Controversy

ControversiesControversies
inin
OrthodonticsOrthodontics
www.indiandentalacademy.comwww.indiandentalacademy.com

CONTROVERSY !!!!!!!!!!!!!
!!!

CONTENTSCONTENTS
 IntroductionIntroduction
 Controversies in Classification of MalocclusionControversies in Classification of Malocclusion
 Controversies in DiagnosisControversies in Diagnosis
a. Diagnostic value of plaster models in contemporarya. Diagnostic value of plaster models in contemporary
orthodonticsorthodontics
b. Reliability of Digital vs. Conventional cephalometricb. Reliability of Digital vs. Conventional cephalometric
RadiologyRadiology
 Controversies in Etiology of malocclusionControversies in Etiology of malocclusion
a. Genetic V/s environmental factorsa. Genetic V/s environmental factors..
b. Role of nasal obstruction and tongue thrust.b. Role of nasal obstruction and tongue thrust.
c.c. Third molars – a dilemma! Or is it?Third molars – a dilemma! Or is it?
 Controversies in Treatment planningControversies in Treatment planning
a. Extraction versus Non-extraction.a. Extraction versus Non-extraction.
b. Timing of Orthodontic Treatmentb. Timing of Orthodontic Treatment

 Controversies in Treatment modalitiesControversies in Treatment modalities
 Orthopedics in orthodontics; fiction or realityOrthopedics in orthodontics; fiction or reality
 Controversies in PEA:Controversies in PEA:
-- Torque in the Base vs. Torque in the FaceTorque in the Base vs. Torque in the Face
- 018” vs. 022” slot- 018” vs. 022” slot
- Controversies in Bracket prescription- Controversies in Bracket prescription
 Root resorption related to orthodontic treatmentRoot resorption related to orthodontic treatment
 Orthodontic treatment and temporomandibularOrthodontic treatment and temporomandibular
disordersdisorders
 Conclusion and ReferencesConclusion and References
CONTENTSCONTENTS

IntroductionIntroduction
 ControversyControversy – A prolonged argument/– A prolonged argument/
dispute especially when conducted publicly.dispute especially when conducted publicly.
 Orthodontics traditionally has been aOrthodontics traditionally has been a
specialty in which opinions of leaders werespecialty in which opinions of leaders were
important, to the point that professionalimportant, to the point that professional
groups coalesced around a strong leadergroups coalesced around a strong leader

 Angle, Begg, Tweed societies still exist-Angle, Begg, Tweed societies still exist-
“disagreements are then a risk rather than“disagreements are then a risk rather than
exception”.exception”.

 Cults and charismatic leaders have beenCults and charismatic leaders have been
more instrumental in establishing ourmore instrumental in establishing our
value systems than has any demonstratedvalue systems than has any demonstrated
superiority of one method over another.superiority of one method over another.

ResultResult
 Thus its more “Opinion –based” ratherThus its more “Opinion –based” rather
than “evidence – based”.than “evidence – based”.
 Such science can neither validate theSuch science can neither validate the
superiority of a technique nor help tosuperiority of a technique nor help to
make rational choices among alternatives.make rational choices among alternatives.

 In time, for most clinicians, practice becomesIn time, for most clinicians, practice becomes
routine, standardized and decreasinglyroutine, standardized and decreasingly
introspective.introspective.
 Hence,Hence, clinical experience + common senseclinical experience + common sense
assume a more commanding role inassume a more commanding role in
Decision makingDecision making..

InIn
Classification ofClassification of
MalocclusionMalocclusion

Ambiguities of Angle’s classification :Ambiguities of Angle’s classification :
1989 .Donald J. Rinchuse, Daniel J. Rinchuse1989 .Donald J. Rinchuse, Daniel J. Rinchuse..
 In 1900, Edward H. Angle wroteIn 1900, Edward H. Angle wrote
that all teeth should bethat all teeth should be
considered when classifyingconsidered when classifying
casescases
 In 1907, he emphasized usingIn 1907, he emphasized using
the maxillary first molars asthe maxillary first molars as
reference teeth.reference teeth.
 Arguments are presented toArguments are presented to
illustrate the confusion in relyingillustrate the confusion in relying
solely on Angle’s system ofsolely on Angle’s system of
classificationclassification

The changes in Angle’s thinking and writingsThe changes in Angle’s thinking and writings
between 1900 and 1907 have created a dilemma:between 1900 and 1907 have created a dilemma:
 Should the orthodontist use only theShould the orthodontist use only the
permanent first molars to determine thepermanent first molars to determine the
classification of an Malocclusion?classification of an Malocclusion?
 Or, should the canines be included?Or, should the canines be included?
 If so, which teeth, the molars or canines,If so, which teeth, the molars or canines,
should be given priority when determiningshould be given priority when determining
the classification of an occlusion?the classification of an occlusion?
 Or, should the orthodontist use all theOr, should the orthodontist use all the
teeth to assign a case to one of Angle’steeth to assign a case to one of Angle’s
Classifications?Classifications? www.indiandentalacademy.comwww.indiandentalacademy.com

 The situation arising where one side of a dentition isThe situation arising where one side of a dentition is
in a Class II relation, while the other side is in a Classin a Class II relation, while the other side is in a Class
III relation, is beyond the parameters of Angle’sIII relation, is beyond the parameters of Angle’s
ClassificationClassification
 A dilemma could arise when the first molars are in aA dilemma could arise when the first molars are in a
Class I relationship and the rest of the dentition is in aClass I relationship and the rest of the dentition is in a
Class II relation.Class II relation.
Ambiguities of Angle’s classification :Ambiguities of Angle’s classification :
1989 No. 4, 295 - 298Donald J. Rinchuse, Daniel J. Rinchuse.1989 No. 4, 295 - 298Donald J. Rinchuse, Daniel J. Rinchuse.

 What does “subdivision left” describe?What does “subdivision left” describe?
 Some orthodontists believeSome orthodontists believe that it refers to anthat it refers to an
asymmetrical occlusion, with a Class II molarasymmetrical occlusion, with a Class II molar
relationship on the patient’s left side and a Class Irelationship on the patient’s left side and a Class I
molar relationship on the right side. Othermolar relationship on the right side. Other
orthodontists perceive just the opposite.orthodontists perceive just the opposite.
 As a result, orthodontists in the United States cannotAs a result, orthodontists in the United States cannot
agree on the meaning of a Class II Division 1agree on the meaning of a Class II Division 1
subdivision malocclusion.subdivision malocclusion.
A matter of Class: interpreting subdivision inA matter of Class: interpreting subdivision in
a malocclusion.a malocclusion.
Am J Orthod Dentofacial Orthod. 2002 DecAm J Orthod Dentofacial Orthod. 2002 Dec

 A survey was sent to the chairperson of eachA survey was sent to the chairperson of each
orthodontic department in teaching facilities in theorthodontic department in teaching facilities in the
United States. Fifty-seven surveys were mailed. TheUnited States. Fifty-seven surveys were mailed. The
survey consisted of a 1-page questionnaire thatsurvey consisted of a 1-page questionnaire that
asked whether, in the orthodontic residencyasked whether, in the orthodontic residency
program’s philosophy,program’s philosophy, subdivisionsubdivision refers to therefers to the
Class I side or the Class II side.Class I side or the Class II side.
AA matter of Class: interpreting subdivision inmatter of Class: interpreting subdivision in
a malocclusion.a malocclusion.

 Thirty-four surveys were returned (returnThirty-four surveys were returned (return
rate about 60%) with mixed results. Twenty-rate about 60%) with mixed results. Twenty-
two respondents believe thattwo respondents believe that subdivisionsubdivision
refers to the Class II side, 8 believe it refersrefers to the Class II side, 8 believe it refers
to the Class I side, and 3 teach theirto the Class I side, and 3 teach their
students neither meaning forstudents neither meaning for subdivisionsubdivision..
A matter of Class: interpreting subdivision in aA matter of Class: interpreting subdivision in a
malocclusion.malocclusion.

Diagnostic value ofDiagnostic value of
plaster models inplaster models in
ContemporaryContemporary
OrthodonticsOrthodontics

 Models are the only three dimensionalModels are the only three dimensional
records available to represent dentitionrecords available to represent dentition
in a functional occlusionin a functional occlusion

Advantages of ModelsAdvantages of Models
 Measurement of dentition and arch lengthMeasurement of dentition and arch length
are easierare easier
 As per ABO study models allow for gradingAs per ABO study models allow for grading
system evaluating treatment resultssystem evaluating treatment results
 They also serve as a Medico legal recordThey also serve as a Medico legal record

Diagnostic value of plaster models inDiagnostic value of plaster models in
Contemporary Orthodontics:Contemporary Orthodontics:
Chad Callahan, P. Lionel Sadowsky and AndreChad Callahan, P. Lionel Sadowsky and Andre
Ferreira.Ferreira.
Seminar in Orthodontics 2005Seminar in Orthodontics 2005
 20 Orthodontic patients( 11 Class I, 7 Class II, 220 Orthodontic patients( 11 Class I, 7 Class II, 2
Class III ) were selectedClass III ) were selected
 Four Orthodontists participated with aFour Orthodontists participated with a
experience of 8 to 30 yearsexperience of 8 to 30 years
 Initially Extra oral photographs, RadiographsInitially Extra oral photographs, Radiographs
are providedare provided

 Following which a questionnaire is givenFollowing which a questionnaire is given
consisting of 20 diagnostic criteria includingconsisting of 20 diagnostic criteria including
Molar relationship, Canine relationship,Molar relationship, Canine relationship,
Arch form, Overbite, Overjet, Crowding etc.Arch form, Overbite, Overjet, Crowding etc.
Ferreira.Ferreira.

 Plaster models were later provided and thePlaster models were later provided and the
Diagnosis and treatment plan were revisitedDiagnosis and treatment plan were revisited
to evaluate whether models added anyto evaluate whether models added any
value to the diagnosisvalue to the diagnosis
Ferreira.Ferreira.

ResultsResults::
 83 Diagnostic values changed of a possible83 Diagnostic values changed of a possible
1600 i.e., about 95 % of the Diagnostic1600 i.e., about 95 % of the Diagnostic
values remain unchanged.values remain unchanged.
 Only 5 out of 20 Diagnostic values wereOnly 5 out of 20 Diagnostic values were
determined to be statistically significantdetermined to be statistically significant
including Molar, Canine relationship,including Molar, Canine relationship,
Overjet, Overbite, Depth of curve of spee.Overjet, Overbite, Depth of curve of spee.

Rheude B, Sadowsky Pl, Ferriera A, Jacobson A. An evaluation of theRheude B, Sadowsky Pl, Ferriera A, Jacobson A. An evaluation of the
use of digital study models in orthodontic diagnosis and treatmentuse of digital study models in orthodontic diagnosis and treatment
planning Angle Orthod 2005planning Angle Orthod 2005
 They comparedThey compared
Digital models toDigital models to
plaster modelsplaster models
 They found 14 out ofThey found 14 out of
20 diagnostic criteria20 diagnostic criteria
showed variationshowed variation
 They concluded thisThey concluded this
variation as clinicallyvariation as clinically
insignificantinsignificant

Han U. Consistency of orthodonticHan U. Consistency of orthodontic
treatment decisions relative to diagnostictreatment decisions relative to diagnostic
recordsrecords
AJO DO 1991AJO DO 1991
 In contrast to previous studies, DiagnosticIn contrast to previous studies, Diagnostic
models could provide adequate amount ofmodels could provide adequate amount of
information for treatment planning in 55%information for treatment planning in 55%
of casesof cases

Current view pointCurrent view point
 Diagnostic changes made following theDiagnostic changes made following the
addition of study models to the other recordsaddition of study models to the other records
proved not to be clinically significant.proved not to be clinically significant.
Plaster models are
currently being
replaced by digital
models and have
been proven to be
excellent alternative

Reliability ofReliability of
DigitalDigital
vs.vs.
ConventionalConventional
cephalometriccephalometric
RadiologyRadiology

 CephalometricsCephalometrics
remains the onlyremains the only
practical quantitativepractical quantitative
method that permitsmethod that permits
investigation andinvestigation and
examination of theexamination of the
spatial relationshipsspatial relationships
between both cranialbetween both cranial
and dental structuresand dental structures

Advantages of Digital CephalometricsAdvantages of Digital Cephalometrics
 Instantaneous imageInstantaneous image
acquisitionacquisition
 Reduction of radiationReduction of radiation
dosedose
 Facilitated imageFacilitated image
enhancement andenhancement and
archivingarchiving
 Elimination of techniqueElimination of technique
sensitive developingsensitive developing
process and its costsprocess and its costs
 Facilitated image sharingFacilitated image sharing

Reliability of Digital vs. ConventionalReliability of Digital vs. Conventional
cephalometric Radiology: A comparativecephalometric Radiology: A comparative
evaluation of landmark identification error.evaluation of landmark identification error.
Scott R. McClure etal Seminar in Orthodontics 2005.Scott R. McClure etal Seminar in Orthodontics 2005.
 Purpose:Purpose: The accuracy of landmarkThe accuracy of landmark
identification utilizing these two differentidentification utilizing these two different
image acquisition methods should beimage acquisition methods should be
comparedcompared
 19 commonly used cephalometric landmarks19 commonly used cephalometric landmarks
are used in the analysisare used in the analysis

MethodMethod
 The landmarks location on the digital imagesThe landmarks location on the digital images
and transparent acetate films could than beand transparent acetate films could than be
described by using X and Y co-ordinates withdescribed by using X and Y co-ordinates with
the aid of computerized programthe aid of computerized program
 The average position for each landmark wasThe average position for each landmark was
also used to facilitate accurate superimpositionalso used to facilitate accurate superimposition
in the creation of scatterograms for eachin the creation of scatterograms for each
landmark.landmark.

Results:Results:
1.1. Three of the 19 landmarks indicatedThree of the 19 landmarks indicated
statistically significantly higher landmarkstatistically significantly higher landmark
identification error for film basedidentification error for film based
identification methods than for digital imageidentification methods than for digital image
based identificationbased identification
2.2. But the error is less than 1 mm indicatingBut the error is less than 1 mm indicating
unlikely clinical significance.unlikely clinical significance.

Trpkova etalTrpkova etal
 Conducted similar study in 15 skeletalConducted similar study in 15 skeletal
landmarkslandmarks
 Concluded landmark identification using digitalConcluded landmark identification using digital
images had more precision in both x and yimages had more precision in both x and y
dimensions than conventional film baseddimensions than conventional film based
landmark identification.landmark identification.

 The advantages of digital cephalometryThe advantages of digital cephalometry
coupled with proven clinical performancecoupled with proven clinical performance
equal to that of film may lead to shift in whatequal to that of film may lead to shift in what
is considered the standard for cephalometricis considered the standard for cephalometric
radiography in future.radiography in future.

ETIOLOGYETIOLOGY
OFOF
MALOCCLUSIONMALOCCLUSION

 A strong influence ofA strong influence of
inheritance on facialinheritance on facial
features is obvious tofeatures is obvious to
recognize.recognize.
 It is also apparentIt is also apparent
that certain types ofthat certain types of
malocclusion run inmalocclusion run in
families.families.
e.g. Hapsburg jaw .e.g. Hapsburg jaw .
Royal GermanRoyal German
familiesfamilies

Malocclusion could be produced by inheritedMalocclusion could be produced by inherited
characteristics in two possible ways:characteristics in two possible ways:
 Inherited disproportion between the size of teethInherited disproportion between the size of teeth
and that of the jaws-producingand that of the jaws-producing
crowding/spacing.crowding/spacing.
 Inherited disproportion between size/shape ofInherited disproportion between size/shape of
upper and lower jaws –producing improperupper and lower jaws –producing improper
occlusal relations.occlusal relations.
According to ProfittAccording to Profitt

 There is considerableThere is considerable
anthropological evidence thatanthropological evidence that
population groups that arepopulation groups that are
genetically homogenous tendgenetically homogenous tend
to have a normal occlusionto have a normal occlusion
e.g.: Melanesians of Philippinee.g.: Melanesians of Philippine
islands, this is the result ofislands, this is the result of
genetic isolation and uniformity.genetic isolation and uniformity.

 Based on this evidence,Based on this evidence,
workers of the yesteryearsworkers of the yesteryears
were tempted to concludewere tempted to conclude
that the great increase inthat the great increase in
population and itspopulation and its
mobilization was the primarymobilization was the primary
explanation for the increaseexplanation for the increase
in malocclusion in modernin malocclusion in modern
manman
 They blamed this on the improper function
of jaws under degenerate modern conditionswww.indiandentalacademy.comwww.indiandentalacademy.com

The earlier part of the 20th centuryThe earlier part of the 20th century
Development of classical MendelianDevelopment of classical Mendelian
genetics.genetics.
 The new view is that malocclusion is primarilyThe new view is that malocclusion is primarily
the result of inherited dentofacial disproportionsthe result of inherited dentofacial disproportions
strengthened by the breeding experimentsstrengthened by the breeding experiments
carried out by Prof. Stock hard (1930).carried out by Prof. Stock hard (1930).

Later part of 20Later part of 20thth
centurycentury
 A revival and a swing back to the earlierA revival and a swing back to the earlier
concept that jaw function is related toconcept that jaw function is related to

 A number of familial and twin studies in theA number of familial and twin studies in the
latter part of the century by workers likelatter part of the century by workers like
Lundstrom (1984), Corrucini (1980), PotterLundstrom (1984), Corrucini (1980), Potter
(1986), Bolton and Brush, Harris and Johnson(1986), Bolton and Brush, Harris and Johnson
(1991) gave a more balanced view showing that(1991) gave a more balanced view showing that
there is no single explanation for malocclusionthere is no single explanation for malocclusion
in terms of function, heredity or environment,in terms of function, heredity or environment,
but is a result of a complex interplay of thesebut is a result of a complex interplay of these
elements.elements.
Current view point:

RESPIRATORY PATTERNRESPIRATORY PATTERN
 Respiration is the Primary determinant ofRespiration is the Primary determinant of
jaw and tongue posture.jaw and tongue posture.
 Altered respiratory patternAltered respiratory pattern  changechange
posture of head, jaw, and tongueposture of head, jaw, and tongue  altersalters
equilibriumequilibrium  jaw growth and toothjaw growth and tooth
position affected.position affected.

Harvold, Tomer and Vargevik (1981)Harvold, Tomer and Vargevik (1981)
 Total nasal obstruction in monkeys, for aTotal nasal obstruction in monkeys, for a
prolonged time led to the development ofprolonged time led to the development of
 Placing a block on the roof of the mouth,Placing a block on the roof of the mouth,
forcing the tongue to a more downwardforcing the tongue to a more downward
position, producing a variety of malocclusion.position, producing a variety of malocclusion.

 Because total nasal obstruction in humansBecause total nasal obstruction in humans
is so rare, the important question is whetheris so rare, the important question is whether
partial nasal-obstruction is a risk factor inpartial nasal-obstruction is a risk factor in
causing malocclusion ?causing malocclusion ?
 Does nasal obstruction equatesDoes nasal obstruction equates  mouthmouth
breathing + lip-apart posture ?breathing + lip-apart posture ?

Ballard andBallard and
Gwynne-Evans (1958)Gwynne-Evans (1958)
 Nose breathers, who have a lip - apartNose breathers, who have a lip - apart
posture, usually have post seal with tongueposture, usually have post seal with tongue
against soft palate as an adaptiveagainst soft palate as an adaptive
mechanism.mechanism.

Wood side, Linder, Aronson,Wood side, Linder, Aronson,
Lundstrom (1991)Lundstrom (1991)
Concluded that change from mouth-open to mouth-Concluded that change from mouth-open to mouth-
closed breathing after adenoidectomy for severeclosed breathing after adenoidectomy for severe
nasopharyngeal obstruction in 38 childrennasopharyngeal obstruction in 38 children
 Greater mandibular growth expressed at chin in bothGreater mandibular growth expressed at chin in both
sexes:sexes:
3.8mm in males & 2.5mm in girls3.8mm in males & 2.5mm in girls
 Greater facial growth expressed atGreater facial growth expressed at
midface, only in males.midface, only in males.
No change in maxillary growth direction.No change in maxillary growth direction.

BushyBushy
 Found no relationship between nasalFound no relationship between nasal
respiration and linear measurements ofrespiration and linear measurements of
adenoids in lateral cephalogram before andadenoids in lateral cephalogram before and
after adenoidectomy.after adenoidectomy.

Fields et al (1991)Fields et al (1991)
 Compared respiratory mode in normal and long-Compared respiratory mode in normal and long-
faced subjects.faced subjects.
 Results:Results:
Long-facedLong-faced  significantly smaller component ofsignificantly smaller component of
nasal air flow (40%) but total volume and nasalnasal air flow (40%) but total volume and nasal
cross-sectional area were similarcross-sectional area were similar..
 He concluded that significant difference in airwayHe concluded that significant difference in airway
impairment does not have direct effect on breathingimpairment does not have direct effect on breathing
modemode  behaviorally determined than structurallybehaviorally determined than structurally
dependent.dependent.

RME and Nasal obstructionRME and Nasal obstruction
 RME for transverse maxillary deficiency correction alsoRME for transverse maxillary deficiency correction also
increases nasal airflow.increases nasal airflow.
 Hart Gerick et al (1987)Hart Gerick et al (1987)
-No increase in % of nasal breathing.-No increase in % of nasal breathing.
-Can decrease in nasal resistance.-Can decrease in nasal resistance.
-Did not change respiratory mode of-Did not change respiratory mode of
the patientthe patient

Bell (1977) andBell (1977) and
Spalding et al (1991):Spalding et al (1991):
 No decreased nasal resistance and noNo decreased nasal resistance and no
increased % of nasal airflow.increased % of nasal airflow.
 Provides another example why cliniciansProvides another example why clinicians
and researchers should not assume thatand researchers should not assume that
because one of the parameters of nasalbecause one of the parameters of nasal
respiration is affected, others like cross-respiration is affected, others like cross-
sectional area, peak nasal flow rate andsectional area, peak nasal flow rate and
respiratory mode will all be similarlyrespiratory mode will all be similarly
affected”.affected”.

Contemporary viewContemporary view
 2 opposing principles, leaving large gray area2 opposing principles, leaving large gray area
between them:between them:
1.1. Total nasal obstruction likely to alter pattern ofTotal nasal obstruction likely to alter pattern of
growth and lead to malocclusion. – Highgrowth and lead to malocclusion. – High
percentage of oral respiratory is over representedpercentage of oral respiratory is over represented
in long-face population.in long-face population.
2.2. Majority of individuals with long-face deformityMajority of individuals with long-face deformity
have no evidence of nasal obstruction becausehave no evidence of nasal obstruction because
some other etiological factor as principal cause.some other etiological factor as principal cause.

Tongue-thrust as etiologic factorTongue-thrust as etiologic factor
 The term tongue-thrust is aThe term tongue-thrust is a
misnomer, since it implies thatmisnomer, since it implies that
the tongue is forcefully thrustthe tongue is forcefully thrust
forward.forward.
 Laboratory studies indicateLaboratory studies indicate
that individuals who place thethat individuals who place the
tongue tip forward when theytongue tip forward when they
swallow do not have moreswallow do not have more
tongue force against teeth thantongue force against teeth than
those who keep tongue tipthose who keep tongue tip
back- in fact, tongue force mayback- in fact, tongue force may
be lower.be lower. – Profitt (1972)www.indiandentalacademy.comwww.indiandentalacademy.com

 Tempting to blame tongue-thrust as a cause forTempting to blame tongue-thrust as a cause for
open bite, since these individuals keep theiropen bite, since these individuals keep their
tongue between the anterior teeth when theytongue between the anterior teeth when they
swallow.swallow.
 The mature/ adult swallow pattern appears inThe mature/ adult swallow pattern appears in
some normal children as early as age 3, but notsome normal children as early as age 3, but not
present in majority until about age 6 & is neverpresent in majority until about age 6 & is never
achieved in 10-15% of a typical populationachieved in 10-15% of a typical population

 Some times children & adults who placeSome times children & adults who place
their tongue between anterior teeth aretheir tongue between anterior teeth are
spoken of as having a retained infantilespoken of as having a retained infantile
swallow- this is clearly incorrect, sinceswallow- this is clearly incorrect, since
only brain damaged children retain a trulyonly brain damaged children retain a truly
infantile swallow in which posterior part ofinfantile swallow in which posterior part of
the tongue has little or no role. (Williamthe tongue has little or no role. (William
Profitt)Profitt)

 Equilibrium theoryEquilibrium theory: Light but sustained: Light but sustained
pressure by tongue against the teethpressure by tongue against the teeth
would be expected to have significantwould be expected to have significant
effect. Tongue-trust swallowing simply haseffect. Tongue-trust swallowing simply has
too short a duration to have an impact ontoo short a duration to have an impact on
tooth position.tooth position.

 Tongue pressure against the teeth duringTongue pressure against the teeth during
a typical swallow is < 1 seconds. A typicala typical swallow is < 1 seconds. A typical
individual swallows about 800 times in aindividual swallows about 800 times in a
day, while awake, but has only a fewday, while awake, but has only a few
swallows / hour while asleep. Hence –swallows / hour while asleep. Hence –
total/ day is < 1000 times, & thus 1000total/ day is < 1000 times, & thus 1000
seconds of pressure has little/no effect.seconds of pressure has little/no effect.

Current view point:Current view point:
Tongue –thrust is primarily seen in 2Tongue –thrust is primarily seen in 2
circumstances:circumstances:
 In young children with normal occlusion –In young children with normal occlusion –
transitional stage in normal physiologictransitional stage in normal physiologic
maturation.maturation.
 In individuals of any age with displacedIn individuals of any age with displaced
anterior teeth – adaptive tongue thrustanterior teeth – adaptive tongue thrust

Current view point:Current view point:
 HoweverHowever tongue posturetongue posture is more important.is more important.
 Light pressure for more durationLight pressure for more duration  change inchange in
tooth position.tooth position.

THIRD MOLARS – A DILEMMA! ORTHIRD MOLARS – A DILEMMA! OR
IS IT?IS IT?
 Third molars are usually considered asThird molars are usually considered as
Vestigial organs which may be reserves forVestigial organs which may be reserves for
mutilated dentition.mutilated dentition.
 The role that mandibular third molars play inThe role that mandibular third molars play in
lower anterior crowding has provoked muchlower anterior crowding has provoked much
speculation in the dental literature.speculation in the dental literature.

 In a survey of more than 600In a survey of more than 600
orthodontists and 700 oral surgeons,orthodontists and 700 oral surgeons,
Laskin found, that 65% were of theLaskin found, that 65% were of the
opinion that third molars sometimesopinion that third molars sometimes
produce crowding of the mandibularproduce crowding of the mandibular
anterior teeth.anterior teeth.
 As a result of such opinions, theAs a result of such opinions, the
removal versus the preservation of thirdremoval versus the preservation of third
molars became the subject ofmolars became the subject of
contention in dental circles.contention in dental circles.

The differing viewsThe differing views
 Third molars should be removed even on aThird molars should be removed even on a
prophylactic basis, because they areprophylactic basis, because they are
frequently associated with future orthodonticfrequently associated with future orthodontic
and periodontal complications as well asand periodontal complications as well as
other pathologic conditions.other pathologic conditions.
 There is no scientific evidence of a causeThere is no scientific evidence of a cause
and effect relationship between theand effect relationship between the
presence of third molars and orthodonticpresence of third molars and orthodontic
and periodontal problems.and periodontal problems.

““Pressure from behindPressure from behind” theory” theory::
 The late lower arch crowding is causedThe late lower arch crowding is caused
by pressure from the back of the arch.by pressure from the back of the arch.
But whether this pressure results from:But whether this pressure results from:
1. Developing 3rd molar.1. Developing 3rd molar.
2. Physiologic mesial movement / drift.2. Physiologic mesial movement / drift.
3. Anterior component of force derived3. Anterior component of force derived
from forces of occlusion on mesiallyfrom forces of occlusion on mesially
inclined teeth.inclined teeth.
Is not sureIs not sure

Relationship between 3rd molars and incisorRelationship between 3rd molars and incisor
crowdingcrowding
 Bishara et al (1989 and 1996) reviewedBishara et al (1989 and 1996) reviewed
changes in Lower incisor that occur with timechanges in Lower incisor that occur with time
inin untreateduntreated populations between 12 and 25populations between 12 and 25
years and again at 45 yearsyears and again at 45 years
Increase in tooth size arch length discrepancyIncrease in tooth size arch length discrepancy
with age – consistent decrease in arch length.with age – consistent decrease in arch length.
Average changes 2.7mm in males; 3.5mm inAverage changes 2.7mm in males; 3.5mm in
females. These changes were attributed to afemales. These changes were attributed to a
consistent decrease in arch length thatconsistent decrease in arch length that
occurred with age.occurred with age.

 Fastlicht (1970)Fastlicht (1970) found that in orthodonticallyfound that in orthodontically
treated subjects- 11% had 3rd molars, buttreated subjects- 11% had 3rd molars, but
86% had crowding.86% had crowding.
 Little et al (1981)Little et al (1981) observed that 90% ofobserved that 90% of
extraction cases that were well treatedextraction cases that were well treated
orthodontically ended up with an unacceptableorthodontically ended up with an unacceptable
lower incisor crowding.lower incisor crowding.
Orthodontic treatment patients

 These long term studies indicated that theThese long term studies indicated that the
incidence as well as the severity ofincidence as well as the severity of
mandibular incisor crowding increasedmandibular incisor crowding increased
during adolescents and adulthood in bothduring adolescents and adulthood in both
the normal untreated individuals as well asthe normal untreated individuals as well as
orthodontic treated patients, after allorthodontic treated patients, after all
retention is discontinued.retention is discontinued.

Studies relating 3rd molar to crowding ofStudies relating 3rd molar to crowding of
dentition:dentition:
 Bergstrom and Jensen (1961)Bergstrom and Jensen (1961)
Cross-sectional study examined 30 dental studentsCross-sectional study examined 30 dental students
of whom had unilateral agenesis of upper 3rdof whom had unilateral agenesis of upper 3rd
molar and 27 had agenesis of one lower 3rd molar.molar and 27 had agenesis of one lower 3rd molar.
 More crowding in the quadrant with 3rd molarMore crowding in the quadrant with 3rd molar
present than in the quadrant with the third molarpresent than in the quadrant with the third molar
missing.missing.
 Mesial displacement of lateral dental segmentsMesial displacement of lateral dental segments
on the side with 3rd molar present in theon the side with 3rd molar present in the
mandibular arch not in the maxillary arch.mandibular arch not in the maxillary arch.
 The unilateral presence of a third molar did notThe unilateral presence of a third molar did not
have an effect on the midline.have an effect on the midline.

Lindquist and Thilander (1982)Lindquist and Thilander (1982)
 Extracted third molar unilaterally in 52Extracted third molar unilaterally in 52
patients and found more stable spacepatients and found more stable space
conditions (less increase in crowding) onconditions (less increase in crowding) on
the extraction side compared with thethe extraction side compared with the
control side in 70% of cases.control side in 70% of cases.

Studies indicating lack ofStudies indicating lack of
correlation betweencorrelation between
mandibular 3rd molar andmandibular 3rd molar and
post retention crowdingpost retention crowding

Retrospective studiesRetrospective studies
 Kaplan (1974) :Kaplan (1974) :..
The sample consisted of 75 orthodonticallyThe sample consisted of 75 orthodontically
treated patients on whom pretreatment, posttreated patients on whom pretreatment, post
treatment and 10 years post treatment studytreatment and 10 years post treatment study
models and lateral cephalograms were obtained.models and lateral cephalograms were obtained.
-Mandibular third molars and post retention crowding Kaplan R.
AJO DO 1974

 Presence of 3rd molar does not produce aPresence of 3rd molar does not produce a
greater degree of lower anterior crowdinggreater degree of lower anterior crowding
or rotational relapse after cessation ofor rotational relapse after cessation of
retention.retention.
RESULTSRESULTS

Ades et al (1990)Ades et al (1990)
 In a cephalometric study on a similar sampleIn a cephalometric study on a similar sample
found :found :
No significant differences in mandibularNo significant differences in mandibular
growth patterns between various 3rd molargrowth patterns between various 3rd molar
groups – erupted, impacted or agenesis.groups – erupted, impacted or agenesis.
Majority of cases have incisal crowding, but noMajority of cases have incisal crowding, but no
correlation with 3rd molars.correlation with 3rd molars.

 Although the mandibular third molarAlthough the mandibular third molar
probably does exert an insignificant forceprobably does exert an insignificant force
on the dental arch during its eruption, anon the dental arch during its eruption, an
objective review of the existing informationobjective review of the existing information
regarding this topic must conclude that theregarding this topic must conclude that the
third molars do not significantly influencethird molars do not significantly influence
the lower anterior crowding.the lower anterior crowding.
Current view point

EXTRACTIONEXTRACTION
vs.vs.
NON-EXTRACTIONNON-EXTRACTION
The only life and death
situation in orthodontics
is whether to EXTRACT or NOT

EXTRACT or NOT?????

““To extract or not to extract” wasTo extract or not to extract” was
one of the early debates thatone of the early debates that
clouded orthodontic world everclouded orthodontic world ever
since its beginning.since its beginning.

2 main reasons for extraction:2 main reasons for extraction:
 Provide space to align remaining teeth inProvide space to align remaining teeth in
crowding.crowding.
 Allow teeth to move for camouflagingAllow teeth to move for camouflaging
skeletal malocclusionskeletal malocclusion

Late 1800Late 1800
 Late 1800 saw a casual
attitude towards extraction

Angle proposed 2 keyAngle proposed 2 key
concepts:concepts:
 Skeletal growthSkeletal growth 
Influenced readily byInfluenced readily by
external forces.external forces.
 Proper function of dentitionProper function of dentition
would be the key forwould be the key for
maintaining teeth in theirmaintaining teeth in their
correct position.correct position.
Early 1920’s
For him “relapse” meant – adequate occlusion not reached.www.indiandentalacademy.comwww.indiandentalacademy.com

““If correct occlusion is producedIf correct occlusion is produced
then result is stable, if result is notthen result is stable, if result is not
stable it was the fault ofstable it was the fault of
orthodontist and not the theory”.orthodontist and not the theory”.

Angle’s proposal and BeliefsAngle’s proposal and Beliefs
 Ideal facial esthetics would resultIdeal facial esthetics would result
when the teeth are placed in idealwhen the teeth are placed in ideal
occlusion.occlusion.
 He believed this can be achievedHe believed this can be achieved
when the dental arches arewhen the dental arches are
expanded so that all the teeth wereexpanded so that all the teeth were
in ideal occlusion.in ideal occlusion.

Calvin CaseCalvin Case
 Argued thatArgued that
although the archesalthough the arches
could always becould always be
expanded so thatexpanded so that
the teeth could bethe teeth could be
placed in alignment,placed in alignment,
neither esthetics norneither esthetics nor
stability would bestability would be
satisfactory in thesatisfactory in the
long term for manylong term for many
patientspatients

Dewey vs. CaseDewey vs. Case
 The controversy culminated in a widelyThe controversy culminated in a widely
publicized debate between Angle’spublicized debate between Angle’s
student Dewey and Case in the dentalstudent Dewey and Case in the dental
literature of 1920’s.literature of 1920’s.
- The Extraction debate of 1911 by case, Dewey and Cryer.
Discussion of case: The question of e traction in
orthodontia. AJO 50: 751,1964www.indiandentalacademy.comwww.indiandentalacademy.com

 Angle followers wonAngle followers won : Extraction: Extraction
disappeared between World War I & II.disappeared between World War I & II.
 Even in South America, whereEven in South America, where
removable (Crozat) or twin wireremovable (Crozat) or twin wire
appliances were usedappliances were used  accepted non –accepted non –
extraction and its philosophy underextraction and its philosophy under
pinning.pinning.

From 1930’s – 1970’sFrom 1930’s – 1970’s
 Charles TweedCharles Tweed
re-treated the relapse casesre-treated the relapse cases
with extractionwith extraction; previously; previously
treated with non-extractiontreated with non-extraction
methodology, & foundmethodology, & found
occlusion to be much moreocclusion to be much more
stable.stable.
 He supported his theory byHe supported his theory by
CephalometricsCephalometrics

Late 1940’sLate 1940’s
 Extraction reintroducedExtraction reintroduced
widelywidely
 Raymond BeggRaymond Begg
popularized “Begg”popularized “Begg”
appliance for extractionappliance for extraction
treatment.treatment.
 This was furtherThis was further
strengthened by Prof.strengthened by Prof.
Stockard’s experimentsStockard’s experiments
which showed thatwhich showed that
malocclusion could bemalocclusion could be
inherited – doginherited – dog
experimentexperiment

So why the total change inSo why the total change in
philosophy?philosophy?
 Instability of non extraction results due toInstability of non extraction results due to
Arch length collapse in particularlyArch length collapse in particularly
1. Lower anterior crowding1. Lower anterior crowding
2. Reversion to original class II2. Reversion to original class II
malocclusions and procumbencies.malocclusions and procumbencies.

Between 1970-1990’sBetween 1970-1990’s::
 Saw the revival of non-extractionSaw the revival of non-extraction
philosophyphilosophy..
 Premolar extraction does not guarantee stability ofPremolar extraction does not guarantee stability of
tooth alignment.tooth alignment.
Little, Wallen and Riedel – 1981 AJO.Little, Wallen and Riedel – 1981 AJO.
MC Reynolds and Little – 1991 AngleMC Reynolds and Little – 1991 Angle
OrthodOrthod
 Lower anterior crowding recurred post retentionLower anterior crowding recurred post retention
 Deep bites recurred more readily in all 4 extractionDeep bites recurred more readily in all 4 extraction
casescases

Argument resurfacesArgument resurfaces
““If result not stable either way, whyIf result not stable either way, why
sacrifice teeth at all”.sacrifice teeth at all”.
vs.vs.
““If extraction cases are unstable,If extraction cases are unstable,
non-extraction would be worse”non-extraction would be worse”

 Changing views of estheticsChanging views of esthetics : Fuller: Fuller
profile than orthodontic profileprofile than orthodontic profile
 Change from banding to bonding andChange from banding to bonding and
introduction of functional appliances.introduction of functional appliances.

 The ill-famous litigation – Witzig and SpahlThe ill-famous litigation – Witzig and Spahl
(1980)(1980)
Premolar extraction causes distalization ofPremolar extraction causes distalization of
mandible posteriorly, displacement ofmandible posteriorly, displacement of
condyle resulted in perforation of articularcondyle resulted in perforation of articular
discdisc  TMD.TMD.

What happened? Why this shift back to anWhat happened? Why this shift back to an
approach to treatment which was discardedapproach to treatment which was discarded
50 years ago?50 years ago?

 Management of Non extraction treatmentManagement of Non extraction treatment
has improvedhas improved
 1. Issue of growth and our ability to1. Issue of growth and our ability to
 influence it.influence it.
 2. Reduction of caries maintaining2. Reduction of caries maintaining
 arch length.arch length.
 (Mixed dentition treatment)(Mixed dentition treatment)
 3. Reduced camouflage treatment3. Reduced camouflage treatment

Treatment modalities convertingTreatment modalities converting
borderline cases into non –extractionborderline cases into non –extraction
cases:cases:
Early interventionEarly intervention::
 Use of ‘E’ space.Use of ‘E’ space.
 Proximal stripping of primary teeth.Proximal stripping of primary teeth.
 Space regainer with space maintainers.Space regainer with space maintainers.
 Arch expansion.Arch expansion.
 Use of functional appliances.Use of functional appliances.
 Molar distalization.Molar distalization.
 Bonded attachments rather than banded ones.Bonded attachments rather than banded ones.

Treatment modalities convertingTreatment modalities converting
borderline cases into non - extractionborderline cases into non - extraction
cases:cases:
 Adult:Adult:
 Molar distalization.Molar distalization.
 Inter-proximal reduction.Inter-proximal reduction.
 Arch expansion.Arch expansion.
 Surgery for skeletal discrepancies.Surgery for skeletal discrepancies.

Expansion vs ExtractionExpansion vs Extraction
 Acceptable range ofAcceptable range of
protrusion in biologic limitsprotrusion in biologic limits
– expand.– expand.
 Control space closure byControl space closure by
combination of retractioncombination of retraction
(anteriors) and protraction(anteriors) and protraction
(posteriors) – extract.(posteriors) – extract.

Importance of soft tissueImportance of soft tissue
 Lip separation – increases with toothLip separation – increases with tooth
prominence.prominence.
 Thick, full lips – can afford prominent incisors.Thick, full lips – can afford prominent incisors.
 Cephalometric readings can serve asCephalometric readings can serve as
guidelines.guidelines.
 Size of nose and chin.Size of nose and chin.
 Lip strain i.e. lack of well defined labiomentalLip strain i.e. lack of well defined labiomental
sulcus.sulcus.

Beauty lies in the eyes
of the beholder and
in the face of the beheld
But who is the better
judge of the beauty?

Saint Louis university,Saint Louis university,
 63 Border line Extraction and Non63 Border line Extraction and Non
extraction patients selected byextraction patients selected by
discriminate analysisdiscriminate analysis
 Patients evaluated own pre and postPatients evaluated own pre and post
treatment profile photographstreatment profile photographs
Paquette etal 1991, Johnson etal 1994

 50% of Non - Extraction patients thought50% of Non - Extraction patients thought
orthodontic treatment improved their facialorthodontic treatment improved their facial
profile.profile.
 58% of Extraction patients also thought58% of Extraction patients also thought
that it improved the facial profile.that it improved the facial profile.
Saint Louis universitySaint Louis university

 63 Border line Extraction and Non63 Border line Extraction and Non
extraction patients selected byextraction patients selected by
discriminate analysisdiscriminate analysis
 Patients evaluated own pre and postPatients evaluated own pre and post
frontal photographs 14 years postfrontal photographs 14 years post
treatmenttreatment
Paquette etal 1991, Johnson etal 1994

 57% of Non - Extraction patients thought57% of Non - Extraction patients thought
orthodontic treatment improved Frontalorthodontic treatment improved Frontal
Facial appearanceFacial appearance
 69% of Extraction patients thought the69% of Extraction patients thought the
samesame

Johnson, AO 1993Johnson, AO 1993
Mean start, finish and recall facial Polygons for the extreme
extraction and non extraction samples. At recall, it was the non
extraction subjects
Who tended to have the “flatter” profile
ExtractionExtraction Non extractionNon extraction

 Witzig and Spahl 1987 and Dierkes 1987Witzig and Spahl 1987 and Dierkes 1987
have askedhave asked
““What are the spaces at the corners of smileWhat are the spaces at the corners of smile
from extraction treatment?”from extraction treatment?”

Washington universityWashington university
 Sample of 60 Extraction and NonSample of 60 Extraction and Non
extraction patientsextraction patients
 Panel of 10 lay personsPanel of 10 lay persons
 Evaluation of post treatmentEvaluation of post treatment smilesmile
photographsphotographs
- Johnson and smith 1990

Washington universityWashington university
 No predictable relationship betweenNo predictable relationship between
extraction of premolars and Esthetics ofextraction of premolars and Esthetics of
smilesmile
- Johnson and smith 1990

 If the inter canine width or arch form isIf the inter canine width or arch form is
maintained during treatment, whethermaintained during treatment, whether
extraction or non extraction, the width ofextraction or non extraction, the width of
the smile would be the same postthe smile would be the same post
treatmenttreatment

The effects of buccal corridor spaces and arch form onThe effects of buccal corridor spaces and arch form on
smile estheticssmile esthetics
Roden-Johson D., Gallerano R, English AJO 2005Roden-Johson D., Gallerano R, English AJO 2005
• 60 Dentists, orthodontists, and lay persons
evaluated photos of patients with buccal
corridor spaces and those without
• No difference in smile scores related to
Buccal corridor Spaces
• Lay person have no preference for arch form
• Dentists & Orthodontists like broader arch
forms

 The claim that theThe claim that the
Negative spaces inNegative spaces in
the Buccal corridorthe Buccal corridor
are a routine resultare a routine result
of extractionof extraction
treatment appearstreatment appears
to be false.to be false.

HOW DO YOU DECIDE WHEN TOHOW DO YOU DECIDE WHEN TO
EXTRACT ?????????????????????EXTRACT ?????????????????????

Contemporary ExtractionContemporary Extraction
Guidelines:Guidelines:
For Class I crowding / protrusionFor Class I crowding / protrusion::
 Arch length discrepancy < 4mm with no verticalArch length discrepancy < 4mm with no vertical
discrepancy:discrepancy: non-extractionnon-extraction..
 Arch length discrepancy = 5-9mmArch length discrepancy = 5-9mm
Non-extractionNon-extraction : Transverse expansion of: Transverse expansion of
premolar segment.premolar segment.
ExtractionExtraction : Any pattern of extraction: Any pattern of extraction
depending on hard and soft tissues.depending on hard and soft tissues.
 Arch length discrepancy > 10mm :Arch length discrepancy > 10mm :ExtractionExtraction

Lower lip to E- planeLower lip to E- plane
(Caucasians(Caucasians))
Bowman and Johnston AJO DO 2000www.indiandentalacademy.comwww.indiandentalacademy.com

 We find that we have completed the circleWe find that we have completed the circle
and rather than anterior crowding beingand rather than anterior crowding being
the principal reason for extractionthe principal reason for extraction
treatment, facial cosmetics should assumetreatment, facial cosmetics should assume
the major diagnostic role in border linethe major diagnostic role in border line
cases.cases.

EARLYEARLY
VSVS
LATELATE
TREATMENTTREATMENT

 The optimal timing of treatment of childrenThe optimal timing of treatment of children
with malocclusion remains controversial.with malocclusion remains controversial.
 Determining the relative merits ofDetermining the relative merits of
alternative treatments is complex, not onlyalternative treatments is complex, not only
because of variability in initial conditionsbecause of variability in initial conditions
and treatment response, also because ofand treatment response, also because of
differences between orthodontists indifferences between orthodontists in
treatment beliefs, goals techniques andtreatment beliefs, goals techniques and
even skillseven skills..

Early treatmentEarly treatment
 Treatment started either in primary orTreatment started either in primary or
mixed dentition that is performed tomixed dentition that is performed to
enhance the dental and skeletalenhance the dental and skeletal
development before the eruption of thedevelopment before the eruption of the
permanent dentition.permanent dentition.

Goals and benefits of phase IGoals and benefits of phase I
treatmenttreatment
1. Superior facial esthetics1. Superior facial esthetics
2. Greater ability to modify the growth process2. Greater ability to modify the growth process
3. Fewer extractions3. Fewer extractions
4. Reduction in the duration and difficulty of subsequent therapy4. Reduction in the duration and difficulty of subsequent therapy
5. Consistent and predictable elimination of phase II treatment5. Consistent and predictable elimination of phase II treatment
6. Improvement in patients self concept6. Improvement in patients self concept
7. Reduction in the fracture potential of protruding maxillary7. Reduction in the fracture potential of protruding maxillary
incisorsincisors
8. Greater patient compliance8. Greater patient compliance
9. Eliminate, if not reduce the need for future jaw surgery9. Eliminate, if not reduce the need for future jaw surgery
10.Greater stability10.Greater stability www.indiandentalacademy.comwww.indiandentalacademy.com

Iatrogenic damages of earlyIatrogenic damages of early
treatmenttreatment
1. Longer overall treatment time1. Longer overall treatment time
2. Loss of compliance2. Loss of compliance
3. Greater risk due to prolonged treatment such as3. Greater risk due to prolonged treatment such as
root resorption, white spot lesion, bone lossroot resorption, white spot lesion, bone loss
cariescaries
4. Increased cost4. Increased cost
5. Dilacerations of roots5. Dilacerations of roots
6. Impaction of maxillary canines by premature6. Impaction of maxillary canines by premature
Uprighting of the roots of lateral incisorsUprighting of the roots of lateral incisors
7. Impaction of maxillary second molars7. Impaction of maxillary second molars

The procedures inThe procedures in
phase I treatment arephase I treatment are
1. Growth modification1. Growth modification
a. Headgearsa. Headgears
b. Functional appliancesb. Functional appliances
c. Face maskc. Face mask
d. Chin capd. Chin cap
2. Arch length discrepancy2. Arch length discrepancy
a. Serial extractiona. Serial extraction
b. Arch expansionb. Arch expansion
c. Preservation of arch lengthc. Preservation of arch length
3. Open bite correction3. Open bite correction
4. Correction of tooth eruption disturbances4. Correction of tooth eruption disturbances

Melsen (AJO-2003)Melsen (AJO-2003)
 She did a long term study on intermaxillaryShe did a long term study on intermaxillary
molar displacement. The first time in themolar displacement. The first time in the
year 1978 and then again 7 years lateryear 1978 and then again 7 years later
with patients treated with the Kloehnwith patients treated with the Kloehn
headgear along with cervical traction.headgear along with cervical traction.
 A strong tendency of the molars to returnA strong tendency of the molars to return
to the class II relationship wasto the class II relationship was
demonstrated.demonstrated.

Melsen (AJO-2003)Melsen (AJO-2003)
 No evidence that a Class I relationship obtainedNo evidence that a Class I relationship obtained
by extraoral traction was more stable than thatby extraoral traction was more stable than that
obtained by functional or intermaxillaryobtained by functional or intermaxillary
appliances.appliances.
 It was noted, however, that the variation in theIt was noted, however, that the variation in the
vertical development was related more to eachvertical development was related more to each
patient’s growth pattern than to the force systempatient’s growth pattern than to the force system
applied.applied.
 After cessation of the headgear, intramaxillaryAfter cessation of the headgear, intramaxillary
displacement of the molars was noted, and thedisplacement of the molars was noted, and the
total displacement of the molars did not differtotal displacement of the molars did not differ
from that of the untreated group.from that of the untreated group.www.indiandentalacademy.comwww.indiandentalacademy.com

Functional appliancesFunctional appliances
 For 30 years, investigators have notedFor 30 years, investigators have noted
facial skeletal changes in monkeys as afacial skeletal changes in monkeys as a
result of altered oral function.result of altered oral function.
 The potential for changes both as a resultThe potential for changes both as a result
of increased mandibular length and alsoof increased mandibular length and also
effective mandibular position by means ofeffective mandibular position by means of
temporomandibular joint remodeling wastemporomandibular joint remodeling was
proposed.proposed.

University of North CarolinaUniversity of North Carolina
(AJODO 1997)(AJODO 1997)
PHASE I Randomized
Observation Functional Appliances Headgear
End of Phase I in 15
months
Retention Phase for 1 year
Assigned to four different
orthodontists for phase II

 It was a prospective long term study.It was a prospective long term study.
 It had an almost ideal research design.It had an almost ideal research design.
 Conducted by Drs. Camilla Tulloch andConducted by Drs. Camilla Tulloch and
William ProfittWilliam Profitt
 All subjects were children with overjet ofAll subjects were children with overjet of
7mm7mm
(AJODO 1997)(AJODO 1997)

University of North Carolina(1997-University of North Carolina(1997-
2004) Results2004) Results
 There was no difference between theThere was no difference between the
groups with regard to ANB angle either atgroups with regard to ANB angle either at
the start or after phase II of treatment.the start or after phase II of treatment.
 No difference in the quality of dentalNo difference in the quality of dental
occlusion between the children who hadocclusion between the children who had
early treatment and those who did not.early treatment and those who did not.
 There was approximately the sameThere was approximately the same
distribution of success and failure with anddistribution of success and failure with and
without early treatment.without early treatment.

(AJODO 1997) Results(AJODO 1997) Results
 Early treatment did not reduce the numberEarly treatment did not reduce the number
of children needing extraction of premolarsof children needing extraction of premolars
or other teeth during phase II of treatment.or other teeth during phase II of treatment.
 Early treatment did not reduce theEarly treatment did not reduce the
eventual need for orthognathic surgery.eventual need for orthognathic surgery.
 There was little influence on the timeThere was little influence on the time
duration that both groups spent wearingduration that both groups spent wearing
fixed appliances.fixed appliances.

(AJODO 1997) Results(AJODO 1997) Results
 Early treatment did reduce severity ofEarly treatment did reduce severity of
class II malocclusion.class II malocclusion.
 Overjet did decrease in the treated groupsOverjet did decrease in the treated groups
whether the appliance was a headgearwhether the appliance was a headgear
restricting the maxilla or a functional onerestricting the maxilla or a functional one
positioning the mandible forward.positioning the mandible forward.
 Still doubt whether early treatment is betterStill doubt whether early treatment is better
or not as long as treatment is provided ator not as long as treatment is provided at
some point in timesome point in time..

Studies on Arch length discrepancyStudies on Arch length discrepancy
(Little AJO 2002).(Little AJO 2002).
 Without treatment a short arch length willWithout treatment a short arch length will
only get worse.only get worse.
 Cases that underwent expansion showedCases that underwent expansion showed
the poorest long-term resultsthe poorest long-term results
 Serial extraction followed by routineSerial extraction followed by routine
treatment yields no greater long-termtreatment yields no greater long-term
improvement over premolar extraction inimprovement over premolar extraction in
the full dentition.the full dentition.

TWO PHASE TREATMENT ORTWO PHASE TREATMENT OR
NOT????????????NOT????????????

 There is very little evidence in the literature toThere is very little evidence in the literature to
suggest the two phase treatment cansuggest the two phase treatment can
significantly modify growth or eliminate the needsignificantly modify growth or eliminate the need
for protracted phase two treatment nor can it befor protracted phase two treatment nor can it be
justified to result is fewer extractions orjustified to result is fewer extractions or
avoidance of orthognathic surgery.avoidance of orthognathic surgery.
 Early phase one treatment is beneficial inEarly phase one treatment is beneficial in
reducing the incidence of incisors trauma andreducing the incidence of incisors trauma and
may be useful in correction of eruptionmay be useful in correction of eruption
disturbances.disturbances.

TO BE CONTINUEDTO BE CONTINUED
……………..……………..

Orthopedics in
Orthodontics fiction or
reality?

 DuterlooDuterloo defines orthopedic effect indefines orthopedic effect in
orthodontics as a change in the position oforthodontics as a change in the position of
bones in the skull in relation to each otherbones in the skull in relation to each other
induced by therapyinduced by therapy
 According toAccording to IsaacsonIsaacson, orthopedic appliances, orthopedic appliances
provide a new muscular and functionalprovide a new muscular and functional
environment for the facial bones thatenvironment for the facial bones that
encourages growth changes of either theencourages growth changes of either the
mandible or the maxilla.mandible or the maxilla.

Class III Orthopedic changesClass III Orthopedic changes
Stimulation of maxillary growth in allStimulation of maxillary growth in all
cases, inhibition of mandibularcases, inhibition of mandibular
growth as a result of class IIIgrowth as a result of class III
therapy was reported in 67% of thetherapy was reported in 67% of the
studiesstudies
Orthopedics in orthodontics: Fiction or reality. A reviewOrthopedics in orthodontics: Fiction or reality. A review
of the literature—Part II AJO-DO 1996 Decof the literature—Part II AJO-DO 1996 Dec

Chin Cup therapyChin Cup therapy
 Few studies report on long-term effects ofFew studies report on long-term effects of
chin cup therapy. The findings ofchin cup therapy. The findings of
Sugawara et al. indicate that chin cupSugawara et al. indicate that chin cup
therapy did not necessarily guaranteetherapy did not necessarily guarantee
positive correction of the skeletal profilepositive correction of the skeletal profile
after complete growth.after complete growth.
Sugawara J, Asano T, Endo N, Mitani H. Long-termSugawara J, Asano T, Endo N, Mitani H. Long-term
effects of chin cap therapy on skeletal profile ineffects of chin cap therapy on skeletal profile in
mandibular prognathism. Am JODO 1990mandibular prognathism. Am JODO 1990

Normal Maxillary growthNormal Maxillary growth
 According to Bolton studies the yearlyAccording to Bolton studies the yearly
increase in interjugular width isincrease in interjugular width is
approximately 1mm, which coincidesapproximately 1mm, which coincides
with Rocky Mountain Standardswith Rocky Mountain Standards

Normal Maxillary growthNormal Maxillary growth
 Savara claims that the maxillary width,Savara claims that the maxillary width,
expressed as distance between bothexpressed as distance between both
pterygomaxillary fissures, increased withpterygomaxillary fissures, increased with
0.18mm between 12 and 16 years,0.18mm between 12 and 16 years,
because of normal growth.because of normal growth.
 Savara BS, Singh U. Norms of size and annual increments of sevenSavara BS, Singh U. Norms of size and annual increments of seven
anatomical measures of maxillae in boys from three to sixteen yearsanatomical measures of maxillae in boys from three to sixteen years
of age. Angle Orthod 1968of age. Angle Orthod 1968

 Therapeutically induced maxillaryTherapeutically induced maxillary
expansion is larger than the increaseexpansion is larger than the increase
expected because of normal growth,expected because of normal growth,
within a short observation period.within a short observation period.
 As stated by Sarnäs, the net increaseAs stated by Sarnäs, the net increase
out of retention is only 1.6 mm beingout of retention is only 1.6 mm being
within anticipated normal growth.within anticipated normal growth.
 Sarnäs KV, Björk A, Rune B. Long-term effect ofSarnäs KV, Björk A, Rune B. Long-term effect of
rapid maxillary expansion studied in one patient withrapid maxillary expansion studied in one patient with
the aid of metallic Implants and roentgenthe aid of metallic Implants and roentgen
stereometry. EJO 1992stereometry. EJO 1992

 No scientific evidence exists so far toNo scientific evidence exists so far to
indicate that an orthodontist can induceindicate that an orthodontist can induce
a stable enlargement of maxillary basala stable enlargement of maxillary basal
bone that exceeds normal growth.bone that exceeds normal growth.
Current view pointCurrent view point inin MaxillaryMaxillary
ExpansionExpansion

Bite Opening controversyBite Opening controversy
 Although the sagittal construction biteAlthough the sagittal construction bite
advancement concept generally was acceptedadvancement concept generally was accepted
by clinicians in Europe (it varied from 3 to 6 mm)by clinicians in Europe (it varied from 3 to 6 mm)
depending on the severity of anteroposteriordepending on the severity of anteroposterior
dysplasia and resultant abnormal buccaldysplasia and resultant abnormal buccal
segment interdigitation, the theory pertaining tosegment interdigitation, the theory pertaining to
the amount of vertical opening and its effects onthe amount of vertical opening and its effects on
the muscles produced considerable controversy.the muscles produced considerable controversy.

 Anderson and Haupl’sAnderson and Haupl’s interpretationinterpretation
presupposed freedom for the mandible topresupposed freedom for the mandible to
assume the physiologic rest positionassume the physiologic rest position

 SlagsvoldSlagsvold, later professor of Orthodontia, later professor of Orthodontia
at Oslo, reported that his ownat Oslo, reported that his own
observations did not substantiate thisobservations did not substantiate this
premise completely. Nevertheless hepremise completely. Nevertheless he
concurred that forward posturing shouldconcurred that forward posturing should
not exceed the rest position verticalnot exceed the rest position vertical
opening of 2 – 4 mm.opening of 2 – 4 mm.

 Too wide on opening made complianceToo wide on opening made compliance
more difficult and could produce amore difficult and could produce a
depressing force on the teeth, hardlydepressing force on the teeth, hardly
desirable in deep bite, class IIdesirable in deep bite, class II
malocclusions.malocclusions.
 Grude and Frankel strongly support thisGrude and Frankel strongly support this
construction bite limitconstruction bite limit

 The philosophy ofThe philosophy of Harvold & WoodsideHarvold & Woodside
has been to exceed the free way spacehas been to exceed the free way space
limits, if for no other reasons than to keeplimits, if for no other reasons than to keep
the appliance in place at night duringthe appliance in place at night during
sleep or as to maintain a correctivesleep or as to maintain a corrective
stimulus.stimulus.

Incremental vs one stepIncremental vs one step
advancementadvancement
FrankelFrankel recommends incremental smallrecommends incremental small
advancements of 2 to 3 mm for hisadvancements of 2 to 3 mm for his
appliances rather than the great leap forwardappliances rather than the great leap forward
of 5 to 7mm. Reactivation of optimal tissueof 5 to 7mm. Reactivation of optimal tissue
response as well as enhanced patientresponse as well as enhanced patient
compliance are factors. This conceptcompliance are factors. This concept
encourages daytime wear. The frequency ofencourages daytime wear. The frequency of
deglutition is increased and phasic muscledeglutition is increased and phasic muscle
activity is enhanced.activity is enhanced.
Frankel R: Clinical relevance of step by stepFrankel R: Clinical relevance of step by step
mandibular advancement in the treatment ofmandibular advancement in the treatment of
mandibular retrusion using the Frankelmandibular retrusion using the Frankel
appliance AJO 1996,1989appliance AJO 1996,1989

Sander and SchmuthSander and Schmuth also have studied the effectalso have studied the effect
of large protrusion construction bites withof large protrusion construction bites with
tendency to disocclude the appliance bothtendency to disocclude the appliance both
during the day and at night reducing the desiredduring the day and at night reducing the desired
effect and jiggling selective teeth.effect and jiggling selective teeth.
Milestones in the development and practical application of functionalMilestones in the development and practical application of functional
appliancesappliances
AJO 1984,1983AJO 1984,1983

 Also histological evidence support periodicAlso histological evidence support periodic
incremental advancement because of theincremental advancement because of the
periodically enhanced condylar and fosseperiodically enhanced condylar and fosse
response with each adjustmentresponse with each adjustment
 With single 6 to 7 mm the condylar and fosseWith single 6 to 7 mm the condylar and fosse
growth stimulus is of shorter duration, daytimegrowth stimulus is of shorter duration, daytime
wear becomes more difficult and adverse labialwear becomes more difficult and adverse labial
proclination of mandibular incisors may beproclination of mandibular incisors may be
greater.greater.

Day time vs Night time wearDay time vs Night time wear
 Selmer OlsenSelmer Olsen believedbelieved
that the muscles could notthat the muscles could not
actually be stimulatedactually be stimulated
during sleep. Nature hadduring sleep. Nature had
designed them to rest atdesigned them to rest at
night and swallowingnight and swallowing
occurred only 4 to 8 timesoccurred only 4 to 8 times
any hourany hour
 Komposch and Hackenjos, Sander,
Schmuth, Herren corroborated the finding that
activator does not activate muscles during
sleep. www.indiandentalacademy.comwww.indiandentalacademy.com

 Harvold and Woodside, RickettsHarvold and Woodside, Ricketts
recommend nighttime wear of appliancerecommend nighttime wear of appliance
for maximum effect.for maximum effect.
Day time vs Night time wearDay time vs Night time wear

Effect of head posture during sleepEffect of head posture during sleep
 Mandibular rest position depends on the headMandibular rest position depends on the head
and body posture thereby the restriction ofand body posture thereby the restriction of
muscle movement required to create the desiredmuscle movement required to create the desired
mandibular position change without the activatormandibular position change without the activator
in place varies constantly involving differentin place varies constantly involving different
muscle groups and creating different forcemuscle groups and creating different force
vectors on the activator.vectors on the activator.
 Variation in head posture during sleep alters theVariation in head posture during sleep alters the
magnitude and direction of force.magnitude and direction of force.

 The phase of sleep, intraoral air pressure,The phase of sleep, intraoral air pressure,
dream cycle, state of mind are additionaldream cycle, state of mind are additional
conditioning factors all uncontrolled byconditioning factors all uncontrolled by
clinician.clinician.
 Only the mandibular position and theOnly the mandibular position and the
potential effect on glenoid fossa andpotential effect on glenoid fossa and
controlled.controlled.
Effect of head posture during sleepEffect of head posture during sleep

What happens with the use of functionalWhat happens with the use of functional
appliances?appliances?
 In spite of considerable research and debate theIn spite of considerable research and debate the
precise mode of action of functional applianceprecise mode of action of functional appliance
remains obscure.remains obscure.
 Dentoalveolar changesDentoalveolar changes: Harvold and others: Harvold and others
have stressed the importance of a verticalhave stressed the importance of a vertical
manipulation of the functional occlusal plane inmanipulation of the functional occlusal plane in
achieving class II corrections with removableachieving class II corrections with removable
functional appliances.functional appliances.

Dentoalveolar changesDentoalveolar changes
 Prevention of the eruption of maxillaryPrevention of the eruption of maxillary
buccal segments which is normally inbuccal segments which is normally in
downward and mesial directiondownward and mesial direction
 Removal functional appliance do notRemoval functional appliance do not
distallised the upper dentition unlessdistallised the upper dentition unless
Headgear is used.Headgear is used.

 Midface restrictionMidface restriction
 Effect on Mandibular growth:Effect on Mandibular growth: is again ais again a
controversycontroversy
What happens with the use of functionalWhat happens with the use of functional
appliances?appliances?

Can we grow smaller Mandibles?Can we grow smaller Mandibles?
 Much of the work demonstrating theMuch of the work demonstrating the
ability of functional appliances toability of functional appliances to
stimulate mandibular, growth as basedstimulate mandibular, growth as based
on animal experimentation.on animal experimentation.

Animal studiesAnimal studies
 Cartilage proliferation by increased mitoticCartilage proliferation by increased mitotic
activity in pre-chondroblastic zoneactivity in pre-chondroblastic zone  growthgrowth
increments of condyle.increments of condyle.
Petrovic A, Stutzmann J, Oudet CL.Petrovic A, Stutzmann J, Oudet CL.
 Increase in effective length of mandibleIncrease in effective length of mandible
McNamara Jr. JA, Bryan FA. Long-termMcNamara Jr. JA, Bryan FA. Long-term
mandibular adaptations to protrusivemandibular adaptations to protrusive
function: an experimental study in Macacafunction: an experimental study in Macaca
mulatta. Am J Orthod 1987mulatta. Am J Orthod 1987

 Therapeutic remodeling of glenoid fossaTherapeutic remodeling of glenoid fossa
Woodside DG, Metaxas A., Altuna G. TheWoodside DG, Metaxas A., Altuna G. The
influence of functional appliance therapy oninfluence of functional appliance therapy on
glenoid fossa remodeling. Am J Orthod 1987glenoid fossa remodeling. Am J Orthod 1987
 Catch-up growth after treatment independent ofCatch-up growth after treatment independent of
direction of therapeutic force.direction of therapeutic force.
Elder JR, Tuenge RH. Cephalometric andElder JR, Tuenge RH. Cephalometric and
histologic changes produced by extraoral high-histologic changes produced by extraoral high-
pull traction to the maxilla in Macaca mulatta.pull traction to the maxilla in Macaca mulatta.
Am J Orthod 1974Am J Orthod 1974

 Several investigators showedSeveral investigators showed
dramatic changes in mid-face ofdramatic changes in mid-face of
monkeys after headgear treatment.monkeys after headgear treatment.
Henry HL, CleallHenry HL, Cleall
Joho JPJoho JP
Mel drum RJ.Mel drum RJ.

 The same story holds true for maxillary protractionThe same story holds true for maxillary protraction
studies on monkeys.studies on monkeys.
Kambara T. Dentofacial changes produced by extraoralKambara T. Dentofacial changes produced by extraoral
forward force in the Macaca irus. Am J Orthod 1977forward force in the Macaca irus. Am J Orthod 1977
 Experiments on mandibular retrusion in rats showExperiments on mandibular retrusion in rats show
histological and some macroscopic decrease ofhistological and some macroscopic decrease of
mandibular length.mandibular length.
Charlier et al (1969),Petrovic et al (1975),Janzon and BluherCharlier et al (1969),Petrovic et al (1975),Janzon and Bluher
(1965),Ajano (1986)(1965),Ajano (1986)

 Whether these findings on animal modelsWhether these findings on animal models
are applicable to human beings duringare applicable to human beings during
routine clinical treatment is debatable.routine clinical treatment is debatable.
 Discrepancies between animal and humanDiscrepancies between animal and human
studies are expected since animalstudies are expected since animal
experimentation frequently involves theexperimentation frequently involves the
use of continuous forces.use of continuous forces.
 These types of forces usually areThese types of forces usually are
impractical and often undesirable in mostimpractical and often undesirable in most
clinical situations therefore treatmentclinical situations therefore treatment
results can be expected to be lessresults can be expected to be less
dramatic and more variabledramatic and more variable

inin
Pre AdjustedPre Adjusted
ApplianceAppliance

Torque in BaseTorque in Base
VsVs
Torque in FaceTorque in Face
 By 1988, about 30 % of all AmericanBy 1988, about 30 % of all American
orthodontists were using the straight wireorthodontists were using the straight wire
appliance, another 50% were using Partlyappliance, another 50% were using Partly
programmed edgewise appliancesprogrammed edgewise appliances
 Patent restrictions allowed them toPatent restrictions allowed them to
reproduce no more than four of the eightreproduce no more than four of the eight
vital features that appear in fullyvital features that appear in fully
programmed bracketsprogrammed brackets
( David Webb, “A” company)( David Webb, “A” company)

a. Non programmed bracket without slot or base inclination
b. Partly programmed bracket with 22 deg. Of slot inclination
c. Fully programmed with 22 deg of base inclination

 The Torque In the base allows the slot ofThe Torque In the base allows the slot of
the fully programmed bracket targetthe fully programmed bracket target
correctly on the crown’s mid transversecorrectly on the crown’s mid transverse
planeplane
 Torque in the face causes occluso-Torque in the face causes occluso-
gingival variation in the placement of slotgingival variation in the placement of slot
point over mid transverse planepoint over mid transverse plane

 Hence the Torque in base was anHence the Torque in base was an
important issue with the first and secondimportant issue with the first and second
generation PEA brackets because Levelgeneration PEA brackets because Level
slot line up was not possible with bracketsslot line up was not possible with brackets
designed for Torque in Face.designed for Torque in Face.
 Modern Bracket systems like MBT system,Modern Bracket systems like MBT system,
have been developed using CAD-CAMhave been developed using CAD-CAM
systemsystem

 The computer is firstThe computer is first
able to locate theable to locate the
precise location forprecise location for
the bracket slot,the bracket slot,
relative to in-outrelative to in-out
distance and torquedistance and torque
position for eachposition for each
teeth. Once thisteeth. Once this
position isposition is
established, it canestablished, it can
be build up the in –be build up the in –
fill areas to optimizefill areas to optimize
all requirements ofall requirements of
the bracketsthe brackets

018 vs 022 Slot:018 vs 022 Slot:
 Steiner introduced the 0.457 mm × 0.711 mmSteiner introduced the 0.457 mm × 0.711 mm
(0.018-inch × 0.028-inch) slot for stainless steel(0.018-inch × 0.028-inch) slot for stainless steel
wires in lieu of the 0.559 mm × 0.711 mmwires in lieu of the 0.559 mm × 0.711 mm
(0.022-inch × 0.028-inch) slot for gold alloy(0.022-inch × 0.028-inch) slot for gold alloy
wires.wires.
 Original intention of 022 slot was not meant forOriginal intention of 022 slot was not meant for
sliding mechanics, (as it is ideally suited) but it issliding mechanics, (as it is ideally suited) but it is
for Torque movement control when 22 X 28 goldfor Torque movement control when 22 X 28 gold
wires were used.wires were used.

 With the advent of stainless steel wires,With the advent of stainless steel wires,
edgewise brackets were redesignededgewise brackets were redesigned
from 022 to 018 slot.from 022 to 018 slot.
 022 slot however was superior when022 slot however was superior when
sliding of teeth is necessary by the usesliding of teeth is necessary by the use
of undersized stiffer wires, but is inferiorof undersized stiffer wires, but is inferior
to 018 slot in Effective torqueto 018 slot in Effective torque
expression due to limited springinessexpression due to limited springiness
and range of stiffer wires used in widerand range of stiffer wires used in wider
slot.slot.
018 vs 022 Slot:018 vs 022 Slot:

 Role of Titanium arch wires becameRole of Titanium arch wires became
evident in alignment and torque control inevident in alignment and torque control in
wider 022 slot by the characteristics likewider 022 slot by the characteristics like
higher range and resistance to permanenthigher range and resistance to permanent
deformation.deformation.
 Even undersized stiffer wires are theEven undersized stiffer wires are the
alternate solutionalternate solution
018 vs 022 Slot:018 vs 022 Slot:

In Andrew’s Original System:In Andrew’s Original System:
Concerning the 1st
order information: There
is no antirotation system on any tooth, except
a 10° distal offset on upper molars.
Concerning the 2nd
order information: Teeth
of the buccal segments all present a positive
angulation, meaning that they all have a
mesial crown tip, mostly for the 1st
and 2nd
upper molars.

Concerning the 3Concerning the 3rdrd
order information:order information:
On the upper arch:On the upper arch:
The upper incisor only has a 7The upper incisor only has a 7°° torquetorque
The upper canine has a negative torque ofThe upper canine has a negative torque of
-7,-7,
equal to the torque of the bicuspids.equal to the torque of the bicuspids.
- The torque is slightly greater on molars.- The torque is slightly greater on molars.
In the Lower archIn the Lower arch--
The torque on the buccal segments isThe torque on the buccal segments is
progressive from the canines to the 2progressive from the canines to the 2ndnd
molars.molars.

A torque of 7° on central incisors was soon foundA torque of 7° on central incisors was soon found
to be insufficient, since the play between archto be insufficient, since the play between arch
wire and bracket slot, which wasn’t taken intowire and bracket slot, which wasn’t taken into
account, creates important loss of informationaccount, creates important loss of information
during retraction stages and hence the amountduring retraction stages and hence the amount
torque necessary to compensate for thetorque necessary to compensate for the
unwanted lingual tipping was clearly greater thanunwanted lingual tipping was clearly greater than
7°7°

Andrew’s system soon got theAndrew’s system soon got the
reputation of being an “anchoragereputation of being an “anchorage
burning appliance” - - -burning appliance” - - -
Increased tip in anterior brackets to compensate for
“wagon wheel effect”

In 1974, Ronald Roth:In 1974, Ronald Roth:
Based on anticipation of relapse during and
after treatment came up with his fully
programmed universal appliance. Thus he
systematically included the information for
over correction in all three planes of space.

Concerning the 1st
order information: All
teeth in the buccal segment – anti rotation
system. Upper molars reinforce distal
offset from 10° to 14° and lower molars 4°
anti-rotation
 Concerning the 2nd
order information :
Canine angulation increased to 11° to 13°
Maxillary buccal segment lose their mesial
tip and are in more anchorage situation.

Controversy

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Viewers also liked

Viewers also liked (12)

Similar to Controversy

Similar to Controversy (20)

More from Indian dental academy

More from Indian dental academy (20)

Recently uploaded

Recently uploaded (20)

Controversy

Editor's Notes