EHNIKH OPOONTIKH EIEPHH

/ Interview

YNENTEYH

I NTERVIEW

Professor Bj o
/ rn U. Zachrisson
.
,
.

This interview was given to Dr. Panagiotis

Skoularikis, Member of the Editorial Board of the
Hellenic Orthodontic Review.

2012;15:1-13.

Hell Orthod Rev 2012;15:1-13.

YNTOMO BIOPAIKO HMEIMA

SHORT CURRICULUM VITAE

. Bj o/ rn Zachrisson , 1970
,
. 250
, , , .

Dr. Bj o/ rn Zachrisson is Professor Emeritus at the Department of

Orthodontics, University of Oslo, Norway and since 1970
maintained a private orthodontic practice in Oslo, restricted to
the treatment of adult patients. He has published more than
250 scientific and clinical articles in international journals, and
textbooks in orthodontics, periodontics, traumatology, and
general dentistry, and presented worldwide.

. Zachrisson
. ,
, , ,
Salzmann (1986), Steiner (1990), Friel (1997), Mershon (1998),
Northcroft (1999), Seward (2000), Merrifield (2000) Case (1996),

(Orthodontic Education and Research Foundation, OERF) (1995),
Associated Journals of Europe (1997), Burstone (1999), Kokich/Shapiro
Visiting Scholar (1999), 8th SIDO World (2001), Dewel (2003).
2007 Ketcham
Jarabak .

Dr. Zachrisson has presented numerous keynote lectures and

pre- or post-congress courses at International Orthodontic
Congresses worldwide. He has received many awards and
honors from orthodontic societies in Europe, USA, Asia,
Australia, and Africa, including the Salzmann (1986), Steiner
(1990), Friel (1997), Mershon (1998), Northcroft (1999), Seward
(2000), and Merrifield (2000) Lectures, and the Case (1996), the
OERF (Orthodontic Education and Research Foundation) (1995),
the Associated Journals of Europe (1997), Burstone (1999),
Kokich/Shapiro Visiting Scholar (1999), 8th SIDO World (2001),
and Dewel (2003) Awards. In 2007, he received both the
prestigious Ketcham and Jarabak awards from the American
Association of Orthodontists.

. Zachrisson
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,
Tweed, .
Journal of Clinical
Orthodontics .

Dr. Zachrisson is a Honorary Member of the Orthodontic

Societies of Ireland, Republic of China (Taiwan), South Africa,
Israel, Poland, Serbia and Montenegro, Peru, Czech Republic,
Norway and The International Tweed Foundation, as well as of
the Scandinavian Academy of Esthetic Dentistry and the
Interdisciplinary Dental Society of the Caribbean. He is
Associate Editor of the Journal of Clinical Orthodontics and a
Member of the Editorial Boards of several orthodontic and
dental journals.

. : . Zachrisson, ,

Dr. Skoularikis: Prof. Zachrisson, first of all, I would like

to welcome you to the interview section of the Hellenic

Orthodontic Review. As a member of the Editorial Board

I would like to tell you that it is a great honor to have

such a distinguished guest in our journal, as your scien-

EHNIKH OPOONTIKH EIEPHH 2012 TOMO 15 TEYXO 1 & 2

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HELLENIC ORTHODONTIC REVIEW

Professor Bj o/ rn U. Zachrisson

Dr.

, . , . ,
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tific contribution to our specialty is well known and very

much recognized. Please, let me start this interview with
a general question. What is, according to your opinion,
the future of orthodontics and which are the current
trends in orthodontic research nowadays?

. Zachrisson: ,


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Angle
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twin bite blocks.
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Dr. Zachrisson: In coming years, clinical orthodontics will

have to become oriented more towards generally accepted biological principles and boundaries, and depend less
on mechanical manipulation. At present, there exists various non-extraction expansion treatments that use very
light continuous forces from superelastic wires, and
claiming that such arch expansion will "develop" the
alveolar bony base. Edward Angle also believed that the
environment could be modified by orthodontic treatment, and that orthodontic treatment could regenerate
new alveolar bone, which would make it possible to produce stable occlusions without tooth extractions. However, we know now that it is not the bone, but the functional and resting soft tissue forces that determine final
tooth positions. Bone yields to pressure.
Also, pronounced frontal proclination of mandibular
incisors is a common side effect when using several different bite-jumping devices, including the Herbst appliances and twin bite blocks. Proclination of the mandibular incisors during treatment (except where a habit pattern has held the segment to the lingual) can be expected to lead to lingual collapse and crowding. There is little, if any, clinical research that provides evidence that

HELLENIC ORTHODONTIC REVIEW 2012 VOLUME 15 ISSUE 1 & 2

EHNIKH OPOONTIKH EIEPHH

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EHNIKH OPOONTIKH EIEPHH 2012 TOMO 15 TEYXO 1 & 2

/ Interview

lateral expansion and incisor proclination treatments will

result in long-term stable outcomes. The lack of proof
worries me a great deal (Zachrisson, 2007a), since such
techniques seem to be popular among many young
orthodontists.
However, other trends like those toward more interdisciplinary cooperation between orthodontists and other
dental specialists, as well as orthodontic implant site
development (vertically and horizontally), will presumedly become increasingly important in coming years.
So I believe that we will see an increased emphasis on
biological boundaries for stability of orthodontic treatment results and appreciate more interdisciplinary treatments in both adults and children.
Dr. Skoularikis: Esthetics is a highly discussed topic in
orthodontics and has also been a considerable field of
your research over the years. Taking into consideration
the fact that general esthetic principle can vary according to parameters as fashion, customs, ethnicity etc, can
those principles be in harmony with the standardized
"orthodontic" esthetic rules which most orthodontists
follow?
Dr. Zachrisson: There are two important esthetic principles that are commonly overlooked by many orthodontists at present. Both relate to the display of the dentition during speech and smile. We are treating human
beings, and not only malocclusions. Therefore the way
the dentitions of our patients are exposed during social
interactions is important if we want to produce meaningful optimal esthetics.
There is agreement in esthetic dentistry that an adequate
and age-related display of the maxillary central incisors
with the lips at rest and during conversation is significant. This indicates that for most deep overbites, it is the
lower and not the upper incisors that should be intruded
in order not to make the patients appear older than they
are.
Similarly, every orthodontist should provide a definition
of what he/she considers to be a beautiful and full smile.
In my opinion, the key to a full smile is an adequate display of the maxillary first and second premolars. This
becomes difficult with negative torque in the premolar
brackets, which is common to most prescriptions. I prefer a very slight lingual crown torque for the upper
canines and upright premolars (Figures 1-5). This means
that the lower canines and posterior teeth should also
be uprighted during treatment, since excessive lingual

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HELLENIC ORTHODONTIC REVIEW

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1. - (A,F).
(A). (B). , (C-D). . (F).
Figure 1. Adult female patient with constricted smile and excessive gingiva-to-lip distance on the right side (A,F). Note lingual tilt of all
maxillary and mandibular teeth before treatment (A). Increased lingual root torque was provided in rectangular stainless steel archwires (B).
The maxillary archform was not expanded laterally, but merely rounded off (C-D). Electrosurgery was performed from right second premolar
to left lateral incisor. The very slight lingual crown torque for the canines and the upright premolars make the post-treatment smile appear
full and radiant with symmetric gingival exposure (F).

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torque ,
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torque
( 1-5).

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crown tilt is a common side effect of all fixed-appliance

therapies.
Dr. Skoularikis: Anterior teeth may be missing as one of
a number of possible causes. Given your extensive
involvement in missing anterior teeth cases, what are the
most common orthodontic implications caused by space
closure?
Dr. Zachrisson: There is enough evidence by now that single implant crowns in the anterior maxilla frequently
results in long-term esthetic problems. Several such
problems are listed in Table 1. Since implants are unpredictable and by no means perfect in a life-long perspec-

2. 14 . (A). . , (
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(B).
Figure 2. Unilateral agenesis of the maxillary right lateral incisor in 14-year-old girl. Midline shift towards the agenesis side and deep overbite
(A). The treatment of choice was space closure on the right side and extraction of the upper left first premolar. After treatment, porcelain
veneers were placed on the intruded first premolar (substituting for the canine) and the extruded canine (replacing the missing lateral incisor).
The midline was intentionally slightly overcorrected. The tooth sizes, shapes, and colors are almost identical on the canine substitution side
and the natural left side (B).

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HELLENIC ORTHODONTIC REVIEW

3. (A,B).
(C) (D).
Figure 3. Space closure treatment for adolescent male patient with unilateral agenesis of the maxillary left lateral incisor (A,B). The
orthodontic treatment result (C), and the interdisciplinary treatment result with five porcelain laminate veneers (D).

;
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( 2,3) (Rosa and Zachrisson, 2001; Zachrisson et
al., 2011). ,

tive, other alternatives to replace missing central and/or

lateral incisors, including orthodontic space closure and
autotransplantation of developing premolars may frequently be preferable.
This implies that for almost all cases with congenitally
missing maxillary lateral incisors in young patients, my
preference is space closure, combined with techniques
from esthetic dentistry (Figures 2,3) (Rosa and Zachrisson, 2001; Zachrisson et al., 2011). For missing central
incisors, my first choice would be a premolar transplant
(Fig. 4) or space closure (Fig. 5).
Dr. Skoularikis: Given your experience on the subject, do
you consider that auto-transplantation is a feasible alternative to implant restorations?
Dr. Zachrisson: Autotransplantation of developing premolars is an excellent method to replace missing incisors

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4.
. , (A).
(B). ,
( ) (C).
, (D). .
Figure 4. Autotransplanted mandibular right second premolar to help replacing two neighboring missing maxillary incisors lost in traumatic
accident in young girl. Note mesial drift and excessive lingual crown inclination of maxillary canines and premolars, constricting the smile (A).
The situation after restoration with composite resin build-up on the transplanted premolar (B). During treatment the first premolar (to
substitute the canine) was intruded to level the gingival margins, and the canine used to replace the lateral incisor was extruded and ground
incisally (C). Three porcelain veneers were placed on the "new" canine, lateral incisor and central incisor (D). The upright canines and posterior
teeth broadened the smile significantly.

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EHNIKH OPOONTIKH EIEPHH 2012 TOMO 15 TEYXO 1 & 2

in young patients. Most traumatic injuries resulting in

exarticulation and loss of maxillary incisors occur at 8
10 years of age, and then the transplant is usually the
only viable treatment option (Fig. 4).
Dr. Skoularikis: Are there any specific indications and
clinical measures to enhance the efficiency of autotransplanted teeth? Are there any contra-indications?
Dr. Zachrisson: The surgical technique for autotransplantation of premolars cannot be learned by reading or
watching a video of the operation. Most oral surgeons

 /Interview

HELLENIC ORTHODONTIC REVIEW

5. (A).
. (B)
( ) ( ) , (B). (C)
(D).
Figure 5. Young girl with traumatically lost maxillary right central incisor and mesial drift of the teeth (A). Orthodontic space closure was
chosen with the purpose to move the entire maxillary right quadrant one tooth width mesially. The midline was corrected (B) and gingival
leveling was achieved by intrusion of the first premolar (replacing the canine) and lateral incisor (to replace the central incisor), and extrusion
plus grinding of the canine, which was to substitute for the lateral incisor (B). The orthodontic treatment result (C), and the interdisciplinary
treatment result with five porcelain veneers (D).

8-10
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who over the years have learned the technique from our
experts in Oslo have claimed that they became aware of
a multitude of small tricks that must be learned during a
live demonstration of the operation.
The contraindication for autotransplantation is a premolar with fully formed roots. Whereas the prognosis for a
successful long-term result is better than 90 per cent
when the root is from 1/2 to 3/4 developed, it may be
reduced to around 50 per cent when the root is fully
developed and the apex closed. So we do not transplant
such premolars.
Dr. Skoularikis: During the last years new technologies

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1.

Table 1. Frequent complications registered in follow-up studies of single implant-supported porcelain crowns

Blue-coloring of labial gingiva

( )

Progressive infra-occlusion (even in adults)

(, )

Visible abutment with time (metal, porcelain)

Peri-implantitis, and alveolar bone loss

( )

Dont upright (like natural incisors)

Non-adjustable by orthodontic means

(
)

Interdental recession (particularly distal papilla)

Not easy to make crown entirely natural

(>10-15 )

Few long-term (>10-15 years) observations

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(Maino et al., 2007; Kadioglu et al., 2008)



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EHNIKH OPOONTIKH EIEPHH 2012 TOMO 15 TEYXO 1 & 2

have been used in orthodontics, as, for example, the

miniscrew implants. Many consider these modalities as
an innovation in orthodontics, but very few speak about
their disadvantages or risks in using them. We would like
to have your comments on this.
Dr. Zachrisson: Actually, there seems to be few disadvantages and risks involved with the use of miniscrew
implants. Our original research (Maino et al., 2007;
Kadioglu et al., 2008) demonstrated that root surfaces
that touch miniscrews may show swift repair and almost
complete healing within a few weeks after removal of
the miniscrew implant or the orthodontic force. This
does not mean, of course, that such miniscrew implants
should be used indiscriminately when they are not needed.
Dr. Skoularikis: What is the most usual damage caused
on periodontal tissues during orthodontic treatment and
which are the most common mistakes that orthodontists
do producing iatrogenic harm to teeth and supporting
structures?
Dr. Zachrisson: The most common problem in young
patients may be development of gingival recessions as a
consequence of improper arch expansion. On the other

 /Interview

HELLENIC ORTHODONTIC REVIEW

6. . (C)
.
(A,B). (D).
Figure 6. Individualized retention regimen for complicated adult female patient, in whom the maxillary right first molar and left second
premolar were extracted. The mandibular arch (C) was treated non-extraction associated with marked interproximal stripping. The short
maxillary labial retainers to hold the closed extraction sites (A,B). The bonded retainer from first premolar to first premolar supplemented by
two short labial retainers to assist in holding the positions of the corrected mandibular second premolars (D).

. :


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10

hand, an incisor in protruded, crowded position that is

orthodontically moved into the dental arch is likely to
have an improved situation with return of the marginal
labial gingiva. For adults with pronounced periodontal
tissue breakdown, it may be disastrous to neglect bleeding on probing around molars, and treat the patient
without the necessary oral hygiene instruction and follow-up (Zachrisson, 1996).
Dr. Skoularikis: Long-term post-treatment stability is an
issue of great concern to all orthodontists. Which are the
factors, which may play a role as predictors for long-term
prognosis of possible post-retention changes?
Dr. Zachrisson: The key to the successful practice of

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(Zachrisson, 1996).
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JCO 1997,


(Zachrisson, 1997).
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EHNIKH OPOONTIKH EIEPHH 2012 TOMO 15 TEYXO 1 & 2

/Interview

orthodontics is to re-examine our treated patients, carefully evaluate the results, and learn from previous mistakes. The JCO article that I wrote in 1997 contains an
evaluation of all the different factors that may contribute as predictors to relapse (Zachrisson, 1997). The
concepts are still valid, and provide clinical guidelines on
how improvements can be made. It is my experience that
cases finished to excellent results have better stability
than cases that, upon closer examination, have been
under-corrected or expanded.
Sound treatment principles, including maintenance of an
original normal mandibular archform, are essential for
stability. Rounding of maxillary archform during treatment will be followed by a change to a more tapered
form after retention, and the greater the treatment
change, the greater is the tendency for post-retention
change. Any short-term mechanical interference with a
complex biological system has little long-term impact.
Relapse may be due to any of the following reasons:
incomplete correction of some details of the original
malocclusion; not placing 2-2 outside 3-3; unintended or
deliberate lateral or frontal expansion; return of habits;
inadequate retention; unfavorable growth pattern;
tongue and orofacial muscle activity: imbalances
between mandibular posture and occlusal or eruptive
forces; and other causes. Key procedures to improve stability include: full correction of all rotations (comparing
the results with pretreatment models, using a mouth
mirror to check the maxillary teeth); avoiding even slight
expansion of a normal mandibular intercanine width,
using the original archform as a guide; ensure a small
interincisal angle by providing adequate torque of the
maxillary incisors, thereby reducing the risk of vertical
relapse of deep overbite correction; and use of prolonged retention with fixed retainers (Zachrisson, 1997).
Dr. Skoularikis: You have published many articles concerning retention, which, once again resulted from your
long clinical experience. Obviously, we cannot extensively cover this subject. However, could you share with us
the most important of your conclusions about bonded
retainers and how effective they are in a long term
prospective?
Dr. Zachrisson: In 2007, I published an update on our
long-term experiences with direct-bonded retainers, and
gave some clinical advice for retention in young and
adult patients (Zachrisson, 2007b). It was recommended
to use a "differential retention" approach with individu-

11

 /Interview

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HELLENIC ORTHODONTIC REVIEW

alized retention for selected patients.
Various retainer designs were described, including the
mandibular "stability" retainer in thick (0.030 inch) solid
gold-coated wire bonded to the canines only, and different designs of thinner (0.0215 inch five-stranded) goldcoated flexible spiral wire which are bonded to all teeth
in a segment (Figures 1,6). Short labial retention wires
may be very useful for retaining closed extraction spaces
in adults, and to hold corrected premolars that were in
awkward positions initially (Fig. 6).
Experiences with bonded retainers over 10 or 15 years
have generally been quite satisfactory, provided a careful
wire bending and bonding technique is used. It is inconceivable to me that some clinicians still rely solely on
removable Hawley plates or vacuum-formed acrylic
splints for retention of their cases. However, it is my
opinion that permanent retention with bonded retainers
should be restricted to those patients who really need it.
This may include adults with advanced periodontal tissue
breakdown, in whom the bonded retainers serve the
dual purpose of preventing relapse and acting as splints,
patients with marked median diastemas, and adults with
pronounced maxillary incisor crowding.
Dr. Skoularikis: Do you consider that third molars may
cause crowding of the lower anterior teeth? Do you follow any protocol on taking preventive measures to avoid
this phenomenon?
Dr. Zachrisson: None of the available "classical" studies
on third molars and crowding is optimally designed to
isolate the effect of third molar eruption from the multitude of other contributing factors.
Impacted and non-erupting third molars do not cause
increased crowding of mandibular incisors. However, a
third molar that is actively erupting may have a threedimensional effect by changing the eruption vectors of
the second and first molars. The mandibular first molars
still continue their eruption in persons between 20 and
30 years of age. There is a potential influence of the
eruptive pressure from third molars on the tendency to
forward movement of the buccal segments and anterior
crowding. This has been studied in clinical experiments in
which the mandibular second or third molars are extracted. Such studies have provided evidence that the presence of an actively erupting third molar may indeed be
one of the causes of increased mandibular arch crowding
(Zachrisson, 2009).
For practical reasons, there are only two alternatives for

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/Interview

third molar removal associated with orthodontic therapy: either (1) between 8 to 10 years of age when these
teeth are germs and located above the second molars or
(2) between 20 to 25 years of age, or older, with the third
molars in a partially erupted position. Impacted diseasefree third molars may safely be left in situ, indefinitely, in
adults. However, extraction is indicated in cases with
root resorption in second molars.
Dr. Skoularikis: Prof. Zachrisson, on behalf of the Editorial Board and the readers of the Hellenic Orthodontic
Review I would like to thank you for this interview and
for sharing your valuable knowledge and experience.
Dr. Zachrisson: It has been a pleasure to share my
thoughts on some everyday aspects of our challenging
profession.
References
Kadioglu O, Bykyilmaz T, Zachrisson BU, Maino BG. Contact
damage to root surfaces of human premolars touching miniscrews during orthodontic treatment. Amer J Orthod Dentofac
Orthop 2008:134:353-60.
Maino G, Weiland F, Attanasi A, Zachrisson BU, Bykyilmaz T. Root
damage after contact with miniscrews: a histological assessment. J Clin Orthod 2007;41:762-766.
Rosa M, Zachrisson BU. Integrating esthetic dentistry and space
closure in patients with missing maxillary lateral incisors. J Clin
Orthod 2001;35:221-34.
Zachrisson BU. Clinical implications of recent orthodontic-periodontic research findings. Semin Orthod 1996;2:4-12.
Zachrisson BU. Important aspects of long-term stability. J Clin
Orthod 1997;31:562-83.
Zachrisson BU. Mandibular third molars and late lower arch crowding the evidence base.World J Orthod 2005;6:180-6.
Zachrisson BU. Proper quality orthodontics vs the new mechanical
systems. World J Orthod 2007a;8:308-14.
Zachrisson BU. Long-term experience with direct-bonded retainers:
Update and clinical advice. J Clin Orthod 2007b;41:728-37.
Zachrisson BU, Rosa M, Toreskog S. Congenitally missing maxillary
lateral incisors: Canine substitution. Am J Orthod Dentofac
Orthop 2011;139:434-45.

. : . Zachrisson,
,
.

:
Reprint requests to:
Dr. Bj orn
/ U. Zachrisson
Frognerveien 51
0266 Oslo
Norway

. Zachrisson:

.

E-mail: b.u.zachrisson@odont.uio.no

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