0090 Vol 27 No 1 May 2011 - 2

Contents
Editorial
1 What is a journal?
Craig Dreyer
Obituary
2 Gerald Richard Dickinson (1940-2010)
Original articles
4 A comparison of shear bond strength of immediate and delayed bonding of brackets to FRC bars using various
orthodontic adhesives
Farzin Heravi, Saied Mostafa Moazzami, Navid Kerayechian and Elham Nik
10 The effects of the Pendulum distalising appliance and cervical headgear on the dentofacial structures
Ebubekir Toy and Ayhan Enacar
17 Comparison of dietary intake between fixed orthodontic patients and control subjects
Alireza Sarraf Shirazi, Majid Ghayour Mobarhan, Elham Nik, Navid Kerayechian and Gordon A. Ferns
23 Evaluation of primary surgical outcomes in New Zealand patients with unilateral clefts of the lip and palate
Hannah C. Jack, Joseph S. Antoun and Peter V. Fowler
28 The effects of various surface treatments on the shear bond strengths of stainless steel brackets to artificially-aged
composite restorations
Ladan Eslamian, Ali Borzabadi-Farahani, Nasim Mousavi and Amir Ghasemi
33 A systematic review of the association between appliance-induced labial movement of mandibular incisors and gingival
recession
Tehnia Aziz and Carlos Flores-Mir
40 Skeletal, dental and soft tissue changes in Class III patients treated with fixed appliances and lower premolar extractions
Elham S.J. Abu Alhaija and Susan N. Al-Khateeb
46 Presence of cariogenic streptococci on various bracket materials detected by polymerase chain reaction
Smitha Pramod, Vignesh Kailasam, Sridevi Padmanabhan and Arun B. Chitharanjan
52 Effectiveness and acceptability of Essix and Begg retainers: a prospective study
Arun G. Kumar and Anchal Bansal
Case reports
57 Orthodontic management of ectopic maxillary first permanent molars: a case report
Jadbinder Seehra, Lindsay Winchester, Andrew T. DiBiase and Martyn T. Cobourne
63 Alignment of an ectopic canine with mini-implant anchorage: a case report
Priyanka Sethi Kumar, K. Nagaraj, Ruchi Saxena and Juhi Yadav
69 Treatment of a Class III patient: a case report
Rahman Showkatbakhsh and Abdolreza Jamilian
Letters
74 Optimal force
Brian W. Lee
Control 21 Stress-Breaking Bracket
Felix Goldschmied
General
76 Book reviews
83 Recent publications
89 New products
91 Calendar
Australian
Orthodontic Journal
Volume 27 Number 1, May 2011
Australian Orthodontic Journal Volume 27 No. 1 May 2011
Australian Orthodontic Journal Volume 27 No. 1 May 2011 1
Editorial
In November 2010, I had the opportunity and
privilege of attending a short course for editors of
medical journals which was held in Oxford, England.
The weather was cold and grey, heralding the snow
and freezing temperatures that were to affect Europe
in the weeks ahead. The atmosphere on the course was
educational and convivial as twenty-four other newly
appointed medical editors of highly prestigious
medical journals were educated in the craft of editing.
The consulting and publishing company providing
the course introduced, in sequence, the four areas of
the process that are crucial to journal production.
Editing consideration needs to be given to the
owner(s) of the journal (in this case the Australian
Society of Orthodontists), the authors (whose manu-
scripts are assessed for publication), the readership
(who need to be informed) and the public (who sup-
port the journal either through advertising or legal
services). With research communication changing
dramatically in the electronic age, all need to be
managed carefully and flexibly for a journal to survive.
Apart from defining a profession, a primary purpose
of a journal is the dissemination of information and
the advancement of knowledge. However, research has
indicated that journals are not good at persuading
clinicians to change and improve their practice. Words
on paper rarely lead directly to change. Slowly journals
have begun to look less like traditional scientific
periodicals and more like popular magazines, with
shorter articles, brief summaries and graphics. A
perusal of this current issue will attest to this fact.
During the Editors Course, the participants were
invited to consider the precise definition of a journal
and, as an example, to consider what distinguishes the
Australian Orthodontic Journal from a newsstand mag-
azine. Both publish articles to inform special interest
groups. In the case of the AOJ, orthodontic informa-
tion is provided for clinicians, but in the case of a
magazine, content information targets a different but
selective interest group. The AOJ carries advertise-
ments and most magazines derive income from their
advertising spreads which may be the means by which
their success is judged. Both are supported by a pro-
prietary group. In the case of the AOJ, it is the ASO,
but in the case of a magazine, it is likely to be a
publishing company whose purpose is business. To
quote Richard Smith,
1
a past editor of the British
Medical Journal, journals are about the fundamental
business of disseminating science rather than making
societies or publishers rich. While newsstand maga-
zines also disseminate knowledge, they are largely of
pecuniary benefit to the publishing company.
Both types of publication pass through an editorial
process and/or an editorial panel which provides a
policy framework and is responsible for content.
However, the significant and important difference
between the two types of publication is that submitted
manuscripts/papers to a scientific journal are carefully
peer reviewed to determine their suitability for publica-
tion. While the purpose of peer review is to advise on
the merits of a manuscript, it does not necessarily
guarantee quality. It does mean that a process of self-
regulation has been undertaken and a submitted paper
has been evaluated and advanced along the editorial
pathway. A valued panel of reviewers serves the AOJ
and ensures that critical peer-review remains the
fundamental and important difference between a
scientific journal and a magazine.
With concern, the process of peer review is currently
under scrutiny because it is said to apportion spurious
weight to a published article and can delay publica-
tion. To combat this, an open review system has been
suggested in which the authors and the reviewers
names are known. This creates the possibility of
favouritism, fraud or the denigration of rival research.
This will not be pursued and the current system of
closed review will prevail for the AOJ.
A good journal should be an asset to the scientific
community. On the world stage of scientific journals,
the Australian Orthodontic Journal is a small player.
Nevertheless, it is a journal of the Australian Society of
Orthodontists and therefore belongs to the member-
ship and subscribers. It is published to educate and
inform, to encourage debate, set agendas and draw atten-
tion to innovation, but essentially to make people think.
So, what do you think . . . ?
Craig Dreyer
Reference
1. Smith R. The trouble with medical journals. J R Soc Med
2006;99:115-19.
What is a journal?
Gerry Dickinson was born in St Arnaud, a country
town in Victorias wheat belt. He had a rural up-
bringing and acquired many bush skills during his
formative years. From St Arnaud, Gerry went to board
at St Patricks in Ballarat for his secondary schooling.
In 1959 he commenced Dentistry at Melbourne
University and was resident and later student
President at Newman College. Gerry graduated in
1963 and almost immediately commenced his
Masters degree in Orthodontics. In those years, the
course was 4 years part-time. During this time and for
years after, Gerry tutored in Anatomy. It remained one
of his favourite subjects.
After achieving his Masters in 1968, Gerry went into
practice with Alan Parker in Spring Street in
Melbourne. He subsequently went solo with help
from Paul Buchholz and Anne-Marie Vincent at
2 Collins Street, and in 1969 Gerry went to Los
Angeles with Bill Chalmers and did a long course in
Ricketts lightwire edgewise philosophy and tech-
nique, which had a large impact on Gerrys clinical
practice. He was a dedicated orthodontist and despite
his protracted illness, he was still seeing his patients
until he retired at the end of May last year.
Gerry made a massive contribution to the profession
of Dentistry, to the specialty of Orthodontics and to
the University of Melbourne. He was an active
member of the Australian Dental Association. From
1967 to 1978, Gerry served on the Fluoridation
Committee of the ADAVB. Together with Gavan
Oakley, he was instrumental in achieving the fluorida-
tion of Melbournes water supplies. This is arguably
the greatest Public Health measure ever seen in
Melbourne. He served on the ADAs Professional
Provident Funds policy advisory committee for over
two decades and in 2000 received the Branchs
Distinguished Service Award for this and his work on
the 1993 ADA Congress.
Gerry gave more than 30 years of continuous service
to the Australian Society of Orthodontists, commenc-
ing in 1975 on the Victorian Branch Executive,
through to 2007, when he retired from the Chair of
the ASO Foundation for Research and Education.
Between those years Gerry was Chairman of Congress
Obituary
Gerald Richard Dickinson
1940 2010
OBITUARY
3
in 1984 and ASO Federal President from 1993 to
1996. In 2006 he was awarded Honorary Life
Membership of the ASO.
Gerry has been involved with the University of
Melbourne almost continuously from student days in
1959, then as a teacher in Anatomy and
Orthodontics and later on Faculty. More recently he
had been involved as a board member of the
Cooperative Research Centre for Oral Health Science
where he had worked closely with Professor Eric
Reynolds. He was instrumental in securing a large
donation which will form the nucleus of a trust fund
to support the Orthodontic Chair at the Melbourne
Dental School. He was also a Fellow of the
International College of Dentists and was to be the
incoming President. His overall contribution to the
profession has been second to none.
Gerry had many interests outside Dentistry. He was a
keen skier, both downhill and cross country, and
competed in many marathon ski races in the Falls
Creek and Mt Hotham area. He was also a keen
runner and had a sub 3-hour marathon to his credit.
He competed in many pier to pub swimming events
and was an Anglesea surfer, a competent scuba diver
and an astute fisherman. He was a member of
Victoria and Barwon Heads Golf Clubs, an avid road
cyclist and a proud supporter of The Cats. Gerry
travelled extensively throughout the world, but he
loved Central Australia. Every year, with great enthu-
siasm, he planned a 4WD expedition with family
and friends, to explore the Kallakoopah, the Simpson
and other remote regions of the centre.
In 1964 he married Anne Louise Liddy and they had
4 children, Sarah, John, Jane and Andrew. There are
now 5 grandchildren and he was proud of all of them.
Together with Annie, he developed a large grazing
property near Colac and in the last 15 years or so,
returned to his rural roots.
Everything Gerry did, he did with enthusiasm and
passion. He will be greatly missed by all who knew
him.
John Armitage
Introduction
Fibre reinforced composite (FRC) is a conglomerate
of S-glass fibres, a Bis-GMA matrix and unfilled
resins that produce a glass-like, highly resistant struc-
ture.
1
It has the same colour as enamel, which appeals
to patients who prefer aesthetic appliances. This tech-
nology was developed and may be used for periodon-
tal splinting of teeth, endodontic post and cores, fixed
prosthodontic appliances and as a mechanism to
stabilise traumatised teeth.
26
In orthodontics, FRCs have been used as bonded
retainers, space maintainers, splints and as anchorage
adjuncts during active tooth movement.
7,8
For
anchorage, the FRC bars can unite several teeth
into a single unit. The bars are tooth-coloured and
attachments can be directly bonded (Figure 1).
9
The
Australian Orthodontic Journal Volume 27 No. 1 May 2011 Australian Society of Orthodontists Inc. 2011 4
A comparison of shear bond strength of immediate
and delayed bonding of brackets to FRC bars
using various orthodontic adhesives
Farzin Heravi,
*
Saied Mostafa Moazzami,
Navid Kerayechian
*
and Elham Nik
+
Department of Orthodontics and Dental Research Center,
*
Department of Operative Dentistry and Dental Research Center,
Mashhad University
of Medical Sciences, Iran and Department of Pediatric Dentistry, School of Dentistry, Ahvaz University of Medical Sciences,
+
Ahvaz, Iran
Background: Fibre reinforced composite bars (FRC) have applications as bonded retainers, space maintainers and anchor-
age/movement units. However, the bond strength of attachments to FRC anchorage bars is unknown.
Aims: To compare the shear bond strengths of brackets bonded immediately to FRCs with different orthodontic adhesive systems
and bonded with the same adhesives after a 48-hour delay, abraded with a diamond bur and etched with phosphoric acid.
Method: One hundred and five recently extracted upper premolars were randomly assigned to seven groups (N = 15 teeth per
group). FRCs were bonded to the buccal surfaces of the teeth and stainless steel orthodontic brackets were bonded to the FRCs
with the following adhesive systems: Group 0 (Tetric Flow); Groups 1, 2 and 3 (Immediate bonding with chemically cured,
no-mix and light cured composites, respectively, the bars covered with Tetric Flow); Groups 4, 5 and 6 (Bonding to FRCs
delayed 48 hours, then bonded with chemically cured, no-mix and light cured composites, respectively, the bars covered with
Tetric Flow). The FRC bars in Groups 4, 5 and 6 were abraded with a coarse-grit diamond bur before bonding the
attachments to the bars. The shear bond strengths (SBS) were measured with a universal testing machine, and the adhesive
remaining on the teeth after debonding was scored with the Adhesive Remnant Index (ARI). Data were analysed using analysis
of variance (ANOVA), Duncans post-hoc and Fishers Exact test.
Results: There were no statistically significant SBS differences between Groups 0 (Mean SBS: 9.56 MPa), 1 (Mean SBS: 9.74
MPa), 2 (Mean SBS: 10.72 MPa) or 3 (Mean SBS: 9.54 MPa). Groups 4, 5 and 6 (Bonding delayed by 48 hours) had
SBSs of 11.79 MPa, 11.63 MPa and 13.11 MPa, respectively, and were significantly higher than the SBSs in Groups 1, 2
and 3 (Immediate bonding). There were no significant differences in ARI scores among the groups.
Conclusions: The mean SBSs in all groups fell within the clinically acceptable range (> 7 MPa). The combination of a 48-hour
delay between placement of an FRC bar and bonding an attachment, abrading the FRC with a diamond bur and etching with
phosphoric acid resulted in higher bond strengths.
(Aust Orthod J 2011; 49)
Received for publication: December 2009
Accepted: May 2010
Farzin Heravi: heravif@mums.ac.ir
Saied Mostafa Moazzami: MoazzamiM@mums.ac.ir
Navid Kerayechian: Kerayechiann861@mums.ac.ir
Elham Nik: nike861@mums.ac.ir
BOND STRENGTHS OF BRACKETS TO FRC BARS
disadvantages are that the bars cannot be used in all
stages of comprehensive orthodontic treatment and
there is limited information on the bond strengths of
attachments to the bars, particularly if bonding is
delayed and the surface of the FRC bar is abraded
before bonding.
9,10
The present study aimed to determine the SBS values
of brackets bonded to FRC bars with a flowable com-
posite and three conventional orthodontic adhesives
(chemically cured, no-mix and light cured resin
composites).
Material and methods
One hundred and five non-carious human upper pre-
molars were used in this study. Teeth with hypo-
plastic areas, enamel cracks or irregularities or treated
with chemical agents were excluded. The extracted
teeth were randomly divided into seven equal groups
and were stored in distilled water at room tempera-
ture until required. All teeth were bonded and tested
within 2 months of extraction.
The teeth were carefully mounted in self-cure acrylic
blocks so that their labial surfaces were parallel to the
shearing force. The buccal surfaces were cleaned and
polished with a non-fluoridated pumice and rubber
prophylactic cups, washed with water and air dried.
The buccal surfaces of the teeth were etched for 30
seconds with 37 per cent phosphoric acid gel (3M
Dental products, St. Paul, MN, USA), rinsed with
water for 30 seconds and dried with a blast of oil-free
air for 20 seconds, until the etched surfaces appeared
frosty white.
A thin layer of Margin Bond (Coltne/Whaledent,
Altstatten, Switzerland) was applied to the etched sur-
face and thinned by gently blowing air on the resin
for 10 seconds. The resin was cured with an Astralis 7
visible light unit (Ivoclar, Vivadent, Schaan,
Liechtenstein) with the intensity of 780 mW/cm
2
for
20 seconds. A layer of flowable resin (Tetric Flow,
Ivoclar, Vivadent, Schaan, Liechtenstein) was applied
to the enamel. A glass fibre FRC bar, pre-impregnat-
ed with Bis-GMA (Interlig ngelus, Londrina, PR,
Brazil), was cut with scissors to the size of an upper
central incisor stainless steel edgewise bracket and
placed in the centre of the crown. Pressure was
applied to the FRC to express excess resin, which was
removed with an explorer. The flowable resin was
then light cured for five seconds.
Stainless steel, central incisor edgewise brackets (3M
Unitek, St. Paul, MN, USA) with a mean bonding
surface area of 12.54 mm
2
were bonded to the FRCs
(Table I):
1. Group 0 (TF: Tetric Flow): a flowable composite
resin was applied to the bracket base and the bracket
positioned on the FRC. The composite resin was
light cured on the mesial (20 seconds) and distal (20
seconds) sides of the bracket bases.
2. Group 1 (CC-IB: chemically cured, immediate
bonding): a layer of Tetric Flow resin was applied to
the FRC to completely cover the fibre bar and light
Table I. Summary of the adhesive systems and the time delay in
bonding attachments.
Bonding
Groups Immediate Delayed
Group 0 (TF) *
Group 1 (CC-IB) *
Group 2 (NM-IB) *
Group 3 (LC-IB) *
Group 4 (CC-DB) *
Group 5 (NM-DB) *
Group 6 (LC-DB) *
TF, Tetric Flow; CC, chemically cured (Concise); NM, no mix (Unite);
LC, light cured (Transbond XT); IB, immediate bonding; DB, delayed
bonding
Delayed 48 hours, abraded with diamond bur and etched with phos-
phoric acid
Figure 1. FRC used to form posterior anchor units.
cured for 40 seconds. The brackets were bonded to
the FRC bar with a chemically cured composite resin
(Concise, 3M Dental Products, St Paul, MN, USA).
During curing the brackets were pressed firmly in
place and excess adhesive was removed with an
explorer.
3. Group 2 (NM-IB: no-mix, immediate bonding):
the FRC was covered with Tetric Flow and light cured
for 40 seconds as in Group 1. The brackets were
bonded to the FRC bars with a no-mix composite
resin (Unite, 3M Unitek, Monrovia, CA, USA).
Primer was applied to the surface of the FRC bar and
the bracket. The adhesive was then applied to the
base of the bracket and the bracket positioned on the
covered FRC bar.
4. Group 3 (LC-IB: light cured, immediate bonding):
the FRC was covered with Tetric Flow as in Groups 1
and 2 and light cured for 40 seconds. The brackets
were bonded to the FRC bars with Transbond XT
(3M Unitek, Monrovia, CA, USA). A thin layer of
primer (Transbond XT primer, 3M Unitek) was
applied to the covered FRC bar and a layer of
Transbond XT composite resin placed on the base of
the bracket. The brackets were positioned on the
FRC bar and pressed firmly into place. Excess adhe-
sive was removed with an explorer before curing.
The complex was cured for 40 seconds with the light-
curing protocol used in Group 0 (20 seconds on the
mesial side and 20 seconds on the distal side of the
bracket base).
5. Group 4 (CC-DB: chemically cured, delayed
bonding): the FRC was again covered with Tetric
Flow as in Groups 1, 2 and 3. The samples were then
stored in distilled water at room temperature for 48
hours. The surface of the covered FRC bars was
abraded with a high-speed coarse-grit diamond bur
(No.534, SS White Lakewood, NJ, USA) irrigated
with a water spray, etched with 37 per cent phos-
phoric acid for 10 seconds, washed thoroughly with
water and air dried. A thin layer of primer (Margin
bond) was applied to the surface and thinned by
gently blowing air on the resin for 10 seconds.
The primer was then light cured for 20 seconds and
the brackets were bonded to the surface with the
chemically cured composite resin (Concise) used in
Group 1.
6. Group 5 (NM- DB: no-mix, delayed bonding): the
FRC bar was covered in Tetric Flow as in Group 4.
The brackets were bonded to the covered FRC bars
(after the surface of the bars had been abraded) with
a no-mix composite resin (Unite), according to the
manufacturers instructions.
7. Group 6 (LC-DB: light cured, delayed bonding):
the procedure used in Groups 4 and 5 was followed.
The brackets were bonded to the FRC bars (after the
bars had been abraded) with the light cured compos-
ite resin (Transbond XT) used in Group 4 and
according to the manufacturers instructions.
Debonding procedure
After bonding, all samples were stored in distilled
water at room temperature for 24 hours. The speci-
mens were mounted in a universal testing machine
(Zwick GmbH, Ulm, Germany) and the brackets
debonded with shear load applied to the bracket base
by a blade at a crosshead speed of 1 mm/min. The
maximum load required to debond the fibre bar was
recorded in newtons (N) and converted to mega-
pascals (MPa).
Residual adhesive
After debonding the brackets, the buccal surfaces
were examined at x10 magnification and the amount
of adhesive remaining on the tooth recorded using
adhesive remnant index (ARI).
11
The criteria for
scoring were 0, no adhesive on the tooth; 1, less than
half of adhesive on the tooth; 2, more than half of the
adhesive on the tooth; and 3, all adhesive on the tooth.
Statistical method
The Kolmogorov-Smirnov test was used to determine
if the data were normally distributed. The mean SBSs
were compared with an analysis of variance
HERAVI ET AL
Table II. The shear bond strengths of the groups.
Groups N Mean SD Range Test*
(MPa) (MPa) (MPa)
Group 0 (TF) 15 9.56 3.08 5.71 - 16.31 a
Group 1 (CC-IB) 15 9.74 1.52 8.09 - 13.05 a
Group 2 (NM-IB) 15 10.72 1.67 8.15 - 14.50 a, c
Group 3 (LC-IB) 15 9.54 1.87 6.58 - 13.39 a
Group 4 (CC-DB) 15 11.79 1.82 8.41 - 15.37 b, c
Group 5 (NM-DB) 15 11.63 2.33 8.51 - 17.06 b, c
Group 6 (LC-DB) 15 13.11 1.98 8.88 - 16.52 b
*Groups with the same letters are not significantly different from each
other
(ANOVA) and Duncan post-hoc test. The ARI scores
among the different groups were compared with
Fishers Exact test. All statistical analyses were per-
formed using the SPSS software package (SPSS for
windows, version 15, SPSS Inc, Chicago IL, USA). A
p < 0.05 was considered significant.
Results
The results of this study demonstrated that Group 6
had a higher mean SBS value (13.11 1.98 MPa)
compared with the other groups (Table II). Groups 4,
5 and 6 had similar SBS values (p > 0.05). Group 0
(TF) had a mean SBS value of 9.56 3.08 MPa
which differed significantly from Groups 4 , 5 and 6,
but not Groups 1, 2 and 3. The mean shear bond
strengths of all groups exceeded 7 MPa, the shear
bond strength regarded as clinically acceptable.
12
The ARI scores for the 7 groups are given in Table III.
There were no significant group differences in the
locations of the bond failures (p = 0.8), regardless of
the adhesive material, and the delay in bonding and
surface treatment of the FRC. Bond failure occurred
mainly within the bonding material.
Discussion
The bond strengths of orthodontic attachments
bonded to FRC bars with conventional orthodontic
adhesives was examined in the present study. Previous
studies have assessed the physical properties but not
the effectiveness of different methods of bonding
attachments to the bars.
2,1319
It was found that the
bond strengths of the six orthodontic adhesives that
were examined exceeded the minimum 7 MPa bond
strength for clinical use.
12
The combination of delay-
ing bonding for 48 hours, abrading the surface of the
bar with a coarse grit diamond bur and then etching
with phosphoric acid resulted in high SBSs, but the
delay is unlikely to be acceptable to many clinicians
and patients.
Orthodontic attachments and FRC bars may be
bonded in a one-step procedure with the flowable
composite resin used in the study, but the attach-
ments were inclined to drift until the resin was
cured.
9
Contradictory reports exist in the literature
regarding the shear bond strengths of flowable resins
compared with conventional orthodontic adhesives.
Several investigators have reported that the SBSs of
flowable resins are significantly lower than the SBS of
Transbond XT while others have reported similar
bond strengths to Transbond XT.
2023
The findings of
the present study support the view that attachments
bonded to FRC bars with conventionally chemically
cured, no-mix and light cured orthodontic adhes-
ives (Concise, Unite, Transbond XT) will result in
acceptable SBSs.
In several groups, bonding to the FRC bar was
delayed for 48 hours, in order to mimic clinical situ-
ations. In this circumstance, the bar was abraded with
Table III. Distribution of ARI scores.
Groups ARI Fishers
0 1 2 3 Exact
(Per cent) (Per cent) (Per cent) (Per cent) test
*
Group 0 (TF) 1 (6.7) 3 (20) 8 (53.3) 3 (20) a
Group 1 (CC-IB) 1 (6.7) 3 (20) 11 (73.3) 0 (0.0) a
Group 2 (NM-IB) 1 (6.7) 6 (40) 8 (53.3) 0 (0.0) a
Group 3 (LC-IB) 1 (6.7) 4 (26.7) 8 (53.3) 2 (13.3) a
Group 4 (CC-DB) 1 (6.7) 6 (40) 8 (53.3) 0 (0.0) a
Group 5 (NM-DB) 1 (6.7) 7 (46.7) 7 (46.7) 0 (0.0) a
Group 6 (LC-DB) 1 (6.7) 5 (33.3) 8 (53.3) 1 (6.7) a
Total 7 34 58 6
ARI scores: 0, no adhesive remaining on tooth; 1, less than half of adhesive remaining
on tooth; 2, more than half of adhesive remaining on tooth; 3, all adhesive remaining
on the tooth
*
Groups with the same letter are not significantly different from each other. Fishers
Exact test: 12.24, p = 0.83
a diamond bur and its surface etched with phosphor-
ic acid to determine changes in bond strength.
Together these steps resulted in significantly higher
bond strengths for the chemically cured (Concise)
and light cured resins (Transbond XT) but not the
no-mix resin (Unite). It was considered that the abra-
sion and etching removed by-products of the poly-
merisation process and/or contamination by foods
and drinks in the 48-hour period.
24
For the no-mix
adhesive, the delay and subsequent surface treatment
had little effect on bond strength, possibly because
the solvents in this adhesive were ineffective in
preparing the surface of the FRC for bonding and
enhancing bond strength.
Etching the surface of an orthodontic adhesive with
phosphoric acid has been advocated by clinicians for
making composite additions and bonding ortho-
dontic attachments.
24
Abrasion with a diamond bur
may have smoothed the surface of the bars and
enhanced micromechanical retention and also may
have removed food, polymerisation and degradation
products. The solvents in the uncured orthodontic
resins appear to have removed the products as no sig-
nificant differences in the bond strengths of the
immediate (Group 2) and delayed (Groups 4 and 5)
groups were found.
The majority of the attachments failed cohesively and
there were no significant ARI differences between the
groups. However, in Groups 3 (Transbond XT,
immediate bonding) and 6 (Transbond XT, delayed
bonding), all of the adhesive was left on the tooth sur-
face in 13 and 6 per cent of the teeth, suggesting that
the curing light may not have reached the resin in the
deepest parts of the bonding pad. Of the brackets
bonded immediately with Tetric Flow, 20 per cent
also failed at the bracket interface, suggesting that this
adhesive did not have the cohesive strength of the
orthodontic adhesives.
Conclusions
The following conclusions may be drawn from this
study:
Orthodontic brackets bonded immediately to FRC
bars with either a flowable adhesive or various
orthodontic adhesive systems that had adequate bond
strengths.
The bond strengths were significantly greater for the
chemically cured (Concise) and light cured
(Transbond XT) adhesives when bonding was
delayed 48 hours and the surfaces of the Tetric Flow
covered bars were abraded with a diamond bur and
etched with phosphoric acid.
No significant differences in ARI scores were found
among the groups.
Corresponding author
Dr Navid Kerayechian
Department of Orthodontics
School of Dentistry
Mashhad University of Medical Sciences
Mashhad
Iran
Tel: +98 511 8419814
Fax: +98 511 8829500
Email: Kerayechiann861@mums.ac.ir
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Introduction
Dentoalveolar Class II malocclusions may be treated
by the distal movement of the maxillary teeth.
Treatment options range from extra-oral appliances,
such as cervical headgear, to an ingenious collection
of intra-oral devices designed to move the maxillary
teeth distally. These appliances use magnets, wire
springs, orthodontic screws and Class II intermaxil-
lary traction to achieve their objectives.
111
The intra-
oral treatment methods rely less on patient com-
pliance for success compared with the extra-oral
appliances, and in the absence of mini-screws, derive
anchorage from the maxillary teeth and/or the hard
palate. A frequent side effect of an intra-oral approach
to molar distalisation is a loss of anterior anchorage.
Although the dental and skeletal effects of the
Pendulum intra-oral appliance have been pre-
viously reported,
1,2,1217
only one randomised trial
has compared the skeletal and dental effects of intra-
and extra-oral treatment approaches.
10,18,19
There-
fore, the aim of the present study was to compare the
effects of an intra-oral distalising appliance and cer-
vical headgear on the dentofacial structures of
adolescents.
Subjects and methods
The subjects comprised 30 consecutive patients,
referred to the Department of Orthodontics,
Hacettepe University, who fulfilled the following
inclusion criteria:
The effects of the Pendulum distalising appliance
and cervical headgear on the dentofacial structures
Ebubekir Toy
*
and Ayhan Enacar
Department of Orthodontics, I
nn University, Malatya
*
and the Department of Orthodontics, Hacettepe University, Ankara,
Turkey
Background: Headgears are effective in distalising maxillary molars, but success depends on patient compliance and
tolerance. Intra-oral distalising appliances are simple to construct and use and may be a better alternative for patients who are
non-compliant or cannot tolerate headgear.
Aims: To compare the Pendulum (PEN) appliance and cervical headgear (CHG) on distal movement of maxillary first molars in
patients requiring maxillary molar distalisation.
Methods: Thirty patients were randomly divided into two groups. Both groups had comparable occlusal and cephalometric
characteristics before treatment. Fifteen patients (9 girls, 6 boys) with a mean age of 11.45 1.54 years (Range:
8.5813.50 years) were treated with Pendulum appliances and 15 patients (10 girls, 5 boys) with a mean age of 11.72
1.24 years (Range: 9.5813.33 years) were treated with a Ricketts-type CHG. A pilot study of four patients estimated that the
time required to distalise the maxillary molars with the Pendulum appliance was five months. Therefore, the end of treatment
records for the CHG group were taken after 4.96 0.35 months. Lateral and postero-anterior cephalometric radiographs
were taken of both groups at the start (T1) and end of distalisation/treatment (T2). Changes in cephalometric measurements in
the two groups were compared with Wilcoxon and Mann-Whitney U tests.
Results: Measurements indicated that U6-ANS distance, overjet and U1-APo distance increased, U6-PP angle and U6-PTV
distance reduced, and the molar relationship improved more in the PEN group compared with the CHG group. Statistically,
significant right molar left molar differences were found between the two groups. Distalisation produced significant side
effects, resulting in distal tipping of the first molars and an increase in overjet, whereas the CHG reduced the overjet.
Conclusion: The Pendulum appliance was more effective than the CHG in distalising the maxillary first molars.
Received for publication: October 2009
Accepted: July 2010
Deceased
Ebubekir Toy: ebubekirtoy@hotmail.com
EFFECTS OF PENDULUM APPLIANCE AND CERVICAL HEADGEAR
1. Skeletal Class I malocclusion with a bilateral Class
II molar relationship.
2. Radiographic confirmation that at least one third
of the roots of the unerupted maxillary second molars
had developed.
3. Nonextraction treatment plan.
4. Good oral hygiene.
5. No or minimal crowding in the mandibular dental
arch.
6. No signs of a temporomandibular joint disorder.
The subjects were randomly allocated to either a
group treated with an intra-oral Pendulum appliance
with a midline expansion screw (PEN) or a group
treated with a Ricketts-type cervical headgear
(CHG).
20
The 15 subjects in the PEN group (9 girls,
6 boys) had a mean age of 11.45 1.54 years (Range:
8.5813.50 years) and the 15 subjects in the CHG
group (10 girls, 5 boys) had a mean age of 11.72
1.24 years (Range: 9.5813.33 years). A pilot study
on four subjects in the PEN group established that
the Pendulum appliance distalised the maxillary
molars in 5 months. Therefore progress records were
taken as close as possible to 5 months after the
appliances were fitted (4.96 0.35 months).
The subjects in the PEN group received an appliance
similar to that described by Hilgers.
2
A palatal acrylic
button was anchored to the maxillary first and second
premolars with bonded occlusal rests. A midline
screw and bilateral 0.032 inch TMA cantilever
springs (Ormco Corporation, Glendora, CA, USA)
were inserted into lingual sheaths on the first molar
bands (Figure 1). The springs were initially activated
90 degrees, and the subjects were monitored at three-
week intervals. The appliance was left in situ until the
molars were in a slightly overcorrected (Class III)
position,
21
which, on average, took 4.83 0.96
months (Range: 3.436.40 months). To prevent a
posterior crossbite from developing, the subjects were
instructed to turn the expansion screw a quarter turn,
once a week.
The CHG group received an appliance described by
Ricketts et al. to distalise the maxillary molars.
20
It was activated to deliver 500 g of force and the
subjects were requested to wear the appliance for
1214 hours per day, especially at night. Progress
records were taken after 4.96 0.35 months of treat-
ment. The subjects were monitored at three-week
intervals and the headgear was adjusted when
clinically indicated.
Figure 1. The Pendulum appliance.
Figure 2. Lateral cephalometric measurements:
1. U6-PP: posterior angle between molar axis and the palatal plane
(degrees)
2. U5-PP: posterior angle between premolar axis and palatal plane
(degrees)
3. U1-PP: posterior angle between upper incisor axis and palatal plane
(degrees)
4. U6-ANS: distance from the line constructed through the upper first molar
to palatal plane to ANS (mm)
5. U6-PTV: distance from upper first molar distal surface to PTV (mm)
6. Molar relation: distance between mandibular first molar distal surface and
maxillary first molar distal surface measured along the occlusal plane (mm)
7. Incisor overjet (mm)
8. U1-APo: angle between the axis of the upper incisor and APo line
(degrees)
9. U1-APo: tip of the upper incisor to APo line (mm)
10. U6 mesial root-ANS (mm)
11: U6 distal root-ANS (mm)
12: Tilt of the occlusal plane: angle between occlusal plane and corpus axis
(degrees)
TOY AND ENACAR
Cephalometric analysis
Lateral, basilar and postero-anterior cephalometric
radiographs were taken at the start of treatment (T1)
and after completion of molar distalisation (T2) or, in
the case of the CHG group, after 4.96 0.35 months
of treatment. The basilar cephalometric radiographs
were taken with the mouth fully open.
The cephalometric radiographs were traced and
measured using Jiffy Orthodontic Evaluation (JOE)
digitising software (Rocky Mountain Orthodontics,
Denver, CO, USA). Conventional lateral and pos-
tero-anterior cephalometric measurements were
applied (Figures 2 and 3). The distalising and rota-
tional effects of both appliances were measured on the
basilar cephalometric radiographs (Figure 4).
Statistical analysis
Shapiro-Wilks and Levenes variance homogeneity
tests were used to test the normality of the data. As
the data were not normally distributed and there was
no homogeneity of variance between the groups, the
intra-group comparisons were performed with the
non-parametric Wilcoxon test and intergroup
changes were analysed with the Mann-Whitney U test.
All statistical analyses were performed using the
Statistical Package for the Social Sciences, version
13.0 for Windows (SPSS Inc., Chicago, IL, USA).
Error of the method
Two weeks after the first measurements, 45 films (15
postero-anterior, 15 lateral and 15 basilar radio-
graphs) were selected at random and remeasured by
the same investigator and a paired t-test was applied
to the first and second measurements. There were no
statistically significant differences between the first
and second measurements. Pearson correlation
analyses were applied to the same measurements, the
highest r value was .997 for U6-PTV and the lowest
r value was .930 for the lower lip to aesthetic plane
distance.
Results
The results are presented in Table I.
Pendulum group
The lower anterior face height (LAFH) angle (p =
0.001), maxillary depth angle (p = 0.041), lower lip-
E plane (p = 0.007) and upper lip length (p = 0.021)
Figure 3. Postero-anterior measurements:
1. R6-L6 width: distance between the buccal sur-
faces of the right and left first molars (mm)
2. Maxillary width: distance between right and left
jugular points (mm)
Figure 4. Basilar measurements:
A. R6 distance: distance from the perpendicular to the maxillary right first
molar and the anterior margin of the foramen occipitale, measured along the
midsagittal plane (mm)
B. R6 rotation: anterior angle between axis of the maxillary right first molar
and midsagittal plane (degrees)
C. L6 distance (mm)
D. L6 rotation (degrees)
increased significantly during treatment. Of the
dentoalveolar measurements, the U6-PP angle
(p = 0.001) and the U6-PTV distance (p = 0.001)
reduced, the molar relationship (p = 0.001)
improved, and the U6-ANS distance (p < 0.001),
incisor overjet (p = 0.024) and U1-APo distance
(p = 0.001) increased.
The R6 distance (p = 0.001) and L6 distances (p =
0.001) reduced and R6-L6 width (p = 0.001), maxil-
lary width (p = 0.006) and L6 rotation (p = 0.029)
increased significantly. The maxillary right first molar
rotated approximately 4.5 degrees.
CHG group
There were no statistically significant skeletal or soft
tissue changes. Of the dentoalveolar measurements,
only the U6-PP angle, U5-PP angle and U1-PP angle
did not change significantly.
Table I. Dentofacial changes after distalisation with Pendulum (PEN) and cervical headgear (CHG) appliances.
Variables PEN group CHG group
Mean difference p* Mean difference p* p
(T2-T1) (T2-T1) PEN vs CHG
Skeletal and soft tissue measurements
Total facial height (degrees) 0.79 0.140 -0.14 0.995 0.436
Lower anterior face height (degrees) 1.63 0.001 0.28 0.460 0.267
Mandibular arch (degrees) 0.62 0.590 0.12 0.865 0.567
Mandibular plane angle (degrees) 0.65 0.164 0.15 0.887 0.389
Facial axis (degrees) -0.60 0.061 0.23 0.650 0.056
Maxillary depth angle (degrees) 0.66 0.041 0.00 0.944 0.250
Lower lip-E plane (mm) 0.65 0.007 0.75 0.221 0.713
Upper lip length (mm) 0.79 0.021 0.00 0.910 0.217
Nasolabial angle (degrees) 0.17 0.977 -3.83 0.281 0.412
Dentoalveolar measurements
U6 -PP (degrees) -15.10 0.001 0.90 0.616 0.000
U5-PP (degrees) 0.93 0.496 1.80 0.092 0.870
U1-PP (degrees) 1.67 0.112 -0.53 0.529 0.116
U6-ANS (mm) 4.07 0.001 1.73 0.001 0.001
U6PTV (mm) -3.69 0.001 -0.77 0.038 0.000
Molar relation (mm) -3.55 0.001 1.08 0.025 0.001
Incisor overjet (mm) 0.54 0.024 -0.82 0.005 0.000
U1-APo (degrees) 2.10 0.052 -1.67 0.016 0.001
U1-APo (mm) 1.05 0.001 -0.62 0.006 0.000
U6-Mesial root-ANS (mm) 0.47 0.427 2.10 0.003 0.037
U6-Distal root-ANS (mm) -0.17 0.691 1.80 0.003 0.007
Occlusal plane (degrees) 0.75 0.514 2.58 0.005 0.161
Upper molars measurements
R6-L6 width (mm) 3.17 0.001 0.93 0.213 0.015
Maxillary width (mm) 1.43 0.006 2.10 0.002 0.455
R6 Distance (mm) -3.87 0.001 -2.10 0.002 0.008
R6 Rotation (degrees) 4.43 0.100 10.06 0.001 0.081
L6 Distance (mm) -4.00 0.001 -1.87 0.002 0.000
L6 Rotation (degrees) 6.87 0.029 8.36 0.001 0.575
Significant differences are in bold
p
*
Wilcoxon test
p
Mann-Whitney U test
All maxillary molar measurements, except the R6-L6
width, changed significantly during treatment.
Intergroup comparisons
There were no statistically significant skeletal or soft
tissue changes. There were six statistically signifi-
cant dentoalveolar differences: U6-ANS distance
(p = 0.001), U6-PTV distance (p < 0.001), molar
relationship (p = 0.001), incisor overjet (p < 0.001)
and U1-APo distance (p < 0.001). In all cases the
changes in the PEN group were greater than the
changes in the CHG group. Importantly, both right
and left molars distalised approximately 2 mm more
in the PEN group compared with the CHG group.
Discussion
Many intra-oral molar distalisation appliances have
been designed to minimise or eliminate the need for
patient cooperation. In the present comparative study
of different appliances, postero-anterior and basilar
cephalometric radiographs were added to standard
records to assess transverse, rotational and distalising
effects on maxillary molars.
As an example of a non-compliant device, the
Pendulum appliance efficiently distalised the maxil-
lary molar teeth to a Class I relationship without the
need for patient cooperation. Furthermore, only one
activation period was required. These are distinct
advantages of the appliance when compared with
other mechanistic approaches requiring patient com-
pliance, such as CHG and Class II elastics.
Studies of the effects of the Pendulum appliance
usually do not use a control group because the obser-
vation period is invariably short (4.83 0.96 months
for the Pendulum and 4.96 0.35 months for the
CHG, in the current study) for normal growth
changes to play a significant role in the treatment
result.
4,7,1416,18,22
Previous studies describing the
appliance have revealed that approximately 45
months of treatment time has been adequate.
3,23
Joseph and Butchart
3
reported that Pendulum appli-
ance treatment time ranged from 1.5 to 5 months.
Angelieri et al.
23
found that the mean time for distal-
isation of the maxillary molars was 5.85 months.
While accepting these published time periods, the
present study required confirmation of the effective
time period to take second records and apply the
result to gathering progress records of the CHG
group. At the end of the pilot study, it was confirmed
that a five-month treatment period was adequate.
The amount of distal movement of the maxillary first
molars was higher and more rapid with the Pendulum
appliance compared with the CHG and was a signif-
icant finding of the current study.
24
As seen on the
lateral cephalograms measured by U6-ANS, the cor-
rection of the Class II relationship was achieved by
maxillary first molar distalisation of 4.07 mm in the
Pendulum appliance group and 1.73 mm in the
CHG group. The amount of molar distalisation was
statistically greater in the Pendulum group than in
the CHG for each subject. Overcorrection is desirable
because it has been noted that molar anchorage loss
invariably occurs during retraction of the premolars,
the canines and especially the incisors.
25
The distali-
sation values generated by the Pendulum appliance
agree with those previously reported by Ghosh and
Nanda,
14
Byloff and Darendeliler,
15
Bolla et al.
8
and
Gelgor et al.
24
However, the mean molar distalisation
value of 1.73 mm for the CHG group was less than
the data of Hubbard et al.,
26
who found 2.4 mm of
Kloehn type CHG movement in four months.
A potentially undesirable effect of Pendulum appli-
ance treatment is excessive distal tipping of the upper
first molars. According to the U6-PP measurement,
the maxillary first molars were tipped distally 15.1
degrees in the Pendulum and 0.9 degrees in the CHG
group. Gosh and Nanda,
14
and Byloff and
Darendeliler
15
found tipping, as a result of the
Pendulum appliance treatment, to range from 8.3
and 14.5 degrees. The value of 15.1 degrees of
tipping of the first molar was similar to the 14.5
degrees of distal tipping described by Byloff and
Darendeliler,
15
when the original Pendulum design
was evaluated. The small amount of molar tipping in
the CHG group was contrary to the findings of
Ringenberg and Butts,
27
who reported substantial
tipping. Byloff and Darendeliler
15
attempted to cor-
rect molar tipping by incorporating an uprighting
bend in the Pendulum spring after distalisation of the
molar had been completed. The uprighting bend
appeared to be successful in uprighting the roots of
the tipped molars, but has the potential to increase
anchorage loss.
The Pendulum appliance group suffered mild
anchorage loss as defined by maxillary incisor pro-
trusion (U1-APo mm) (mean differences 1.05 mm)
and increased overjet (mean differences 0.54 mm).
TOY AND ENACAR
No clinical importance was attributed to the changes
because of their minor nature. U5-ANS, U1-PP and
U1-APo angles showed no statistically significant
changes during treatment. Anchorage loss, as defined
by the significant maxillary incisor proclination and
concomitant increase in overjet has been clearly
shown previously.
15
The present study determined a
comparatively smaller increase in overjet.
The possible bite-opening effect of CHG is well
known, and so any appliance that is capable of distal-
ising molar teeth without adversely altering the ver-
tical dimension is advantageous in the treatment of
high-angle Class II and/or dentally crowded patients.
Distalisation and tipping of the upper first molars can
result in molar extrusion relative to the palatal plane
and therefore affect face height. In the present study
and in agreement with previous reports, the
Pendulum appliance produced clockwise mandibular
rotation, demonstrated by statistically significant
increases (1.63 degrees) in LAFH.
1,17
In addition, a
statistically significant increase (0.66 mm) in maxil-
lary depth was seen in the same group. However, over
the short time frame of treatment, no statistically sig-
nificant skeletal differences were observed in the CHG
group. According to Ghosh and Nanda,
14
a small
backward rotation of the mandible (Mean 1.09 ) was
reported following CHG use. While there was a trend
toward an increase in the mandibular plane angle
observed after treatment, it was not statistically sig-
nificant. In the opinion of Ngantung et al.,
28
the
increase in LAFH during treatment was a result of
normal vertical craniofacial growth. Burkhardt et al.
29
explained the change as an increase in inclination
of the mandibular plane as a result of Pendulum
appliance effects.
An advantage of CHG is that as molar distalisation
occurs, distal movement of the maxillary incisors also
takes place. This implies a decrease in overjet, which
is a desired aim in the treatment of Class II division 1
malocclusions. However, when the maxillary molars
are distalized by an intra-oral appliance, anchorage
loss or forward movement of the anterior teeth is like-
ly.
14,15,3033
The maxillary incisors were proclined by
2.1 degrees and protruded by 1.05 mm by the Pen-
dulum appliance and retroclined by 1.67 degrees and
retruded by 0.62 mm in the CHG group. A similar
amount of mesial and distal movement of maxillary
incisors was observed by Bondemark and Karlsson
19
for intra-oral and extra-oral appliances. Escobar et
al.
34
and nag et al.
35
described distal incisor move-
ment in their implant-supported Pendulum appli-
ance groups. In contradistinction, Taner et al.
18
found that incisors showed a significant amount of
proclination due to molar distalisation following
Pendulum appliance treatment. In support of Taner
et al.,
18
additional authors
9,14,30,36
have reported pro-
clination of anterior teeth during molar distalisation
with intra-oral mechanics.
Conclusion
The findings demonstrated that the Pendulum appli-
ance was more effective than CHG in producing
distal movement of the maxillary first molars. The
distalisation time and rate of movement were sig-
nificantly shorter with the Pendulum appliance
compared with CHG. However, this gain in molar
distalisation was at the expense of significant side
effects, including molar tipping and anchorage loss at
the incisors. CHG treatment produced more upright
molar distalisation and a decrease in overjet. Molar
distalisation occurred without any significant changes
to the mandibular plane angle. To achieve success-
ful results, the effects of each treatment modality
on dentofacial structures need to be taken into
individual patient consideration.
Dr Ebubekir Toy
I
nn niversitesi, Dis hekimligi Fakltesi

Ortodonti Anabilim Dal, Kamps
44280 Malatya
Turkey
Email: ebubekirtoy@hotmail.com
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of a pendulum appliance for molar distalization related to
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Dentoalveolar and skeletal changes associated with the pen-
dulum appliance followed by fixed orthodontic treatment.
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24. Gelgor IE, Karaman AI, Buyukyilmaz T. Comparison of 2
distalization systems supported by intraosseous screws. Am J
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25. Gelgor IE, Buyukyilmaz T, Karaman AI, Dolanmaz D,
Kalayci A. Intraosseous screw-supported upper molar distal-
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26. Hubbard GW, Nanda RS, Currier GF. A cephalometric eval-
uation of nonextraction cervical headgear treatment in Class
II malocclusions. Angle Orthod 1994;64:35970.
27. Ringenberg QM, Butts WC. A controlled cephalometric
evaluation of single-arch cervical traction therapy. Am J
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28. Ngantung V, Nanda RS, Bowman SJ. Posttreatment evalua-
tion of the distal jet appliance. Am J Orthod Dentofacial
Orthop 2001;120:17885.
29. Burkhardt DR, McNamara JA Jr, Baccetti T. Maxillary molar
distalization or mandibular enhancement: a cephalometric
comparison of comprehensive orthodontic treatment includ-
ing the pendulum and the Herbst appliances. Am J Orthod
30. Bondemark L, Kurol J. Distalization of maxillary first and
second molars simultaneously with repelling magnets. Eur J
Orthod 1992;14:26472.
31. Bondemark L. A comparative analysis of distal maxillary
molar movement produced by a new lingual intra-arch Ni-Ti
coil appliance and a magnetic appliance. Eur J Orthod 2000;
22:68395.
32. Papadopoulos MA, Mavropoulos A, Karamouzos A.
Cephalometric changes following simultaneous first and sec-
ond maxillary molar distalization using a non-compliance
intraoral appliance. J Orofac Orthop 2004;65:12336.
33. Fortini A, Lupoli M, Giuntoli F, Franchi L. Dentoskeletal
effects induced by rapid molar distalization with the first
class appliance. Am J Orthod Dentofacial Orthop 2004;125:
697705.
34. Escobar SA, Tellez PA, Moncada CA, Villegas CA, Latorre
CM, Oberti G. Distalization of maxillary molars with the
bone supported pendulum: a clinical study. Am J Orthod
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implants with pendulum springs for maxillary molar distal-
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Orthop 2007;131:1626.
36. Keles, A, Saynsu K. A new approach in maxillary molar dis-
talization: intraoral bodily molar distalizer. Am J Orthod
Introduction
Adolescence is a period of profound physiological and
psychosocial change that is also associated with
altered nutritional needs.
1
Adolescents are vulnerable
because of increased dietary requirements during this
period when changes in lifestyle and food habits
greatly affect nutrient intake.
2
In addition, adoles-
cents are typically involved in orthodontic treatment,
during which modified nutritional needs are required
but poor dietary behaviour is likely.
3
It is accepted
that orthodontic treatment causes pressure sensitivity
to the teeth which leads to pain, discomfort and func-
tional limitations.
47
The mastication of hard foods is
therefore difficult for patients and there is a tendency
for soft foods to be eaten. The avoidance of hard-to-
chew natural foods usually involves the elimination of
solid foods such as raw vegetables and fresh fruit,
811
stringy foods such as meat
1214
and dry foods such as
bread or bagels
12,13
from the diet.
A previous examination of patient nutrient intake
before and after orthodontic adjustment reported a
decrease in the intake of copper and manganese and
Australian Society of Orthodontists Inc. 2011 Australian Orthodontic Journal Volume 27 No. 1 May 2011 17
Comparison of dietary intake between fixed
orthodontic patients and control subjects
Alireza Sarraf Shirazi,
*
Majid Ghayour Mobarhan,
Elham Nik,
+
Navid Kerayechian
and Gordon A. Ferns
Department of Pediatric Dentistry and the Dental Research Center;

*
Cardiovascular Research Center and Biochemistry and Nutrition Research
Center,
Mashhad University of Medical Sciences, Mashhad, Iran; Department of Pediatric Dentistry, Ahvaz University of Medical Sciences,
Ahvaz, Iran;
+
Department of Orthodontics, Mashhad University of Medical Sciences, Mashhad, Iran
and the Institute for Science and

Technology in Medicine, University of Keele, United Kingdom
Background: Adolescence is a period of rapid physiological and psychological development which is associated with an
increased demand in nutritional requirements. Orthodontic therapy is also commonly initiated during this phase of life and
nutritional intake may also change during treatment.
Aims: To compare the nutrient intakes of adolescents wearing fixed orthodontic appliances and a control group matched for
age and gender.
Method: A total of 180 patients aged between 15 and 17 years participated in this study (90 in the study group and 90
controls). Demographic data were collected by questionnaire and dietary intake was assessed using a 24-hour memory recall
and was analysed using Dietplan6 software (Forestfield Software Ltd, UK). Comparisons between groups were assessed by the
Independent sample t- test and the SPSS was used for statistical analysis.
Results: Orthodontic patients consumed a similar number of total calories, protein and carbohydrate (p > 0.05); however, they
had a greater intake of total fat, saturated fat, monosaturated fat, polysaturated fat, linolenic fat, linoleic fat and cholesterol and
significantly lower intake of fibre, chromium and beta-carotene (p < 0.05) compared with the Control group. The intake of
other macro- and micro-nutrients did not differ significantly between groups.
Conclusions: Adolescents receiving orthodontic treatment have an altered dietary intake that can be harmful to their health.
As adolescents are at a critical stage of development and dietary intake is of particular importance, it is recommended that
targeted nutritional guidance is provided to patients during orthodontic treatment.
Received for publication: August 2010
Accepted: December 2010
Alireza Sarraf Shirazi: SarrafA@mums.ac.ir
Majid Ghayour Mobarhan: GhayourM@mums.ac.ir
Elham Nik: Nike861@mums.ac.ir
Navid Kerayechian: Kerayechiann861@mums.ac.ir
Gordon A Ferns: g.a.a.ferns@istm.keele.ac.uk
SHIRAZI ET AL
a possible detrimental effect on the rate of tooth
movement.
15
Orthodontists recommend that patients
avoid hard foods that may cause appliance damage
which, in turn, may affect nutrient intake. Moreover,
occlusal changes during treatment may also impair
mastication and patients may cope by altering their
diet or by swallowing coarse particles leading to diges-
tive disorders. In both circumstances, impaired dietary
intake may increase nutrition-induced disease risks.
16
In 1981, Nanda and Hickory
3
stated that, although
orthodontists rarely see manifestations of nutritional
deficiencies in their patients, suboptimal levels of
certain nutrients are common and may affect the bio-
logic response of tissues. It has been reported that
between 17 and 72 per cent of orthodontic patients
may have suboptimal levels of ascorbic acid and a
deficiency may affect the connective tissue of the
periodontal ligament and the formation of
osteoid.
17,18
In addition, nutritional stress to the
periodontium, coupled with the irritation of ortho-
dontic bands and brackets, may cause an altered
gingival response.
3
There are few reports that have examined the effects
of orthodontic treatment on a patients diet.
Therefore, the aim of the present study was to com-
pare the dietary intake of individuals receiving ortho-
dontic treatment with healthy teenagers who were
gender and age matched.
Material and methods
Subjects
Two groups totalling 180 adolescents aged 15 to 17
years participated in the study. Each group contained
90 individuals; 31 boys and 59 girls in the
Orthodontic treatment group and 34 boys and 56
girls in the Control group. The sample was derived
from teenagers seeking orthodontic treatment in the
Mashhad Faculty of Dentistry, Mashhad, Iran. The
socioeconomic status of the two groups was com-
parable and comprehensive orthodontic treatment of
the test group had been implemented for at least six
months prior to the nutritional assessment. Orthog-
nathic surgery patients were excluded from the study.
The Control group comprised individuals between
15 to 17 years of age, who were eligible but yet to
receive orthodontic treatment. Patients in the con-
trol group who had active dental disease were also
excluded from the study.
All patients provided informed consent and partici-
pation in the study was approved by the Ethics
Committee of the Research Council of Mashhad
University of Medical Sciences.
Anthropometric assessment
Measurements of the height (in centimetres) and
weight (in grams) were performed in all subjects.
Height was measured to the nearest millimetre with a
wall-mounted Harpenden stadiometer (Holtain Ltd,
Croswell, Crymych, UK) and weight was measured
with electronic scales (Model 1609N; Tanita
Corporation, Tokyo, Japan) to the nearest 0.1 kg.
Body mass index (BMI) in kg/m
2
was also calculated.
Dietary assessment
A questionnaire was designed to collect demographic
data (age, gender) as well as information regarding
the 24-hour dietary recall. A trained interviewer
asked subjects in a face-to-face interview, to recall and
describe every item of food and drink consumed
over the previous 24 hours.
2
The recording of foods
and beverages for individuals who were ill at the
scheduled time for dietary assessment were postponed
to the next appointment. Individual nutritional
intakes were assessed with the use of Dietplan
6
soft-
ware (Forestfield Software Ltd., UK) which can
analyse and identify macro and micro nutrient intake.
The results obtained from the Nutrition Analysis
Software were entered into the SPSS software for
statistical analysis. Comparisons of macro-and micro-
Table I. Demographic data of the orthodontic patients and the control
subjects.
Orthodontic group Control group p
*
N = 90 N = 90
Age (years) 15.95 1.40 15.91 1.38 0.348
Weight (kg) 53.85 8.93 54.60 9.20 0.766
Height (cm) 162.80 7.55 159.85 7.53 0.178
BMI (kg/m
2
) 20.55 2.56 21.58 2.24 0.435
Values expressed as Mean SD
*
Students t- test
BMI, body mass index
nutrient dietary intake between the Orthodontic
group and the Control group were assessed by the
Independent sample t-test with a Bonferroni correc-
tion for multiple measurements. A p value < 0.05 was
considered significant.
Results
The descriptive statistics including the means and
standard deviations of demographic data (in both
groups) are presented in Table I. The mean values of
age, height, weight and BMI of the Orthodontic
group were not significantly different from the
Control group (p > 0.05).
Comparison of the macronutrient intakes
The orthodontic patients had a markedly greater
intake of total fat (p = 0.011), cholesterol (p = 0.004),
saturated fat (p = 0.002), monosaturated fat
(p = 0.04), polysaturated fat (p = 0.043), linoleic fat
(p = 0.039), linolenic fat (p = 0.045) and significant-
ly lower intake of fibre (p = 003) in comparison with
the Control group, but consumed a similar number
of calories, protein and carbohydrate (Table II).
Comparison of the micronutrient intakes
The mean intakes of chromium (p = 0.024) and beta-
carotene (p < 0.001) in the Control group were
DIETARY INTAKE COMPARISONS
Table II. Dietary intake of calories and macronutrients of orthodontic patients and control subjects.
Calories/Macronutrients Mean intake p*
Orthodontic group Control group
N = 90 N = 90
Food energy (kcal) 1703.66 608.92 1634.68 738.130 0.492
Fat
Total fat (g) 69.88 35.33 56.54 34.93 0.011
Cholesterol (mg) 232.26 186.74 166.05 111.090 0.004
Saturated fat (g) 23.39 14.03 17.75 9.700 0.002
Monounsaturated (g) 20.77 11.40 17.01 13.10 0.040
Polyunsaturated (g) 20.31 13.81 16.16 13.79 0.043
Oleic fat (g) 12.86 9.79 10.88 12.11 0.227
Linoleic fat (g) 18.11 13.68 14.11 12.29 0.039
Linolenic fat (g) 0.91 1.26 0.58 0.90 0.045
EPA-Omega 3 (g) 0.003 0.017 0.0001 0.0010 0.068
DHA-Omega 3 (g) 0.02 0.086 0.008 0.010 0.222
Carbohydrates
Total carbohydrates (g) 212.08 85.270 226.32 112.57 0.337
Sugar (g) 63.58 39.81 74.62 49.65 0.100
Glucose (g) 9.04 9.67 020.98 105.85 0.288
Galactose (g) 3.30 3.00 3.71 5.56 0.538
Fibre
Dietary fibre (g) 9.47 7.04 12.70 9.370 0.007
Soluble fibre (g) 0.20 0.25 0.39 0.58 0.003
Insoluble fibre (g) 1.46 2.03 2.57 3.47 0.009
Crude fibre (g) 4.22 3.04 4.92 4.37 0.215
Protein (g) 69.29 29.78 66.57 34.19 0.568
*
Students t-test, significant values in bold
EPA, eicosapentaenoic acid
DHA, docosahexaenoic acid
SHIRAZI ET AL
significantly higher compared with the Orthodontic
group. The nutrition analysis indicated that there
were no significant differences between two groups
in the intake of other vitamins and trace elements
(Table III).
Discussion
The most important finding of this study was the sig-
nificantly higher intake of fat and lower intake of
fibre in the Orthodontic group compared with the
Control group. In addition, the intake of chromium
and beta-carotene was lower in the Orthodontic
group relative to the Control group. Furthermore, the
intake of saturated, monosaturated and polysaturated
fat and cholesterol was significantly higher in the
Orthodontic group.
Consistent with the present findings, Riordan
15
showed that the intake of fat was higher after ortho-
dontic adjustment. However, the differences that
have been previously reported did not reach statistical
significance. This may be possibly related to the small
sample size (10 participants; 3 boys, 7 girls between
the ages of 12 and 16 years) and the short time of
intervention in the earlier study.
Saturated fatty acids are reported to be a risk factor
for atherosclerosis and increased cholesterol and
saturated fatty acid intake increases the risk of cardio-
vascular disease.
1921
In addition, it is known that a
diet high in fat is associated with obesity, which in
turn increases the risk of hypertension,
22
cardiovas-
cular disease and noninsulin-dependent diabetes.
23,24
Further concern was noted in the dietary intake of
Table III. Dietary intake of vitamins and trace elements (Micronutrients) of orthodontic patients and control subject
Vitamins, minerals and Mean intake p*
trace elements Orthodontic group Control group
N = 90 N = 90
Sodium (mg) 2533.49 1287.97 2267.21 1677.78 0.231
Potassium (mg) 2513.76 1089.15 2860.09 1682.35 0.099
Iron (mg) 9.47 4.59 9.11 5.92 0.648
Calcium (mg) 1007.68 583.72 1033.16 891.85 0.820
Magnesium (mg) 253.50 122.54 258.14 136.03 0.809
Phosphorus (mg) 1231.85 587.50 1237.29 891.76 0.961
Zinc (mg) 8.78 4.08 8.39 5.00 0.569
Copper (mg) 1.13 0.87 1.14 1.15 0.935
Manganese (mg) 2.96 2.39 3.05 1.75 0.765
Chromium (mg) .016 .018 .026 .034 0.024
Vitamin A (Ug) 0 834.87 1055.91 767.40 704.67 0.612
Beta-Carotene (Ug) 072.10 114.70 278.34 528.57 <0.0010
Vitamin E (mg) 10.74 11.33 9.92 6.06 0.541
Thiamin(B1) (mg) 1.27 0.56 1.42 0.85 0.176
Riboflavin(B2) (mg) 1.92 1.14 2.01 1.62 0.682
Niacin (B3) (mg) 15.60 9.77 16.92 9.99 0.369
Pyridoxine (B6) (mg) 1.13 0.57 1.40 1.19 0.052
Folic Acid (Ug) 228.13 129.56 226.70 152.27 0.946
Cobalamin(B12) (Ug) 2.78 1.84 2.30 1.82 0.076
Pantothenic Acid (mg) 3.00 1.62 3.06 2.02 0.838
Vitamin C (mg) 78.32 76.39 100.00 84.18 0.070
Vitamin D (Ug) 1.61 1.83 1.18 1.86 0.119
Vitamin K (mg) 68.64 93.94 68.06 92.21 0.966
* Students t- test, significant values in bold
fibre which was lower in orthodontic patients com-
pared with control subjects. Fibre has been shown to
have beneficial physiological functions in the gastro-
intestinal tract and in reducing the risk of coronary
artery disease and cancer.
2
Fibre binds bile acids and
increases the excretion of bile acid-derived choles-
terol. It also prevents dietary fat and cholesterol absorp-
tion by the binding of bile acids to fat and lipids.
2
Chromium is involved in insulin secretion and also
supports normal cholesterol levels. Chromium
deficiency results in insulin resistance and lipid
abnormalities have also been reported.
2,24
Foods rich
in beta-carotene protect the cells from the damaging
effects of free radicals, provide a source of vitamin A,
enhance the functioning of the immune system and
maintain a healthy reproductive system. Food sources
of beta-carotene include sweet potatoes, carrots,
spinach, turnips and green leaf vegetables.
2,25,26
It is
possible that the significant difference in carotene
intake between the groups was due to the low con-
sumption of hard vegetables (especially carrots) in
orthodontic patients during the treatment. The lower
intake of fibre and vitamin C (although not sig-
nificantly different) in orthodontic patients in com-
parison with control subjects is consistent with this
finding. Riordans
15
results demonstrated that the
intake of copper and manganese decreased signifi-
cantly after orthodontic adjustment; however, in the
present study, although the intake of these two
elements was lower in the Orthodontic group, the
difference was not statistically significant.
The results of Riordans
15
study of the dietary changes
and nutrient intake before and after orthodontic
adjustment reflected the short study time frame.
Alterations in nutrient intake are likely to occur over
longer-term orthodontic treatment. Past studies have
demonstrated that an adaptation to pain and discom-
fort occurs during the first week after the placement
of the orthodontic appliances.
2732
In the present
study, the 24-hour memory recall was obtained
approximately three or four weeks after the ortho-
dontic adjustment visit, at a time when patients were
experiencing little pain and pressure sensitivity.
However, the results indicated that nutrient intake
had been affected and likely due to poor dietary
behaviour established during the treatment rather
than from short-term discomfort.
A limitation of the present study is its cross-sectional
design. It is not possible to be certain that the
associations between fixed orthodontic therapy and
the nutrient intake of the patients are directly related.
The 24-hour recall method of data collection requires
individuals to remember the specific amounts of
food consumed in the previous 24 hours.
2
Patients
did not anticipate that their diet was being analysed
and therefore ate normally. However, the inability to
accurately recall and the uncertainty regarding the
patients normal intake, produce possible flaws in the
methodology.
2
According to Proffit,
33
patients with severe malocclu-
sion often have difficulty in normal mastication.
These individuals have learnt to avoid certain foods
that are hard to incise and chew, and may have
problems with cheek and lip biting.
33
Therefore, it is
possible that an altered nutrient intake during ortho-
dontic treatment could be due to the malocclusion
and not the orthodontic therapy per se. Therefore, to
eliminate this bias, matched control subjects were
selected and assessed from individuals who were
awaiting orthodontic therapy.
Conclusions
Fixed orthodontic therapy may have an associated
bearing on the nutrient intake of patients. In the pres-
ent report, the most important changes were in the
intake of foods containing fats and fibre.
A significantly higher intake of fat and lower intake of
fibre were characteristics of orthodontic patients in
comparison with a matched Control group. This may
increase the risk of cardiovascular diseases and cancer
in these patients.
It is recommended that nutritional guidance be pro-
vided to orthodontic patients and in this respect, the
help of a dietitian may be worthwhile.
Associate Professor Majid Ghayour Mobarhan
Cardiovascular Research Center
Biochemistry and Nutrition Research Center
Faculty of Medicine
Mashhad University of Medical Sciences
Mashhad
Iran
Tel: +98-511-8828573
Fax: +98-511-8828574
Email: GhayourM@mums.ac.ir
DIETARY INTAKE COMPARISONS
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Introduction
It is important that treatment outcomes of patients
who present with cleft lip and palate are regularly
evaluated, to ensure quality and consistency of patient
care, as well as allow outcome comparisons between
different cleft care centres.
13
For clinical audits to be
conducted effectively, emphasis should be placed on
the development of methods of assessing treatment
outcomes.
4
Previous reports have recommended
indices that assess arch relationships and one sug-
gested method is to measure the degree of crossbite
for individual teeth in order to calculate an overall
score.
5,6
However, this method can be cumbersome
and time-consuming and inaccurately represent the
overall severity of the malocclusion. It is possible that
a mild generalised irregularity may yield a higher
score than a more severe but localised anomaly.
4
An effective method used in a number of multicentre
audits to assess dental arch relationships in complete
unilateral cleft lip and palate patients (UCLP) is the
Goslon (Great Ormond Street London and Oslo)
Yardstick.
7,8
Unlike other indices, the Goslon
Yardstick assesses the difficulty of orthodontic cor-
rection as well as the severity of malocclusion. The
measure has been shown to be simple and reliable
when used by calibrated examiners.
7,9,10
It allows
Evaluation of primary surgical outcomes in New
Zealand patients with unilateral clefts of the lip
and palate
Hannah C. Jack,
*
Joseph S. Antoun
*
and Peter V. Fowler
Orthodontic Department, School of Dentistry, University of Otago, Dunedin

*
and the Oral Health Centre, Christchurch Hospital,
Christchurch,
New Zealand
Objective: To evaluate and compare the primary surgical outcomes of complete unilateral cleft lip and palate (UCLP) patients in
two New Zealand cleft care centres.
Methods: This is a retrospective study of two providers of cleft care in New Zealand: Centre A in the North Island and Centre
B in the South Island of New Zealand. Pre-orthodontic study models were evaluated from 28 UCLP patients from Centre A with
primary surgical repairs performed between 19871999 and 31 UCLP patients from Centre B with primary surgical repairs
performed between 19842000. Dental arch relationships were measured using the Goslon Yardstick. A Goslon score of 1 is
considered to be an excellent outcome, whereas a score of 5 is a very poor treatment outcome.
Results: Intra- (Kappa: 0.84 0.93) and inter-examiner (Kappa: 0.63 0.69) reliabilities revealed good to very good agree-
ment between examiners using the Goslon Yardstick. The mean Goslon score for Centre A was 3.5, with no cases in Group 1,
five cases in Group 2 (17.9 per cent), nine cases in Group 3 (32.1 per cent), 11 cases in Group 4 (39.3 per cent) and three
cases in Group 5 (10.7 per cent). The mean score for Centre B was 3.1, with one case in Group 1 (3.2 per cent), nine cases
in Group 2 (29.0 per cent), eight cases in Group 3 (25.8 per cent), 11 cases in Group 4 (35.5 per cent) and two cases in
Group 5 (6.5 per cent). There were no statistically significant differences between the two centres (p > 0.05).
Conclusions: The outcome scores from the two cleft centres, based on historic records, were disappointing and higher than
expected. It is recommended that a review of primary surgical protocols be implemented to ensure outcomes comparable with
international standards. The results provide useful benchmarks for future comparisons of treatment.
Received for publication: June 2010
Hannah C. Jack: hcajack@gmail.com
Joseph S. Antoun: joe.antoun@gmail.com
Peter V. Fowler: peter.fowler@braces.co.nz
JACK ET AL
categorisation of dental arch relationships in the late
mixed or early permanent dentition stage into five
discrete categories. The anteroposterior relationship
of the arches is of greatest clinical importance as it
reflects the underlying skeletal relationship.
Generalised dental crowding and irregularity is rela-
tively less important. Accordingly, Goslon Groups 1
and 2 (excellent/good result) have occlusions that
require simple orthodontic treatment or none at all,
while Group 3 (fair result) requires complex ortho-
dontic treatment to correct malocclusions, although a
good result can be anticipated. In contrast, Goslon
Groups 4 and 5 (poor/very poor result) have poor
dental arch relationships and often require orthog-
nathic surgery to correct underlying skeletal
disharmonies.
4,7
Previous studies have suggested a higher rate of non-
syndromic orofacial clefts in New Zealand compared
with European studies.
1113
Previously reported New
Zealand data has revealed an incidence of 1.5 to 1.94
per 1000 live births in patients of European
descent
1113
and 2.26 per 1000 live births in patients
of Maori descent.
12
In contrast, the incidence in the
United Kingdom and in most parts of Europe ranges
from 1.28 to 1.81 per 1000 live births.
14,15
The
relatively high incidence of non-syndromic orofacial
clefts in New Zealand further illustrates the impor-
tance of auditing and assessing the outcome of
primary surgery, in order to achieve sustainability of
improved cleft care standards.
Treatment outcomes of cleft care in New Zealand
have not been previously audited using the Goslon
Yardstick. Therefore, the aim of this study was to
evaluate and compare the primary surgical outcomes
of complete unilateral cleft lip and palate (UCLP)
patients in two New Zealand cleft care centres using
this Yardstick. A secondary objective was to compare
the New Zealand findings with those from the
Eurocleft study
1,7
which examined primary surgical
outcomes in six European centres. It is expected that
the data will provide a useful baseline against which
future national clinical audits may be compared.
Materials and methods
An audit of primary surgical treatment outcomes in
New Zealand children with complete UCLP was car-
ried out in June 2008. The study included two
providers of cleft care identified as Centre A in the
North Island and Centre B in the South Island of
New Zealand. The sample consisted of 28 UCLP
patients presenting consecutively for alveolar bone
grafting from Centre A from 19871999, and 31
UCLP patients presenting consecutively for alveolar
bone grafting from Centre B from 19842000.
All had a history of non-syndromic complete uni-
lateral cleft lip and palate, with surgical lip repair
completed approximately 3 months after birth and
palate repair approximately 9 months after birth.
Patients with Simonarts bands were excluded and all
patients were reassessed prior to commencing ortho-
dontic treatment.
Dental study models were obtained from the ortho-
dontic clinics of the dental departments of the two
respective hospitals, and de-identified. The models
were assessed by two orthodontists experienced in
cleft care and who had been calibrated in the use of
the Goslon Yardstick. During assessor calibration,
very good intra-examiner agreement (Weighted
Kappa: 0.82, 0.89) and good inter-examiner agree-
ment (Weighted Kappa: 0.77) was demonstrated. A
set of Goslon reference models representing each
Yardstick category was available for comparison and
reference during the model assessment. Each assessor
worked independently and repeated the model exam-
ination in order to evaluate intra-examiner reliability.
Neither assessor was associated with the two cleft care
centres involved in the present audit.
Data were analysed using the Statistical Package for
Social Sciences (SPSS v 16.0, SPSS Incorporated,
Chicago, IL, USA). Bivariate associations were inves-
tigated using Chi-squared tests with the alpha level
set to 0.05. Intra-examiner and inter-examiner
reliabilities were calculated using weighted Kappa
statistics.
16
A Kappa statistic greater than 0.6 indi-
cated good agreement, while one greater than 0.8
indicated very good agreement.
17
Results
The mean age of the sample was 9.9 years (S.D: 1.53)
in Centre A and 9.6 years (SD: 1.69) in Centre B.
There were greater proportions of males and left-
sided UCLP patients in both centres (Table I). No
statistically significant differences in patient demo-
graphics were found between the two centres.
The intra-examiner reliability of both examiners
was very good, as indicated by the Weighted Kappa in
the Centre A (Examiner A: 0.93; Examiner B: 0.84)
and Centre B samples (Examiner A: 0.91; Examiner
B: 0.86). The inter-examiner reliability was also
considered good (Weighted Kappa: > 0.6) in both
centres. The distribution of Goslon scores for the
New Zealand centres is shown in Table II. The mean
Golson score for Centres A and B were 3.5 and 3.1
respectively. There were no statistically significant dif-
ferences in the Goslon score between the two centres.
Centre A and Centre B performed similarly to the
worst ranked of the European centres reported by the
Eurocleft study
1,7
(Figure I). Nearly half of the Centre
A and Centre B samples were classified as having
poor/very poor (Groups 4 and 5) treatment outcomes.
Discussion
The Goslon Yardstick was used to evaluate dental
arch relationships and primary surgical treatment
outcomes of complete UCLP in two New Zealand
cleft care centres. This Yardstick has been widely used
and shown to be a reliable and robust means of meas-
urement when used in multicentre audits.
1,4,810,1820
Although subjective,
4
it is a rapid and simple way of
measuring dental arch relationships. It has the
benefit of being based on the clinical features that are
most difficult to treat, thus giving a practical indica-
tion of the requirements of treatment, whether by
orthodontics or a combination of orthodontics and
surgery.
7
The Eurocleft study
1,7
involved the direct Goslon
Yardstick comparison of treatment outcomes from six
European treatment centres. It showed that cen-
tralised and standardised treatment protocols, in cleft
centres that managed a large number of clefts, were
associated with the best treatment results. A compar-
ison of the Goslon ratings between the Eurocleft
study and the New Zealand UCLP audit indicates
that New Zealand patients would benefit from
improvements in primary cleft care. The difference in
the standard of treatment outcomes between the New
Zealand sample and those of the best Eurocleft
centres appears to be considerable. For example, the
proportion of patients with poor treatment outcomes
(Groups 4 and 5) in the present sample (46 per cent)
was most comparable with the centre which had the
worst treatment outcome of the European centres. By
comparison, the three best centres in the Eurocleft
study had fewer than 10 per cent of its samples in
Groups 4 or 5.
7
The present studys findings suggest
that a large proportion of the New Zealand patients
are likely to have underlying skeletal discrepancies
that may require future orthognathic surgery.
There were no statistically significant differences in
treatment outcome between the two cleft care cen-
tres, even though different surgical techniques for
palatal repair were preferred by each centre. The pref-
erence in Centre A was for the Wardill-Kilner pro-
cedure, which was performed by a number of surgeons.
Centre B had one operating surgeon who preferred
the Von Langenbeck procedure. Ethnic data for this
sample was not recorded and any racial variations
within the sample, which may affect the Golson
ratings, were not considered.
Overall, the audit results were disappointing. A pos-
sible reason to explain the unsatisfactory treatment
outcomes observed in New Zealand is the relatively
low population density and the low number of sur-
SURGICAL OUTCOMES IN UCLP PATIENTS
Table I. Sociodemographic characteristics and distribution of UCLP loca-
tion in the New Zealand study samples.
NZA NZB Total
N (Per cent) N (Per cent) N (Per cent)
Gender
Male 16 (57.1) 22 (71.0) 38 (64.4)
Female 12 (42.9) 9 (29.0) 21 (35.6)
Age
710 years 19 (67.9) 23 (74.2) 42 (71.2)
1114 years 9 (32.1) 8 (25.8) 17 (28.8)
Location
Left 16 (57.1) 19 (61.3) 35 (59.3)
Right 12 (42.9) 12 (38.7) 24 (40.7)
Table II. Goslon Yardstick distribution in the New Zealand study
samples.
Golson grade NZA NZB Total
N (Per cent) N (Per cent) N (Per cent)
Group 1 0 (0.0) 1 (3.2) 1 (1.7)
Group 2 5 (17.9) 9 (29.0) 15 (25.4)
Group 3 9 (32.1) 8 (25.8) 16 (27.1)
Group 4 11 (39.3) 11 (35.5) 21 (35.6)
Group 5 3 (10.7) 2 (6.5) 6 (10.2)
JACK ET AL
gical patients. At present, there are five treatment
centres throughout New Zealand, with varying num-
bers of cleft patients. To centralise the New Zealand
treatment model further would mean increasing
travel distances for patients which adds to the burden
of care associated with UCLP. However, a centralised
model would help increase operator volume, which
has been suggested as an important factor in
treatment proficiency and outcome.
2,19
It is also worthwhile noting that the collected data is
historical and the audited cleft centres have moved to
a model in which all primary surgery is performed by
a principal surgeon in each centre. The effects of such
a model on primary surgical outcomes will be evalu-
ated at a later date in an expanded plan to assess all
cleft care centres in New Zealand.
Although the present audit used the Goslon
Yardstick, it is noteworthy that UCLP evaluation
involves other indices. Factors such as hearing, speech
and facial profile, as well as self-reported quality of
life, are additional parameters which must be taken
into account when assessing overall treatment out-
come. Improvements in skeletal base relationships
should not come at the expense of any of the other
parameters.
A Clinical Standards Advisory Group report
2
advised
that for a high standard of cleft care to be achieved, a
national comprehensive database is needed. A New
Zealand database was established in 2000 to ensure
uniform data collection for all cleft patients. This data
was unavailable for the current study. It is expected to
provide a valuable resource and source of information
for future clinical audits as it will contain more
detailed, robust and standardised data of New Zealand
cleft patients. Ethnicity data is now routinely col-
lected which will allow for future research into the
incidence and treatment of orofacial clefts in ethnic
minorities.
Conclusions
The primary surgical outcomes of complete UCLP
patients in New Zealand were audited in two cleft
care centres using the Goslon Yardstick. There
were no statistically significant differences between
the two New Zealand treatment centres, even though
different primary palatal repair surgical procedures
were preferred. The overall treatment outcomes from
New Zealand compare unfavourably with the
European centres reported in the Eurocleft study.
Future national clinical audits need to be carried
0 10 20 30 40 50 60 70 80 90 100
Per cent
Figure 1. Comparisons of Golson score distributions between the present study and the Eurocleft study.
7
C
l
e
f
t

c
e
n
t
r
e
out to evaluate and improve the standard of cleft
care.
Acknowledgments
The authors would like to thank orthodontists Dr
David Healey from the University of Otago, Dr Matt
Barker from Hutt Hospital and Dr Heather Keall
from Middlemore Hospital for their help with the
study.
Dr Hannah Jack
Orthodontic Department
University of Otago
Dunedin
New Zealand
Tel: +64 27 307 7185
Fax: +64 3 477 0673
Email: hcajack@gmail.com
References
1. Shaw WC, Asher-McDade C, Brattstrm V, Dahl E,
McWilliam J, Mlsted K et al. A six-center international
study of treatment outcome in patients with clefts of the lip
and palate: Part 1. Principles and study design. Cleft Palate
Craniofac J 1992;29:3937.
2. Sandy J, Williams A, Mildinhall S, Murphy T, Bearn D,
Shaw B et al. The Clinical Standards Advisory Group
(CSAG) cleft lip and palate study. Br J Orthod 1998;25:
2130.
3. Semb G, Brattstrm V, Mlsted K, Prahl-Andersen B, Shaw
WC. The Eurocleft study: intercenter study of treatment
outcome in patients with complete cleft lip and palate.
Part 1: introduction and treatment experience. Cleft Palate
4. Mars M, Plint DA, Houston WJB, Bergland O, Semb G.
The Goslon Yardstick: a new system of assessing dental arch
relationships in children with unilateral clefts of the lip and
palate. Cleft Palate Craniofac J 1987;24:31422.
5. Huddart AG, Bodenham RS. The evaluation of arch form
and occlusion in unilateral cleft palate subjects. Cleft Palate
J 1972;9:194209.
6. Mossey PA, Clark JD, Gray D. Preliminary investigation of
a modified Huddart/Bodenham scoring system for assess-
ment of maxillary arch constriction in unilateral cleft lip
and palate subjects. Eur J Orthod 2003;25:2517.
7. Mars M, Asher-McDade C, Brattstrm V, Dahl E, Mlsted
K, McWilliam J et al. A six-center international study of
treatment outcome in patients with clefts of the lip and
palate: Part 3. Dental arch relationships. Cleft Palate
8. Mlsted K, Brattstrm V, Prahl-Andersen B, Shaw WC,
Semb G. The Eurocleft study: intercenter study of treatment
outcome in patients with complete lip and palate. Part 3:
dental arch relationships. Cleft Palate Craniofac J 2005;
42:7882.
9. Hathorn I, Roberts-Harry D, Mars M. The Goslon Yardstick
applied to a consecutive series of patients with unilateral
clefts of the lip and palate. Cleft Palate Craniofac J 1996;33:
4946.
10. Morris DO, Roberts-Harry D, Mars M. Dental arch rela-
tionships in Yorkshire children with unilateral cleft lip and
palate. Cleft Palate Craniofac J 2000;37:45362.
11. Hanify JA, Metcalf P, Nobbs CL, Worsley KJ. Congenital
malformations in the newborn in Northland: 19661977.
NZ Med J 1980;92:2458.
12. Chapman CJ. Ethnic differences in the incidence of cleft lip
and palate in Auckland, 19601976. NZ Med J 1983;96:
3279.
13. Fowler P, Esson I. Non-syndromal orofacial clefts in the
Canterbury/West Coast region, 19602000. NZ Dent J
2005;101:724.
14. Derijcke A, Eerens A, Carels C. The incidence of oral clefts:
a review. Br J Oral Maxillofac Surg 1996;34:48894.
15. Gregg T, Boyd D, Richardson A. The incidence of cleft lip
and palate in Northern Ireland from 19801990. Br J
Orthod 1994;21:38792.
16. Altman DG. Statistics in medical journals: developments in
the 1980s. Stat Med 1991;10:1897913.
17. Landis JR, Koch GG. An application of hierarchical kappa-
type statistics in the assessment of majority agreement
among multiple observers. Biometrics 1977;33:36374.
18. Williams AC, Bearn D, Mildinhall C, Murphy T, Sell D,
Shaw WC et al. Cleft lip and palate care in the United
Kingdom the Clinical Standards Advisory Group (CSAG)
Study. Part 2: Dentofacial outcomes and patient satisfaction.
Cleft Palate Craniofac J 2001;38:249.
19. Susami T, Ogihara Y, Matsuzaki M, Sakiyama M, Takato T,
Shaw WC et al. Assessment of dental arch relationships in
Japanese patients with unilateral cleft lip and palate. Cleft
Palate Craniofac J 2006;43:96102.
20. Zreaqat M, Hassan R, Halim AS. Dentoalveolar relation-
ships of Malay children with unilateral cleft lip and palate.
Cleft Palate Craniofac J 2009;46:32630.
SURGICAL OUTCOMES IN UCLP PATIENTS
Introduction
The bond strength of composite resin to an aged
composite restoration is frequently reduced, leading
to early failure of the resin addition.
17
Because the
usual method of etching the surface of the aged
restoration with phosphoric acid does not result in a
satisfactory bond strength, mechanical and chemical
methods of surface treatment have been tried. The
mechanical methods include sandblasting
8
or rough-
ening the surface of the restoration with rotating
tungsten carbide
8
or diamond burs.
9
The chemical
methods include longer exposure to phosphoric
acid,
1012
etching with hydrofluoric acid
13
or the
application of silane/coupling agents.
8,1215
However,
there is no agreement on a preferred protocol.
1618
The purpose of the present laboratory investigation
The effects of various surface treatments on the
shear bond strengths of stainless steel brackets to
artificially-aged composite restorations
Ladan Eslamian,
*
Ali Borzabadi-Farahani,
Nasin Mousavi
+
and Amir Ghasemi
$
Department of Orthodontics and Dental Research Center, School of Dentistry, Shahid Beheshti University of Medical Sciences, Tehran, Iran;
*
Craniofacial Orthodontics, Division of Dentistry and Orthodontics, Childrens Hospital Los Angeles, Center for Craniofacial Molecular Biology,
University of Southern California, Los Angeles, CA, USA;
Private Practice, Tehran, Iran

+
and Department of Operative Dentistry and Dental
Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
$
Objective: To compare the shear bond strengths (SBS) of stainless steel brackets bonded to artificially-aged composite
restorations after different surface treatments.
Methods: Forty-five premolar teeth were restored with a nano-hybrid composite (Tetric EvoCeram), stored in deionised water for
one week and randomly divided into three equal groups: Group I, the restorations were exposed to 5 per cent hydrofluoric
acid for 60 seconds; Group II, the restorations were abraded with a micro-etcher (50 m alumina particles); Group III, the
restorations were roughened with a coarse diamond bur. Similar premolar brackets were bonded to each restoration using the
same resin adhesive and the specimens were then cycled in deionised water between 5 C and 55 C (500 cycles). The
shear bond strengths were determined with a universal testing machine at a crosshead speed of 1 mm/min. The teeth and
brackets were examined under a stereomicroscope and the adhesive remnants on the teeth scored with the adhesive remnant
index (ARI).
Results: Specimens treated with the diamond bur had a significantly higher SBS (Mean: 18.45 3.82 MPa) than the
group treated with hydrofluoric acid (Mean: 12.85 5.20 MPa). The mean SBS difference between the air-abrasion
(Mean: 15.36 4.92 MPa) and hydrofluoric acid groups was not significant. High ARI scores occurred following abrasion
with a diamond bur (100 per cent) and micro-etcher (80 per cent). In approximately two thirds of the teeth no adhesive was
left on the restoration after surface treatment with hydofluoric acid.
Conclusion: Surface treatment with a diamond bur resulted in a high bond strength between stainless steel brackets and
artificially-aged composite restorations and was considered to be a safe and effective method of surface treatment. Most of the
adhesive remained on the tooth following surface treatment with either the micro-etcher or the diamond bur.
Received for publication: July 2010
Ladan Eslamian: l-eslamian@dent.sbmu.ac.ir
Ali Borzabadi-Farahani: afarahani@chla.usc.edu
Nasim Mousavi: nasim77m@yahoo.com
Amir Ghasemi: amir_gh_th@yahoo.com
EFFECT OF SURFACE TREATMENTS ON SHEAR BOND STRENGTH
was to compare the shear bond strengths (SBS) of
stainless steel brackets bonded to artificially-
aged composite restorations after different surface
treatments.
Specimen preparation
Forty-five recently extracted, non-carious human pre-
molars with sound buccal surfaces were obtained.
The teeth were cleaned, lightly pumiced and stored
in distilled water at room temperature before use. A
6 mm diameter by 1 mm deep cavity was cut in the
buccal surface of each tooth with a fissure bur and
etched with 37 per cent phosphoric acid solution for
30 seconds. The cavities were then rinsed, air dried
and a thin layer of Heliobond bonding resin (Ivoclar
Vivadent Technical, Schaan, Liechtenstein) applied to
the base of the cavity prior to filling it with a nano-
hybrid resin-based composite Tetric EvoCeram
(Ivoclar Vivadent Technical, Schaan, Liechtenstein).
The composition and properties of Tetric EvoCeram
are provided in Table I. The restorations were shaped
with diamond burs and sandpaper discs and polished
with rubber cups and paste. All specimens were stored
in deionised water for one week at room temperature
and randomly assigned to three equal groups:
Group I. The buccal surface was etched for 60 seconds
with 5 per cent hydrofluoric acid (Ivoclar Vivadent
Technical, Schaan, Liechtenstein) at room tempera-
ture, rinsed for 60 seconds with water and air dried.
Group II. The buccal surface was abraded with
50 m alumina particles directed perpendicular to
the surface of the restoration for 7 seconds with a
micro-etcher (Danville Engineering Incorpor-
ated, Danville, CA, USA). The cleaning and drying
procedures described in Group I were applied.
Group III. The buccal surface was roughened with a
coarse diamond bur with grit sizes 125150 m (863
Grit, Drendell and Zweilling, Berlin, Germany)
rotating at high speed with a constant water spray.
The rotating bur was passed over the composite sur-
face three times. The cleaning and drying procedures
described in Group I were again applied.
Stainless steel upper first premolar brackets
(Dentaurum, Ispringen, Germany) were bonded to
the composite restorations with a no-mix adhesive
resin (Resilience, Confi-Dental Products Company,
Louisville, CO, USA). A thin layer of adhesive primer
was painted on the surface of each restoration. The
adhesive resin paste was applied to the bracket base
and the bracket seated on the surface of the restor-
ation with a force of approximately 5 N. Excess
adhesive resin was removed with an explorer before
polymerisation with a curing light according to the
manufacturers directions. All specimens were thermo-
cycled 500 times between 5 C and 55 C with a
dwell time of 30 seconds between each cycle. To facil-
itate debonding, the teeth were mounted in acrylic
resin blocks (Orthoresin, De Trey, Dentsply,
Weybridge, UK) such that the buccal surfaces were
close to parallel with a debonding blade.
Shear bond strength
The brackets were debonded with a universal testing
machine (Z020, Zwick GmbH, Ulm, Germany) at a
crosshead speed of 1 mm/min. The shear force was
applied at the bracket-tooth interface. The force
required to shear the bracket was recorded and the
SBS calculated in megapascals (MPa).
Adhesive remnant index
The buccal surfaces and bracket bases were examined
with a stereomicroscope (Olympus, SZX9, Tokyo,
Japan) at x20 magnification and the adhesive remain-
ing on the teeth was scored with the adhesive rem-
nant index (ARI):
19
0, no adhesive left on the tooth
1, less than half of the adhesive left on the tooth
2, more than half of the adhesive left on the tooth
3, all of the adhesive left on the tooth with the mesh
pattern visible.
Table I. Standard composition and selected physical properties of Tetric
EvoCeram, according to the manufacturer.
Standard composition Per cent
Dimethacrylates 16.8
Barium glass filler, Ytterbium trifluoride, mixed oxide 48.5
Prepolymers 34.0
Additives, stabilisers and catalysts 0.7
Pigments < 0.1
Selected physical properties MPa
Flexural strength 120
Modulus of elasticity 10000
Compressive strength 250
A statistical analysis was performed using SPSS soft-
ware, Ver. 17.0 (Statistical Package for Social Sciences,
SPSS Inc., Chicago, IL, USA). The SBSs were com-
pared with the one-way analysis of variance (ANOVA)
and Tukeys post hoc test. The chi-squared test was
used to compare the distributions of the ARI scores in
the groups. The level of significance was set at p < 0.05.
Results
The mean shear bond strengths of the brackets in
Group I was 12.85 MPa (Range: 7.8220.72 MPa);
in Group II it was 15.36 MPa (Range: 7.5924.50
MPa) and in Group III it was 18.45 MPa (Range:
10.6125.61 MPa). Only the shear bond strengths of
the brackets in Groups I (treatment with hydro-
fluoric acid) and III (roughened with a diamond bur)
were significantly different (Table II).
The ARI scores for stainless steel brackets bonded to
the aged composite restorations are provided in Table
III. In Group I, wide variation occurred in the ARI
scores. In 10 teeth, there was no adhesive left on the
tooth surface but at least half of the adhesive was left
after debonding the remaining teeth. At least half of
the resin was left on the teeth in Groups II and III.
The ARI scores for Groups I (hydrofluoric acid) and
II (air abrasion), Groups I and III (diamond bur) and
Groups II and III were significantly different.
Discussion
The effects of three methods of surface treatment on
the shear bond strengths of orthodontic brackets
bonded to artificially-aged composite restorations
were investigated. A significantly lower bond strength
after surface treatment with hydrofluoric acid com-
pared with abrasion using a diamond bur was found.
No significant difference was detected between the
bond strengths following abrasion with a micro-
etcher or a diamond bur. The examined methods
of surface treatment increased the shear bond
strengths above the values considered to be clinic-
ally acceptable, and failure occurred either at the
restoration adhesive interface (after treatment with
hydrofluoric acid), within the adhesive (after air
abrasion) or at the bracket adhesive interface
(after roughening the restoration with a diamond
bur).
The clinical situation was simulated by preparing
standardised restorations in extracted human pre-
molars and ageing the restorations artificially by
thermocycling each tooth 500 times. The mechanical
abrasive methods promoted interlocking and chemical
bonding of the restoration by roughening the surface
layer of the aged restoration. Hydrofluoric acid is
thought to dissolve the glass microfillers which are a
characteristic of the Tetric EvoCeram and leave gaps
or pores for micromechanical retention of the bond-
ing adhesive. While laboratory studies of shear bond
strengths are less time-consuming and less expensive,
clinical bond strengths have been shown to be
approximately 40 per cent lower than those measured
in laboratory models.
20
There is also evidence of
a gradual decrease in bond strength between new
and old composite resins after ageing and storage in
saliva.
1,3,21
ESLAMIAN ET AL
Table II. Comparison of the shear bond strengths of stainless steel brack-
ets bonded to composite restorations after various surface treatments.
Group and N Mean (SD) p
surface treatment (MPa)*
Group I Group II
Hydrofluoric Air
acid abrasion
Group I
Hydrofluoric acid 15 12.85 (5.20)
Group II
Air abrasion 15 15.36 (4.92) 0.32
Group III
Diamond bur 15 18.45 (3.82) 0.006 0.18
*ANOVA, p = 0.008
Tukey post-hoc test, significant value in bold
Table III. Comparison of the adhesive remaining on composite restora-
tions following different surface treatments.
Group and N ARI score count (Per cent)
surface treatment
0 1 3
Group I
Hydrofluoric acid 15 10 (66.7) 0 4 (26.7)
Group II
Air abrasion 15 0 3 (20) 5 (33.3)
Group III
Diamond bur 15 0 0 14 (93.3)
Chi-squared, p = 0.00
Hydrofluoric acid vs Air abrasion, p = 0.001
Hydrofluoric acid vs Diamond bur, p = 0.000
Air abrasion vs Diamond bur, p = 0.003
EFFECT OF SURFACE TREATMENTS ON SHEAR BOND STRENGTH
The bond strength between an orthodontic bracket
and a composite restoration should be sufficient to
withstand the forces generated by mastication, last
the duration of orthodontic treatment but allow
straightforward removal at the end of treatment with-
out damage to the underlying restoration. The mini-
mum bond strength for orthodontic purposes falls
within the range of 6 to 8 MPa.
22,23
In the present
study, the mean shear bond strengths ranged from
12.85 to 18.45 MPa and all were well above the bond
strength recommended for clinical use.
22,23
The bond
strengths of the specimens treated with hydrofluoric
acid (Group I) and micro-abrasion (Group II) were
more variable than those roughened with the dia-
mond bur (Group III). Based on the current findings,
surface treatment of composite restorations with any
of the investigated methods should result in bond
strengths able to last the duration of orthodontic
treatment. However, a significantly high bond strength
between the adhesive resin and a restoration has dis-
advantages. Fracture or loss of the underlying restora-
tion during debonding could occur and remnants of
adhesive require removal. The additional cost of clean-
up or replacement of the restoration must be considered.
Hydrofluoric acid, even in low concentrations, is a
hazardous chemical that is ill-advised for clinical
practice. If used, an adequate tissue barrier and high
volume suction must be available. It is not recom-
mend as a routine method of treating the surfaces of
composite restorations to enhance bonding.
Micro-etcher abrasion requires protection of the eyes,
nose and throat to prevent tissue irritation from the
fine powder particles. It was found that lightly abrad-
ing the surface of an aged restoration with a coarse
grit diamond bur was simple and clinically effective.
Conclusions
Surface treatment with a diamond bur resulted in the
highest bond strength between stainless steel brackets
and an artificially aged composite restoration.
All methods of restoration surface treatment resulted
in high bond strengths.
High shear bond strength following abrasion with
either a micro-etcher or a diamond bur resulted in
adhesive remnants remaining after bracket debonding.
For safety reasons, surface treatment of composite
restorations with hydrofluoric acid is not recom-
mended prior to bonding.
Acknowledgment
The present research has been approved and funded
by the Directory of Research, School of Dentistry,
Shahid Beheshti University of Medical Sciences
(Grant Number: 9297)
Dr Ali Farahani
Craniofacial Orthodontics
Division of Dentistry and Orthodontics
Childrens Hospital Los Angeles
4650 Sunset Blvd., MS #116
Los Angeles, CA 90027
United States of America
Email: afarahani@chla.usc.edu
References
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ESLAMIAN ET AL
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bond strengths of orthodontic brackets bonded to enamel
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sive composite resin to the same material: bond strength and
clinical techniques. J Prosthet Dent 1989;61:66975.
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Introduction
Gingival recession is defined as apical movement of
the marginal gingival tissue resulting in exposure of
the tooth root surface. The prevalence of gingival
recession increases with age, with 50 per cent of 18-
64 year-olds and 88 per cent of adults 65 years of age
or older presenting with one or more sites of recession.
1
Anteroposterior expansion of the mandibular arch to
correct anterior crowding is used to achieve good
facial aesthetics and optimal occlusal results.
2
Labial
movement of lower incisors is also carried out for
camouflage treatment of mild to moderate Class II
division 1 malocclusions (skeletal or dental), in Class
II division 2 malocclusions to reduce lower incisor
retroclination without significant intrusion, and in
skeletal Class III malocclusions to decompensate the
lower incisors prior to surgery.
3
Several human studies have focused on gingival
recession accompanying labial movement of lower
incisors during and following orthodontic treat-
ment
2,6,810,19,20
and the effects of appliance-induced
proclination on periodontal health remains contro-
versial. There are claims that labial movement of the
mandibular incisors can cause the gingival attach-
ment to migrate apically.
47
However, other studies
have reported that no such association exists.
2,810
Since labial tooth movement of the maxillary and
mandibular incisors reduces the thickness of the
A systematic review of the association between
appliance-induced labial movement of mandibular
incisors and gingival recession
Tehnia Aziz
*
and Carlos Flores-Mir
Private practice
*
and the Division of Orthodontics, Department of Dentistry, Faculty of Medicine and Dentistry, University of Alberta,
Edmonton, Canada
Objective: To determine if an association exists between appliance-induced labial movement of mandibular incisors and
gingival recession.
Methods: Electronic databases were searched for studies with the terms: incisor, incisor proclination, tooth movement,
orthodontic tooth movement, gingival recession and orthodontic appliance. The original articles and abstracts that met the
initial inclusion criteria were retrieved, and their references hand searched for possible articles missed by the database
searches. Inclusion criteria included human studies that suggested a link between labial movement of lower incisors produced
by orthodontic treatment and gingival recession. Exclusion criteria included significant intrusion or extrusion of the mandibular
incisors, periodontal disease, subjects taking medication that affects gingival health and subjects with systematic diseases.
Results: Seven articles fulfilled the selection criteria. Gingival recession after labial movement of lower incisors was assessed on
dental casts, intra-oral slides, lateral cephalograms and gingival examination. The articles were analysed to determine the
impact of their treatment methodology on the outcomes.
Conclusions: No association between appliance-induced labial movement of mandibular incisors and gingival recession was
found. Factors that may lead to gingival recession after orthodontic tipping and/or translation movement were identified as a
reduced thickness of the free gingival margin, a narrow mandibular symphysis, inadequate plaque control and aggressive tooth
brushing.
Submitted for publication: September 2010
Accepted: November 2010
Tehnia Aziz: tehniaaziz@yahoo.com
Carlos Flores-Mir: carlosflores@ualberta.ca
AZIZ AND FLORES- MIR
tissues covering the roots of the teeth, gingival reces-
sion is more likely to involve the mandibular incisors
than the maxillary incisors due to the anatomically
thin labial plate of bone and often, inadequately
keratinised gingival tissue.
9
Additional studies have examined periodontal
changes that accompany labial tooth movement in
animals.
1118
Conflicting results have also been
encountered as some studies reported periodontal
damage,
11,1517
while others found no evidence of
damage after orthodontic proclination of the lower
incisors.
1214
In the absence of strong evidence to support either
view, the aim of the present study was to syste-
matically review published reports to determine if an
association exists between appliance-induced labial
movement of the lower incisors and gingival recession
in humans.
An electronic database search was conducted using
Medline (from 1966 to the first week of July 2010),
PubMed (from 1966 to the first week of July 2010),
Embase (from 1980 to the first week of July 2010),
Web of Science (from 1945 to the first week of July
2010), and all evidence-based medicine (EBM)
reviews (Cochrane Database of Systematic Review,
American College of Physicians Journal Club, data-
base of abstracts of reviews of effects, and Cochrane
database of trial registration) to the second quarter of
2010. The terms applied to the database searches
were: incisor, incisor proclination, tooth move-
ment, orthodontic tooth movement, gingival reces-
sion and orthodontic appliance. The assistance of an
experienced librarian, who had knowledge of health
sciences database searches, was valuable in the selec-
tion and specific use of database search terms. The
following initial inclusion and exclusion criteria were
used to select potential articles from the published
abstracts and/or titles:
1. Human clinical trials.
2. No individual case reports.
3. Abstracts that included orthodontic treatment and
periodontal status of the mandibular incisors.
No attempt was made at this stage to identify studies
that included subjects having pre-existing periodontal
disease, gingival alterations or systemic disease that
affected gingival health. Each author selected
abstracts considered to meet the inclusion criteria.
Subsequently, both authors compared their results
and discussed any disagreements until a consensus
was obtained. Ten abstracts, from a total of 34, met
the initial inclusion criteria. The full-text original
articles of the 10 selected abstracts were then col-
lected and read. The reference lists in the retrieved
articles were also hand searched for additional rele-
vant publications that may have been missed by the
database searches.
The main inclusion criteria were studies that dis-
cussed an association between appliance-induced labial
movement of lower incisors and gingival recession.
The following exclusion criteria were applied:
1. If pre-existing periodontal disease was noted.
2. If the permanent mandibular incisors were moved
labially with stated significant extrusion or intrusion
during orthodontic treatment.
3. Subjects taking medication known to affect
gingival health.
4. Subjects who had systemic disease that affected
their periodontal tissues.
5. Subjects who had high labial or lingual frenal
attachments to either the free gingivae or the inter-
dental papilla between the mandibular central incisors.
A consensus was reached regarding the articles which
met the final selection criteria and these articles were
included in the systematic review. Three studies were
excluded because the main goal of treatment was to
avoid labial movement of the lower incisors during
orthodontic treatment.
2123
Although an assessment
of the measurement error is needed for an accurate
interpretation of the clinical significance of findings,
it was not considered a valid reason to reject an article,
but it was considered when the data were analysed.
A methodological scoring process was used to screen
the selected studies as it was expected that method-
ologically sound studies would provide more reliable
data (Table I).
24
Although there is no strong evidence
regarding the validity of the methods used in a
study, it has been suggested that the influence of
methodology on the outcome is considered when the
information is to be used clinically.
24
Results
The database search resulted in 32 abstracts, of which
eight met the initial selection criteria. A further two
abstracts
19,20
were found while conducting an online
search,
10
resulting in 10 abstracts that met the initial
inclusion criteria (out of 34 abstracts). Key details of
the selected studies are given in Tables I and II.
All studies were retrospective in nature with no ran-
domisation of subjects to control or treatment
groups. Blinding of the examiner was only carried out
in two studies, and blinding of the statistician was not
mentioned in any study.
10,20
All studies included
statistical analyses that seemed valid for the data
collected (Table I).
Six studies denied an increased risk of gingival reces-
sion after labial advancement of mandibular incisors
due to orthodontic treatment (Table II).
2,810,19,20
One study concluded that lower incisor proclination
greater than 10 degrees would inevitably lead to gin-
gival recession in patients with a narrow mandibular
symphysis. Recession was reported during treatment
and also during the first three years post-treatment
(Table II).
6
There was no statistical difference in the
amount of recession between the control and treat-
ment groups after that time period. In another study,
8
the sample was divided into a high final proclination
group (16 patients with 16.4 degrees of proclination)
and a low final proclination group (17 patients with
2.7 degrees of proclination) which resulted in no dif-
ference in the incidence of gingival recession in either
group after orthodontic treatment (Table II).
Discussion
A systematic review of the literature was conducted to
determine if an association existed between labial
movement of the lower incisors and gingival reces-
sion, and found no strong evidence to support this
hypothesis. The literature indicated that gingival
recession is more likely to be associated with other
ASSOCIATIONS BETWEEN LABIAL MOVEMENT OF INCISORS AND GINGIVAL RECESSION
Table I. Methodological scores of selected articles.
Articles A B C D E F G H I J K L M N Total Per
score cent
Artun and Krogstad
6
1 0.5 1 0.5 2 1 0 1 0 1 1 1 1 2 13 65
Ruf et al.
8
1 1 2 1 2 0 0 1 0 1 1 1 1 2 14 70
Artun and Grobety
2
1 0.5 0.5 1 0 1 0 1 0 1 1 1 1 2 11 55
Djeu et al.
9
1 1 1 1 0 0 0 1 0 1 1 1 0 2 10 50
Melsen and Allias
10,20*
1 1 2 1 2 0 0 0.5 1 1 1 1 1 2 14.5 73
Yared et al.
19
1 0.5 2 1 1 0 0 1 0 1 1 1 1 2 12.5 63
* Both studies
10,20
were pooled as one
This table was adapted from Flores-Mir and Major
24
Fulfillment of methodological criteria:
A: Objective clearly described (Single criterion)
B: Population clearly described (Single criterion)
C: Selection criteria clearly described and adequate (Two criteria)
D: Sample size considered adequate, estimated before collection of data (Two criteria)
E: Baseline characteristics similar between groups (Two criteria)
F: Timing prospective, long term follow up (Two criteria)
G: Randomisation stated (Single criterion)
H: Measurement method appropriate to the objective stated (Single criterion)
I: Blind measurement blinding (examiner, statistician) (Two criteria)
J: Reliability described clearly (Single criterion)
K: Dropouts included in data analysis (Single criterion)
L: Statistical analysis appropriate for data (Single criterion)
M: Confounders included in analysis (Single criterion)
N: Statistical significance level p value stated, confidence interval (Two criteria).
Explanation:
Single criterion, maximum possible score = 1
Two criteria, maximum possible score = 2
No criteria met = 0
All criteria from letters A to N were added. The maximum possible score was 20.
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variables such as the level of oral hygiene and the
health and physical characteristics of the investing
alveolar bone and gingival tissues.
Little consideration was given to the different types of
tooth movement and the affect on the periodontal
tissues supporting the lower incisors. Of the reviewed
articles, the lower incisors were tipped in some
studies,
6,8,9,19,20
translated
2
or tipped and translated
10
in other studies, but no study associated gingival
recession with the type of tooth movement. Although
it is widely believed that proclination of the lower
incisors leads to loss of gingival support, it is surpris-
ing that there are few studies that have investigated
the issue and provided substantive evidence.
All of the selected studies were found to have
methodological limitations (Table I). One of the
limitations was the method of measuring gingival
recession from the clinical crown height on a dental
cast. These measurements were questionable because
it was assumed that there had been no extrusion,
wear, crown fracture or restoration of the teeth.
25
The
estimates of recession and crown height were
improved when measurements from the study casts
were compared with the intra-oral slides.
Several studies reported gingival recession involving
the lower incisors before orthodontic treatment,
8,10,20
which could indicate prior periodontal disease and/or
thin gingival tissue susceptible to damage by external
factors, such as toothbrush trauma. The presence of
prior gingival recession may render the gingivae more
vulnerable to damage from orthodontic tooth move-
ment. In addition, most studies measured gingival
recession and the inclination of lower incisors on the
initial (i.e. pretreatment) and final (i.e. end-of-treat-
ment) records, but not during treatment. It is pos-
sible that in some subjects, the lower incisors were
moved labially to correct a discrepancy, which caused
the recession, and were then moved lingually/
retroclined before the final records were taken. In
such cases, the transient recession will not be detected
by an observer relying on the pre- and post-treatment
records.
It has been proposed that labial movement of
mandibular incisors can contribute to gingival reces-
sion because the roots of incisors may have a thin
bony covering and poorly keratinised gingival tissue.
9
It has also been suggested that as long as the incisors
are moved within the alveolar process, there is very
little risk of gingival recession.
17
When a lower
incisor is moved beyond the anatomical boundary of
the alveolar bone, a bony dehiscence and/or fene-
stration may occur. In addition to the osseous
changes, the apico-coronal height and thickness of
the marginal gingival tissue is reduced.
26
Thin gingi-
val tissue is more likely to be affected detrimentally by
the accumulation of plaque or aggressive tooth brush-
ing. A bony dehiscence, produced during excessive
labial movement of lower incisors, may repair if the
teeth are retroclined towards the end of treatment.
Two long-term follow-up studies reported that only a
few teeth developed gingival recession, and only in
patients who had recession during orthodontic
therapy.
2,6
This finding and previous findings on the
importance of physical characteristics of the gingival
tissues suggests that recession during orthodontic
treatment is not progressive and the response may be
related to individual variation in the quality of the
gingival tissues.
In studies warning against proclination of incisors
during orthodontic treatment, it is possible that the
proclining force caused local necrosis and ischemia
which contributed to gingival recession. Such an
injury to the periodontal tissues usually results in gin-
gival recession rather than pocketing, especially if the
gingival tissue is thin and/or poorly keratinised.
6
Significant extrusion of the mandibular incisors,
along with labial tipping, could initiate the same
problem.
11
The enrolment of subjects with poor oral
hygiene and/or pre-existing mucogingival problems
may have also contributed to the contradictory
results.
A lack of information on smoking and oral hygiene
control during orthodontic treatment may confound
some studies. It was considered that deliberate labial
movement of the lower incisors in subjects with
mucogingival defects was unethical, regardless of the
steps taken to control dental plaque. Failure to
prevent or correct gingival recession negates the
treatment objective of causing no harm. In this
regard, the most valuable studies for systematic
review are observational studies or randomised con-
trol trials, in which gingival recession is an unplanned
or secondary outcome of treatment.
A recent systematic review
27
also focused on ortho-
dontic treatment and a possible link to gingival
recession in animals and humans. The conclusions
were similar, but methodological differences were
identified. Although the stated inclusion criteria of
the recent review required human controlled or ran-
domised control trials, the reported studies were ret-
rospective. With concern, no discussion of the aetiol-
ogy of gingival recession resulting from labial move-
ment of lower incisors during orthodontic treatment
was considered, even though it is a factor of likely
high importance.
Conclusions
There is no consistent association between appliance-
induced labial tipping or translation and gingival
recession. Gingival recession may be more related to
individual local factors, such as the quality of the gin-
gival tissue and biotype, the thickness of the alveolar
bone and oral hygiene. The host immune response is
also likely to be a determinant and thus genetic
factors are an area requiring further investigation. In
addition, pronounced labial movement of incisors
during orthodontic treatment cannot be discounted
as contributing to gingival recession.
Dr Carlos Flores-Mir
Faculty of Medicine and Dentistry
University of Alberta Dentistry
4051 Dentistry/Pharmacy Centre
University of Alberta
Edmonton, AB T6G 2N8
Canada
Email: carlosflores@ualberta.ca
References
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influence the level of the gingival margin? A case control
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Introduction
The orthodontic treatment of Class III malocclusions
may involve dental compensation using upper and
lower fixed appliances and, in some cases, premolar
extractions.
1
The prevalence of Class III mal-
occlusions in Jordanians is 1.4 per cent, which is at
the lower end of the range (116 per cent) found in
other population groups.
26
Class III malocclusions
present in a variety of configurations and treatment
may involve growth modification, dentoalveolar
compensation (camouflage treatment) and orthog-
nathic surgery.
7
Surgery is usually reserved for severe
Class III discrepancies and camouflage treatment for
less severe conditions. While the skeletal, dento-
alveolar and soft tissue changes following orthopaedic
and surgical treatment have been extensively reported,
there is only limited information regarding the
changes following fixed orthodontic treatment with
lower premolar extractions.
811
The purpose of this retrospective study was to com-
pare the skeletal, dental, and soft tissue changes in
Class III patients treated with fixed appliances and
lower premolar extractions with a matched control
group of untreated Class III patients.
Pretreatment study casts of patients treated in the
orthodontic clinic at the Dental Teaching Centre,
Jordan University of Science and Technology,
between 2002 and 2007, were used to identify
patients with Class III incisor and molar relation-
ships. All patients with a negative overjet and no
Skeletal, dental and soft tissue changes in Class III
patients treated with fixed appliances and lower
premolar extractions
Elham S.J. Abu Alhaija and Susan N. Al-Khateeb
Preventive Dentistry Department, Faculty of Dentistry, Jordan University of Science and Technology, Irbid, Jordan
Background: Mild Class III malocclusions can be treated by upper incisor proclination and lower incisor retroclination following
extraction of the lower first premolars.
Aims: To compare the skeletal, dental and soft tissue changes in Class III patients treated with fixed appliances, Class III traction
and lower first premolar extractions with the changes in a group of untreated Class III patients.
Methods: The Treatment group consisted of 30 Class III patients (Mean age 13.69 1.48 years) who were treated by upper
and lower fixed appliances, Class III intermaxillary traction and lower first premolar extractions for 2.88 1.12 years. The
Control group consisted of 20 untreated Class III patients (Mean age 13.51 0.95) matched for age and gender. The T1 to
T2 changes in the treated and untreated groups were compared using a paired t-test while differences between the two groups
were compared with an independent t-test.
Results: During treatment, the upper incisors were proclined about 1 degree and the lower incisors were retroclined 8 degrees.
Small, but statistically significant changes in SNB, Wits and the overlying soft tissues accompanied the changes in incisor
inclination. At the end of treatment a positive overbite and overjet were achieved. The increase in lower facial height in the
Treatment group was comparable with the change in the Control group.
Conclusions: A range of mild to moderate Class III malocclusions can be treated by dentoalveolar compensation.
Accepted: March 2011
Elham S. J. Abu Alhaija: elham@just.edu.jo
Susan N. Al-Khateeb: susank@just.edu.jo
TREATMENT CHANGES IN CLASS III PATIENTS
reported mandibular functional shift at the start of
treatment were included in the study. Before and after
treatment, lateral cephalometric radiographs (LC) of
these patients were retrieved and assessed for suitabil-
ity. Three of the patients had either inadequate data
(lost data regarding age and treatment duration) or
poor quality of the lateral cephalogram. Accordingly,
these were excluded, which left a final treated sample
of 30 patients (17 females, 13 males). Lateral cepha-
lometric radiographs of 20 untreated patients (11
females, 9 males) with Class III malocclusion,
matched for age and malocclusion with the
Treatment group, were obtained from the ortho-
dontic clinic archives. The Control patients had at
least two lateral cephalometric radiographs taken for
diagnostic purposes between 1998 and 2008 and they
received no orthodontic treatment during this period.
The patients in the Treatment group were treated for
an average duration of 2.88 1.12 years with upper
and lower fixed orthodontic appliances (preadjusted
Roth prescription appliances with 0.022 inch slots)
following extraction of the lower first premolars.
Class III elastics were used as necessary and no upper
teeth were removed. Cephalometric radiographs were
taken before treatment (T1) at a mean age of 13.69
1.48 years and at the end of active treatment (T2) at
a mean age of 15.71 1.31 years. The initial radio-
graph in the Control group was taken at a mean age
of 13.51 0.95 years and the second radiograph was
taken 2.42 1.34 years later.
All cephalometric radiographs were taken using the
same cephalostat (Orthophos-5, Siemens AG,
Munich, Germany). Patients were orientated in cen-
tric occlusion with lips in repose, Frankfort
Horizontal Plane parallel to the floor and the
machine ear rods fixed in place.
Lateral radiographs were traced and conventional
linear and angular parameters measured to the near-
est 0.1 mm and 0.5 degree (Figure 1). In addition,
two arbitrary points, SH and SV, were identified on
sella-horizontal and sella-vertical lines (Figure 1).
Wits appraisal was used to determine the antero-
posterior jaw relationship, and to adjust for occlusal
plane changes during treatment, the bisector of the
maxillary and mandibular plane angle was used.
12
Method errors
All films were retraced and remeasured and the
method errors calculated.
13,14
The Dahlberg error
Figure 1. Cephalometric measurements.
S-N, sella-nasion line
ANS-PNS, maxillary plane
Go-Me, mandibular plane
SH, an arbitrary point on the line 7 degrees below the S-N line
SV, an arbitrary point on the perpendicular to S.H.
BV, the perpendicular distance from B point to sella vertical
AUST, AUL-Sn-Tang
NNP, sN-NT- sPog
NAP, sN-sA-sPog
AUV, the perpendicular distance from AUL to the sella vertical line
ALV, the perpendicular distance from ALL to sella vertical line
sBV, the perpendicular distance from sB to the sella vertical line
sPV, the perpendicular distance from sPog to the sella vertical line
sPH, the perpendicular distance from sPog to the sella horizontal line
Figure 2. Superimposition of the T1 (continuous line) and T2 (interrupted line)
tracings of a subject in the Treatment group.
ABU ALHAIJA AND AL- KHATEEB
Table I. Comparisons of the skeletal, dental and soft tissue measurements in subjects with treated and untreated Class III malocclusions.
Variable Treatment group Control group
T1 T2 Mean T1 T2 Mean Mean
Mean Mean difference Mean Mean difference difference
(SD) (SD) (T2-T1) (SD) (SD) (T2-T1) (Control vs
Treatment)
Skeletal
SNA () 78.78 (4.94) 78.44 (4.52) -0.34 78.38 (3.86) 78.97 (4.49) -0.60 -0.94
SNB () 79.45 (4.39) 78.80 (4.47) -0.65* 78.90 (3.77) 79.74 (4.10) -0.84** -1.49***
ANB () -0.70 (1.54) -0.33 (1.56) -0.38 -0.59 (1.15) -0.84 (1.81) -0.25 -0.63
Wits (mm) -10.28 (2.82) -8.88 (3.22) -1.39** -9.36 (2.36) -10.13 (2.95) -0.76* -2.15***
S-Gn (mm) 127.45 (11.30) 130.93 (10.99) -3.48*** 121.36 (11.78) 127.18 (10.69) -5.82*** -2.34*
Ar-Gn (mm) 110.57 (9.08) 114.48 (8.87) -3.91*** 105.75 (9.98) 110.68 (8.06) -4.93*** -1.02
Ar-Go (mm) 46.82 (5.72) 50.13 (5.71) -3.31*** 43.34 (5.97) 46.44 (6.48) -3.10*** -0.21
Go-Me (mm) 72.43 (5.62) 73.72 (4.86) -1.28** 69.85 (5.71) 72.72 (4.87) -2.87** -1.59
N-Me (mm) 122.49 (10.15) 125.88 (10.45) -3.38*** 117.49 (10.39) 122.35 (10.72) -4.86*** -1.48
BV (mm) 62.60 (8.76) 62.98 (8.88) -0.38 59.35 (9.38) 61.66 (8.96) -2.31*** -1.94*
Max/Mand () 27.66 (4.26) 26.93 (5.04) -0.73 29.04 (6.44) 29.79 (5.73) -0.75 -0.02
LFH (mm) 69.29 (7.15) 71.48 (7.57) -2.18*** 66.16 (7.97) 69.59 (8.92) -3.43*** -1.24*
FP (per cent) 0.56 (0.02) 0.56 (0.02) -0.00 0.56 (0.03) 0.57 (0.03) -0.01 -0.01
Dental
Ui/Max () 111.54 (9.15) 112.45 (6.14) -0.91 112.06 (6.23) 112.64 (5.91) -0.58 -0.33
Li/Mand () 90.38 (5.80) 82.45 (7.45) -7.93*** 86.86 (5.57) 87.89 (5.85) -1.03 -8.95***
Ui/Li () 129.23 (9.12) 138.97 (13.57) -9.74*** 130.94 (8.24) 130.50 (9.89) -0.44 -10.18***
OJ (mm) -1.25 (2.01) 1.71 (1.01) -2.96*** -0.04 (2.60) -0.43 (2.48) -0.39 -3.35***
OB (mm) 0.45 (1.23) 1.73 (1.29) 1.27*** 1.10 (2.10) 0.96 (1.74) -0.14 -1.40**
Li/A-Pog (mm) 5.77 (3.33) 2.17 (3.13) -3.61*** 4.93 (2.21) 5.10 (2.59) -0.18 -3.78***
Soft tissue
AUST () 111.94 (12.71) 112.31 (14.34) -0.37 110.28 (11.93) 112.50 (10.62) -2.22** -1.86
NNP () 132.52 (3.49) 131.87 (4.44) -0.65 133.46 (4.12) 133.13 (4.11) -0.34 -0.31
NAP () 169.72 (6.00) 170.00 (6.30) -0.28 168.38 (3.47) 171.64 (4.45) -3.26*** -2.98
AUV (mm) 83.85 (9.82) 85.16 (8.54) -1.31* 80.89 (10.00) 82.60 (9.33) -1.71** -0.40
ALV (mm) 83.15 (10.39) 83.17 (8.69) -0.02 79.54 (10.44) 81.63 (9.43) -2.09*** -2.07*
sBV (mm) 74.33 (9.17) 74.89 (8.62) -0.56 71.09 (9.01) 73.34 (8.76) -2.25*** -1.69
sPV (mm) 74.28 (9.99) 75.73 (9.58) -1.45 70.70 (9.71) 74.29 (9.07) -3.59*** -2.14
sPH (mm) 105.77 (9.35) 107.31 (9.72) -1.54* 101.33 (8.52) 105.85 (9.85) -4.52*** -2.98**
*p < 0.05, **p < 0.01, ***p < 0.001
varied from 0.46 to 0.95 mm and from 0.49 to 0.93
degrees. Houstons coefficients of reliability were all
above 0.90, indicating good agreement between the
two measurements.
The mean differences (T2 minus T1) in both groups
were compared with paired t-tests, thus positive dif-
ferences shown in the table indicated an increase in
the measurement. The overall mean changes in the
Control and Treatment groups were compared using
independent t-tests.
Results
The results are provided in Table I. There were two
statistically significant differences between the Treat-
ment and Control groups at T1: articulare gonion
length (Ar-Go) and the inclination of the lower inci-
sors to the mandibular plane (Li/Md). Both variables
were significantly larger in the Treatment group.
Treatment group
Skeletal changes
There was a small, but significant, reduction of 0.65
degrees in SNB at the end of treatment (p < 0.05)
which produced an increase in ANB from -0.70 to
-0.33. In addition, treatment changes involved a sig-
nificant increase in the modified Wits appraisal of
1.39 mm, total anterior face height (N-Me) of 3.38
mm and lower anterior face height (LFH) of 2.18
mm. Variables that indicated the size (Ar-Gn, Ar-Go,
Go-Me) and position of the mandible (S-Gn) also
increased significantly during treatment (Table I).
The cephalometric changes of one patient are shown
in Figure 2.
Dental changes
At the end of treatment, the lower incisors (Li/Mand)
had tipped lingually on average 8 degrees and the
interincisal angle (Ui/Li) increased almost 10 degrees.
The overjet changed from a negative value to 2.96
mm and the overbite increased 1.27 mm. The dis-
tance from the most prominent lower incisor edge to
the A-Pogonion line increased by 3.61 mm.
Soft tissue changes
Only two significant soft tissue changes were identi-
fied. The perpendicular distance from the upper lip
(AUL) to the sella-vertical line moved 1.31 mm ante-
riorly, and soft tissue pogonion, relative to the sella-
horizontal line (sPH), moved 1.54 mm inferiorly.
Control group
Skeletal changes
During the observation period, the SNB angle, the
size (Ar-Gn, Ar-Go, Go-Me) and position (S-Gn) of
the mandible, the perpendicular distance from B
point to the sella-vertical line (BV) and total (Na-Me)
and lower (LFH) anterior face heights increased sig-
nificantly. The modified Wits appraisal (Wits) was
the only measurement to improve in these patients
over the observation period.
Dental changes
There were no significant changes in the dental
measurements.
Soft tissue changes
All but one (NNP: sN-NT-sPog) of the soft tissue
measurements increased significantly over the obser-
vation period. Increases were seen in the nasolabial
angle (AUST), the NAP angle, the distance from the
upper lip to the sella-vertical line (AUV), the distance
from the lower lip to sella-vertical line (ALV), the dis-
tance from sB point to the sella-vertical line (sBV),
the soft tissue pogonion (sPog) to the sella-vertical
line distance (sPV) and the soft tissue pogonion to
the sella-horizontal line (sPH).
Comparisons between the Treatment and
Control groups
Skeletal changes
There were five statistically significant mean differ-
ences between the Treatment and Control groups.
The SNB angle increased significantly in the Control
group, but reduced in the Treatment group; the Wits
appraisal worsened in the Control group, but
improved in the Treatment group and S-Gn, Bv and
LFH increased more in the Control group than in the
Treatment group.
Dental changes
There were five statistically significant differences
between the Treatment and Control groups. In the
Treatment group, the lower incisors retroclined, but
in the Control group the incisors proclined slightly
over the observation period. The interincisal angle,
overjet, overbite and Li/A-Pog increased more in the
treated group compared with the untreated group.
Soft tissue changes
Two statistically significant Treatment Control soft
tissue differences were identified. The distance from
the lower lip to Sella-vertical line (ALV) increased
significantly in the Control group, and soft tissue
pogonion (sPog) moved more inferiorly in the
Control group compared with the Treatment group.
Discussion
This investigation aimed to determine skeletal, dental
and soft tissue changes in adolescents with Class III
malocclusion after orthodontic treatment with
upper and lower fixed orthodontic appliances, Class
III intermaxillary elastics and lower first premolar
extractions.
Although it has been reported that the prevalence of
Class III malocclusion is more common in boys than
girls,
15
the male to female ratio in the present study
was very similar. The ratio slightly favoured females,
possibly because more girls and their parents sought
orthodontic treatment.
16
The assessed patients had Class III malocclusions that
varied from mild to moderate. Severe cases identified
in the archives elected to be treated via orthognathic
surgery. The Control group consisted of untreated
Class III patients in which the ratio of males to
females was consistent with that seen in the
Treatment group. The Control group comprised
patients who declined treatment or who were willing
to defer. All pretreatment parameters (at T1) were
similar for both groups except Ar-Go and Li/Mand,
whose values were greater in the Treatment group.
Evaluation at (T2) showed that ramus length (Ar-Go)
increased similarly in both groups. The lower incisors
retroclined significantly after orthodontic treatment
while the Control group maintained lower incisor
inclination. Additionally, after treatment, the upper
incisors were slightly proclined and overbite and over-
jet increased significantly, in keeping with the
changes expected as a consequence of lower premolar
extraction and Class III traction.
Although differences in the timing and amount of
growth exist between males and females,
17
no
attempts were made for comparisons in this study
due to the small sample size. It was recognised that
during orthodontic treatment, Class III patients were
still growing and uncertainty may prevail over the
specific long-term effects of fixed appliance treat-
ment. It is often expected that growth in Class III
patients continues at a greater rate compared with
others,
17
and therefore, a matching control group was
chosen to isolate the effects of treatment. In agree-
ment with previous studies,
18
several skeletal, dental
and soft tissue changes were found in the treated
group. In contrast, Zenter et al.
11
reported that the
orthodontic correction of Class III malocclusions was
restricted to dentoalveolar changes.
Mandibular prognathism, as measured by point B in
relation to the cranial base, and intermaxillary differ-
ence (Wits) improved in the treated group and
worsened in the untreated control group. The
improvement might be explained by a remodelling of
point B as a result of the retraction of the lower
incisors into the extraction space.
19
It has also been
suggested that a partial correction of the sagittal posi-
tion of the mandible occurs due to backward rotation
of the mandible following the application of Class III
elastics.
20,21
A reduction of mandibular prognathism
and an improvement of Wits appraisal have been
reported in previous studies.
11,22
Although backward
rotation of the mandible was anticipated, no changes
were noticed in the maxillary/mandibular planes
angle. Furthermore, following a downward and back-
ward rotation of the mandible, the anterior maxilla
may move in a downward direction and stabilise the
vertical relationship between the jaws.
23
Lower facial
height was found to increase in both Treatment and
Control groups, but a more pronounced increase was
seen in the Control group. While most of the treat-
ment effects were dental in nature, changes in the
lower lip, upper lip and subnasale followed the minor
skeletal effects favourably. The soft tissue changes
resulted in an improvement in the patients profiles.
These results are in agreement with other earlier stud-
ies which reported that soft tissue effects follow the
hard tissue changes, but disproportionately.
24,25
The findings of this investigation demonstrate that
fixed orthodontic treatment may beneficially influ-
ence the Class III soft tissue profile. Therefore, it may
be possible for some patients with a mild to moderate
skeletal Class III to obtain a satisfactory soft tissue
outcome using Class III traction. However, an
ABU ALHAIJA AND AL- KHATEEB
additional review of the patients after retention and
growth completion would be valuable.
Conclusions
Both skeletal and dental changes occurred as a result
of Class III treatment. However, dental movements
accounted for most of these changes.
Skeletal changes in the treated patients involved a
slight reduction of mandibular prognathism and an
improvement of the intermaxillary discrepancy (Wits
appraisal).
The dental changes were related to the lower arch
extractions.
Favourable soft tissue changes occurred in the
Treatment group compared with the Control group.
The soft tissues accompanied the skeletal changes.
Camouflage treatment using fixed appliances with
Class III traction might be an option for mild to
moderate skeletal Class III patients with little dento-
alveolar compensation.
Dr Elham S. J. Abu Alhaija
School of Dentistry
Jordan University of Science and Technology
P.O. Box 3030
Irbid
Jordan
Email: elham@just.edu.jo
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Introduction
Enamel demineralisation or white spot lesions around
orthodontic appliances is an unwelcome finding at
the end of orthodontic treatment. It is caused by
organic acids produced mainly by Streptococcus
mutans and the closely-related Streptococcus sobrinus
which are the organisms largely responsible for dental
caries.
1,2
These cariogenic streptococci can be isolated
and identified by biochemical, immunologic or
genetic tests, but the laboratory procedures can be
time-consuming and imprecise.
35
Recently, the
polymerase chain reaction (PCR) has been used to
overcome these limitations, as it is possible to
amplify a single piece of identifiable, microbial DNA
to generate multiple copies.
6
Orthodontic brackets are made of materials such as
stainless steel, ceramic, plastic and gold. The complex
design of many brackets provides a unique environ-
ment for micro-organisms and impedes cleaning of
tooth surfaces adjacent to the bracket base.
7
As a
result, the plaque that accumulates around the base
can lead to enamel decalcification and gingival
inflammation and bleeding. Oral hygiene can be
assessed using the Visible Plaque Index (VPI) and
gingival bleeding assessed using the Gingival Bleed-
ing Index (GBI).
8,9
Although it is known that the
Presence of cariogenic streptococci on various
bracket materials detected by polymerase
chain reaction
Smitha Pramod, Vignesh Kailasam, Sridevi Padmanabhan and Arun B. Chitharanjan
Department of Orthodontics, Faculty of Dental Sciences, Sri Ramachandra University, Chennai, India
Objective: To determine the in vivo presence of Streptococcus mutans and Streptococcus sobrinus on different bracket materials
and to correlate the prevalence with the Visible Plaque Index (VPI) and the Gingival Bleeding Index (GBI).
Methods: Orthodontic brackets made of different materials (stainless steel, gold, ceramic, plastic) were bonded to the
upper and lower second premolars in 40 subjects receiving fixed orthodontic appliances. After 30 days, the brackets were
debonded and the presence of S. mutans and S. sobrinus on the brackets was determined using the polymerase chain reaction
(PCR) technique. The VPI and GBI were recorded and the relationship between the prevalence of the streptococci and the level
of oral hygiene was calculated.
Results: There were fewer S. mutans and S. Sobrinus over the surface of gold and stainless steel brackets compared with the
plastic and ceramic brackets. A statistically significant difference was observed in S. mutans and S. sobrinus prevalence
between the metal brackets and the aesthetic brackets. However, there were no statistically significant differences in S. mutans
and S. Sobrinus prevalence when the gold and stainless steel brackets were compared. Comparison between the plastic and
ceramic brackets revealed a similar finding. Furthermore, a significant correlation was found between the in vivo prevalence of
S. mutans and S.sobrinus and the oral hygiene indices (p < 0.05), suggesting that the oral hygiene indices could be a good
indicator of S. mutans and S. sobrinus prevalence.
Conclusions: Since microbial adhesion is greater on aesthetic brackets, good oral hygiene during treatment should be
emphasised.
Accepted: May 2010
Smitha Pramod: drsmithapramod@gmail.com
Vignesh Kailasam: theorthodontist@gmail.com
Sridevi Padmanabhan: sridevipadu@gmail.com
Arun B. Chitharanjan: arunchith@gmail.com
BRACKET MATERIALS AND CARIOGENIC STREPTOCOCCI
intra-oral microbial population changes following
placement of fixed orthodontic appliances, little
information is available on the relationships between
the bracket material, plaque accumulation and the
micro-organisms. The purpose of this in vivo study
was to determine the presence of S. mutans and
S. Sobrinus on orthodontic brackets made from four
different materials and the possible correlation
between the prevalence of S. mutans and S. sobrinus
and the VPI and GBI.
Forty subjects (Mean age: 21.3 years; Range:
17.625.9 years) with Class I malocclusions and less
than 2.5 mm crowding were selected for this study.
The subjects were matched for caries experience and
the first premolars were extracted as part of the ortho-
dontic treatment plan. Stainless steel brackets (.022 x
.028 inch MBT, Victory, 3M Unitek, Monrovia, CA,
USA) were bonded to the upper and lower teeth,
except the second premolars, using Transbond XT
composite resin (3M Unitek, Monrovia, CA, USA).
Using a split mouth design
10
and a randomisation
table, either a stainless steel bracket (Victory, 3M,
Unitek, Monrovia, CA, USA), a gold bracket (Mag-
num Gold, Orthodontic Design and Production
Incorporated, Vista, CA, USA), a ceramic bracket
(InVu Ceramic, TP Orthodontics Inc, La Porte, IN,
USA) or a plastic bracket (Brilliant, Forestadent,
Pforzheim, Germany) were bonded to the second
premolar in each quadrant. The design ensured that
the brackets made of the different materials were
equally distributed to the quadrants since the location
of the bracket was considered a possible factor in
bacterial adhesion.
After bonding the study brackets, 0.016 inch NiTi
archwires (3M Unitek, Monrovia, CA, USA) were
ligated with elastomeric modules. The same post-
bonding instructions were given to all subjects and no
antimicrobial mouthwashes were prescribed. The
patients were recalled after 30 days for review.
Subjects with debonded brackets within this period
were eliminated from the study. The VPI and GBI
were used to assess the amounts of plaque and gingi-
val bleeding around the second premolars. Four
gingival areas of the tooth (facial, mesial, distal and
lingual) were assessed by running a periodontal probe
along the soft tissue wall of the gingival crevice for
presence of plaque and gingival bleeding and scored
from 0 to 3. A score of 0 meant normal gingiva and a
score of 3 meant severe inflammation.
Debonding procedure
The second premolar brackets were carefully removed
using debonding pliers and placed in eppendorf jars
containing 100 l of sterile normal saline.
Chromosomal DNA was immediately extracted from
the adhering bacteria. The 100 l sample was diluted
with an equal volume of 0.1M HCl-Tris buffer at a
pH of 8.0. Following a previous protocol,
11
the mix-
ture was incubated at 100 C for 60 minutes, centri-
fuged at 10,000 g for 5 minutes and the supernatant
stored at 4 C for later PCR assay.
Known specific primers that amplify the dextranase
gene of S. mutans and S. sobrinus were selected.
6,12
For S. mutans the upper primer - 5-TAT GCT GCT
ATT GGA GGT TC-3 is complementary to the
sequence 973 to 992 and the lower primer - 5-AAG
GTT GAG CAA TTG AAT CG-3 is complement-
ary to the sequence 2225 to 2244. The size of the
expected PCR product was 1215 base pairs (bp). For
S. sobrinus the upper primer 5-TAC TAT CTT TCC
CTA GCA TG-3 is complementary to the sequence
134 to 153, and the lower primer 5-GGT ATT
CGG TTT GAC TGC-3 is complementary to the
sequence 1743 to 1726.The size of the expected PCR
product was 1610 bp. All primers were commercially
synthesised (Synergy scientific services, Chennai,
India). Taq polymerase buffer 5 l, dNTP mix 2 l,
primers 2 l, DNA template 20 l, Taq polymerase
Figure 1. Electrophoretic bands examined with a UV transilluminator.
Streptococcus mutans Streptococcus sobrinus
PRAMOD ET AL
enzyme 0.5 l and double distilled water 20.5 l were
added to the PCR tubes to make a total of 50 l. The
PCR tubes were then subjected to thermocycling and
the sample was subsequently presented for agarose
gel electrophoresis. The generated electrophoretic
bands were examined with a UV transilluminator
(Figure 1).
The data were analysed with SPSS version 15 (SPSS
Incorporated, Chicago, IL, USA). One-way ANOVA
and Scheff post-hoc tests were used to compare the
prevalence of each micro-organism adhering to the
brackets and their relationships with the oral hygiene
indices. A value of p < .05 was considered significant.
Results
A positive PCR response indicated that the number
of streptococci adhering to the brackets was over
1000 cells. The gold brackets had the least number of
bacteria and the ceramic brackets had more than
twice the number of bacteria as the gold brackets
(Table I). The prevalence of the bacteria increased
from the gold brackets (Mean: 0.25 0.44), to the
stainless steel brackets (Mean: 0.38 0.49), to the
plastic brackets (Mean: 0.75 0.44) and finally, to
the ceramic brackets (Mean: 0.88 0.34). There was
no statistically significant difference between either
the gold and stainless brackets or between the plastic
and ceramic brackets (Table II). Similar results were
found for the prevalence of S. sobrinus alone and
Table I. Prevalence of S. mutans, S. sobrinus and cariogenic streptococci on premolar brackets.
Groups S. mutans S. sobrinus Cariogenic
Brackets streptococci
(Number) Mean SD Mean SD Mean SD
Stainless Steel (SS) 40 0.38 0.49 0.28 0.45 0.65 0.89
Gold 40 0.25 0.44 0.20 0.41 0.45 0.82
Ceramic 40 0.88 0.34 0.75 0.44 1.63 0.71
Plastic 40 0.75 0.44 0.58 0.50 1.33 0.86
Total 160 0.56 0.50 0.45 0.50 1.01 0.95
Table II. Multiple comparisons with Post Hoc tests.
(I) Group (J) Group S. mutans p S. sobrinus p Cariogenic p
streptococci
Mean Mean Mean
difference difference difference
(I vs J) (I vs J) (I vs J)
SS Gold 0.13* 0.56 0.75 0.88 0.20* 0.70
Ceramic -0.50* 0.00 -0.48 0.00 -0.98* 0.00
Plastic -0.38* 0.00 -0.30 0.02 -0.68* 0.00
Gold SS 0.13* 0.56 0.75 0.88 -0.20* 0.70
Ceramic -0.63* 0.00 -0.55 0.00 -1.18* 0.00
Plastic -0.50* 0.00 -0.38 0.00 -0.88* 0.00
Ceramic SS 0.50* 0.00 0.48 0.00 0.98* 0.00
Gold 0.63* 0.00 0.55 0.00 1.18* 0.00
Plastic 0.13* 0.56 0.18 0.31 0.30* 0.36
Plastic SS 0.38* 0.00 0.30 0.02 0.68* 0.00
Gold 0.50* 0.00 0.38 0.00 0.88* 0.00
Ceramic -0.13* 0.56 -0.18 0.31 -0.30* 0.36
* p < 0.05
Significant values in bold
S. mutans and S. sobrinus together on the different
bracket materials.
For all brackets, the VPI and GBI correlated well and
were equally accurate in predicting the prevalence of
S. mutans and S. sobrinus (Table III). For 37 of the
brackets, S. mutans and S. sobrinus were not sensitive
to PCR and therefore not detected. The associated
VPI and GBI yielded smaller mean values (VPI: 0 .32
0.48; GBI: 0.19 0.40). The highest prevalence
was found on 67 brackets in which both S. mutans
and S. sobrinus were sensitive to PCR (VPI: 0.93
0.27; GBI: 0.88 0.33). ANOVA showed a sig-
nificant relationship between the prevalence of
S. mutans and S. sobrinus and the oral hygiene
indices.
Discussion
Enamel demineralisation is caused by organic
acids produced mainly by S. mutans and its variant,
S. sobrinus.
13,14
Patients undergoing fixed appliance
orthodontic treatment are at greater risk of enamel
demineralisation. The aim of the present study was to
investigate the presence and prevalence of S. mutans
and S. sobrinus on different bracket materials using
the polymerase chain reaction (PCR) technique and
to correlate the prevalence of these streptococci with
the Visible Plaque Index (VPI) and Gingival Bleeding
Index (GBI). The results of the present study show
that microbial adhesion was greater around aesthetic
brackets. Also, the prevalence of S. mutans and
S. sobrinus was significantly associated with oral
hygiene indices in the premolar regions. A lack of oral
hygiene was strongly associated with the accumul-
ation of cariogenic streptococci in this area and
therefore may be considered as an indicator of
bacterial population.
Gwinnett et al.,
15
has shown that extensive plaque
accumulation is associated with bonded orthodontic
brackets and Mitchell
16
has documented that fixed
appliances with orthodontic brackets caused specific
changes in the oral environment, such as decreased
pH and increased plaque accumulation. The bacteri-
al adhesion to orthodontic brackets may be a primary
step leading to plaque accumulation and, because the
adhering bacteria continue to grow on the tooth sur-
faces near the brackets, enamel demineralization
around brackets is likely.
7
Since the initial affinity
of bacteria to solid surfaces is mostly due to electro-
static and hydrophobic interactions, the bracket
material could play a role in the level of bacterial
adhesion and plaque accumulation that leads to an
increased risk of caries.
The finding that there were fewer S. mutans and
S. sobrinus on the metal brackets and more on the
aesthetic brackets agrees with the findings of Ahn et
al.
7
However, other reports have indicated that there
were no obvious differences in the adhesion of
S. mutans to stainless steel, plastic and ceramic
brackets.
1719
This may be explained by the
differences in the detection methods.
The adhesion of micro-organisms to orthodontic
brackets is a complex and poorly understood process.
Microbial adhesion has been attributed to the surface
energy of the substrata (i.e. the bracket material), to
an adsorbed salivary protein layer or to surface rough-
ness of the bracket.
2023
Van Dijk et al.
20
showed
greater bacterial adherence to surfaces with high
Table III. Relationship between prevalence of S. mutans and S. sobrinus and Visible Plaque
Index (VPI) and Gingival Bleeding Index (GBI) on various premolar brackets with One-way
ANOVA.
S. mutans S. sobrinus VPI GBI
Brackets Mean Brackets Mean
(Number) score SD (Number) score SD
N N 37 0.32 0.48 37 0.19 0.40
N P 23 0.43 0.51 23 0.39 0.50
P N 33 0.52 0.51 33 0.48 0.51
P P 67 0.93 0.27 67 0.88 0.32
Total 160 0.63 0.48 160 0.59 0.49
N = negative, P = positive
p < .05
surface energy and Eliades et al.
21
reported that stain-
less steel, because of a high critical surface tension,
has increased attachment potential. However, these
observations might not be directly applicable as
Weerkamp et al.
22
reported that the adhesion of oral
micro-organisms to bracket surfaces was governed by
the properties of an adsorbed protein layer. Although
Eliades et al.
21
and Bauer et al.
23
showed that plastic
materials have lower surface-free energy than metal
bracket materials, the variation can be explained by
the surface energy characteristics of plastic brackets
which are strengthened by the addition of filler. The
combination of plastic and filler may produce rough
surfaces which increase the adherence and retention
of cariogenic streptococci.
The results of the present study have shown a signifi-
cant relationship between the prevalence of strep-
tococcal organisms and the oral hygiene indices. It
follows that the patients oral hygiene status is associ-
ated with cariogenic streptococci and therefore con-
sidered as an indicator of this bacterial population.
Nyvad et al.
24
reported that the proportion of
S. mutans is significantly lower and comprised only
0.5 per cent of dental plaque after 24 hours.
Although the population of streptococci could be
small, the high sensitivity of the PCR technique and
its ability to detect as few as 1000 cells, offers con-
fidence that the oral hygiene indices provided reliable
measures of cariogenic streptococci presence.
The duration of the present study was 30 days even
though it is recognised that plaque formation can
occur within 24 hours. It was expected that a 30-day
period would be sufficient to assess the oral hygiene
routine of the patients. The significant relationship
between the oral hygiene indices and bacterial pre-
valence suggests that the clinician should critically
evaluate the patients oral hygiene practises to prevent
white spot formation during and prior to treatment.
The results of the present study indicate that aes-
thetic brackets are more likely to attract cariogenic
bacteria and therefore increase the risk of enamel
decalcification. Future studies with bracket raw mate-
rials are required to identify the main component in
the bracket that causes the attraction. Furthermore,
the patients diet, oral hygiene including types of
toothbrushes, toothpastes and mouthwashes, the type
of adhesive and even fixed appliance components
could affect the adhesion and prevalence of cariogenic
bacteria. It is suggested the use of aesthetic brackets
requires the consideration of additional oral hygiene
aids that reduce plaque accumulation.
Conclusion
The results of this study suggest that oral hygiene is
of greater importance when aesthetic brackets are
used for fixed appliance treatment.
Professor Vignesh Kailasam
Faculty of Dental Sciences
Sri Ramachandra University
1, Ramachandra Nagar
Porur
Chennai 600116
India
Email: theorthodontist@gmail.com
References
1. Wisth PJ, Nord A. Carious experiences in orthodontically
treated individuals. Angle Orthod 1977;47:5964.
2. Loesche WJ. Role of Streptococcus mutans in human dental
decay. Microbiol Rev 1986;50:35380.
3. Hamada S, Slade HD. Biology, Immunology and cariogenic-
ity of Streptococcus mutans. Microbio Rev 1980;44:331384.
4. Beighton D, Hardie JM, Whiley RA. A scheme for the iden-
tification of viridians streptococci. J Med Microbiol 1991;
35:36772.
5. de Soet JJ, van Delen TJ, Pavicic MJAMP, de Graff J.
Enumeration of mutans streptococci in clinical samples by
using monoclonal antibodies. J Clin Microbiol 1990;28:
246772.
6. Igarashi T, Yamamoto A, Goto N. PCR for detection and
identification of Streptococcus sobrinus. J Med Microbiol
2000;49:106974.
7. Ahn SJ, Lim BS, Lee SJ. Prevalence of cariogenic strepto-
cocci on incisor brackets detected by polymerase chain reac-
tion. Am J Orthod Dentofacial Orthop 2007;131:73641.
8. Loe H, Silness J. Periodontal disease in pregnancy. I.
Prevalence and severity. Act Odontol Scand 1963;21:
53351.
9. Silness J, Loe H. Periodontal disease in pregnancy. II.
Correlation between oral hygiene and periodontal con-
dition. Act Odontol Scand 1964;22:12135.
10. Thiyagarajah S, Spary DJ, Rock WP. A clinical comparison
of bracket bond failures in association with direct and indi-
rect bonding. J Orthod 2006;33:198204.
11. Mayoral C, Norona M, Baroni MR, Giani R, Zalazar F.
Evaluation of a nested PCR assay for Streptococcus pneu-
moniae detection in pediatric patients with community-
acquired pneumonia. Rev Argent Microbiol 2005;37:1848.
12. Igarashi T, Yamamoto A, Goto N. Direct detection of
Streptococcus mutans in human dental plaque by polymerase
chain reaction. Oral Microbiol Immunol 1996;11:2948.
13. Artun J, Brobakken B. Prevalence of carious white spots after
orthodontic treatment with multibonded appliances. Eur J
Orthod 1986;8:22934.
PRAMOD ET AL
14. Gorelick L, Geiger AM, Gwinnett AJ. Incidence of white
spot formation after bonding and banding. Am J Orthod
1982;81:938.
15. Gwinnett AJ, Ceen RF. Plaque distribution on bonded
brackets: A scanning microscope study. Am J Orthod
1979;75:66777.
16. Mitchell L. Decalcification during orthodontic treatment
with fixed appliance: an overview. Br J Orthod
1992;19:199205.
17. Papaioannou W, Gizani S, Nassika M, Kontou E, Nakou M.
Adhesion of Streptococcus mutans to different types of
brackets. Angle Orthod 2007;77:10905.
18. Fournier A, Payant L, Bouclin R. Adherence of Streptococcus
mutans to orthodontic brackets. Am J Orthod Dentofacial
Orthop1998;114:41117.
19. Brusca MI, Chara O, Sterin-Borda L, Rosa AC. Influence of
different orthodontic brackets on the adherence of microor-
ganisms in vitro. Angle Orthod 2007;77:3316.
20. Van Dijk J, Herkstrter F, Busscher H, Weerkamp AH,
Jansen H, Arends J. Surface-free energy and bacterial adhe-
sion. An in vivo study in beagle dogs. J Clin Periodontol
1987;14:3004.
21. Eliades T, Eliades G, Brantley WA. Microbial attachment on
orthodontic appliances: I. Wettability and early pellicle for-
mation on bracket materials. Am J Orthod Dentofacial
Orthop 1995;108:35160.
22. Weerkamp AH, Van Der Mei HC, Busscher HJ. The surface
free energy of oral streptococci after being coated with sali-
va and its relation to adhesion in the mouth. J Dent Res
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23. Bauer RE, Glantz PO. Characterization of oral in vivo films
formed on different types of solid surfaces. Act Odontol
Scand 1978;36:289301.
24. Nyvad B, Kilian M. Comparison of the initial streptococcal
microflora on dental enamel in caries-active and in caries-
inactive individuals. Caries Res 1990;24:26772.
Introduction
Retainers are routinely fitted at the end of active
orthodontic treatment to allow the teeth to adjust to
their new positions.
1,2
Frequently used appliances are
the Hawley retainer, lingual bonded retainers, wrap-
around or Begg retainers and the recently introduced
Essix retainer. Begg retainers lack clasps and rely on
close contact between the wire labial bow and acrylic
baseplate for retention. They tend to become loose
over a period of time and allow the teeth to shift. The
visible wire labial bow may make the appearance of
the retainer less acceptable to patients.
Vacuum-formed retainers, such as the Essix, are
claimed to be aesthetic, comfortable and inexpensive
alternatives to traditional orthodontic retainers.
3
These appliances are thermoformed from a thin plastic
sheet material and are less bulky than traditional
acrylic retainers. Thermoformed retainers are consid-
ered to be more effective than Hawley retainers for
retaining the overjet and overbite and alignment of
the incisors.
4
This study was designed to compare the
effectiveness and acceptability of Essix and Begg
retainers over six months.
This prospective study was conducted in the
Department of Orthodontics and Dentofacial
Orthopedics, College of Dental Sciences, Davangere,
India. Ethical approval was obtained from the insti-
tution, and the subjects were treated by postgraduate
students in the department.
Effectiveness and acceptability of Essix and Begg
retainers: a prospective study
Arun G. Kumar and Anchal Bansal
Department of Orthodontics and Dentofacial Orthopedics, College of Dental Science, Davangere, Karnataka, India
Background: Retainers vary in their effectiveness in maintaining teeth in their treated positions and in their acceptability by
patients.
Aims: To compare the effectiveness and acceptability of Essix and Begg retainers.
Methods: Two hundred and twenty-four patients were randomly assigned to receive either upper and lower Essix or upper and
lower Begg retainers. Subject acceptability was evaluated with seven questions related to chewing and biting, fit, speech,
appearance, oral hygiene, comfort and maintenance recorded on a 10-point visual analogue scale. The effectiveness of the
retainers to maintain alignment was assessed on study models taken on the day after debonding (T1), after three months reten-
tion (T2) and six months retention (T3) with the Peer Assessment Rating (PAR) and Irregularity Index (II). In addition to the upper
and lower retainers, all subjects had bonded lower lingual retainers placed at the end of active treatment.
Results: There were small, but statistically significant, deteriorations in the PAR scores in both groups at T2 and T3. The T2-T1
and T3-T1 differences between the groups were statistically significant (Begg > Essix), but the differences did not exceed 2
points. For the Irregularity Index, the T3-T1 difference was statistically significant (Begg > Essix), but clinically insignificant as the
difference was only 0.25 points. Subjects preferred the Begg retainer for chewing and biting (p = 0.000), and liked the
appearance (p = 0.000) and comfort (p = 0.05) of the Essix retainers. The subjects in both groups reported both retainers had
an acceptable fit.
Conclusions: More subjects wearing Essix retainers considered their retainers were comfortable and had an acceptable appear-
ance than subjects wearing Begg retainers, and more subjects with Begg retainers considered that their retainers were accept-
able for biting and chewing than the subjects wearing Essix retainers. Both retainers allowed some relapse of teeth post-treat-
ment, but the 6-month differences were small and may not be clinically significant.
Received for publication: February 2010
Accepted: May 2010
Arun G. Kumar: orthoarun@yahoo.co.in
Anchal Bansal: bansalanchal@yahoo.co.uk
EFFECTIVENESS AND ACCEPTABILITY OF ESSIX AND BEGG RETAINERS
Subjects who were due to have their fixed orthodon-
tic appliances removed were assessed and included in
the study providing they met the following criteria:
they had received fixed appliance treatment in both
arches; only preadjusted edgewise appliances were
used for treatment and they were willing to wear
maxillary and mandibular retainers. Two hundred
and twenty-four patients met the inclusion criteria
and were randomly allocated to receive either an Essix
or a Begg retainer. Each group had 112 subjects.
The retainers were fabricated to standardised designs.
Upper and lower Begg retainers were constructed
with acrylic baseplates and labial bows made of 0.9
mm stainless steel wire. The labial bows had U loops
opposite the premolars and extended past the last
erupted molars (Figure 1). Upper and lower Essix
retainers
5
were thermoformed using Essix 1.5 mm A+
sheet (Raintree Essix, New Orleans, LA, USA) and
trimmed to provide 2 mm buccal and 34 mm
lingual extensions. The Essix retainer covered the
occlusal surfaces up to and including the most distal
molars (Figure 2). The retainers were fitted on the day
the subjects were debonded. The subjects were
instructed to wear both retainers 24 hours per day for
the first six months and 12 hours per day (night time
wear) for the next six months, to eat with the
retainers in place and remove the retainers after eating
for cleaning. Lower lingual retainers, extending from
canine to canine, made from coaxial wire were bond-
ed in all subjects.
Subject acceptance was evaluated three months after
fitting the retainers, using a 10-point visual analogue
scale.
6
The subjects were given oral instructions and
explanations on how to complete the questionnaires,
which contained questions on chewing and biting,
fitting of the appliance, speech, appearance, oral
hygiene, comfort and maintenance. The subjects were
asked to score each question according to how the
words at the extremes expressed how they felt. The
lowest (least favourable) score was 1 and the highest
(most favourable) score was 10. For example, if the
retainer was very uncomfortable it was scored as 1
and if it was very comfortable, as 10.
Occlusal stability was assessed with the Peer
Assessment Rating (PAR) and lower incisor crowding
with the Irregularity index (II) on study models taken
on the day after debonding (T1), after 3 months
retention (T2) and after 6 months retention (T3).
7,8
The Wilcoxon test was used to compare the relapse
from T1 to T3 in the groups. The Mann-Whitney
U test was used to compare the occlusal indices and
Figure 1. Maxillary and mandibular Begg retainers. Figure 2. Maxillary and mandibular Essix retainers.
the acceptability of the Essix and Begg retainers. A
p value of 0.05 or less was considered to be significant.
Results
Occlusal stability
The mean changes in the PAR scores after three
months of retention (T2-T1) was 0.71 0.54 in the
Essix group and 1.79 1.34 in the Begg group
(Table I). The mean difference in the PAR scores over
six months was 0.79 0.54 in the Essix group and
2.50 1.35 in the Begg group. The mean differences
(T2-T1 and T3-T1) in the PAR scores were signifi-
cantly larger in the Begg group compared with the
Essix group.
In spite of the bonded lower retainers, the alignment
of the lower incisors deteriorated steadily in both
groups, but did not exceed 1 mm (Table II) of dis-
placement. When the group changes T2-T1 and
T3-T1 were compared, only the 6-month difference
was statistically significant (p = 0.02). The irregular-
ity of the lower incisors in the Begg group increased
0.25 mm more than the incisor irregularity in the
Essix group.
Questionnaire analysis
The subjects in the Begg group scored their retainers
more highly (Mean score: 9) for chewing and biting
than the subjects in the Essix group (Mean score: 2.4;
p = 0.000). The subjects in the Essix group scored the
appearance and comfort of their retainers more
highly than the subjects in the Begg group (Table III).
The subjects in both groups considered the fit of their
retainers was acceptable. The differences in scores
between the two groups in terms of maintaining oral
hygiene, maintenance of the appliance and effect on
speech, were not statistically significant.
Discussion
The effectiveness of Essix and Begg retainers to main-
tain treated alignment and occlusion after ortho-
dontic treatment was compared, along with subject
acceptance of both retainers. The subjects were asked
to complete their questionnaires after three months
and reviewed after six months because most patients
were expected to still be wearing their retainers as
directed. Although there were small, but statistically
significant, deteriorations in the PAR scores in both
KUMAR AND BANSAL
Table I. PAR scores for Essix and Begg retainers.
Retainer T1 T2 T3 Difference Difference
(T2-T1) (T3-T1)
Essix Mean SD 5.88 2.71 6.58 2.84 6.67 2.80 0.71 0.54 0.79 0.54
p* - - - 0.007 0.006
Begg Mean SD 7.54 3.60 9.33 4.09 10.04 4.11 1.79 1.34 2.50 1.35
p* - - - 0.005 0.002
Essix vs Begg Mean SD - - - 1.08 1.71
p* - - - 0.05 0.004
* Wilcoxon signed rank test, significant values in bold
Table II. Irregularity Index scores for Essix and Begg retainers.
Retainer T1 T2 T3 Difference Difference
(T2-T1) (T3-T1)
Essix Mean SD 0.46 0.39 0.53 0.44 0.58 0.46 0.08 0.11 0.12 0.12
p* - - - 0.041 0.017
Begg Mean SD 0.33 0.23 0.52 0.40 0.69 0.45 0.19 0.26 0.37 0.29
p* - - - 0.026 0.005
Essix vs Begg Mean SD - - - 1.12 0.25
p - - - 0.41 0.02
* Wilcoxon signed rank test, significant values in bold
EFFECTIVENESS AND ACCEPTABILITY OF ESSIX AND BEGG RETAINERS
retainer groups, the differences did not exceed 2
points. The subjects assigned to the Begg retainer
group scored their retainers highly for their ability to
chew and bite, whereas the subjects assigned to the
Essix group preferred the appearance and comfort of
their retainers. The subjects in both groups reported
that their retainers fitted satisfactorily. Although the
Begg retainers provided excellent retention and no
occlusal interferences, the retainers required regular
supervision and adjustment of the labial wire.
It has been reported that Essix retainers are as effi-
cient as either bonded or Hawley retainers.
3
However,
if the occlusion requires settling during retention, the
Hawley-type appliance has been suggested as the
retainer of choice because it allows more vertical
movement of the posterior teeth and its labial wire
may be adjusted to correct minor irregularities.
9
Although each case was finished so that minimal/no
settling of the occlusion was necessary, small occlusal
changes occurred.
Although both groups had identical bonded lower
retainers and lower removable retainers, the irregular-
ity of the mandibular incisors increased statistically
significantly in both groups. However, the six-month
findings were not considered clinically significant.
Lindauer and Shoff conducted a study of Hawley and
Essix retainers and similarly reported increased lower
incisor irregularity in both retainer groups, although
their findings did not reach statistical significance.
3
Subsequently, bonded lower lingual retainers have
been found to provide excellent long-term retention
with no damage to the teeth and/or hard and soft
tissues adjacent to the affixed wire.
1012
Most of the deterioration in the PAR scores occurred
in the first three months of retainer wear and was
found to be greater in the Begg group compared with
the Essix group; 1.79 1.34 points and 0.71 0.54
points, respectively. However, the Begg group had a
slightly higher, but not statistically significant, PAR
score at T1 than the Essix group, which may indicate
that the Begg group had more severe initial mal-
occlusions and/or were less well finished than the
Essix group. The greater change in the PAR scores of
the two retainer groups occurred between T2 and T3.
Essix retainers are made to closely fit the teeth and
maintain small corrections that Begg retainers are
unable to achieve, because the teeth are held by the
labial wire and acrylic baseplate.
1,5
If the labial wire is
deformed during normal wear and/or repeated
removal of the appliance, the teeth are free to move.
The Begg retainer is, however, easily adjusted and
modified to achieve small corrections, whereas the
Essix is less easily modified and usually has to be
remade.
Subjects wearing the Essix retainers found biting and
chewing food difficult, presumably because the appli-
ances covered the occlusal surfaces and the incisal
edges of the teeth. These problems were not reported
by subjects wearing Begg retainers. Both groups con-
sidered their retainers fitted well, did not interfere
with speech, and were easy to clean and maintain.
Speech was not usually altered if only one removable
retainer was worn, and any distortion in speech was
reported as temporary.
13
However, each subject only
experienced one type of retainer and was therefore
unable to make comparisons which may have
produced an alternative result.
Not surprisingly, the subjects in the Essix group were
pleased with the appearance of their retainers (Range
of scores: 810). The labial wire of the Begg retainers
Table III. Acceptability of Essix and Begg retainers.
Question Essix Begg Essix vs Begg
Mean Median Range Mean Median Range p*
Chewing and biting 2.4 2 2-3 9.0 9 8-10 0.000
Fit 7.9 8 7-9 7.8 8 5-9 0.89
Speech 8.3 9 5-10 7.9 8 6-9 0.35
Appearance 8.9 9 8-10 4.5 4 3-7 0.000
Oral hygiene 8.3 9 6-9 8.2 8 6-9 0.59
Comfort 8.4 8.5 7-10 6.9 8 3-9 0.05
Maintenance 8.6 9 8-9 7.5 7.5 5-9 0.06
* Mann-Whitney U test, significant values in bold
KUMAR AND BANSAL
was visible and a number of subjects expressed mild
dissatisfaction (Range of scores: 37). However,
thermoplastic retainers such as the Essix have demon-
strated poor wear resistance and durability after only
a few months of use and may need to be replaced.
This reduces their cost-effectiveness.
14
The Essix
group considered their retainers were comfortable
(Range: 710), whereas the responses from the Begg
group were more variable (Range: 39). The closely
adapted Essix retainer was less likely to cause dis-
comfort than the acrylic and wire components of the
Begg retainer, and if a retainer was comfortable it was
more likely to be worn.
15
Conclusions
The present study evaluated the effectiveness and
acceptability of Essix and Begg retainers. There were
small, but statistically significant, differences in the
effectiveness of both retainers in maintaining the
occlusion for six months. The occlusal changes and
differences may not be clinically significant.
The subjects wearing Essix retainers were more
pleased with the appearance and comfort of their
retainers compared with the subjects wearing Begg
retainers.
The subjects in the Begg group preferred their
retainers for chewing and biting, whereas the subjects
wearing Essix retainers were dissatisfied with the
functional capabilities of their retainers.
Dr Arun G. Kumar
Orthopedics
College of Dental Science
Davangere 577004
Karnataka
India
Tel: (Mobile): +919448114073
Fax: +918192-251070
Email: orthoarun@yahoo.co.in
References
1. Graber TM, Vanarsdall RL. Current principles and tech-
niques in orthodontics, 4th edn 2005; 112348.
2. Bearn DR. Bonded orthodontic retainers: a review. Am J
3. Lindauer SJ, Shoff RC. Comparison of Essix and Hawley
Retainers. J Clin Orthod 1998;32:957.
4. Rowland H, Hichens L, Williams A, Hills D, Killingback N,
Ewings P et al. The effectiveness of Hawley and vacuum-
formed retainers: a single-center randomized controlled
trial. Am J Orthod Dentofacial Orthop 2007;132:7307.
5. Sheridan JJ, LeDoux W, McMinn R. Essix Retainers: fabri-
cation and supervision for permanent retention. J Clin
Orthod 1993;27:3745.
6. Ngan P, Kess B, Wilson S. Perception of discomfort by
patients undergoing orthodontic treatment. Am J Orthod
7. Richmond S, Shaw WC, OBrien KD, Buchanan IB, Jones
R, Stephens CD et al. The development of the PAR index:
reliability and validity. Eur J Orthod 1992;14;12539.
8. Little RM. The Irregularity Index: a quantitative score of
mandibular anterior alignment. Am J Orthod 1975;68:
55463.
9. Sauget E, Covell DA Jr, Boero RP, Lieber WS. Comparison
of occlusal contacts with use of Hawley and clear overlay
retainers. Angle Orthod 1997;67:22330.
10. Dahl EH, Zachrisson BU. Long-term experience with direct-
bonded lingual retainers. J Clin Orthod 1991;25: 61930.
11. Artun J. Caries and periodontal reactions associated with
long-term use of different types of bonded lingual retainers.
Am J Orthod 1984;86:11218.
12. Gorelick L, Geiger AM, Gwinnett AJ. Incidence of white
spot formation after bonding and banding. Am J Orthod
1982;81:938.
13. Haydar B, Karabulut G, Ozkan S, Aksoy AU, Cig er S.
Effects of retainers on the articulation of speech. Am J
14. Gardner GD, Dunn WJ, Taloumis L. Wear comparison of
thermoplastic materials used for orthodontic retainers. Am J
15. Wong P, Freer TJ. Patients attitudes towards compliance
with retainer wear. Aust Orthod J 2005;21:4553.
Introduction
Interceptive orthodontic treatment aims to restore
normal development of the dentition and is com-
monly prescribed during the mixed dentition. In
essence, intervention is of short duration and should
result in clinical improvement of the occlusion.
1
An
ectopic position of a maxillary first permanent molar
results in a local malocclusion and occurs due to a
more mesial eruptive path. The resultant close con-
tact between the first molar and the second primary
molar causes atypical resorption localised to the distal
aspect of the primary molar and subsequent locking
of the permanent molar within the resorption cavity.
2
The radiographic prevalence of ectopic maxillary first
permanent molars in non-syndromic individuals has
been reported as 4.3 per cent
3
and is increased in cleft
children to 21.8 per cent.
2
This eruption disturbance
has a higher reported prevalence in males,
3,4
can
occur bilaterally or unilaterally, and is more common
in the maxilla.
5
The ectopic position of the maxillary first molar may
be classified both radiographically
3
and clinically.
5,6
Historically, the ectopic molar position has been
termed jump or hold cases.
7
A contemporary ver-
sion of this classification was proposed by Bjerklin
and Kurol
3
who graded ectopic molar position as
either reversible (jump) or irreversible (hold). In addi-
tion, the reported incidence of both types of
impaction varied with reversible types (59 per cent)
more frequent than irreversible (41 per cent).
3
In
contrast, the clinical classification is based on the
assessment of the width of the marginal ridge of the
first permanent molar in relation to the distal aspect
of the primary second molar.
5,6
Orthodontic management of ectopic maxillary
first permanent molars: a case report
Jadbinder Seehra,
*
Lindsay Winchester,
Andrew T. DiBiase
+
and Martyn T. Cobourne
Guys and St Thomas NHS Foundation Trust, Department of Orthodontics and Pediatrics, London and Queen Victoria Hospital NHS
Foundation Trust, East Grinstead, West Sussex;
*
Queen Victoria Hospital NHS Foundation Trust, East Grinstead, West Sussex;
East Kent
Hospitals University NHS Foundation Trust, Kent and Canterbury Hospital, Canterbury, Kent;
+
Kings College London Dental Institute,
Department of Orthodontics and Craniofacial Development, Kings College London Dental Institute, London,
United Kingdom
Background: Ectopic position of a maxillary first permanent molar results in a local malocclusion within the mixed dentition and
occurs when the tooth erupts more mesially to its normal path of eruption. The prevalence of ectopic maxillary first
permanent molars has been reported at approximately 4 per cent. Possible treatment options include the extraction of the
primary second molar and the placement of a space maintainer, extraction of the primary second molar and later regaining
lost space during comprehensive treatment of the malocclusion or implementing interceptive treatment to disimpact the maxillary
first permanent molar and preserving arch length.
Aim: To describe the aetiology, classification and management of ectopic maxillary first permanent molars and to present two
cases of intervention using simple orthodontic appliances.
Methods: A sectional fixed appliance and orthodontic separators were used to correct the ectopic maxillary first permanent
molars.
Results: Successful disimpaction resulted in normal vertical eruption and arch length preservation.
Conclusions: Management of ectopic maxillary first molars can be successfully achieved in the mixed dentition.
Received for publication: October 2010
Accepted: April 2011
Jadbinder Seehra: jad_Seehra@hotmail.com
Lindsay Winchester: Lindsay.winchester@qvh.nhs.uk
Andrew T. DiBiase: Andrew.dibiase@ekht.nhs.uk
Martyn T. Cobourne: martyn.cobourne@kcl.ac.uk
SEEHRA ET AL
Both genetic and environmental factors have been
cited in the aetiology of ectopic maxillary first per-
manent molars. A genetic basis is proposed due to a
reported familial tendency,
8
a higher prevalence in
cleft children
2
and the presence of associated dental
anomalies.
9
Local factors include a more mesial erup-
tion path or mesial angulation of the maxillary first
permanent molar,
5,10
a reduced maxillary length
10
and an increased molar width.
10
The severity of the
atypical resorption of the distal root of the primary
second molar can ultimately lead to premature exfoli-
ation of the primary tooth or its planned extraction.
In the event of either outcome, a reduction of
arch length is anticipated due to mesial drifting and
tipping/rotation of the first permanent molar.
Possible treatment options to manage the situation
include the extraction of the primary second molar
and the placement of a space maintainer, the extrac-
tion of the primary second molar and later regaining
space during comprehensive treatment of the mal-
occlusion, or implementing interceptive treatment to
disimpact the maxillary first permanent molar and
preserve arch length.
The following is a description of two clinical cases of
ectopically positioned maxillary first permanent
molars in which dental development was restored
with the aid of two simple orthodontic interceptive
measures. The diagnosis and management of ecto-
pically positioned maxillary first permanent molars
are discussed.
Case 1
A medically fit 9 year-old female was referred by her
general dental practitioner to the orthodontic depart-
ment for the management of bilaterally impacted
upper first permanent molars. She presented in the
mixed dentition with a Class II division 1 mal-
occlusion on a mild skeletal II base, complicated by
bilaterally ectopic 16 and 26 and crowding of both
dental arches. Radiographic and clinical examin-
ation confirmed the ectopic position of 16 and 26
(Figure 1) and the treatment plan aimed to disimpact
the molars. Discing reduction of the distal aspect of
the 55 and 65 was performed over two visits in com-
bination with placement of elastomeric separators
Figure 1. Upper occlusal photograph and OPT radiograph demonstrating the bilaterally impacted 16 and 26.
Figure 2. Placement of elastomeric separators
following distal reduction of the primary second
molars.
Figure 3. Successful correction of the 26. The 16
position failed to improve following discing and
separation.
(Figure 2). The 26 responded favourably; however, 16
resulted in limited improvement (Figure 3). The
decision was made to refer the patient to her gen-
eral dental practitioner for the extraction of the
55 and to subsequently regain lost space during a
comprehensive phase of orthodontic treatment.
Case 2
A medically fit 8 year-old female was referred by
her general dental practitioner to the orthodontic
department regarding an impacted 26. The patient
presented in the mixed dentition with a Class II
division 1 malocclusion on a skeletal I pattern com-
plicated by a digit sucking habit. Crowding was
localised to 22 and the ectopic 26 was clinically and
radiographically confirmed (Figure 4). The treatment
plan was directed at the disimpaction of 26 followed
by the extraction of 63. Discing reduction of the
distal aspect of the 65 was initially performed which
resulted in limited improvement in the position of
the 26. Following this reduction, a sectional pre-
adjusted edgewise appliance (0.022 x 0.028 inch slot)
using a MBT prescription was bonded to the 64, 65
and 26. An initial 0.014 inch NiTi archwire was
engaged and a light NiTi open coil spring placed
between the 65 and 26 (Figure 5). The patient was
reviewed on a monthly basis and, after two visits, the
ectopic 26 was visibly free from the distal surface of
65. At the following visit, the fixed appliance was
removed and a post-treatment radiograph confirmed
the corrected position of the previously ectopic 26
(Figure 6).
ORTHODONTIC MANAGEMENT OF ECTOPIC MAXILLARY FIRST PERMANENT MOLARS
Figure 4. Intra-oral photographs and bitewing radiograph demonstrating the impacted 26.
Figure 5. Sectional fixed appliance in-situ.
SEEHRA ET AL
Discussion
In cases of ectopically positioned maxillary first per-
manent molars, the decision to intervene relies on
differentiating between irreversible or reversible types
of impaction. While the majority of cases are diag-
nosed at approximately 8 years age,
4,11
Bjerklin and
Kurol
10
suggested that reversible types are likely to
self-correct at 7 years of age and persistence beyond
this time is consistent with irreversible types. Specific
dental factors associated with irreversible types of
impaction include an increased molar tooth width, a
greater mesial angulation of first maxillary molars and
a tendency for reduced maxillary length.
10
However,
the need to consider individual variation of dental
eruption and development, coupled with a period of
observation may be required before confirming the
diagnosis and eventual treatment plan. In both pre-
sented cases, crowding of the dental arches was evi-
dent clinically and radiographically and the preven-
tion of possible further arch length loss influenced the
decision to intervene.
The ideal radiograph used to assess the position of an
ectopically placed first molar may be either a peria-
pical or bitewing film;
12
however OPT radiographs
have been used in large sample studies and are clinic-
ally acceptable.
5,10
In these studies, the mesial angul-
ation of the ectopic molar was determined by the
intersection of the orbital plane (plane extending
between the lowest points of the right and left orbital
fossa) and the tangent from the mesial surface of the
crown and mesiobuccal root of maxillary first
molar.
10
Chintakanon and Boonpinon
5
reported the
mean angulation of ectopic maxillary first molars was
82.5 degrees (SD 6.0). This finding was supported by
Bjerklin and Kurol
10
who suggested that the meas-
urement of the molar mesial angulation can aid in
assessing the severity of the impaction and provide an
indication of the potential treatment outcome. In
Case 1, the mesial angulations of the 16 and 26 were
measured at 67 degrees and 78 degrees respectively. In
comparison with the reported mean mesial angula-
tion of ectopic first permanent molars, the 16 may be
regarded as severely impacted and hence, it was not
surprising that the position of this tooth failed to
improve with interceptive treatment.
The treatment option adopted will therefore depend
on the type and magnitude of the diagnosed
impaction. Additional factors that are worthy of con-
sideration include patient compliance, the underlying
malocclusion, evidence of arch length discrepancy,
eruption status of the first molar, access to the inter-
proximal region between the primary and permanent
molar, mobility of second primary molar teeth, level
of oral hygiene and potential plaque retention.
Young
7
reported that 66 per cent of cases of ectopic
first maxillary molars are likely to self-correct and no
Figure 6. Clinical and radiographic improvement of the ectopic position of the 26.
active treatment considered. However, this cannot be
reliably predicted and treatment is indicated if no
improvement has occurred within 36 months of
observation.
13
Reversible types of impaction usually
require no treatment as the maxillary first permanent
molar self-corrects into normal vertical position.
Interestingly, the long-term prognosis of the resorbed
second primary molar is generally favourable.
14
In
irreversible types of impactions, interceptive treat-
ment is justified. Kurol and Bjerklin
15
suggested that
the aims of any intervention should result in distal
movement of the impacted permanent molar to
regain space, correction of mesial tipping and
rotations and an increase of intermolar distance if
necessary.
A relatively simple intervention is to create space
between the primary and permanent molar. The
removal of any obstruction should allow the mesial
aspect of the permanent molar to free itself from the
resorption cavity and erupt into its normal occlusal
position. This may be achieved with brass wire, elasto-
meric separators or separating springs with or without
discing of the distal surface of the second primary
molar.
12
Elastic separators are easier to place and
better tolerated compared with springs or brass
wire.
13
This treatment modality may be considered if
the contact point between the first permanent molar
and second primary molar is readily accessible. If
access is poor then appliance therapy is indicated.
13
In Case 1, placement of elastomeric separators in con-
junction with discing was performed on two separate
occasions. The position of the 26 was successfully
corrected, however 16 proved resistant due to the
degree of impaction. In contrast, in Case 2, initial
discing of the distal surface of the primary molar
without separation resulted in minor clinical
improvement of the ectopic position.
Kurol and Bjerklin
15
reported that removable or
fixed orthodontic appliances may be used to achieve
molar disimpaction. However, the clinical effective-
ness of removable appliances can be compromised
due to the reliance on patient compliance and inade-
quate retention in the mixed dentition.
12,13
These
shortcomings may be overcome by fixed appliances
which range from single bands placed on the primary
molars with uprighting springs,
16
to attachments
placed on the ectopic molar,
17
to anterior transpalatal
arches incorporating distalising and uprighting
springs.
12
Anchorage management is critical to successful fixed
appliance treatment of ectopic molars. Case 2 pre-
sented a sectional fixed appliance to disimpact 16.
Anterior anchorage was reinforced by bonding both
primary molars and by the use of a lightly activated
NiTi open coil spring. A more buccally-directed force
was generated rather than a true distal and upright-
ing movement of the permanent molar. However, this
eccentric force was sufficient to correct the mesial tip-
ping and rotation, resulting in normal molar vertical
eruption.
If a case is unresponsive to separation mechanics and
appliance therapy, or alternatively, if there is excessive
mobility of the primary teeth or a severely ectopically
positioned molar, then active treatment may not be
appropriate. In this circumstance, planned extraction
of the primary second molar tooth may be indicated
3
with a subsequent decision to construct a space main-
tainer or regain lost space at a later date. Because elas-
tomeric separation was unsuccessful in Case 1, extrac-
tion of the primary molar was required. In view of the
lack of consensus regarding the use of space main-
tainers,
18
the patients age and avoidance of exhaust-
ing future compliance, a space maintainer was not
provided. Later options to regain space for the second
premolar may include the use of removable or fixed
appliances and extra-oral traction. The use of Kloehn
type cervical headgear has been reported to produce
uprighting of maxillary molars and a space gain of up
to 1.5 mm. The use of cervical headgear should be
avoided in Class III malocclusions and individuals
with vertical growth patterns.
13
In addition, headgear
alone may be considered when no further ortho-
dontic intervention is planned, a mild space require-
ment exists and the second premolar is close to
eruption.
19
Conclusions
Correction of ectopic maxillary first permanent
molars can be performed in the mixed dentition.
In cases in which an underlying arch length dis-
crepancy is evident, interceptive treatment can result
in normal vertical eruption of the molar whilst
preventing an increase in crowding. Several treatment
options are available, ranging from elastomeric sepa-
ration to orthodontic appliance therapy, all of which
have the potential to simplify future treatment,
provided that there is no excessive loss of arch space.
ORTHODONTIC MANAGEMENT OF ECTOPIC MAXILLARY FIRST PERMANENT MOLARS
Dr Martyn T. Cobourne
Department of Orthodontics and Craniofacial
Development
Floor 22 Guys Tower
Kings College London Dental Institute
London SE1 9RT
United Kingdom
Email: martyn.cobourne@kcl.ac.uk
References
1. King GJ, Brudvik P. Effectiveness of interceptive orthodon-
tic treatment in reducing malocclusions. Am J Orthod
2. Bjerklin K, Kurol J, Paulin G. Ectopic eruption of the max-
illary first permanent molars in children with cleft lip and/
or palate. Eur J Orthod 1993;15:53540.
3. Bjerklin K, Kurol J. Prevalence of ectopic eruption of
the maxillary first permanent molar. Swed Dent J 1981;5:
2934.
4. Barberia-Leache E, Suarez-Cla MC, Saavedra-Ontiveros D.
Ectopic eruption of the maxillary first permanent molar:
characteristics and occurrence in growing children. Angle
Orthod 2005;75:61015.
5. Chintakanon K, Boonpinon P. Ectopic eruption of the first
permanent molars: prevalence and etiologic factors. Angle
Orthod 1998;68:15360.
6. Harrison LM Jr, Michal BC. Treatment of ectopically erupt-
ing permanent molars. Dent Clin North Am 1984;28:
5767.
7. Young DH. Ectopic eruption of the first permanent molar. J
Dent Child 1957;24:15362.
8. Kurol J, Bjerklin K. Ectopic eruption of maxillary first per-
manent molars: familial tendencies. ASDC J Dent Child
1982;49:358.
9. Bjerklin K, Kurol J, Valentin J. Ectopic eruption of maxil-
lary first permanent molars and association with other tooth
and developmental disturbances. Eur J Orthod 1992;14:
36975.
10. Bjerklin K, Kurol J. Ectopic eruption of the maxillary first
permanent molar: etiologic factors. Am J Orthod 1983;84:
14755.
11. Dixon DA. Impactions of the first permanent molar. Br
Dent J 1959;106:2813.
12. Kurol J, Bjerklin K. Ectopic eruption of maxillary first per-
manent molars: a review. ASDC J Dent Child 1986;53:
20914.
13. Kennedy DB, Turley PK. The clinical management of
ectopically erupting first permanent molars. Am J Orthod
14. Kurol J, Bjerklin K. Resorption of maxillary second primary
molars caused by ectopic eruption of the maxillary first per-
manent molar: a longitudinal and histological study. ASDC
J Dent Child 1982;49:2739.
15. Kurol J, Bjerklin K. Treatment of children with ectopic
eruption of the maxillary first permanent molar by cervical
traction. Am J Orthod 1984;86:48392.
16. Pulver F, Croft W. A simple method for treating ectopic
eruption of the first permanent molar. Pediatr Dent 1983;5:
1401.
17. Halterman CW. A simple technique for the treatment of
ectopically erupting permanent first molars. J Am Dent
Assoc 1982;105:10313.
18. Laing E, Ashley P, Naini FB, Gill DS. Space maintenance.
Int J Paediatr Dent 2009;19:15562.
19. Bjerklin K, Gleerup A, Kurol J. Long-term treatment effects
in children with ectopic eruption of the maxillary first per-
manent molars. Eur J Orthod 1995;17:293304.
SEEHRA ET AL
Introduction
Transposition is an uncommon type of ectopia in
which two adjacent teeth swap arch positions or a
tooth either develops or erupts in a position nor-
mally occupied by a non-adjacent tooth.
1
Tooth
transpositions can be complete with the crowns and
roots transposed and parallel to each other, or incom-
plete with the crowns transposed, but the root apices
in relatively normal positions.
1
Because the condition
occurs bilaterally and amongst relatives
4,5
it is
thought to have a genetic background.
26
Small teeth,
missing teeth and teeth with unusual crown forms,
particularly the maxillary lateral incisors, have been
reported to occur more frequently in subjects with
transposed teeth than in the general population.
46
Retained deciduous canines, often found in subjects
with transposed teeth, were once thought to deflect
the permanent canine from its normal path of erup-
tion, but recent evidence suggests that prolonged
retention of a deciduous canine is a consequence of
the positional alteration of the permanent tooth and
not the cause of the tranposition.
5,6
The prevalence of transposed teeth in the general
population is 0.4 per cent and more frequently found
unilaterally
5,7
in the maxilla,
6
and affecting (in
descending order) canines and first premolars,
canines and lateral incisors, and lateral and central
incisors.
4,7
In the mandibular arch, the canines and
lateral incisors and, less frequently, canines and first
premolars are the teeth likely to be transposed.
3,8
The treatment of a transposed maxillary canine
involving movement past an adjacent tooth and root
repositioning can be challenging. Careful consider-
ation of alveolar width and the integrity of the
attached supporting tissue is essential. Often the best
approaches are to either move a partially transposed
tooth into a fully transposed position or to leave fully
transposed teeth in position.
1
If either of these
approaches is adopted, careful finishing and reshap-
ing of the transposed tooth is necessary to improve
appearance and occlusal relationships.
Recently, skeletal anchorage systems involving mini-
plates, palatal implants, mini-implants and miniscrews
Alignment of an ectopic canine with mini-implant
anchorage: a case report
Priyanka Sethi Kumar,
*
K. Nagaraj,
Ruchi Saxena
+
and Juhi Yadav
*
Department of Orthodontics and Dentofacial Orthopedics, Santosh Dental College and Hospital, Ghaziabad;
*
Department of Orthodontics and
Dentofacial Orthopedics, Institute of Dental Sciences, (Karnataka Lingayat Education) University, Belgaum;
Department of Orthodontics and

Dentofacial Orthopedics, Vydehi Institute of Dental Sciences and Research Centre, Bangalore,
+
India
Aims: To describe the treatment of an ectopic maxillary left canine and Class II molar relationship in a 12 year-old girl.
Methods: A pendulum appliance was used in a first phase of treatment to distalise the maxillary molars to a Class I molar rela-
tionship. In the second phase of treatment, a mini-implant, inserted between the roots of the left maxillary central and lateral
incisors, provided anchorage to move an ectopic maxillary left canine into position.
Results: The implant remained stable throughout treatment and a maxillary canine first premolar transposition was corrected.
Good overjet and overbite were achieved and have been maintained one year after completion of active treatment.
(Aust Orthod J 2011: 6368)
Received for publication: April 2010
Priyanka Sethi Kumar: priyankakumar@rediffmail.com
K. Nagaraj: nagi154@rediffmail.com
Ruchi Saxena: sruchi112@yahoo.com
Juhi Yadav: drjuhiyadav@gmail.com
KUMAR ET AL
have revolutionised orthodontic treatment and bio-
mechanics by providing more secure anchorage. Of
these devices, mini-implants or miniscrews have
many advantages as they may be easily inserted and
removed, may be loaded immediately, placed in a
number of anatomical locations including between
the roots of teeth, and are relatively inexpensive.
9
In
this case report, the methods of treating transposed
canines are discussed and the treatment of an ectopic
maxillary canine with anchorage from a mini-implant
is described.
Diagnosis
A 12 year-old girl attended the Department of
Orthodontics and Dentofacial Orthopedics,
Karnataka Lingayat Education University, accompa-
nied by her father. The presenting chief complaint
was an ectopic maxillary left canine. The extra-oral
examination revealed a symmetrical face with a
straight profile and competent lips (Figure 1).
Relative to the facial midline, the maxillary midline
was displaced to the left by 1 mm and the mandibu-
lar midline to the right by 1 mm. The first molars
were end-on and a Class I canine relationship on the
right side was evident. All permanent teeth (except
the third molars) had erupted and the deciduous
maxillary left canine was retained. The permanent
maxillary left canine had erupted buccally between
the premolars. The overbite was 3 mm, the overjet
was 4 mm and the maxillary right central incisor had
a small area of hypoplasia (Figure 2). The panoramic
radiograph confirmed the presence of a complete
dentition with developing third molars (Figure 3).
Treatment objectives
The treatment objectives were:
1. To level and align the maxillary and mandibular
arches.
2. To correct the transposed maxillary left canine and
first premolar.
3. To achieve a Class I molar occlusion.
4. To achieve a Class I canine relationship on the left
and maintain the Class I canine relationship on the
right.
5. To correct the maxillary and mandibular midlines.
Treatment alternatives
An extraction and a nonextraction treatment option
were considered in order to achieve the treatment
objectives. Extraction of the maxillary first premolars
and the deciduous canine would eliminate the dental
crowding and enable the straightforward correction
of the transposed canine. While an extraction pro-
gramme would be faster and the mechanics simpler,
treatment could lead to a deterioration in the
patients straight profile. In addition, the maxillary
arch was only mildly crowded. Therefore, a nonex-
traction treatment approach was considered with two
mechanical possibilities. The first option was the use
of cervical headgear to distalise the maxillary molars
and retain the teeth in their transposed order, and the
second option was to use an intra-oral appliance to
distalise the maxillary molars, followed by a mini-
implant to correct the transposed tooth. The extrac-
tion treatment plan was rejected because of profile
Figure 1. Pretreatment and post-treatment profile photographs.
concerns and after a discussion with the patient, the
intra-oral appliance coupled with the mini-implant
was selected as the treatment option of choice.
Although treatment would likely be shorter if the
transposition was accepted, space was still required
for the transposed canine. A further disadvantage of
this option was the expected difficulty in finishing
and avoiding cuspal interference during mandibular
function. Successful headgear treatment requires
patient compliance, and the correction of the trans-
posed teeth using conventional mechanics would be
time-consuming. The patient refused to wear a head-
gear and after discussion, considering all options, it
was decided to use an intra-oral distalisation appli-
ance to correct the molar relationship and use skele-
tal anchorage derived from a mini-implant to manage
the transposed canine. Following patient and parent
consent, the third molars were removed to facilitate
distal movement of the first molars.
Treatment progress
In the first phase of treatment, the maxillary first
molars and first premolars were banded and a pendu-
lum appliance was placed (Figure 5).
10
The remaining
maxillary teeth and mandibular teeth were bonded
with a preadjusted edgewise appliance (0.022 inch
Roth slot, GAC International, Central Islip, NY,
USA) and aligned with 0.016 inch NiTi archwires.
After five months of distalisation a bilateral Class I
molar relationship was obtained. Although a Nance
button was used to reinforce anchorage, the maxillary
incisors flared during this phase of the treatment.
After the arches had been levelled and aligned, a
self-drilling custom-made titanium mini-implant
ALIGNMENT OF AN ECTOPIC CANINE
Figure 2. Pretreatment intra-oral photographs.
Figure 3. Pretreatment panoramic radiograph.
Figure 4. Radiograph confirming the position of the
mini-implant.
(1.3 mm x 8 mm, S.K. Surgical, Pune, India) was
inserted in the labial alveolar bone between the roots
of the left central and lateral incisors at the mucogin-
gival junction. The availability of interdental bone
and the possibility of soft tissue irritation from an
implant were considerations in site selection.
11
Bone
quality and quantity were evaluated using panoramic
and intra-oral periapical radiographs. To aid place-
ment of the implant, a stainless steel guide bar was
embedded in an acrylic pad that rested on the palatal
surface of the maxilla. The mini-implant was placed
using infiltration anaesthesia and immediately
checked for mobility (primary stability). A radio-
graphic image confirmed that the implant did not
contact the roots of the adjacent teeth (Figure 4). A
preadjusted edgewise bracket was bonded on the
facial surface of the canine and elastomeric chain,
delivering approximately 50 g of force, was attached
between the mini-implant and the canine (Figure 6).
As treatment progressed, a 0.017 x 0.025 inch stain-
less steel archwire was used to control movement of
the canine.
Six months into treatment, the deciduous canine was
extracted to provide space for the ectopic canine. An
open-coil spring, threaded over a 0.017 x 0.025 inch
stainless steel archwire, was used to create space for
the ectopic tooth.
12
An elastomeric chain was placed
between the right maxillary first molar and the left
lateral incisor to correct the maxillary midline and a
second elastomeric chain, from the bracket on the
ectopic canine to the lateral incisor bracket, to move
the canine into the arch (Figure 7). When the ectopic
canine reached an appropriate occlusal level, a 0.016
inch NiTi archwire was placed to align all teeth.
When the maxillary left canine was aligned, rectan-
gular wires were used to detail the occlusion and
parallel the roots.
Fixed lingual retainers made from 0.017 inch
multi-strand wire (Unitek coaxial, 3M Unitek,
Monrovia, CA, USA) were bonded to the lingual
surfaces of the anterior teeth in both arches. The
mini-implant remained stable throughout treat-
ment, was free of complications and was well toler-
ated by the subject. It was removed under topical
anesthesia.
Treatment results
At the end of treatment, adequate facial proportions
and the patients straight profile were maintained
(Figure 1). The maxillary and the mandibular arches
were levelled and aligned and the midlines were coin-
cident with the facial midline. A well-seated Class I
KUMAR ET AL
Figure 7. Vertical force from the lateral incisor
bracket to the canine bracket.
Figure 8. Post-treatment intra-oral photographs.
Figure 5. Pendulum appliance. Figure 6. Mesial elastic force from mini-implant to
the canine.
molar and canine occlusion was obtained (Figure 8).
Canine guidance existed during right and left excur-
sive movements with no balancing interferences.
Centric occlusion and centric relation were coinci-
dent. Radiographically, the roots were parallel except
for the maxillary left central incisor, which was
inclined mesially. No root resorption was evident on
the maxillary left canine nor on the maxillary left first
premolar. The total treatment time was 17 months.
At the 12-month follow-up review, the occlusion and
heights of the gingivae on the maxillary left canine
appeared stable.
Discussion
The treatment of transposition can be extremely
difficult, particularly if the transposed teeth are
orthodontically moved into their normal arch
positions.
1,8,1317
Many clinicians prefer to retain
the teeth in their transposed state and treat any
occlusal interferences that may arise at the end of
treatment.
4
Whereas a transposed maxillary canine
and the lateral incisor should be corrected for
aesthetic reasons, a transposed maxillary canine and
first premolar may be left in their transposed
positions.
13
If the palatal cusp of the first premolar
is unsightly or causes an occlusal interference,
occlusal adjustment is indicated. The acceptance of a
transposition usually means a shorter treatment
time.
4
Skeletal anchorage has been the focus of much atten-
tion in orthodontics because it provides absolute
anchorage and has simplified treatment of many dif-
ficult cases. The simple design and small size of mini-
implants ensures that they may be easily placed in
sites close to the roots of the teeth. While mini-
implants are well tolerated by patients, care needs to
be exercised in their placement to avoid damag-
ing adjacent structures. When there is insufficient
interradicular space for a mini-implant, the roots of
the teeth should be separated before placing the
implant.
The treatment time for the presented case was only
17 months compared with previous reports of ortho-
dontic treatment of similar transpositions that have
ranged over considerably longer periods.
1415
The
current shorter treatment duration was attributed to
the mini-implant anchorage and simplified mechan-
ics. The patient experienced no problems and the
mini-implant remained stable, which assisted in
ensuring treatment success. Previous clinical reports
have suggested that implants remain stable if applied
forces range between 50 g (0.05 N) and 450 g (4.5
N).
18,19
However, the expectation of mini-implant
stability under orthodontic load cannot be guaran-
teed as bone remodelling can take place in response to
the mechanical stress.
20,21
An elastic force of approx-
imately 50 g was applied between the mini-implant
and the canine and the implant remained stable
throughout treatment.
Conclusion
The presented case report demonstrates ortho-
dontic correction of an ectopic maxillary canine using
a mini-implant as the source of anchorage. The
ectopic canine was manipulated into its normal posi-
tion in the arch without the need for undue patient
cooperation. The mini-implant remained stable
throughout treatment and caused no soft tissue
complications.
Dr Priyanka Sethi Kumar
Senior Lecturer
Orthopedics
Santosh Dental College & Hospital
1 Santosh Nagar
Ghaziabad- 201009, U.P.
India
Email: priyankakumar@rediffmail.com
Tel: +919810723900
References
1. Shapira Y, Kuftinec MM. Tooth transpositions: a review of
the literature and treatment considerations. Angle Orthod
1989;59:2716.
2. Shapira Y, Kuftinec MM. Early detection and prevention of
mandibular tooth transposition. J Dent Child (Chic) 2003;
70:2047.
3. Peck S, Peck L, Katajia M. Mandibular lateral incisor-canine
transposition, concomitant dental anomalies, and genetic
control. Angle Orthod 1998;68:45566.
4. Peck S, Peck L. Classification of maxillary tooth trans-
positions. Am J Orthod Dentofacial Orthop1995;107:
50517.
5. Peck L, Peck S, Attia Y. Maxillary canine first premolar
transposition, associated dental anomalies and genetic basis.
6. Chattopadhyay A, Srinivas K. Transposition of teeth and
genetic etiology. Angle Orthod 1996;66:14752.
7. Shapira Y, Kuftinec MM. Maxillary tooth transpositions:
characteristic features and accompanying dental anomalies.
Am J Orthod Dentofacial Orthop 2001;119:12734.
ALIGNMENT OF AN ECTOPIC CANINE
8. Shapira Y. Bilateral transposition of mandibular canines and
lateral incisors: orthodontic management of a case. Br J
Orthod 1978;5:2079.
9. Prabhu J, Cousley RR. Current products and practice: bone
anchorage devices in orthodontics. J Orthod 2006;33:
288307.
10. Hilgers J. The pendulum appliance for Class II non-compli-
ant therapy. J Clin Orthod 1992;26:70614.
11. Kim T, Kim H, Lee S. Correction of deep overbite and
gummy smile by using a mini-implant with a segmental
wire in a growing Class II div 2 patient. Am J Orthod
12. Kohavi D, Becker A, Zilberman Y. Surgical exposure, ortho-
dontic movement, and final tooth position as factors in
periodontal breakdown of treated palatally impacted
canines. Am J Orthod 1984;85:727.
13. Shapira Y, Kuftinec MM, Stom D. Maxillary canine-lateral
incisor transposition orthodontic management. Am J
14. Maia FA. Orthodontic correction of a transposed maxillary
canine and lateral incisor. Angle Orthod 2000;70:33948.
15. Maia FA, Maia NG. Unusual orthodontic correction of
bilateral maxillary canine first premolar transposition.
16. Kuroda S, Kuroda Y. Nonextraction treatment of upper
canine premolar transposition in an adult patient. Angle
Orthod 2005;75:4727.
17. Shapira Y, Kuftinec MM. A unique treatment approach for
maxillary canine lateral incisor transposition. Am J
18. Park HS, Bae SM, Kyung HM, Sung JH. Micro-implant
anchorage for treatment of skeletal Class I bialveolar protru-
sion. J Clin Orthod 2001;35:41722.
19. Kyung SH, Hong SG, Park YC. Distalization of maxillary
molars with a midpalatal miniscrew. J Clin Orthod
2003;37:226.
20. Liou EJ, Pai BC, Lin JC. Do miniscrews remain stationary
under orthodontic forces? Am J Orthod Dentofacial Orthop
2004;126:427.
21. Gedrange T, Bourauel C, Kobel C, Harzer W. Three-dimen-
sional analysis of endosseous palatal implants and bones
after vertical, horizontal and diagonal force application. Eur
J Orthod 2003;25:10915.
KUMAR ET AL
Introduction
An Angle Class III malocclusion can exhibit a variety
of skeletal and dental components, including a large
or prognathic mandible, a retrusive maxilla, a pro-
trusive mandibular dentition, a retrusive maxillary
dentition or a combination of these components.
1
The incidence of Class III malocclusion varies
amongst racial groups with a ratio of 1 to 4 per cent
among Caucasian populations, and 4 to 14 per cent
in Asians.
2
In addition, Ellis and McNamara
3
reported
that 30 per cent of Class III subjects presented with
maxillary retrusion and mandibular prognathism.
Furthermore, the incidence of Class III patients with
maxillary retrusion with a normally positioned
mandible or mandibular protrusion with a normally
positioned maxilla were 19.5 and 19.1 per cent,
respectively.
3
The etiology of this malocclusion is
therefore variable but implicated factors include
heredity, environmental influences (e.g. anterior
functional shifts of the mandible or mouth breath-
ing), and pathological circumstances (e.g. pituitary
tumors responsible for excessive growth hormone).
The literature reports a number of treatment
approaches regarding orthopaedic management in
Class III malocclusions as a result of maxillary defi-
ciency. Delaire
4
developed the orthopaedic facemask
to stimulate maxillary development. Nanda and
Goldin
5
studied the effects of posteroanterior
orthopaedic forces on the maxillary complex and, as
an alternative, used ankylosed primary canines as
anchorage for orthopaedic protraction.
6,7
Recently,
tongue appliances,
8
Bollard modified miniplates
9
and
miniscrews
10
have also been employed for the treat-
ment of maxillary deficiency. Treatment of Class III
patients with mandibular prognathism is most likely
to require orthognathic surgery.
11
Class III patients who have a combination of maxil-
lary deficiency and mandibular prognathism provide
treatment challenges and require complex treatment
plans. The literature describes two methods of poss-
ible treatment. The first aims to correct maxillary
deficiency at an early age and postpone mandibular
surgery until completion of mandibular growth. The
second method aims to delay all treatment until the
completion of skeletal growth, after which, orthog-
nathic surgery would be considered and offered to the
patient. Each method has advantages and disadvan-
tages which therefore creates a clinical dilemma.
Treatment of a Class III patient: a case report
Rahman Showkatbakhsh
*
and Abdolreza Jamilian
Department of Orthodontics, Shahid Beheshti University of Medical Sciences

*
and Dental Branch, Islamic Azad University,
Tehran, Iran
Background: The skeletal Class III malocclusion may be characterised by mandibular prognathism, maxillary deficiency or both.
Aim: To describe the early treatment of a skeletal Class III patient.
Methods: This case report presents a 10 year-old boy with a Class III malocclusion comprising a combination of maxillary
deficiency and mandibular prognathism. Two treatment plans were considered. The first was to correct maxillary deficiency at
an early age, while the second aimed to postpone treatment until after skeletal growth completion and then offer bimaxillary
surgery. The case was treated early and a tongue appliance was used for maxillary protraction.
Results: The post-treatment SNA angle showed a 5 degree increase and a positive overbite and overjet were achieved after
23 months of active treatment. However, mandibular prognathism was still evident.
Conclusion: Both treatment options have advantages and disadvantages which require informed clinical consideration.
Received for publication: July 2010
Accepted: April 2011
Rahman Showkatbakhsh: Showkatbakhsh@hotmail.com
Abdolreza Jamilian: info@jamilian.net.
SHOWKATBAKHSH AND JAMILIAN
Case history
A 10 year-old boy was initially referred for manage-
ment of his dentofacial deformity. His medical
history was clear and there were no signs or symp-
toms of temporomandibular joint dysfunction. Extra-
and intra-oral examinations revealed a concave profile
and underlying midface deficiency, resulting in an
anterior crossbite (Figure 1). A cephalometric analysis
confirmed the Class III skeletal pattern with maxil-
lary deficiency and true mandibular prognathism
(Table I) (Figure 2). The diagnosis was a dental and
skeletal Class III malocclusion created by a com-
bination of maxillary deficiency and mandibular
prognathism. The patient also had mild mandibular
deviation to the right due to the occlusal disharmony
but there was no evidence of a forward slide
contributing to the Class III.
Treatment objectives
The treatment objectives for this patient were to:
1. Correct the midface deficiency and the deficient
maxillary arch, ideally by protracting the maxilla.
2. Establish an ideal overjet and overbite.
3. Correct the mandibular prognathism.
4. Correct the mandibular lateral shift.
Treatment alternatives
Postponing treatment until after the completion of
skeletal growth was considered as a management pos-
sibility. Treatment at this time would require orthog-
nathic procedures but this was unacceptable to the
patients parents who insisted on early intervention
for psychological reasons. It was therefore decided to
adopt an orthopaedic approach and attempt protrac-
tion of the maxilla by means of a tongue appliance.
8
The use of other orthopaedic maxillary protraction
devices such as the Delaire facemask,
4
reverse chin
cup,
12
and miniscrew
10
were also considered.
Treatment progress
A tightly-fitting and well-retained upper removable
appliance was fabricated with Adams clasps on the
(a) (b)
Figure 1. Pretreatment photographs. (a) Frontal view. (b) Lateral view. (c) Intra-oral.
Table I. Pre- and post-treatment cephalometric analysis.
Cephalometric index Pretreatment Post-treatment
SNA (degrees) 78 83
SNB (degrees) 80 81
ANB (degrees) -2 2
U1 to MxPl (degrees) 120 120
L1 to MnPl (degrees) 85 79
Interincisal angle (degrees) 131 138
MMPA (degrees) 23 23
Facial Proportion (Per cent) 55 54
L1 to A-Pog Line (degrees) 0.7 0.1
SN to MxPl (degrees) 6 6.2
(c)
upper first permanent molars and two C clasps on the
upper permanent central and lateral incisors. A long
tongue crib was placed in the intercanine area in an
effort to restrict the tongue (Figure 3). The patient
was instructed to wear the appliance full-time except
for eating, during contact sports and for tooth clean-
ing. The patient was examined and progress moni-
tored monthly and the tongue appliance was replaced
every 7 months for improved adaptation.
Results
A positive overjet and overbite were achieved after 23
months of appliance wear. The maxillary deficiency
was corrected which allowed the mandible to adopt a
better position and resolve the functional lateral shift
(Figure 4). The post-treatment cephalometric radio-
graph tracing showed a favourable increase of 5 and 4
degrees in the SNA and ANB angles respectively
(Table I) (Figure 5). The superimposition of pre- and
post-treatment cephalometric tracings on the anterior
cranial base is shown in Figure 6.
Discussion
The Class III malocclusion of the presented case was
a combination of both maxillary deficiency and
mandibular prognathism, which required a complex
treatment plan. While the clinicians considered
the use of orthopaedic traction in the form of a
TREATMENT JUSTIFICATION
(a)
(b)
Figure 2. Pretreatment radiographs. (a) Panoramic radiograph. (b) Lateral cephalometric radiograph.
(a) (b)
Figure 3. Tongue appliance in the mouth. (a) Frontal view. (b) Occlusal view.
SHOWKATBAKHSH AND JAMILIAN
facemask,
4
reverse chin cup
12
or the use of Bollard
modified miniplates,
9
the patient rejected the use of
extra-oral appliances. A tongue appliance
8
was used
in this case which, when worn, placed considerable
expansive pressure on the deficient maxilla. It is
hypothesised that the mechanism of force application
was generated in the following ways:
1. The pressure of the tongue in the act of swallowing
could reach 2300 grams and the frequency of
swallowing could be up to 1200 times in 24
hours. This heavy, intermittent force was possibly
transferred through the tongue appliance to the
deficient nasomaxillary complex.
8
2. The resting posture of the tongue is altered by the
caged restraint of the tongue appliance. Resting force
may displace the maxilla into a more forward position
by force transmission through the appliance to the
underlying tissues.
(a) (b)
Figure 4. Post-treatment photographs. (a) Frontal view. (b) Lateral view. (c) Intra-oral.
(c)
(b)
Figure 5. Post-treatment radiographs. (a) Panoramic. (b) Lateral cephalometric radiograph.
(a)
An analysis of the results indicated that the maxillary
deficiency was successfully corrected by the tongue
appliance.
8
However, despite the positive overjet
achieved by the treatment, some mandibular prog-
nathism is still reflected in the patients profile view.
It would be beneficial if treatment continued until
the completion of growth and the patient reviewed
periodically and assessed for the need for additional
care.
An alternative treatment approach was deferral until
the cessation of skeletal growth. Even after successful
treatment of the maxillary deficiency, an orthog-
nathic surgical procedure may still be necessary. This
could be considered unacceptable by many patients
after an extended initial period of orthodontic treat-
ment. In addition, deferring treatment and particu-
larly in this case, if treatment had been deferred, the
patient may have risked developing psychological
problems.
The possibility of oral dysfunction was also a treat-
ment consideration as continuing growth could exag-
gerate the skeletal discrepancy and further complicate
management.
Conclusion
The advantages and disadvantages of early or deferred
treatment placed the clinicians in a treatment dilemma
which was resolved by the patients wishes. Neverthe-
less, the costs and benefits of each method remain
unpredictable but are important factors.
Dr Abdolreza Jamilian
No 2713, Vali Asr St.
Tehran 1966843133
Iran
Tel: 0098-21-22011892
Fax: 0098-21-22022215
Email: info@jamilian.net
References
1. Ellis E, McNamara JA Jr. Components of adults Class III
open-bite malocclusion. Am J Orthod 1984;85:27790.
2. Liu PH, Chang HP. The morphometric analysis of maxil-
lopalatal and mandibular changes of skeletal Class III mal-
occlusion treated with orthopedic therapy. J Med Biol Eng
2009;29:32630.
3. Ellis E, McNamara JA Jr. Components of adult Class III
malocclusion. Int J Oral Maxillofac Surg 1984;42:295305.
4. Delaire J, Verdon P, Lumineau JP, Cherga-Negrea A,
Talmant J, Boisson M. Some results of extra-oral traction
with front-chin rest in the orthodontic treatment of Class
III maxillomandibular malformations and of bony sequelae
of cleft lip and palate. Rev Stomatol Chir Maxillofac 1972;
73:63342.
5. Nanda R, Goldin B. Biomechanical approaches to the study
of alterations of facial morphology. Am J Orthod 1980;78:
21326.
6. Kokich VG, Shapiro PA, Oswald R, Koskinen-Moffett L,
Clarren SK. Ankylosed teeth as abutments for maxillary pro-
traction: a case report. Am J Orthod 1985;88:3037.
7. da Silva Filho OG, Ozawa TO, Okada CH, Okada HY,
Carvalho RM. Intentional ankylosis of deciduous canines to
reinforce maxillary protraction. J Clin Orthod 2003;37:
31520.
8. Jamilian A, Showkatbakhsh R. The effect of tongue appli-
ance on the maxilla in Class III malocclusion due to maxil-
lary deficiency. Int J Orthod Milwaukee 2009;20:1114.
9. De Clerck HJ, Cornelis MA, Cevidanes LH, Heymann GC,
Tulloch CJ. Orthopedic traction of the maxilla with
miniplates: a new perspective for treatment of midface
deficiency. J Oral Maxillofac Surg 2009;67:21239.
10. Jamilian A, Showkatbakhsh R. Treatment of maxillary defi-
ciency by miniscrew implants: a case report. J Orthod 2010;
37:5661.
11. Proffit WR, Fields HW, Sarver DM. Orthodontic Treatment
Planning: Limitations, Controversies, and Special Problems.
In: Proffit WR, Fields HW, Sarver DM. Contemporary
orthodontics. 4th ed. St Louis: Mosby; 2007, pp. 268328.
12. Showkatbakhsh R, Jamilian A. A novel approach in treat-
ment of maxillary deficiency by reverse chin cup. Int J
Orthod Milwaukee 2010;21:2731.
TREATMENT JUSTIFICATION
Figure 6. Pre- and post-treatment tracings superimposed on S-N, at sella.
Letters
Optimal force
Sir,
I thank Dr Goldschmied for his letter published in the
November 2010 issue of the Australian Orthodontic
Journal (Aust Orthod J 2010;26:208). He raises sever-
al points regarding two methods of measuring root
length and width, namely, direct measurement and
cone beam radiology. Using those methods we com-
pared the measurements of root width and length
using teeth obtained from the alveolus of the
mandible of a dried skull. The teeth were extracted
intact and measured directly in the hand using an
external dial gauge (MTL DUALOS type YD-8)
(Figure 1.) These measurements were taken to be
accurate and the teeth were returned to their sockets.
The cone beam measurements were compared with
the direct measurements and it was found that two
measurements of width in the sample (N = 14) were
coincident with the direct measurements.
Two operators tested the cone beam machine in
Hobart, by comparing the dimensions of the width
and length images with those of the actual teeth taken
from the skull.
The range of actual direct width measurements was
7.1 to 12.5 mm (range 5.4 mm, mean 0.39) and for
length, 13.9 to 20.5 mm (range 6.6 mm, mean 4.7).
Width data showed 10 negative and 4 positive values,
the negative being shortenings and the positive being
lengthenings when the cone beam data was compared
with actual direct measurement. Length data showed
12 negative and 2 positive. Scarfes values showed 9
negative and 1 positive.
Scarfe
1
found no difference in mean absolute error
between the scan settings for all measurements. The
CBCT resulted in lower measurements for nine
dimensions of the skull (mean difference range: 3.1
mm 0.12 mm to 0.56 mm 0.07 mm) and a greater
measurement for one dimension (mean difference 3.3
mm 0.12 mm). CBCT measurements were consis-
tent between scan sequences and for direct measure-
ments. Because the fiducial landmarks on the skulls
were not radio-opaque, the inaccuracies found in
measurement could be due to the methods applied
rather than to innate inaccuracies in the CBCT scan
reconstructions or 3D software employed. DOI:
10.2319/122407-599.1
Because two operators in Australia and one in the
USA all recorded overall shortening of the images, the
question arises as to whether some distortion is built
into the CBCT machines or perhaps a lower magnifi-
cation results if posterior teeth are closer to the x-ray
source.
The above results show the importance of being aware
of the characteristics of particular cone beam units if
accurate estimates of root area are to be obtained.
The optimal force for a particular tooth is that force
which will subject the tooth to a pressure of 200 gf
cm
-2
. This means that the force-producing device
(spring, elastic archwire, etc.) would be required to
Letters and brief communications are welcomed and need not be related to content published in the Australian Orthodontic Journal. The Journal will print
experimental, clinical and philosophical observations, reports of works in progress, educational notes and travel reports relevant to orthodontics.
The Journal reserves the right to edit all Letters to meet requirements of space and format. All financial interests relevant to the content of a Letter must be
disclosed. The views expressed in Letters represent the personal opinions of individual writers and not those of the Australian Society of Orthodontists Inc,
the Editor, or BPA Print Group Pty. Ltd.
Figure 1. Showing the clinical use of the external dial gauge.
exert forces in the range of 92 gf for the smallest lower
incisor to 324 gf for the largest upper canine.
2
Each
tooth would then be subjected to optimal force in
order to obtain an optimal pressure of 200 gf cm
-2
.
Stress-breaking needs to be defined in terms of
optimal pressure. The fact that archwires can be
treated to deliver limited forces must be taken into
account in future discussions on the meaning of
stress-breaking appliances.
Meanwhile, Dr Goldschmied has issued an invitation
to those in the profession and the Industry to join
him in developing a bracket which can be adjusted
to suit the morphology of every one of the sixteen
permanent teeth.
As far as an instruments convenience is concerned, I
have no means of assessing this highly subjective
matter.
Brian W. Lee
3 Lynden Road
Bonnet Hill
Tasmania 7053
Australia
Email: bjlee3@bigpond.com
References
1. Scarfe W. Linear accuracy of cone beam CT derived 3D
images. Angle Orthod 2009;79:150-7.
2. Lee BW. The dimensions of the roots of the permanent
dentition as a guide to the selection of optimal orthodontic
forces. Aust Orthod J 2010;26:1-9. (Appendix)
Control 21 Stress-Breaking Bracket
Sir,
I would like to invite interested orthodontists and
manufacturers of brackets to join me in developing
the Control 21 Stress-Breaking Bracket (C21 SB
Bracket) in its manufacture and trialing. I have devel-
oped the bracket over considerable time, some fifteen
years, and now believe the latest form of the bracket,
which is yet to be published, to have considerable
advantages over edgewise and light wire brackets. In
the old art, the stop to prevent the slide from dissoc-
iating from the base was externally placed to the
base.
1,2
In the new art, all the mechanics to allow the
slot to open and close, and precision stops to deter-
mine varying slot dimension are internally placed
within the body of the bracket base. It is intended to
publish the new art once patents are confirmed.
The appearance and dimensions of the bracket are
similar to an edgewise bracket; it can be used as an
active or passive slot system with self ligating features,
(pending patents prior to disclosure) and is the same
dimension as the edgewise bracket. As a result of the
brackets stress-breaking ability it can also be used in
light wire treatment formats. The published work
undertaken so far, but excluding the C21 SB Bracket
can be viewed in the Australian Orthodontic Journal.
Felix Goldschmied
P.O. Box 187
Kings Meadows 7249
Tasmania
Australia
Email: goldschm@bigpond.net.au
References
1. Goldschmied F. A new bracket system: Control 21 Part I.
Aust Orthod J 2001;17;1-7.
2. Goldschmied F. A new bracket system: Control 21 Part
II: Tooth movement. Aust Orthod J 2001;17;55-68.
LETTERS
75
Lingual Orthodontics
Author: Giuseppe Scuzzo and Kyoto
Takomoto
Publisher: Quintessence Publishing
2010 (www.quintpub.com.)
ISBN: 978 1 85097 192 4
Price: USD $230.00
The Introduction provides a short summary of the
Aims of Orthodontic Treatment as well as indicating
that To be good-looking is always an advantage, espe-
cially in relationships between adults. Then the
authors indicate that Today, the main goal of ortho-
dontic treatment is to achieve facial balance, and the
orthodontic treatment plan has to provide a balance
between esthetic treatment, functionality, and a
patients aspiration, and concludes that the highly
esthetic, invisible orthodontics has a fundamental role
to play in achieving this. Somehow, it must be assumed
that lingual orthodontics answers all these criteria.
Chapter 2 discusses some different bracket types (pre-
fabricated and customised) used in lingual ortho-
dontics. Chapter 3 deals with A New Treatment
Philosophy called the Light Lingual philosophy. The
Scuzzo-Takemoto bracket (STb) was developed
according to this philosophy. In this chapter the
authors strongly promote the innovative low-friction
design of the STb and its great reduction in chairside
time and improved patient comfort. The anterior STb
have two different degrees of torque but are not pre-
angulated, with the slot size being 0.018 x 0.025. The
brackets accept conventional metallic or elastic ties.
The upper molar brackets are different left and right
while the lower molar brackets are the same on left
and right. They come with hooks.
Chapter 4 gives an insight into the mechanics of
lingual brackets, which is fully based on the edgewise
system; i.e. archwires with rectangular cross-section
are used to transmit the torsional moments from the
archwire to the tooth. A study is described which
investigated the influence of play between archwire
and bracket slot, as well as the bracket strength, to
withstand archwire torsional force without deforming.
Using a number of different 0.018 x 0.025 stainless
steel brackets, the researchers found a remarkable dif-
ference in actual bracket slot dimension between
different manufacturers as well as from the same
manufacturer. The researchers point to the fact that
the larger the distance from the tooth cusp to the slot
of the attached bracket, the more pronounced will be
the influence of a torque error, and furthermore, that
the amount of play between archwire and slot should
be as small as possible. The researchers conclude
that the STb brackets had the most precise slot size,
with the bracket being strong enough to withstand
torsional moments.
Chapter 5, written by the same researchers, provides
the reader with an understanding of the importance of
archwire in the biomechanical aspect of lingual ortho-
dontics. Most important is the wire cross-section in
relation to bracket slot size and wire stiffness. An
additional problem in lingual orthodontics is the
small interbracket distance. Superelastic archwires
have greatly solved some problems such as the close
relationship between wire cross-section and wire stiff-
ness. Furthermore, truly superelastic archwire is
almost completely independent of inter-bracket dis-
tance. In contrast to buccal orthodontics, lingually
placed archwires may cause a special form of binding
within the bracket due to the narrow archwire
curvature. The authors provide advice on bracket
placement, wire type use and low-fraction ligation.
Chapter 6 throws some light on the effect of force
levels on tissue reaction. Magnitude and duration are
major factors to obtain reaction. Force regime appears
to have a greater role than force level intermittent
loads, resulting in an increase in bone activity. High
force levels do not enhance tooth movement and over-
loading may cause hyalinization and ischemia in the
PDL. A description is provided of the three targets of
Book
reviews
BOOK REVIEWS
77
orthodontic force application; periodontal ligament,
alveolar bone and root surface. As the magnitude of
the force generated depends on the type of archwire
and the degree of activation, in lingual orthodontics,
lower forces should be used than in the buccal
technique, because of the smaller distance between
bracket slot and centre of resistance. An optimal force
level has not yet been identified, with small forces
being recommended.
Chapter 7 provides us with New Diagnostic
Concepts revealing that Tweeds lower incisor to
mandibular plane philosophy is old fashioned and a
new era in diagnosis has arrived. It is a most impor-
tant topic, yet the chapter consists of only a page and
a half. The author explains that we should look at the
maxillary incisors in relation to the maxillary plane
(110 degrees) or to the maxillary occlusal plane
(56 degrees in women and 57 degrees in men). The
incisor edge of the upper teeth should be 23 mm
below the resting upper lip. Miniscrews can be used
to adjust the maxillary occlusal plane angle. Chapter
8 describes research into friction between bracket slot
and archwire and comparing the STb with other
brackets, edgewise and self-ligating. The STb
brackets showed second-best results, with the self-
ligating brackets providing least friction. The author
therefore concludes that the length of treatment time
of lingual orthodontics is not longer than labial
orthodontics. Chapter 9 gives us a wonderful defini-
tion of the centre of resistance of a tooth as being
within its alveolus and . . . is the point on the root
through which the application of the horizontal force
results in pure translation of the tooth, i.e., without
any rotational movement. The chapter explains the
biomechanics involved in orthodontic treatment, as
well as comparing the effects between labially and
lingually applied forces.
Chapter 10 points to the large variations and irregul-
arities of the lingual anatomy. The laboratory may
customize the bracket bases, using Resin pads, to
accommodate this. There is a full explanation of how
the models may be digitised and a virtual set-up
made to be utilised in actual bracket positioning, by
constructing virtual brackets and virtual lingual
archwires. The clinician receives the customised
lingual brackets as well as the individualised pre-
formed archwires from the laboratory.
Chapter 11, one of the most important chapters in
the book, discusses extraction mechanics and
anchorage control. Variations in teeth to be extracted
are considered, anchorage is divided into horizontal
and vertical types, implants are reviewed, treatment
steps followed in treatment with lingual brackets are
discussed and the concept of sliding mechanics is
showcased using lingual orthodontics. It includes lots
of wonderful diagrams and photographs of typodont
and actual cases.
Chapter 12 presents different extraction cases treated
with STb brackets. All cases are female with an age
range between 17 and 32 years old. Retention and
long-term prognosis was not mentioned. Chapter 13
discusses nonextraction mechanics. There is further
discussion on different options available to treat with-
out extractions, such as transverse or sagittal widen-
ing. This chapter also deals with the relationship of
second and third molars, Curve of Spee, distalisation
mechanics and anchorage. Chapter 14 deals with
nonextraction and the STb lingual system. Several
cases are discussed in detail.
Chapter 15 considers the social aspect of patient
treatment. The STb Social 6 Light Lingual System is
the most esthetic treatment option available on the
market today, offering patients and clinicians
unprecedented comfort, speed of treatment, invisibil-
ity, and consistently high-quality results. Chapter 16
shows the influence of the Straight Wire philosophy
and the new STb design. The authors suggest a
certain archwire sequence for both nonextraction and
extraction cases. Several treatment cases are also
shown.
Chapter 17, the last chapter, introduces the reader to
a number of indirect bonding techniques. The
Torque Angulation Reference Guide TARG was
designed to transfer bracket prescriptions from the
labial surface to the lingual surface at a given bracket
height. There could be various possible errors in its
application. CLASS (Custom Lingual Appliance Set-
up Service) is an improvement over TARG. Both
TARG and CLASS use silicone transfer trays, how-
ever, the Resin Core Indirect Bonding (RCIB) system
utilises hard transfer trays, which is more accurate,
although this method is complicated and expensive.
A different method, a precise direct bonding system
called KommonBase is promoted by the authors.
The book has seventeen chapters with ten different
authors. It presents well, with a modern attractive
cover. The case presentations are excellent with won-
derful photographs. The illustrations are clear and
BOOK REVIEWS
elaborate. The practicing non-lingual orthodontist
will find the book very interesting and educational,
even to the point of tempting the orthodontist to try-
out some simple lingual treatments. The order of the
chapters is somewhat different from what I would
expect, with the chapters on actual treatment coming
prior to the discussion on indirect/direct bonding.
Furthermore, the frequent pointing towards the
advantage of a certain bracket (STb) throughout
the book seems to be somewhat biased. There are sev-
eral chapters which discuss orthodontic theory
and practical application in a decidedly educational
manner.
Overall, this book is highly recommended to the
practicing orthodontist as well as being suitable for
post-graduate students, to widen their orthodontic
horizon.
Aart Taverne
Essentials of Orthognathic Surgery.
Second Edition
Author: Johan P. Reyneke
Publisher: Quintessence Publishing 2010
(www.quintpub.com)
ISBN: 978 0 86715 500 6
Price: USD $180.00
The scope of clinical challenges, channelled treat-
ment planning, orthodontic preparation and surgical
options in Essentials of Orthognathic Surgery. Second
Edition make this a highly recommended text. The
comments in the preface outline the improve-
ments from the first edition. These have been well
attended to.
Orthognathic surgery addresses the dental and also
the dentofacial deformity. Facial appearance is altered
with most treatments and it is critical for a successful
outcome for the treating team to satisfy the patient
request or at least to recognise if something cannot be
achieved. The early chapters including Systematic
Patient Evaluation and Diagnosis and Treatment
Planning are excellent. The background wealth of
information is clearly presented.
The author puts together a well-structured chapter on
Basic Guidelines for the Diagnosis and Treatment of
Specific Dentofacial Deformities. Once the treatment
objective has been defined the treating team are
guided through the orthodontic preparation and the
suggested surgical procedure or procedures.
Some important considerations which are not
included involve stabilising segments with or without
bone grafting, especially when dealing with asym-
metry cases with differential downward movement of
the maxilla. Relying simply on fixation plates seems
to be the method of choice.
Segmental surgery, especially in the maxilla under-
taken at the time of the major skeletal movements,
can often be replaced by surgically assisted expansion.
Anterior open bite cases seem easily dismissed by the
author. Further strong guidance should be given
when contemplating limiting treatment to the lower
jaw. The changes in the soft and hard tissues of the
region make these cases often a treatment challenge
with a high percentage of relapse.
Condylysis or condylar hypertrophy is always a con-
sideration in open bite and asymmetry cases. Imaging
of the condyles to help guide the treatment can be
difficult.
1
Should an unstable condyle fossa complex
be present then correction of this is essential to avoid
collapse of the mandibular position. The custom-
made TMJ total joint replacement device now over-
comes the problem described by the author with
three-dimensional positioning of the mandible with
the stock prostheses.
The patient with the fine facial soft tissue drape over
the facial skeleton is a challenge. Rotation of the
mandible, especially with an advancement, may result
in a lack of harmony of the face as one side appears
fuller. Genioplasty procedures frequently leave a step
which can be unsightly. Guidance for the surgeon
may be an appropriate inclusion. The chapter on
Surgical Technique has great illustrations of the sur-
gical cuts of the different procedures. The preferred
fixation technique for the mandibular procedures
seems to be bicortical screw fixation. A comment by
the author regarding placement of intra-oral plate fix-
ation for mandibular sagittal split procedures would
be welcome as this is a popular technique and avoids
a facial access scar.
The Intra-oral Vertical Mandibular Ramus
Osteotomy is described in detail. This technique can
result in an unsightly swelling in the posterior cheeks
due the lateral displacement of the proximal
segments. Control of the condyle can be difficult
BOOK REVIEWS
79
subsequently should it not stay as expected in the
glenoid fossa.
The aim of the text is to form an instruction base for
the team treating dentofacial deformities. The text is
clear and the line drawings excellent. I would highly
recommend this book.
Michael Hase
Reference
1. Bone scintigraphy as a diagnostic method in unilateral
hyperactivity of the mandibular condyles: a review and
meta-analysis of the literature. Saridin C, Raijmakers P,
Tuinzing D, Becking A. Int J Oral Maxillofac Surg 2011;40:
11-17.
Manual of Wire Bending Techniques
Author: Eiichiro Nakajima
Publisher: Quintessence 2010
(www.quintpub.com)
ISBN: 978 0 86715 495 5
Price: USD $85.00
In these days of preadjusted appliances, preformed
archwires and computer generated appliances of
all types, it is refreshing to review a text book
devoted to the art and science of wire bending.
Although the book concentrates on the bio-
progressive appliance, which would limit its appeal,
its classical approach would bring joy to the heart of
the traditionalist.
The text begins by justifying the necessity for wire
bending by using the example of variation of tooth
morphology not being accommodated by preformed
brackets.
Chapter 3 introduces the biospecial pliers, the only
wire bending pliers referred to in the book, which
alerts the reader to the extremely specialised informa-
tion to follow. The remainder of this chapter, the bulk
of the book, beautifully illustrates in great detail the
procedures involved in bending the loops, stops,
retractors, utility and closing arches and ideal arches
used in the bio-progressive technique.
Chapter 4 describes, with excellent clinical photo-
graphs, useful tips for individual specialised
tooth movement mechanics. It concludes with a
selection of case reports demonstrating the authors
possibly unnecessarily complicated treatment
approach, but emphasising the necessity for over-
correction and artistic wire bending for proper
finishing of a case.
In summary, this textbook would be extremely useful
for young orthodontists keen to advance their knowl-
edge with the bio-progressive technique. However, it
would be of limited assistance to the majority of
orthodontists worldwide, although its value in
reminding those reliant on preformed brackets and
archwires of the limitations of that approach cannot
be under estimated.
Colin C. Twelftree
Current Concepts on Temporomandibular
Disorders
Author: Daniele Manfredini
Publisher: Quintessence Publishing
2010 (www.quintpub.com)
ISBN: 978 1 85097 199 3
Price: USD $215.00
This book is a compilation of over forty articles con-
tributed by authors who practise mainly in Europe. It
is a virtual smorgasbord of procedures used in various
approaches to treatment of TMD. It is not my inten-
tion to review all the contributions except to say that
the reader can choose those procedures which fit into
his or her mode of treatment.
Several features discovered whilst thumbing through
the pages for the first time are the excellence of the
production of photographs, charts and tables.
Summaries of the literature, experimental methods
and results were presented in tabular form, enabling
the full scope of the data to be easily grasped and
understood by the reader. Each contribution is sup-
ported by extensive bibliographies, three references
being cited in 2008. There are four main sections of
BOOK REVIEWS
contents: Fundamentals, containing applied anatomy;
Diagnosis, containing the assessments of muscle
disorders, disc displacements and osteoid con-
ditions; Etiology, containing how osteoarthritis
affects the joint and management of a range of
muscle disorders, as well as interesting chapters on
pharmacology, surgical procedures, research and
ethical considerations. The approaches to treatment
range in complexity from studies of posture, physical
therapy, auto-massage and stretching of the muscles
of mastication, through to occlusal therapy, oral
appliances, surgical, orthodontic and prosthetic
management.
As a practitioner of the techniques used by Eugene
Williamson since 1986, I am surprised (nay,
astounded!) that omissions of his writings and pro-
cedures used in his treatment of TMD have been
allowed by the authors. There is scant reference to the
use of mounted models, anterior repositioning splints
and the treatment to centric relation, with more than
one contributor describing occlusal therapy as old
fashioned.
Towards the end of the book Manfredini writes of the
measures required to standardise research results, stat-
ing that the call by academics and researchers for
more diagnostic data to be drawn from the medical
rather from the dental array of signs and symptoms
suggests dissatisfaction with the occlusal approach.
Did they try diagnosing from CR?
Crawford
1
has assessed the TMD research which has
been regarded as controversial and he found that
most of these cases were diagnosed without the use of
adjustable articulators. He advocates mandatory use
of the articulator in the assessment of cases for
research. He stresses the importance of treatment to
centric relation because it gives us a mechanical and
functional reference point from which to assess cases
and plan treatment.
In conclusion, I can recommend this book as a well-
documented reference to lesser-known therapies for
treatment of TMD, to the exclusion of sophisticated
occlusal therapy.
Brian W. Lee
Reference
1. Crawford SD. Condylar axis position, as determined by the
occlusion and measured by the CPI instrument, and signs
and symptoms of temporomandibular dysfunction. Angle
Orthod 1969;2:103-14.
Biomechanics in Orthodontics
Principles and Practice
Authors: Ram S. Nanda and
Yahya S. Tosun
Publisher: Quintessence 2010
(www.quintpub.com)
ISBN: 978 0 86715 505 1
Price: USD $98.00
Once the correct diagnosis, treatment objectives and
plan have been identified, then executing the plan
involves a sound understanding of the basic
principles of biomechanics to assist in the selection
of the most appropriate appliance system to achieve
the desired treatment outcomes. This book,
Biomechanics in Orthodontics. Principles and Practice,
aims at dealing with this aspect of orthodontics.
It comprises nine chapters dealing with all the
issues pertaining to the principles of biomechanics,
anchorage control, appliance selection and the cor-
rection of vertical, transverse and antero-posterior
discrepancies.
Chapter 1 provides an overview of the basic principles
of biomechanics including the introduction of the
concept of moment to force ratio which can be
troubling to grasp for the orthodontic postgraduate
student.
The second chapter examines the relationship
between orthodontic biomechanics and orthodontic
materials and appliance design. Physical properties
of wires, brackets and elastics including the bio-
mechanics of cantilevers, Class II and III elastics are
discussed.
Chapter 3 deals solely with two-tooth segment force
systems created when straight or bent wires are placed
in brackets. It discusses the different types of
Burstone geometry classes, an area difficult to find
properly described in other textbooks or in con-
temporary refereed literature. It describes V-bends,
stepped-arch mechanics, anchorage bends and lace-
backs.
Chapter 4 revolves around introducing the reader to
friction and how this factors in to the bracket wire
relationship. This is nicely followed by Chapter 5,
which deals with anchorage control. The authors
discuss TADs and other methods of anchorage con-
trol however there is a significant amount of
information regarding the biomechanics of extra-oral
appliances or headgears. Considering there is prac-
tically little or no information available in the
contemporary literature regarding headgears, this
information serves to help the reader (whether they
use headgears or not) to consolidate their under-
standing in basic biomechanics.
Chapter 6 deals with vertical discrepancies and the
most effective methods of correcting them. Deep
bites, methods of incisor intrusion, the utility arch
versus the segmented approach, altering the curve of
Spee and skeletal and dental open bites are all very
well discussed. Transverse discrepancies and how to
manage them are discussed in Chapter 7. Chapter 8
solely deals with managing antero-posterior discrep-
ancies, including molar distalization, protraction,
uprighting and de-rotation and Chapter 9, the
final chapter, concentrates on space closure following
orthodontic extractions. The focus is centred on
determining the appropriate strategy for space closure
for the individual patient, which is stressed through-
out the chapter. Other aspects discussed include
differential, continuous and segmented space closure.
A positive feature of this book is its focus on ortho-
dontic biomechanics from the grass roots level.
Although it respects the importance and the place
TADs have in contemporary orthodontics, it also
helps the reader identify situations manageable with-
out TADs with the selection of the appropriate force
or appliance system. After all, how have we been
managing all these decades? This chapter is then
immediately followed by a glossary of orthodontic
terms.
Practicing in todays orthodontic environment
appears to involve more than obtaining the correct
diagnosis and treatment plan and using the most
appropriate biomechanics. It seems to be geared
towards practice management/marketing and utiliz-
ing the appliance of the day. Less emphasis is placed
on maintaining high clinical standards with current
best evidence and technologies. It is refreshing that
the authors do not push any particular product and
throughout the textbook they consistently stress the
importance of being knowledgeable of the basic con-
cepts of biomechanics and utilizing the most appro-
priate appliance system for the individual patient.
Complex aspects of biomechanics are not discussed;
this is understandable as it would be quite difficult to
achieve in a simple text format without the appropri-
ate guidance. Further, this textbook does not have
any coloured diagrams, illustrations or clinical photos
which for some readers can impact or influence their
ability to fully appreciate what is being described.
Despite this limitation, this book is a good guide,
especially for the orthodontic postgraduate student
keen to develop a sound foundation on the basic
concepts of biomechanics.
Sanjivan Kandasamy
and for the children
Ginger McFlea Will Not Clean Her Teeth
Author: Lee Fox
Publisher: Hatchette Australia Pty Ltd
2009 (www.hachettechildrens.com.au)
Hardback ISBN: 978 073 441 1051
Price: AUD $28.99;
Soft cover ISBN: 978 073 441 1297
AUD $16.99
Ginger McFlea Will Not Clean Her Teeth is by Lee Fox
(Author) and Mitch Vane (Illustrator). It is a fict-
ional childrens book. The theme of the book is about
inspiring children to look after and care about their
teeth. The story is about a little girl, Ginger McFlea,
who hates to brush her teeth, much to the distress of
her parents. Although she is stubborn, Ginger is gen-
erous and good-natured. The story is educational and
entertaining, familiarising children with dental terms
in a fun and humorous manner using rhyming sen-
tences. Also included is simple but important infor-
mation regarding sugary treats and dental decay.
Mitch Vanes illustrations are charming and humor-
ous. The pictures are an excellent complement to the
story line. My favourite parts of the book include the
contributions of the cute pet turtle Keith, the Tooth
Fairy who is delightfully illustrated and the Dentist
with mad spiky hair.
I would highly recommend this book to be placed in
the waiting room of any dental practice and it would
also be a great bedtime story book for children.
Laura Barbagallo
BOOK REVIEWS
81
BOOK REVIEWS
How the Tooth Mouse Met the Tooth Fairy
Authors: Lizzette de Vries and
Cecile de Vries
Publisher: Quintessence
Publishing 2010
(www.quintpub.com)
ISBN: 978 0 86715 507 5
PRICE: USD $19.95
This childrens storybook follows the dental adven-
tures of Bobby, who is about to lose his first baby
tooth, and can hardly wait to leave it for Max the
Tooth Mouse. Before the wobbly tooth falls out,
Bobbys parents announce that the family is moving
from South Africa to Canada. Here, Bobby, his
family, and Max the Tooth Mouse, come into contact
with Fia the Tooth Fairy, who is responsible for the
care of exfoliated deciduous teeth in this part of the
world.
Intertwined with the story are basic yet important
dental health messages for children and their carers.
Included in these are the importance of good oral
hygiene, regular dental visits and a healthy diet for
the maintenance of healthy teeth and smile.
Published by Quintessence in 2010, this hard cover
book of 32 pages is ideally suited to children aged 4
to 8 years. The co-authors are Lizzette and Cecile de
Vries, a mother and daughter team, who have an
interest in dental health education, particularly for
the underprivileged. It is written with the guidance of
Mickey Emmons Wener, a Canadian Dental
Hygienist and is beautifully illustrated by Tul
Suwannakit, an artist from Thailand.
This story is bound to keep young children enter-
tained and would make a delightful addition to your
waiting room literature.
Tracey Shell
Orthodontic anchoring techniques and its
influence on pain, discomfort, and jaw
function a randomized controlled trial
I. Feldmann, T. List and L. Bondemark
European Journal of Orthodontics 2011: doi: 10.1093/ejo/cjq171
Pain is reported in 95 per cent of individuals receiving
orthodontic treatment. The development of pain has
been well documented, peaking at 24 hours following
placement of an initial archwire and diminishing to
almost pre-placement levels after 7 days. There are few
reports regarding skeletal anchorage and the patients
perception of pain. The aim of the current article was
to evaluate and compare perceived pain and func-
tional impairment in individuals undergoing ortho-
dontic treatment with skeletal anchorage versus
conventional anchorage in the form of headgear or
a transpalatal bar.
One hundred and twenty consecutively recruited
patients were randomly assigned into three groups.
Group A (30 males and 30 females, mean age 14.3
years) underwent placement of skeletal anchorage
(Onplant or Orthosystem implant), group B (15
males and 15 females, mean age 14.0 years) received
headgear and group C (15 males and 15 females,
mean age 14.4 years) had a transpalatal bar placed. All
individuals were treated with a standard straightwire
appliance with a 0.022 slot size and continuous light
forces by two experienced orthodontists. Question-
naires to assess pain intensity, discomfort, analgesic
consumption and jaw function impairment were com-
pleted prior to treatment, every evening during the
first 7 days post-placement, at 6 weeks, at the com-
pletion of levelling/aligning (mean 8.2 months),
following space closure (mean 17.4 months) and at
the first scheduled visit in the retention phase. The
response rate for the separate questionnaires ranged
from 94 to 100 per cent.
Of the 113 individuals who completed the trial, no
difference in analgesic consumption or jaw function
impairment between the three treatment groups was
identified. Pain intensity peaked on day 2 and
returned to baseline by day 7 in all groups. Incisal
contact and the molar region presented as sites with
the highest pain rating, although there was consider-
able individual variability. No significant differences
were noted between the three groups in regard to pain
levels from incisal contact. Skeletal anchorage group A
displayed significantly less pain intensity in the molars
compared with the transpalatal bar group C during
the first 4 days and at 6 weeks into treatment. No sig-
nificant difference however was noted between group
A and the headgear group B. Individuals in the skele-
tal anchorage group A and transpalatal bar group C
also reported significantly more discomfort through-
out the early recording periods when compared with
the headgear group B. Females were noted to com-
plain significantly more regarding pain, discomfort
and difficulty in eating hard foods than their male
counterparts.
This article highlighted the minimal differences in
perceived pain, discomfort and functional limitation
between skeletal and conventional anchorage devices.
However, no mention was made of pain as a direct
result of surgical placement or removal of the
skeletal anchorage devices. This also needs to be con-
sidered in the overall assessment of patient tolerance
of treatment.
Trudy Stewart-Reid
Effect of curing time on the bond strength
of a bracket-bonding system cured with a
light-emitting diode or plasma arc light
M.C. DallIgna, E.M. Marchioro, A.M. Spohr and E.G. Mota
European Journal of Orthodontics 2011; 33: 55-59
Light curing brackets to teeth has gained acceptance
in orthodontics since Buonocore (1955) first reported
acid-etched bonding to enamel. The use of ultraviolet
Recent
publications
These reviews have been prepared by the orthodontic postgraduate students from the University of Adelaide, South Australia
RECENT PUBLICATIONS
light has been widespread, but the authors aimed to
compare a light-emitting diode (LED) versus a
plasma arc light (PAC) on the shear bond strength
(SBS) of brackets bonded to enamel. Ninety bovine
teeth were allocated into 6 groups. A LED group
(Ortholux; 3M Unitek) was subjected to the curing
light for 5, 10 or 15 seconds. Specimens in a PAC
group (Apollo 95E; DenMed Technologies) were
light cured for 3, 6 and 9 seconds. The brackets were
the same and all were bonded with Transbond XT
(3M-Unitek), stored in distilled water at 37 C for 24
hours and then submitted to SBS recording in a uni-
versal testing machine. The adhesive remnant index
(ARI) was used to evaluate the amount of adhesive
remaining on the teeth.
The LED (800mW/cm
2
) groups measured 13.92
MPa, 14.76 MPa, 16.68 MPa for the 5, 10 and 15
seconds of curing time, respectively. The PAC (1800
mW/cm
2
) groups measured 8.29 MPa, 9.96 MPa,
12.66 MPa for the 3, 6 and 9 seconds. The method
of light curing did not inuence the ARI, with a score
of 3 predominating as an indication of failure at
the bracket resin interface. Failure at this location
indicated incomplete resin polymerization at the
base of the bracket due to the short period of light
exposure. This may be advantageous to reduce the
likelihood of damage to the enamel surface during
debonding.
While the energy of emitted light ultimately influ-
ences the number of photons reaching the composite
resin, the authors considered that there were other
factors which influence the degree of adhesive resin
polymerization. The present study suggests that expo-
sure time had a greater impact on the conversion of
monomer into polymer.
It was concluded that the LED at 5 seconds and the
PAC at 3 seconds provided sufcient mean SBS to be
clinically acceptable.
Mun Jong
Meta-analysis of skeletal mandibular
changes during Frankel appliance treatment
L. Perillo, R. Cannavale, F. Ferro, L. Franchi, C. Masucci,
P. Chiodini and T. Baccetti
How do patients respond to Frankel appliance
treatment? This was the question posed by the
authors of this study who conducted a meta-
analysis in order to seek answers. The literature was
searched for articles which reported mandibular
changes produced by the Frankel-2 (FR-2) appliance
in the treatment of Class II malocclusion. The
FR-2 has a large emphasis on exercise and muscle
training and is indicated especially in patients with a
Class II malocclusion associated with mandibular
deficiency.
The authors used the following search terms Class II
malocclusion, Frankel appliance or FR-2 appliance
on Pub Med, the Cochrance Central Register of
Controlled Trials, Scirus, Lilacs, Embase and
Scopus. The inclusion criteria was extensive and
included a publication date between January 1966
and January 2009, original prospective and retro-
spective longitudinal studies based on human
samples, randomised controlled studies, systematic
reviews, meta-analyses, studies conducted on growing
patients with Class II malocclusions, concurrent
untreated growing subjects, historical controls with
Class II malocclusions and studies with cephalo-
metric measurements.
Two independent readers scored and carried out a
quality evaluation of the articles and used parameters
such as prospective design, randomisation, sample
size, method error analysis, blinding in measure-
ments and adequate statistics. Out of 39 evaluated
papers, 32 were excluded as they did not meet
the inclusion criteria. The reasons for exclusion
included inappropriate malocclusions, no cepha-
lometric analysis, expert opinion, case reports and
linear mandibular measurements, adult patients, con-
trol groups or quantitative data. Quantitative
mandibular changes were measured by assessing body
length, changes in total length and changes in ramus
height.
Results of the meta-analysis revealed that although
the FR-2 had statistically significant results on the
dimensions in the mandible of patients that had
received treatment, it was clinically minimal to mod-
erate. The authors reported that the quality of the
studies, the treatment duration, inconsistent diag-
nosis and data generated tended to overstate the
benefits of the FR-2 appliance. It was suggested that
an evidence-based approach to the orthodontic out-
comes of FR-2 appliance treatment is needed, by
selecting and comparing groups of patients with the
same cephalometric characteristics with and without
treatment.
Berna Kim
RECENT PUBLICATIONS
85
Evaluation of orthodontic treatment after 1
year of retention a randomized controlled
trial
G.E. Tynelius, L. Bondemark and E. Lilja-Karlander
The question regarding the most appropriate type of
orthodontic retention is often asked because all have
advantages and disadvantages for the clinician and
the patient. The aim of this study was to compare
three different retention methods, a vacuum-formed
retainer (VFR) in the maxilla and bonded canine-to-
canine retainer in the mandible (V-CTC), VFR in the
maxilla combined with stripping of 10 proximal sur-
faces of the lower anterior teeth (V-S), and a prefab-
ricated positioner (P) covering all teeth in the maxilla
and mandible.
Seventy-five patients, treated by a single orthodontist,
were involved in the study. Inclusion criteria were
defined by crowding in both arches, a skeletal and
dental Class I relationship without vertical or trans-
verse discrepancies and a treatment plan that required
the extraction of the four first premolars. Following
fixed appliance therapy, a VFR retainer was worn for
2 days full time then nightly for 12 months, while the
P retainer was worn for 30 minutes during the day-
time and during sleep for 12 months. Dental cast
assessment was performed using Littles Irregularity
Index as well as post-treatment and postretention
comparisons of arch length, intercanine and inter-
molar widths, overbite and overjet. The measurements
were statistically validated.
After 1 year of retention, no clinically significant dif-
ferences in retention capacity were detected between
the three retention methods. In all three groups, the
mean intercanine width was reduced in the maxilla,
but to a greater extent in those wearing the P and less
in the two groups wearing the VFR. In the lower
incisor area, the mean increase in Littles Irregularity
Index was largest in the P group, followed by V-S and
V-CTC groups. Interproximal lower incisor stripping
without any conjunctive methods was sufficient to
retain the treatment result on a short-term basis.
It was concluded that there was no evidence support-
ing a particular retention strategy following ortho-
dontic treatment as all three retention methods were
successful in preventing significant post-treatment
tooth movement. It was noted that provided patient
cooperation could be assured, short-term tooth
stability could be guaranteed.
Cherry Zaw
The diagnostic efficacy of cone beam CT for
impacted teeth and associated features: a
systematic review
M. Guerrero, M. Shahbazian, E. Bekkering,
O. Nackaerts, R. Jacobs and K. Horner
Journal of Oral Rehabilitation 2011; 38: 208-216
Dental impaction has been reported to affect as many
as 25-50 per cent of the population with the third
molars and maxillary canines having the highest inci-
dence. Treatment planning and management requires
accurate localisation of the impacted tooth as well as
knowledge of its relationship with surrounding struc-
tures. Three-dimensional views obtained by cone
beam computed tomography (CBCT) have been
advocated because of the uncertainty and limitations
of 2-dimensional plain films. However, CBCT is rel-
atively new and requires a systematic assessment to
confirm its clinical usefulness.
The authors therefore aimed to evaluate the current
evidence for the efficacy of cone beam computed
tomography for diagnosing impacted teeth (includ-
ing third molars, canines and supernumerary teeth)
and their associated features.
PubMed, Embase and the Cochrane Library were
searched using medical subject headings such as
tooth, impacted, mandibular nerve and cone beam
computed tomography. A time period was set from
January 1998 to November 2009 and was considered
appropriate as CBCT was introduced to clinical prac-
tice in the late 1990s. Two of the authors independ-
ently assessed the original studies for quality and
internal validity according to the quality assessment
of diagnostic accuracy studies (QUADAS) tool.
The search yielded 96 abstracts although only six
original studies were considered relevant and there-
fore, read in full. Hand searching the reference lists
produced only one additional original study for
consideration.
The authors determined that due to the heterogene-
ity and the inadequacy of primary investigations, a
conclusion on the diagnostic efficacy of CBCT for
impacted teeth could not be made. Intuitively, 3-D
imaging is better for the localisation of impacted
teeth and the investigators admit that this belief is a
likely reason for the paucity of valid and reliable stud-
ies. However, it was suggested that further planned
research is required to determine the diagnostic accu-
racy of CBCT localisation of impacted teeth as well
as the consequences and prognosis of management.
Wayne Chen
RECENT PUBLICATIONS
Orthodontic measurements on digital study
models compared with plaster models:
a systematic review
P.S. Fleming, V. Marinho and A. Johal
Orthodontics and Craniofacial Research 2011; 14: 1-16
Traditionally, plaster study models have been used for
orthodontic diagnosis and treatment planning.
Unfortunately, these are prone to loss, fracture and
degradation. Recently, digital study models have been
developed which solve storage problems and have fur-
ther potential benefits, including instant accessibility
of 3-D information, the ability to perform accurate
and simple diagnostic set-ups and objective model
grading analysis. Virtual images may be transferred
globally for instant referral or consultation.
The authors questioned the accuracy of digital
models and aimed to evaluate their validity to assess
tooth size, arch length, irregularity index, arch width
and crowding versus measurements generated on
hand-held plaster models with digital calipers.
Multiple databases including MEDLINE, LILACS,
BBO, ClinicalTrials.gov, the National Research Reg-
ister and Pro-Quest Dissertation Abstracts and Thesis
database were searched to identify studies which com-
pared linear and angular measurements obtained on
digital and standard plaster models. There was no
restriction relating to publication status or language
of publication. Two authors were involved in study
selection, quality assessment and the extraction of
data using a Systematic Reviews checklist. No meta-
analysis was conducted. Comparisons between
measurements of digital and plaster models made
directly within studies were collated and the
difference between the (repeated) measurement
means for digital and plaster models were considered
as estimates. Seventeen relevant studies were
included.
The findings indicated that the absolute mean differ-
ences between direct and indirect measurements on
plaster and digital models were minor and clinically
insignificant. Orthodontic measurements with digital
models were comparable to those derived from
plaster models and studies have demonstrated excel-
lent concordance of treatment planning decisions.
It was concluded that the use of digital models, as an
alternative to conventional measurements on plaster
casts, can be supported, although the identified
evidence was of variable quality.
Tan Wee Han
Gingival crevicular fluid alkaline
phosphatase activity as a non-invasive
biomarker of skeletal maturation
G. Perinetti, T. Baccetti, L. Contardo and R. Di Lenarda
Orthodontics and Craniofacial Research 2011; 14: 4450
Treatment timing has a significant role in the out-
come of orthopaedic treatment of dentoskeletal
disharmonies in growing patients. The usual methods
of clinical growth determination involve radiography
of the hand-wrist, the cervical spine or serial cephalo-
metrics. Biomarkers avoid radiographic exposure and
represent agents that are involved directly in bone
growth and remodelling.
The aim of the present study was to evaluate the gin-
gival crevicular fluid (GCF) alkaline phosphatase
(ALP) activity in growing subjects in relation to the
stages of individual skeletal maturation.
Seventy-two consecutive, healthy, growing subjects
from the Department of Biomedicine, University
of Trieste (45 females and 27 males; age range of
7.817.7 years) were examined. Excluded were
patients taking antibiotics or anti-inflammatory
drugs in the month preceding the study, patients with
gingival probing depths greater than 4 mm for the
whole dentition or 3 mm for the anterior sextants and
patients with a full-mouth plaque score and a full-
mouth bleeding score 25 per cent. Prior to GCF
collection, all patients underwent professional
supragingival and subgingival scaling and were asked
to rinse twice a day with 0.012 per cent chlorhexidine
mouthwash. In a double-blind, prospective, cross-
sectional study, samples of GCF were collected from
each subject at the mesial and distal sites of the upper
and lower central incisors. Enzymatic activity
was determined spectrophotometrically. Skeletal
maturation was assessed through the cervical
vertebral maturation (CVM) method.
A twofold peak in enzyme activity was seen at the
CS3 and CS4 pubertal stages, compared to the pre-
pubertal stages (CS1 and CS2) and postpubertal
stages (CS5 and CS6) at both the maxillary and
mandibular sites. No differences were seen between
the sites or between the genders. The relationship
between GCF ALP activity and CVM stages was
deemed to be significant.
As an adjunct to standard methods based upon radio-
graphic parameters, the GCF ALP may be a useful
clinical biomarker for the identification of the puber-
tal growth spurt in periodontally-healthy subjects
scheduled for orthodontic treatment. GCF sampling
involves a simple, rapid and non-invasive procedure
that can be readily performed. However, further
studies are warranted to confirm the absolute
diagnostic accuracy of the GCF ALP test.
Vandana Katyal
Efficacy of a novel pacifier in the prevention
of anterior open bite
S. Zimmer, C.R. Barthel, R. Ljubicic, M. Bizhang and
W. Raab
Pediatric Dentistry 2011; 33: 52-55
Pacifiers are commonly used to calm children during
stress, lull children to sleep and alleviate teething dis-
comfort. They have been reported to decrease the
incidence of sudden infant death syndrome (SIDS)
and hence their use is no longer discouraged. The use
of pacifiers has been recommended with a degree of
dental caution since non-nutritive sucking has been
known to cause changes in the occlusion including
decreasing overbite, increasing overjet and encourag-
ing the formation of a posterior crossbite. Although
these detrimental effects may self correct if pacifier
use is discontinued by 2-3 years of age, the intensity
and duration of prolonged pacifier use can be signifi-
cant. To combat this, a new and novel pacifier was
developed and introduced.
The aim of this study was to evaluate the influence of
a novel pacifier on the formation of an anterior open-
bite in infants. The new pacifiers design included a
narrower and tapered teat to prevent palatal disten-
sion and a thin and stepped connector between the
teat and shield to allow the pacifier to fit unobtru-
sively between the maxillary and mandibular incisors.
After ethics approval and parental permission, 129
newborn German children were recruited and
randomly assigned into two experimental groups.
Exclusion criteria included pre-term births, congeni-
tal maxillofacial anomalies and systemic diseases in
the infants. Group 1 used a NUK pacifier (N; N =
73), Group 2 infants were provided with the novel
Dentistar pacifier (D; N = 56) and Group 3 infants
did not use a pacifier and served as controls (C; N =
42). At varying time intervals, 121 infants (66
females; 55 males) were reassessed in the final analy-
sis (N: N = 42, D: N = 43, C: N = 36) conducted by
a single blinded operator. At re-examination the
mean age of the infants was 15.9 ( 3.9 SD) months.
An openbite, measured to the nearest 0.5 mm, was
diagnosed if there was a gap between the maxillary
and mandibular incisor edges. Overjet was measured
from the mesial and lingual corner of maxillary
incisors to the labial surfaces of mandibular incisors.
The results showed that in all groups, most infants
had fully-erupted incisors but molar position was
variable. An anterior open bite was seen in 16
children (38%) in Group 1 (NUK), 2 (5%) in Group
2 (Dentistar) and none in Group 3 (controls). The
incidence of openbite was significantly less in Groups
2 and 3 compared with Group 1 (chi-square test,
p < .001). No significant difference was found
between Groups 2 and 3. In addition, Group 1
showed significantly more cases of anterior open bite
than Group C (chi-square test, p < 0.001). There
were no statistically significant differences in regard
to overjet between the three groups. However, there
was a shorter reported daily pacifier use in Group 2
than Group 1 (Mann-Whitney U test, p < .01).
The authors concluded that the new Dentistar
pacifier seldom caused an anterior openbite com-
pared with the commonly used NUK pacifier in 16
month-old children. This novel pacifier was therefore
recommended in children up to that age.
Balya Sriram
Effects of different pacifiers on the primary
dentition and oral myofunctional structures
of preschool children
C.G. del Conte Zardetto, C.R.M.D. Rodrigues and
F.M. Stefani
Pediatric Dentistry 2002: 24: 552-560
The earliest record of the use of infant feeding teats
dates back as far as 100 AD. The modern pacifier was
likely preceded by a sugar rag which was made from
a rag or chamois filled with breadcrumbs and sugar
and tied in the shape of a teat. A natural sucking
instinct is necessary in order for an infants survival; if
this sucking urge is not satisfied, a child may develop
a non-nutritive sucking habit.
The aim of this study was to evaluate the relationship
between the arches, as well as to assess the lips,
tongue, cheeks and hard palate in 36-60 month old
children who sucked a pacifier. Two hundred and
fifty questionnaires were completed by mothers and
of these, only 61 were completed correctly. The 61
children for examination were divided into three
groups: 1) those who had never sucked a pacifier
(control group), 2) those who exclusively sucked a
RECENT PUBLICATIONS
87
physiological pacifier, and 3) those who exclusively
sucked a conventional pacifier. The sample consisted
of 37 males (61%) and 24 females (39%). The mean
age at the time of examination was 46 months, and
the mean reported time of use was 43 months for the
physiological and 45 months for the conventional
pacifier.
Statistical results showed that: 1) the use of both types
of pacifiers led to an anterior open bite (prevalence of
50% in both groups, p = .001); 2) a posterior cross-
bite was present only in children who had a paci-
fier-sucking habit; 3) the mean overjet was greater in
children who sucked physiological (3.6 mm) or con-
ventional (3.7 mm) pacifiers when compared with
those with no sucking habits (1.3 mm; p = .001); 4)
intercanine distance in the upper arch was signifi-
cantly reduced in children who sucked pacifiers (29.6
mm in the physiological group and 29.2 mm in the
conventional pacifier group) than those who did not
(31.2 mm) and 5) the children who never sucked a
pacifier showed a higher prevalence of normality of
cheek mobility (74%; p = .022) and hard palate shape
(78%; p = .042). More occlusal and oral myofunc-
tional abnormalities were detected among children
with a pacifier habit (either physiological or con-
ventional) when compared with those with no
sucking habits (control group). In agreement with
earlier reports, the present study concluded that
children with a prolonged pacifier-sucking habit were
more likely to display occlusal disharmonies and
myofunctional problems compared to habit-free
children.
Tony Gagliardi
Efficiency of the distal screw in the distal
movement of maxillary molars
M. Cozzani, F. Zallio, L. Lombardo and A. Gracco
World Journal of Orthodontics 2010; 11: 341-345
The management of dentoalveolar protrusion relies
on space creation by extractions or by the distal
movement of the entire dentition. The distal jet is
one of many distalising appliances that relies less on
patient compliance and offers aesthetic appeal. It is
comprised of two Ni-Ti coil springs attached to
bands on the maxillary molars and supported by
intra-oral anchorage. The distal screw is a skeletally-
anchored alternative to the conventional distal jet and
uses palatal paramedial mini-implants for anchorage
which reportedly results in almost complete bodily
molar movement.
The aim of this study was to evaluate the effectiveness
of the distal screw to move molars distally. The study
examined 18 patients (9 males, 9 females) who pre-
sented with a dentoalveolar Class II occlusion. Mini-
implants were used to fix a mouldable metal plaque
in the anterior palatal vault. Superelastic springs con-
nected to the molars were fixed to the metal plaque
by means of attachment screws which were adjusted
to deliver a compressive force of 240 cN. Force reac-
tivation was carried out at 4-weekly intervals. Quan-
tification of distal movement was determined by pre-
and post- treatment cephalometric superimpositions
employing the Ghosh and Nanda method.
The average time required to achieve a Class I molar
relationship was 9.1 months with a mean distal move-
ment of the maxillary molars of 4.7 mm with distal
tipping of 2.6 degrees. The first premolars moved dis-
tally an average of 2.1 mm with distal tipping of 2.0
degrees. The incisors tipped labially 0.3 degrees and
the molars and premolars extruded minimally.
It was concluded that the distal screw achieved more
upright distallisation of the molars but required more
clinical time. This was compensated by the simplicity
of the procedure and the minimal effect on other
teeth. The study did not have any controls and the
comparative assessments were based on the authors
clinical experience. Nevertheless, the distal screw was
considered effective as a molar-distallising non-com-
pliant appliance.
Ahmad Abdulkarim
RECENT PUBLICATIONS
Avex Mxi metal brackets from
Opal Orthodontics
According to the manufacturer, CNC pre-
cision-milled Avex MX stainless steel
brackets offer low profile comfort, exacting
tolerances and strength. They feature the
same in/out dimensions for each tooth as
Avex CXi ceramic brackets, making them
completely interchangeable.
For further information contact Gunz Dental
Tel: Australia: 1800 025 300; NZ: 0800 301 010
Email: dentalsales@gunz.com.au
Website: www.opalorthodontics.com
Opal Seal from Opal Orthodontics
fluoride releasing and recharging primer
Opal Seal is a 38 per cent filled primer contain-
ing nano fillers and GIC, used to prepare etched
enamel for orthodontic bonding. According to
the manufacturer, a thin layer of Opal Seal
applied to the etched enamel prior to bracket
placement enhances bond strength with the
added benefit of recharging fluoride uptake
throughout the course of orthodontic treatment.
Opal Seal is compatible with all types of
adhesive bonding systems.
For further information contact Gunz Dental
Tel: Australia: 1800 025 300; NZ: 0800 301 010
Email: dentalsales@gunz.com.au
Website: www.opalorthodontics.com
AccleDent System from OrthoAccel
The AcceleDent System is a simple,
hands free appliance used twenty
minutes daily to accelerate orthodontic
tooth movement. According to the
manufacturer, the pulsating mouthpiece,
clinically evaluated in a randomized, controlled and blinded
study, demonstrated that gentle vibrations in combination with
standard orthodontics can safely move teeth 38 per cent to
50 per cent faster. The device works in combination with
all fixed and removable orthodontic appliances and is
applicable for patients of all ages.
For further information contact the Australian and New
Zealand distributor, AB Orthodontics Pty Ltd
Tel: 1800 335 895
Email: sales@ortho.com.au Website: www.acceledent.com
Ormco Nexus metal and clear brackets
The new features of Ormcos Nexus metal
and Nexus clear brackets include con-
toured slot edges to minimise friction, an
auxiliary horizontal slot, three-sided chan-
nelling on the base to assist in clean up and
a pad base with hooked undercuts that allows deeper pene-
tration of the adhesive for greater bond reliability. The manu-
facturer claims these properties provide the next era of active
self-ligation.
For further information contact your Ormco representative
Tel: Australia 1800 023 603;
New Zealand 0800 446 140
Ormco Damon Splint
The Damon Splint (through AOA
Labs) is designed to help maintain
muscular balance following Class II,
Class III, and bilateral crossbite treat-
ment. The Damon Splint holds teeth
and arches in a fully corrected relationship, reinforcing all the
elements of correction. The splint may be used for adult and
mixed dentitions following Phase I functional treatment. A
minimal vertical opening from the posterior to the anterior
accommodates the airway slot. The splint is available in three
materials: hard pressure-formed, dual hardness/soft liner and
elastic silicone.
For further information contact your Ormco representative.
Tel: 1800 023 603; NZ 0800 446 140
TP Originator Clear Aligner System
The Originator Clear Aligner System is
a simple aesthetic solution for correcting
minor to moderate anterior crowding,
spacing, and minor orthodontic relapse.
According to the manufacturer, the
system corrects teeth incrementally
through a series of clear aligner trays, each one generating
up to 0.5 mm of movement. Patients wear originator aligners
sequentially in three- to four-week intervals, removing them
only to eat, drink, brush and floss. The final aligner tray can
be worn as a retainer.
For further information contact TP Orthodontics
Tel: 1800 643 055
Email: tpaus@tportho.com Website: www.tportho.com
New
products
NAOL Ortho Organizers Intra-oral
appliances
NAOL/Ortho Organizers has a full line of intra-oral appli-
ances that all mount into .036 horizontal lingual sheaths.
These include: palatal expanders, molar rotators, lingual
arches, TPAs and TransForce appliances. Individual band kits
are available with pre-welded lingual sheaths and buccal
tubes.
For further information contact NAOL/Ortho Organizers
Tel: 1300 ORDERZ (1300 673 379)
Email: sales@naol.com.au
Website: www.naol.com.au
NiTi palatal expander Molar rotator
Contoured transverse Controlled fixed
palatal arc lingual arches
TransForce 2 TransForce 2
transverse arch sagittal arch
developer developer
Ortho Organizers Fixed Twin Block 2.0
The new Fixed Twin Block 2.0 has
been clinically tested for six years.
According to the manufacturer this tech-
nique produces rapid correction of
distal occlusion with a full time fixed
functional appliance that is comfortable
to wear and can be combined with
fixed appliances at any stage of treat-
ment. Available in single patient kit form, key features
include: efficient treatment for skeletal Class II malocclusion,
elimination of buccal and lingual appliance bulk, preformed
occlusal blocks that bond directly to the teeth with no labo-
ratory work required and suitablility for either direct or
indirect techniques.
For more information contact NAOL/Ortho Organizers
Tel: 1300 ORDERZ (1300 673 379)
Email: sales@naol.com.au
Website: www.naol.com.au
NEW PRODUCTS
New products are presented as a service to our readers,
and in no way imply endorsement by the
Australian Orthodontic Journal.
Australian Orthodontic Journal Volume 27 No.1 May 2011 91
2011
June 19-23
87th European Orthodontic Society Congress, Istanbul
Convention and Exhibition Centre, Istanbul, Turkey
Website: www.eos2011.com
Email: secretariat@eos2011.com
September 22-24
Canadian Society of Orthodontists 63rd Annual Scientific
Session, Halifax Marriott Harbourfront Hotel, Halifax, Nova
Scotia, Canada
Website: www.cao-aco.org
September 22-24
Sociedad Argentina de Ortodoncias 4th National Meeting,
Salta, Argentina
Website: www.ortodoncia.org.au
Email: secretaria@ortodoncia.org.ar
September 22-25
Indian Orthodontic Societys 46th Indian Orthodontic
Conference, Hotel Clarks, Khajuraho, India
Web: www.46ioc.com
Email: drvskohli@gmail.com
September 25-28
British Orthodontic Society Conference 2011, Harrogate
International Centre, Harrogate, United Kingdom
Website: www.bos.org.uk
Email: ann.wright@bos.org.uk
October 6-8
3rd WIOC World Implant Orthodontic Conference in conjunction
the 8th AidOR/ASIO National Congress, Palazzo della Gran
Guardia, Verona, Italy
Web: www.wioc2011.it
Email: academia@oltrex.it
October 7-9
Australasian Society of Lingual Orthodontists (ASLO) and
Singapore Orthodontic Society (SOC), Singapore
Email: marie.t.aslo@gmail.com
October 12-15
8th Brazilian Orthodontic Association International Congress,
Belo Horizonte, Brazil
Web: www.abormg.org.br/abor2011
November 3-5
Korean Association of Orthodontists 44th Annual Scientific
Congress, COEX Convention and Exhibition Centre, Seoul, Korea
Web: www.kao.or.kr
Email: kao100@chol.com
November 10-12
Societa Italiana di Ortodonzias 23rd International Congress,
Rome, Italy
Web: www.sido.it
2012
February 11-14
23rd Australian Orthodontic Congress, Perth Convention Centre,
Perth, Australia
Web: www.aso2012perth.com
Email: asocongress@wsm.com.au
October 17-20
21st Congress of the International Association for Disability and
Oral Health, Sydney Australia
Web: www.iadh2012.com
Email: info@iadh2012.com
November 23-26
8th Asian Pacific Orthodontic Society Conference, New Delhi,
India
Web: www.ap-os.org
2015
September 27-30
8th International Orthodontic Congress and 5th Meeting of the
World Federation of Orthodontists, ExCel London, London,
United Kingdom
Web: www.wfo2015london.org
Orthodontic
calendar

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Contents

nn niversitesi, Dis hekimligi Fakltesi

and Gordon A. Ferns

Department of Pediatric Dentistry and the Dental Research Center;

and the Institute for Science and

Orthodontic Department, School of Dentistry, University of Otago, Dunedin

Private Practice, Tehran, Iran

Department of Orthodontics and

Department of Orthodontics, Shahid Beheshti University of Medical Sciences

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