleagues and competitors. 78 ORTHODONTICS The Art and Practice of Dentofacial Enhancement
    • Many of us spend years attempting to obtain our degrees and certificationand progress through our careers without much thought about our professionalrelationships and networks. Those of us who do pay attention to our relation-ships and build valuable connections do so intuitively and go with what feelsright. Most of us do not look at someone in the organization and conduct acost-benefit analysis with regard to a potential friendship with this person. Whyare relationships not approached strategically? We are very strategic about thetype of training we get, the professional school we attend, and the locationof practice, but why are we not strategic about what helps us achieve all theabove? Would we not be more successful if we actually evaluated a potentialrelationship with someone, thought about the type of relationship we want tobuild with the specific person, and for how long we want to maintain that re-lationship? For example, wouldn’t we be better off if we thought about whomwould be the best person to study with for exams at school? Who are the bestindividuals to work with during specialization? Whom not to befriend? Theserelationships are likely to influence and guide us throughout our careers, and itought to be important to choose them carefully. Since most of us deal with relationships every day and are judged by thequality of the ties that we build and maintain, and since our reputation is in thehands of these individuals, why is a course on relationship building not a re-quired course in all professional schools and disciplines? Why is it rarely offeredin psychology departments and business schools around the world? In this short commentary, I argue for the importance of not only provid-ing skilled professionals their specialized training but also preparing such toptalent for the challenges they are likely to face as they enter existing work-places or as they attempt to build their own practices and clinics. I encourageprofessional schools to incorporate basic practical and managerial skills intotheir curriculum in areas such as strategy, marketing, leadership, and effec-tive relationships and social networks. Since training or courses on the latterare not readily available, I would hereby like to suggest types of analyses thatprofessionals can conduct to reflect on their relational skills and think of waysto improve them. In the following section, I raise a number of questions withthe hope that these will guide readers as they begin to think about building ef-fective relationships and networks for personal and professional advancement.• What does my current professional network look like? Before thinking about improving one’s existing relationships and network, one should first become aware of the status quo. Therefore, the first stage is to evaluate one’s current network. As one conducts such analysis, thought should Volume 12, Number 1, 2011 79
    • Management The dentist as a manager: Building effective relationships and networks Denmark Belgium Spain Orthodontists United Kingdom Professors Peers 2010 Finland The Netherlands Online Admin Med school Annual European conference China Union Academics Marketing United Media avenues States Dentist Colleagues Friends with clinics Josh Family Specialists network David Practitioners Key Cousin competitors Stacy Steven Mom Sister Dad John Jessica fig 1 Example of a sociogram of a clinician’s ideal network. Original diagram created with Node XL. be made with regard to direct ties as well as indirect ties—those to whom we are connected to via another person. One could make a list of all the direct and indirect ties and map all the connections in the form of a sociogram2 or a network map (Fig 1). • What should my ideal network look like? Once we become aware of our current network, the next step is to think about how an ideal network should look. The answer to this question is quite complex and will vary greatly from one individual to the next. A help- ful guiding question is to think about what one’s professional goals are and map the network that will help achieve those goals. For example, if my aim is to open my own clinic, the ideal network should include all the individuals I know who can help me build and maintain an effective and efficient prac- tice. These should include colleagues who have their own practices and can provide advice and refer me to relevant sources as well as individuals who can help market my new business, friends who can help spread the word, individuals who can help me reach patients, suppliers, professional clubs, and relevant academic institutions and academies. • What type of a relationship should I have with each person in my ideal network? Once all the relevant individuals and constituencies are on the map, it is important to think of the type of relationship currently in place with each 80 ORTHODONTICS Th e Art and Practice of Dentofacial Enhancement
    • Dotan Management individual and the type or relationship one should have with him or her. One way to decide on the type of relationship is to conduct a needs analysis, which is divided into three stages: (1) an analysis of needs to help achieve professional goals, (2) a determination of who in my professional network can satisfy these needs, and (3) an analysis of what I can provide/offer the other to motivate him or her to build the relevant relationship with me. To succeed professionally and achieve professional goals, we have career/ professional needs and psychosocial needs.3 By conducting an analysis of these needs and then thinking who can help satisfy these needs, I can begin to think of the type of relationship I should have with each person. For example, an ex- perienced orthodontist who has a very busy schedule and cannot answer all pa- tients’ requests may decide to bring in a young orthodontist to the practice to help take some of the load. A relationship with the young colleague will require the older specialist to provide guidance and teach the younger orthodontist various procedures and best practices—a typical mentor-protégé relationship. Thus, by first identifying the need for assistance and a protégé (stage 1), theexperienced orthodontist can review all the individuals in a network and de-termine who can fulfill the protégé position (stage 2). Nevertheless, althoughshe may want to have a mentor-protégé relationship with a specific personin her network, the other person may not be available or interested in such arelationship. Therefore, an additional analysis should be conducted to try topersuade the other person to develop the required relationship. The experi-enced orthodontist will need to demonstrate to the potential protégé the pos-sible advantages that she, as a mentor, can offer the protégé and the value ofentering into such a relationship (stage 3). Thus, an analysis of who can satisfy my various needs and what I can providethe other should be conducted to help determine with whom to connect, whattype of a relationship to build with him or her, and what professional needs thisrelationship will satisfy. Once all the needs are satisfied using various relationshipswith diverse individuals, a chart of the ideal network can be derived and mapped. The above framework is a useful guide to help map one’s ideal network forachieving personal and career goals. However, mapping the network is onlythe starting point. The next critical step is to think about how to actually buildsuch relationships and maintain them—for example, how to build trust with anew patient, manage conflicts with individuals in my network, and leverage mynetwork to enhance my reputation in my industry? Many of us should be thinking about the above questions as we reflect on ourprofessional relationships and networks and as we attempt to reach our businessobjectives. The ability to manage these effectively will determine whether we willsucceed and whether we will be able to maintain that success over time. Professional schools provide the basic knowledge and certification to prac-tice our professions. Managerial and relational skills provide us the tools totake charge of our profession and bring it to where we want it to be.REfERENCES 3. Hill L. Beyond the myth of the perfect mentor: Building a network of develop-1. Dotan H. Workplace friendships: Origins mental relationships (case no. 9-491-096). and consequences for managerial effec- Boston: Harvard Business School Case tiveness. Academy of Management Best Services, 1991. Paper Proceedings, 2009.2. Wasserman S, Faust K. Social Network Analysis. Cambridge: Cambridge Univer- sity Press, 1994. Volume 12, Number 1, 2011 81
    • V gne es “ Vignette: a brief evocative description, account, or episode. ” I —World Dictionary t has been said that orthodontic practice is more of an art form than a scienti c discipline. For the sake of argument, most clinicians would agree that in any given day of practice, it probably is a little bit of both. However, orthodontists like to think in absolutes and would prefer to see the orthodontic microcosm as black or white rather than shades of subtle gray. This desire to separate art from science has inadvertently created a paradigm shift in contemporary orthodontic literature. Pick up just about any orthodontic journal, and you will nd that the evidence-based systematic review has supplanted the clinical narrative review of yesteryear. Orthodontics is no longer a cultural mosaic replete with a vibrant dramatis personae but a drab melting pot of homogeneity. For those who see orthodontics as a science, this is a welcome change. For those who view it as an art, it is not. As I re ect on this shift, I am reminded of a wonderful vignette told to me by my father, Jim Ackerman, the second of three orthodontic generations. At a conference of German anatomists nearly a half-century ago, he and the late Melvyn Baer were presenting a case report about cebocephalia.1 When they nished presenting the paper, the moderator opened the discussion with ques- tions from the audience. A very senior German anatomist stood up and stat- ed, “Anyone familiar with the literature knows that patients with cebocephalia do not live to the age of your patient.” My father was at a complete loss for words, facing the prospect that he had misdiagnosed the patient in the case report. Without missing a beat, Mel Baer grabbed the microphone and retorted, “Our patient has obviously not read the literature!” Orthodontics: The Art and Practice of Dentofacial Enhancement is designed to give the reader a glimpse of both the art and science sides of the orthodontic coin. In this section, Vignettes, we have reserved a place for authors to recount (in fewer than 500 words) their unique experiences in practice and to pay hom- age to those individuals who have shaped the course of our specialty. Marc Bernard Ackerman, DMD, MBA Director, Department of Orthodontics Children’s Hospital Boston Boston, Massachusetts, USA CORRESPONDENCE Dr Marc Bernard Ackerman REFERENCE Children’s Hospital Boston 300 Longwood Ave Boston, MA 02115 1. Ackerman JL, Takagi Y, Prof t WR, Baer MJ. Craniofacial growth Email: Marc.ackerman@ and development in cebocephalia. Oral Surg Oral Med Oral childrens.harvard.edu Pathol 1965;19:543–554. To submit an interesting Vignette, please go to http://www.manuscriptmanager.com/ortho.82 ORTHODONTICS e Ar n P a ce D nto cia En ancemen
    • Interdisciplinary Treatment Planning Principles, Design, Implementation Edited by Michael Cohen This book articulates the process by which master clinicians treatment plan their cases. In the rst part of each chapter, 18 of the world’s most respected clinicians share the key principles that guide their case-planning decisions. In the second part, they present the diagnostic ndings of one of their own cases, invite the reader to treatment plan the case, then present their own plan and the actual treatment rendered along with large, full-color treat- ment and posttreatment images. 568 pp; 1,350 illus (mostly color); ISBN 978-0-86715-474-0 (B4740); US $328 Contributors • Gerard J. Chiche • Henry I. Nichols • Vincent G. Kokich • Neil L. Starr • Sonia S. Leziy/Brahm A. Miller • Ward M. Smalley • John D. West • Ariel J. Raigrodski • Lloyd M. Tucker • Stephen Rimer • John C. Kois • Ricardo Mitrani • Andrew M. Alpert • Galip Gürel • Frank Spear/Greggory Kinzer • Michael Cohen ORDER FORM For fast service CALL TOLL FREE (800) 621-0387 (within USA & Canada) or FAX (630) 736-3633 Please send me Interdisciplinary Treatment Planning: Principles, Design, Implementation US $328NAMEADDRESSCITY STATE ZIP – COUNTRYEMAIL FAX General Practitioner Specialist Other Charge to my credit card plus shipping & handling VISA/MasterCard American Express Discover CardCARD NO. EXPIRESSIGNATUREPrices subject to change without notice. All sales are final. Shipping and handling charges will be added to all orders. For Illinois and Canadian residents, sales tax will be added if applicable. Payment must be made in US funds. 04/11 Quintessence Publishing Co Inc, 4350 Chandler Drive, Hanover Park, IL 60133 Phone: (630) 736-3600 • Fax: (630) 736-3633 Email: service@quintbook.com • Website: www.quintpub.com