289_Editorial2009_04 11/6/09 2:29 PM Page 289

EDITORIAL
Welcome aboard . . .
ladies and gentlemen. This is your You might wonder what planes,
captain speaking. My name is Mr boats, and trains have to do with
Smith. My first officer, Mr Meyer, the World Journal of Orthodontics?
and I invite you to sit back and Well, this journal is also in a sense
enjoy your flight. a system of transportation: It
We usually hear something moves knowledge that impacts
along these lines after settling our minds and ultimately drives
into our seats on a plane. Such an our clinical activities. This means
announcement makes us feel that the knowledge thus delivered
comfortable because we subcon- will determine in part how well we
sciously realize that if the senior treat our patients, indeed how well
pilot had a problem, the second in we fulfill the oath of Hippocrates.
command could take over and the Oh, Hippocrates is a good key-
plane would still arrive at its final word. The responsibility this jour-
destination without any notice- nal demands has led us to invite
able difference. someone else from Greece to help
Not only do planes have this us maintain the high standards of
backup safety scheme, but so do World Journal of Orthodontics.
cruise boats, trains, and other modes of transportation. This person is Dr Moschos Papadopoulos, whom we in-
What we can learn from this model is that demanding troduce by way of a short biography below. Or would
transport systems, such as those with high responsibil- that mean to carry owls to Athens, as they say in my
ity requirements, regularly have two individuals to guar- home country? Anyway, we are glad that you have
antee a smooth delivery. joined our team,

. . . Dr Mike Papadopoulos

Moschos A. Papadopoulos, DDS, Dr Med Dent is associate professor and post-

graduate program coordinator at the Department of Orthodontics, School of Den-
tistry, Aristotle University of Thessaloniki, Greece. He received his dental degree
from the same university in 1986 and his doctorate degree (1988) and certificate
in orthodontics (1990) from the University of Freiburg, Germany. Dr Papadopoulos
has also served as research collaborator at the Department of Experimental Rainer-Reggie Miethke
Surgery, Swiss Research Institute, Davos, Switzerland. Editor-in-Chief
Dr Papadopoulos is editor of the Hellenic Orthodontic Review and associate
editor of Stoma. He is a member of the editorial board and serves as referee for
many journals. He is also an active member of nine Greek and six international
societies, federations, and unions. He is the recipient of several awards, including
the A. Tsoukanelis Award of the Aristotle University of Thessaloniki (1993), the
Annual Scientific Award of the German Association of Plastic Surgeons (2004),
and the Joseph E. Johnson Clinical Award of the American Association of Ortho-
dontists (2009).
Dr Papadopoulos’ main clinical and research interests include noncompliance
orthodontic treatment, mini-implants as temporary anchorage devices, and
evidence-based orthodontics. He is the author of the book Orthodontic Treatment
for the Class II Non-compliant Patient: Current Principles and Techniques, has
published more than 120 scientific articles, and has presented more than 200
lectures, courses, and papers.

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MAXILLARY ARCH WIDTH CHANGES Simona Tecco, DDS1

DURING ORTHODONTIC TREATMENT Stefano Tetè, MD, DDS2

Letizia Perillo, MD, DDS3

WITH FIXED SELF-LIGATING AND
Claudio Chimenti, MD,
TRADITIONAL STRAIGHT-WIRE DDS4

APPLIANCES Felice Festa, MD, DDS5

Aim: To evaluate the transverse dimensions of the maxillary arch

induced by fixed self-ligating and traditional straight-wire appliances
during orthodontic therapy. Patients and Methods: Forty consecutive
patients (age range 14 to 30 years) with normal or low mandibular
plane angle, normal overbite, and mild crowding were included. The
traditional appliance was composed of Victory Series MBT brackets
(3M Unitek), and the self-ligating appliance of Damon-3MX brackets
(Ormco). The leveling and aligning phase with round archwires lasted
6 months and was followed by another 6 months of rectangular arch-
wires. The archwire sequence with the MBT appliance was 0.016-inch
and 0.019 ⫻ 0.025-inch Ni-Ti form II (3M Unitek), while in the Damon-
3MX, it was 0.014-inch and 0.016-inch followed by 0.016 ⫻ 0.025-inch
copper nickel-titanium (Ormco). Intercanine, first and second interpre-
molar, and intermolar widths in the maxilla were recorded before
treatment (T0) and 12 months later (T1). Results: In both groups, a sig-
nificant increase from T0 to T1 was recorded for all transverse mea-
surements, but no significant difference was observed between groups.
Conclusion: Within 12 months of treatment, both appliances increased
maxillary dentoalveolar widths. World J Orthod 2009;10:290–294.

Key words: arch width, dentoalveolar width, maxillary expansion, MBT

brackets, self-ligating brackets
1PhD Student, Department of Oral
Science, University G. D’Annunzio,
Chieti/Pescara, Italy.
2Associate Professor, Department of

onextraction treatment is of ten
N accompanied by dentoalveolar
expansion.1–5 Dental arch width plays an
and 2.96 mm2 (as reported by Franchi et Oral Science, University G. D’Annun-
al8 and Bennet and McLaughlin9).
New low-friction self-ligating brackets
zio, Chieti/Pescara, Italy.
3Full Professor, Department of Oral

Science, University of Naples, Fed-

impor tant role in smile esthetics 1 are reported to induce (a significant) erico II, Naples, Italy.
because a small dental arch is typically maxillary arch expansion during the ini- 4Full Professor, Department of Oral

associated with an increase of blind buc-
cal corridors.6 In addition, dental arch
width seems to be an important aspect
of posttreatment stability.7
During fixed orthodontic treatment,
intercanine width increases between
0.55 mm1 and 2.13 mm,2 the interpre-
molar width (at the second premolars)
between 2.10 mm1 and 4.94 mm,2 and
the intermolar width between 1.53 mm1
tial therapy phase when superelastic Science, University of L’Aquila, Italy.
5Full Professor, Department of Oral
nickel-titanium archwires are used.8,10–12
Science, University G.D’Annunzio,
Generally, three hypotheses exist in con- Chieti/Pescara, Italy.
nection with bracket systems and arch
expansion: (1) light wires produce an CORRESPONDENCE
efficient expansion of the dental arch, Dr Simona Tecco
Via Le Mainarde 26
(2) with less buccal tipping, and (3) less
65121 Pescara
incisor protrusion because the light Italy
forces cannot overrule the labial/buccal Email: simtecc@tin.it,
musculature. simtecc@unich.it

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VOLUME 10, NUMBER 4, 2009
Fig 1 Maxillary occlusal view of a patient
in group 1 (MBT brackets) with a 0.019 ⫻
0.025-inch Ni-Ti form II archwire after
12 months of treatment.
In the Franchi et al8 study, low-friction
ligatures were evaluated so it seemed
reasonable to conduct a similar investi-
gation with self-ligating brackets that also
produce low friction. According to Harra-
dine,13 compared to conventional ones,
self-ligating brackets have a lower friction
coefficient, which leads to a more rapid
tooth alignment, and better anchorage
management.10,14–17
The aim of this study was to investi-
gate the changes of the maxillary trans-
verse dimensions produced by self-
ligating and traditional preadjusted
brackets with conventional elastic liga-
tures after using rectangular archwires.
PATIENTS AND METHODS
The sample consisted of 40 nonextraction
patients (23 females, 17 males) with a
mean age of 15 years 8 months (age
range 14 to 30 years), consecutively
treated at the Department of Oral Sci-
ence, University G. D’Annunzio, Chieti/
Pescara, Italy.
The inclusion criteria were permanent
dentition, normal or low mandibular
plane angle, normal or increased over-
bite, straight or concave profile, and at
least 2-mm crowding in the maxillary
arch. All subjects gave informed consent
to participate in this study.
According to the treatment protocol, the
20 patients of group 1 wore preadjusted
brackets (MBT Victory Series, 3M Unitek)
with conventional ligatures (Alastik,
3M Unitek) coupled with 0.016-inch
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Tecco et al
Fig 2 Maxillary occlusal view of a patient
in group 1 (Damon-3MX brackets) with a
0.016 ⫻ 0.025-inch copper Ni-Ti archwire
after 12 months of treatment.
Fig 3 The reference points used to mea-
sure intercanine, interpremolar (at the first
and second premolar), and intermolar
widths. Actual measurements were per-
formed on study casts (compare to Fig 4).
superelastic nickel-titanium archwires
(Nitinol archwire, 3M Unitek), followed by
0.019 ⫻ 0.025-inch Nitinol (Orthoform II,
archform selection, 3M Unitek, Fig 1).
The 20 patients in group 2 received
self-ligating brackets (Damon-3MX, Ormco)
and copper nickel-titanium 0.014-inch
archwires (copper Ni-Ti, Ormco) followed by
0.016-inch and 0.016 ⫻ 0.025-inch cop-
per Ni-Ti archwires (Fig 2).
Leveling and aligning with the respec-
tive round wires lasted an average of
6 months. Thereafter, the round wires
were replaced by rectangular ones. Dental
casts were produced at T0 (immediately
before treatment) and T1 (after 1 year).
The following measurements were made
on the maxillary casts at both time points
(Fig 3):
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Tecco et al WORLD JOURNAL OF ORTHODONTICS

Fig 4 Width measurement on a dental

cast using a fine-pointed digital calliper;
approximation of all readings was made to
the second decimal place.

Table 1 Descriptive statistics and comparison of maxillary measurements at T0 and T1

MBT (n = 20) Damon-3MX (n = 20)
T0 T1 ⌬T (T1–T0) T0 T1 ⌬T (T1–T0)
Measurements Mean ± ⌬T Paired t test, Mean ± ⌬T Paired t test,
(mm) Mean SD Mean SD SD (T1–T0) significance Mean SD Mean SD SD (T1–T0) significance

Intercanine 32.3 2.0 34.3 1.5 2.6 ± 2.4 6.2% t = 2.6, P < .05 31.1 2.3 34.1 1.4 3.3 ± 2.6 10.0% t = 2.6, P < .05
Interpremolar (first) 31.2 1.8 35.6 1.6 4.3 ± 2.1 14.1% t = 5.8, P < .05 30.8 1.9 35.2 0.5 4.4 ± 2.5 14.3% t = 5.9, P < .05
Interpremolar (second) 36.4 1.4 40.5 2.1 4.1 ± 2.1 11.3% t = 5.0, P < .05 36.2 1.9 40.4 0.5 4.2 ± 1.8 11.6% t = 6.8, P < .05
Intermolar 43.9 2.3 46.0 1.8 2.4 ± 2.0 4.8% t = 2.2, P < .05 42.9 1.5 44.8 0.9 2.3 ± 1.5 4.4% t = 3.2, P < .05

There was no significance in the unpaired t test MBT vs Damon at T0 or unpaired t test MBT vs Damon at T1 for any measurement.

• Intercanine width: distance between were performed on 10 randomly selected

the maxillary canine tips or between
the centers of the surfaces in case of
worn cusps
• First interpremolar width: distance
between the central fossae on the
occlusal surfaces of the maxillary first
premolars
• Second interpremolar width: distance
between the central fossae on the
occlusal surfaces of the maxillary sec-
ond premolars
• Intermolar width: distance between
the mesial ends of the central fissures
on the occlusal surfaces of the maxil-
lary first molars
The individual reference points on the
dental casts were digitized in accordance
with other researchers,18–20 using a fine-
pointed digital calliper (Tresna, Guilin
Guanglu Measuring Instrument); the
measurements were approximated to the
second decimal place (Fig 4).
To avoid interoperator error, all mea-
surements were carried out by a single
investigator. To assess error due to land-
mark identification, double measurements
dental casts. The data sets were com-
pared using Dahlberg’s formula21:
␦ = √(⌺d2/2N)
in which ␦ is the difference between the
two measurements and N is the number
of double registrations.
Statistical analysis
All statistical computations were per-
formed with SPSS 12 software (SPSS).
Descriptive statistics were calculated for
the measurements at T0 and T1 and for
the T0-T1 comparisons (Table 1). The Kol-
mogorov-Smirnov test showed a normal
data distribution at T0 and T1. Conse-
quently, the means and standard devia-
tions were computed.
The paired student t test was used to
identify significant differences (P < .05)
between T0 and T1, and the unpaired stu-
dent t test was used to compare the data
between the groups at both T0 and T1.

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VOLUME 10, NUMBER 4, 2009
RESULTS
The variance of the intraoperator method
error for the double measurements was
less than 5% of the observed variance in
the whole sample. Thus, all measure-
ments were accepted.
From T0 to T1, the intercanine width
showed a significant increase of 2.6 ± 2.4
mm (6.2%) and 3.3 ± 2.6 mm (10.0%) in
the MBT and Damon-3MX groups, respec-
tively.
The first interpremolar width increased
significantly by 4.3 ± 2.1 mm (14.1%) and
4.4 ± 2.5 mm (14.3%) in the MBT and
Damon-3MX groups, respectively.
Similarly, the second interpremolar width
increased significantly by 4.1 ± 2.1 mm
(11.3%) and 4.2 ± 1.8 mm (11.6%) in the
MBT and Damon-3MX groups, respectively.
The changes in intermolar width were
2.4 ± 2.0 mm (4.8%) and 2.3 ± 1.5 mm
(4.4%) in the MBT and Damon-3MX
groups, respectively.
No significant difference between the
two groups was observed at either time
point.
DISCUSSION
In this study, the transverse dimensional
changes of the maxillary arch produced
by conventional and self-ligating brackets
during orthodontic therapy were evaluated.
Damon observed a posterior expan-
sion of the dental arch with self-ligating
brackets and superelastic nickel-titanium
0.014-inch archwires.10 The present find-
ings showed significant increases in max-
illary arch widths with no difference
between the groups with conventional
and self-ligating brackets when coupled
with rectangular archwires. Obviously,
expansion with round archwires can be
achieved only when low-friction brackets
are used as demonstrated by Franchi et
al. 8 These authors further noted that
after using round archwires, the arch
widths were in the same range as after
the entire orthodontic treatment,1–5 con-
firming that low-friction systems obtain
expansion during just the aligning phase.
Conventional systems do the same only
after rectangular archwires are used.
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Tecco et al
Still, caution is indicated because Franchi
et al8 worked with low-friction elastic liga-
tures (slide ligatures).
The aforementioned three hypotheses
could not be confirmed by this study
because it did not consider buccal tip-
ping or incisor protrusion. Instead, its
emphasis was on whether rectangular
archwires (after light round archwires)
play a role in the final width of the maxil-
lary dental arch. But even after the inser-
tion of rectangular archwires, tipping and
protrusion between the two systems
could not be compared due to their dif-
ferent inclination prescriptions.
The two samples of the present inves-
tigation consisted of only patients with
mild crowding. However, the amount of
crowding could play an important role in
the determination of the final arch width.
In this study, the greatest expansions
were recorded for the premolars (14.1%
and 14.3% for the first premolars; 11.3%
and 11.6% for the second premolars).
They were followed by the canines (6.2%
and 10.0%), whereas the smallest
increase was found for the first molars
(4.8% and 4.4%). This is in accordance
with Franchi et al,8 who explained this as
a possible result of the archwire form
(Tru-Arch form), which is especially wide
in the canine and first premolar region. It
can be assumed that the form II arch-
wires used in this study caused the same
outcome.
CONCLUSIONS
The findings of this study indicate that a
low-friction system consisting of self-ligat-
ing brackets produces a significant
increase of maxillary transverse den-
toalveolar width. When rectangular arch-
wires are used, conventional brackets
produce an arch width increase compara-
ble to that of self-ligating brackets.
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Tecco et al WORLD JOURNAL OF ORTHODONTICS

REFERENCES 11. Fortini A, Lupoli M, Cacciafesta V. A new low-

friction ligation system. J Clin Orthod 2005;39:
464–470.
1. Kim E, Gianelly AA. Extraction vs nonextraction:
12. Baccetti T, Franchi L, Fortini A. Orthodontic
Arch widths and smile esthetics. Angle Orthod
treatment with preadjusted appliances and
2003;73:354–358.
low-friction ligatures: Experimental evidence
2. BeGole EA, Fox DL, Sadowsky C. Analysis of
and clinical observations. World J Orthod
change in arch form with premolar expansion.
2008;9:7–13.
Am J Orthod Dentofacial Orthop 1998;113:
13. Harradine NW. Self-ligating brackets: Where are
307–315.
we now? J Orthod 2003;30:262–273.
3. Bishara SE, Cummins DM, Zaher AR. Treatment
14. Koenig HA, Burstone CJ. Force systems from an
and posttreatment changes in patients with
ideal arch—Large deflection considerations.
Class II, Division 1 malocclusion after extrac-
Angle Orthod 1989;59:11–16.
tion and nonextraction treatment. Am J Orthod
15. Damon DH. The rationale, evolution, and clini-
Dentofacial Orthop 1997;111:18–27.
cal application of the self-ligating bracket. Clin
4. Isık F, Sayınsu K, Nalbantgil D, Arun T. A com-
Orthod Res 1998;1:52–61.
parative study of dental arch widths: Extraction
16. Voudouris JC. Interactive edgewise mecha-
and non-extraction treatment. Eur J Orthod
nisms: Form and function comparison with con-
2005;27:585–589.
ventional edgewise brackets. Am J Orthod
5. Paquette DE, Beattie JR, Johnston LE Jr. A long-
Dentofacial Orthop 1997;111:119–140.
term comparison of nonextraction and premo-
17. Tecco S, Di Iorio D, Cordasco G, Verrocchi I,
lar extraction edgewise therapy in “borderline”
Festa F. An in vitro investigation of the influ-
Class II patients. Am J Orthod Dentofacial
ence of self-ligating brackets, low friction liga-
Orthop 1992;102:1–14.
tures, and archwire on frictional resistance.
6. Braun S, Hnat WP, Fender DE, Legan HL. The
Eur J Orthod 2007;29:390-397.
form of the human dental arch. Angle Orthod
18. Walkow TM, Peck S. Dental arch width in Class
1998;68:29–36.
II Division 2 deep-bite malocclusion. Am J
7. Nojima K, McLaughlin RP, Isshiki Y, Sinclair PM.
Orthod Dentofacial Orthop 2002;122:608-613.
A comparative study of Caucasian and Japan-
19. Buschang PH, Stroud J, Alexander RG. Differ-
ese mandibular clinical arch forms. Angle
ences in dental arch morphology among adult
Orthod 2001;71:195–200.
females with untreated Class I and Class II mal-
8. Franchi L, Baccetti T, Camporesi M, Lupoli M.
occlusion. Eur J Orthod 1994;16:47-52.
Maxillary arch changes during leveling and
20. Bishara SE, Jakobsen JR, Treder J, Nowak A.
aligning with fixed appliances and low-friction
Arch width changes from 6 weeks to 45 years
ligatures. Am J Orthod Dentofacial Orthop
of age. Am J Orthod Dentofacial Orthop 1997;
2006;130:88–91.
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9. Bennet JC, McLaughlin RP. Orthodontic Treat-
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10. Damon DH. The Damon low-friction bracket: A
biologically compatible straight-wire system.
J Clin Orthod 1998;32:670–680.

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A. Hamid Zafarmand,
DDS, MSD, PhD1 EVALUATION OF THE PERIODONTAL
G. Ali Gholami, DDS, MS2 STATUS OF PALATALLY IMPACTED
MAXILLARY CANINES AFTER EXPOSURE
USING A MODIFIED WINDOW
TECHNIQUE
Aim: To evaluate the periodontal status of surgically exposed maxil-
lary canines after their alignment. Patients and Methods: Twenty con-
secutive patients with one palatally impacted maxillary canine and
one fully erupted synergist were selected. The impacted canines were
surgically exposed with a modified window technique, an attachment
was bonded, and the teeth were extruded and aligned. Six months
after therapy, the periodontal status of both canines was evaluated by
registering the following parameters: (1) keratinized gingiva level,
(2) attached gingiva level, (3) sulcus probing depth, (4) length of clini-
cal crown, (5) quality of marginal tissue, (6) bleeding on probing, and
(7) height of alveolar bone. The data were analyzed with the Mann-
Whitney test. Results: There was no significant difference between the
periodontal status of the two canine groups concerning the keratinized
gingival level, the attached gingival level, the sulcus probing depth,
and the length of the clinical crown. The quality of marginal tissue and
bleeding on probing were acceptable. However, the level of alveolar
bone was significantly lower in the surgically exposed group. Conclu-
sion: The periodontal health of impacted maxillary canines that were
exposed using a modified window technique and subsequently ortho-
dontically aligned is acceptable. The only concern is a somewhat
reduced alveolar bone level. World J Orthod 2009;10:295–300.

Key words: alveolar bone level, canine exposure, impacted canines,

keratinized gingiva, marginal tissue

1Associate Professor, Department of

Orthodontics, M.C. School of Den-
tistry, Shahid Beheshti University
M.C., Tehran, Iran.
2Associate Professor, Department of
Periodontics, M.C. School of Den-
tistry, Shahid Beheshti University
M.C., Tehran, Iran.
CORRESPONDENCE
Dr A. Hamid Zafarmand
Department of Orthodontics
School of Dentistry
Shahid Beheshti University M.C.
Evin Tehran
I.R. of Iran 19839
Email: zafarmand@alum.bu.edu
he canine is vital for esthetics, continu-
T ity within the dental arch, and function.
Palatally impacted maxillary canines are
a dilemma for the patient, as well as for
the orthodontist. To expose them, the oral
surgeon, orthodontist, and periodontist
should choose a safe procedure that
results in a healthy periodontium. If not
aligned, an impacted canine can cause
root resorption of adjacent teeth, a com-
promised occlusion, and an unpleasant
appearance.1–9 Rarely, the crown of the
impacted canine itself may be resorbed.10
After the third molar, the maxillary
canine is the most frequently impacted
tooth.11 Nearly 2% of the patients who
are referred for orthodontic treatment
have an impacted canine.6,12–14 Maxillary
canines are impacted 10 times as often
as their mandibular counterparts. It also
appears that females face with this prob-
lem more frequently than males.5,11,15–17
The general consensus is that maxillary
canines are 2 to 12 times more palatally
impacted than buccally.11,18

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Zafarmand/Gholami
The etiology of maxillar y canine
impaction is obscure.5 However, at least
16 factors are reported as potential
causes. 3,5,16,17,19–25 A few of these are
heredity, insufficient space, ankylosis,
trauma, cysts, and supernumerary teeth.
In case of space deficiency, it must be
determined whether any teeth (first pre-
molars) should be removed.19,24
Early diagnosis (between 9 and 10
years of age) is possible by palpating the
maxilla palatally. According to Ericson and
Kurol,26 5% of 10- to 11-year-old children
have nonpalpable unerupted canines. The
impaction site can be localized radio-
graphically with Clark’s principle. 6,27
Recently, Faber et al 28 recommended
computed tomography with rapid prototyp-
ing to improve diagnosis and treatment
planning. Even more highly recommended
is digital volumetric tomography.25 It must
be mentioned that the prognosis of
impacted canines worsens with age.29 The
duration of treatment is influenced by fac-
tors such as depth of impaction, patient
age, and angle of the tooth’s long axis to
the occlusal plane.30 Because of possible
complications, timely diagnosis and treat-
ment is strongly recommended.
Treatment
Generally, four treatment options exist for
impacted teeth: observation, intervention,
relocation, or extraction.31 Occasionally,
impacted canines erupt spontaneously.
More often, however, surgery is required. If
intervention is indicated, surgical exposure
and orthodontic treatment are two viable
choices.13,32–34 The type of surgical proce-
dure is particularly decisive for periodontal
health after treatment completion. The
surgery is not simple and increases the
length of treatment. 16,21,35,36 Surgery
becomes even more complicated if the
patient is missing any permanent teeth or if
he has an Angle Class III.37,38
Boyd 39 introduced the window tech-
nique for labially impacted canines. In its
modified form, it involves the least possi-
ble tissue excision to provide enough
access for bonding an attachment.
Various methods for ligation and
orthodontic extrusion are proposed in the
296
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WORLD JOURNAL OF ORTHODONTICS
relevant literature.40 Originally, banding
of the impacted tooth was recom-
mended. 24,41 Other outdated methods
include lasso ligation, cementing a pin
into the crown, and ligating or cementing
a custom-cast gold cap onto the tooth.
These procedures are replaced by bond-
ing buttons or others onto the respective
tooth.11,24,41,42 According to Boyd,42 direct
bonding guarantees the best success for
the orthodontic management of palatally
exposed canines. Despite all efforts, the
prognosis of impacted canines is some-
times poor, meaning they must be
removed. 49
It is of fundamental importance at the
completion of treatment that the origi-
nally impacted canine is periodontally
healthy compared to a normally erupted
canine. This investigation was designed
to find a response to this issue.
PATIENTS AND METHODS
Twenty patients, 10 males (mean age 16.4
± 2.5 years, range 13 to 20 years) and 10
females (mean age 17.0 ± 1.2 years, range
15 to 18 years) (total mean age 16.7 ± 1.9
years) were included in this study. All had
unilaterally a palatally impacted maxillary
canine and a normally erupted synergistic
canine. Palatal impaction was verified
using Clark’s principle. Inclusion criteria
were no history of orofacial trauma, no sys-
temic diseases, no congenital disorders,
no prepubertal periodontitis, no mental
retardation, and no consumption of any
gingival hyperplasia (inducing medications
such as carbamezapines, phenitoines, and
cyclosporine A).
Prior to surgery, all patients were
bracketed and banded. If the patient pre-
sented with insufficient space in the den-
tal arch, expansion or premolar extraction
was initiated. Surgical crown exposure of
the impacted tooth was performed with a
modified window technique (Fig 1). It was
limited to expose only 4 to 5 mm of the
crown to preserve the gingival tissue and
supporting bone. An advantage of this
approach is that it results in less postop-
erative discomfort for the patient.
The modified window technique begins
with the use of a no. 15 scalpel to excise
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VOLUME 10, NUMBER 4, 2009 Zafarmand/Gholami

Fig 1 (left) Intraoral situation

after dressing removal. Note
minimum crown exposure
with almost no inflammation.
Molars were previously
banded.

Fig 2 (right) Situation after

completed bonding proce-
dure.

Fig 3 (a) Initial distal trac-

tion with power chain—the
crown of the previously
impacted canine is close to
the lateral incisor; (b) situa-
tion 4 months later.

a b

Fig 4 Panoramic radiograph of a 16-year-old

patient with a palatally impacted maxillary left
canine. Note the distally tipped crown of the
lateral incisor due to the anteriorly positioned
canine crown.

the soft tissue covering the crown of the
palatally impacted canine. The incision is
limited to the area needed to attach a but-
ton or cleat. Any bone is removed with a
chisel or no. 2 round diamond bur. The in-
cised gingival edges are beveled to prevent
their proliferation into the exposure site,
which is then compressed with wet gauze
for 10 minutes to control bleeding. The pro-
cedure concludes with a Co-Pack surgical
dressing stabilized with a few sutures.
Occasionally bleeding may be controlled
with electrosurgical coagulation. In case of
postsurgical discomfort, over-the-counter
analgesic medication can help. Patients
should rinse with 0.2% chlorhexidine solu-
tion for 2 weeks following surgery. After
1 week, the dressing is removed and the
site professionally cleaned with physiologic
saline. The patient is also instructed to
gently clean the exposed location with a
soft brush. During the second week, the
patient is referred for bonding an attach-
ment to the exposed enamel (Fig 2).
At the same time, the remaining teeth
are bracketed. If the canine is close to
the lateral incisor root, it will initially be
pulled distally with a power chain before
it is tied with elastic thread to the arch-
wire (Fig 3).16,18,24,33,49 Panoramic radi-
ographs will help define the direction of
traction (Fig 4). During active orthodontic

297

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Zafarmand/Gholami
Table 1 Periodontal status of the two groups of teeth (in mm)
Parameter Normal (mean ± SD)
Gingival sulcus (DB) 2.3 ± 0.7
Gingival sulcus (MB) 2.5 ± 1.2
Gingival sulcus (midB) 1.9 ± 1.2
Gingival sulcus (L) 2.4 ± 0.7
Length of clinical crown 9.3 ± 1.7
Keratinized gingiva level 5.0 ± 1.4
Attached gingiva level 3.2 ± 1.1
SD = standard deviation; DB = distobuccal; MB = mesiobuccal; midB = midbuccal; L= lingual.
therapy, the patient is recalled every 3 to
5 months for professional periodontal
maintenance therapy.43
The periodontal status of both maxil-
lary canines was evaluated 6 months
after therapy. The evaluation included
registration of (1) keratinized gingiva
level, (2) attached gingiva level, (3) sul-
cus probing depth, (4) length of clinical
crown, (5) quality of marginal tissue, (6)
bleeding on probing, and (7) height of the
alveolar bone.44
All examinations were performed with
a Williams periodontal probe by one den-
tist under the supervision of a periodon-
tist. To evaluate the bone level, the
distance between the cementoenamel
junction and the alveolar bone crest was
measured. The length of the clinical
crown was computed buccally with a
Vernier digital caliper as the distance
between the deepest curvature of the
gingival margin and the canine cusp tip.
Bleeding on probing is categorized in
six levels44:
0 Healthy gingiva, no bleeding on probing
1 Healthy gingiva, but bleeding on prob-
ing
2 Altered gingiva color and bleeding on
probing
3 Altered gingiva color, slightly edema-
tous, and bleeding on probing
4 Altered gingiva color, greatly edema-
tous, and bleeding on probing
5 Altered gingiva color, greatly edema-
tous, and self-bleeding
The Mann-Whitney test was used to
compare the two groups of teeth (nor-
mally erupted vs orthodontically erupted)
for their periodontal condition.
298
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WORLD JOURNAL OF ORTHODONTICS
Impacted (mean ± SD) P
2.3 ± 0.5 ≤ .9
2.7 ± 1.3 ≤ .7
1.8 ± 0.9 ≤ 1.0
2.5 ± 0.9 ≤ .8
9.9 ± 1.6 ≤ .5
4.5 ± 1.4 ≤ .4
2.6 ± 0.7 ≤ .2
RESULTS
The quality of the gingival margin was
acceptable in 16 patients but unaccept-
able in the remaining four. The Bleeding In-
dex was 0 in 12 and 1 in eight individuals.
The remaining results are listed in
Table 1. The clinical crown length ranged
between 5.4 and 12.0 mm in the control
group (9.3 ± 1.7 mm) and from 6.7 to
12.0 mm (9.9 ± 1.6 mm) in the study
group (P ≤ .5). The range of the kera-
tinized gingiva in the control group was
from 4.0 to 8.0 mm (5.0 ± 1.4 mm) and
from 3.0 to 7.0 mm (4.5 ± 1.4 mm) in the
study group (P ≤ .4). For the level of the
attached gingiva the respective values
were 2.0 to 5.0 mm (3.2 ± 1.1 mm) in
the control group and 2.0 to 4.0 mm
(2.6 ± 0.7 mm) in the study group
(P ≤ .2).
The range of the bone level in the con-
trol group varied between 0 and 1.0 mm
(0.1 ± 0.3 mm) and between 0 and
2.0 mm (1.0 ± 0.5 mm) in the study
group (P ≤ .006).
DISCUSSION
In 1987, Gaulis and Joho46 studied the
periodontal condition of surgically
exposed teeth. They found mucogingival
problems in the surgically treated teeth,
especially when they were impacted
vestibularly. A Swedish study concluded
similar periodontal conditions on both
sides.9 But even if the periodontal condi-
tion of the exposed tooth is unfavorable,
it should not be forgotten that the
adverse condition can gradually reverse
to some degree. 47
295_Zafarmand.qxd 11/6/09 2:30 PM Page 299
VOLUME 10, NUMBER 4, 2009
Boyd39 used a window approach for
labially impacted canines, during which
the entire crown was exposed. Subse-
quently, the periodontal condition of the
respective teeth after orthodontic treat-
ment was characterized by gingival reces-
sions, inflammation, and attachment
loss. These consequences possibly relate
to the fact that the entire crown was
exposed. Thus, this technique was modi-
fied for the present study. Here, a window
was created by removing only a very
small part of the soft and hard tissue
over the crown.
In this investigation, no significant dif-
ference was found for the measurements
of the keratinized gingiva level, attached
gingiva level, sulcus probing depth,
length of clinical crown, quality of mar-
ginal tissue, and bleeding on probing.
If the height of the alveolar bone was
0.9 mm less in the previously impacted
teeth, it should be taken into considera-
tion that this deficiency could be substi-
tuted with synthetic bone.35
The results of this research could only
partially be compared to other publica-
tions because none evaluated all seven
of the aforementioned periodontal fac-
tors. D’Amico et al9 found in their study of
unilaterally impacted canines similar peri-
odontal conditions as in normally erupted
canines with the exception of sulcus
probing depth. According to Kohavi et
al, 36 the surgical exposure technique
plays an important role to achieve an
acceptable alignment with minimal peri-
odontal complications. Their study also
indicated that no difference was found
between the exposed and control side,
except for the loss of bony support.
It should be realized that not all
unerupted teeth can be salvaged and
that they must be removed in certain sit-
uations.49 In those cases, restorative pro-
cedures are an alternative to orthodontic
treatment.50
The combination of the described sur-
gical technique and orthodontic therapy
leads to a successful alignment of
impacted canines with sound periodontal
conditions.
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Zafarmand/Gholami
CONCLUSION
Based upon the results of this study, the
periodontal status of impacted maxillary
canines that are orthodontically aligned
into the dental arch is comparable to rou-
tinely treated canines. A modified window
technique is superior to surgically expose
impacted canines.
ACKNOWLEDGMENT
The authors would like to thank Dr Azadeh Sharif-
Zadeh for her sincere assistance in collecting the
data of this study.
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48. Danan M, Zenou S, Bouaziz-Attal AS, Dridi SM.
Orthodontic traction of an impacted canine
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49. Vanarsdall RL, Corn H. Soft-tissue management
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301_Seliem.qxd 11/6/09 2:31 PM Page 301

Essam Nassef Seliem, BDS,

MSc, PhD1 SOFT TISSUE CEPHALOMETRICS:
Khaled Hazem Attia, BDS, AN OVERDUE EVALUATION
MSc, PhD1

Saba Al-Hadithiy, BDS, The purpose of this study was to compare the accuracy of cephalo-
MSc, MOrth (RCSEd)2 metric soft tissue linear measurements obtained from conventionally
traced cephalograms with those taken directly on patients. This study
Yehya Ahmed Mostafa, was conducted on 11 orthodontic patients. Small pieces of orthodon-
BDS, FDSRCS(Ed), MS, tic wire were fixed on five soft tissue landmarks in the midline of the
PhD3 face of each patient. Five linear measurements were taken directly on
each patient’s face using an electronic Boley gauge reading to the
nearest 0.05 mm. Also, a lateral cephalogram was taken of each
patient with the aforementioned wires still in place. Using the same
gauge, the same linear measurements were taken from the tracings of
all cephalograms. The two sets of readings were statistically analyzed
using the concordance correlation coefficient and Pearson correlation
coefficient. The study concluded that soft tissue measurements on lat-
eral cephalometric radiographs do not give reliable values. A single
magnification factor cannot be applied for lateral cephalometric soft
tissue measurements in all patients, nor within the same patient.
World J Orthod 2009;10:301–304.

Key words: lateral cephalometry, soft tissue, linear measurements,

profile

ephalometric radiography is important method limitations do not allow an accu-

1Assistant Professor, Orthodontic
Department, Faculty of Oral and
Dental Medicine, Cairo University,
Cairo, Egypt.
2Visiting Resident, Orthodontic
Department, Faculty of Oral and
Dental Medicine, Cairo University,
Cairo, Egypt.
3Professor and Head, Orthodontic
Department, Faculty of Oral and
Dental Medicine, Cairo University,
Cairo, Egypt.
CORRESPONDENCE
Dr Yehya Ahmed Mostafa
Orthodontic Department
Faculty of Oral and Dental Medicine
Cairo University
52 Arab League Street
Mohandesseen, Giza, Egypt
Email: mangoury@usa.net
C for both clinicians and researchers,
especially those studying craniofacial
growth.1 Over the years, a variety of meth-
ods have been established for the analy-
sis of lateral cephalograms. 2–5 A
cephalogram is a 2D representation of a
3D object. Thus, due to the laws of projec-
tion, the images are displaced vertically
and horizontally. The amount of displace-
ment is proportional to the focus/object/
film or recording plane distance.6
Moreover, cephalometric analyses are
based on the hypothesis that accurate
superimposition of the right and left
sides occurs on the midsagittal plane.
Per fect superimposition is seldom
observed because facial symmetry is
rare, but more so because of relative
image displacement. These inherent
rate assessment of craniofacial abnor-
malities and facial asymmetries.6
Another important factor in this issue
is the significant amount of external
error, known as radiographic projection
error, which is associated with image
acquisition. These errors comprise mag-
nification, incorrect positioning, as well
as projective distortion. 7 In addition,
manual data collection and processing
in cephalometrics have been shown to
have low accuracy.7 Despite these limita-
tions, countless cephalometric analyses
have been developed to help diagnose
skeletal malocclusions and dentofacial
deformities.
The aim of this study was to evaluate
the accuracy of cephalometric soft tis-
sue measurements.

301

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Seliem et al WORLD JOURNAL OF ORTHODONTICS

Fig 1 Patient on whom short
sections of orthodontic wire were
fixed with clear adhesive tape on
five soft tissue landmarks.
Fig 2 Direct linear measure-
ment on the patient’s face using
an electronic Boley gauge.
Fig 3 Linear measure-
ment on a cephalometric
radiograph using the
same electronic Boley
gauge.

MATERIAL AND METHODS observer. His reliability was also tested by

Small pieces of orthodontic wire (Ormco)
(0.016 ⫻ 0.022-inch stainless steel,
3-mm long) were fixed with clear surgical
tape horizontally to the floor in the mid-
line of the faces of 11 randomly selected
orthodontics patients on five soft tissue
landmarks in the midsagittal plane (Fig
1). These landmarks were:
• G, glabella = most anterior point of the
forehead
• N, soft tissue nasion = deepest point
of the concavity between the forehead
and the nose
• SLS, superior labial sulcus = deepest
point of the concavity of the upper lip
between subnasale and labrale
superius
• ILS, inferior labial sulcus = deepest
point of the concavity of the lower lip
between labrale inferius and soft tis-
sue pogonion
• Me, soft tissue menton = lowest point
on the contour of the soft tissue chin
Five linear measurements (G-N, N-SLS,
N-ILS, N-Me, and SLS-Me) were taken
directly on each patient’s face and on
each cephalometric radiograph using an
electronic Boley gauge, which was read
to the nearest 0.05 mm (Figs 2 and 3).
To ensure measurement reliability, all
measurements were made by the same
repeating all measurements 1 day after the
first set of measurements was attained.
The data were collected, tabulated,
and analyzed with a reproducibility index,
called the concordance correlation coeffi-
cient (CCC), introduced by Lin.8 It evalu-
ates the agreement between two readings
(from the same sample) by measuring the
variation for the 45-degree line through
the origin (the concordance line).9,10 The
CCC contains the measurements of accu-
racy and precision. It was used to evalu-
ate the equivalence and association
between the direct and cephalometric
measurements. Also, the reproducibility
of all measurements was assessed with
the CCC statistical test.
RESULTS
The results and consequent comparison
between the direct and cephalometric
measurements are represented in Table
1 and Fig 4.
The CCC showed that of the five linear
measurements, three agreed poorly and
two fairly between the two modalities.
Error assessment between repeated mea-
surements, as represented in Table 2 and
Fig 5, depicted an excellent correlation.
The percentage of magnification was
not constant among patients, nor within
the same patient (Table 3).

302

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301_Seliem.qxd 11/6/09 2:31 PM Page 303

VOLUME 10, NUMBER 4, 2009 Seliem et al

Table 1 Mean, standard deviation (SD), and concordance

44 correlation coefficient (CCC) test for the direct clinical (DC)
and cephalometric (CEPH) measurements (mm)
42
Mean SD CCC
40
G-N
DC 34.931 4.103 0.633**
38
Ceph

CEPH 39.148 5.197

N-SLS
36
DC 56.715 4.009 0.306***
34 CEPH 65.132 4.750
N-ILS
32 DC 90.425 6.616 0.342***
CEPH 102.713 7.214
30 N-Me
30 32 34 36 38 40 42 44 DC 112.283 7.948 0.108***
Direct CEPH 120.895 18.054
SLS-Me
DC 58.360 5.223 0.486**
Fig 4 Graphic representation of the CCC for the direct (clini- CEPH 64.656 4.981
cal) and cephalometric (ceph) linear measurements.
** = .40 > P < .75 (fair agreement).
*** = P < .40 (poor agreement).

Table 2 Mean, standard deviation (SD), and concordance

44 correlation coefficient (CCC) test of intraobserver
difference between the first (Obs 1) and second (Obs 2)
42 measurement (mm)
40 Mean SD CCC

G-N
38
Osb 2

Obs 1 34.93 4.103 0.995*

36 Obs 2 35.07 3.999
N-SLS
34 Obs 1 56.71 4.009 0.978*
Obs 2 56.74 3.919
32 N-ILS
Obs 1 90.42 6.616 0.998*
30 Obs 2 90.43 6.595
30 32 34 36 38 40 42 44 N-Me
Obs 1 Obs 1 112.28 7.948 0.992*
Obs 2 112.37 7.717
SLS-Me
Fig 5 Graphic representation of the CCC for the intraob- Obs 1 58.36 5.223 0.986*
server error assessment between the first (Obs 1) and sec- Obs 2 58.15 5.322
ond (Obs 2) measurement of both direct and cephalometric
linear parameters. *= P > .75 (excellent agreement).

Table 3 Percentage of magnification between the direct

and cephalometric measurements (mm)
Subject G-N N-SLS N-ILS N-Me SLS-Me

1 14.21 8.20 10.69 12.33 10.52

2 3.03 15.78 10.27 8.79 2.88
3 9.98 12.98 13.23 10.94 10.45
4 9.54 14.79 13.93 13.47 10.10
5 14.43 14.79 13.92 14.19 13.64
6 10.66 11.19 12.52 12.01 10.62
7 11.61 11.53 6.92 7.79 3.26
8 13.3 14.34 11.80 10.90 13.07
9 11.19 12.94 13.20 12.47 10.64
10 14.78 11.05 10.91 11.10 9.96
11 3.39 14.15 14.13 12.53 12.14

303

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301_Seliem.qxd 11/6/09 2:31 PM Page 304
Seliem et al
DISCUSSION
In contemporary orthodontics, systematic
quantitative measurements based on
hard and soft tissue landmarks deter-
mined on cephalometric films are used
on a daily basis. Precision and repro-
ducibility in data obtained from cephalo-
grams are important for the orthodontist.
Errors in conventional methods arise
from image acquisition, landmark identi-
fication, and measurement method.11–13
In cephalometry, the validity of the
measurements must be ascertained by
comparing the measurements from
cephalograms with measurements made
directly on the same skull in the case of
hard tissue measurements and directly on
the same face in the case of soft tissue
measurements.14 In this study, the accu-
racy was tested by comparing the linear
measurements obtained on cephalograms
and directly on the same patients’ faces.
All five selected soft tissue landmarks
were in the midline of the face so as to
avoid superimpositions. Moreover, only lin-
ear measurements were tested because
angular measurements would be more dif-
ficult to acquire and should be relatively
independent of the measurement method.
Magnification, inherent to radiographic
projection, must be considered when
comparing cephalometric data from vari-
ous sources. This applies to only linear
dimensions, because angular values
would not be affected.
Although the number of individuals
was limited to 11, the results obviate the
need to expand the sample size.
CONCLUSIONS
From this study, the following conclusions
could be drawn:
• Soft tissue analysis showed that linear
soft tissue measurements extracted
from lateral cephalometric radiographs
do not represent the true values to be
found in a particular patient.
• A single magnification factor cannot
be applied as a correction factor for
the lateral cephalometric soft tissue
measurements.
304
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WORLD JOURNAL OF ORTHODONTICS
REFERENCES
1. Broadbent BH Sr. A new x-ray technique and its
application to orthodontia. Angle Orthod
1931;1:45–66.
2. Tweed CH. The Frankfort-mandibular plane
angle in orthodontics. Am J Orthod 1946;32:
175–230.
3. Downs WB. Variations in facial relationship:
Their significance in treatment and prognosis.
Am J Orthod 1948;34:812–840.
4. Graber TM. New horizons in case analysis—
Clinical cephalometrics. Am J Orthod 1952;38:
603–624.
5. Ricketts RM. Cephalometric synthesis. Am J
Orthod 1966;46:647–673.
6. Athanasiou AE. Orthodontic Cephalometry. Lon-
don: Mosby-Wolfe, 1997.
7. Adams GL, Gansky SA, Miller AJ, Harrell WE Jr,
Hatcher DC. Comparison between traditional 2-
dimensional cephalometry and a 3-dimensional
approach on human dry skulls. Am J Orthod
Dentofacial Orthop 2004;126:397–409.
8. Lin LI. A concordance correlation coefficient to
evaluate reproducibility. Biometrics 1989;45:
255–268.
9. Lin LI. Assay validation using the concordance
correlation coefficient. Biometrics 1992;48:
599–604.
10. Lin L, Torbeck LD. Coefficient of accuracy and
concordance correlation coefficient: New statis-
tics for methods comparison. PDA J Pharm Sci
Technol 1998;52:55–59.
11. Houston WJB, Maher RE, McElroy D, Sherriff M.
Sources of error in measurements from
cephalometric radiographs. Eur J Orthod
1986;8:149–151.
12. Forsyth DB, Shaw WC, Richmond S. Digital
imaging of cephalometric radiography, Part 1:
Advantages and limitations of digital imaging.
Angle Orthod 1996;66:37–42.
13. Forsyth DB, Shaw WC, Richmond S, Roberts CT.
Digital imaging of cephalometric radiographs,
Part 2: Image quality. Angle Orthod 1996;66:
43–50.
14. Potter JW, Meredith HV. A comparison of two
methods of obtaining biparietal and bigonal
measurements. J Dent Res 1948;27:459–466.
José Augusto Mendes
Miguel, MSc, PhD1 ORTHODONTIC TREATMENT NEEDS
Daniela Feu, Esp2 OF BRAZILIAN 12-YEAR-OLD
Rogéria Mendes Brêtas,
MSc3
SCHOOLCHILDREN
Aim: To assess the orthodontic treatment need of 12-year-old Brazil-
Cristiane Canavarro, MSc4
ian school children using the Index of Orthodontic Treatment Need
(IOTN). Methods: One experienced examiner evaluated the IOTN’s
Marco Antonio de Oliveira
dental health component (DHC) and its esthetic component (EC) in
Almeida, MSc, PhD5
1,182 individuals from 50 randomly selected state schools of Rio de
Janeiro. He also requested that these students score their own EC
(self-perception). Results: The DHC showed that 51.1% of the children
had no/little need, while 26.7% had a need/high need/priority for
orthodontic treatment. There was no significant difference between
the two sexes (P = .156). According to the EC, esthetics were good in
59.1% of the children, borderline in 32.7%, and unattractive in 8.1%.
The self-perception of the EC showed that 89.0% judged themselves
as having good esthetics, with girls significantly more critical than
boys (P = .035). The statistical correlation between EC (examiner) and
EC (children) was low (kappa coefficient = .13). Conclusions: About
half of the scored Brazilian 12-year-old schoolchildren had no/little
need for treatment. Orthodontists were more critical in their esthetic
evaluation than the children themselves, with girls being more critical
in self-perception than boys. World J Orthod 2009;10:305–310.

Key words: dental health component, esthetic component, IOTN, occlusal

indices, treatment need

1Adjunct Professor, Department of
Orthodontics, Rio de Janeiro State
University, Rio de Janeiro, Brazil.
2Specialist in Orthodontics and MSc
Student, Rio de Janeiro State Uni-
versity, Rio de Janeiro, Brazil.
3Pedodontics Master, State University
of Rio de Janeiro, Rio De Janeiro,
Brazil.
4PhD Student, State University of Rio
de Janeiro, Rio de Janeiro, Brazil.
5Chair, Department of Orthodontics,
Rio de Janeiro State University, Rio
de Janeiro, Brazil.
CORRESPONDENCE
Daniela Feu Rosa Kroeff de Souza
Moacir Ávidos Street, n° 156 /
apartment 804
Praia do Canto – Vitória – E.S.
Cep: 29055-350
Brazil
Email: danifeutz@yahoo.com.br
or many years, occlusal indices have
F been widely used to uniformly evalu-
ate orthodontic treatment need.1,2 Sev-
eral indices have been developed to
categorize malocclusions into groups
that reflect the level of treatment need.
Assessing treatment need is indispens-
able for public health purposes and spe-
cialist-training programs.3 Such data is
limited for the Brazilian population. 4
Most of the published data deal with
specific occlusal traits, which makes
comparisons difficult and provides little
information about treatment need.
The Index of Orthodontic Treatment
Need (IOTN) incorporates two compo-
nents: a dental health component (DHC),
based on the recommendations of the
Swedish Medical Board, 5 which ranks
five progressive levels of occlusal irregu-
larities, and an esthetic component (EC),
which grades dental attractiveness
based on a set of 10 color photographs.
Grade 1 represents the most attractive
and grade 10 the least attractive appear-
ance.6 Since its introduction, the IOTN
has been widely applied by orthodontists
the world over.7,8 The reproducibility and
validity of the IOTN is approved, which
enforces its use.1,9,10
Although dissatisfaction with dental
appearance is related to the severity
of occlusal irregularities,11,12 there are
differences in the recognition and evalua-
tion of dental features.13 Previous inves-
tigations have suggested that dental
professionals have a more critical view of
malocclusions than laypersons, when

305

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 Miguel et al
considering treatment in conditions
acceptable to laypersons.7,11,12,14–18 Addi-
tionally, ranking dental attractiveness is
subjective and may be related to the
judge’s background, with differences
among patients’ self-perception usually
related to sex,12,19–21 age,22–24 ethnicity,
and cultural conditions.25
The aims of this study were to evaluate
the orthodontic and esthetic treatment
need, as well as the self-perception, of
12-year-old schoolchildren from Rio de
Janeiro.
METHODS
One thousand two hundred and fifty 12-
year-old schoolchildren from 50 state
schools in Rio de Janeiro were evaluated.
These schools were randomly selected
from all 390 Rio de Janeiro schools in
this age group, respecting the city’s
regions’ ratios. Twenty-five children were
chosen from each class independent of
their sex. Sixty-eight (5.4%) were under-
going or had undergone orthodontic
treatment. Subsequently, they were
excluded from the sample, bringing the
final number to 1,182. Of these, 550
(46.5%) were male and 632 (53.5%)
female, with no significant difference
between sexes (P = .93).
Permission to undergo the survey was
obtained from the city of Rio de Janeiro’s
education department, each school, and
each child’s parent. Each party was
asked to consent to their child’s coopera-
tion in the study through an informative
letter including a consent form that was
approved by the Ethics Research Commit-
tee of the authors’ university.
One examiner (who had been previ-
ously trained in the use of the IOTN index
at the University of Manchester) carried
out the screening. He was evaluated on
a set of 30 plaster casts previously exam-
ined (gold standard). To test his (intraex-
aminer) reliability, these casts were
re-examined after 7 days.
The complete investigation was car-
ried out in natural light using a mouth
mirror. No radiographs, study casts, or
written records were used. All occlusal
anomalies of the DHC were recorded and
306
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WORLD JOURNAL OF ORTHODONTICS
scored separately on an individual form.
The DHC grade was then determined
according to the highest scoring anomaly.
The EC score was evaluated by both the
investigator and each individual.
For the DHC, 10 malocclusions/symp-
toms were considered: overjet, anterior
crossbite, overbite, open bite, lateral cross-
bite, displacement of teeth, clefts of lip or
palate, Class II, Class III buccal occlusion,
and hypodontia. The EC complements the
DHC by assessing the appearance of the
anterior tooth alignment.2
The DHC of the IOTN has five grades,
while the EC has 10. DHC grades 1 to 2
and EC grades 1 to 4 represent no/little
need for treatment, DHC grade 3 and EC
grades 5 to 7 correspond to a moderate
or borderline need for treatment, and
DHC grades 4 to 5 and EC grades 8 to 10
represent a high need/priority for treat-
ment.2
Data analysis was performed using
SPSS 9.0, SPSS. The chi-square test was
used to analyze qualitative data and
determine differences in treatment need
among subgroups. The significance level
was set at .05. The agreement evaluation
between the examiner scores and stan-
dard scores (gold standard) and intra-
examiner reliability were analyzed with
kappa statistics.
RESULTS
In the examiner gold-standard evaluation,
good agreement was found for DHC
(kappa = .73) and EC (kappa =.72). Intra-
examiner reliability had a kappa of .92,
indicating a substantial agreement.5
According to the IOTN-DHC, 51.1% of
the children had no/little need for treat-
ment, 22.2% had a moderate/borderline
need, and 26.7% a high need/priority
for treatment (Fig 1). There was no signifi-
cant dif ference between the sexes
(P = .156).
According to the IOTN-EC (examiner),
59.2% of the children had no/little need
for treatment, 32.7% had a moderate/bor-
derline need, and 8.1% a high need/prior-
ity for treatment (Fig 2). Again, there was
no significant difference between the
sexes (P = .279, Table 1).
VOLUME 10, NUMBER 4, 2009 Miguel et al

25
45
40.6
40 20
35 17.3 17.4 17.1

Frequency (%)
Frequency (%)

30 15
25 22.2 11.7 11.4
20.2
20 10 9.6
15 7.3
10.5
10 6.5 5 3.6 4.1
5
0.5
0 0
1 2 3 4 5 1 2 3 4 5 6 7 8 9 10
DHC score EC score

Fig 1 Perceptual frequency of the five DHC scores. Fig 2 Perceptual frequency of the 10 ECs (examiner).

Table 1 IOTN-EC examiner categorization according to sex

Female Male Total
EC n % n % n %

1–4 (No/little need) 386 61.1 313 56.9 699 59.1

5–7 (Moderate/borderline need) 200 31.6 187 34.0 387 32.7
8–10 (High need/priority for treatment) 46 7.3 50 9.1 96 8.1
Total 632 100.0 550 100.0 1,182 100.0

n = number of individuals.

35 32.7

30

25 22.8
Frequency (%)

21.6
20

15 12.0
10
6.1
5 2.2 1.3
0.9 0.4 0.1
0
1 2 3 4 5 6 7 8 9 10
EC score

Fig 3 Perceptual frequency of the 10 ECs (children).

Table 2 IOTN-EC children categorization according to sex

Female Male Total
EC n % n % n %

1–4 (No/little need) 575 91.0 477 86.7 1052 89.0

5–7 (Moderate/borderline need) 48 7.6 65 11.8 113 9.6
8–10 (High need/priority for treatment 9 1.4 8 1.5 17 1.4
Total 632 100.0 550 100.0 1,182 100.0

n = number of individuals.

According to the IOTN-EC (children) ment (Fig 3). A significant difference was
89.0% had no/little need for treatment, identified between the sexes (P = .035,
9.6% had a moderate/borderline need, Table 2), revealing that girls were more criti-
and 1.4% a high need/priority for treat- cal in their esthetic self-perception.

307

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 Miguel et al
Table 3 Relationship between examiner-assessed EC and DHC scores
1–4 (No/
DHC score little need)
1–2 (No/little need) 560
3 (Moderate/borderline need) 106
4–5 (High need/priority for treatment) 33
Total 699
Table 4 Relationship between children-assessed EC and DHC scores
1–4 (No/
DHC score little need)
1–2 (No/little need) 567
3 (Moderate/borderline need) 238
4–5 (High need/priority for treatment) 247
Total 1,052
In this study, the two most frequent
occlusal features responsible for the DHC
categorization were overjet (32.9%) and
crowding (30.4%). The most common fea-
ture responsible for a DHC grade 5 was
nonerupted teeth.
Cross-tabulation between DHC and EC
(examiner) scores showed moderate reli-
ability (kappa = 0.45, Table 3). The corre-
lation of DHC and EC (children) scores
was found to be very low (kappa = .056,
Table 4). The correlation between EC
(examiner) and EC (children) was again
low (kappa: .13). This disagreement indi-
cates a less critical evaluation of the
affected children.
DISCUSSION
The present cross-sectional study is one
of the few Brazilian surveys using the
IOTN to evaluate the treatment need and
perception of dental attractiveness in
Brazilian children. The sample does not
represent the entire Brazilian 12-year-old
population but rather gives an overview
of the potential request for orthodontic
therapy in the studied area.
The 26.7% who, according to the DHC,
had an objective need for orthodontic
treatment (with a DHC of 4 to 5) are simi-
lar to the 21.3% of the 9- to 12-year-old
French schoolchildren, 3 the 22.0% of
308
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WORLD JOURNAL OF ORTHODONTICS
EC score
5–7 (Moderate/ 8–10 (High need/
borderline need) priority for treatment) Total
43 1 604
146 10 262
198 85 316
387 96 1,182
EC score
5–7 (Moderate/ 8–10 (High need/
borderline need) priority for treatment) Total
35 2 604
22 2 262
56 13 316
113 17 1,182
Tanzanian 9 to 18 year olds,25 the 22.0%
of the Arabian 12 to 18 year olds,26 and
the 21.0% to 24.0% for British 11 to 12
year olds.9
However, the percentage for high treat-
ment need in this study was lower than
the 32.7% and 32.0% found for 11- to
12-year-old British children in the Brook
and Shaw 1 and Holmes 14 studies,
respectively. It was also lower than the
38.8% reported for 11- to 14-year-old
Turkish children in Uçüncü and Eturgay’s8
study, the 37.0% for 12- to 13-year-old
Swedish children in the study of Josefs-
son et al,11 and the 42.6% for 12- to 13-
year-old Senegalese children in Ngom’s
et al25 study.
Hamdan19 reported that 71.0% of the
children in Jordan with a mean age of
15.3 years had an objective need for
orthodontic treatment. In another study of
12- to 14-year-old Jordanian individuals,
Abu Alhaija et al27 found that only 34.0%
had an objective treatment need. This dif-
ference in treatment need between chil-
dren of similar age shows the impact of
sample selection because the individuals
of the first survey sought orthodontic or
orthognathic surgery treatment at the
Jordan University Hospital, whereas the
second sample was schoolchildren.
In the IOTN-DHC index, only the most
severe occlusal trait is considered for cat-
egorization, despite the fact that other
VOLUME 10, NUMBER 4, 2009
severe symptoms may be present. In this
study, the two most common occlusal
traits responsible for the final DHC cate-
gorization were increased overjet and
crowding. Similarly, Souames et al 28
recorded crowding as the most common
trait, followed by increased overjet. Again,
Ngom et al 25 and Abu Alhaija et al 27
found crowding as the most common
occlusal trait. These authors thought that
this finding should have implications on
public dental health, because crowding is
most commonly associated with poor
periodontal condition.
According to the EC of the IOTN, Brazil-
ian children had exactly the same fre-
quency of a high need/priority for
treatment (examiner EC = 8 to 10) as Tan-
zanian children (8.1%).24 Similar results
were found for French,28 Arabian,16 and
Senegalese children. 25 However, in
British and Turkish children, the EC val-
ues were much lower.8,9
In Brazil, Frazão and Narvai29 evalu-
ated 13,801 12 to 18 year olds in São
Paulo state using the Dental Esthetic
Index (DEI). They concluded that 16.5%
of the sample had severe or very severe
malocclusions. In 12-year-old children,
these authors did not find a significant
sex differences in dental appearance
perception, corroborating the present
study’s findings.
According to the EC, 89.0% of the chil-
dren of this study perceived themselves as
not to have an esthetic need for treatment,
which is in contrast to this examiner’s
view as to that of dental professionals like
Shaw et al,12 Prahl-Anderson,20 Holmes,14
Hunt et al,15 Josefsson et al,11 and Ngom
et al.25 The low correlation between EC
score (children) and DHC score and
between EC (children) and EC (examiner)
scores in this study is in agreement with
Ngom et al,25 Josefsson et al,11 and Ham-
dan.19 The EC scores (examiner) showed a
moderate correlation with the DHC scores,
while Souames et al28 found a higher cor-
relation for the same comparison.
The statistical analysis of this study
revealed that girls were more critical in
their esthetic evaluation than boys. This
is in agreement with the findings of oth-
ers.12,17,21,29
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Miguel et al
On the other hand, when Hunt et al15
asked 19-year-old British individuals to
rank other person’s and their own dental
esthetics, they did not find any sex differ-
ences. Similarly, Locker and Slade, 30
Locker, 23 and Dolan and Gooch 22
reported that age directly influences
esthetic self-perception. These authors
concluded that the level of criticism
increases in laypersons as they grow
older, independent of their sex.
CONCLUSIONS
From this study, the following conclusions
were drawn:
• More than half of the 12-year-old
Brazilian schoolchildren who took part
in this study had a DHC score indicat-
ing no/little need for treatment, where-
as a quarter had a high need/priority
for treatment.
• According to the EC, as evaluated by
an orthodontist, 8.1% of the children
had a high need/priority for treatment.
• The examiner was more critical in his
esthetic evaluation than were the chil-
dren. Girls, though, were more critical
in their esthetic self-perception than
boys.
• Increased overjet and crowding were
the most common occlusal features
defining the DHC categorization.
ACKNOWLEDGMENTS
The authors would like to thank Drs Kevin O’Brien
and William Shaw for their help with IOTN calibration.
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25. Ngom PI, Diagne F, Dieye F, Diop-Ba K, Thiam F.
Orthodontic treatment need and demand in
Senegalese school children aged 12–13 years.
Angle Orthod 2007;77:323–330.
26. Kiyak HA. Cultural and psychologic influences
on treatment demand. Semin Orthod 2000;6:
242–248.
27. Abu Alhaija ES, Al-Nimri KS, Al-Khateeb SN.
Orthodontic treatment need and demand in
12-14-year-old north Jordanian school children.
Eur J Orthod 2004;26:261–263.
28. Souames M, Bassigny F, Zenati N, Riordan PJ,
Boy-Lefevre ML. Orthodontic treatment need in
French schoolchildren: An epidemiological
study using the Index of Orthodontic Treatment
Need. Eur J Orthod 2006;28:605–609.
29. Gravely JF. A study of need and demand for
orthodontic treatment in two contrasting
National Health Service Regions. Br J Orthod
1990;17:287–292.
30. Locker D, Slade G. Oral health and the quality of
life among older adults: the oral health impact
profile. J Can Dent Assoc 1993;59:830–833.
311_Sharma.qxd 11/6/09 2:32 PM Page 311

Jagan Nath Sharma, BDS,

MDS (Orthodontics)1 EPIDEMIOLOGY OF MALOCCLUSIONS
AND ASSESSMENT OF ORTHODONTIC
TREATMENT NEED FOR THE POPULATION
OF EASTERN NEPAL
Aim: To evaluate the prevalence of malocclusions in eastern Nepal,
estimate the treatment need, and compare the findings with those of
other populations. Methods: Seven hundred patients between 7 and
48 years of age were evaluated. Their orthodontic treatment need was
assessed subjectively and via the Index of Orthodontic Treatment
Need (IOTN) (dental health component [DHC]). Dependency of the
subjective assessment grades and those of the IOTN (DHC) on sex
were checked with the chi-square test. Age and Angle class were
cross-tabulated to test for relationships using analysis of variance
(ANOVA). Results: The prevalence of Class I, II, and III were 67.5%,
28.8%, and 3.7%, respectively. The most common age group was 12 to
24 years. The female to male ratio was 2:1. The subjective assessment
indicated that treatment was indicated in 66.9%, urgently indicated in
30.9%, and not indicated in 2.2%. The IOTN (DHC) showed that 62.0%
had a severe/extreme need of treatment, 28.1% a moderate/border-
line need, and 9.9% little/no need. The mean age was not related to
any specific malocclusion. Also, there was no relationship among
sex, IOTN, and the subjective assessment grades (except for IOTN
grade 4, which was found significantly more frequently in females).
Conclusion: Class I malaoolusion is the most common, while Class III is
the least prevalent in eastern Nepal. The most prevalent age group
seeking treatment was that of 12 to 24 years of age, with more females
than males. The majority of those visiting the orthodontic department
actually needed treatment. World J Orthod 2009;10:311–316.

Key words: IOTN, DHC, epidemiology, treatment need, subjective

assessment

pidemiology of malocclusions and Malocclusions can be assessed with

1Associate
E assessment of orthodontic treatment
need is of national importance in many
various methods,20–25 but not one has
gained universal acceptance. The Index
Professor and Head,
Department Of Orthodontics, BP countries and were thus included in of Orthodontic Treatment Need (IOTN)
Koirala Institute of Health Sciences, numerous national-level health sur- was developed to grade malocclusions
Dharan, Nepal.
veys.1–16 These assessments are neces- on the basis of the significance of vari-
CORRESPONDENCE sar y to plan suf ficient treatment ous occlusal traits for dental health and
Dr Jagan Nath Sharma facilities and develop adequate training esthetic impairment.25 The IOTN incorpo-
Deparment of Orthodontics programs for respective specialists. rates a dental health component (DHC)
College Of Dental Surgery
Many studies reported on the general based on the recommendation of the
BP Koirala Institute of Health
Sciences prevalence of malocclusions in popula- Swedish Medical Board 24 and an
Dharan, Nepal tions, but only a few evaluated it in a esthetic component. 26 Being widely
Email: dr.jnsharma@yahoo.com referred population.17–19 accepted, the IOTN (DHC) was used in

311

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Sharma
Table 1 Age (in years) and sex
distribution
Sex n % Mean age
Males 253 36.1 18.5
Females 447 63.9 19.9
Total 700 100.0 19.5
n = number of patients; SD = standard deviation.
this study to identify the treatment need
of the eastern Nepalese population. Fur-
ther, the aims of this study were to esti-
mate the respective orthodontic treatment
need and compare these data with that of
other populations.
MATERIAL AND METHODS
This study was conducted after approval
by the Research Committee, BP Koirala
Institute of Health Sciences, Dharan,
Nepal. Consent was obtained from all
patients before recording their data. The
sample comprised 700 patients (447
females, 253 males) who were referred
from district and zonal hospitals of east-
ern Nepal to the Department of Ortho-
dontics at BP Koirala Institute of Health
Sciences. Their ages ranged from 7 to 48
years. All were permanent inhabitants of
Nepal. None had previously undergone
orthodontic treatment or suffered from
any systemic disease. A standard form
was prepared to record all relevant data.
Alginate impressions were taken and
plaster casts prepared to define Angle
classes, other occlusal traits, and the
IOTN. The IOTN (DHC) was used to assess
orthodontic treatment need. The treat-
ment need was also appraised subjec-
tively in three grades: grade 1, treatment
not required; grade 2, treatment
required; and grade 3, treatment urgently
required.
312
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Page 312
WORLD JOURNAL OF ORTHODONTICS
80
70 67.5
SD 60
50
5.7
%
40 28.8
5.7 30
5.8 20
10 3.7
0
Class I Class II Class III
Fig 1 Distribution of the malocclusion
according to the Angle classification.
All data were analyzed with SPSS soft-
ware (SPSS). The level of significance was
set at .05. To test the intraexaminer agree-
ment, the records of 150 patients were
reexamined 1 month after the initial exam-
ination and checked with kappa statistics.
The dependency of sex and IOTN (DHC) on
the subjective assessment grades were
tested with the chi-square test. Mean age
and the various Angle classes were cross-
tabulated, so they could be compared with
analysis of variance (ANOVA) for any signif-
icant relationship.
RESULTS
The mean age of the population was
18.5 ± 5.7 years for males and 19.9 ± 5.7
years for females (Table 1). The age was
categorized in four groups: younger than
12 years (10.5%), 12 to 24 years (76.7%),
24 to 36 years (11.7%), and older than
36 years (1.1%).
As demonstrated in Fig 1, 28.8% had
a Class II relationship, of which 22.0%
(154) were classified as Class II, Division
1, 4.1% (28) as Class II, Division 1 subdi-
vision, 2.7% (19) as Class II, Division 2,
and 3.7% (26) as Class III.
Three hundred four (43.4%) of the
67.5% (473) Class I patients had a
crowded dentition, 17.1% (120) an
incisor protrusion, 4.9% (34) an anterior
crossbite, 1.7% (12) a posterior crossbite,
and 0.4% (3) a mesial migration of their
posterior teeth.
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VOLUME 10, NUMBER 4, 2009 Sharma

60
53.1
50
40.7
40 35.7

30
%

27.0

20 16.4
12.0 10.7
10
3.7 4.4
2.0
0
Absent Super- Ectopic Midline Incisor Anterior Malformations Increased Deep Anterior
numerary eruption diastema crowding spacing overjet bite open bite

Fig 2 Distribution of various occlusal traits.

Table 2 Relationship between mean age

47.0
and malocclusions
50
40 Age (y) SD P
30 28.1
Class I (n = 473) 19.5 5.8 .79
%

20 15.0 Class II, Division 1 (n = 182) 19.3 5.3 .77

8.9 Class II, Division 2 (n = 19) 19.8 8.8 .80
10 Class III (n = 26) 4.3 0.2 .26
1.0
0 n = number of patients; SD = standard deviation.
Grade 1 Grade 2 Grade 3 Grade 4 Grade 5
No Little Moderate/ Severe Extreme
need of need of borderline treatment treatment
treatment treatment need of need need
treatment

Fig 3 Treatment need as per IOTN (DHC).

Other occlusal traits were absent
teeth 12% (84), supernumerary teeth
3.7% (26), ectopic eruption 10.7% (75),
midline diastema 16.4% (115), maxillary/
mandibular incisor crowding 53.1% (372),
anterior spacing 27.0% (189), malforma-
tions 2.0% (14), increased overjet (> 4 mm)
40.7% (285), anterior open bite 4.4%
(31), and deep bite (> 4 mm) 35.7% (250)
(Fig 2).
The IOTN (DHC) showed the following
distribution: grade 1, 1.0% (7); grade 2,
8.9% (62); grade 3, 28.1% (197); grade 4,
47.0% (329); and grade 5, 15.0% (105)
(Fig 3). Subjective assessment of ortho-
dontic treatment need showed that treat-
ment was required in 66.9% (468),
urgently required in 30.9% (216), and not
required in 2.2% (16).
There was no significant relationship
between age and the various Angle
classes (Table 2). The same was true for
the relationship between sex and the IOTN
(DHC) and the subjective assessment

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Sharma WORLD JOURNAL OF ORTHODONTICS

Table 3 Relationship between the IOTN (DHC) grades Table 4 Relationship between the grades of
and both sexes subjectively assessed treatment need and sexes
Grade Females Males Total % P
P (chi-
square 1 (Treatment not required) 10 6 16 2.2 .42
IOTN (DHC) Females Males Total % test) 2 (Treatment required) 300 168 468 66.9 .46
3 (Treatment urgently required) 137 79 216 30.9 .51
Grade 1: no need of treatment 5 2 7 1.0 .51
Total 447 253 700 100.0
Grade 2: little need of treatment 41 21 62 8.9 .41
Grade 3: moderate/borderline need 133 64 197 28.1 .12
Grade 4: severe treatment need 198 131 329 47.0 .03*
Grade 5: extreme treatment need 70 35 105 15.0 .30
Total 447 253 700 100

* = significant.

grades except for IOTN grade 4, which was
significantly (.03) more frequent in
females (Tables 3 and 4).
The kappa value for the intraexaminer
variability was 0.90, indicating a high
agreement among repeated observations.
DISCUSSION
The distribution of malocclusions among
patients living in eastern Nepal who were
referred for orthodontic treatment had
not yet been reported in the literature.
Sari18 evaluated 1,602 Turkish patients
and showed that 61.7% of them had a
Class I; 25.1% a Class II, Division 1; 3.2%
a Class II Division 2; and 10.2% a Class
III. Thus, the frequency of Class I occlu-
sions was lower than in the present
study, whereas that of Class IIIs was con-
siderably higher. Proffit et al1 reported
that 30.0% of their sample had a normal
occlusion 50.0% a Class I, 15.0% a Class
II, and 1.0% a Class III. Lew et al16 evalu-
ated 1,050 Chinese children and stated
that 7.1% had a normal occlusion; 58.8%
a Class I malocclusion; 18.8% a Class II,
Division 1; 2.7% a Class II, Division 2;
and 12.6% a Class III. Sayin et al 17 stud-
ied 1,356 patients and found in 64.0% a
Class I, in 19.0% a Class II, and in 12% a
Class III. The difference in the frequency
of the various Angle classes in all these
studies can mainly be explained by differ-
ences in sample size and ethnicity.
In this study, congenitally missing
teeth mainly involved lateral incisors.
Supernumerary teeth occurred mostly in
the form of mesiodens. Ectopic eruption
was most often observed in maxillary
canines and lateral incisors but also in
mandibular premolars. Midline diastemas
were typically associated with fibrous
frenum. Malformed teeth were usually
peg-shaped lateral incisors.
Ucuncu et al27 pointed out that 4.8% of
referred Turkish patients had a slight or
no need for treatment, 12.0% a moderate
need, and 83.2% a great need of treat-
ment. Brook and Shaw25 studied the IOTN
(DHC) in 222 individuals and found the
following distribution for treatment need:
no need 5.9%, moderate need 19.7%,
and great need 74.4%. In a study of
1,025 patients by Richmond et al, 28
the respective numbers were 3.0%,
19.0%, and 78.0%. A similar distribution
was observed by Firestone et al29 in 95
persons (4.1%, 14.3%, and 81.6%). Over-
all, the results of this investigation are
quite comparable with those of previous

314

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VOLUME 10, NUMBER 4, 2009 Sharma

Table 5 Treatment need according to the IOTN (DHC)

in referred populations studied by various authors
No/little Moderate Great
Author Country n need (%) need (%) need (%)

Brook and Shaw25 England 222 5.9 19.7 74.4

Richmond et al28 England 1,025 3.0 19.0 78.0
Firestone et al29 Switzerland 95 4.1 14.3 81.6
Ucuncu et al27 Turkey 250 4.8 12.0 83.2
Present study Nepal 700 9.9 28.1 62.0

n = number of patients.

publications, though the number of sub-
jects urgently requiring treatment was
somewhat lower (Table 5).
The subjective assessment of treat-
ment need in this study by categorizing
three grades was felt to be a more realistic
approach to assess the severity of existing
malocclusions and to determine treatment
priority. Besides this, the results of the
subjective assessment and the IOTN
(DHC) ratings are very comparable.
The age group of 12 to 24 years was
the most frequent, which seems to be a
consequence of a high self-consciousness
for esthetics, ie, the motivation of these
individuals for seeking orthodontic treat-
ment was the greatest. The same motiva-
tion might apply when females sought for
orthodontic treatment approximately two
times more frequently than males. Also,
parental motivation due to social reasons
might explain this difference.
CONCLUSION
Angle Class I was the most prevalent and
Class III the least common occlusal trait
in this study. The most prevalent age
group seeking orthodontic treatment was
that of 12 to 24 years. Females showed
more interest than males for orthodontic
treatment. The IOTN (DHC) showed that
62.0% had a great need for treatment,
28.1% had a borderline need, and 9.9%
little or no need of treatment. Subjective
assessment showed that most of the
patients who visited the orthodontic
department required treatment. Subjec-
tive assessment seems to be a more
realistic and easy approach to determine
treatment necessity. The percentage of
individuals with a high need for orthodon-
tic treatment in eastern Nepal draws spe-
cial attention to the arrangement of
treatment facilities and trained orthodon-
tists in this region.
ACKNOWLEDGMENTS
The author thanks his teacher Prof R.K. Singh for
helping to approve this study; Mr D.D. Baral for his
statistical analysis; and Drs Mamta Dali, Dilip Das,
and Kundan Singh and Mr Youbaraj Bajgain and
departmental staff for their valuable support. The
author would also like to express his sincere grati-
tude to the Research Committee, BP Koirala Insti-
tute of Health Sciences, Dharan, Nepal, for
approval and funding of this research project (no.
Aca.667/061/062, dated March 21, 2005,
research code 15/13).

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Sharma WORLD JOURNAL OF ORTHODONTICS

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8. Ghabrial E, Wiltshire WA, Zietsman ST, Viljoen E.
25. Brook PH, Shaw WC. The development of an
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317_Uslu.qxd 11/6/09 2:33 PM Page 317

Özge Uslu, DDS, PhD1

LONG-TERM FOLLOW-UP OF PATIENTS
M. Okan Akcam, DDS,
PhD2 WITH A SKELETAL ANGLE CLASS III
RELATIONSHIP TREATED WITH CHIN CAPS
Aim: To evaluate the long-term result of chin-cap treatment in
patients with a skeletal Angle Class III relationship due to mandibular
prognathism. Material and Methods: Records of nine patients (five
girls and four boys) with a mean age of 10.8 ± 1.6 years at the start of
treatment were retrieved from the archives. The records comprised
lateral cephalograms, intra- and extraoral photographs, and dental
casts. The subjects were recalled at 6.1 ± 1.5 years after the comple-
tion of active orthodontic treatment. Cephalometric measurements
from the treatment’s beginning (T1), end (T2), and follow-up (T3)
were calculated by using PorDios software. Subjects with a positive
overjet at T3 were grouped as stable, and those with a negative over-
jet were grouped as relapse. Differences between the two groups
were analyzed by repeated measures analysis of variance (ANOVA)
and the Duncan test. Results: Five individuals maintained a positive
overjet at T3, while four relapsed as indicated by a negative overjet.
SNA increased in the stable group between T2 and T3 but not in the
relapse group. Conclusion: About half of the young individuals with a
mandibular prognathism treated with a chin cap relapsed over time.
The relapse seemed to originate from skeletal rather than dentoalve-
olar changes. World J Orthod 2009;10:317–322.

Key words: chin cap, follow-up, long-term observation, skeletal Angle

Class III relationship

1Research Assistant, Department of
Orthodontics, School of Dentistry,
Ankara University, Ankara, Turkey.
2Associate Professor, Department of
Orthodontics, School of Dentistry,
Ankara University, Ankara, Turkey.
CORRESPONDENCE
Dr Özge Uslu
Department of Orthodontics
School of Dentistry
Ankara University
Besevler 06500
Ankara, Turkey
Email: osgeuslu@gmail.com
or many years after its introduction
F by Amos Westcott in the 1840s,1–11
chin-cap therapy was one treatment
alternative in patients with mandibular
prognathism. Age and related skeletal
growth are important factors for suc-
cessful treatment with a chin cap.
Another influencing factor is patient
cooperation, as are the direction and
amount of the applied force.
Mitani and Sakamoto5 showed that if
used properly, chin-cap therapy can be
effective within certain limits. Decisive
are the long-term results from an ortho-
pedic correction of skeletal Class IIIs,
about which repor ts are still fairly
sparse.2,3,6,8-12 Uner at al13 found that
even after 4 years of chin-cap therapy,
relapse is still a possibility.
Consequently, the aim of this study
was to evaluate the long-term results of
treatment with chin caps in patients with
a skeletal Angle Class III relationship
due to mandibular prognathism.
MATERIALS AND METHODS
Fifty-five individuals with a skeletal Angle
Class III were randomly selected from
the archives of the orthodontic depart-
ment of the Ankara University and
invited for a follow-up visit. Only nine per-
sons (five girls, four boys) responded
and agreed to be involved in this study.
The mean age of these subjects was
10.8 ± 1.6 years at the beginning of
treatment. They all were treated with

317

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317_Uslu.qxd 11/6/09 2:33 PM Page 318
Uslu/Akcam
Fig 1 Patient from the stable group; (left) pretreatment, (center) posttreatment, and (right) long-term follow-up extra- and
intraoral photographs.
chin caps and comprehensive fixed appli-
ances. The mean treatment duration was
3.3 ± 1.1 years. The applied chin caps
exerted a force of 500 cN and were to be
used at least 16 hours per day. For reten-
tion, Hawley-type retainers were worn full-
time in both arches with a chin cap at
night for at least 1 year.
From all participating individuals of
this follow-up, lateral cephalograms,
intra- and extraoral photographs, and
dental casts were obtained. This
occurred on average 6.1 ± 1.5 years after
orthodontic treatment. The respective
records were taken according to the prin-
ciples outlined in the Declaration of
Helsinki, and an informed consent form
was signed by each person.
Cephalometric parameters from the
beginning (T1) and end (T2) of treatment,
as well as the follow-up (T3), were calcu-
lated using PorDios software (Purpose on
Request Digitizer Input Output System).
The study casts were inspected for pre-
sent overjet. Patients who had a positive
overjet were classified as stable and
318
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WORLD JOURNAL OF ORTHODONTICS
those with a negative overjet as relapse.
Changes between the groups were ana-
lyzed by repeated measures analysis of
variance (ANOVA) and the Duncan test.
RESULTS
Five individuals maintained a positive
overjet (Fig 1), while four showed relapse
(Fig 2). Changes of their cephalometric
variables are shown in Fig 3 and Table 1.
SNA showed an increase in both
groups from T1 to T3 (P < .05). It
increased further in the stable group
from T2 to T3 but not in the group with
relapse. SNB showed a slight increase in
both groups from T2 to T3. However, it
was larger in the relapse (76.8 degrees to
79.3 degrees) than in the stable group
(79.8 degrees to 80.4 degrees). From T2
to T3, ANB showed a decrease in the
relapse group (1.5 degrees to –1.3
degrees), in contrast to the stable group
(1.6 degrees to 2.3 degrees). SND
showed a significant difference (P < .001)
317_Uslu.qxd 11/6/09 2:33 PM Page 319

VOLUME 10, NUMBER 4, 2009 Uslu/Akcam

Fig 2 Patient from the relapse group; (left) pretreatment, (center) posttreatment, and (right) long-term follow-up extra- and
intraoral photographs.

from T1 to T3 with a larger increase in

the relapse than in the stable group.
From T2 to T3, SN-GoGn decreased in
the stable group, but it did not change in
the relapse group. SN-OcP decreased in
both groups from T2 to T3 (P < .01). N
S
UI-NA increased significantly (P < .01)
in both groups from T1 to T2. LI-NB was
similar between T1 and T2 in the stable
group, whereas it increased significantly
A
(P < .05) from 3.0 mm to 4.9 mm in the
group with relapse. Go LI
UI
Lower lip-soft tissue line measurement
decreased from T1 to T3 in both groups B
D
and in the total study sample (P < .05).
Gn

Fig 3 Cephalometric landmarks used in

DISCUSSION this study: S = sella, N = nasion, A = A
point, UI = upper incisor tip, LI = lower
incisor tip, B = B point, D = geometrical
The major variable that determines long- midpoint of symphysis, Go = gonion, Gn =
term success with chin-cap therapy is the gnathion.
amount and direction of mandibular
growth during and after adolescence.
According to many authors, 14–18 the
length of the mandible is fundamental
for long-term success or failure.

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Table 1 Cephalometric measurements (means and standard deviations), ANOVA,

and Duncan test for the three time points
T1 T2 T3 P

SNA (degrees)
Stable 80.2 ± 3.4 81.4 ± 3.8 82.7 ±3.3 **
Relapse 76.6 ± 2.1 78.3 ± 1.5 78.0 ± 3.2
Total b 78.6 ± 3.3 a 79.8 ± 3.2 a 80.6 ± 3.9

SNB (degrees)
Stable 79.3 ± 4.6 79.8 ± 4.3 80.4 ± 3.5 NS
Relapse 77.8 ± 3.5 76.8 ± 2.8 79.3 ± 3.6
Total 78.6 ± 4.0 78.4 ± 3.8 79.9 ± 3.4
ANB (degrees)
Stable 0.9 ± 1.9 1.6 ± 2.5 2.3 ± 2.0 NS
Relapse –1.1 ± 2.6 1.5 ± 2.1 –1.3 ± 2.6
Total –0.1 ± 2.4 1.6 ± 2.2 0.7 ± 2.8
SND (degrees)
Stable 75.3 ± 4.0 76.2 ± 3.3 77.4 ± 3.8 ***
Relapse 74.3 ± 4.1 75.5 ± 3.1 77.5 ± 3.4
Total c 74.8 ± 3.8 b 75.8 ± 3.0 a 77.4 ± 3.4

SN-OcP (degrees)
Stable 21.4 ± 7.2 18.0 ± 6.8 15.8 ± 3.3 *
Relapse 19.0 ± 4.0 17.5 ± 1.7 16.5 ± 2.4
Total a 20.3 ± 5.8 b 17.8 ± 4.9 b 16.1 ± 2.8

SN-GoGn (degrees)
Stable 37.2 ± 5.3 35.8 ± 8.0 34.4 ± 8.6 NS
Relapse 38.0 ± 7.0 39.2 ± 7.0 39.2 ± 6.9
Total 37.5 ± 5.7 37.3 ± 7.3 36.6 ± 7.8
UI-NA (mm)
Stable 2.3 ± 1.9 5.0 ± 2.0 4.1 ± 1.6 **
Relapse 3.0 ± 1.2 6.3 ± 1.7 6.1 ± 2.9
Total b 2.7 ± 1.5 a 5.6 ± 1.9 a 5.1 ± 2.3

UI-NA (degrees)
Stable 24.0 ± 6.4 23.0 ± 3.9 24.8 ± 5.5 NS
Relapse 23.5 ± 5.7 28.5 ± 2.9 26.5 ± 5.2
Total 23.8 ± 5.7 25.4 ± 4.3 25.5 ± 5.1
LI-NB (mm)
Stable a 4.9 ± 1.9 a 4.1 ± 2.6 a 4.4 ± 3.2 **
Relapse b 3.0 ± 2.4 a 4.9 ± 3.1 ab 3.9 ± 3.6
Total 4.0 ± 2.2 4.4 ± 2.7 4.2 ± 3.1
LI-NB (degrees)
Stable 25.2 ± 5.8 25.0 ± 6.3 22.8 ± 8.0 NS
Relapse 18.7 ± 4.6 22.2 ± 2.9 18.0 ± 5.8
Total 22.3 ± 6.0 23.8 ± 5.0 20.7 ± 7.1
Pg-NB (mm)
Stable 0.3 ± 0.7 1.2 ± 1.0 0.4 ± 1.8 NS
Relapse 1.4 ± 2.3 2.4 ± 2.1 2.9 ± 2.9
Total 0.8 ± 1.6 1.7 ± 1.6 1.5 ± 2.5
UI-LI (degrees)
Stable 126.3 ± 10.1 128.8 ± 7.7 130.0 ± 10.3 NS
Relapse 137.5 ± 8.9 129.2 ± 9.8 137.0 ± 11.4
Total 131.3 ± 10.8 129.0 ± 8.0 133.1 ± 10.8
Holdaway difference (mm)
Stable 4.6 ± 2.1 2.9 ± 3.5 4.0 ± 4.7 NS
Relapse 1.6 ± 4.5 2.5 ± 4.9 1.0 ± 6.4
Total 3.3 ± 3.5 2.7 ± 3.9 2.7 ± 5.4
Upper lip-soft tissue line (mm)
Stable –1.4 ± 1.3 –0.5 ± 1.6 –0,8 ± 1.3 NS
Relapse –2.9 ± 3.5 –1.8 ± 2.5 –3.0 ± 2.4
Total –2.1 ± 2.5 –1.1 ± 2.0 –1.8 ± 2.1
Lower lip-soft tissue line (mm)
Stable 1.2 ± 0.8 0.7 ± 1.1 –0.4 ± 1.1 **
Relapse 0.1 ± 2.3 1.5 ± 3.0 –0.5 ± 2.9
Total a 0.7 ± 1.6 a 1.1 ± 2.0 b –0.4 ± 1.9

NS = not significant; *P < .01; **P < .05; ***P < .001. Groups (T1-T2-T3) with different letters are signifi-
cantly different from one another.

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VOLUME 10, NUMBER 4, 2009
In their study, Uner et al 13 saw the
return of the original skeletal pattern
after chin-cap removal. Somewhat in con-
trast to this, Ferro et al12 observed that
on average, 9 years after treatment, only
six of 52 patients had a clinical relapse
(overjet ≤ 0). This is a significantly lower
rate than in the current study. Ferro et al
noted that Wits appraisal, ANB, SNB, and
overbite were the best predictors of
relapse. They suggested that long-term
stability can be enhanced by a deep over-
bite and an optimal skeletal correction.
Other authors also feel that the degree of
overbite is an important factor when pre-
dicting relapse.3,9–10
According to Baccetti et al, the cranial
base angle is central.15 An acute angle
could project the mandible forward and
thus favor treatment failure. Other para-
meters of the discriminant function of
Baccetti et al are mandibular length and
ramus height. Their equation success-
fully identified 83% of the sample from
which it was derived. The discriminant
function derived by Ghiz et al18 identified
the sagittal position of the mandible rela-
tive to the cranial base, mandibular
length, ramus height, and gonial angle as
key indicators.
Patient age has also to be considered
because significant skeletal corrections
can only be achieved in young patients.
That is why some suggest19 starting chin
cap therapy before the age of 9 years.
Age could explain the relatively high
relapse rate in the current study in which
the mean patient age at the start of treat-
ment was 10.8 years. However, others20
observed no significant difference in the
skeletal profiles after chin-cap applica-
tion at the age of 7 and 11 years.
Wells et al 14 investigated the long-
term result of reverse-pull headgear in
prognathic children (early mixed dentition
stage) with an anterior crossbite. They
reported 25% to 30% relapse in overjet
after at least 5 years posttreatment. Late
horizontal mandibular growth was sug-
gested as a reason for relapse. They fur-
ther concluded that up to an age of 10
years, the time at which reverse-pull
headgear treatment begins is not a major
factor in maintaining a positive overjet in
the long term. Still, treatment should
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Uslu/Akcam
start quite early relative to most other
skeletal problems. Baccetti et al 16
reported that maxillary skeletal changes
are most likely in children younger than
8 years of age.
In the current study, SNA, ie, maxillary
protrusion, increased in only the stable
group. Therefore, it can be speculated
that the stimulation of forward maxillary
development could be meffective in pre-
venting long-term relapse.
The results of this study should be
interpreted with caution because of the
relatively small sample. However, all fol-
low-up investigations are difficult, espe-
cially as the time after orthodontic treat-
ment increases.
CONCLUSION
Half of the individuals with mandibular
prognathism treated with a chin cap
showed relapse at a follow-up investiga-
tion. This relapse seems to originate from
skeletal rather than from dentoalveolar
changes. It can be hypothesized that
stimulation of maxillary forward growth is
important to prevent relapse in skeletal
Class III patients.
REFERENCES
1. Wahl N. Orthodontics in 3 millennia. Chapter 2:
Entering the modern era. Am J Orthod Dentofa-
cial Orthop 2005;127:510–515.
2. Deguchi T, Kuroda T, Minoshima Y, Graber TM.
Craniofacial features of patients with Class III
abnormalities: Growth-related changes and
effects of short-term and long-term chincup
therapy. Am J Orthod Dentofacial Orthop 2002;
121:84–92.
3. Battagel JM. Predictors of relapse in orthodon-
tically-treated Class III malocclusions. Br J
Orthod 1994;21:1–13.
4. Moon YM, Ahn SJ, Chang YI. Cephalometric pre-
dictors of long-term stability in the early treat-
ment of Class III malocclusion. Angle Orthod
2005;75:747–753.
5. Mitani H, Sakamoto T. Chin cap force to a grow-
ing mandible. Long-term clinical reports. Angle
Orthod 1984;54:93–122.
6. Sugawara J, Mitani H. Facial growth of skeletal
Class III malocclusion and the effects, limita-
tions, and long-term dentofacial adaptations
to chincap therapy. Semin Orthod 1997;3:
244–254.
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7. Danaie SM, Salehi P. Cephalometric evaluation
of class-III patients with chin cap and tongue
guard. J Indian Soc Pedod Prev Dent 2005;23:
63–66.
8. Arat ZM, Akçam MO, Gökalp H. Long-term effects
of chin-cap therapy on the temporomandibular
joints. Eur J Orthod 2003;25:471–475.
9. Abu Alhaija ES, Richardson A. Long-term effect
of the chincap on hard and soft tissues. Eur J
Orthod 1999;21:291–298.
10. Wendell PD, Nanda R, Sakamoto T, Nakamura
S. The effects of chin cup therapy on the
mandible: A longitudinal study. Am J Orthod
1985;87:265–274.
11. Ritucci R, Nanda R. The effect of chin cup ther-
apy on the growth and development of the cra-
nial base and midface. Am J Orthod Dentofa-
cial Orthop 1986;90:475–483.
12. Ferro A, Nucci LP, Ferro F, Gallo C. Long-term sta-
bility of skeletal Class III patients treated with
splints, Class III elastics, and chincup. Am J
Orthod Dentofacial Orthop 2003;123:423–434.
13. Uner O, Yuksel S, Ucuncu N. Long-term evalua-
tion after chincap treatment. Eur J Orthod
1995;17:135–141.
14. Wells AP, Sarver DM, Proffit WR. Long-term effi-
cacy of reverse pull headgear therapy. Angle
Orthod 2006;76:915–922.
15. Baccetti T, Franchi L, McNamara JA Jr. Cephalo-
metric variables predicting the long-term suc-
cess or failure of combined rapid maxillary
expansion and facial mask therapy. Am J
Orthod Dentofacial Orthop 2004;126:16–22.
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WORLD JOURNAL OF ORTHODONTICS
16. Baccetti T, McGill JS, Franchi L, McNamara JA
Jr, Tollaro I. Skeletal effects of early treatment
of Class III malocclusion with maxillary expan-
sion and face-mask therapy. Am J Orthod
Dentofacial Orthop 1998;113:333–343.
17. Westwood PV, McNamara JA Jr, Baccetti T,
Franchi L, Sarver DM. Long-term effects of
Class III treatment with rapid maxillary expan-
sion and facemask therapy followed by fixed
appliances. Am J Orthod Dentofacial Orthop
2003;123:306–320.
18. Ghiz MA, Ngan P, Gunel E. Cephalometric vari-
ables to predict future success of early ortho-
pedic Class III treatment. Am J Orthod Dentofa-
cial Orthop 2005;127:301–306.
19. Neuman D. Treatment of true progenua in the
decidious dentition. Transactions of the Euro-
pean Orthodontic Society 1970;213–223.
20. Ülgen M. Ortodontik Tedavi Prensipleri (Ortho-
dontic treatment principles) [thesis]. Ankara:
Ankara Üniversitesi Basımevi, 1983.
21. Sakamoto T. Effective timing for the application
of orthopedic force in the skeletal class III mal-
occlusion. Am J Orthod 1981;80:411–416.
22. Sugawara J, Asano T, Endo N, Mitani H. Long-
term effects of chincap therapy on skeletal pro-
file in mandibular prognathism. Am J Orthod
Dentofacial Orthop 1990;98:127–133.
323_Farret_.qxd 11/6/09 3:45 PM Page 323

Milton M.B. Farret, DDS,

MSD1 STRATEGIES TO FINISH ORTHODONTIC
Marcel M. Farret, DDS, TREATMENT WITH A CLASS III MOLAR
MSD2

Alessandro M. Farret, DDS3

RELATIONSHIP: THREE PATIENT REPORTS
The purpose of this article is to review treatment concepts for
patients with congenitally missing teeth in the mandible, for patients
in whom teeth in only the mandibular arch were extracted, or for
patients with Class III camouflage treatment. The therapy result in
these situations is a Class III molar relationship. With this type of
intercuspation, esthetic and functional aspects must be observed.
World J Orthod 2009;10:323–333.

Key words: Class III molar relationship, camouflage treatment, intercus-

pation, uniarch extraction, orthodontic finalization

he existing concept of normal occlu- The extraction of two mandibular premo-

1Professor and Chair, Department of
Orthodontics, Universidade Federal
de Santa Maria—RS; PhD Student,
Pontifícia Universidade Católica, RS;
Santa Maria, Brazil.
2PhD Student, Department of Ortho-
dontics, Pontifícia Universidade
Católica—RS, Porto Alegre, Brazil.
3MSD Student, Department of Oral
and Maxillofacial Surgery, Pontifícia
Universidade Católica—RS, Porto
Alegre, RS, Brazil.
CORRESPONDENCE
Dr Marcel Marchiori Farret
1000/113 Floriano Peixoto St.
Downtown, Santa Maria,
Rio Grande do Sul
Brazil 97015-370
Email: marcelfarret@yahoo.com.br
T sion in orthodontics calls for the first
molars occluding in a Class I relation-
ship, which ensures ideal intercuspation
of all posterior teeth. However, nearly
45% of patients who seek orthodontic
treatment demonstrate a Class II or III
molar relationship.1 These malocclusions
can be of dental or skeletal origin. If they
are of skeletal origin and the patient still
has some potential for growth, he can be
treated with orthopedic appliances,
which will influence the development of
the basal bones, as well as dentoalveolar
remodeling, simultaneously leading to a
dental Class I relationship. However, in
adult patients, mainly those with Class III
occlusions, the involvement of orthodon-
tics and orthognathic surgery is often
necessary to accomplish a satisfactory
treatment outcome. If, on the other
hand, the skeletal deformity is only mod-
erate or the malocclusion is solely of
dentoalveolar origin, the possibility of
camouflage exists.2–4
In a patient with a Class II relation-
ship, extraction of two maxillary teeth,
generally the first premolars, is often the
therapy of choice because it reduces
treatment time and allows for an excel-
lent esthetic and functional finish. 5
When dealing with a Class III occlusion,
orthodontists become more cautious:
lars could lead to a Class III molar rela-
tionship at the end of treatment, ie, the
mandibular first molar will occlude with
two maxillary premolars, leading to a
somewhat awkward intercuspation due to
the dissimilar cusp configuration. Thus,
the involved teeth have to be reshaped by
either grinding or restoration.6
Camouflaging with extractions in the
mandible can be indicated for certain
patients with a Class III, but a similar sit-
uation will evolve in patients with tooth
agenesis in only the mandibular arch.
Agenesis of mandibular premolars
occurs in about 3% of the population.7 If
a patient with missing mandibular teeth
presents with a convex profile, a Class II
relationship, excessive incisor protrusion,
and increased overjet, the orthodontist
may consider extracting two maxillary
premolars to compensate for the missing
ones in the mandible, thus ending with a
Class I relationship. However, if the afore-
mentioned situation is not present,
extraction of maxillary premolars is con-
traindicated and treatment will finish
with the molars in a Class III relationship.
Subsequently, three patients are
presented in whom the mandibular pre-
molars were extracted or genetically
missing, leading at the end of therapy to
a Class III molar relationship.

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Farret et al
CLINICAL EXAMPLES
Patient CG
Patient CG was a 13-year-old male who
had congenitally missing mandibular sec-
ond premolars. His facial appearance
was very agreeable. He presented with a
Class I molar relationship and excellent
maxillary incisor inclination (Figs 1 and
2). The patient was treated using a stan-
dard edgewise technique, no extraction
of maxillary premolars, and space clo-
sure in the mandibular arch by moving
the mandibular molars mesially.
Treatment with extraction of the first or
second maxillary premolars was con-
traindicated because it would have nega-
tively affected the incisor inclination and
the patient’s facial profile.
With the aforementioned approach, the
patient’s facial profile was maintained,
even though his chin showed accentuated
growth. At the completion of therapy, the
patient had an excellent Class I canine
and a Class III molar relationship (Fig 3)
with parallel roots of all his posterior teeth
(Fig 4). Figure 5 shows the patient
13 years posttreatment. The treatment
result was stable and all tissue healthy.
Patient MT
Patient MT was a 17-year-old male whose
mandibular first premolars were
extracted. The patient showed an exces-
sive projection of the lower lip. The molar
and canine relationships were Class III
with an edge-to-edge incisal relationship
(Figs 6 and 7). The treatment plan fore-
saw the extraction of the mandibular first
premolars to retract the mandibular
incisors without anchorage loss, thus
improving the profile, establishing a cor-
rect incisor relationship, and finishing
with the canines in a Class I and the
molars in a Class III relationship.
An alternative would have been to
extract the mandibular second premolars.
However, this approach would have cer-
tainly resulted in a greater loss of anchor-
age and therefore in less retraction of the
incisors. It would have also been more dif-
324
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WORLD JOURNAL OF ORTHODONTICS
ficult to establish a correct overjet and
overbite, as well as resulting in less
reduction of the lower lip projection.
At the end of treatment, the profile
was considerably improved due to retrac-
tion of the incisors and the subsequent
uprighting of the lower lip. The intraoral
photographs document an optimal inter-
cuspation with the canines in Class I and
the molars in Class III occlusion (Fig 8).
The final panoramic radiograph reveals
root parallelism, and the lateral cephalo-
gram exhibits the repositioning of the
mandibular incisors as a remodeling of
the mandibular symphysis (Fig 9).
Patient RL
Patient RL was a 14-year-old male in
whom the mandibular right second pre-
molar was absent. This patient shows a
straight profile with pleasant facial fea-
tures. The molar relation was Class I on
the left and Class III on the right side. The
canines were Class I on the right and
slightly Class II on the left side due to a
deviation of the mandibular midline to the
left. Besides an agenesis of the mandibu-
lar right second premolar, the patient pre-
sented with a retention cyst of his
mandibular left second premolar (Figs 10
and 11). The patient was again treated
with the standard edgewise technique.
The cyst of the left second premolar was
surgically removed and the tooth aligned
within the arch, establishing a Class I
molar relationship on this side. The space
of the right second premolar was closed
by mesial movement of the posterior seg-
ment, resulting in a Class III molar rela-
tionship.
Nowadays, a viable alternative treat-
ment for this patient would be the place-
ment of an implant. However, this patient
was treated about 15 years ago when
implant use was still arguable. The final
result of this treatment is shown in Fig
12. The panoramic radiograph reveals
correct root parallelism (Fig 13). Figure
14 depicts the patient 14 years posttreat-
ment with excellent stability and optimal
tissue health.
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VOLUME 10, NUMBER 4, 2009 Farret et al

Fig 1 Patient CG. A 13-year-old male

with persisting primary second molars,
agreeable facial appearance, Class I
molar relationship, and physiologic max-
illary incisor inclination.

Fig 2 Patient CG. Cephalogram and panoramic radiograph at the beginning of treatment revealing normal maxillary incisor
inclination and congenitally missing mandibular second premolars.

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Farret et al WORLD JOURNAL OF ORTHODONTICS

Fig 3 Patient CG. Extra- and intraoral

appearance of patient at the end of
treatment. The profile was maintained
despite some remarkable chin growth;
excellent Class I canine and a Class III
molar relationship are visible.

Fig 4 Patient CG. Cephalogram and panoramic radiograph at the end of treatment revealing normal maxillary incisor inclination
and good root parallelism of all posterior teeth.

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323_Farret_.qxd 11/6/09 3:45 PM Page 327
VOLUME 10, NUMBER 4, 2009
Fig 5 Patient CG. Thirteen years post-
treatment showing a stable result and
healthy tissue.
DISCUSSION
Angle 8 advocated that all treatments
should finish with a Class I molar relation-
ship. Since extractions were introduced in
orthodontics, principally by Tweed,9 the
sagittal relationship of the molars has
lost importance. Today, professionals
emphasize the canine relationship more,
which is considered fundamental for func-
tion. This gives orthodontists increased
therapy options.
In a Class III relationship, the man-
dibular first molar occludes with both
maxillary premolars. The anatomy of
these teeth can hamper occlusion, and
adjustments with first and third order
bends should therefore take place.6,10 In
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Farret et al
all three patients, the mandibular first
molars were positioned more lingually
than usual, ie, without an offset, as
when finished in a Class I relationship. In
addition, the maxillary premolars and
molars received accentuate offsets with
no toe-in for the first molar. To further
improve the occlusal contacts, special
care should be taken vis a vis the incli-
nation of the posterior teeth. The
mandibular molars may receive accentu-
ated lingual crown inclination, whereas
the palatal inclination of the maxillary
molars and premolars can be reduced.
Even then, intercuspation is some-
times compromised and some recontour-
ing is indicated. This includes reducing
the palatal cusps of the maxillary premo-
327
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Farret et al WORLD JOURNAL OF ORTHODONTICS

Fig 6 Patient MT. A 17-year-old male

with excessive lower lip projection,
Class III occlusion, and edge-to-edge
incisor relationship. Situation prior to
extraction of mandibular first premolars
to maximally retract mandibular incisors
for improvement of profile and incisor
relationship.

Fig 7 Patient MT. Cephalogram and panoramic radiograph at the beginning of treatment revealing bimaxillary protrusion and
congenitally missing maxillary third molars.

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VOLUME 10, NUMBER 4, 2009 Farret et al

Fig 8 Patient MT. Extra- and intraoral

appearance of patient at the end of
treatment. Considerable profile
improvement due to incisor retraction
and subsequent uprighting of the lower
lip. Optimal intercuspation with canines
in Class I occlusion and molars in Class
III occlusion.

Fig 9 Patient MT. Cephalogram and panoramic radiograph at the end of treatment revealing repositioning of the mandibular
incisors, remodeling of the mandibular symphysis, and good root parallelism.

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Farret et al WORLD JOURNAL OF ORTHODONTICS

Fig 10 Patient RL. A 14-year-old male

with large spaces between the
mandibular first premolars and first
molars, straight profile with pleasant
facial features, Class I molar relation-
ship on the left side and Class III on the
right side, and Class I canines on the
right and slightly Class II on the left side
due to mandibular midline deviation to
the left.

Fig 11 Patient RL. Cephalogram and

periapical radiograph at the beginning of
treatment revealing agenesis of the
mandibular right second premolar and
retention cyst of the mandibular left
second premolar.

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VOLUME 10, NUMBER 4, 2009 Farret et al

Fig 12 Patient RL. Extra- and intraoral

appearance of patient at the end of
treatment showing a straight profile,
Class I canine and a Class III molar rela-
tionship, as well as midline correction.

Fig 13 Patient RL. Panoramic radi-

ograph at the end of treatment reveal-
ing good root parallelism of posterior
teeth.

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323_Farret_.qxd 11/6/09 3:46 PM Page 332
Farret et al
lars and molars or the augmentation of
the buccal cusps of the mandibular
molars with restorative material.6,10
According to Hisano and Soma, 11
masticatory efficiency is not severely
reduced in a Class III molar relationship.
In addition, Bakke 12 ascribes the
occlusal force more to the number and
quality of occlusal contacts than to the
sagittal relationship between the poste-
rior teeth. Therefore, regardless of the
molar relationship at the end of treat-
ment, orthodontists should always strive
for an excellent intercuspation.
In camouflage therapy of patients with
a Class III occlusion, orthodontists can
opt for extraction of the mandibular first
or the second premolars. Second premo-
lars should be the chosen when:
332
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WORLD JOURNAL OF ORTHODONTICS
Fig 14 Patient RL. Patient 14 years
posttreatment with excellent stability of
occlusion (third molars have erupted)
and optimal tissue health.
• They are blocked out and severely lin-
gually tipped
• Anterior crowding is absent or less
than moderate
• The patient has a straight or concave
profile
• The mandibular incisors are posi-
tioned upright or even slightly lingually
inclined, ie, when retraction require-
ments are not preponderant and
some anchorage loss is acceptable
The first premolar should be extracted
in situations in which greater anchorage
is needed, which is when:
• Anterior crowding is severe
• Mandibular incisors are excessively
tipped labially
323_Farret_.qxd 11/6/09 3:46 PM Page 333
VOLUME 10, NUMBER 4, 2009
• The sagittal discrepancy between the
arches is pronounced
• The facial profile is compromised by a
projection of the lower lip, as in
patient MT
According to Janson et al,13 bone re-
modeling of the symphysis will occur with
a controlled retraction of the mandibular
incisors, as documented by all patients
presented here.
In patients with agenesis or extraction
of mandibular premolars, the extraction
of maxillary teeth should always be con-
sidered. Extraction should especially be
taken into account when the patient:
• Shows a convex profile
• Presents with severely inverted lips
• Demonstrates excessive maxillary
incisor protrusion
• Suffers from severe crowding and
increased overbite5
None of the patients presented here
fulfilled these characteristics, which is
why no maxillary teeth were extracted
Nowadays, replacing missing teeth
with implants is often the first choice. In
this situation, the orthodontist mainly
reestablishes the necessary space for the
implant. Because the first and third
patient were treated in the early ‘90s, this
treatment alternative was not considered.
At that time, space closure was the most
viable option. This option should never be
overlooked as there are always patients
who object to implant placement.
When finishing with a Class III molar
relationship, mandibular third molars
should have erupted so that the maxillary
second molars have an antagonist. Also,
any present maxillary third molars should
be extracted or splinted to the adjacent
teeth to prevent supraeruption.13,14
CONCLUSION
Based upon the related literature and the
clinical examples presented here, the
establishment of a Class III molar rela-
tionship to compensate for congenitally
missing or extracted mandibular premo-
lars is viable. However, specific details
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MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Farret et al
during diagnosis, treatment planning,
and execution have to be observed.
REFERENCES
1. Silva Filho OG, Freitas SF, Cavassan AO. Preva-
lence of normal occlusion and malocclusion in
the mixed dentition on schoolars in Bauru (Säo
Paulo). Rev Assoc Paul Cir Dent
1989;43:287–290.
2. Costa Pinto TM, Ustrell Torrent JM, Correira
Pinto JG. Orthodontic camouflage in the case
of a skeletal Class III malocclusion. World J
Orthod 2004;5:213–223.
3. Hamanci N, Basaran G, Sahin S. Nonsurgical
correction of an adult skeletal class III and
open-bite malocclusion. Angle Orthod
2006;76:527–532.
4. Moullas AT, Palomo JM, Gass JR, Amberman
BD, White J, Gustovich D. Nonsurgical treat-
ment of a patient with a Class III malocclusion.
Am J Orthod Dentofacial Orthop 2006;129(4
suppl):S111–118.
5. Mailankody J, Janson G. Enigma of Class II
molar finishing. Reader’s forum. Am J Orthod
Dentofacial Orthop 2004;126:15A–17A.
6. Popp TW, Gooris CGM, Schur JA. Nonsurgical
treatment for a Class III dental relationship: A
case report. Am J Orthod Dentofacial Orthop
1993;103:203–211.
7. Pinzan A, Pinzan CRM, Santos JAZ. Abordagem
alternativa para o tratamento precoce da
Classe II, 1 divisao associada a agenesia dos
segundos pre-molares inferiores. J Bras Ortod
Ortop Facial 2002;7:361–369.
8. Angle EH. Classification of malocclusion. Dent
Cosmos 1899;248–264.
9. Tweed CH. Indications for the extraction of
teeth in orthodontic procedures. Am J Orthod
Oral Surg 1944;30:405–428.
10. Gelgör IE, Karaman AI. Non-surgical treatment
of Class III malocclusion in adults: Two case
reports. J Orthod 2005;32:89–97.
11. Hisano M, Soma K. Energy-based re-evaluation
of Angle’s Class I molar relationship. J Oral
Rehabil 1999;26:830–835.
12. Bakke M. Bite force and occlusion. Semin
Orthod 2006;12:120–126.
13. Janson G, de Souza JE, Alves Fde A, et al.
Extreme dentoalveolar compensation in the
treatment of Class III malocclusion. Am J
Orthod Dentofacial Orthop 2005;128:
787–794.
14. Lin J, Gu Y. Lower second molar extraction in
correction of severe skeletal class III malocclu-
sion. Angle Orthod 2006;76:217–225.
333
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SURGICALLY ASSISTED RAPID Susana M. Deon Rizzatto,

DDS, MSD1

MAXILLARY EXPANSION COMBINED Luciane Macedo de

Menezes, DDS, MSD,
WITH MAXILLARY PROTRACTION PhD1

IN AN ADULT: A PATIENT REPORT Marcel M. Farret, DDS,

MSD2
The aim of this article is to discuss an alternative treatment for adult Eduardo Martinelli S. de
patients who have a dental or skeletal Class III relationship. A 20-year- Lima, DDS, MSD, PhD2
old woman presented with a dental and skeletal Class III relationship
and a transverse maxillary deficiency. Surgically assisted rapid maxil- Rogério Belle, DDS, MSD,
lary expansion was followed by maxillary protraction with a face PhD3
mask and orthodontic treatment with standard edgewise technique.
At the end of treatment, a Class I molar and canine relationship was Michel A. Lanes, DDS,
attained with an adequate transverse intercuspation and improve- MSD4
ment of the patient’s facial profile. World J Orthod 2009;10:334–344.

Key words: Class III, maxillary deficiency, rapid maxillary expansion,

protraction, SARME

he treatment of a skeletal Class III this situation, a surgically assisted rapid

T relationship in a young (growing)
patient can consist of rapid maxillary
expansion (RME) and maxillary protrac-
tion with a face mask because RME dis-
ar ticulates the sutures and allows
orthopedic changes. 1–19 Because this
approach is not promising in adults,
camouflage or orthognathic surgery are
options, depending on the severity of the
anteroposterior discrepancy and the
patient’s preference.
When the sagittal discrepancy between
maxilla and mandible is not severe, a sat-
isfactory facial profile and a correct dental
relation with camouflage treatment can
be achieved. This approach often includes
maxillary expansion (SARME) with a total
Le Fort I osteotomy is the therapy of
choice. If, at the same time, the sagittal
skeletal and dentoalveolar relationships
are not severe, SARME can be combined
with maxillary protraction by a face
mask, as one would use in a growing
1Professor, Department of Orthodon-
patient. Similar procedures are de-
scribed in the literature.3,24–26 tics, Pontifical Catholic University,
Rio Grande do Sul, Brazil.
This case report describes a 20-year- 2Graduate PhD Student, Department
old woman who sought orthodontic of Orthodontics, Pontifical Catholic
treatment at the School of Dentistry at University, Rio Grande do Sul, Brazil.
3Professor, Department of Oral and
Pontifical Catholic University of Rio
Grande do Sul, Brazil. The patient’s chief Maxillofacial Surgery, Pontifical
Catholic University, Rio Grande do
complaint was the unesthetic position of Sul, Brazil.
her maxillary right canine and facial 4Department of Orthodontics, Pontifi-

protrusion of the maxillary and retrusion
of the mandibular anterior teeth or extrac-
tion of mandibular premolars.20–22 If the
skeletal discrepancy is severe, the only
way to achieve a proper sagittal relation-
ship is orthognathic surgery, in addition to
maxillary advancement or mandibular set-
back (or a combination of the two).23
Many adult patients exhibiting a
skeletal Class III relationship also pre-
sent a transverse maxillary deficiency. In
esthetics.
DIAGNOSIS
Facial analysis showed a mandibular
deviation to the right and an increased
lower facial third (Figs 1a to 1c). The
patient’s facial profile was concave with
retrusive lips. Her smile was unesthetic
due to 6.5-mm crowding in the maxillary
cal Catholic University, Rio Grande
do Sul, Brazil.
CORRESPONDENCE
Dr Marcel Marchiori Farret
Department of Orthodontics
Pontifícia Universidade Católica
Av. Ipiranga 6061/6/410,
Porto Alegre
Rio Grande do Sul, Brazil
Email: marcelfarret@yahoo.com.br,
smdr@uol.com.br (Dra Susana M.D.
Rizzatto)

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VOLUME 10, NUMBER 4, 2009 Rizzatto et al

a b c

d e f

Fig 1 (a to c) Initial facial photographs

showing a concave profile with retru-
sive lips, a mandibular deviation to the
right, and an increased lower facial
third. (d to h) Initial intraoral pho-
tographs showing 6.5 mm of crowding
in the maxillary and 3 mm of crowding
in the mandibular arch, a Class III molar
relationship, an edge-to-edge incisor
relationship, a maxillary transverse defi-
ciency, a posterior crossbite, an open g h
bite between the lateral incisors and the
premolars on both sides, and a devia-
tion of the maxillary midline to the right.

arch, a deviation of the maxillary midline Pretreatment panoramic radiographs

to the right, a maxillary transverse defi-
ciency, and a posterior crossbite (Figs 1d
to 1h). Crowding in the mandibular arch
amounted to 3 mm. Further, she had a
Class III molar relationship, an edge-to-
edge incisor relationship, and an open
bite between the lateral incisors and pre-
molars on both sides.
revealed that the third molars were pre-
sent partially with cystic extensions of
their pericoronal space; further, a fourth
molar was detected on the maxillary left
side (Fig 2a). The respective measure-
ments for the lateral cephalogram (Fig
2b) are in Table 1. On the frontal cephalo-
gram, the deviation of the mandible to
the right became evident as there was an
insinuation of the maxillary transverse
deficiency (Fig 2c).

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Rizzatto et al
b c
TREATMENT OBJECTIVES
The treatment objectives were to align all
teeth, establish a normal overbite and
overjet, attain a stable occlusion, correct
the posterior crossbite, match the dental
midlines to each other and the facial mid-
line, and improve the patient’s facial and
dental appearance.
TREATMENT OPTIONS
Three treatment options were consid-
ered. The first called for extraction of all
second premolars with the intent of elimi-
nating the crowding without much retru-
sion of the incisors, avoiding a flattening
of the facial profile. However, as the
336
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WORLD JOURNAL OF ORTHODONTICS
Fig 2a Initial panoramic radiograph.
All third molars are present, partially
with cystic extensions of their pericoro-
nal space; further, a fourth molar is visi-
ble on the maxillary left side.
Fig 2b Initial lateral cephalogram.
Fig 2c Initial frontal cephalogram
showing a deviation of the mandible to
the right and hinting at a transverse
maxillary deficiency.
patient had a straight to concave profile,
this option would have compromised her
facial esthetics even further and was
consequently rejected.
The second option was a slow expan-
sion of the maxilla and interproximal
enamel reduction (IPR) to align all teeth
in both arches. This option was also dis-
regarded because of the patient’s chief
complaint of facial esthetics and the risk
of increasing the maxillary posterior teeth
recession via expansion.
Based on the patient’s concern about
esthetics, SARME followed by maxillary
protraction with a face mask and IPR of
the mandibular posterior teeth, as well as
protrusion of the maxillary and mandibu-
lar incisors, was the optimal option.
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VOLUME 10, NUMBER 4, 2009
Fig 3 Extra- and intraoral views at the
beginning of treatment, starting with
leveling and aligning in the mandibular
arch followed by insertion of a Hyrax
appliance, which was cemented on the
maxillary first premolars and first
molars.
TREATMENT INITIATION
Treatment started in the mandibular arch
with IPR, leveling and aligning with a
slight protrusion of the incisors, and
uprighting the lingually tipped posterior
teeth to allow a larger expansion of the
maxillary arch. Subsequently, a Hyrax
appliance was cemented to the first pre-
molars and first molars and the patient
underwent surgery (Fig 3). After a week,
the Hyrax appliance was activated twice
daily. One week later, the first effects of
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Rizzatto et al
the orthopedic expansion were observed
and face mask protraction was initiated.
Elastics producing a force of 350 cN per
side and running at a 15-degree angle
downward to the palatal plane were
applied 14 hours per day. The Hyrax appli-
ance was activated for 3 weeks, until
there was a transverse overcorrection.
Figure 4 depicts the patient after expan-
sion with an 11-mm diastema, revealing a
considerable improvement in the volume
of the middle face; the respective radi-
ographs are shown in Fig 5.
337
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Rizzatto et al WORLD JOURNAL OF ORTHODONTICS

Fig 4 Extra- and intraoral views after

3 weeks of expansion with an 11-mm
diastema; a considerable improvement in
the volume of the middle face is visible.

Fig 5 Panoramic radiograph and lat-

eral and frontal cephalogram taken at
the same time as photographs in Fig 4.

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VOLUME 10, NUMBER 4, 2009 Rizzatto et al

a b c

d e f

Fig 6 (a to c) Extraoral view after

3.5 months of maxillary protraction,
considerably improved facial esthetics
due to the increased volume in the mid-
dle facial third, and an increased con-
vexity in facial profile. (d to h) Intraoral
view with a reduced diastema and
improved sagittal relationship between
maxilla and mandible.

g h

TREATMENT PROGRESS

After 3.5 months of maxillary protraction,

the facial esthetics had improved consid-
erably due to an increased volume in the
middle facial third and an increased con-
vexity in the facial profile (Figs 6a to 6c).
Intraorally, the diastema was reduced,
and the sagittal relation between the two
arches improved (Figs 6d to 6g).

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Rizzatto et al
After 6 months of retention, a trans-
palatal arch replaced the Hyrax expander
and brackets were attached to all maxil-
lary teeth (with the exception of maxillary
right lateral incisor and canine) (Fig 7).
The facial aspect was similar to the previ-
ous appearance. The molars and the left
canine presented a Class I relationship
with a good intercuspation of most poste-
rior teeth, both midlines coincided, and
340
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WORLD JOURNAL OF ORTHODONTICS
Fig 7 Extraoral and intraoral views
after 6 months of retention; a trans-
palatal arch substituted the Hyrax
expander, all maxillary teeth except the
maxillary right lateral incisor and canine
received brackets, and an open-coil
spring was placed between the central
incisor and first premolar to create
space to align the two teeth.
there was adequate overjet and overbite.
An open-coil spring was positioned
between the maxillary right central incisor
and first premolar to create space. Soon
after, the lateral incisor was included into
the appliance, whereas the canine was
slowly drawn toward the archwire so as to
avoid a gingival recession.
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VOLUME 10, NUMBER 4, 2009 Rizzatto et al

a b c

d e f

Fig 8 (a to c) Extraoral view at the

end of treatment. Improved profile con-
vexity is visible. (d to h) Intraoral view
at the end of treatment showing good
transverse relationship between both
arches, normal overbite and overjet, and
a Class I molar and canine relationship.

g h

RESULTS shows no root resorption but good root

At the end of treatment, the profile
convexity was improved (Figs 8a to 8c).
Intraorally, there was a good transverse
relationship between the arches, a nor-
mal overbite and overjet, and a Class I
molar and canine relationship (Figs 8d to
8h). The final panoramic radiograph
parallelism (Fig 9a). The final cephalo-
grams and the superimposition are
depicted in Figs 9b and 9c; the respec-
tive measurements are listed in Table 1.
The frontal cephalogram reveals an ade-
quate transverse relationship between
maxilla and mandible (Fig 9d).

341

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Rizzatto et al WORLD JOURNAL OF ORTHODONTICS

Fig 9 (a) Final panoramic radiograph

revealing no root resorption and good
root parallelism. (b and c) Final lateral
cephalogram and superimposition of
tracings from the initial (solid line) and
final (dotted line) cephalogram. (d) Final
frontal cephalogram revealing an ade-
quate transverse relationship between
maxilla and mandible.

b c d

Table 1 Results of cephalometric analysis before, during, and at the end

of treatment
Norm Pretreatment Postexpansion Posttreatment

SNA (degrees) 82 76 75 75
SNB (degrees) 80 76 76 75
ANB (degrees) 2 0 –1 0
SN-GoGn (degrees) 32 39 40 40
U1-NA (degrees) 22 18 22 26
U1-NA (mm) 4 7 910 9
L1-NB (degrees) 25 22 32 23
L1-NB (mm) 4 4 6 6
U1-L1 (degrees) 131 140 128 134
IMPA (degrees) 93 85 92 87
FMA (degrees) 25 29 28 27
FMIA (degrees) 62 66 60 66

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VOLUME 10, NUMBER 4, 2009
DISCUSSION
A Class III malocclusion may be charac-
terized by maxillary retrognathism, pre-
sent in about 60% of the af fected
patients; mandibular prognathism, found
in 20%; or a combination of the
two.2,4,6–9,11 In patients who have exces-
sive mandibular length, the prognosis in
growing individuals is especially unfavor-
able because it is very difficult to foresee
and control mandibular growth. However,
with maxillary retrognathism, the progno-
sis in growing patients is quite favorable
because excellent stable results can be
obtained with RME followed by protrac-
tion with a face mask.2,6–9,11,12,16,27
In patients with primary or mixed den-
titions, RME promotes the disarticulation
of the sutures around the maxillary
region and an intensification of cellular
activity.1,6,15,19 However, in adult patients,
suture release is no longer possible and
protraction also becomes unviable.
In such a situation, it is difficult to
determine whether camouflage is still
indicated or if orthognathic surgery is
preferable. The patient presented here
was in this borderline range because she
had a Class III molar/canine relationship
and a concave facial profile. According to
the Wits appraisal, she was skeletally
Class III, though the Steiner analysis indi-
cated a Class I relationship. Most of her
findings spoke in favor of orthognathic
surgery. On the other hand, this patient
also had a transverse maxillary defi-
ciency, which required an expansion. In
adults, such an expansion usually
requires a total Le Fort I osteotomy by
which the entire maxilla is released to
make protraction with a face mask possi-
ble. However, in this patient, an antero-
posterior change of the maxillary region
was not evident. The esthetic improve-
ment of the profile had to be attributed to
the protrusion and extrusion of the maxil-
lary anterior teeth as to a general protrac-
tion of the maxillary dentition. A long
period of retention was necessary to
avoid relapse.
The results obtained in this individual
prove that in situations with minor dental
and skeletal discrepancies but transverse
and anteroposterior maxillary deficiencies,
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Rizzatto et al
SARME and maxillary dentoalveolar pro-
traction is a viable treatment alternative.
This allows dissolving the existing crowd-
ing, avoiding extractions, correcting cross-
bites, and improving facial appearance.
CONCLUSION
In patients with a mild Class III discrep-
ancy, camouflage treatment with only
maxillary osteotomy and protraction is
feasible. The accomplished results are
esthetically and functionally satisfying
and also help to prevent extractions and
orthognathic surgery.
ACKNOWLEDGMENTS
The authors would like to thank colleagues Guil-
herme Thiesen, Janara Feldens, and Maira Massua
for their contribution in diagnosis, planning, and
treatment of this patient.
REFERENCES
1. Hata S, Itoh T, Nakagawa M, et al. Biomechani-
cal effects of maxillary protraction on the cran-
iofacial complex. Am J Orthod Dentofacial
Orthop 1987;91:305–311.
2. Turley PK. Orthopedic correction of Class III
malocclusion with palatal expansion and cus-
tom protraction headgear. J Clin Orthod
1988;22:314–325.
3. Roberts CA, Subtelny JD. An American Board of
Orthodontics case report. Use of the face mask
in the treatment of maxillary skeletal retrusion.
Am J Orthod Dentofacial Orthop 1988;93:
388–394.
4. Mermigos J, Full CA, Andreasen G. Protraction
of the maxillofacial complex. Am J Orthod
Dentofacial Orthop 1990;98:47–55.
5. Popp TW, Gooris CGM, Schur JA. Nonsurgical
treatment for a Class III dental relationship: A
case report. Am J Orthod Dentofacial Orthop
1993;103:203–211.
6. Ngan P, Hägg U, Yiu C, Merwim D, Wei S. Soft
tissue and dentoskeletal profile changes asso-
ciated with maxillary expansion and protraction
headgear treatment. Am J Orthod Dentofacial
Orthop 1996;109:38–49.
7. Shanker S, Ngan P, Wade D, et al. Cephalomet-
ric A point changes during and after maxillary
protraction and expansion. Am J Orthod Dento-
facial Orthop 1996;110;423–430.
343
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8. Williams MD, Sarver DM, Sadowsky PL, Bradley
E. Combined rapid maxillary expansion and
protraction facemask in the treatment of Class
III maloclusions in growing children: A prospec-
tive long-term study. Semin Orthod 1997;
3:265–274.
9. Ngan P, Hägg U, Yiu C, Wei SHY. Treatment
response and long-term dentofacial adapta-
tions to maxillary expansion and protraction.
Semin Orthod 1997;3:255–264.
10. Merwin D, Ngan P, Hägg D, Yiu C, Wei SHY. Tim-
ing for effective application of anteriorly
directed orthopedic force to the maxilla. Am J
Orthod Dentofacial Orthop 1997;112:292–299.
11. Pangrazio-Kulbersh V, Berger J, Kersten G.
Effects of protraction mechanics on the mid-
face. Am J Orthod Dentofacial Orthop 1998;
114:484–491.
12. Ngan P. Yiu C, Hu A, Hägg U, Wei SHY, Gunel E.
Cephalometric and occlusal changes following
maxillary expansion and protraction. Eur J
Orthod 1998;20:237–254.
13. da Silva Filho OG, Magro AC, Capelozza Filho L.
Early treatment of the Class III malocclusion
with rapid maxillary expansion and maxillary
protraction. Am J Orthod Dentofacial Orthop
1998;113:196–203.
14. Suda N, Ishii-Suzuki M, Hirose K, Hiyama S,
Suzuki S, Kuroda T. Effective treatment plan for
maxillary protraction: Is the bone age useful to
determine the treatment plan? Am J Orthod
Dentofacial Orthop 2000;118:55–62.
15. Saadia M, Torres E. Sagittal changes after max-
illary protraction with expansion in Class III
patients in the primary, mixed, and late mixed
dentitions: A longitudinal retrospective study.
Am J Orthod Dentofacial Orthop 2000;117:
669–680.
16. Ngan P, Yiu C. Evaluation of treatment and
posttreatment changes of protraction face-
mask treatment using the PAR index. Am J
Orthod Dentofacial Orthop 2000;118:
414–420.
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MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
WORLD JOURNAL OF ORTHODONTICS
17. Keles A, Tokmak EÇ, Erverdi N, Nanda R. Effect
of varying the force direction on maxillary
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18. Ngan P. Biomechanics of maxillary expansion
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582–583.
19. Cha KS. Skeletal changes of maxillary protraction
in patients exhibiting skeletal Class III maloclu-
sion: A comparison of three skeletal maturation
groups. Angle Orthod 2003;73:26–35.
20. Costa Pinho TM, Ustrell Torrent JM, Correia
Pinto JGR. Orthodontic camouflage in the case
of a skeletal Class III maloclusion. World J
Orthod 2004;5:213–223.
21. Proffit WR, White RP. Surgical-Orthodontic
Treatment. St Louis: Mosby, 1991.
22. Litton SF, Ackermann LV, Isaacson RJ, Shapiro
BL. A genetic study of Class 3 malocclusion.
Am J Orthod 1970;58:565–577.
23. Gelgör IE, Karaman AI. Non-surgical treatment
of Class III maloclusion in adults: Two case
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24. Ahn JG, Figueroa AA, Braun S, Polley JW. Biome-
chanical considerations in distraction of the
osteotomized dentomaxillary complex. Am J
Orthod Dentofacial Orthop 1999;116:264–270.
25. Figureroa AA, Polley JW. Management of severe
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26. Polley JW, Figueroa AA. Management of severe
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27. Franchi L, Baccetti T, McNamara JA. Postpuber-
tal assessment of treatment timing for maxil-
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Orthop 2004;126:555–568.
345_Almeida.qxd 11/6/09 2:37 PM Page 345

Rhita C. Almeida, MsD1

ORTHODONTIC MANAGEMENT
Felipe A.R. Carvalho,
MsD1 OF A PATIENT WITH IMPACTED AND
Marco A.O. Almeida, TRANSPOSED MANDIBULAR CANINES
PhD2
This patient report describes the treatment of a 10-year-old female
Jonas Capelli Júnior, PhD2
with complete transposition of her impacted mandibular canines and
lateral incisors. The patient had a Class I occlusion, and her mandibu-
lar lateral incisors were in crossbite with the maxillary central
incisors. The treatment objectives were to create space for the
impacted canines and align them with the incisors, one of which was
extracted. After treatment, the appearance of the patient’s teeth was
improved, the occlusion was preserved, and overjet and overbite
were corrected. World J Orthod 2009;10:345–349.

Key words: ectopic eruption, impacted mandibular canines, impaction,

transposed mandibular canines

n ectopic position of a (permanent) canines were absent and her mandibu-

1PhD Student, Department of Ortho-
dontics, State University of Rio de
Janeiro, Rio de Janeiro, Brazil.
2Professor, Department of Orthodon-
tics, State University of Rio de
Janeiro, Rio de Janeiro, Brazil.
CORRESPONDENCE
Dr Rhita Almeida
Av. das Américas
3434 bl.5 sala 223. Barra da Tijuca
Rio de Janeiro, RJ Brasil
Cep. 22640-102
Email: rhita.almeida@gmail.com
A tooth bud can lead to ectopic erup-
tion. It occurs most often in the maxillary
first molars and mandibular incisors.1,2
Ectopic eruption of mandibular lateral
incisors may lead to transposition of
them and the canines. Due to an incor-
rect path of eruption or lack of space,
eruption of the canines is frequently im-
peded, oftentimes resulting in impaction.
Even when there is adequate space,
canines can erupt ectopically and
become transposed with a premolar or
lateral incisor.3
This article describes the treatment
of a young patient who had impacted
mandibular canines that transposed
with her lateral incisors.
DIAGNOSIS AND
TREATMENT PLAN
A 10-year-old female presented with a
convex profile but good facial proportions.
Clinical examination showed a Class I
occlusion with a crossbite of her man-
dibular lateral incisors with the maxillary
central incisors (Fig 1). Her mandibular
lar right primary second molar was still
present.
The panoramic radiograph revealed a
complete transposition of the mandibu-
lar lateral incisors and impacted
canines. The cephalogram showed a
skeletal Class II (ANB = 5 degrees) with
protruded mandibular incisors and a
convex profile (Fig 2).
The treatment objectives were to
improve the patient’s dental appearance
by creating space for the mandibular
canines and aligning them with the
incisors.
Treatment progress
The 0.022 ⫻ 0.028-inch Roth prescrip-
tion brackets were bonded, and a lingual
arch appliance was inser ted in the
mandibular arch to maintain enough
space to correct the rotation of the left
second premolar and allow the eruption
of the right second premolar. After this
tooth (which was peg-shaped) had
erupted, the lingual arch appliance was
removed. The treatment plan for the

345

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345_Almeida.qxd 11/6/09 2:37 PM Page 346
Almeida et al
a b
d e
g h
maxillary arch foresaw conventional level-
ing and alignment of all teeth. In the
mandibular arch, a 0.016-inch stainless
steel archwire with a coil spring between
the lateral incisors was used to move
these two teeth distally, thus making
space for the canines (Fig 3).
When the right canine started to erupt
in the lateral incisor position, it became
apparent that there was insufficient
346
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WORLD JOURNAL OF ORTHODONTICS
c
f
Fig 1 (a to c) A 10-year-old girl prior to
treatment exhibiting a convex profile
but good facial proportions; (d to f)
mesially tipped mandibular incisors; (g)
relatively well-aligned maxillary arch; (h)
and missing mandibular canines,
retained mandibular right primary sec-
ond molar, and rotated mandibular left
second premolar.
space proper alignment. Because the
patient’s mandibular incisors were
already protruded, the left lateral incisor
was extracted. The lingual arch appliance
was preventing the canines’ eruption, so
it was removed, as well. With adequate
space, both canines erupted sponta-
neously. Nickel-titanium and stainless
steel archwires were used to align these
two teeth (Fig 4).
345_Almeida.qxd 11/6/09 2:37 PM Page 347

VOLUME 10, NUMBER 4, 2009 Almeida et al

a b
Fig 2 (a) Panoramic radiograph revealing a complete transposition of the impacted canines and mandibular lateral incisors.
(b) Cephalogram before treatment showing a skeletal Class II with protruded mandibular incisors and a convex profile.

a a
Fig 3 Occlusal view of the mandibular Fig 4 (a and b) Occlusal view of both arches toward the completion of treatment;
arch with inserted lingual arch appliance (b) with the canines aligned.
for space preservation and distal move-
ment of lateral incisors with an open
coil spring.

In the maxillary arch, some interproxi-
mal enamel reduction was performed to
solve the Bolton discrepancy created by
the extraction of the mandibular left lat-
eral incisor.
Treatment outcome
The patient’s dental appearance was
improved, and the molar relationship was
preserved. In spite of the uniarch extrac-
tion, treatment concluded with a correct
overjet and overbite; the maxillary mid-
line coincided with the middle of the
mandibular right central incisor (Fig 5).
The patient’s oral hygiene was unfortu-
nately very poor, and multiple demineral-
izations had established. Radiographs
taken at the end of treatment revealed
that the roots were parallel, especially in
the mandibular anterior area (Fig 6).

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Almeida et al WORLD JOURNAL OF ORTHODONTICS

a b c

d e f

Fig 5 Patient at the completion of

treatment (a to c) with improved dental
appearance; (d to f) preserved molar
relationship, correct overjet and over-
bite, maxillary midline coinciding with
the middle of the mandibular right cen-
tral incisor; (g) well-aligned teeth in the
maxillary arch; and (h) tooth sequence
in the mandibular arch is left canine, left
central incisor, right central incisor, right
g h canine, and right lateral incisor. Multiple
demineralizations due to insufficient
oral hygiene are visible throughout.

a b
Fig 6 (a) Panoramic radiograph revealing good root parallelism, especially in the mandibular anterior area. (b) Cephalogram
showing an almost identical situation as that at the beginning of therapy.

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345_Almeida.qxd 11/6/09 2:37 PM Page 349
VOLUME 10, NUMBER 4, 2009
DISCUSSION
In situations of tooth transpositions, treat-
ment options include extractions, align-
ment in the transposed position,4–7 or
orthodontic relocation. 5,8–10 When the
respective teeth are aligned in their trans-
posed position, they should be recon-
toured with composite.4,5 It is often said
that moving transposed teeth into their
normal position provides a more esthetic
result. However, this does not always prove
possible or true. Treatment planning must
include an assessment of the root apex
position, the amount of available bone at
the relocation site,11 esthetics, periodontal
support,12 the anticipated occlusion, and
the patient’s expected cooperation during
a prolonged treatment.5,8,9
In the mandible, a transposition would
require moving the canine around the lat-
eral incisor, which would lead to bone loss
and gingival recession. For the sake of
esthetics and safety, it was decided to
leave the canine in its transposed position
in this patient.
CONCLUSION
This case report shows that a satisfactory
result can be obtained by maintaining
the transposition and that correction,
even when possible, is not always advis-
able from a cost-benefit viewpoint.
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Almeida et al
REFERENCES
1. Bjerklin K, Kurol J. Ectopic eruption of the max-
illary first permanent molar: Etiologic factors.
Am J Orthod 1983;84:147–155.
2. Shapira Y, Kuftinec MM. The ectopically
erupted mandibular lateral incisor. Am J Orthod
1982;82:426–429.
3. Proffit W, Fields HW Jr. Contemporary Ortho-
dontics, ed 2. St Louis: Mosby, 1993:113.
4. Shapira Y, Kuftinec MM. Orthodontic manage-
ment of mandibular canine-incisor transposi-
tion. Am J Orthod 1983;83:271–276.
5. Shapira Y, Kuftinec MM, Storm D. Maxillary ca-
nine-lateral incisor transposition—Orthodontic
management. Am J Orthod Dentofacial Orthop
1989;95:439–444.
6. Kreia TB, Tanaka O. Transposição dentária. Rev
Dent Press Ortod Ortop Facial 2004;9:129–136.
7. Peck S, Peck L. Classification of maxillary tooth
transpositions. Am J Orthod Dentofacial Orthop
1995;107:505–517.
8. Shapira Y, Kuftinec MM. A unique treatment
approach for maxillary canine-lateral incisor
transposition. Am J Orthod Dentofacial Orthop
2001;119:540–545.
9. Schott K, Capelli J Jr. Transposição de canino
superior com incisivo lateral: Relato de caso e
revisão da literatura. Rev Bras Odont 1997;
54:359–361.
10. Mucha JN. Transposição de canino e primeiro
pré-molar com ausência congênita de incisivos
laterais superiores- conduta ortodôntica. Rev
Soc Bras Ortod 1989;1:54–61.
11. Parker WS. Transposed premolars, canines,
and lateral incisors. Am J Orthod Dentofacial
Orthop 1990;97:431–448.
12. Sato K, Yokozeki M, Takagi T, Moriyama K. An
orthodontic case of transposition of the upper
right canine and first premolar. Angle Orthod
2002;72:275–278.
349
350_Suzuki.qxd 11/6/09 2:38 PM Page 350

TREATMENT OF A PERIODONTALLY Eduardo Yugo Suzuki,

DDS, PhD1

COMPROMISED PATIENT WITH Boonsiva Suzuki, DDS,

PhD2
MINI-IMPLANT ANCHORAGE
Background: Advanced periodontal disease and its sequelae are char-
acterized by severe attachment loss, tooth mobility, and migration.
This pathology often leads to compromised function and esthetics. A
multidisciplinary approach combining orthodontic, periodontic, and
restorative treatment is necessary to provide complete rehabilitation
both in terms of function and esthetics with a satisfactory long-term
prognosis. Methods: A simple and effective treatment of an adult
patient with periodontally migrated teeth using mini-implants in the
maxilla and mandible is described. Mini-implant placement was
aided by a 3D surgical guide, which made the procedure exceedingly
safe. Results: Gradual intrusion of the maxillary and mandibular
anterior teeth was achieved with a relatively simple orthodontic force
system. A significant profile improvement was observed during the
18 months of treatment due to the retraction and intrusion of the
incisors in both arches. This intrusion was accomplished without any
sign of apical root resorption. The mandibular incisors were uprighted
6.5 degrees, and their maxillary counterparts were uprighted 13.4
degrees. The 2-year follow-up examination revealed a stable result
with an increase in periodontal attachment as well as esthetics and
function. Conclusion: A combined orthodontic, periodontic, and
restorative treatment approach with adequate patient motivation can
lead to improved masticatory function, esthetics, and periodontal
conditions. World J Orthod 2009;10:350–360.

Key words: mini-implant anchorage, periodontally compromised patient,

adult orthodontics

dvanced periodontal disease and its
A sequelae are characterized by severe
attachment loss, reduction of alveolar
bone, marginal gingival recession,
inflammation is controlled and the peri-
odontium is healthy.8,9 To obtain a signif-
icant intrusion, either J-hook headgear
1Lecturer, Department of Orthodon-
tics, Faculty of Dentistry, Chiang Mai
University, Chiang Mai, Thailand.
or intrusion wires are necessary. How- 2Associate Professor, Department of

increased tooth mobility, and tooth
migration. 1,2 This condition will often
lead to compromised function and
esthetics.3 A combined orthodontic, peri-
odontic, and restorative treatment
approach can completely rehabilitate an
affected patient both in terms of func-
tion and esthetics with a satisfactory
long-term prognosis.4–7
Periodontally migrated teeth can be
orthodontically realigned after existing
ever, J-hook headgear is not an esthetic Orthodontics, Faculty of Dentistry,
appliance and requires patient compli- Chiang Mai University, Chiang Mai,
ance; intrusion wire mechanics will often Thailand.
lead to a reactive extrusion, as well.10 CORRESPONDENCE
Recently, mini-implants have become Dr Boonsiva Suzuki
important in obtaining absolute ortho- Department of Orthodontics, Faculty
dontic anchorage.11–17 Mini-implants are of Dentistry, Chiang Mai University
Suthep Road
relatively inexpensive, easy to handle,
Amphur Muang
and permit immediate loading.14–17 Ini- Chiang Mai 50200
tially, they were used to treat patients Thailand
who were unwilling to wear extraoral Email: boonsiva@chiangmai.ac.th

350

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350_Suzuki.qxd 11/6/09 2:38 PM Page 351
VOLUME 10, NUMBER 4, 2009
Fig 1 Pretreatment facial and intraoral
photographs of a 42-year-old female
Class I patient with bimaxillary protru-
sion.
anchorage. Because these implants are
small in diameter, they can be implanted
between the roots of adjacent teeth,
which makes the force system relatively
simple.18,19
This article describes a simple and
effective approach to manage periodon-
tally migrated teeth using orthodontic
mini-implants.
PATIENT REPORT
A 42-year-old woman was referred for
treatment to the orthodontic clinic of the
Faculty of Dentistry, Chiang Mai University,
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MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Suzuki/Suzuki
Thailand. She presented with a severely
periodontally compromised dentition and
pathologic migration of her anterior teeth.
This resulted in a severe diastema of her
maxillary and mandibular anterior teeth.
Her chief complaint was the unfavorable
appearance of her teeth, caused by their
excessive extrusion. This led to a lack of
self-confidence and a fear of smiling and
talking to friends (Fig 1).
Initially, the patient was treated peri-
odontally at the University Hospital. This
included instruction in oral hygiene and a
6-month recall for professional scaling,
root planing, and curettage. After the
inflammation was adequately controlled
351
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Suzuki/Suzuki
and the periodontal tissue had recov-
ered, the patient was referred to the
orthodontic clinic for complementary
treatment.
Pretreatment facial photographs
showed a symmetric face with mild
bimaxillary protrusion. Intraorally, the
diastema in the maxillary and mandibu-
lar anterior regions were most prominent.
Clinical examination revealed severe ver-
tical bone loss in the anterior dentoalveo-
lar areas of both arches, which was
accompanied by excessive dental extru-
sion. All teeth were severely mobile, but
pocket-probing depths were not greater
than 3 mm. Because of the mobile teeth,
352
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WORLD JOURNAL OF ORTHODONTICS
Fig 2 Initial panoramic and periapical
radiographs and intraoral view of the
incisor relationship.
the patient’s masticatory function was
also compromised.
Radiographic examination demon-
strated significant bone loss of the maxil-
lary and mandibular anterior area (Fig 2).
Cephalometric analysis showed that the
maxilla and mandible were normally posi-
tioned relative to Thai standards (Fig 3).
However, all incisors were protruded; the
overjet and overbite were 6.5 mm and
4.0 mm, respectively.
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VOLUME 10, NUMBER 4, 2009 Suzuki/Suzuki

Fig 3 Lateral cephalometric analysis. (a) Pre- and

(b) posttreatment cephalometric values relative to Mean SD a b
adult Thai female standards. Facial angle 89.1 2.7 86.4 85.9
Convexity 8.8 4.1 6.5 6.5
A-B plane –4.2 2.3 –9.5 –7.1
Mandibular plane 22.0 4.6 30.2 28.0
Y-axis 63.2 9.5 64.0 64.5

Occlusal plane 6.8 3.6 13.2 9.2

Interincisal angle 121.3 7.1 95.5 122.3
LI to OP 29.7 7.9 42.1 28.2
LI to MP 96.8 5.1 99.6 93.1
UI to A-P plane 3.0 0.7 6.5 3.3
FMIA 61.2 4.5 50.2 58.8
FH to SN 7.7 2.1 9.5 9.6

SNA 85.0 3.5 83.1 82.6

SNB 81.2 2.8 78.4 78.9
ANB 3.8 1.8 4.7 3.6
UI to N-P plane 9.7 2.7 15.8 10.1

UI to FH 116.9 5.3 127.4 114.1

UI to SN 109.2 5.4 117.9 104.5

Gonial angle 114.6 5.0 119.6 117.8

Ramus inclination 6.0 3.8 1.6 2.1

TREATMENT PLAN alveolar bone between the maxillary and

The treatment plan was to realign
(intrude) the migrated teeth using light
continuous orthodontic forces. Mini-
implants were inserted in the maxilla and
mandible to provide absolute anchorage
for this intrusion. Intensive control of the
patient’s oral hygiene and a strict peri-
odontal care regimen were planned
throughout orthodontic treatment. For
retention, an intracoronal splint connect-
ing all maxillary incisors was planned.
TREATMENT PROGRESS
mandibular central incisors. This was
aided by a 3D surgical guide (Y&B Prod-
ucts)19 to avoid root damage to the adja-
cent teeth (Fig 4). The extruded teeth
were intruded with elastomeric ligatures
(50 cN), which ran between the mini-
implants and the incisors (Fig 5). At the
same time, the maxillary anterior teeth
were retracted with Ni-Ti coil springs,
which again delivered a force of 50 cN.
Following the original plan, the teeth
were stabilized for 3 months after treat-
ment with an intracoronal splint to allow a
preliminary remodeling of the underlying
bone.

Orthodontic treatment was performed

with a 0.018 ⫻ 0.025-inch preadjusted
appliance. Leveling was initiated with
0.016-inch Sentalloy archwires for 2
months, followed by a 0.016 ⫻ 0.022-
inch improved superelastic nickel-titanium
(L&H Titan) archwire. After 3 months,
mini-implants (diameter 1.6 mm, length
8.0 mm) were inserted into the buccal
IMPLANT PROCEDURE
The 3D surgical guide was connected to
the orthodontic wire and positioned as
accurately as possible at the preselected
mini-implant site (Fig 4). A periapical radi-
ograph of this area was taken with the
long-cone paralleling technique aided by

353

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Suzuki/Suzuki WORLD JOURNAL OF ORTHODONTICS

Fig 4 Mini-implants inserted into the

buccal alveolar bone with the aid of a
3D surgical guide.

Fig 5 Elastomeric ligatures between the mini-implants and anterior incisors.

a film holder (Rinn XCP film holding sys-
tem, Dentsply).15,16 During exposure, the
patient bit into a bite registration made
from conventional elastomeric impres-
sion material. Thus, a standardized
series of radiographs of the implant site
could be obtained throughout the
implant placement procedure. The long-
cone technique reduced the distortion
and standardized the film–x-ray tube dis-
tance (Fig 6). 15,16 Radiographs were
taken until a possible implant position
was found that would not violate the
neighboring tooth roots.

354

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350_Suzuki.qxd 11/6/09 2:38 PM
VOLUME 10, NUMBER 4, 2009
Fig 6 Film holder used to
ensure precise mapping of the
optimum implant site.
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Page 355
Minor adjustments of the position of
the 3D surgical guide allow varying the
recommended implant angulation to the
long axes of the teeth. These angulation
changes produce an increased surface
contact between the implant and the
bone.17,20,21
After the optimum implant position
was determined, a pilot hole was pre-
pared with a manual drill under normal
saline irrigation to avoid excessive heat
and remove bone debris (see Fig 4).
The mini-implant was inserted into the
pilot hole through the 3D surgical guide
tube with a manual screwdriver to reduce
the risk of a deviation during insertion
and to assure the precise 3D placement
into the preoperatively planned position.
After insertion, an additional radiograph
with the custom-made film holder was
taken to confirm the proper position.
Suzuki/Suzuki
RESULTS
Significant profile improvement was
observed during the first 6 months of treat-
ment. After 18 months, the patient showed
an acceptable occlusion with a Class I
molar relationship (Fig 7). Although the
maxillary and mandibular incisors were
retracted and intruded, there was no sign of
apical root resorption. The ANB angle was
reduced from 4.7 degrees to 3.6 degrees.
The proclined incisors were uprighted by
6.5 degrees and 13.4 degrees in the man-
dible and maxilla, respectively. Cephalomet-
ric superimposition demonstrated a bodily
retraction of the maxillary anterior teeth
with an intrusion of the incisors in both
arches. The maxillary posterior teeth were
uprighted, but no other significant move-
ment was observed. The mandibular
molars moved slightly mesially (Fig 8).
355
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Suzuki/Suzuki WORLD JOURNAL OF ORTHODONTICS

Fig 7 The patient’s profile was signifi-

cantly improved after 18 months of
active treatment with retraction and
intrusion of the maxillary and mandibu-
lar incisors.

Fig 8 Superimposition of
cephalometric tracings
(black) before and (red)
after treatment showing
controlled bodily retraction
of maxillary anterior teeth
without anchorage loss.

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VOLUME 10, NUMBER 4, 2009 Suzuki/Suzuki

Fig 9 Final panoramic and periapical

radiographs reveal gain of periodontal
attachment. Frontal view and incisor
relationship show good tooth alignment.

Fig 10 An intracoronal splint connects

all maxillary incisors to avoid relapse
and to improve esthetics.

General radiographic examination re- Following active orthodontic treatment,

vealed an increase of periodontal attach- instead of the orignally planned bridge, an
ment and bony support of the maxillary intracoronal splint for the four maxillary
and mandibular anterior teeth (Fig 9). incisors was inserted to prevent relapse
and improve esthetics and function (Fig 10).

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350_Suzuki.qxd 11/6/09 2:39 PM Page 358
Suzuki/Suzuki
A 2-year follow -up examination
revealed no current tooth migration,
more gain of periodontal attachment,
and good esthetics and function (Fig 11).
DISCUSSION
Periodontal disease and its sequelae,
such as pathologic tooth migration,
diastema, and gingival recessions, often
lead to compromised function and
esthetics.1–8
This article describes the treatment of a
patient with a severe periodontal disease
358
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WORLD JOURNAL OF ORTHODONTICS
Fig 11 Two-year follow-up pho-
tographs showing a successful esthetic
and functional result.
and a disfiguring migration of her incisors
that resulted in severe diastemata in both
dental arches. To provide complete re-
habilitation in terms of both esthetics and
function with a satisfactory long-term
prognosis, a multidisciplinary approach
combining or thodontic-periodontic-
restorative was essential.4–7
This treatment involved initial peri-
odontal intervention to control the inflam-
mation of the periodontium, followed by
orthodontic treatment to realign and
intrude the migrated teeth. Thus, all
diastemas were closed, and an appropri-
ate occlusal relationship re-established.
350_Suzuki.qxd 11/6/09 2:39 PM Page 359
VOLUME 10, NUMBER 4, 2009
Several techniques have been
described how to intrude periodontally
migrated teeth.1–8 These include the use
of extra- and intraoral devices, such as
J-hook headgear or specific archwire
mechanics. However, these are not with-
out limitations. Although J-hook headgear
can provide an intrusive force to the den-
tition, it is not esthetically well-accepted
and requires patient compliance. This
could become a problem, especially for
adult patients. On the other hand, the
use of intraoral archwire mechanics to
obtain true intrusion is again not without
any problems. To obtain a true intrusion
of the incisors, an archwire with an
accentuated curve of Spee in the maxilla
and a reversed one in the mandible is
combined with intermaxillary elastics to
prevent an undesirable labial tipping.
However, these elastics may cause again
an extrusion of the incisors. Moreover,
such mechanics will likely extrude the
posterior teeth.10
Mini-implants are employed to treat
complex malocclusions, in which conven-
tional anchorage would not be sufficient
to obtain satisfactory results.22–24
In this patient, a relatively simple force
system was used to deliver light and con-
tinuous intrusive forces to the anterior
teeth. Because skeletal anchorage was
used, undesirable dental effects were
avoided. Instead, the light and continu-
ous forces delivered by the springs and
wires stimulated the formation of new
bone attachment.
Previous reports have demonstrated
that with adequate plaque control, teeth
with reduced periodontal support can be
successfully moved without compromis-
ing their periodontal condition.1–8 In the
present patient, the initial periodontal
status was improved by scaling and root
planing. The obtained result including the
use of the mini-implants was similar to
that presented by Melsen et al. 8 How-
ever, Melsen et al needed complex ortho-
dontic mechanics to obtain an adequate
intrusion of the migrated teeth.
According to Melsen et al8 the gradual
intrusion of periodontally involved teeth in
adults with marginal bone loss is benefi-
cial because new attachment is gener-
ated. However, these authors also pointed
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MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Suzuki/Suzuki
out that prior to orthodontic treatment,
the gingival inflammation must be elimi-
nated, which includes adequate scaling of
the root surfaces.
The radiographic images suggest a
reconstruction of the periodontal liga-
ment space. This is in accordance with
Melsen et al9 who found in monkeys with
controlled oral hygiene formation of new
cementum and new collagen attachment
after periodontal treatment and orthodon-
tic intrusion.
CONCLUSION
With a multidisciplinary approach, com-
bining orthodontic, periodontic, and
restorative treatment together with ade-
quate patient motivation and cooperation,
masticatory function, esthetics, and the
condition of the periodontium can be
improved.
ACKNOWLEDGMENTS
The authors acknowledge the assistance of Dr M.
Kevin O’Carroll, professor emeritus of the University
of Mississippi School of Dentistry and faculty con-
sultant at Chiang Mai University Faculty of Den-
tistry, in the preparation of the manuscript. Part of
this study was supported by grant MRG5080347
from Thailand Research Funding.
REFERENCES
1. Rabie AM, Gildenhuys R, Boisson M. Manage-
ment of patients with severe bone loss: Bone
induction and orthodontics. World J Orthod
2001;2:142–153.
2. Ong MMA, Wang HL. Periodontic and orthodon-
tic treatment in adults. Am J Orthod Dentofacial
Orthop 2002;122:420–428.
3. Melsen B, Agerbaek N, Markenstam G. Intru-
sion of incisors in adult patients with marginal
bone loss. Am J Orthod Dentofacial Orthop
1989;96:232–241.
4. Feng X, Oba T, Oba Y, Moriyama K. An interdis-
ciplinary approach for improved functional and
esthetic results in a periodontally compromised
adult patient. Angle Orthod 2005;75:
1061–1070.
5. Claman L, Alfaro MA, Mercado A. An interdisci-
plinary approach for improved esthetic results
in the anterior maxilla. J Prosthet Dent 2003;
89:1–5.
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6. Cirelli JA, Cirelli CC, Holzhausen M, Martins LP,
Brandao CH. Combined periodontal, orthodon-
tic, and restorative treatment of pathologic
migration of anterior teeth: A case report. Int J
Periodontics Restorative Dent 2006;26:
501–506.
7. Re S, Corrente G, Abundo R, Cardaropoli D. The
use of orthodontic intrusive movement to
reduce infrabony pockets in adult periodontal
patients: A case report. Int J Periodontics
Restorative Dent 2002;22:365–371.
8. Melsen B, Agerbaek N, Eriksen J, Terp S. New
attachment through periodontal treatment and
orthodontic intrusion. Am J Orthod Dentofacial
Orthop 1988;94:104–116.
9. Melsen B. Tissue reaction following application
of extrusive and intrusive forces to teeth in adult
monkeys. Am J Orthod 1986;89:469–475.
10. Creekmore TD, Eklund MK. The possibility of
skeletal anchorage. J Clin Orthod 1983;17:
266–269.
11. Kanomi R. Mini-implant for orthodontic anchor-
age. J Clin Orthod 1997;31:763–767.
12. Costa A, Raffainl M, Melsen B. Miniscrews as
orthodontic anchorage: A preliminary report.
Int J Adult Orthodon Orthognath Surg 1998;13:
201–209.
13. Bae SM, Park HS, Kyung HM, Kwon OW, Sung
JH. Clinical application of micro-implant anchor-
age. J Clin Orthod 2002;36:298–302.
14. Kyung HM, Park HS, Bae SM, Sung JH, Kim IB.
Development of orthodontic micro-implants for
intraoral anchorage. J Clin Orthod 2003;37:
321–328.
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15. Suzuki EY, Suzuki B. Accuracy of miniscrew
implant placement with a 3-D surgical guide.
J Oral Maxillofac Surg 2009;67:2245–2253.
16. Biggerstaff RH, Phillips JR. A quantitative com-
parison of paralleling long-cone and bisection-
of-angle periapical radiography. Oral Surg Oral
Med Oral Pathol 1976;62:673–677.
17. Lin JC, Liou EJ. A new bone screw for orthodon-
tic anchorage. J Clin Orthod 2003;37:676–681.
18. Carano A, Velo S, Leone P, Siciliani G. Clinical
applications of the Miniscrew Anchorage Sys-
tem. J Clin Orthod 2005;39:9–24.
19. Suzuki EY, Suzuki B. Adjustable traction hooks
for anterior torque control with miniscrew
anchorage. J Clin Orthod 2007;41:14–19.
20. Suzuki EY, Buranastidporn B. An adjustable
surgical guide for miniscrew placement. J Clin
Orthod 2005;39:588–590.
21. Weiland FJ, Bantleon H, Droschl H. Evaluation
of continuous arch and segmented arch level-
ing techniques in adult patients—A clinical
study. Am J Orthod Dentofacial Orthop 1996;
110:647–652.
22. Paik CH, Woo YJ, Boyd RL. Treatment of an
adult patient with vertical maxillary excess
using miniscrew fixation. J Clin Orthod 2003;
37:423–428.
23. Park HS, Kwon OW, Sung JH. Micro-implant
anchorage for forced eruption of impacted
canines. J Clin Orthod 2004;38:297–302.
24. Park HS, Bae SM, Kyung HM, Sung JH. Micro-
implant anchorage for treatment of skeletal
Class I bialveolar protrusion. J Clin Orthod
2001;35:417–422.
361_Siqueira.qxd 11/10/09 4:15 PM Page 361

Danilo Furquim Siqueira,

PhD, MSc1 THE IMPORTANCE OF THE FACIAL
Marinês Vieira da Silva PROFILE IN ORTHODONTIC DIAGNOSIS
Sousa, MSC2

Paulo Eduardo Guedes

Carvalho, PhD, MSc1
Karyna Martins do Valle-
Corotti, PhD, MSc1
AND TREATMENT PLANNING:
A PATIENT REPORT
Orthodontic treatment to improve not only tooth alignment but also
facial esthetics is a given in modern society. This paper illustrates this
assumption with a report of a patient with a Class I, maxillary retrusion,
concave profile, and retrusion of the upper and lower lips. Maxillary
expansion was followed by face mask therapy and orthodontic treat-
ment, which significantly improved the soft tissue profile by projecting
the upper lip. World J Orthod 2009;10:361–370.

Key words: esthetics, diagnosis, orthodontic profile, lips

he concept of facial beauty and har- analyses. Subsequently, numerous angu-

1Associate Professor, Department of
Orthodontics, University of São
Paulo City (UNICID), São Paulo,
Brazil.
2Graduate Student, Postgraduate
Dentistry, Area of Concentration in
Orthodontics, Methodist University,
São Paulo, Brazil.
CORRESPONDENCE
Dr Danilo Furquim Siqueira
Rua Costa Aguiar, 875, apto 111
CEP: 04204-000
Ipiranga, São Paulo, SP, Brazil
Email: danilofurquim@uol.com.br
T mony has changed over the cen-
turies. Facial beauty can be defined as
harmony and balance among facial pro-
portions, established by skeletal struc-
tures, teeth, and soft tissue. 1,2 The
desire to improve one’s dentofacial
esthetics is one of the main reasons
patients seek orthodontic treatment.3
Changes in the soft tissue profile are
closely related to dental and skeletal
changes, caused by either orthodontic
treatment or growth.4
In 1907, Angle emphasized the impor-
tance of soft tissues and facial esthetics
in orthodontics. He believed that, to a
great extent, facial harmony and balance
depend on the shape and beauty of the
mouth.5 Therefore, the main goal of any
orthodontic treatment had to be a per-
fect dental relationship. 6 In 1924,
Carrea7 conducted the first investigation
on facial profile on radiographs; in 1944,
Tweed emphasized that ideal positioning
of the mandibular incisors is imperative
for facial balance and harmony. Ortho-
dontists such as as Downs8 and Hold-
away9 included soft tissue profile mea-
surements in their cephalometric
lar and linear measurements with
respective norm values were presented.
With Ricketts’ esthetic plane,10 the
position of the lower lip in relation to line
E (soft tissue pogonion—nose tip) is eval-
uated. Ideally, the upper and lower lips
should be positioned about 2.0 mm
behind the E line. Steiner11 suggested to
use line S (a tangent from soft tissue
chin to S = intersection of nasal col-
umella and upper lip). If the lips touch
the S line, the profile is straight. It is con-
vex if the lips are positioned in front of
this line and concave if positioned
behind. In 1967, Burstone12 suggested a
line through subnasale and soft tissue
pogonion to verify the ideal position of
the upper and lower lips in thranteropos-
terior direction. On average, the upper
lip should be 3.5 ± 1.4 mm in front of
this line, whereas the lower lip should be
2.2 ± 1.6 mm behind it. In 1983, Hold-
away13 defined line H, which connects
the upper lip and soft tissue pogonion
(Ls-Pg). Line H and line NB determine
the angle H, which according to Hold-
away, should ideally range between 7.0
degrees and 15.0 degrees.

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Siqueira et al
Another important factor for facial
analysis is the nasolabial angle, which is
formed by Sn-Co (columella) and Sn-Ls
(upper lip).14,15 This angle was suggested
by Scheideman et al16 in 1980. According
to McNamara,17 it should be the main
guide for defining the sagittal position of
the maxilla. The ideal value of the naso-
labial angle ranges from 90.0 degrees to
110.0 degrees, indicating maxillary retru-
sion if greater 110.0 degrees and protru-
sion if less than 90.0 degrees.
Since physical appearance became
ever more important to society, analyses
such as the ones of Arnett et al18 and
Bergman 19 became more and more
complex comprising a big number of refer-
ence soft tissue points. Today, the analy-
sis of the profile on lateral photographs
and cephalograms is a substantial part of
orthodontic diagnosis and treatment
planning.20–24 Still, according to Suguino,25
it is a challenge to convert the results of
any analysis into a well-defined, objective
therapeutic goal. If orthodontic treatment
aims at overcoming psychosocial difficul-
ties related to facial and dental appear-
ance, the evaluation of esthetics becomes
increasingly more important.26
State-of-the-art orthodontic diagnosis
and treatment planning aims at a balance
and harmony among facial dimensions
and proportions, primarily considering the
soft tissue profile. Thus, the esthetic
impact of dental correction on a patient’s
362
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WORLD JOURNAL OF ORTHODONTICS
Fig 1 Initial frontal and lateral facial
views showing maxillary retrusion, a
slightly concave profile, obtuse
nasolabial angle, and some facial asym-
metry.
face should routinely be considered. In
view of the importance of facial evalua-
tion at the onset of orthodontic/orthope-
dic therapy, the following patient report
will demonstrate that the profile improve-
ment was predominant for orthodontic
treatment planning.
PATIENT REPORT
A 14-year-old white female, presenting a
Class I molar and canine relationship and
an anterior crossbite of her maxillary left
lateral incisor, requested orthodontic
treatment with the chief complaint of
buccally ectopic canines (Figs 1 and 2).
Frontal and lateral facial analysis
revealed a deficiency in zygomatic projec-
tion, indicating a maxillary retrusion. Fur-
ther, a slightly concave profile and facial
asymmetry were obvious.
In agreement with the subjective facial
evaluation, the soft tissue analysis indi-
cated a concave profile, maxillary retru-
sion, and retrusion of the upper and
lower lips (Table 1).
Intraoral and dental cast analysis
revealed a slight maxillary constriction
with increased lingual inclination of the
mandibular posterior teeth, a buccally
ectopic maxillary left canine, a reverse
overbite of the maxillary left lateral
incisor, and a maxillary midline deviation
to the left (Figs 2 and 3).
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VOLUME 10, NUMBER 4, 2009 Siqueira et al

Fig 2 Initial intraoral photographs

revealing buccally ectopic maxillary left
canine, reverse overbite of the maxillary
left lateral incisor, maxillary midline
deviation to the left, and slight maxillary
constriction with lingual inclination of
the mandibular posterior teeth.

Table 1 Soft tissue profile analysis with initial values, ideal values,
and interpretation
Parameter Initial values Ideal values Interpretation

Ricketts’ esthetic plane LL 5.0 mm behind E-line LL 2.0 mm behind E-line Retrusion of lower lip
Steiner’s S line UL and LL behind S-line UL and LL touch S-line Concave profile
Burstone’s line UL 0 mm; LL 1.0 mm in UL 3.5 ± 1.4 mm in UL retruded,
front front, LL 2.2 ± 1.6 mm LL protruded
behind Burstone’s line
Nasolabial angle 133 degrees 90 degrees to 110 degrees Maxillary retrusion
H angle 8 degrees 7 degrees to 15 degrees Normal

LL = lower lip; UL = upper lip.

Fig 3 Initial photographs of dental

casts (compare with Fig 2).

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Table 2 Initial and final cephalometric

measurements
Cephalometric
measurements Initial Final

NAP (degrees) –4.0 0.0

SNA (degrees) 81.5 85.0
SNB (degrees) 82.0 83.0
ANB (degrees) –0.5 2.0
SN-Gn (degrees) 67.0 68.0
SN-Po (degrees) 11.0 11.0
IMPA (degrees) 85.0 86.0
FMA (degrees) 18.0 25.0
SN-GoMe (degrees) 32.0 30.0
UI-NA (degrees) 32.0 25.0
UI-NA (mm) 6.5 5.0
LI-NB (degrees) 16.0 22.0
LI-NB (mm) 1.8 5.0
H-NB (degrees) 7.0 8.0
H-nose (mm) 13.0 14.0

Fig 4 Initial lateral cephalogram and panoramic radiograph showing concave profile, slight maxillary retrusion, and reduced
facial height. Protruded maxillary and retruded mandibular incisors compensate the Class III configuration.

Initial cephalometric measurements lip.15,18 Rapid maxillary expansion (RME)

(Table 2) also confirmed a concave pro-
file, slight maxillary retrusion, reduced
facial height, and protruded maxillary and
retruded mandibular incisors compensat-
ing the skeletal Class III. The analysis of
the initial panoramic radiograph did not
reveal any significant findings (Fig 4).
TREATMENT OPTIONS
Tooth extraction to gain space for the
maxillary left canine and correct the mid-
line had to be excluded because this
treatment would have directly worsened
the profile due to a retrusion of the upper
alone was not indicated either because it
would not have improved the profile.
However, it would have provided space
for the maxillary left canine and allowed
for the correction of the maxillary midline
deviation. All in all, RME with a face
mask followed by leveling and aligning all
teeth seemed to be the most reasonable
option.
TREATMENT SEQUENCE
After placement of elastic separators,
bands were adapted on the maxillary first
molars and first premolars and an

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VOLUME 10, NUMBER 4, 2009 Siqueira et al

Fig 5 (a) Intraoral situation after place-

ment of elastic separators; (b) fabri-
cated Haas appliance on the patient’s
dental cast.

a b

Fig 6 (a) Intraoral situation after Haas

appliance insertion; (b) characteristic
diastema after expansion.

a b

Fig 7 (a and b) Right and left lateral

views showing hooks welded to the
premolar bands (c and d) for application
of face mask elastics.

a b

c d

impression was taken for the fabrication
of a Haas appliance (Figs 5 and 6).
RME was performed by daily activa-
tions of the expander screw for 8 subse-
quent days.
After RME, a face mask for maxillary
protraction (600 cN per side) was applied
to hooks on the Haas expander (Fig 7).
The face mask was used for 5 months
and then removed due to a lack of

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Siqueira et al WORLD JOURNAL OF ORTHODONTICS

Fig 8 Intraoral view after

insertion of postexpansion
retention plate.

Fig 10 Bite plate with

spring to move left lateral
Fig 9 Creating space with an open coil incisor mesially;at the same Fig 11 Intraoral situation after insertion
spring. time, it is moved labially of superelastic Ni-Ti archwire.
with a power chain.

a b c
Fig 12 (a) Frontal and (b and c) lateral intraoral views after repositioning of the maxillary
left canine bracket and placement of the fixed appliance in the mandible.

patient compliance. At this time, a reten-
tion plate was placed for 6 months (Fig
8). Also, a fixed appliance (Roth prescrip-
tion) was inserted in the maxillary arch.
All teeth were leveled and aligned with
nickel-titanium archwires, followed by
stainless steel wires.
After expansion with an open coil
spring, sufficient space for the labial
movement of the maxillary left lateral
incisor was created (Fig 9). A bite plate
with coil springs was placed to move this
tooth mesially. Simultaneously, a ligature
between the bracket on the maxillary left
lateral incisor and the archwire inclined it
buccally (Fig 10).
This bite plate was used for 2 months;
after the first month, the stainless steel
wire was replaced by a Ni-Ti wire and the
maxillary left lateral incisor and canine
were included in the appliance, as
demonstrated in Fig 11.
After the crossbite correction, the
bracket on the maxillary left canine was
rebonded to accomplish a better angula-
tion. At the same time, the plate was
removed and a fixed appliance was
inserted in the mandibular arch (Fig 12).
RESULTS
After active treatment, a removable
retainer was placed in the maxilla and a
bonded 3-to-3 retainer in the mandible
(Fig 13).
The facial profile was significantly
improved by moving the upper lip for-
ward, as seen in Figs 14 and 15 and
confirmed by the final cephalometric
analysis in Tables 2 and 3. The naso-
labial angle was reduced, the NAP and
SNA angle increased, and the ANB angle
changed to a positive reading.

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VOLUME 10, NUMBER 4, 2009 Siqueira et al

Fig 13 (a and b) Extraoral frontal and

(c to e) intraoral photographs after com-
pletion of treatment.

a b

c d e

Fig 14 (a) Initial and (b) final extraoral

lateral photographs.

Fig 15 (below) Final lateral cephalo-

gram and panoramic radiograph. a b

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Siqueira et al
Table 3 Inital and final soft tissue profile analysis values
Parameter Initial values
Ricketts’ esthetic plane LL 5 mm behind E-line
Steiner’s S line Concave profile
Burstone’s line UL 0 mm
UL 0 mm
Nasolabial angle 133 degrees
H angle 8 degrees
Figure 16 demonstrates satisfactory
stability at the 4-year follow-up.
Figure 17 shows the superimpositions
of the cephalometric tracings at the
beginning, and at the end of treatment
as seen at the 4-year follow-up. The
superimpositions reveal the improvement
of the incisor position and the soft tissue
profile as the treatment stability.
DISCUSSION
Cephalometric analysis is routinely used
for orthodontic diagnosis because it is an
effective method to evaluate faciodental
features. At the same time, it used to be
thought that the achievement of estab-
lished cephalometric standards would
assure a satisfactory esthetic outcome
with regard to the soft tissue profile.6,23,25
However, this proved not to be true,
because a good occlusal relationship
does not necessarily imply facial harmony
or vice versa. The increasing esthetic con-
cern of modern societies and the advent
of better therapeutic resources (advances
in orthognathic surgery) led to an evolu-
tion of cephalometrics by establishing
soft tissue measurements that might indi-
cate facial beauty and harmony. Beside
cephalometric analyses, standardized
photographs provide even more reliable
parameters for treatment planning.
The nasolabial angle is of ten
employed for the evaluation of the facial
profile even though it is influenced by
nasal morphology.14,15,17 That is why Fitz-
gerald et al6 stated that the nasolabial
angle may not reliably describe variations
in the soft tissue profile. This highlights
the importance of evaluating nasal mor-
phology during orthodontic diagnosis. In
the present report, the nasolabial angle
368
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WORLD JOURNAL OF ORTHODONTICS
Final values
LL 5 mm behind E-line
Concave profile
LL 1mm in front
LL 1mm in front
128 degrees
8 degrees
at treatment onset was 133.0 degrees,
which is far from the ideal of 90.0
degrees to 110.0 degrees. Subjective
facial analysis was fundamental in con-
firming this deviation because the profile
evaluation revealed a soft tissue defi-
ciency of this region. The vermillion of the
upper lip was reduced in thickness, even
though the U1-NA (degrees and mm) val-
ues increased, thus favoring some projec-
tion of the upper lip.
Initial analysis in this patient revealed
a facial convexity angle of –4.0 degrees,
indicating a concave skeletal profile and
thereby confirming the need for maxillary
protraction to improve the profile.
Because the nose grows forward and
downward (more intensely during adoles-
cence and slower throughout life)4 and
the chin grows forward, the lips are pro-
gressively retruded.10 However, not to rely
on growth, which is difficult to predict,
seemed to be the best therapeutic option
for this patient.
Even though the patient initially pre-
sented with a Class I molar relationship,
a face mask was used after maxillary
expansion to improve her facial esthetics.
This is justified by the improvement of
the nasolabial angle (133.0 degrees to
128.0 degrees) and the facial convexity
angle (–4.0 degrees to 0 degrees).
Notwithstanding the lack of her compli-
ance, the face mask also helped to cor-
rect the patient’s crossbite.
All treatment goals were fully achieved
in this patient because her chief com-
plaint (buccally ectopic canines) was
eliminated. At the same time, a harmo-
nious profile was established.
361_Siqueira.qxd 11/10/09 4:15 PM Page 369

VOLUME 10, NUMBER 4, 2009 Siqueira et al

Fig 16 (a and b) Extraoral and (c to g)

intraoral photographs at 4-year follow-
up.

a b

c d e

Fig 16 (a and b) Extraoral and (c to g)

intraoral photographs at 4-year follow-
up.

f g

a b c
Fig 17 Superimpositions of cephalometric tracings on point S (S). (a) Superimposition of initial (blue) and final (red) tracing,
(b) superimposition of initial (blue) and follow-up (red) tracing, and (c) superimposition of final (red) and follow-up (blue) tracing.

369

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361_Siqueira.qxd 11/10/09 4:15 PM Page 370
Siqueira et al
CONCLUSION
The search for balance and harmony of
facial proportions for esthetics, especially
in respect to the soft tissue profile, is fun-
damental for sound orthodontic treat-
ment planning. RME with a face mask
was effective for this patient who exhib-
ited a maxillary deficiency in both antero-
posterior and transverse dimension.
Furthermore, this treatment was stable
4 years after therapy.
REFERENCES
1. Langlade M. Diagnóstico Ortodôntico, ed 3.
São Paulo: Ed Santos, 1993:129–159.
2. Hambleton RS. The soft-tissue covering of the
skeletal face as related to orthodontic prob-
lems. Am J Orthod 1964;50:405–420.
3. Burstone CJ. Integumental contour and exten-
sion patterns. Angle Orthod 1959;29:93–104.
4. Subtelny JD. The soft tissue profile, growth, and
treatment changes. Angle Orthod 1961;31:
105–122.
5. Erbay EF, Caniklioglu CM, Erbay SK. Soft tissue
profile in Anatolian Turkish adults: Part I. Evalu-
ation of horizontal lip position using different
soft tissue analyses. Am J Orthod Dentofacial
Orthop 2002;121:57–64.
6. Fitzgerald JP, Nanda RS, Currier GF. An evalua-
tion of the nasolabial angle and the relative
inclinations of the nose and upper lip. Am J
Orthod Dentofacial Orthop 1992;102:
328–334.
7. Carrea CS. Les radiofaces a profile delinee en
orthodontometrie. Semaine Dent 1924;6:
16–19.
8. Downs WB. Analysis of the dentofacial profile.
Angle Orthod 1956;26:191–212.
9. Holdaway RA. Changes in relationship of points
A and B during orthodontic treatment. Am J
Orthod Dentofacial Orthop 1956;42:176–193.
10. Ricketts RM. Planning treatment on the casis
of the facial pattern and an estimate of its
growth. Angle Orthod 1957;27:14–37.
11. Steiner CC. Cephalometric as clinical tool. In:
Kraus B, Riedel RA, eds. Vistas in Orthodontics,
ed 1. Philadelphia: Leandro & Febiger, 1962:
131–161.
12. Burstone CJ. Lip posture and its significance in
treatment planning. Am J Orthod 1967;53:
262–284.
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13. Holdaway RAA. A soft-tissue cephalometric
analysis and its use in orthodontic planning.
Part I. Am J Orthod 1983;84:1–28.
14. Brandão AMB. Avaliação da correlação entre
as características dentárias esqueléticas e
tegumentares em portadores de má oclusão cl.
II div. 1a, obtidas pela cefalometria e análise
facial numérica. R Dental Press Ortodon e
Ortop Facial 2002;7:27–35.
15. Salgado JAP, Moraes LC, Castilho, JCM,
Moraes, MEL. Avaliação do ângulo nasolabial,
em radiografias cefalométricas laterais, divi-
dido em ângulo superior e inferior, por uma
linha paralela ao plano de Frankfort, em indiví-
duos portadores de má-oclusão classe II e
classe III de angle. Cienc Odontol Bras 2003;
6:40–49.
16. Scheideman GB, Bell WH, Legan HL, Finn RA,
Reisch JS. Cephalometric analysis of dentofa-
cial normals. Am J Orthod Dentofacial Orthop
1980;78:404–420.
17. McNamara JAA Jr. Method of cephalometric
evaluation. Am J Orthod 1984;86:449–469.
18. Arnett GW, Jelic JS, Kim J, et al. Soft tissue
cephalometric analysis: Diagnosis and treat-
ment planning of dentofacial deformity. Am J
Orthod Dentofacial Orthop 1999;116:239–253.
19. Bergman RT. Cephalometric soft tissue facial
analysis. Am J Orthod Dentofacial Orthop
1999;116:373–389.
20. Riveiro PF, Quintanilla DS, Chamosa ES, Cun-
queiro MS. Linear photogrammetric analysis of
the soft tissue facial profile. Am J Orthod
Dentofacial Orthop 2002;122:59–66.
21. Scavone H Jr, Trevisan JH Jr, Garib DG, Ferreira
FV. Facial profile evaluation in Japanese-Brazil-
ian adults with normal occlusions and well-bal-
anced faces. Am J Orthod Dentofacial Orthop
2006;129:721.e1–721.e5.
22. Halazonetis DJ. Morphometric evaluation of
soft-tissue profile shape. Am J Orthod Dentofa-
cial Orthop 2007;131:481–489.
23. Lundström A, Forsberg CM, Peck S, McWilliam
J. A proportional analysis of soft tissue facial
profile in young adults with normal occlusion.
Angle Orthod 1992;62:127–133.
24. Chen, K. So, L. L. Soft tissue profile changes of
reverse headgear treatment in Chinese boys
with complete unilateral cleft lip and palate.
Angle Orthod 1997;67:31–38.
25. Suguino R, Ramos AL, Terada HH, Furquim LZ,
Maeda L, Silva Filho OG. Análise Facial. R Dental
Press Ortodon e Ortop Facial 1996;1:86–107.
26. Proffit W, Fields H. Contemporary Orthodontics,
ed 3. St Louis: Mosby, 2000:742– 2000.
371_Koidis.qxp 11/6/09 2:43 PM Page 371

Petros T. Koidis,
DDS, MS, PhD1 ANKYLOSING SPONDYLITIS ASSOCIATED
Ioanna Basli, DDS2 WITH CRANIOMANDIBULAR DISORDER—
Nikos Topouzelis,
DDS, PhD3
A COMBINED ORTHODONTIC AND
PROSTHODONTIC THERAPEUTIC
APPROACH
Ankylosing spondylitis is a disease that causes inflammatory changes
of the involved joints. Although the initial clinical signs are pain and
discomfort, synovial changes progressively involve all the axial
joints, including the temporomandibular joint (TMJ). Eventually, bony
alterations develop (condylar erosions, flattening, sclerosis) that
affect the position of the condyle, the superior joint space, and the
range of movements. These symptoms correlate with the severity of
the disease. Besides physiotherapy and surgery, no dental rehabilita-
tion has been reported for these patients. This report of a female
patient with ankylosing spondylitis and a TMJ disorder emphasizes
dental rehabilitation. The aim of the splint, orthodontic, and prostho-
dontic treatment was to relieve the subjective symptoms through
establishing a stable optimum occlusion. Anamnestic, laboratory, and
clinical findings including pre- and postradiographic examination
records are presented. World J Orthod 2009;10:371–377.

Key words: ankylosing spondylitis, craniomandibular disorders,

rehabilitation

nkylosing spondylitis is a chronic environmental agents.5 A familial cluster-

1Professor, Department of Fixed Pros-
thesis & Implant Prosthodontics,
School of Dentistry, Aristotle Univer-
sity of Thessaloniki, Thessaloniki,
Greece.
2Private Practice, London, England.
3Associate Professor, Department of
Orthodontics, School of Dentistry,
Aristotle University of Thessaloniki,
Thessaloniki, Greece.
CORRESPONDENCE
Dr Nikos Topouzelis
Department of Orthodontics
School of Dentistry
Aristotle University of Thessaloniki
54124 Thessaloniki
Greece
Email: ntopouz@dent.auth.gr
A inflammatory disorder of the axial
skeleton, sacroiliac, and large peripheral
joints.1 The clinical signs vary from mild
mobility limitation to total ankylosis and
can be compounded by extra-articular
manifestations.2
Ankylosing spondylitis has a strong
association with psoriatic arthritis, a sub-
set of reactive arthritis, and arthritis/
sacroiliitis in inflammatory bowel dis-
eases.3 It occurs in 0.2% of the popula-
tion with a male/female ratio of 2.5 to
5.0:1.0. Ankylosing spondylitis typically
presents in young adulthood, but symp-
toms may arise in adolescence or
earlier.4
The etiology of ankylosing spondylitis
is suspected to be an interrelation
between HLA genes, sex factors, and
ing exists, with Class I HLA-B27 antigen
of the major histocompatibility complex
(MHC) being the major allele in 95% of
affected persons. Many candidate gene
loci for the susceptibility of this disease
have been suggested, but no evidence of
linkage is yet confirmed.6 The cytokine
tumor necrosis factor alpha (TNF-␣) may
also be involved.7 Trauma and bacterial
infections act as triggering factors, which
disturb the immune system.8 The 60kDa
heat shock protein of Klebsiella Pneumo-
niae plus its homology in sequence with
other enterobacteria indicate their
involvement in ankylosing spondylitis.9
As for HLA-B27–negative families, a
hypothesis is that genes for psoriasis or
other alleles of the MHC may be etiologi-
cally important.6,10

371

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371_Koidis.qxp 11/6/09 2:43 PM Page 372
Koidis et al
Table 1 Laboratory findings in patients with ankylosing spondylitis showing which
components are elevated, present, or absent
Elevated
ESR HLA-B27
CRP Normochromic normocytic anemia
Akaline phosphatase Leukocytosis
IgA, IgG
The inflammatory process begins at
the ligament, tendon, and joint capsule
attachments to bone—the entheses. This
comprises an agglomeration of chronic
inflammatory cells and bone erosion.
Later, features of healing by fibrosis, scle-
rosis of the underlying bone, and new
bone formation in the adjacent ligaments
can be observed.11 In case of the verte-
bral column, the new bone, termed syn-
desmophyte, forms bridges both laterally
and anteriorly to vertebral bodies. This
leads to a fusion of the spine, thus con-
verting it into a rigid structure, which is
vulnerable to fracture.12
The onset of this disease is insidious,
often beginning in the sacroiliac region
and spreading upward to the thoracic
and cervical spine. A suspicious symp-
tom of ankylosing spondylitis is lower
back pain that persists longer than 3
months, worsening by inactivity but
improving with exercise. In time, flexion
and rotation are inhibited, rigidity
becomes extreme (ankylosis), and the
cervical spine is curved while chest
expansion is limited and respiration
impaired.13,14 Additional symptoms are
low-grade fever, fatigue, tachycardia, and
anorexia responsible for loss of weight
and muscle.15
Peripheral asymmetric oligoarthropa-
thy16 and joint synovitis is seen in 30% of
patients. Systemic manifestations also
include ocular lesions (anterior uveitis
and iridocyclitis) and cardiovascular affec-
tions (aortitis, mitral valve involvement,
and pericarditis). Rare complications are
pulmonary fibrosis, neurologic disorders,
and secondary amyloidosis. 17–19 The
progress of ankylosing spondylitis can be
relentless or can cease at any stage.15
372
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WORLD JOURNAL OF ORTHODONTICS
Present Absent
RA factor
Autoantibodies
Laboratory findings support the inflamma-
tory nature of the disease (Table 1).3,20
Diagnosis of ankylosing spondylitis is
based on a patient’s symptoms: a family
history of iritis, psoriasis, or spondy-
loarthropathies; and physical examina-
tion that demonstrates a decreased
range of spinal motion in all directions.14
Laboratory findings verify the diagnosis;
however, radiographic examination is
helpful. The main laboratory finding that
characterizes ankylosing spondylitis is
the presence of HLA-B27, which is pre-
sent in 40% to 95% of all patients.21 The
radiologic findings of ankylosing spondyli-
tis usually include symmetric sacroiliac
joint space narrowing and blurring of joint
margins, subchondral sclerosis, squaring
of vertebral bodies with paravertebral
syndesmophytes, general erosions, and
sclerosis of ligamentous attachments.
These pathologic findings progressively
lead to the characteristic ankylosed
“bamboo spine.”22,23
Treatment relies on daily physical ther-
apy, including stretching, back extension,
and breathing exercises. Medications
such as NSAIDs suppress ar ticular
inflammation, pain, and muscle spasms;
new NSAIDs, known as COX-2, have even
fewer adverse effects. Sulfasalazine, glu-
cocorticoids, narcotics, analgesics, or
muscle relaxants are also beneficial.24–27
Anti-TNF-␣ agents, such as infliximab28,29
and radium-224 in intravenous injec-
tions, 25 seem promising. If ankylosing
spondylitis leads to immobility, surgical
treatment can be indicated. Radiotherapy
is recommended as a last resort due to
the risk of developing acute myelogenous
leukemia.30,31
371_Koidis.qxp 11/6/09 2:43 PM Page 373
VOLUME 10, NUMBER 4, 2009
Fig 1 Patient’s initial intraoral situation: Increased overbite, crowding, and buccal nonocclusion of the maxillary left first and
second premolars.
TMJ INVOLVEMENT
Ankylosing spondylitis has a tendency to
affect fibrocartilaginous structures such
as the TMJ. In fact, TMJ affections occur in
11% to 35% of all ankylosing spondylitis
patients. The variation in frequency can be
explained by the type of study, the exam-
ined population, and the tools used to
assess TMJ affection.32–35 The most com-
mon subjective symptoms are difficulties
in wide mouth-opening, TMJ crepitus, pain,
stiffness, swelling, and headaches.36,37
Computed tomography (CT) and magnetic
resonance imaging (MRI) images show
temporal flattening, abnormal condylar
shape, erosions, sclerosis, disc alter-
ations, osteophytes and even total ankylo-
sis of the joint. 38,39 TMJ treatment
includes physiotherapy and occasionally
moist heat and ultrasound application.40
In acute phases of TMJ arthritis, glucocor-
ticoid injections are indicated. To prevent
muscle hyperactivity and articular strain
due to bruxism, occlusal splints can be
inserted, but in cases of obvious occlusal
interferences, occlusal adjustment or
prosthetic reconstruction could be neces-
sary. Orofacial pain can be treated with
transcutaneous nerve simulation. When
the TMJ is ankylosed, surgical interven-
tions such as arthroplasty and synovec-
tomy with discectomy are indicated. If not,
a joint prosthesis becomes necessary.37,41
PATIENT REPORT
A 36-year-old female presented with bilat-
eral pain in her masticatory muscles and
both TMJs, headaches localized in the
temporal and iliac region, and a feeling of
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Koidis et al
fatigue during speech. She reported an
earlier diagnosis of scoliosis, iritis, and
an operation on the right inner ear due to
an angiotumor of the tympanon. General
symptoms such as malaise or pain
throughout all joints, especially with
humid weather, were also present. The
clinical examination revealed tenderness
to palpation of the right TMJ as of her
right sternocleidomastoid and posterior
belly of digastric muscles. In addition,
swelling of the ankle joints with persis-
tent depression upon pressure and pain
upon pressure on the distal and proximal
interphalangeal joints were noticed. Maxi-
mum mouth-opening amounted to
49 mm, right/left lateral excursion to
12 mm/13 mm, and protrusion to 12 mm.
She had an Angle Class I molar and
canine relationship and a deep curve of
Spee on her left side (Fig 1). The maxil-
lary and mandibular anterior teeth were
crowded, and the overbite increased so
that the crown of the mandibular left cen-
tral incisor was covered by its antagonist
by 110%. The mandibular left first and
second premolars were severely lingually
inclined, thus leading to a buccal nonoc-
clusion of their antagonists.
Laboratory findings revealed that
rheumatoid factor was negative, while
the HLA-B27 antigen was positive (Table
1). The diagnosis of ankylosing spondyli-
tis was verified by a rheumatologist. The
specific differential diagnosis was based
primarily on the laboratory findings and
only secondarily on the rheumatologic
symptoms.
The aim of the dental rehabilitation
was to relieve the subjective symptoms by
aligning all teeth optimally and establish-
ing an ideal stable occlusion. This was
373
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Koidis et al WORLD JOURNAL OF ORTHODONTICS

Fig 2 Intraoral situation with a mandibular stabilization splint in place at the initiation of orthodontic treatment.

Fig 3 Introaral situation after placement of an anterior repositioning splint.

Fig 4 Patient’s final occlusion after orthodontic therapy with reduced overbite, eliminated crowding, and corrected nonocclu-
sion of the mandibular left first and second premolars.

Fig 5 Clinical try in of the cast copings, including the maxillary right first premolar
and a cantilever for the maxillary right canine; porcelain-fused-to-metal crowns with
metal surfaces restored the posterior teeth.

Fig 6 Intraoral situation at the completion of the prosthetic reconstruction.

374

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371_Koidis.qxp 11/6/09 2:43 PM Page 375
VOLUME 10, NUMBER 4, 2009
a c
achieved by a combination of kinesio- and
splint therapy, followed by orthodontic
and prosthodontic treatment. Kinesiother-
apy for the head and neck was initiated to
diminish the chance of TMJ ankylosis and
relax the masticatory muscles.
The full-coverage stabilization man-
dibular splint aimed at a load reduction of
the TMJ, especially during mastication,
thus reducing the sensitivity of the joints
and masticatory muscles (Fig 2). At the
same time, the splint raised the bite,
which helped to correct the lingual non-
occlusion of the mandibular left first and
second premolars. Subsequently, to relo-
cate both condyles in a more physiologic
position and further unload the TMJ, an
anterior repositioning splint with a signifi-
cant increase of the vertical dimension (8
to 9 mm) was inserted (Fig 3). With the
accompanying orthodontic treatment, the
buccal nonocclusion was corrected and
the crowding alleviated, which led to
desensitization of both the joints and
muscles.
Finally, upon completion of orthodon-
tic treatment (Fig 4), the patient received
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Koidis et al
Fig 7 (a) Pretreatment and (b) post-
treatment panoramic radiographs and
(c) 1-year posttreatment orthopantomo-
graphic sectional images of both joints.
a prosthetic rehabilitation of her poste-
rior teeth (Fig 5). The prosthetic rehabili-
tation was thought to further stabilize the
patient’s occlusion, developing almost
pure canine guidance (the maxillary right
first premolar was included because the
maxillary right canine was a cantilever).
Also, occlusal interferences were elimi-
nated, masticatory function improved,
and esthetics enhanced by replacing the
unattractive prosthetic work (Fig 6).
The combined orthodontic and pros-
thetic therapy was succeeded by periodi-
cal examinations for a period of 2 years.
These follow-ups included both clinical
and radiologic examinations.
All therapeutic efforts resulted in the
elimination of the clinical symptoms in-
cluding reduction of the patient’s head-
aches and fatigue during speech. The
relocated condyles maintained their posi-
tion without any evidence of deterioration
2 years posttreatment as revealed radio-
graphically (Fig 7). With minor occlusal
refinements, the patient remained asymp-
tomatic 8 years after the completion of
treatment.
375
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Koidis et al
CONCLUSION
In a case of ankylosing spondylitis, it was
possible by combined orthodontic and
prosthodontic treatment to relieve sub-
jective symptoms through realignment of
elements of the stomatognathic system,
to achieve optimum tooth and arch posi-
tions and relationships, and to develp a
permanently functional and stable
occlusal scheme.
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Rheum Dis Clin North Am 1998;24:737–751.
25. Braun J, Zochling J, Baraliakos X, et al. Efficacy
of sulphasalazine in patients with inflammatory
back pain due to undifferentiated spondy-
loarhritis and early ankylosing spondylitis: A
multicentre randomised controlled trial. Ann
Rheum Dis 2006;65:1147–1153.
26. Ferraz M, Tugwell P, Goldsmith CH, Atra E.
Meta-analysis of sulfasalazine in ankylosing
spondylitis. J Reumatol 1990;17:1482–1486.
27. Lee CK, Lee EY, Cho YS, Moon KA, Yoo B, Moon
HB. Increased expression of glycorticoid recep-
tor beta messenger RNA in patients with anky-
losing spondylitis. Korean J Intern Med 2005;
20:146–151.
28. Breban M, Vignon E, Claudepierre P, et al. Effi-
cacy of infliximab in refractory ankylosing
spondylitis. Results of a 6-month open-label
study. Rheumatol (Oxford). 2002;41:
1280–1285.
29. Braun J, Brandt J, Listing J, et al. Treatment of
active ankylosing spondylitis with infliximab: A
randomised controlled multicentre trial. Lancet
2002;359:1187-1193.
30. Tiepolt C, Gruning T, Franke WG. Renaissance
of 224 Ra for the treatment of ankylosing
spondylitis: Clinical experiences. Nucl Med
Commun 2002;23:61–66.
31. Walter BJ, Hamilton CM, Israel SM. Principles
of Pathology for Dental Students. Edinburg:
Churchill Livingstone, 1974: 304.
32. Kelley WN, Harris ED, Ruddy S, Sledge CB. Text-
book of Rheumatology ed 3. Philadelphia: WB
Saunders, 1989:1021–1034.
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33. Wenneberg B, Könönen M, Kallenberg A. Radio-
graphic changes in the temporomandibular joint
of patients rheumatoid arthritis, psoriatic arthri-
tis and ankylosing spondylitis. J Craniomandib
Disord 1990;4:35–39.
34. Könönen M, Wenneberg B, Kallenberg A. Cran-
iomandibular disorders in rheumatoid arthritis,
psoriatic arthritis, and ankylosing spondylitis.
A clinical study. Acta Odontol Scand 1992;50:
281–287.
35. Helenius LMJ, Tervahartiala P, Helenius I, et al.
Clinical, radiographic, and MRI findings of the
temporomandibular joint in patients with differ-
ent rheumatic diseases. Int J Oral Maxillofac
Surg 2006;35:983–989.
36. Major P, Ramos Remus C, Suarez-Almazor ME,
Hatcher D, Parfitt M, Russell AS. Magnetic reso-
nance imaging and clinical assessment of tem-
poromandibular joint pathology in ankylosing
spodylitis. J Rheumatol 1999;26:3:616–621.
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MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
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37. Zarb AG, Carlson EG, Sessle JB, Mohl DN. Tem-
poromandibular Joint and Masticatory Muscle
Disorders. Copenhagen: Munksgaard, 1994:
367–372.
38. Ramos-Remus C, Major P, Gomez-Vargas A, et
al. Temporomandibular joint osseous morphol-
ogy in a consecutive sample of ankylosing
spondylitis patients. Ann Rheum Dis 1997;56:
103–107.
39. Ramos-Remus C, Perez-Rocha O, Ludwig RN, et
al. Magnetic resonance changes in the tem-
poromandibular joint in ankylosing spondylitis.
J Rheumatol 1997;24:123–127.
40. Okeson PJ. Management of Temporomandibu-
lar Disorders and Occlusion. St Louis: Mosby,
1989.
41. Wolford ML, Mehra P. Custom-made total joint
protheses for TMJ recontruction. BUMC Pro-
ceedings 2000;13:135–138.
377
378_Coelho.qxd 11/6/09 2:44 PM Page 378

TREATMENT OF A MUTILATED Carlos M. Coelho, DDS,

MSD1

DENTITION WITH THE MANDIBULAR Fabio Coelho, DDS, MSD2

PROTRACTION APPLIANCE: Larry W. White, DDS, MSD3

A PATIENT REPORT
A 35-year-old female presented missing her maxillary right first pre-
molar, left central and lateral incisors, and left second premolar and
mandibular left first molar. The referring dentist had requested that
only the maxillary left first molar be intruded to facilitate the prostho-
dontic replacement of the missing mandibular left first molar. After
clinical examination and consultation with her dentist, it was decided
to protract the mandibular left second and third molars, intrude the
maxillary left first molar, replace the missing incisors with a tempo-
rary partial denture, and restore the missing maxillary right first pre-
molar with an implant. World J Orthod 2009;10:378–382.

Key words: MPA, missing teeth, partial denture

dult patients offer challenges for the INTRAORAL FINDINGS

A orthodontist seldom seen in adoles-
cents: Because of their age and dental
history, they often present with missing
teeth, restorations, and compromised
periodontal conditions. This 35-year-old
female with a Class I occlusion was
missing multiple teeth, had an extruded
maxillary left first molar and mesially
After a clinical examination, the follow-
ing symptom list was compiled (Fig 1):
• Class I occlusion
• Deep anterior overbite with moderate
anterior overjet
• Slight midline shift
1Private
Practice of Orthodontics; for-
merly, Professor, Department of
Orthodontics, Federal University of
Maranhao, Brazil.
2Private Practice of Orthodontics,

tipped mandibular left first and second
molars, and displayed isolated periodon-
tal problems. Her general dentist had
referred her for intrusion of the maxillary
left first molar to facilitate a prosthodon-
tic replacement of the missing mandibu-
lar left first molar. The missing maxillary
left incisors created a big esthetic prob-
lem for orthodontic therapy.
• Multiple missing teeth
• Extruded and periodontally compro-
mised maxillary left first molar
• Generalized attachment loss
• Mesially tipped mandibular left first
and second molars
• Root canal filling of the mandibular
left second premolar
• Straight profile
• Frequently locked temporomandibular
joints (TMJs) upon awakening
Associate Professor, Brazilian Den-
tal Society/Maranhao, Brazil.
3Private Practice of Orthodontics,
Dallas, Texas, USA.
CORRESPONDENCE
Dr Carlos Martins Coelho Filho
Rua Prof. Luis Pinho Rodrigues 20
Sala 204
Renascenca II Ed QUARTZ
65075-740 San Luis, Maranhao
Brazil
Email: carlosm@elo.com.br

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378_Coelho.qxd 11/6/09 2:44 PM Page 379

VOLUME 10, NUMBER 4, 2009 Coelho et al

Fig 1 Patient before therapy (a and b)

with a straight profile; (c to g) a deep
anterior overbite with a moderate ante-
rior overjet, a slight midline shift, multi-
ple missing teeth, an extruded and
periodontally compromised maxillary
left first molar; and (h) a generalized
attachment loss, mesially tipped
mandibular left first and second molars,
and a root canal filling of the mandibular
left second premolar.
a b

c d e

f g

TREATMENT OBJECTIVES closure is described in the literature.1–3

A prime task prior to orthodontic therapy
was to establish normal periodontal con-
ditions. Rather than uprighting and
retracting the mandibular left first and
second molars, these teeth were pro-
tracted using a closing arch and a man-
dibular protraction appliance (MPA). This
procedure for successful posterior space
The maxillary left first molar had to be
intruded, and the maxillary right second
premolar was to be moved mesially into
the area of the first premolar so an
implant could replace the second premo-
lar. The missing maxillary left central and
lateral incisors were to be replaced by a
partial denture with brackets.

379

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378_Coelho.qxd 11/6/09 2:44 PM Page 380

Coelho et al WORLD JOURNAL OF ORTHODONTICS

Fig 2 Intraoral situation after place-

ment of a standard 0.022-inch twin
bracket system. Figure 2a shows the
situation after the brackets were placed
on the archwire, while Fig 2b shows
the situation after they were bonded to
a b the denture.

c d

a b c
Fig 3 Intraoral situation after leveling and aligning. Placement of an archwire with a closing loop on the left side to protract
both molars and insertion of an MPA on the right side to reinforce anchorage in the mandible.

Fig 4 Intraoral situation after protrac-

tion of the mandibular left molars and
moving the maxillary right second pre-
molar into the first premolar’s position.

a b

TREATMENT ALTERNATIVES TREATMENT PROGRESS

One alternative would have been to
remove the maxillary left first molar so
the second and third molars could move
forward. However, the periodontist coun-
seled against this approach because of
the poor osseous condition in that area.
Also, the missing maxillary right first pre-
molar could have been replaced by an
implant, but as treatment progressed, the
periodontist decided to move the second
premolar mesially with a compressed coil
spring. Thus, a better implant site was
accomplished in the original position of
the second premolar.
Standard 0.022-inch twin brackets were
placed on all teeth except for the molars,
which received bands. Brackets for the
denture were initially attached to the
archwire; after insertion of the partial
denture, they were bonded to the artifi-
cial teeth (Fig 2).
After leveling and aligning, an archwire
with only one closing loop on the left side
was placed in the mandible (Fig 3). At the
same time, an MPA was inserted on the
right side to reinforce the anchorage in
the mandible. Figure 4 shows the situa-
tion after the mandibular left molars were
protracted and the maxillary right second
premolar moved into the first premolar’s
position.

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378_Coelho.qxd 11/6/09 2:44 PM Page 381

VOLUME 10, NUMBER 4, 2009 Coelho et al

Fig 5 Situation at the end of treat-

ment. (a and b) Unchanged profile. (c
to g) Bilateral Class I canine occlusion
with a Class I molar occlusion on the
right and a Class II occlusion on the left
side, good overbite and overjet, and
midline correction. The maxillary right
second premolar was replaced by an
implant with a crown, and the partial
denture was still in place. (h) The
panoramic radiograph reveals parallel
root orientation and no pathologies. a b

c d e

f g

RESULTS (Fig 5). The maxillary right second premo-

At the conclusion of treatment, the patient
displayed an unchanged profile, a bilat-
eral Class I canine occlusion with a Class
I molar occlusion on the right and a Class
II occlusion on the left side, good over-
bite and overjet, and a midline correction
lar was replaced by an implant with a
crown. The patient was to keep the par-
tial denture until her dentist determined
what the optimal final restoration of this
area would entail. The patient no longer
suffers from TMJ symptoms.

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378_Coelho.qxd 11/6/09 2:44 PM Page 382

Coelho et al WORLD JOURNAL OF ORTHODONTICS

DISCUSSION REFERENCES

Protracting mandibular posterior teeth is
complicated because the anterior teeth
may move too far distally. The MPA is
proven to prevent this and therefore
became an integral part of this patient’s
treatment plan. Herbst appliances,
Jasper jumpers, or Forsus springs could
provide the same stability for the
mandibular anterior teeth. The many den-
tal deficits of this patient necessitated a
multidisciplinary approach (periodontist,
restorative dentist, and orthodontist).
1. Coelho Filho CM, White LW. Treating adults with
mandibular protraction appliance. Orthod Cyber
J. 2003: http://www.oc-j.com/jan03/MPA2.htm.
2. Coelho Filho CM. Emprego do aparelho de pro-
tração mandibular. In: Grupo Brasileiro de Pro-
fessores de Ortodontia e Odontopediatria. 9º
Livro Anual do Grupo Brasileiro de Professores
de Ortodontia e Odontopediatria, ed 1. São
Paulo: IMC - Image Maker Comunicações,
1997:122–129.
3. Coelho Filho CM. Mandibular protraction appli-
ance IV. J Clin Orthod 2001;35:18–24.

CONCLUSION

After 20 years of author use that

demonstrates high levels of efficiency in
the treatment of several orthodontic
problems, the MPA shows once again
how versatile a tool it can be as a part of
the orthodontic armamentarium.

382

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Tancan Uysal, DDS, PhD1
DENTAL MATURATION IN PATIENTS
Ahmet Yagci, DDS2
WITH UNILATERAL POSTERIOR CROSSBITE
Sabri Ilhan Ramoglu,
DDS, PhD3 Aim: To investigate whether there is a difference in dental maturation
between patients with a skeletal unilateral crossbite and a control
sample (individuals with an Angle Class I and no crossbite) and to
compare the dental maturation on the right and left posterior seg-
ments in both samples. Materials and Methods: The sample consisted
of 101 Turkish individuals (53 boys and 48 girls, 8 to 13 years of age,
mean age 10.90 ± 1.62 years). These subjects were divided into two
groups: unilateral posterior crossbite (23 boys and 28 girls, mean age
10.87 ± 2.01 years) and control (25 boys and 25 girls, mean age 10.93 ±
1.14 years). Each subject’s dental age (according to Demirjian’s dental
maturity score) was determined with an orthopantomogram. A differ-
ence of 6 months at a significance level of P < .05 was considered clini-
cally significant, so the power of the statistical test was 85%. Results:
No sexual dimorphism was detected for the chronological or dental
age in either group. In both groups, the dental ages determined from
Demirjian and Goldstein’s tables were more advanced than the chrono-
logical ages. Dental age did not differ significantly between sides. Sub-
jects with a posterior crossbite had a tendency for a delayed dental
maturation compared to the control individuals. A difference of about
1 month was observed between the right and left sides in the crossbite
and control groups. Conclusion: The difference in dental age between
the crossbite and control groups was big enough to be clinically rele-
vant. No significant side differences in either group were detected.
World J Orthod 2009;10:383–388.

Key words: crossbite, dental age, dental maturation

xamining the formation and eruption Tooth maturation is a multifactorial

1Associate Professor and Chair,
Department of Orthodontics, Faculty
of Dentistry, Erciyes University, Kay-
seri, Turkey.
2Research Assistant, Department of
Orthodontics, Faculty of Dentistry,
Erciyes University, Kayseri, Turkey.
3Assistant Professor, Department of
Orthodontics, Faculty of Dentistry,
Erciyes University, Kayseri, Turkey.
CORRESPONDENCE
Dr Tancan Uysal
Erciyes Üniversitesi
Dis Hekimligi Fak. Ortodonti AD
Melikgazi, Kayseri 38039
Turkey
Email: tancanuysal@yahoo.com
E of the teeth in periapical or panoramic
radiographs can be used to assess the
physiologic maturity of an individual with-
out resorting to hand-wrist radiographs.1
Dental maturity can be determined via
the various stages of tooth formation and
eruption.1–9 Dental eruption is influenced
by various factors such as crowding,
extractions, ankylosis, ectopic positions,
and persistence of primary teeth. Emer-
gence into the oral cavity usually occurs
when 75% of the root formation is com-
plete. Tooth formation is thought to be a
more reliable criterion for determining
dental maturation than tooth eruption.3,4
As such, the Demirjian et al10 analysis is
based on tooth mineralization.
phenomenon. Although Garn et al 11
thought that genes, hormones, and calo-
ries play a role in dental development,
Demirjian12 indicated that dental matura-
tion is largely environmentally influenced.
Differences in the dental development
between various Angle Classes have not
yet been investigated. Only Janson et al13
and Jamroz et al14 evaluated the dental
maturation in patients with short and
long faces. These studies were based on
the fact that Nanda15 evidenced a differ-
ence in the timing of the adolescent
growth spurt when comparing subjects
with either a skeletal open or deep bite.
Janson et al13 showed that subjects with
a long face have in principle a dental

383

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 Uysal et al
maturation advanced by 6 months in
comparison to short-face subjects. How-
ever, according to Jamroz et al,14 the dif-
ference in dental age between patients
with long and short facial configurations
is not enough to be clinically significant.
In patients with a unilateral posterior
crossbite, the buccal cusps of the maxil-
lary teeth occlude lingually to the buccal
cusps of the corresponding mandibular
teeth.16 Crossbites are associated with
asymmetric muscular function, ie, the
muscle activity level in maximum occlu-
sion and during chewing on the crossbite
side is lower compared to the noncross-
bite side and the controls.17 In children
with unilateral posterior crossbites, the
two condyles occupy a different position
in their fossae.18 This asymmetric mor-
phology and function reflects a dissimilar
development of the mandible. The back-
ground of this investigation is that this
asymmetric development and bite force
might affect the dental development and
tooth eruption.
MATERIALS AND METHODS
This investigation was designed as a
cross-sectional study. The material con-
sisted of 101 patients (53 boys, 48 girls)
of the Orthodontic Department, Faculty
of Dentistry, Erciyes University. Their age
ranged from 8 years to 13 years with a
mean age of 10.90 ± 1.62 years (boys
10.93 ± 1.40 years, girls 10.87 ± 1.81
years).
Unilateral posterior prossbite
proup
Fifty-one patients (23 boys, 28 girls) met
the following selection criteria:
• Unilateral posterior crossbite involving
at least two posterior teeth
• Caucasian
• Mandibular dental midline deviation
of at least 1 mm to the crossbite side
• No functional deviation of the mandible
• No systemic disease or developmental
or acquired craniofacial or neuromus-
cular deformity
384
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WORLD JOURNAL OF ORTHODONTICS
• No previous orthodontic treatment
• No signs or symptoms of TMD (tem-
poromandibular disorder)
• No missing teeth (excluding third
molars)
• No caries lesions, extensive restora-
tions, or pathologic periodontal status
• Pretreatment records taken between
2004 and 2007
Control group
Fifty subjects (25 boys, 25 girls) met the
following selection criteria:
• Normal transversal posterior occlusion
• Caucasian
• Angle Class I, normal overjet and over-
bite, and coincidence of both dental
midlines
• Good facial symmetry
• No missing teeth (excluding third
molars)
• No significant medical history
• No previous trauma or orthodontic,
prosthodontic, or surgical treatment
• Pretreatment records taken between
2004 and 2007
All orthopantomograms were assessed
in a dark room with a radiographic illumi-
nator to ensure contrast enhancement.
Tooth mineralization was rated according
to the method described by Demirjian et
al10 (eight stages, Table 1).
Determination of dental maturity
scores and dental age
In children, dental age is defined accord-
ing to scores of tooth mineralization.19
These scores were recorded for all seven
teeth on the left and right side of both
jaws separately for boys and girls.20 The
total score of all teeth constitutes the
dental maturity of each segment. This
score can be converted directly into a
specific dental age by using the standard
table for boys and girls.
VOLUME 10, NUMBER 4, 2009 Uysal et al

Table 1 The eight stages of tooth development according to Demirjian et al10

Stage A Mineralization of single occlusal points without fusion.
Stage B Fusion of mineralization points; the contour of the occlusal surface is recognizable.
Stage C Enamel formation has been completed at the occlusal surface, and dentin formation has
commenced. The pulp chamber is curved, and no pulp horns are visible.
Stage D Crown formation has been completed to the level of the amelocemental junction. Root forma-
tion has commenced. The pulp horns are beginning to differentiate, but the walls of the pulp
chamber remain curved.
Stage E The root length remains shorter than the crown height. The walls of the pulp chamber are
straight, and the pulp horns have become more differentiated than in the previous stage. In
molars, the radicular bifurcation has commenced to mineralize.
Stage F The walls of the pulp chamber form an isosceles triangle, and the root length is equal to or
greater than the crown height. In molars, the bifurcation has developed sufficiently to give the
roots a distinct form.
Stage G The walls of the root canal are parallel, and the apex is partially open. In molars, only the dis-
tal root is rated.
Stage H The root apex is completely closed (distal root in molars). The periodontal membrane sur-
rounding the root and apex is uniform in width throughout.

Table 2 Descriptive statistic values of the chronological and dental age of patients
for investigated groups
Chronological age (y) Dental age (y)
Groups n Mean SD SE Min Max Mean SD SE Min Max

Unilateral cross bite

Male 23 10.88 1.76 0.37 8.00 13.92 11.38 2.55 0.53 7.40 16.00
Female 28 10.87 2.22 0.42 7.25 14.50 11.44 2.78 0.53 6.70 15.80
Total 51 10.87 2.01 0.28 7.25 14.50 11.42 2.65 0.37 6.70 16.00
Control sample
Male 25 10.99 1.02 0.20 7.92 12.50 14.06 4.00 0.80 8.63 26.93
Female 25 10.88 1.27 0.25 8.08 12.92 13.89 1.67 0.33 10.03 15.80
Total 50 10.93 1.14 0.16 7.92 12.92 13.97 3.03 0.43 8.63 26.93

n = sample size; SD = standard deviation; SE = standard error; Min = minimum; Max = maximum.

Statistical analysis pared with the independent sample t test.

All statistical analyses were performed
using SPSS software (Statistical Package
for Social Sciences for Windows 10.1).
Means, standard deviations, and errors of
chronological and dental age were calcu-
lated for each segment in the crossbite
and control group separately for each sex.
A paired-sample t test was used to com-
pare the dental age values of the left and
right sides in the control group and the
crossbite and noncrossbite side in the
crossbite group. Dental age between
crossbite and control patients was com-
From a clinical research–planning per-
spective, a dif ference of at least
6 months between two variables was
considered significant. Taking 6 months
as clinically significant at a level of
P < .05 with a sample size of 50, the
power of the statistical test was 85%.21
A single investigator (A.Y.) assessed all
dental maturity scores and ages. Dental
maturity was reassessed in 15 randomly
selected individuals after a 30-day inter-
val. The reliability in dental age assess-
ment was r = .94.

385

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 Uysal et al WORLD JOURNAL OF ORTHODONTICS

Table 3 Descriptive statistic values and statistical comparisons of the variations of

the dental age (in years) from one side to the other
Unilateral crossbite Control
Crossbite side Control side Right side Left side
Groups Mean SD SE Mean SD SE P Mean SD SE Mean SD SE P

Maxilla 11.41 2.92 0.41 11.34 2.80 0.39 NS 13.39 2.22 0.31 13.29 2.15 0.33 NS
Mandible 11.41 2.63 0.37 11.50 2.59 0.36 NS 13.28 1.74 0.25 13.25 1.80 0.25 NS

SD = standard deviation, SE = standard error, NS = not significant.

Table 4 Statistical comparison of the dental age (in years) in the two
studied groups
Maxilla Mandible
Groups n Mean SD SE P Mean SD SE P

Crossbite 51 11.32 2.83 0.40 *** 11.49 2.62 0.37 ***

Control 50 13.36 2.20 0.31 13.25 1.73 0.24
n = sample size, SD = standard deviation, SE = standard error, ***P < .001.

RESULTS jaws (P < .001) in both groups. Tooth mat-

Table 2 shows the descriptive statistics of
the chronological and dental age for both
groups and sexes, separately and com-
bined. The dental age had a tendency to
be more advanced in both sexes of the
control group as compared with the cross-
bite group. No sexual dimorphism was
detected for chronological and dental age
in the investigated groups. When the com-
bined groups are evaluated, the mean
dental age of the control and the cross-
bite group was 13.97 ± 3.03 years and
11.42 ± 2.65 years, respectively. In both
groups, the dental age as determined by
Demirjian and Goldstein’s20 tables was
slightly advanced as compared to the
chronological age.
The mean, standard deviation, stan-
dard error, and the statistical results are
presented in Table 3. There were no sig-
nificant differences in the dental age
between sides or jaws of both groups.
Table 4 shows the statistical compar-
isons of the dental age between the
crossbite and control group. Significant
differences were determined for both
uration was delayed 2.04 years in the
maxilla and 1.77 years in the mandible in
the crossbite group as compared to the
control group. This finding is statistically
and clinically significant.
DISCUSSION
Age estimation by means of tooth devel-
opment has long been used. After all,
tooth development corresponds well with
chronological age because it is only
slightly affected by exogenic factors such
as malnutrition or systematic dis-
eases.22,23
The differences among populations,
methods, and observers are important
shortcomings of research related to matu-
rity indicators. To overcome some of these
limitations, all subjects in the present
study were Turkish Caucasians and all
orthopantomograms were evaluated by
one skilled observer. In their study, Jam-
roz et al14 included only individuals who
were seen between 1990 and 2000 to
avoid any possible influence of a secular

386

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VOLUME 10, NUMBER 4, 2009
trend. 24 Similarly, here, only patients
whose orthopantomograms were taken
between 2004 and 2007 were evaluated.
In the literature, a range of classifica-
tions for evaluating tooth mineralization
is found. Such classifications were pre-
sented by Nolla,4 Kullman et al,22 Gleiser
and Hunt,25 and Moorrees et al.26 How-
ever, some of these identify a large num-
ber of stages that are difficult to delimit
from one another. The Demirjian et al10
classification distinguishes only four
stages of crown development (stages A to
D) and four stages of root development
(stages E to H). This system uses no
numeric identification so as to not imply
that the dif ferent stages represent
processes of the same duration. All the
stages are defined by changes of shape.
In their study, Dhanjal et al27 concluded
that the Demirjian et al 10 method per-
formed best not only for intra- and inter-
examiner agreement but also for the
correlation between chronological and
developmental age. Because of all these
reasons, this classification was selected
for this study.
Table 2 allows a more detailed compar-
ison of the sample. The boy control group
was on average chronologically 1 month
older than the boy crossbite group; simi-
larly, the dental age was higher. Liversidge
et al 28 (British), Hagg and Matsson 29
(Swedish), Loevy and Goldberg30 (Cau-
casian American), Nystrom et al 31
(Finnish), and Leurs et al 32 (Dutch)
showed that the French–Canadian dental
age standards derived by Demirjian et
al10 could not be considered suitable for
the respective populations. This was also
true for the present study. Therefore, pop-
ulation-specific dental age standards in a
big sample with the methodology of
Demirjian et al10 must be developed.
Proffit and Fields33 indicated that devi-
ations of tooth maturation or eruption on
the two sides of a dental arch are fre-
quent. They claimed that the difference
normally amounts to only a few months.
In this study, no significant side differ-
ences in the crossbite and control group
were observed (Table 3). An approximate
1-month variation between both sides in
the crossbite and control group became
apparent.
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Uysal et al
The significant difference in dental
development between individuals of the
crossbite and control group could be
explained with their individual genetic
background,34 which mutually influences
facial and dental development.
The present sample ranged in age
from 8 to 13 years with a mean age of
10.90 ± 1.62 years. Hagg and Matsson29
indicated that Demirjian’s method was
highly accurate for younger age groups
but was inaccurate in older children.
Thus, it cannot be excluded that the
somewhat older children in the present
evaluation have obscured possible differ-
ences in the dental maturity.
CONCLUSION
From this study, the following conclusions
were drawn:
• No significant differences in the den-
tal age on either side were present
between crossbite patients and con-
trol individuals.
• The crossbite patients presented a ten-
dency for a delayed dental maturation
as compared to the control individuals.
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1. Coutinho S, Buschang PH, Miranda F. Relation-
ships between mandibular canine calcification
stages and skeletal maturity. Am J Orthod
Dentofacial Orthop 1993;104:262–268.
2. Krailassiri S, Anuwongnukroh N, Dechkunakorn
S. Relationships between dental calcification
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individuals. Angle Orthod 2002;72:155–166.
3. Fanning EA. Effect of extraction of deciduous
molars on the formation and eruption of their
successors. Angle Orthod 1962;32:44–53.
4. Nolla CM. The development of the permanent
teeth. J Dent Child 1960;27:254–263.
5. Lewis AB, Garn SM. The relationship between
tooth formation and other maturational factors.
Angle Orthod 1960;30:70–77.
6. Green LJ. Interrelationship among height,
weight and chronological, dental and skeletal
age. Angle Orthod 1961;31:189–193.
7. Garn SM, Lewis AB, Bonne B. Third molar for-
mation and its developmental course. Angle
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8. Chertkow S, Fatti P. The relationship between
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dence of the ulnar sesamoid. Angle Orthod
1979;49:282–288.
9. Uysal T, Sari Z, Ramoglu SI, Basciftci FA. Rela-
tionships between dental and skeletal maturity
in Turkish subjects. Angle Orthod 2004;74:
657–664.
10. Demirjian A, Goldstein H, Tanner JM. A new sys-
tem of dental age assessment. Hum Biol 1973;
45:211–227.
11. Garn SM, Lewis AB, Kerewsky RS. Genetic, nutri-
tional, and maturational correlates of dental
development. J Dent Res 1965;44:228–242.
12. Demirjian A. Dentition. In: Falkner F, Tanner JM
(eds). Human Growth, vol 2. New York: Plenum
Publishers, 1978:413–444.
13. Janson GRP, Martins DR, Tavano O, Dainesi EA.
Dental maturation in subjects with extreme ver-
tical facial types. Eur J Orthod 1998;20:73–78.
14. Jamroz GMB, Kuijpers-Jagtman AM, van’t Hof
MA, Katsaros C. Dental maturation in short and
long facial types. Is there a difference? Angle
Orthod 2006;76:768–772.
15. Nanda SK. Patterns of vertical growth in the
face. Am J Orthod Dentofacial Orthop 1988;93:
103–116.
16. Kiki A, Kilic N, Oktay H. Condylar asymmetry in
bilateral posterior crossbite patients. Angle
Orthod 2007;77:77–81.
17. Sonnesen L, Bakke M, Solow B. Bite force in
pre-orthodontic children with unilateral cross-
bite. Eur J Orthod 2001;23:741–749.
18. Hesse KL, Artun J, Joondeph DR, Kennedy DB.
Changes in condylar position and occlusion
associated with maxillary expansion for correc-
tion of functional unilateral posterior crossbite.
Am J Orthod Dentofacial Orthop 1997;111:
410–418.
19. Gustafson G, Koch G. Age estimation up to 16
years of age based on dental development.
Odontol Rev 1974;25:297–306.
20. Demirjian A, Goldstein H. New systems for den-
tal maturity based on seven and four teeth.
Ann Hum Biol 1976;3:411–421.
21. Marks RG. Design of Research Projects. The
Basics of Biomedical Research Methodology.
New York: Van Nostrand Reinhold Company,
1985.
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WORLD JOURNAL OF ORTHODONTICS
22. Kullman L. Accuracy of two dental and one
skeletal age estimation method in Swedish ado-
lescents. Forensic Sci Int 1995;75:225–236.
23. Melsen B, Wenzel A, Miletic T, Andreasen J,
Vagn-Hansen PL, Terp S. Dental and skeletal
maturity in adoptive children: Assessments at
arrival and after one year in the admitting
country. Ann Hum Biol 1986;13:153–159.
24. Nadler GL. Earlier dental maturation: Fact or
fiction? Angle Orthod 1998;68:535–538.
25. Gleiser I, Hunt EE. The permanent mandibular
first molar: Its calcification, eruption and decay.
Am J Phys Anthropol 1955;13:253–283.
26. Moorrees CFA, Fanning EA, Hunt EE Jr. Age vari-
ation of formation stages for ten permanent
teeth. J Dent Res 1963;42:1490–1502.
27. Dhanjal KS, Bhardwaj MK, Liversidge HM.
Reproducibility of radiographic stage assess-
ment of third molars. Forensic Sci Int 2006;159
(suppl 1):S74–77.
28. Liversidge H, Speechly T, Hector MP. Dental
maturity in British children: Are Demirjian’s
standards applicable? Int J Paediatr Dent
1999;9:263–269.
29. Hagg U, Matsson L. Dental maturity as an indi-
cator of chronological age: The accuracy and
precision of three methods. Eur J Orthod
1985;7:25–34.
30. Loevy HT, Goldberg AF. Shifts in tooth matura-
tion patterns in non-French Canadian boys.
Int J Paediatr Dent 1999;9:105–110.
31. Nystrom M, Ranta R, Kataja M, Silvola H. Com-
parisons of dental maturity between the rural
community of Kuhmo in northeastern Finland
and the city of Helsinki. Community Dent Oral
Epidemiol 1988;16:215–217.
32. Leurs IH, Wattel E, Aartman IH, Etty E, Prahl-
Andersen B. Dental age in Dutch children. Eur J
Orthod 2005;27:309–314.
33. Proffit WR, Fields HW. Contemporary Orthodon-
tics, ed 3. St Louis: Mosby, 2000.
34. Garn SM, Lewis AB, Polacheck DL. Sibling simi-
larities in dental development. J Dent Res
1960;39:170–175.
390_WorldNews2009_04 11/6/09 3:28 PM Page 390
WORLD NEWS
7th International Orthodontic Congress to offer
global perspective on the specialty of orthodontics
Registration deadline is January 31, 2010; onsite registrations
will be taken after this date
The 7th International Orthodontic Congress (IOC) and the
4th Meeting of the World Federation of Orthodontists (WFO) will
draw the world of orthodontics together February 6 to 9, 2010, at
the Sydney Convention & Exhibition Centre in Sydney, Australia.
Be part of this historic event that occurs only once every 5 years.
Orthodontists, allied dental health professionals, and ortho-
dontic staff may register for the conference through January 31,
2010. After this date, registrations will be taken onsite. Register
online at www.wfosydney.com. This Web site offers complete
details on the 7th IOC, as well as information on tour opportuni-
ties and general information about Sydney. At the end of the
early registration period in October, more than 2,200 individuals
from 85 countries had registered for the congress.
The WFO, the Australian Society of Orthodontists (ASO), and
the Asian Pacific Orthodontic Conference are the official hosts of
the 7th IOC. These organizations look forward to welcoming
orthodontists and their staff members to Australia.
“Everyone should visit Sydney once in their lifetime,” said
Dr B. Ian Watson, chair of the 7th IOC Scientific Programme. “As
orthodontists, this is a great time to do so and to bring the fam-
ily. We believe the Scientific Programme is absolutely excellent,
the Social Programme will delight, and Sydney is one of the
world’s truly great cities. Our country is safe, and it is beautiful.
Hence, there are many good opportunities for additional touring.
The Australian Society of Orthodontists’ members are ready to
host you for a great experience.”
Dr Rick Olive, chair of the Sydney International Orthodontic
Congress Committee (SIOCC), hopes each delegate leaves the
7th IOC with great knowledge and fond memories.
“If every delegate leaves Sydney with an enhanced sense of
the strength of the scholarship, science, and commitment to
excellence of orthodontists, wherever they live in the world, then
the 7th IOC will have been worthwhile, and the WFO will bene-
fit,” Dr Olive said. “If they take away some special memories of
Sydney and Australia to match mine from San Francisco, Chicago,
and Paris, then the aura of the IOCs will be enhanced, too.”
The SIOCC urges orthodontists to make an early decision to
participate in the 7th IOC and to book travel, accommodations,
and tours now. Those who are coming into Australia from over-
seas should also apply for visas.
Precongress Workshops
The 7th IOC will feature two precongress workshops: “Temporary
Anchorage Devices/Microimplants in Orthodontics” and “The
390
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Clinician’s Delight – The Aesthetics and Performance of Ortho-
dontic Appliances.” Both of these workshops will be held Friday,
February 5.
A distinguished group of leaders in the orthodontic specialty
will give the course on temporary anchorage devices (TADs) and
microimplants. The speakers will feature doctors from northern
Asia and many other parts of the world. Dr Junji Sugawara of
Japan and Dr Young-Cheol Park of Korea, two of the pioneers in
the field, will each chair a session, along with Dr Hee-Moon
Kyung of Korea and Dr John Jin-Jong Lin of Taiwan. At the end of
the day, Dr Jason Cope of the United States will offer a summary
of the factors important to the success of TADs.
The second workshop embraces the recent history of remov-
able appliances (conventional and sequential), fixed lingual and
buccal appliances (metallic and ceramic), and retention appli-
ances. Dr Anmol Kalha of India will offer an evidence-based sum-
mary at the close of the workshop. Most of the speakers for this
workshop have commercial allegiances.
“I sincerely believe that no delegate should miss attending a
precongress workshop,” Dr Watson said. “The greatest difficulty
will be in deciding which one to attend, as delegates will not be
able to move from one to the other unless fees have been paid
for both. These courses represent extraordinary value for the
material being presented. These events will set the stage for the
next four days and should not be missed. Where else can one
witness such an array of talented speakers? Nowhere—only in
Sydney.”
Scientific Programme Highlights
Dr William R. Proffit, Kenan Professor of Orthodontics at the Uni-
versity of North Carolina at Chapel Hill, is the principal speaker
for the 7th IOC. He will deliver his lecture “New Approaches, New
Technologies in Modern Orthodontics” Saturday, February 6.
“Dr Proffit is a very, very worthy selection as the principal
speaker,” Dr Watson said. “He has made an outstanding contri-
bution to the specialty of orthodontics, and there is no doubt
that he will offer a wonderful presentation that will inform and
challenge delegates and, in particular, inspire all presenters to
raise the bar.”
This lecture will kick off the Scientific Programme for the 7th
IOC, which will feature many keynote speakers and invited
speakers. Go to www.wfosydney.com to review the extensive list
of speakers.
“Across all of the Scientific Programme, including the pre-
congress workshops and the World Village Day, more than one-
third of the speakers will be drawn from the Asian region,”
390_WorldNews2009_04 11/6/09 3:28 PM Page 391
VOLUME 10, NUMBER 4, 2009
Dr Olive said. “This appropriately reflects the growing importance
of Asian orthodontists and their strong contribution to research.
Western orthodontists’ appreciation of the strength of Asian
orthodontic research has been growing, and the exposure of so
many Asian orthodontic academics on the 7th IOC Scientific Pro-
gramme will strengthen the scientific content of the congress
and fairly showcase the achievements of our Asian colleagues.”
In addition to the lectures, attendees can view 76 oral
abstract presentations covering 38 topics. More than 600 indi-
viduals from 63 countries submitted abstracts to the SIOCC.
“The quality and diversity of the abstracts ensured that we were
able to select two excellent oral presentations for every one of
the 38 topics in the main Scientific Programme,” Dr Olive said.
Poster presentations are also part of the Scientific Pro-
gramme. The majority of the posters will be presented electroni-
cally. “We have been thrilled that almost all the presenters have
chosen to make electronic presentations,” Dr Watson said. “We
are very excited about this innovative switch to electronic format,
and we are sure it will end the (traditional) poster era. We will
have numerous pods, or minitheaters, where delegates can view
the presentations on screens. Delegates will be able to down-
load the presentations, if the presenters agree—and most have.
So they (delegates) will be able to take them (the poster presen-
tations) home on a ‘stick’. This is a very exciting development
and should win virtual universal acceptance from presenters and
delegates alike.”
World Village Day
A unique aspect of the 7th IOC is the World Village Day on Mon-
day, February 8. This day will feature the 22nd Australian Ortho-
dontic Congress, lectures offered by the Arab Orthodontic Soci-
ety, the 7th Asian Pacific Orthodontic Conference, lectures
offered by the British Orthodontic Society, the European Village
Day, and the South American Village Day. All of the sessions are
open to congress attendees.
“I have been most impressed by the engagement of all parts
of the world in the World Village Day,” Dr Olive said. “The SIOCC
copied the concept from the 6th IOC European Village Day, but
The famous Sydney Opera House will be the site of the Stanley Wilkin-
son Memorial Oration and International Reception February 7, 2010,
during the 7th International Orthodontic Congress and 4th Meeting of
the World Federation of Orthodontists.
Photo credit: David Druce. Courtesy Tourism New South Wales.
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World News
opened the opportunity to regional associations from all conti-
nents. The Village Day is on the third day, Monday, so it should
be recognized as an integral part of the Scientific Programme,
with every lecture open to all delegates.”
Allied Dental Health Professionals and Staff Programme
The Allied Dental Health Professionals and Staff Programme,
featuring many respected Australian and international speakers,
has been structured to improve the depth of clinical and profes-
sional knowledge of all members of the orthodontic team.
In addition, 10 orthodontic nurses or clerical staff will compete
in the World Champion Orthodontic Nurses and Clerical Staff
Competition Monday, February 8. All attendees are welcome to
watch this competition.
To learn more about the Allied Dental Health Professionals
and Staff Programme, go to www.wfosydney.com.
Social Programme
The Welcome Reception Saturday, February 6, at the Sydney
Convention & Exhibition Centre is complimentary and will feature
“unusual Aussie entertainment,” Dr Olive said.
The Stanley Wilkinson Memorial Oration and International
Reception will celebrate one of the founders of the ASO, Dr Stan-
ley Wilkinson, who also funded the original corpus of the ASO
Foundation for Research and Education. The event will be held
Sunday, February 7 at the Sydney Opera House Concert Hall.
“This function is a fixture of the Australian Orthodontic Con-
gresses and will give delegates an opportunity to attend and
enjoy the Sydney Opera House,” Dr Olive said.
The Presidents’ Reception on Sydney Harbour will be held
Monday evening, February 8. Participants will enjoy an evening
cruise on board the Captain Cook “MV2000.”
The final social event will be the Gala Dinner Tuesday
evening, February 9. This event at the Sydney Convention & Exhi-
bition Centre will feature dinner, drinks, and music.
To learn more about these events and ticket prices, go to
www.wfosydney.com.
The Blue Mountains border Sydney’s metropolitan area. The mountain-
ous region consists mainly of a sandstone plateau, and the area is dis-
sected by gorges.
Photo credit: Hamilton Lund. Courtesy Tourism New South Wales.
391
390_WorldNews2009_04 11/6/09 3:28 PM Page 392
World News
WFO announces representatives to
serve on the 2010–2015 WFO Council
To date, the majority of the World Federation of Orthodontists (WFO) affiliate organizations have informed the WFO of their
representatives who will serve on the WFO Council for the next 5 years. The WFO Council will convene February 4, 2010, in conjunction
with the 7th International Orthodontic Congress and the 4th Meeting of the WFO in Sydney, Australia.
Organizations that have not selected their representatives should do so as soon as possible. Please contact Ms Terri Wise of the
WFO Secretariat. Her email address is wfo@wfo.org.
Africa and the Middle East
• Egyptian Orthodontic Society – Dr Yehya A. Mostafa
• Emirates Society of Orthodontists – Dr Moza Tehwara
• Iranian Association of Orthodontists – Representative not
known at this time
• Iraqi Orthodontic Society – Dr Akram Faisal Al-Huwaizi
• Israel Orthodontic Society – Dr Silvia Geron and
Dr Orna Kaufman
• Jordan Orthodontic Society – Dr Sami Sh. B. Samawi
• Kenya Association of Orthodontists – Dr Mohamed Hanif Butt
• Kuwait Orthodontic Society – Dr Rasha Hamad Al-Mubarak
• Lebanese Orthodontic Association – Dr Ali Fahs
• Namibian Society of Orthodontists – Representative not
known at this time
• Nigerian Association of Orthodontists – Representative not
known at this time
• Palestinian Orthodontic Society – Representative not known
at this time
• Saudi Orthodontic Society – Dr Khalid Ibraheem Albadr
• Societe Marocaine d’Orthopedie Dento-Faciale –
Representative not known at this time
• South African Society of Orthodontists –
Dr Haydn Harry Bellardie
• Sudanese Orthodontic Society –
Dr Omer Elfarouk A. Abuelgasim
• Syrian Orthodontic Society – Dr Jihad Al Chaar
• Tunisian Orthodontic Society – Representative not known at
this time
Central and East Asia
• Bangladesh Orthodontic Society – Dr Md. Zakir Hossain
• Chinese Orthodontic Society – Dr Jiu-Xiang Lin,
Dr Tian-Min Xu and Dr Yan-Heng Zhou
• Hong Kong Society of Orthodontists – Dr Ricky W. K. Wong
• Indian Orthodontic Society – Dr Om Prakash Kharbanda and
Dr E. T. Roy
• Japanese Orthodontic Society – Dr Yasuhiko Asai,
Dr Shigemi Goto, Dr Keiji Moriyama and Dr Kazuo Tanne
• Korean Association of Orthodontists – Dr Chung Ju Hwang,
Dr Sang-Cheol Kim and Dr Young Guk Park
• Macau Association of Orthodontics – Dr Wei Lin
• Orthodontic and Dentofacial Orthopaedic Association of
Nepal - Representative not known at this time
• Pakistan Association of Orthodontists – Dr Amjad Mahmood
• Sri Lanka Orthodontic Society –
Dr Kasinathar Paranthamalingam
• Taiwan Association of Orthodontists – Dr Ching-Huei Horng
and Dr Yeong-Charng Yen
• Thai Association of Orthodontists – Dr Tanan Jaruprakorn
392
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WORLD JOURNAL OF ORTHODONTICS
Central and South America
• Academia Costarricense de Ortodoncia –
Dr Ana Lilia Dobles Jimenez
• Asociación de Ortodoncistas de Nicaragua –
Dr Esteban Bendana
• Asociación Salvadorena de Ortodoncia –
Dr Armando Gutierrez-Oriani
• Associaçao Brasileira de Ortodontia e Ortopedia Facial –
Dr Eustaquio A. Araujo
• Guatemalan Association of Orthodontists – Representative
not known at this time
• Peruvian Orthodontic Society – Dr Lawrence R. Koenig
• Sociedad Argentina de Ortodoncia – Dr José C. Elgoyhen and
Dr Lia Jaquelina Sokolowicz
• Sociedad Boliviana de Ortodoncia – Representative not
known at this time
• Sociedad Colombiana de Ortodoncia –
Dr Julio R. Saldarriaga M.
• Sociedad de Ortodoncia de Chile – Dr Octavio M. Del Real and
Dr Hernan Palomino M.
• Sociedad de Ortodoncia de Honduras – Representative not
known at this time
• Sociedad Dominicana de Ortodoncia Inc. – Dr Saqib Khan
• Sociedad Ecuatoriana de Ortodoncia – Dr Gerson Cabezas B.
• Sociedad Panamena de Ortodoncistas – Dr Francisco Lee
• Sociedad Paraguaya de Ortodoncia – Representative not
known at this time
• Sociedad Venezolana de Ortodoncia – Representative not
known at this time
• Sociedade Brasileira de Ortodontia – Dr Flavia Artese and
Dr Slamad Fernandes Rodrigues
Europe
• Asociatia Nationala Romana de Ortodontie –
Dr Dragos Stanciu
• Associazione Specialisti Italiana Ortodonzia –
Dr Antonio Gracco
• Azerbaijanian Professional Orthodontic Society –
Dr Ziba Gasimova
• Belgian Union of Orthodontists Societies (BUOS) –
Dr Bart Maurice Vande-Vannet
• Berufsverband der Deutschen Kieferorthopaden –
Dr Gundi M. Mindermann
• British Orthodontic Society – Dr Leslie Joffe and
Dr Alison M. Murray
• Bulgarian Orthodontic Society – Dr Laura Andreeva
• Croatian Orthodontic Society – Dr Mladen Slaj
• Cyprus Orthodontic Society – Dr Abraham Kyriakides
• Czech Orthodontic Society – Dr Ivo Marek
390_WorldNews2009_04 11/6/09 3:28 PM Page 393
VOLUME 10, NUMBER 4, 2009
• Danish Society of Orthodontic Specialists – Representative
not known at this time
• Dutch Association of Orthodontists –
Dr Anne Marie Kuijpers-Jagtman and Dr Yijin Ren
• German Association of Orthodontists – Dr Christian Scherer
• German Orthodontic Society – Dr Barbel Kahl-Nieke
• Greek Association for Orthodontic Study and Research –
Dr Evangelia E. Stamou
• Greek Orthodontic Society – Dr Michail Kalavritinos
• Hungarian Association of Pediatric Dentistry and Orthodontics
– Dr Andras Vegh
• Icelandic Orthodontic Society – Dr Teitur Jonsson
• Latvian Orthodontists Association – Representative not
known at this time
• Lithuanian Orthodontic Society – Dr Antanas Sidlauskas
• Moldavian Association of Dentofacial Orthopedics –
Representative not known at this time
• Norwegian Association of Orthodontists – Dr Bjorn Kvaran
• Orthodontic Section of the Finnish Dental Society –
Dr Pertti Pirttiniemi
• Orthodontic Society of Ireland – Dr Georges Takla
• Polish Orthodontic Society – Representative not known at this
time
• Professional Society of Orthodontists Russia –
Dr Olga Arsenina
• Serbian Orthodontic Society – Dr Mirjana Sasic
• Slovak Orthodontic Society – Representative not known at
this time
• Slovenian Orthodontic Society – Representative not known at
this time
• Sociedad Española de Ortodoncia – Representative not
known at this time
• Sociedade Portuguesa de Ortopedia Dento Facial –
Dr Americo R. Ribeiro Ferraz
• Societa Italiana di Ortodonzia – Dr Carmela Savastano
• Societe Belge d’Orthodontie – Dr Danny G. Op Heij
• Société Française d’Orthopédie Dento-Faciale –
Dr Jean-Jacques Aknin
• Societe Luxembourgeoise d’Orthodontie – Dr Germain Becker
• Swedish Association of Orthodontists – Dr Heidrun Kjellberg
• Swiss Orthodontic Society – Dr Christos Katsaros
New voluntary self-assessment system
for European orthodontists takes off
Charged with the responsibility to promote quality orthodontic
care throughout Europe, the European Federation of Orthodontic
Specialists Associations (EFOSA) has developed a voluntary self-
assessment system that allows orthodontists to evaluate their
daily clinical practices to determine which factors lead to the
best patient service. While the EFOSA Self-Assessment System
(ESAS) has been online since 2008, EFOSA officially announced
its availability to orthodontists during the European Orthodontic
Society’s 85th Congress in June in Helsinki, Finland.
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World News
• Syndicat des Spécialistes Français en Orthopédie Dento-
Faciale – Dr Claude Bourdillat-Mikol
• Turkish Orthodontic Society – Dr Selma T. Elekdag-Turk and
Dr Tamer Turk
• Ukrainian Association of Orthodontists – Representative not
known at this time
North America
• Academia Mexicana de Ortodoncia – Dr Adan A. Casasa
• American Association of Orthodontists – Dr Robert J. Bray,
Dr John F. Buzzatto, Dr Gayle Glenn, Dr Lee W. Graber,
Dr Brent E. Larson, Dr Morris N. Poole, Dr Michael B. Rogers,
and Dr Robert E. Varner
• Asociación Mexicana de Ortodoncia – Dr Roberto Carrillo and
Dr Jesus J. Rea
• Canadian Association of Orthodontists – Dr Robert H. Cram
and Dr Ritchie Mah
Australia, Indonesia, Malaysia, New Zealand, Philippines, and
Singapore
• Association of Orthodontists, Singapore – Dr Bryce Lee
• Association of Philippine Orthodontists –
Dr Ermelinda L. Sabater-Galang
• Australian Society of Orthodontists – Dr Frederic Shane Fryer
and Dr John Michele Razza
• Indonesian Association of Orthodontists – Dr Himawan Halim
• Malaysian Association of Orthodontists –
Dr Noraini Binti Hj. Alwi
• New Zealand Association of Orthodontists – Dr Peter V. Fowler
Regional Affiliate Organizations
• Arab Orthodontic Society – Dr Sami Sh. B. Samawi
• Asian Pacific Orthodontic Society – Dr Crisanta C. Santayana
• Asociación Ibero-Americana de Ortodoncistas –
Dr Pablo Echarri Lobiondo
• Asociación Latinoamericana de Ortodoncia –
Dr Augusto J. Urena
• Caribbean Society of Orthodontists –
Dr Sastri Edward Harnarayan
• European Federation of Orthodontic Specialists Associations –
Dr Lars Medin
• European Federation of Orthodontics – Dr Olivier P. Mauchamp
• European Orthodontic Society – Dr Maja Ovsenik
EFOSA encourages European orthodontists to use ESAS, which
provides a controlled comparison of patient data and does not
reveal the identity of the doctors or patients. Orthodontists who
are members of an organization that belongs to EFOSA may regis-
ter to use this free evaluation tool at www.esas.nu. (To determine
if your professional orthodontic organization belongs to EFOSA, go
to www.efosa.eu.)
As of late September, at least 400 practicing orthodontists
had registered to use the site. In addition, EFOSA recently began
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offering this resource to postgraduate orthodontic students.
Orthodontists can also invite their patients to participate in ESAS,
which collects their feedback through an online questionnaire.
Patients’ identities are not revealed to the ESAS users. As the
number of orthodontists using the system increases, the system
will be able to provide more sophisticated statistical comparisons.
Dr Frank de Winter, chair of the EFOSA Quality Committee,
which developed ESAS, said ESAS is based on the EURO-QUAL pro-
ject. This project, which was twice funded by the European Union in
1993 and 1996, led to the development of a philosophy and com-
mon language for quality development in orthodontics. The second
phase of the project resulted in the development of the European
Orthodontic Quality Manual, which assists individual orthodontists
in their efforts to develop their own quality system.
“ESAS seemed to be a logical initiative for EFOSA, and it also
seemed to be a logical continuation of EURO-QUAL,” said Dr de
Winter, who contributed to the EURO-QUAL project and practiced
orthodontics for 30 years in Heemstede, The Netherlands. “Once
one has set up a quality system in the practice, it would be nice
to find out what the end results look like when compared to
other practices, which hopefully helps find ways for continuous
further improvement of orthodontic care.”
He stresses that ESAS is strictly a voluntary self-assessment
resource. ESAS measures treatment results with the help of a
treatment outcome (TO) questionnaire and occlusal indices
(PAR, ICON and IOTN). The treatment process (TP) questionnaire
then evaluates the total orthodontic process and practice rou-
tines. Once orthodontists enter patient data, they can give the
patient a login code. The patient can then enter data into the
system through the patient satisfaction (PS) questionnaire.
ESAS will show the orthodontist an outcome as a percentage
for each item (index, TO, TP and PS) compared to the average of
the database. Once the database increases in size, it will be pos-
sible to compare certain types of treatment and/or certain ortho-
WFO offers guidelines for Postgraduate Orthodontic Education
Review the guidelines at www.wfo.org.
The Executive Committee of the World Federation of Orthodon-
tists (WFO) received and recently approved the Guidelines for
Postgraduate Orthodontic Education, which were prepared and
submitted by a task force that was appointed in 2006. These
guidelines may assist countries, associations, and educational
institutions in need in the development or improvement of such
specialty programs. It is also anticipated that these detailed rec-
ommendations will be used by postgraduate program directors
worldwide and by related educational, scientific, and administra-
tive institutions at all levels of sophistication to measure their
respective curriculum against a worldwide standard.
These guidelines are now available at http://wfo.org/
Guidelines-for-Postgraduate-Orthodontic-Education.cfm. The guide-
lines were also published in the World Journal of Orthodontics
(Volume 10, Number 2).
The guidelines cover 10 elements of postgraduate programs:
program goals and objectives; program duration; residents; faculty;
clinical care, study, and research facilities; required curriculum;
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WORLD JOURNAL OF ORTHODONTICS
dontists, such as those in a particular area or country or those
who are best-scoring. The orthodontist will also be able to review
his average per question per questionnaire in comparison to the
database. “This may help stimulate orthodontists even more to
improve their quality of care,” Dr de Winter said. “Since treat-
ment outcome, for the large part, is based on the treatment
processes, this is where the ESAS user should go to study the
differences per question.”
Entering data into ESAS is not time-consuming, he said.
“Once an orthodontist is a bit familiar with the ESAS Web site,
it will take him or her just over 5 minutes per case to enter all
data into the questionnaires on treatment outcome and on all
five phases of treatment processes,” Dr. de Winter said. “Since
using outcome indices is made very easy in ESAS, entering all
data in PAR takes only 2 minutes, in ICON 1.5 minutes, and IOTN
30 seconds. A series that is widely used—TO-TP-ICON—takes a
total of less than seven minutes. The American Board of Ortho-
dontics Objective Grading System is not yet available in ESAS,
but hopefully will be soon.”
Dr de Winter encourages orthodontists to enter 20 to 50 con-
secutively finished cases each year.
“We hope that ESAS will not only be used by the orthodontists
who do everything already to provide the best possible care, but
that using ESAS will be so normal to the orthodontic profession
that it will be used widely and become a basis for continuous
development of care. In this respect, a quality system like ESAS
must be in continuous development; there is no indicator of
quality that has an eternal value. So we hope and expect that in
the future the ESAS users will have great input in further devel-
opment of the system.”
EFOSA will promote ESAS during the upcoming 7th Interna-
tional Orthodontic Congress and 4th Meeting of the World Feder-
ation of Orthodontists in Sydney, Australia.
sponsoring institution and institutional commitments; program
evaluation; resident evaluation; and outcome assessment. The
guidelines also include the following appendices: Clinical Care,
Study, and Research Facilities; and Educational Topics.
The WFO Task Force on Guidelines for Postgraduate Ortho-
dontic Education was chaired by Dr Athanasios E. Athanasiou,
president of the WFO. The other members of the task force
included Dr M. Ali Darendeliler (Australia), Dr Theodore Eliades
(Greece), Dr Urban Hägg (Hong Kong), Dr Brent Larson (United
States), Dr Pertti Pirttiniemi (Finland), Dr Stephen Richmond
(United Kingdom), Dr Kunimichi Soma (Japan), Dr Alexander
Vardimon (Israel), and Dr William Wiltshire (Canada).
These guidelines reflect the WFO’s efforts to offer support to
recognized orthodontic training programs in every region of the
world.
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VOLUME 10, NUMBER 4, 2009 World News

Slovenia to welcome the 86th EOS Congress in 2010

In 2010, the European Orthodontic Society (EOS) will host its
86th Congress June 15 to 19 at the St Bernardin Adriatic Resort
and Convention Centre in Portorož , Slovenia. Located in the
heart of Europe, Slovenia is surrounded by the Adriatic Sea and
the Alps. This unique geography draws tourists to this European
Union country throughout the year. The coastal city of Portorož,
also known as the Port of Roses, is a beautiful destination that
offers a rich history to all who visit.
The Scientific Program of the EOS Congress will be as
dynamic as the country. Scientific topics include biotechnology
and its future in orthodontics, contemporary diagnostics and
treatment approaches, Class III malocclusion, and free topics.
Dr Urban Hägg will deliver the Sheldon Friel Memorial Lec-
ture. His topic will focus on the facial profile and changes with
and without treatment. Keynote speakers include Dr Tiziano Bac-
cetti, Dr Alan Bagden, Dr Friedrich Byloff, Dr Renato Cocconi,
Dr Nataša Ihan Hren, Dr Fraser McDonald, Dr Peter Ngan,
Dr Stephen Richmond, Dr Jože Trontelj, Dr David Turpin, Dr Frank
Weiland, Dr Andrea Wichelhaus, and Dr Dirk Wiechmann.
Dr Wichelhaus is the featured speaker for Pre-Congress
Course I: “Biomechanical Aspects in Orthodontic Treatment.”
Dr Bagden and Dr Byloff will deliver Pre-Congress Course II:
“Active and Passive Self-Ligation: Clarification from Controversy.”
A panel discussion will follow the precongress course on active
and passive self-ligation.
The postgraduate course is “Time: The Fourth Dimension in
Orthodontics and Dentofacial Orthopaedics.” Dr Baccetti is the
speaker for this session.
The Post-Congress Course I is “Role of High-precision Three-
dimensional Surface Images in Understanding Facial Morpholo-
gies and Planning Virtual Treatment.” Dr Chung How Kau is the
speaker. The Post-Congress Course II, a two-day session, is titled
“The Incognito System in Lingual Orthodontics.” Dr Wiechmann
will present this course.
To learn more about the EOS Congress Scientific Program
and special events, go to www.eos2010.si. Register by March
31, 2010, to qualify for the lowest registration fees. Visit
www.slovenia-tourism.si to learn more about Slovenia.

WFO participates in the Graduate Orthodontic Residents Program

to encourage membership among orthodontic residents
For the second year, the World Federation of Orthodontists (WFO)
participated in the Graduate Orthodontic Residents Program
(GORP) for US and Canadian orthodontic residents/students in an
effort to introduce future orthodontists to the WFO and its mis-
sion. The WFO has accepted student memberships since 2005.
GORP, which began in 1989 at the University of Michigan,
provides an annual opportunity for future orthodontists to grow
professionally and to create interpersonal relationships among
colleagues and representatives from orthodontic manufacturers.
The program’s venue alternates between Ann Arbor, Michigan, USA,
and other university cities. In 2009, the event was held in August
at the University of Minnesota in Minneapolis, Minnesota, USA.
The meeting, which is coordinated by the orthodontic resi-
dents/students, attracts between 350 and 400 attendees each
year. In addition to the scientific program presented by prominent
lecturers, orthodontic residents/students participate in social and
sporting events designed to allow for maximum student interac-
tion. The schedule also allows the participants to meet with repre-
sentatives from the American Association of Orthodontists (AAO),
the Canadian Association of Orthodontists, and AAO-affiliated
organizations.
Dr Larson Keso, a member of the WFO Executive Committee,
represented the WFO at the 2009 and 2008 meetings. This year,
Dr Keso met approximately 200 students and distributed the
new WFO information brochure, student membership applica-
tion, and registration form for the 7th International Orthodontic
Congress (IOC) in Sydney, Australia. Dr Keso also thanked ven-
dors who are under contract to exhibit at the 7th IOC. These ven-
dors received a flyer promoting travel and tour options. He
invited other vendors who market products and services interna-
tionally to consider exhibiting at the 7th IOC. He distributed the
exhibitor prospectus and travel brochure to these vendors.

News & Announcements

The Canadian Association of Orthodontists (CAO) has elected its new officers. Dr Gerald Zeit of Toronto, Ontario, is
president; Dr Howard Steinman of Ajax, Ontario, is president-elect; Dr Ritchie Mah of Vancouver, British Columbia,
is 1st vice president; Dr Paul Major of Edmonton, Alberta, is 2nd vice president; and Dr Garry Solomon of Belleville,
Ontario, is secretary/treasurer. The CAO elected its officers during its 61st Annual Scientific Session in September
in Kelowna, British Columbia.

395

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World News
Taiwan Association of
Orthodontists supports the
Thomas M. Graber
WFO Memorial Fund
The Taiwan Association of Orthodontists (TAO) presented a
$500 check to representatives of the World Federation of
Orthodontists (WFO) in May during the 109th American Associa-
tion of Orthodontists Annual Session in Boston, Massachusetts,
USA. The TAO designated the money for the Thomas M. Graber
WFO Memorial Fund. All monies in this fund are used to pur-
chase subscriptions to the World Journal of Orthodontics for
deserving, qualified academic institutions or deserving individu-
als, including orthodontic students in need. From left are
Dr William DeKock, secretary-general of the WFO; Dr Chia Tze
Kao, past president of the TAO; Dr Athanasios E. Athanasiou,
president of the WFO; Dr Ching Huei Horng, president of the
TAO; and Dr Lee Graber, past president of the WFO and the son
of Dr Thomas M. Graber.
This is the second year that the TAO has made this dona-
tion. “All TAO members support the WFO’s efforts to contribute
to world orthodontics,” Dr Kao said. “Dr T.M. Graber was an
honorary member of the TAO. We respect his contributions,
too. It is hoped that the memorial fund can exist forever to help
those who need it. Although the (TAO’s) donation is small, the
TAO will continue doing it as long as the TAO can financially
support it,” Dr Kao said.
Others who wish to donate to the Thomas M. Graber WFO
Memorial Fund may do so by sending a check in US funds or
credit card number to the WFO, c/o Ms Terri Wise, executive
secretary, 401 N. Lindbergh Boulevard, St Louis, MO 63141-
7816, USA. If you prefer, a credit card number indicating the
amount of the donation may be faxed to Ms Wise at +1-314-
993-5208. A contribution to this fund is not deductible as a
charitable contribution, but may be deductible as a business
expense. Please consult your financial advisor.
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WORLD JOURNAL OF ORTHODONTICS
AAO, WFO leaders
greet Chinese Orthodontic
Society delegation
in May
Members of the American Association of Orthodontists (AAO)
Board of Trustees and members of the World Federation of
Orthodontists (WFO) Executive Committee formally welcomed
the Chinese Orthodontic Society (COS) delegation that
attended the 109th AAO Annual Session in Boston, Massachu-
setts, USA, in May. The Chinese Orthodontic Society became
an affiliate organization of the WFO in 2008.
Pictured here, from left, are Dr Bin Yan of Nanjing Medical
University School of Stomatology; Dr Xiao-Tong Li, associate
professor at Peking University School of Stomatology; Dr Bing-
Shuang Zou, associate professor of Peking University School of
Stomatology; Dr Zhen Wang of the Huizhou Dental Hospital;
Dr Shan Wang of the Nanjing Medical University School of
Stomatology; Dr Wei-Jie Zhong of the Shanghai Stomatological
Disease Center; Dr Ai-Ping Huang of a hospital in the Xin Jiang
Province; Dr A-Ying Ding, a private practitioner in Beijing;
Dr Yan-Heng Zhou, vice president of the COS; Dr Lee Graber,
AAO president-elect; Dr Tian-Min Xu, president of the COS;
Dr Roberto Justus, president-elect of the WFO; Dr Raymond
George Sr, immediate past president of the AAO; Dr Lin Wang,
vice president of the COS; Dr Athanasios E. Athanasiou, presi-
dent of the WFO; Dr William DeKock, secretary-general of the
WFO; Dr Jiu-Xiang Lin, immediate past president of the COS;
Dr Rong-Dang Hu, vice dean of the Affiliated Hospital of Wen-
zhou Medical College; Dr Robert James Bray, president of the
AAO; Dr Li-Li Chen, associate professor at Union Hospital, Tongji
Medical College, Huazhong Science and Technology University;
Dr Yan Yan, clinical professor at the 1st Affiliated Dental Hospi-
tal of Peking University School of Stomatology; Dr Xin-Hua Sun,
a professor at Jilin University School of Stomatology; Dr Yan-
Ping Zuo, an associate professor at the 1st Affiliated Hospital of
He Bei Medical University; Dr Jian-Yong Wu, vice dean of the
Affiliated Dental Hospital, Nanchang University Jiangxi Medical
College; and Dr Xing Zhong Zhang, a former associate profes-
sor at Peking University School of Stomatology and current
third-year resident at Case Western Reserve University.
Photo credit: Fadi Kheir