American Journal of Orthodontics and Dentofacial Orthopedics
Volume 128, Number 2
environment with its fluids, enzymes, forces, and radiation
exposure while collecting and analyzing the particulate debris
and isolating the effluent gases. This is necessary because
formaldahyde gases would be solubilized in the oral cavity
and subsequently digested.
Whether the discipline is chemistry, medicine, or den-
tistry, the action to take when you are confronted by a
potential danger is to presume that it exists and take precau-
tions. We want innovation to prosper in dentistry but not at
the expense of compromising the health and welfare of
patients, especially children whose immune systems could
suffer chronic damage that would affect the rest of their lives.
Indeed, the welfare of vulnerable children is our top priority.
Robert P. Kusy
John Q. Whitley
Chapel Hill, NC
Am J Orthod Dentofacial Orthop 2005;128:148-9
0889-5406/$30.00
Copyright 2005 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2005.06.010
Hemisection treatment of second
deciduous molars
I found Dr William Northways article on hemisection of
the second deciduous molar to have merit in certain situa-
tions, particularly when the tooth is carious and condemned
and the deciduous first molar is gone (Northway WM. The
nuts and bolts of hemisection treatment: managing congeni-
tally missing mandibular second premolars. Am J Orthod
Dentofacial Orthop 2005;127:606-10). This poses the prob-
lem of distal drift of the erupted or erupting first premolar, to
say nothing of the mesial tipping of the first molar. It has long
been recognized that the deciduous second molars are stable,
and, as long as they are present, space maintainers to prevent
their mesial drift are generally not required. When it is
desirable to protract the first molar, hemisection of the second
deciduous molar could be a worthwhile procedure, because
the missing distal half allows mesial tip and drift of the first
molar while the retained mesial half prevents distal drift of
the first premolar and canine, thus shortening the time for
future space closure.
I take issue with Dr Northway about his fear of face
flattening when he invoked Newtons third law of action and
reaction during first-molar-protraction procedures. To counter
the retroclination of anterior teeth, he advised using activators
and fixed functional appliances (eg, Herbst, Jasper), certainly,
in my mind, cumbersome, expensive, and unnecessary ad-
juncts. If it were so, they would have to be used in every
premolar extraction case when space is left over after anterior
alignment, posterior protraction is required, and facial bal-
ance is an important consideration.
Far easier, faster, and controllable in such protraction
procedures is the proper use of basic mechanics: V bends
for crown mesial/root distal moments on the first premolar
and/or canine together with uprighting springs in the vertical
slots (if available) on the canines. This produces exception-
ally effective anterior anchorage that can be reinforced by
Readers forum 149
exaggerated curved upper and reverse curved lower rectan-
gular protraction arches. When activated, they hold the incisal
edges of the incisors where they are (supporting the lips and
thus the profile in these faces) while the centers of resistance
of the 2 segments move toward each other. A moment/force
ratio is engendered that encourages translation of the molars
as the space closes.
Stanley P. Kessel
Hollywood, Fla
Am J Orthod Dentofacial Orthop 2005;128:149
0889-5406/$30.00
Copyright 2005 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2005.06.013
Authors response
Dr Kessels letter reveals some areas that were not well
developed in my article (Northway WM. The nuts and bolts
of hemisection treatment: managing congenitally missing
mandibular second premolars. Am J Orthod Dentofacial
Orthop 2005;127:606-10); some were not even covered in my
earlier article on hemisections.1
I do not advocate hemisection for every incident of
congenitally missing lower second premolars (CML5)just
when orthodontic treatment will be provided anyway, and
certainly when the deciduous second molar will be lost. As Dr
Kessel points out, some lower second deciduous molars can
remain healthy, with a good occlusal and periodontal level for
a lifetime, but not very often. Sletten et al2 showed that, for
adults with CML5 and retained healthy deciduous mandibular
second molars, the potential for retaining them for many years
is excellent. But his search of the records of more than 6000
adults found only 20 who had retained at least 1 second
deciduous molar. That would be less than 8% of all patients
who might be expected to have CML5. Rune and Sarnas3
taught us that the onset of submergence should not occur
later than about one year after peak height velocity. In their
study of root resorption and submergence in retained decid-
uous second molars, they were able to use 31 of 1900 children
who had CML598% would not carry their retained primary
molars to maturity.
Valencia et al4 showed that, by slicing the distal surface
of the tooth and later hemisecting, 80% of patients had
excellent space closure without orthodontics if the treatment
was started by age 9. Their article stated that, when the
procedure was done later or when only an extraction was
performedthe space closure did not occur as uneventfully
or with the same completeness. Therefore, my philosophy is
that if you are going to treat a patient with CML5 orthodon-
tically, and you have the opportunity to treat earlyand you
can do it without flattening the facewhy not remove the
uncertainty by hemisecting, followed by extracting the resid-
ual mesial portion and protracting the molar. I always try to
save my patients the cost of a prosthesis.
As for the challenge to maintaining facial fullness, my
article in the Angle Orthodontist1 looked at the impact of this
procedure on patients who do not otherwise need extractions.
They did not have severe crowding or exaggerated protrusion,
and yet very little facial flattening took place when we