Orthodontics Vol 12 No 1 Romano

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Orthodontics Vol 12 No 1 Romano

  1. 1. Volume 12 • Number 1ORTHODONTICS T e A n P a ce f D nto cia E ancemen Formerly World Journal of Orthodontics
  2. 2. 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
  3. 3. 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
  4. 4. 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.
  5. 5. 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
  6. 6. 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
  7. 7. 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
  8. 8. 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.
  9. 9. 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
  10. 10. 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
  11. 11. 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
  12. 12. 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
  13. 13. 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
  14. 14. 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
  15. 15. 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
  16. 16. 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
  17. 17. 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
  18. 18. 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
  19. 19. 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
  20. 20. 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
  21. 21. 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
  22. 22. 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
  23. 23. 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
  24. 24. 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

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