Cephalometric Analysis of Malay Children With and Without Unilateral Cleft Lip and Palate

Australian
Orthodontic Journal
Volume 26 Number 2, November 2010
Contents
Original articles
109 113 119 127 134 141 149 153 160 165 171 178 184
Indirect bonding do custom bases need a plastic conditioner? A randomised clinical trial Peter Miles The effect of morphine on orthodontic tooth movement in rats Mohammad S.A. Akhoundi, Ahmad Reza Dehpour, Mahsa Rashidpour, Mojgan Alaeddini, Mohammad Javad Kharazifard and Hassan Noroozi Initial and fatigue bond strengths of chromatic and light-cured adhesives June M.L. Lee, George Georgiou and Steven P. Jones A comparative assessment of the forces and moments generated at the maxillary incisors between conventional and self-ligating brackets using a reverse curve of Spee NiTi archwire Iosif Sifakakis, Nikolaos Pandis, Margarita Makou, Theodore Eliades and Christoph Bourauel Bond strengths and debonding characteristics of two types of polycrystalline ceramic brackets Katia Lemke, Xiaoming Xu, Joseph L. Hagan, Paul C. Armbruster and Richard W. Ballard Skeletal and dental changes after rapid maxillary expansion: a computed tomography study Ahmed Ghoneima, Ezzat Abdel-Fattah, Francisco Eraso, David Fardo, Katherine Kula and James Hartsfield Strength of attachment between band and glass ionomer cement Elahe Vahid Dastjerdie, Houman Zarnegar, Mohammad Behnaz and Massoud Seifi Lip - tooth relationships during smiling and speech: an evaluation of different malocclusion types Roozbeh Rashed and Farzin Heravi Effects of orthodontic treatment and premolar extractions on the mandibular third molars Mevlut Celikoglu, Hasan Kamak, Ismail Akkas and Hsamettin Oktay Cephalometric analysis of Malay children with and without unilateral cleft lip and palate Lillybia Emily Ebin, Norzakiah Mohamed Zam Zam and Siti Adibah Othman Factors contributing to stability of protraction facemask treatment of Class III malocclusion Yan Gu Effects of rapid-slow maxillary expansion on the dentofacial structures Nihat Kilic and Hsamettin Oktay Shear bond strengths of buccal tubes Kathiravan Purmal and Prema Sukumaran The effect of a Clark twin block on mandibular motion: a case report Catherine OShea, Andrew Quick, Gillian Johnson, Allan Carman and Peter Herbison Orthodontic treatment of a transmigrated mandibular canine: a case report Gksu Trakyal, S Kavaloglu ldr and Nket Sandall ule Non-surgical treatment of mandibular deviation: a case report Abdolreza Jamilian and Rahman Showkatbakhsh Effective orthodontics Michael Harkness Retirement of Michael Harkness Craig Dreyer Optimal force Felix Goldschmied Book reviews Recent publications
Case reports
189 195 201
Editorial
206 207
Letter
208
General
209 216 220 222
In appreciation New products
223 224
Calendar Index
Australian Orthodontic Journal Volume 26 No. 2 November 2010
Indirect bonding do custom bases need a plastic conditioner? A randomised clinical trial
Peter Miles
Private practice, Caloundra, Queensland, Australia
Aim: To compare the clinical failure rates over six months of indirectly bonded brackets with and without methyl methacrylate monomer (MMM) conditioned custom bases. Methods: Thirty-six consecutive patients satisfying the selection criteria were randomly assigned to two groups in a split-mouth study design. In Group 1, the maxillary right and mandibular left quadrants were indirectly bonded after the custom bases had been conditioned with MMM. The brackets bonded to the teeth in the contralateral quadrants were not conditioned. In Group 2, the custom bases on the brackets indirectly bonded to the teeth in the maxillary left and mandibular right quadrants were conditioned and the brackets in the contralateral quadrants were not conditioned. Over the 6-month observation period all loose brackets were recorded, and the data were compared with a Wilcoxon signed ranks test. Results: Of the 828 brackets placed, six with the MMM conditioning came loose (1.4 per cent failed) compared with five in the Control group (1.2 per cent failed). The difference was not statistically significant (p = 0.74). Conclusion: These results indicate that conditioning custom bases with methyl methacrylate monomer is an unnecessary step when indirectly bonding brackets. (Aust Orthod J 2010; 26: 109112)
Received for publication: November 2009 Accepted: February 2010 Peter Miles: pmiles@beautifulsmiles.com.au
Introduction
The advent of the direct bonding of orthodontic attachments to the etched enamel surface in the mid1960s by Newman1 was a major advance in orthodontic treatment. In 1972 Silverman et al.2 described a method of indirect bonding which involved placement of the brackets on a plaster model and then transfer of the attachments to the patients mouth by means of a tray. In 1979, Thomas3 refined this technique by bonding the brackets to the model with composite resin, thereby creating a custom base, which reduced the flash and facilitated the clean-up. Direct bonding of brackets is still the most popular method of attaching brackets to teeth, but indirect bonding is increasing in popularity. In 1990, 7.8 per cent of practitioners used indirect bonding, whereas by 2008 the number had increased to 13.2 per cent.4 Initially, bond failure rates for indirect bonding (13.9 per cent) were high compared with direct bonding (2.5 per cent).5 However with modifications and improvements to the technique, the two methods
Australian Society of Orthodontists Inc. 2010
now have similar bond strengths and failure rates.68 As with any orthodontic procedure it is desirable for the technique to be effective and efficient. With indirect bonding, goals include minimising bond failures while also keeping laboratory and clinical procedures to a minimum. There are several recommended adhesives and bonding protocols, but limited clinical evidence to support their use. The validities of in-vitro studies of bond strength have been questioned which is exemplified by a clinical trial revealing that the failure rate of the adhesive was seven times that reported as being satisfactory in an in-vitro study.912 For this reason prospective clinical trials are preferred. Light-cured flowable adhesives and plasma and LED lights have reduced the handling times for indirect bonding. Clinical trials of indirect bonding have reported that light-cured adhesives have comparable bracket failure rates to chemically-cured adhesives.13,14 In the clinical studies, the composite resin custom bases were lightly microetched in the laboratory and
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Enrolled
Randomised (N = 40)
Allocation
Allocated to Group 1 (N = 20) Received allocated intervention (N = 17)
Allocated to Group 2 (N = 20) Received allocated intervention (N = 19)
Follow-up
Lost to follow-up (N = 0)
Lost to follow-up (N = 0)
Analysis
Analysed (N = 17) Excluded from analysis (N = 0)
Analysed (N = 19) Excluded from analysis (N = 0)
Figure 1. Study design.
then 10 minutes prior to bonding painted with methyl methacrylate monomer (MMM), which is believed to improve adhesion between the base and the bonding composite.15 Other studies have used plastic conditioners, such as Enhance Adhesion Booster (Reliance Orthodontic Products, Ithaca, IL, USA) or the unfilled resin Orthosolo (Ormco, Glendora, CA, USA) to improve the bond strength.16,17 The only laboratory study evaluating the conditioning of custom bases found that the highest bond strengths were achieved when the custom bases were microetched.18 Conditioning microetched custom bases with Orthosolo resulted in lower bond strengths, particularly if too much resin was applied.19 The evidence suggests that painting a custom base with some form of plastic conditioner is an unnecessary procedure and may even lead to a higher clinical failure rate. With these thoughts, it was decided to compare the clinical failure rates of indirectly bonded brackets with and without conditioned custom bases.
pate. Subjects were randomly assigned to one of two groups in blocks of even numbers to ensure that each group had the same number of subjects. Subjects were excluded if one arch was to be treated, if all teeth (first molar to first molar) could not be bonded at the initial visit or if the number of teeth was asymmetric. After the enrolment period had ended, it was found that four subjects should have been excluded as all brackets could not be bonded at the initial visit so the total number of subjects was 36 (Figure 1). All subjects (17 in Group 1, 19 in Group 2) completed the trial. There were 21 females and 15 males and the mean age of the subjects was 14.2 1.5 years. A total of 828 brackets was placed (Maxilla: N = 406; Mandible: N = 422). The custom bases on the brackets bonded to the teeth in the maxillary right and mandibular left quadrants (from first molar to central incisor) were painted with MMM (Orthocryl, Dentaurum, Pforzheim, Germany) 10 minutes prior to bonding, whereas no conditioning agent was applied to the bases bonded to the teeth in the contralateral quadrants. In Group 2, the custom bases on the brackets indirectly bonded to the teeth in the maxillary left and mandibular right quadrants were conditioned and the brackets in the contralateral quadrants were not conditioned. In both groups the same prescription of precoated
Materials and methods

Forty subjects were prospectively selected from the private orthodontic practice of the author for this randomised clinical trial. All subjects were informed of the purpose of the study and all agreed to partici110
DO CUSTOM BASES NEED A PLASTIC CONDITIONER?
Table I. Bracket failures over the 6-month observation period.
Results
p
Total brackets (N = 828)
Failed Failure (Per cent)
Total - Conditioned (N = 414) Total - Not conditioned (N = 414) Maxilla - Conditioned (N = 203) Maxilla - Not conditioned (N = 203) Mandible - Conditioned (N = 211) Mandible - Not conditioned (N = 211)
6 5 3 4 3 1
1.4 1.2 0.74 1.5 2.0 0.71 1.4 0.5 0.32
Of the 828 brackets placed, a total of 11 brackets came loose during the study (Table I). Of these brackets, six had the MMM applied to the custom bases and five brackets were not conditioned. The failure rates for the brackets with conditioned and untreated bases were 1.4 per cent and 1.2 per cent, respectively (p = 0 .74). In the maxillary arch, three brackets from the MMM quadrants were dislodged, compared with four brackets from quadrants with no monomer applied to the custom bases (p = 0.71). In the mandibular arch, three brackets from the MMM quadrants failed, compared with one bracket in the non-treated quadrants (p = 0.32).
brackets (APC II adhesive, 3M Unitek, Monrovia, CA, USA) was used to form the custom bases and all custom bases were microetched in the laboratory. After etching the enamel with conventional phosphoric acid etch for 2030 seconds, the teeth were rinsed with water and thoroughly dried. A moisture insensitive primer MIP (3M Unitek, Monrovia, CA, USA) was applied to the teeth prior to bonding and all brackets were bonded indirectly using the flowable adhesive, Filtek Flow (3M ESPE, St Paul, MN, USA). The laboratory and clinical techniques have been described previously.13,14 The only variations from this technique were that a flexible inner tray was used and the hard outer tray was omitted. The flexible tray containing the brackets was seated with light finger pressure and the tip of the curing light, to ensure intimate contact between the custom bases and the teeth prior to curing the bonding adhesive. If the brackets interfered in the occlusion, a composite resin bite plane or wedge (Herculite XRV, Kerr Corporation, Orange, CA, USA) was built up on the palatal surfaces of the maxillary incisors or, if this was not suitable, on the buccal cusps of the lower molars, to prevent any contact with the lower brackets. A 0.014 inch thermally active NiTi wire (G & H, Greenwood, IN, USA) was the initial archwire. The normal wire sequence used after 10 weeks was a 0.016 x 0.022 inch thermally active NiTi wire (G & H, Greenwood, IN, USA) and after an additional 10 weeks a 0.016 x 0.022 inch stainless steel wire (G & H, Greenwood, IN, USA) was placed as the working wire. The number of loose brackets over six months was recorded for all subjects. Only the first occasion a bracket was dislodged was used in the analysis. The data were analysed using a Wilcoxon signed ranks test.
Discussion
One of our primary goals as orthodontists is to provide quality, evidence-based treatment in an efficient manner for our patients. Based on the results of this study, the conditioning of custom bases with MMM is an unnecessary step: it did not result in fewer failed brackets. This result is supported by an in-vitro study which suggested that conditioning custom bases with Orthosolo was an unnecessary step when indirect bonding, but microetching the bases was extremely important.18 The present clinical study and the invitro study referred to used brackets precoated with either APC or APC II adhesive from the same manufacturer (3M/Unitek, Monrovia, CA, USA). Adhesives from other manufacturers may have different compositions and bonding strengths so the results from the present study may not be applicable to these adhesives. Other clinical findings relevant to the effectiveness and efficiency of indirect bonding have been published. Light-cured custom bases are reported to result in significantly higher bond strengths and lower bracket failure rates than heat-cured composite resin custom bases.20,21 Another clinical trial found that microetching the enamel prior to conventional etching did not significantly affect the bracket failure rate when indirect bonding, indicating that this is an unnecessary procedure.22 Clinical studies of adhesives have found the chemically-cured Maximum Cure (Reliance Orthodontic Products, Ithaca, IL, USA) and light-cured Filtek Flow (now available as Transbond Supreme LV; 3M Unitek, Monrovia, CA, USA) have lower clinical failure rates than the
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chemically-cured Sondhi Rapid Set (3M Unitek, Monrovia, CA, USA).12,14 Although the delay between the manufacture of the custom bases and the bonding of the brackets may vary from a few days to three weeks, delays up to 30 days have no effect on the bond strength.23 Long delays between impression taking and placement of the brackets should be avoided as minor tooth movement could compromise the fit of the transfer trays and brackets to the teeth. The bracket failure rates in this study (1.4 and 1.2 per cent) were at the low end of the range reported in previous studies of indirect bonding (1.4 to 13.9 per cent).57,12,14,20 The use of composite bite wedges to prevent the teeth from contacting the brackets may explain the lower failure rates in the present study as not all previous studies used wedges to disclude the teeth.6,5,12,14 To determine if the wedges contributed to the lower failure rate will require further investigation. The findings of the present study indicate that conditioning custom bases with MMM can be omitted without sacrificing bracket retention. Indirect bonding is an effective clinical technique with a low clinical failure rate over six months. The efficiency of the technique can be improved by eliminating unnecessary procedures, such as conditioning the custom bases.
References
1. 2. Newman GV. Epoxy adhesives for orthodontic attachments: a progress report. Am J Orthod 1965;51:90112. Silverman E, Cohen M, Gianelly AA, Dietz VS. A universal direct bonding system for both metal and plastic brackets. Am J Orthod 1972;62:23644. Thomas RG. Indirect bonding: simplicity in action. J Clin Orthod 1979;13:93106. Keim RG, Gottlieb EL, Nelson AH, Vogels III DS. 2008 JCO Study of orthodontic diagnosis and treatment procedures, Part 1: Results and trends. J Clin Orthod 2008;42: 62540. Zachrisson BU, Brobakken BO. Clinical comparison of direct versus indirect bonding with different bracket types and adhesives. Am J Orthod 1978;74:6278. Read MJ, OBrien KD. A clinical trial of an indirect bonding technique with a visible light-cured adhesive. Am J Orthod Dentofacial Orthop 1990;98:25962. Aguirre MJ, King GJ, Waldron JM. Assessment of bracket placement and bond strength when comparing direct bonding to indirect bonding techniques. Am J Orthod 1982;82: 26976. Hocevar RA, Vincent HF. Indirect versus direct bonding: bond strength and failure location. Am J Orthod Dentofacial Orthop 1988;94:36771. Eliades T, Brantley WA. The inappropriateness of conventional orthodontic bond strength assessment protocols. Eur J Orthod 2000;22:1323. Swartz ML. Limitations of in vitro orthodontic bond strength testing. J Clin Orthod 2007;41:20710. Klocke A, Shi J, Kahl-Nieke B, Bismayer U. Bond strength with custom base indirect bonding techniques. Angle Orthod 2003;73:17680. Miles PG, Weyant RJ. A clinical comparison of two chemically-cured adhesives used for indirect bonding. J Orthod 2003;30:3316. Miles PG. Indirect bonding with a flowable light-cured adhesive. J Clin Orthod 2002;36:6467. Miles PG, Weyant RJ. A comparison of two indirect bonding adhesives. Angle Orthod 2005;75:101923. Hickham JH. Predictable indirect bonding. J Clin Orthod 1993;27:21518. Polat O, Karaman AI, Buyukyilmaz T. In vitro evaluation of shear bond strengths and in vivo analysis of bond survival of indirect-bonding resins. Angle Orthod 2004;74:4059. Swartz M. Bond strength of a universal orthodontic bonding agent. Clinical Impressions 2005;14:1416. Thompson MA, Drummond JL, BeGole EA. Bond strength analysis of custom base variables in indirect bonding techniques. Am J Orthod Dentofacial Orthop 2008;133:9. e1520. Waugh RL. Optimizing bond retention. Clinical Impressions. 2005;14:27. Miles PG. A comparison of retention rates of brackets with thermally-cured and light-cured custom bases in indirect bonding procedures. Aust Orthod J 2000;16:11517. Klocke A, Shi J, Kahl-Nieke B, Bismayer U. Bond strength with custom base indirect bonding techniques. Angle Orthod 2003;73:17680. Miles P. Does microetching enamel reduce bracket failure when indirect bonding mandibular posterior teeth? Aust Orthod J 2008;24:14. Klocke A, Tadic D, Vaziri F, Kahl-Nieke B. Custom base preaging in indirect bonding. Angle Orthod 2004;74: 10611.
3. 4.
5.
6.
7.
8.
9.
10. 11.
12.
Conclusions
Conditioning custom bases with methyl methacrylate monomer had no influence on the bracket failure rate. The bracket failure rates in this study (less than 1.5 per cent) were low when compared with the literature, indicating that the method of indirect bonding employed in the present study is an effective clinical technique. Occlusal wedges may contribute to bracket retention by protecting brackets from occlusal trauma.
13. 14. 15. 16.
17. 18.
19.
Corresponding author
Dr Peter Miles 10 Mayes Avenue Caloundra Qld 4551 Australia Email: pmiles@beautifulsmiles.com.au
20.
21.
22.
23.
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The effect of morphine on orthodontic tooth movement in rats

Mohammad S.A. Akhoundi, * Ahmad Reza Dehpour, Mahsa Rashidpour, + Mojgan Alaeddini, + Mohammad Javad Kharazifard + and Hassan Noroozi +
Departments of Orthodontics* and Pharmacology, and the Dental Research Center,+ Tehran University of Medical Sciences, Tehran, Iran
Objectives: To investigate the effect of morphine as an exogenous opioid on orthodontic tooth movement. Naltrexone will be used as an opioid antagonist to confirm the results. Methods: Forty rats were randomly divided into four equal groups. The first group received no injection; the second group received daily injections of morphine; the third group received daily naltrexone-morphine injections and the fourth group daily injections of naltrexone-normal saline. The left first maxillary molar in each rat was tipped mesially with a NiTi closed coil spring. The rats were sacrificed after 14 days and the maxillae fixed, sectioned serially and examined histologically. Results: The greatest amount of tooth movement occurred in the Control group and the least amount of tooth movement in the Morphine group. Tooth movement in the Morphine group was significantly different from the other three groups (p < 0.05). The differences in tooth movement in the Control, Morphine-naltrexone and Naltrexone-saline groups were not statistically significant (p > 0.05). No statistically significant histological differences were found. Conclusions: Morphine reduced orthodontic tooth movement in rats. This effect was reversed by the opioid antagonist, naltrexone, which had no effect on tooth movement. (Aust Orthod J 2010; 26: 113118)
Received for publication: April 2009 Accepted: February 2010 Mohammad S.A. Akhoundi: ahmadakh@tums.ac.ir Ahmad Reza Dehpour: dehpour@yahoo.com Mahsa Rashidpour: mahsa_rp@yahoo.com Mojgan Alaeddini: malaeddini@tums.ac.ir Mohammad Javad Kharazifard: mj_khf@yahoo.com Hassan Noroozi: noroozih@yahoo.com
Introduction
During orthodontic tooth movement a series of complex changes occur in the alveolar bone cells and periodontal ligament. These changes are mainly controlled by osteoblasts and osteoclasts in a process called coupling.1 Factors such as certain drugs/ medication taken during orthodontic treatment can interfere with the remodelling mechanisms and affect tooth movement.24 The same drugs can be used in experimental studies to explore some of the mechanisms controlling tooth movement. Non-steroidal anti-inflammatory drugs (NSAIDs), which are taken for pain control during orthodontic treatment, prevent the conversion of arachidonic acid to prostaglandins and so reduce the amount of tooth
movement.5,6 Opioids, which are categorised as exogenous and endogenous, can also interfere with bone metabolism.7,8 Opioid receptors (mu, delta and kappa) can be found in the cells of the central nervous system and in other cells,4,7,9,10 and opioid receptors in osteoblast-like cells are connected with the structure and metabolism of bone.4,11 Opioids may either increase or reduce the rate of tooth movement. For example, endogenous opioids interact with nitric oxide in cholestatic rats and increase the rate of tooth movement, but exogenous opioids taken for pain relief (e.g. acetaminophen codeine) may have an entirely different effect.1214 A recent study of Iranian high school and university students reported that 91 per cent resorted to selfmedication to relieve pain and acetaminophen
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a daily injection of naltrexone (20 mg/kg body weight)-normal saline. All injections were administered intra-peritoneally at 24-hour intervals for 14 days.17
Orthodontic appliance and measurement of tooth movement

Each rat was anaesthetised with an intra-peritoneal injection of chlorpromasine (30 mg/kg body weight) and ketamine (50 mg/kg body weight). The maxillary left first molars were tipped mesially using 6 mm 0.006 x 0.022 inch NiTi closed coil springs for 14 days.12 The springs were anchored at the ends with 0.010 inch stainless steel ligature wires tied to the left maxillary first molars and the upper incisors (Figure 1). The molar ligature wires were passed between the first and second molars and tied around the cervical margins of the first molars. The anterior ligature was tied around the incisors and secured in shallow grooves cut into the labial and distal surfaces of the incisors, close to the gingival margins. A small amount of light-cure composite resin was placed over the ligature wires to protect the wires from damage. Each spring was activated about 1 mm to deliver a 60 g mesial tipping force and it was not reactivated during the course of the study.18,19 After insertion of the appliance, the crowns of the lower incisors were reduced 1.5 mm to prevent the incisors from cutting the ligature wires. Mesial movement of the first molar was measured at the start and end of the experiment with a filler gauge inserted between the first and second maxillary left molars. The initial distance between the molars was zero in all animals. The final measurement was carried out following decapitation, but before the appliances were removed and potential relapse of the first molar into the space between the molars. All measurements were repeated twice by the same operator, who was blinded to the treatment each rat had received. The intraclass correlation coefficient (ICC) between the two sets of measurements was .984.
Figure 1. Schematic view of the appliance.
codeine was the most commonly used analgesic.15 Since orthodontic treatment can be painful and patients may resort to self-medication we decided to investigate the effect of morphine, an exogenous opioid, on tooth movement in the rat. We used naltrexone, an opioid antagonist, which binds opioid receptors in a non-selective manner, to confirm the action of morphine on tooth movement.16
Materials and methods Animals

Forty male Wistar rats between 200 and 250 g body weight were used. The animals were housed in plastic cages, with a 12/12 hour light-dark cycle. They were fed soft laboratory food to minimise any discomfort from the appliances and to reduce the risk of an appliance being dislodged or deformed.12 The experimental protocol was approved by the Ethics Committee of Tehran University of Medical Sciences. The animals were weighed on the day the appliances were placed and immediately before death. All animals had an orthodontic appliance consisting of a NiTi closed coil spring ligated to the left maxillary first molar and both upper incisors. The rats were randomly divided into four equal groups. The first group received no injection, the second group received a daily injection of morphine (5mg/kg body weight), the third group received a daily injection of naltrexone (20 mg/kg body weight)-morphine (5 mg/kg body weight) and the fourth group received
114
Histological evaluation
The maxillae were fixed in 10 per cent formalin for 10 days and decalcified in 5 per cent formic acid for 4 days. The decalcified maxillae were embedded in paraffin and parasagittal serial sections of the mesial roots of first molars cut and stained with haematoxylin and eosin.20
EFFECT OF MORPHINE ON ORTHODONTIC TOOTH MOVEMENT
Figure 2. Parasagittal section of the mesio-buccal root of an upper first molar in the Morphine group. The tooth was moved from right to left. Original magnification x40.
Figure 3. Resorption lacunae on the mesial surface of the mesio-buccal root of a first molar in the Morphine group. Original magnification x100.
.3
Tooth movement (mm)
.2
.1
0.0 Groups Morphine Naltrexone-saline Naltrexone-morphine Control
Figure 4. An osteoclast (circled) on the mesio-buccal root of a specimen in the Morphine group. Original magnification x200.
Figure 5. Tooth movement in the groups. Means and SD bars are shown.
From each tooth, six sections that showed the full width of the root from the cemento-enamel junction (CEJ) to the apex were examined under an Olympus Bx-41 light microscope (Figure 2). Root resorption and the width of the periodontal ligament (PDL) surrounding the mesio-buccal root were evaluated with the aid of an eyepiece graticule with the accuracy of 10 m. The number of resorption lacunae and their maximum depths were used to determine the amount of root resorption (Figures 3 and 4). The latter were measured using the method described by Sekhavat et al.21 Apparent roughness of the dentine or cementum
was considered as resorption. Thus, each section produced a number representing resorption and the mean of the six representative sections determined the amount of resorption affecting a tooth. The number of osteoclasts was also used to determine bone resorption. The width of the PDL was measured on the mesial and distal surfaces of the root in the most coronal and apical regions.22 All sections were measured twice by the same operator and the mean of the two measurements used in all subsequent calculations.
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Table I. Molar separation over 14 days.
Group
Mean (mm)
SD
SE Lower
95% CI Upper
Minimum
Maximum
Morphine Naltrexone - morphine Naltrexone - saline Control
10 10 10 10
0.081 0.164 0.162 0.170
0.029 0.069 0.061 0.089
0.009 0.022 0.019 0.028
0.060 0.114 0.119 0.106
0.102 0.214 0.205 0.233
0.05 0.10 0.08 0.10
0.15 0.30 0.25 0.35
Statistical analysis
Differences between the groups were analysed by the one-way ANOVA followed by Tukey post-hoc tests for multiple comparisons. The statistics were analysed with SPSS 11.5 software. Probability values < 0.05 were considered as statistically significant.
Results
There were no statistically significant differences in the mean overall weights of the groups. All first molars showed evidence of tooth movement (Table I). Among the groups, the Control group showed greatest mesial movement (Mean: 0.170 mm) and the Morphine group (Mean: 0.081 mm) the least mesial movement (Figure 5). The first and second molars in the Morphine group were significantly less separated than the molars in the other three groups (p < 0.05). The differences between the Control, Morphinenaltrexone and Naltrexone-saline groups were not statistically significant (p > 0.05). Osteoclasts were found lining the bone on the mesial surfaces of the roots in all groups, but there were no statistically significant group differences in the number of osteoclasts (p > 0.05). Although the resorption lacunae in mesial roots in the Morphine group were fewer and shallower than the lacunae in the other groups, the differences were not statistically significant (p > 0.05). There were no significant differences in the widths of the PDL on mesio-apical, disto-apical, mesio-coronal and disto-coronal areas of the mesio-buccal root (p > 0.05).
with a simple orthodontic appliance. We found that morphine (an exogenous opioid) reduced the amount of tooth movement and this effect was reversed by naltrexone. We found no differences in tooth movement between the groups that received naltrexone either with morphine or with saline, or the Control group, which suggests that the naltrexone did not affect tooth movement. Our histological methods failed to disclose supporting differences in the number and depths of resorption lacunae or the width of the PDL. Previous studies have shown that opioids affect osteoblasts and bone remodelling.4,7 Since there are three opioid receptors (mu, delta and kappa) on osteoblast-like cells (MG-63), the high concentration of morphine, as an agonist of mu receptor sites, prevented the synthesis of osteocalcin, which is a marker of osteoblastic activity.7 Rosen et al. suggested the existence of opioid receptors in osteoblasts and confirmed the presence of specific mRNA of kappa receptors in rat osteoblasts.4,23 Our results can be compared with a study of the role of opioid systems on orthodontic tooth movement in cholestatic rats.12 Endogenous opioids in cholestasic animals may interfere with bone remodelling by affecting osteoblast-like cells and, in turn, increasing the rate of orthodontic tooth movement.12 In these conditions, endogenous opioids interacting with nitric oxide were thought to be responsible for the increased rate of orthodontic tooth movement.24,25 In these studies, naltrexone blocked the increase in endogenous plasma opioids and inhibited the rate of orthodontic tooth movement, whereas we found it had no effect on the rate of tooth movement. It appears that endogenous and exogenous opioids have quite different effects: endogenous opioids increase tooth movement and exogenous opioids reduce it. Part of the answer may lie with the strength and/or
Discussion
We determined the magnitude of tooth movement in rats administered morphine, an exogenous opioid, by measuring separation of the maxillary first and second molars following mesial movement of the first molar
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EFFECT OF MORPHINE ON ORTHODONTIC TOOTH MOVEMENT
dosage of the opioid used. For instance, codeine is a relatively weak opioid, but morphine and heroin are strong opioid agonists, and pentazosine is an agonistantagonist opioid. The latter appears to work as a kappa agonist and mu antagonist.9 We measured tooth movement 14 days after appliance activation, because the period for completion of the bone remodelling cycle is 1014 days.12,18,26 Although we found a difference in macroscopic tooth movement between the groups there was no statistically significant group difference in the number of osteoclasts or the maximum depths of the resorption lacunae. One view of the difference in tooth movement is that morphine reduces the activity of osteoclasts rather than reducing the number of osteoclasts. Our methods did not enable us to confirm or refute this notion. Future studies should investigate the histological changes over longer periods of time, use histological methods able to detect smaller changes in cell activity and investigate different dosages of morphine.27,28 Our results, which demonstrated that morphine reduced tooth movement in a small laboratory animal, cannot be extrapolated to humans. The results suggest that a clinical trial of tooth movement in subjects using opiate-based analgesics should be initiated to determine if small pharmacological doses affect orthodontic tooth movement.
References
1. 2. Newman M, Takei H, Carranza F. Carranzas clinical periodontology. 9th ed. 2002;47. Adachi H, Igarashi K, Mitani H, Shinoda H. Effects of topical administration of a bisphosphonate (risedronate) on orthodontic tooth movements in rats. J Dent Res 1994;73: 147886. Yamasaki K, Miura F, Suda T. Prostaglandin as a mediator of bone resorption induced by experimental tooth movement in rats. J Dent Res 1980;59:163542. Rosen H, Metzer E, Benzakine S, Bar-Shavit Z. Functional opioid receptors on skeletal cells. J Bone Miner Res 1997; 12:(suppl).411. Zhou D, Hughes B, King GJ. Histomorphometric and biochemical study of osteoclasts at orthodontic compression sites in the rat during indomethacin inhibition. Arch Oral Biol 1997;42(1011):71726. Chumbley AB, Tuncay OC. The effect of indomethacin (an aspirin-like drug) on the rate of orthodontic tooth movement. Am J Orthod 1986;89:31214. Perz-Costrilln JL, Olmos JM, Gomez JJ, Barrallo A, Riancho JA, Perera L et al. Expression of opioid receptors in osteoblast-like MG-63 cells, and effects of different opioid agonists on alkaline phosphatase and osteocalcin secretion by these cells. Neuroendocrinology 2000;72:18794. Hall TJ, Jagher B, Schaeublin M, Wiesenberg I. The analgesic drug buprenorphine inhibits osteoclastic bone resorption in vitro, but is proinflammatory in rat adjuvant arthritis. Inflamm Res 1996;45:299302. Pleuvry B J. Opioid mechanisms and opioid drugs. Anaesthesia and intensive care medicine 2005;6:304. Brownstein MJ. A brief history of opiates, opioid peptides, and opioid receptors. Proc Natl Acad Sci U S A 1993;90: 53913. Rico H, Costales C, Cabranes JA, Escudero M. Lower serum osteocalcin levels in pregnant drug users and their newborns at the time of delivery. Obstet Gynecol 1990;75:9981000. Nilforoushan D, Shirazi M, Dehpour AR. The role of opioid systems on orthodontic tooth movement in cholestatic rats. Angle Orthod 2002;47680. Saper JR, Lake AE. Continuous opioid therapy (COT) is rarely advisable for refractory chronic daily headache: limited efficacy, risk, and proposed guidelines. Headache 2008; 48:83849. Minai-Tehrani D, Minoui S, Sepehre M. Inhibitory effect of codeine on sucrase activity. Drug Metab Lett 2009;3: 5860. Sedighi B, Ghaderi-Sohi S, Emami S. Evaluation of selfmedication prevalence, diagnosis and prescription in migraine in Kerman, Iran. Saudi Med J 2006;27:37780. Farid W.O, Dunlop S.A, Tait R.J, Hulse G.K. The effects of maternally administered methadone, buprenorphine and naltrexone on offspring: review of human and animal data. Curr Neuropharmacol 2008;6:12550. Brudvik P, Rygh P. The repair of orthodontic root resorption: an ultrastructural study. Eur J Orthod 1995;17: 18998. King GJ, Fischlschweiger W. The effect of force magnitude on extractable bone resorptive activity and cemental cratering in orthodontic tooth movement. J Dent Res 1982;61: 7759. Igarashi K, Woo JT, Paula H. Effect of a selective cyclo oxygenase-2 inhibitor on bone resorption and osteoclastogenesis in vitro. Biochem Pharmacology 2001;63:52332.
3.
4.
5.
6.
7.
8.
9. 10.
11.
12.
Conclusions
1. Morphine reduces the rate of tooth movement in rats. 2. This effect was reversed by administering the opioid antagonist, naltrexone, which had no effect on orthodontic tooth movement. 3. Further studies are needed to investigate the effects and modes of action of morphine and other opiates on tooth movement in rats and man.
13.
14.
15.
Dr Hassan Noroozi Dental Research Center Faculty of Dentistry Tehran University of Medical Sciences Tehran Iran Tel: +98 21 88986677 Fax: +98 21 88986688 Email: noroozih@yahoo.com
16.
17.
18.
19.
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20. Leiker BJ, Nanda RS, Currier GF, Howes RI, Sinha PK. The effects of exogenous prostaglandins on orthodontic tooth movement in rats. Am J Orthod Dentofacial Orthop 1995; 108:3808. 21. Sekhavat AR, Mousavizadeh K, Pakshir HR, Aslani FS. Effect of misoprostol, a prostaglandin E1 analog, on orthodontic tooth movement in rats. Am J Orthod Dentofacial Orthop 2002;122:5427. 22. Tengku BS, Joseph BK, Harbrow D, Taverne AA, Symons AL. Effect of a static magnetic field on orthodontic tooth movement in the rat. Eur J Orthod 2000;22:47587. 23. Rosen H, Polakiewiez RD, Benzakine S, Bar-Shavit ZB. Proenkephaline A in bone-derived cells. Proc Natl Acad Sci USA 1991;88:37059. 24. Namiranian K, Samini M, Mehr SE, Gaskari SA, Rastegar H, Homayoun H et al. Mesenteric vascular bed responsiveness in bile duct-ligated rats: roles of opioid and nitric oxide systems. Eur J Pharmacol 2001;423:18593.
25. Nahavandi A, Mani AR, Homayounfar H, Akbari MR, Dehpour AR. The role of the interaction between endogenous opioids and nitric oxide in the pathophysiology of ethanol-induced gastric damage in cholestatic rats. Fundam Clin Pharmacol 2001;15:1817. 26. Gameiro GH, Nouer DF, Pereira-Neto JS, Urtado MB, Novaes PD, de Castro M et al. The effects of systemic stress on orthodontic tooth movement. Aust Orthod J 2008;24: 1218. 27. Rozisky JR, Dantas G, Adachi LS, Alves VS, Ferreira MB, Sarkis JJ, Torres IL. Long-term effect of morphine administration in young rats on the analgesic opioid response in adult life. Int J Dev Neurosci 2008;26:5615. 28. Zarrindast MR, Ebrahimi-Ghiri M, Rostami P, Rezayof A. Repeated pre-exposure to morphine into the ventral pallidum enhances morphine-induced place preference: involvement of dopaminergic and opioidergic mechanisms. Behav Brain Res 2007;181:3541.
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Initial and fatigue bond strengths of chromatic and light-cured adhesives

June M.L. Lee, George Georgiou and Steven P. Jones
UCL Eastman Dental Institute, London, United Kingdom
Aim: To compare the initial and fatigue shear bond strengths of a chromatic adhesive with a light-cured adhesive in an ex vivo laboratory study. Methods: Hydroxyapatite discs were used as the bonding substrate. They were produced by cold uni-axial compression at 20 tons, sintered at 1300 C and embedded in epoxy resin before grinding and polishing. One hundred and fifty upper left central incisor brackets were bonded to the discs with Transbond PLUS Color Change (3M Unitek, Monrovia, CA, USA) while another 150 similar brackets were bonded with Transbond XT (3M Unitek, Monrovia, CA, USA). Seventy-five brackets from each group were subjected to cyclic loading (5000 cycles at 2 Hz) at 50 per cent of the mean bond strength in a Dartec Series HC10 Testing Machine. Initial (unfatigued) and fatigued bond strengths were determined by applying a shear force at the bracket-substrate interface using a custom-made metal jig in an Instron Universal Testing Machine. One-way ANOVA with Bonferroni post-hoc correction and two-way ANOVA were used to analyse the differences between the initial and fatigue mean shear bond strengths of the adhesives. The survival and bond reliability of both adhesives were evaluated with the KaplanMeier and Cox regression analyses. Results: The initial mean shear bond strength for Transbond PLUS Color Change (16.72 MPa) was higher than Transbond XT (15.11 MPa), but this was not statistically significant (p = 0.109). The fatigue mean shear bond strength for Transbond XT (15.87 MPa) was similar to that of Transbond PLUS Color Change (15.33 MPa), and the difference was not statistically significant (p > 0.999). There were no significant differences when the effects of the material (p = 0.264) or fatiguing (p = 0.512) were considered separately, but in combination, the effect on bond strength was statistically significant (p = 0.026). The survival analysis showed that both adhesives demonstrated similar survival patterns in the unfatigued and fatigued states. Analysis of the material type and fatiguing showed no effect on the survival pattern for both adhesives (p = 0.098). Conclusions: There were no statistically significant differences between the mean initial (unfatigued) and fatigue bond strengths of Transbond XT and Transbond PLUS Color Change under laboratory conditions. A survival analysis for both resins with and without fatigue loading exhibited similar behaviour with respect to their survival patterns. Although this may imply that under clinical conditions the two adhesives could behave similarly, the clinical extrapolation of these results should be interpreted with caution. (Aust Orthod J 2010; 26: 119126)
Received for publication: February 2010 Accepted: March 2010 June M. L. Lee: june_lee21@hotmail.com George Georgiou: g.georgiou@eastman.ucl.ac.uk Steven P. Jones: s.jones@eastman.ucl.ac.uk
Introduction
A clinically effective bonding adhesive should provide a secure bond between an orthodontic attachment and the tooth surface during treatment, but then allow removal of the attachment at the end of treatment without damaging the enamel. The search for the ideal bonding material in orthodontics has been the focus for much research and development,
leading to the introduction of newer bonding materials to the market. In addition to any new properties, an adhesive must also retain the strengths found in current adhesives used by clinicians for it to be a viable substitute. The process of developing a new bonding agent relies on effective ex vivo laboratory studies which are commonly carried out prior to clinical trials, although comparisons
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between laboratory studies can be fraught with difficulties due to variations in their methodology and protocols. This has led to the emphasis on the importance of standardised test parameters and protocols.1,2 During fixed appliance therapy, patients may be at a significant risk of developing white spot lesions if oral hygiene is suboptimal.3,4 Chromatic adhesives were developed to aid the removal of flash adhesive during bonding, since it has been suggested that the removal of flash may reduce plaque accumulation and the incidence of enamel demineralisation. These adhesives may either be photochromatic, where the adhesive turns clear on exposure to the curing light; or thermochromatic, where the adhesive turns clear above 32 C and then reverts to its original colour below 32 C to allow complete removal at debonding. Transbond PLUS Color Change adhesive (3M Unitek, Monrovia, CA, USA) is a light-activated photochromatic composite resin that changes from a pink-coloured resin to a tooth-coloured resin upon curing. The manufacturer claims that the colour changing property aids bracket positioning and flash clean-up around brackets, although this was not supported by a typodont study which found that the use of chromatic adhesive did not result in improved removal of excess adhesive and that significant amounts of adhesive flash remained after bonding.5 There is limited published data relating to the bond strength of this material.6,7 Ex vivo laboratory bonding studies have traditionally used extracted human premolar teeth as the bonding substrate and the shear bond strengths of brackets bonded to human enamel has been reported to be in the range of 1520 MPa.810 The use of extracted human teeth has potential disadvantages which include the inconsistencies of crown contour and morphology, presence of surface defects and restorations, variations in fluoride mineralisation, coupled with an increasing difficulty in collecting suitable teeth for adequate sample sizes and problems related to the storage and sterilisation of human teeth. A previous study considered alternative substrates for the mineral phase of enamel, thereby introducing a biomimetic approach to laboratory bond strength testing. The use of cold-pressed commercially available pure hydroxyapatite powder has been recommended as an alternative substrate to enamel for comparative laboratory studies.11,12
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Fatigue can be defined as degradation of materials subjected to a number of load changes, with a tendency to fracture under cyclic stress. Fatigue failure is a phenomenon whereby stress values well below the ultimate tensile or shear stress of a material can produce premature fracture, because microscopic flaws grow slowly over many cycles of stress.13 The structure eventually fails after being repeatedly subjected to loads that are so small that one application apparently causes no damage. Fatigue may be caused by thermal insults or by mechanical means. During fixed appliance therapy, bonded attachments may be subjected to repeated loading from masticatory forces or via the archwires. These forces vary in frequency, duration and magnitude, and when repeated over long periods of time may eventually result in structural or fatigue failure. It is important that when selecting a particular bonding material for clinical use, the fatigue resistance of the material is considered, as it will affect the durability of bonded attachments throughout the course of treatment.14 The conventional method for comparing two bonding adhesives has been a comparison of their initial bond strengths. However, fatigue testing is a more appropriate test to investigate the survival and durability of the bonding adhesive in the mouth, since the life expectancy of an adhesive is influenced by cyclic loading from occlusal forces. Fatigue failure could be a factor in predicting the bond strength and eventually the long-term survival of the bonding adhesive in a clinical environment.15 This study was designed to compare the initial (unfatigued) and fatigue bond strengths of Transbond PLUS Color Change with Transbond XT in a laboratory setting. The results of this study will form a foundation for future in vivo clinical trials.

Circular hydroxyapatite discs were manufactured from commercially available hydroxyapatite powder Captal R (Plasma Biotal Ltd., Tideswell, UK) by cold-pressing at 20 tons in a hydraulic press. These were sintered at 1300 C in a furnace, allowed to cool to room temperature overnight and then embedded in acrylic resin before being polished to a standard protocol. The manufacturing and polishing protocols have been described in detail.11,12 A small pilot study confirmed that a sample size of 75 per test group would provide 80 per cent power
SHEAR BOND STRENGTHS OF TWO ADHESIVES
Figure 1. Jig mounted in Instron for bond strength testing, showing two opposing brackets in position.
Figure 2. Jig mounted in Dartec Series HC10 for cyclic fatigue loading, showing two opposing brackets in position.
( = 0.05). Three hundred upper left central incisor, Victory Series stainless steel brackets (3M Unitek, Monrovia, CA, USA) were bonded to the hydroxyapatite discs with either Transbond XT (N = 150) or Transbond PLUS Color Change (N = 150) adhesives. The hydroxyapatite discs were etched with 35 per cent ortho-phosphoric acid gel prior to bonding, using a standardised bonding protocol.11,12 Four brackets were bonded peripherally on each disc in order to allow the disc to be used for four separate shear tests. These were bonded in two stages using only opposing pairs of brackets at any one time to avoid dislodging the other brackets during testing. The Instron Universal Testing Machine 4505 (Instron Limited, High Wycombe, UK) was used to carry out the shear bond strength testing of the bonded brackets. During testing each hydroxyapatite disc was held securely in place in the machine with a specially constructed metal jig (Figure 1). The load
cell used for shear bond testing was 1 kN, at a crosshead speed of 1 mm per minute. Shear force was applied to the bracket-disc interface until the bracket failed. The maximum load at failure was recorded in kilonewtons (kN) and then converted to shear bond strength in megapascals (MPa) by dividing the maximum load at failure by the cross-sectional surface area of the bracket base. Fatigue loading of bonded orthodontic brackets was carried out in the Dartec Series HC10 (Zwick/Roell, Herefordshire, UK). The cyclic mode of loading in this machine is designed to simulate repetitive occlusal forces to which the orthodontic brackets would be exposed intra-orally. The cyclic load applied was 50 per cent of the mean bond strength suggested by the pilot study. The loading cycle was 5000 cycles with the load applied in the form of a sine wave at a frequency of 2 Hertz (Figure 2). Once the fatigue cycle was completed, the bracket was then sheared to
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Initial (Unfatigued) 1.0 0.8 0.6 0.4 0.2 0.0 9.00 12.00 15.00 18.00 21.00 24.00 Bond strength (MPa) Transbond XT Composite resin Transbond Plus Cumulative survival 1.0 0.8
Fatigued Composite resin
Cumulative survival
Transbond XT 0.6 0.4 0.2 0.0 6.00 9.00 12.00 15.00 18.00 21.00 24.00 Bond strength (MPa) Transbond Plus
Figure 3. Kaplan-Meier plot for unfatigued brackets.
Figure 4. Kaplan-Meier plot for fatigued brackets.
failure in the Instron machine in order to determine the bond strength after fatigue cyclic loading. As suggested from the sample size calculation, 75 brackets bonded with Transbond XT Light Cure Orthodontic Adhesive and 75 brackets bonded with Transbond PLUS Color Change Adhesive were sheared to failure without fatigue loading (initial bond strength test) and the same number of brackets for both adhesives were sheared to failure after fatigue loading. A modified Kaplan-Meier survival curve was produced by plotting the cumulative survival probability against the bond strength to failure for the bonded brackets. This is a useful survival analysis tool to determine the bond reliability and survival probability at specific loads. A Cox regression analysis was used to investigate the simultaneous effect of a number of explanatory variables on survival.
(p = 0.109). Transbond XT had a higher mean shear bond strength after fatiguing (15.87 MPa) than Transbond PLUS Color Change (15.33 MPa), but again this was not statistically significant (p > 0.999). Fatiguing produced no statistically significant differences in shear bond strength for either adhesive (Transbond PLUS Color Change: p = 0.248; Transbond XT: p > 0.999). A two-way ANOVA was used to investigate the influence on bond strength of changing a single variable (the composite type or the introduction of fatigue), and whether there were any interactions when the composite type and fatigue were combined. There were no statistical significances when considering either the composite resin (p = 0.264) or the effect of fatiguing on the bonded brackets (p = 0.512). However, when composite type and fatigue were analysed in combination, the effect on bond strength was statistically significant (p = 0.026). Figures 3 and 4 show modified Kaplan-Meier survival plots for unfatigued brackets and fatigued brackets respectively, for both composite resins. The Y-axis represents cumulative survival, such that a survival of 1.0 is 100 per cent survival, and 0.25 represents 25 per cent survival. Horizontal lines are drawn to highlight 25, 50 and 75 per cent survival. The profile plots for all test groups were comparable and this was confirmed by the Cox regression analysis that found no statistical significance between all the variables on the survival of the brackets. There were
Results
The mean shear bond strengths for all test groups are summarised in Table I. The data were found to be normally distributed and so parametric analyses were carried out. The mean differences in the shear bond strengths between the test groups were compared with a one-way ANOVA adjusted with the Bonferroni post-hoc correction for multiple comparisons. Transbond PLUS Color Change had a higher mean shear bond strength (16.72 MPa) than Transbond XT (15.11 MPa), but this was not statistically significant
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Table I. Shear bond strength values (MPa) for test groups.
Group
Mean
95% CI
SD
Minimum
Maximum
SE
Transbond Transbond Transbond Transbond
XT Initial PLUS Initial XT Fatigued PLUS Fatigued
75 75 75 75
15.11 16.72 15.87 15.33
14.13, 15.87, 14.85, 14.38,
16.10 17.56 16.89 16.29
4.29 3.66 4.42 4.15
8.26 9.13 7.54 7.75
24.19 23.91 24.85 22.97
0.49 0.42 0.51 0.48
no statistically significant differences between the survival plots when considering the effects of the material (Transbond XT versus Transbond PLUS Color Change, p = 0.184), initial bond strength versus fatigue bond strength (p = 0.290) or the interaction between material and fatigue status (p = 0.098).
Discussion
The bonding technique used in this study was carried out in a dry field area following the manufacturers instructions. A strict bonding protocol was adhered to for each bracket to ensure that every attempt was made to standardise the variables during the bonding process.1,2 Polishing the enamel surfaces of the teeth with pumice is a common clinical practice before acid etching commences. It is also a common procedure in laboratory studies that have used human or animal teeth in bond strength testing. In this study, the hydroxyapatite discs were not pumiced because the disc surfaces had been ground and polished following a meticulous protocol to produce a uniformly polished surface. These surfaces were not covered by an organic pellicle which has been shown to cause poor bonding to enamel surfaces intra-orally.16 Pumicing the hydroxyapatite surfaces would have offered no advantage and instead could become an unnecessary variable in this comparative bonding study. One of the parameters in bond strength testing, which shows large inter-study variation, is the rate of force application as determined by the crosshead speed of the testing machine. Previous work has shown that varying the crosshead speed between 0.1 mm/min and 5.0 mm/min did not significantly influence either the debonding forces or the mode of failure of the bonded brackets.17 In this study, a crosshead speed of 1.0 mm/min was used which fell within the previously proposed acceptable range and permitted an acceptable laboratory time per test. The load application chosen to debond the brackets was a shearing mode as this has been described to more
closely resemble the occlusal forces exerted on bonded brackets intra-orally.1820 For the purpose of this study, a custom-made jig was used to hold the embedded hydroxyapatite discs firmly while the sliding blade directed the applied force vertically and as close as possible to the hydroxyapatite adhesive interface.11,12 The placement of the samples in the jig was carried out with great care to ensure that the direction of the applied force and the point of application of the force were consistent in all the samples. This is important because changes in the location of the applied force can cause significant differences in shear bond strength measurements and the failure pattern of the bond.21 The cyclic loading of the bonded brackets to simulate fatigue was carried out using a Dartec Series HC10, which is a hydraulic stress and strain testing machine. The fatigue load applied to the brackets was an estimation based on the initial bond strength from the pilot study. No standard force level or specific frequency of force application has been established to represent the forces to which bonded orthodontic brackets are subjected during a course of treatment. In this study, the fatigue load was set at 50 per cent of the mean bond strength and loaded for 5000 cycles, so that brackets were not debonded during fatiguing. This was deemed to be adequate to represent masticatory forces ranging from 40 to 120 N.18 This technique of testing the shear bond strength after a fixed number of fatigue cycles mirrored that of a previous study.22 In order for meaningful comparisons to be made between different studies, the materials and methodology of the studies should be identical.1 These should include parameters such as the type of bracket and resin used, as well as the bonding and testing protocols. In this current study, the methods employed in the fabrication of the hydroxyapatite discs, the bonding and debonding protocols were similar to two reported studies.11,12
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Table II. Survival percentiles for all test groups.
25 per cent Initial/Fatigued Composite Resin Estimate SE
50 per cent Estimate SE
75 per cent Estimate SE
Initial
Fatigued
Overall
Transbond Transbond Overall Transbond Transbond Overall Overall
XT PLUS XT PLUS
18.67 19.57 19.29 19.01 18.67 18.89 19.01
0.966 0.629 0.454 0.462 0.832 0.426 0.308
14.64 16.96 15.86 17.04 15.17 15.43 15.78
0.534 0.654 0.601 0.953 0.554 0.865 0.502
11.50 14.50 12.84 11.90 11.55 11.74 12.02
0.852 0.960 0.550 0.523 0.344 0.291 0.319
The mean initial (unfatigued) bond strength value for Transbond XT bonded to hydroxyapatite was found to be 15.11 MPa. This was lower than the value found in previous studies.11,12 However, the mean shear bond strength of Transbond XT in the present study still lies within the accepted range of 1520 MPa for shear bond strength of brackets bonded to enamel.810 Although the methodology was identical, the differences between the bond strengths from this study and previous studies may reflect the fact that the brackets used were from different manufacturers.11,12 The mean initial bond strength for Transbond PLUS Color Change was found to be 16.72 MPa. There are limited studies in the literature on the bond strength of Transbond PLUS Color Change and to date there is no published study of this bonding adhesive to hydroxyapatite to enable reliable comparison with the findings of this study. In the studies that have investigated the bonding strength of Transbond PLUS Color Change, the substrate, the bonding conditions and protocols were diverse. Bonding in dry and wet conditions with various primers on bovine enamel was used in one study,7 while human premolars bonded in a dry field have been reported in another.6 The manufacturer claims that the bond strength of Transbond PLUS Color Change is comparable to the conventional bonding adhesive Transbond XT. In this study, the difference in bond strengths between the two adhesives was not statistically significant (p = 0.109). This supported the findings of Vicente et al. who found no significant difference between the bond strengths of these two adhesives when bonding was performed in dry conditions with no contamination.7 However, when Transbond PLUS Color Change was used in wet conditions with moisture tolerant or self-etching primers, the bond strengths
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were significantly higher than Transbond XT. It was suggested by the authors that this could be due to a lower content of hydrophobic (Bis-GMA) monomer in Transbond PLUS Color Change and the addition of polyethylene glycol dimethacrylate which renders it less sensitive to wet conditions.7 It has been postulated by researchers that the mean bond strength values of bonded brackets after fatigue loading would be lower compared to the unfatigued brackets. This was based on the assumption that fatigue loading may cause, or at least influence the process of mechanical failure of the substrate-adhesive-bracket interfaces. In this study there were no statistically significant differences in bond strength for either adhesive following fatiguing (Transbond PLUS Color Change: p = 0.248; Transbond XT: p > 0.999). The two variables, composite resin and fatigue loading, were analysed using a two-way ANOVA to investigate whether these variables influenced the shear bond strength of the bonded brackets. When the composite resin type alone was tested, it did not show a significant effect on the bond strength (p = 0.264). This suggested that the differences in the material type, which may include factors such as composition, physical and chemical properties of the materials per se, did not influence the shear bond strength. This was also demonstrated when fatigue loading was analysed in isolation (p = 0.512) suggesting that fatigue alone did not significantly affect the shear bond strength. However, when ANOVA analysed the two variables in combination, the interaction between the material type and fatigue loading was found to be statistically significant (p = 0.026). This may imply that the interaction could influence the bond strength by acting synergistically.
Survival analysis, such as the Weibull or KaplanMeier analysis, has been proposed by previous authors for orthodontic bond strength studies to provide more information for the clinician on the survival and reliability of the bonded brackets.1,23 These analyses focus on the bond strength values at the lower end of the range (tail end of the distribution) which are more critical in the assessment of the probability of failure of the bonded bracket. This helps clinicians to evaluate whether a particular bonding system might perform safely and successfully when used clinically. The shear bond strength data from this study was subjected to a modified Kaplan-Meier survival analysis. The estimated bond strengths at the 25 per cent, 50 per cent and 75 per cent survival percentiles for all test groups are shown in Table II. For brackets that were bonded with Transbond XT and not fatigued, at an estimated shear force of 11.50 MPa, 75 per cent of the brackets survived while 75 per cent of unfatigued Transbond PLUS Color Change survived a higher shear force of 14.50 MPa. When the brackets bonded to Transbond XT were subjected to fatigue loading, the mean shear force for 75 per cent survival was estimated to be 11.90 MPa and for Transbond PLUS Color Change, 11.55 MPa. This suggests that the probability of survival and behaviour of the fatigued brackets bonded with either type of adhesive are similar at the lower end of the shear force range. Although laboratory findings should be extrapolated to the clinical environment with caution, a number of clinical implications can be considered from this comparative study. There was no significant difference between the mean initial shear bond strengths for Transbond XT and Transbond PLUS Color Change. This suggests that the changes in constituents associated with the colour change material have resulted in no deterioration in bond strength performance. Neither material demonstrated significant differences in mean shear bond strength as a result of the fatigue process used in this study. The cyclic forces used may be considered as representative of the nature of loads produced by intra-oral masticatory forces. Both materials resisted these cyclic forces adequately and did not demonstrate significantly lower bond strengths as a result of fatigue. This suggests that the materials should resist intra-oral fatigue equally, with neither adhesive demonstrating superior performance over the other. The equality in perform-
ance of the two adhesives was reflected in the similarity of the Kaplan-Meier survival curves and lack of significant difference shown by the Cox regression. In order to confirm the findings of this laboratory study, it would be beneficial to follow this up with an in vivo clinical trial.
Conclusions
There was no statistically significant difference between the mean initial (unfatigued) bond strengths of Transbond XT and Transbond PLUS Color Change (p = 0.109). There was no statistically significant difference between the fatigue bond strengths of Transbond XT and Transbond PLUS Color Change (p > 0.999). There were no statistically significant differences between the initial and fatigue bond strengths for either Transbond XT (p > 0.999) or Transbond PLUS Color Change (p = 0.248). A survival analysis for both composite resins with and without fatigue loading exhibited similar behaviour with respect to their survival patterns (p = 0.098). In a laboratory setting, the shear bond strength of Transbond PLUS Color Change, a new chromatic adhesive, was comparable to Transbond XT in both fatigue and unfatigued conditions. Although this may imply that under clinical conditions the two adhesives could behave similarly, the clinical extrapolation of these results should be interpreted with caution.
Acknowledgments
The authors would like to acknowledge the support of Professor David Moles from the Biostatistics Unit and Professor Jonathan Knowles of the Biomaterials Department, UCL Eastman Dental Institute. We also wish to thank 3M Unitek (UK) for generously donating the materials used in this study.
Dr S. P. Jones Orthodontic Unit UCL Eastman Dental Institute 256 Grays Inn Road London, WC1X 8LD United Kingdom Tel: (+44 0) 20 7915 1068 Fax: (+44 0) 20 7915 1238 Email: s.jones@eastman.ucl.ac.uk
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References
1. Fox NA, McCabe JF, Buckley JG. A critique of bond strength testing in orthodontics. Br J Orthod 1994;21: 3343. 2. Bishara SE, Soliman M, Laffoon J, Warren JJ. Effect of changing a test parameter on the shear bond strength of orthodontic brackets. Angle Orthod 2005;75:8325. 3. Gorelick L, Geiger AM, Gwinnett AJ. Incidence of white spot formation after bonding and banding. Am J Orthod 1982;81:938. 4. Travess H, Roberts-Harry D, Sandy J. Orthodontics. Part 6: Risks in orthodontic treatment. Br Dent J 2004;196:717. 5. Armstrong D, Shen G, Petocz P, Darendeliler MA. Excess adhesive flash upon bracket placement. A typodont study comparing APC PLUS and Transbond XT. Angle Orthod 2007;77:11018. 6. Endo T, Ozoe R, Shinkai K, Aoyagi M, Kurokawa H, Katoh Y, Shimooka S. Shear bond strength of brackets rebonded with a fluoride-releasing and recharging adhesive system. Angle Orthod 2009;79:56470. 7. Vicente A, Mena A, Ortiz AJ, Bravo LA. Water and saliva contamination effect on shear bond strength of brackets bonded with a moisture-tolerant light cure system. Angle Orthod 2009;79:12732. 8. Buonocore MG, Matsui A, Gwinnett AJ. Penetration of resin dental materials into enamel surfaces with reference to bonding. Arch Oral Biol 1968;13:6170. 9. Gilpatrick RO, Ross JA, Simonsen RJ. Resin-to-enamel bond strengths with various etching times. Quintessence Int 1991;22:479. 10. Barkmeier WW, Shaffer SE, Gwinnett AJ. Effects of 15 vs 60 second enamel acid conditioning on adhesion and morphology. Oper Dent 1986;11:11116. 11. Imthiaz N, Georgiou G, Moles DR, Jones SP. Comparison of hydroxyapatite and dental enamel for testing shear bond strengths. Aust Orthod J 2008;24:1520.
12. Jones SP, Cheuk GC, Georgiou G, Moles DR. Comparison of fluoridated apatites with pure hydroxyapatite as potential biomimetic alternatives to enamel for laboratory-based bond strength studies. Aust Orthod J 2009;25:1218. 13. Daskalogiannakis J. Glossary of Orthodontic Terms. Chicago: Quintessence Publishing Company, Inc., 2000; 112. 14. Moseley HC, Horrocks EN, Pearson GJ, Davies EH. Effects of cyclic stressing on attachment bond strength using glass ionomer cement and composite resin. Br J Orthod 1995;22: 237. 15. Scherrer SS, Wiskott AH, Coto-Hunziker V, Belser UC. Monotonic flexure and fatigue strength of composites for provisional and definitive restorations. J Prosthet Dent 2003;89:57988. 16. Gwinnett AJ. Bonding of restorative resins to enamel. Int Dent J 1988;38:916. 17. Klocke A, Kahl-Nieke B. Influence of cross-head speed in orthodontic bond strength testing. Dent Mater 2005;21: 13944. 18. Reynolds IR. A review of direct orthodontic bonding. Br J Orthod 1975;2:1718. 19. Tavas MA, Watts DC. Bonding of orthodontic brackets by transillumination of a light activated composite: An in vitro study. Br J Orthod 1979;6:2078. 20. Lopez JI. Retentive shear strengths of various bonding attachment bases. Am J Orthod 1980;77:66978. 21. Klocke A, Kahl-Nieke B. Influence of force location in orthodontic shear bond strength testing. Dent Mater 2005; 21:3916. 22. Hashim NA. Fatigue of a new fluoride-releasing composite bonding agent. MSc. Thesis, University of London 2005. 23. Brantley WA, Eliades T, Litsky. Chapter 2: Mechanics and mechanical testing of orthodontic materials. In: Brantley WA, Eliades T, eds. Orthodontic Materials: Scientific and Clinical Aspects. Stuttgart, New York: Thieme, 2001; 435.
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A comparative assessment of the forces and moments generated at the maxillary incisors between conventional and self-ligating brackets using a reverse curve of Spee NiTi archwire
Iosif Sifakakis, * Nikolaos Pandis, Margarita Makou, * Theodore Eliades and Christoph Bourauel +
Department of Orthodontics, National and Kapodistrian University of Athens, Greece,* Private practice, Corfu, Greece, Department of Orthodontics, Aristotle University of Thessaloniki, Greece and the School of Dentistry, Rheinische Friedrich-Wilhelms University of Bonn, Germany+
Objectives: To compare the intrusive forces and labio-palatal moments generated at the maxillary incisors by a 0.017 x 0.025 inch reverse curve NiTi wire using self-ligating and conventional brackets. Methods: Ten 0.017 x 0.025 inch reverse curve NiTi archwires were used with each of the following 0.022 inch bracket systems: Titanium Ortho (Ormco/Sybron, CA, USA), In-Ovation R (GAC International, NY, USA) and Damon System 3MX (Ormco/Sybron, CA, USA). The wires were inserted on bracketed maxillary Frasaco models, with segmented maxillary incisors. Simulated intrusion from 0.0-1.0 mm was performed on the Orthodontic Measurement and Simulation System, which recorded the intrusive forces and the labio-palatal moments at 0.05 mm increments. The data were analysed with the ANOVA and Scheffe tests. Results: The intrusive forces were significantly different between all bracket types. The highest force was recorded with the conventional Titanium Orthos brackets (8.2 N), followed by the Damon 3MX brackets (6.3 N) and the In-Ovation R brackets (5.5 N). The moments were found to be significantly different between the conventional and the self-ligating brackets, but not between the two types of self-ligating brackets. The highest moments were recorded with the self-ligating brackets (16.6-16.9 N/mm), followed by the conventional brackets (10.8 N/mm). Conclusions: The intrusive forces exerted on the maxillary incisors by a 0.017 x 0.025 inch reverse curve NiTi archwire during the final 1 mm of levelling are very high and beyond the necessary intrusive force level for these teeth. Lower intrusive forces, but higher labio-palatal moments, were recorded with the self-ligating brackets. (Aust Orthod J 2010; 26: 127133)
Received for publication: December 2009 Accepted: May 2010 Iosif Sifakakis: isifak@gmail.com Nikolaos Pandis: npandis@yahoo.com Margarita Makou: mmakou@dent.uoa.gr Theodore Eliades: teliades@ath.forthnet.gr Christoph Bourauel: bourauel@uni-bonn.de
Introduction
Self-ligating bracket usage has been on the rise over the last two decades due to their claimed greater clinical efficiency. These brackets present a fourth wall, which converts the slot into a tube. Two main types of self-ligating brackets have been developed: active brackets that possess a spring clip which presses
against the archwire and passive brackets whose clips do not exert any forces on the archwire, but just close the slot. Several studies have been conducted to test the friction, force and torque delivery by these brackets with inconclusive results.17 It has been postulated that self-ligation increases intra-slot wire play, which reduces the generated
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SIFAKAKIS ET AL
ligating brackets with these wires it might be possible to apply biologically acceptable intrusive forces to these teeth. The aim of this study was to compare the intrusive forces and torquing moments generated at the maxillary incisors by a continuous 0.017 x 0.025 inch reverse curve NiTi wire and three different bracket types: an active self-ligating bracket, a passive selfligating bracket and a conventional bracket.
Material and methods Experimental apparatus and configuration

Figure 1. The acrylic Frasaco model mounted on the positioning tables of the OMSS. Conventional brackets were bonded on the teeth up to the first molars.
forces.1 However, other research failed to show this difference.2 Recently, Pandis et al. have demonstrated force differences between different directions of displacement, when applied to the mandibular teeth.3,4 The authors concluded that these differences in force level between conventional and self-ligating brackets follow a complex pattern and seem to be influenced by many factors including the method of ligation, bracket width, archform and tooth position: each contributing with variable weightings depending on the specific characteristics of the dental arch and the wire. The torque expression of these brackets has also been evaluated, but the results were again inconclusive.57 Active self-ligating brackets are expected to be more effective in torque expression than passive ones, a finding that was confirmed in vitro by Badawi et al.5 Other in-vitro research concluded that the generated moments depend on the direction of movement and the examined tooth.6 In a clinical trial, self-ligating brackets seem to be as efficient as conventional brackets in delivering torque to the maxillary incisors.7 Reverse curve NiTi archwires are commonly used in straight-wire mechanotherapy of deep-bite cases. The low modulus of elasticity of the NiTi wires promises a reduction in the magnitude of the intrusive forces. However, to date there is a lack of evidence on the quantitative assessment of forces and moments generated from continuous rectangular reverse curve NiTi archwires on the maxillary incisors. By using self128
The Orthodontic Measurement and Simulation System (OMSS) is a measuring system developed specifically for investigating biomechanical issues in orthodontics and its set-up and applications have been described in detail.8,9 It has been used for the invitro evaluation of different intrusion mechanics.8,10 The simulation of tooth movement with the OMSS is conducted using two measuring tables comprising a 6-axis positioning table and a 6-component forcetorque sensor, monitored by a personal computer. Each sensor consists of a central element with four axes. A strain gauge (HBM 6/350LY43) is fixed to each side of the axes, resulting in 16 strain gauges, which are electrically connected to form eight halfbridges. The OMSS programme running on the computer, written in C language, calculates the force-torque vectors acting on the centre of resistance and with a mathematical model, the resulting vectors in the movement of the teeth. The system allows the registration of the complete force-torque vectors during the movement of the tables along a specified path.8,10 In this study, an acrylic replica of an upper Frasaco model (Franz Sachs and Company GmbH, Tettnang, Germany), with a levelled and aligned dental arch, was used for the intrusion simulation. This model was split into an anterior segment, comprising the four incisors and a posterior segment, which included the canines and the posterior teeth. Each of these model segments was mounted on the positioning tables of the OMSS with an appropriate adaptor (Figure 1). Three different bracket systems with 0.022 inch slots were evaluated separately. In each case, new brackets and tubes were bonded on the teeth up to the first molars. The brackets were bonded on the centre of each tooth mesio-distally and at the suggested height with the aid of a Unitek
REVERSE CURVE NITI FORCE SYSTEM
Table I. Bracket specifications.
Bracket type
Titanium Orthos
In-Ovation R
Damon 3MX
Slot size (inches) Slot width (mm)
Tip (Degrees) Torque (Degrees) Rotation (Degrees) Slot composition Clip composition
U1 U2 U3 U1 U2 U3 U1 U2 U3 U1 U2 U3
0.022 x 0.028 3.54 2.66 3.35 5 9 10 15 9 0 0 0 0 -
0.022 x 0.028 2.93 2.77 2.96 5 9 13 12 8 2 0 0 4 Stainless steel Cobalt chromium
0.022 x 0.027 2.65 2.65 2.65 5 9 6 12 8 0 0 0 0 Stainless steel Stainless steel
bracket positioning gauge (3M Unitek, MN, USA). Before every evaluation, the complete levelling of the attachments in every segment as well as between the two segments was ensured with the aid of a straight 0.019 x 0.025 inch stainless steel archwire. This archwire was ligated to the two segments and they were both mounted on the positioning tables of the OMSS. The system was adjusted with the straight wire in place and all forces/moments generated were nullified. In the absolute measurement mode, the dental arch was initially levelled. During the measurement procedure the anterior segment was intruded to 1.0 mm and the forces/moments generated in the sagittal plane in the anterior segment were measured in 0.05 mm steps.
measurement cycle, the wires were not cinched back. The overall measurement set-up was installed in a temperature chamber (VEM 03/400, Vtsch Hereus, Germany) at a constant temperature of 37 C, which reasonably approximated the intra-oral temperature.8,11 In the conventional brackets, the wires were ligated by the same person with 0.010 inch metal ligatures. This study evaluated the intrusive and labio-palatal torque components of the reverse curve archwires ligated in different bracket types, hence only measurements of the intrusive forces (Fx) and the moments My (labio-palatal torque) were used. The other forces (Fy, Fz) and moment vectors (Mx, Mz) are greatly affected by factors such as proper adjustment of the anterior segment relative to the posterior segment and proper archwire insertion. Since these factors introduce unnecessary variability, the components Fy, Fz, Mx, Mz were adjusted to zero.
Materials
The following brackets were evaluated, as regard to the forces/moments generated at the anterior maxillary segment (Table I): Titanium Orthos (Ormco/Sybron, CA, USA), In-Ovation R (GAC International, NY, USA) and Damon System 3MX (Ormco/Sybron, CA, USA). Ten reverse curve NiTi 0.017 x 0.025 inch archwires, each one taken at random from a different package (NI-TI Preformed Archwires, Ormco, CA, USA), were used in each type of bracket and each of the wire specimens was evaluated three times. During the
Descriptive statistics presenting the mean and standard deviation of the intrusive forces and moments per bracket type were calculated (Tables II and IV). The force and moment values of all wire specimens at 1.0 mm of intrusion were statistically analysed using one-way analysis of variance (ANOVA) with force or moment serving as the dependent variable and bracket system being the explanatory variable (Tables III and V). Post-hoc pairwise comparisons were
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SIFAKAKIS ET AL Table II. Intrusion force for each bracket at 1 mm wire displacement. Table III. Intrusion force versus bracket type.
Intrusion force (N) Bracket type Mean SD Tukey grouping*
Intrusion force (N)
Sum of squares
df
Mean square
p*
Titanium Ortho In-Ovation R Damon System 3MX
8.2 5.5 6.3
0.5 0.2 0.3
A B C
Between groups Within groups Total

* ANOVA
38.177 3.884 42.061
2 27 29
19.088 0.144 1.450
132.68
0.000
* Means with same letter are not significantly different at the 0.05 level
Table IV. Intrusion moment (torque) results for each bracket at 1mm wire
Table V. Moments (torque) versus bracket type.
displacement. Moments (N/mm) Bracket type Mean SD Tukey grouping*
Intrusion force (N)
Sum of squares
df
Mean square
p*
Conventional In-Ovation R Damon System 3MX
10.8 16.9 16.6
2.7 1.0 1.2
A B B
Between groups 235.982 Within groups Total

* ANOVA
2 27 29
117.991 3.304 11.214
35.71
0.000
89.219 325.200
* Means with same letter are not significantly different at the 0.05 level
performed using the Scheffe test at the 0.05 error rate. All statistical analyses were performed with Stata 10.1 statistical software (College Station, TX, USA).
Discussion
Continuous reverse curve 0.017 x 0.025 inch NiTi archwires, with or without torque, might be useful to complete intrusion of maxillary incisors in deep-bite malocclusions because they deliver an intrusive force and a labio-palatal moment on the anterior teeth. It was initially suggested that the magnitude of the force applied during intrusion of the four upper incisors could be as high as 11.6 N12,13 and that some light rectangular wires with low moduli of elasticity could be used even during the early stages of treatment,14,15 but recently van Steenbergen et al. demonstrated that only 0.4 N of force is necessary to intrude the four maxillary incisors at the same rate as double the magnitude.16 In comparison, the intrusive forces measured in this study are very high and this discourages the use of a continuous reverse curve 0.017 x 0.025 inch NiTi archwire in an unlevelled dental arch, regardless of the type of bracket. With only 1 mm simulated intrusion of the incisor segment, the intrusive forces were 5.56.3 N for the selfligating and 8.2 N for the conventional brackets. When using a continuous arch, such as the reverse curve NiTi archwire used in this study, the force magnitude on the anterior segment is primarily determined by the dimensions and curvature of the wire and the distance between the canine and lateral
Results
Table II summarises the mean intrusive forces at 1.0 mm of intrusion for each bracket system tested. The highest force was recorded with the conventional brackets (8.2 N), followed by the Damon 3MX (6.3 N) and the In-Ovation R (5.5 N) system (Table II). ANOVA showed statistically significant differences between the forces generated by the bracket systems (Table III). Figure 2 depicts the range of intrusion forces (Fx) per bracket type and vertical displacement from 0.01.0 mm (0.05 mm increments). The mean labio-palatal moments (torque) developed in the anterior segment are shown in Table IV. The conventional brackets exerted the lowest moment (10.8 N/mm), followed by the self-ligating brackets (16.616.9 N/mm). ANOVA indicated significant differences in the moments generated by the conventional and the self-ligating brackets, but not between the two types of self-ligating brackets (Table V). Figure 3 depicts the bucco-lingual moments (My) per bracket type and displacement for a range of 1.0 mm (0.01.0 mm), in 0.05 mm increments.
130
8 6 Force (N) 4
In-Ovation R Damon
20
Force (Nmm)
Conventional
15
Damon In-Ovation R
10
Conventional
2 5 0 0 .2 .4 .6 Displacement (mm)
Conventional In-Ovation R
.8
Damon
.2
.4 .6 Displacement (mm)
Conventional In-Ovation R
.8
Damon
Figure 2. Graph depicting the mean intrusion force (Fx) per bracket type and level of intrusion for a range of 1.0 mm (0.01.0 mm) in 0.05 mm increments.
Figure 3. Graph depicting the mean labio-palatal moments (My) per bracket type and level of intrusion for a range of 1.0 mm (0.01.0 mm) in 0.05 mm increments.
incisor brackets.17 Clinically, the moments created by this statically indeterminate force system are expected to tip the teeth rapidly, but in a rather unpredictable manner.15,18 The highest intrusive force was recorded by the Titanium Orthos brackets (8.2 N), followed by the Damon 3MX (6.3 N) and the In-Ovation R (5.5 N) system. These forces are applied to the gingival wall of the slot and they depend upon the wire deflection, the size of the span, the superelasticity of the wire and the ability of the wire to slide distally. The variable in this experiment was the bracket type. The width of the slot is different between brackets, so the interbracket distance between the cuspid and the lateral incisor is significant in determining the magnitude of the intrusive force. This distance was smaller in the case of Titanium Orthos (by 0.7 mm with Damon 3MX and by 0.3 mm with In-Ovation R). However inter-bracket distance alone is not a reliable predictor of force magnitude during archwire engagement.3 Although the Damon 3MX brackets had the smallest width, they exerted higher intrusive forces than the In-Ovation R brackets, possibly underlining the importance of ligation mode on force levels, i.e. the flexibility of the active clip in the case of the InOvation R bracket offers the wire the possibility to move more easily through the neighbouring bracket slots. Longitudinal mechanical stress in the wire is balanced and thus forces in neighbouring brackets are reduced. A reduction in the second order force levels has been noted for self-ligating systems in comparison
with conventional brackets.3,4 This finding could be attributed to the increased play of wires in the slot and the lack of obstacles arising from the contact of a ligature outside the wings. Resistance to sliding at the bracket-wire interface represents a combination of friction produced by the ligation method and wire-bracket binding as well as wire notching.19,20 The force values measured with the OMSS testing unit were influenced by friction at the bracket-wire interface. Passively ligated selfligating brackets produce less frictional resistance than actively ligated systems,21,22 and the higher the friction at the bracket-wire interface, the lower is the force released by the system to produce bracket alignment.19,23 In the experimental model used here, significant binding can be expected at the mesial aspect of the canine brackets and at the distal aspect of the lateral incisor brackets but, in contrast to friction, this phenomenon is similar for conventional and all types of self-ligating brackets.22 Notching appears to be more prevalent when hard ceramic brackets are opposed by soft metallic wires and depends, in part, on the frequency and forces of mastication.23 The conventional brackets used in this study showed the lowest torquing values (10.8 N/mm), about 65 per cent of the values recorded for the self-ligating brackets (16.516.9 N/mm). Currently, studies comparing torquing moments and effectiveness of torque correction between conventional and self-ligating systems are scarce. It seems that neither the bracket
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SIFAKAKIS ET AL
system nor archwire predominantly affects the generation of torque during the correction of vertical and horizontal malalignments. Hence it is the initial malalignment that is primarily responsible for the resulting torque movement in such a levelling situation.2 Further research revealed that in the bucco-lingual direction, a light round copper NiTi archwire exerted higher rotating moments into the self-ligating systems compared with the conventional brackets.3 Again, this might be explained by the rigidity of the self-ligating clips, acting as a rigid barrier, whereas the elastic ligatures in the case of the conventional brackets offer some flexibility and thus reduce the force couple generated in the bracket slot. This was obvious in the moments generated in the horizontal plane during rotational correction of teeth with a 0.014 x 0.025 inch copper NiTi.6 Active self-ligating brackets may be more effective in torque expression than the passive ones, due to a reduction in the amount of archwire play in the bracket slot by the active ligating mechanism.5,21 But in the case of a 0.019 x 0.025 inch stainless steel wire, torque starts to be expressed at an angle of 15 degrees of torsion for Damon brackets compared with an angle of 7.5 degrees for In-Ovation brackets.5 This difference was not recorded in the present study, since the wire used was of smaller cross-section and lower torsional stiffness. According to the specifics of the OMSS force-torque transducers, described by Bourauel et al.,8 the resolution for the force measurements is 0.02 N and for the torque measurements is 0.5 N/mm. In the configuration used in this study, these values are of minor importance, since the standard deviations of the present measurements are much higher than the resolution. The experimental set-up used in this study is a model that approximates the clinical situation where forces and moments are exerted by an archwire onto brackets. The actual force system acting on the teeth will probably vary, because of the presence of periodontal ligament, whose mechanical properties affect the transmission of the force system. The OMSS is based on the principle of the two-tooth model and approximates the clinical situation of initial tooth movement within the periodontal space. It does not account for factors such as intra-oral aging and influence of saliva, which influence the forces and moments experienced by teeth over time. Additionally, it has not yet been possible to predict
132
the centre of resistance of the four incisors, and the intrusion of these teeth should be carefully monitored in order to avoid side effects. Further investigation of intrusive biomechanics using different bracket types of the same width would expand the conclusions of this study. Another suggested area for future research would be the evaluation of the intrusive forces of brackets and wires from different manufacturers, taking into account differences between the actual and stated dimensions of the materials.
Conclusions
A comparison of three different bracket systems revealed that a continuous 0.017 x 0.025 inch reverse curve NiTi archwire exerted very high intrusive forces on the upper incisor segment. Conventional brackets (Titanium Orthos) exerted 30 per cent higher forces in comparison with the Damon 3MX brackets and 49 per cent higher forces in comparison with the InOvation R brackets. Differences were detected between the two selfligating systems in labio-palatal torquing moments generated at the maxillary incisors, but the conventional brackets showed the lowest torque, about 65 per cent of the values recorded for the self-ligating brackets.
Dr Theodore Eliades 57 Agnoston Hiroon Nea Ionia, 14231 Greece Tel. (+30) 2102 717555 Fax: (+30) 2102 717867 Mob: 306932 340 955 Email: teliades@ath.forthnet.gr Website: www.orthodontix.gr
References
1. Berger JL. The influence of the SPEED brackets self-ligating design on force levels in tooth movement: a comparative in vitro study. Am J Orthod Dentofacial Orthop 1990;97: 21928. Fansa M, Keilig L, Reimann S, Jger A, Bourauel C.The leveling effectiveness of self-ligating and conventional brackets for complex tooth malalignments. J Orofac Orthop 2009; 70:28596. Pandis N, Eliades T, Bourauel C. Comparative assessment of forces generated during simulated alignment with self-ligating and conventional brackets. Eur J Orthod 2009;31: 5905.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12. 13.
Pandis N, Eliades T, Partowi S, Bourauel C. Forces exerted by conventional and self-ligating brackets during simulated first- and second-order corrections. Am J Orthod Dentofacial Orthop 2008;133:73842. Badawi HM, Toogood RW, Carey JP, Heo G, Major PW. Torque expression of self-ligating brackets. Am J Orthod Dentofacial Orthop 2008;133:7218. Pandis N, Eliades T, Partowi S, Bourauel C. Moments generated during simulated rotational correction with self-ligating and conventional brackets. Angle Orthod 2008;78: 10304. Pandis N, Strigou S, Eliades T. Maxillary incisor torque with conventional and self-ligating brackets: a prospective clinical trial. Orthod Craniofac Res 2006;9:1938. Bourauel C, Drescher D, Thier M. An experimental apparatus for the simulation of three-dimensional movements in orthodontics. J Biomed Eng 1992;14:3718. Drescher D, Bourauel C, Thier M. Application of the orthodontic measurement and simulation system (OMSS) in orthodontics. Eur J Orthod 1991;13:16978. Sifakakis I, Pandis N, Makou M, Eliades T, Bourauel C. Forces and moments generated with various incisor intrusion systems on maxillary and mandibular anterior teeth. Angle Orthod 2009;79:92833. Moore RJ, Watts JT, Hood JA, Burritt DJ. Intra-oral temperature variation over 24 hours. Eur J Orthod 1999;21: 24961. Burstone CR. Deep overbite correction by intrusion. Am J Orthod 1977;72:122. Ricketts RM, Bench RW, Gugino CF, Hilgers JJ, Schulhof RJ. Bioprogressive therapy. Denver: Rocky Mountain Orthodontics, 1979:p.189. Page no is correct
14. Burstone CJ. Variable-modulus orthodontics. Am J Orthod 1981;80:116. 15. Kapila S, Sachdeva R. Mechanical properties and clinical applications of orthodontic wires. Am J Orthod Dentofacial Orthop 1989;96:1009. 16. van Steenbergen E, Burstone CJ, Prahl-Andersen B, Aartman IH. The influence of force magnitude on intrusion of the maxillary segment. Angle Orthod 2005;75:7239. 17. Halazonetis DJ. Ideal arch force systems: a center-of-resistance perspective. Am J Orthod Dentofacial Orthop 1998; 114:25664. 18. Burstone CJ, Koenig HA. Force systems from an ideal arch. Am J Orthod 1974;65:27089. 19. Baccetti T, Franchi L, Camporesi M, Defraia E, Barbato E. Forces produced by different nonconventional bracket or ligature systems during alignment of apically displaced teeth. Angle Orthod 2009;79:5339. 20. Burrow SJ. Friction and resistance to sliding in orthodontics: a critical review. Am J Orthod Dentofacial Orthop 2009;135:4427. 21. Budd S, Daskalogiannakis J, Tompson BD. A study of the frictional characteristics of four commercially available selfligating bracket systems. Eur J Orthod 2008;30: 64553. 22. Thorstenson GA, Kusy RP. Comparison of resistance to sliding between different self-ligating brackets with secondorder angulation in the dry and saliva states. Am J Orthod Dentofacial Orthop 2002;121:47282. 23. Kusy RP, Whitley JQ. Friction between different wire-bracket configurations and materials. Semin Orthod 1997;3: 16677.
133
Bond strengths and debonding characteristics of two types of polycrystalline ceramic brackets
Katia Lemke, * Xiaoming Xu, Joseph L. Hagan, + Paul C. Armbruster and Richard W. Ballard
Private practice, Kissimmee, Florida,* Department of Comprehensive Dentistry and Biomaterials, School of Public Health+ and the Department of Orthodontics, Louisiana State University Health Sciences Center, New Orleans, LA, United States of America
Objectives: To compare the shear bond strengths and modes of failure of three orthodontic brackets: a polycrystalline ceramic bracket, a collapsible polycrystalline ceramic bracket and a metal bracket. Methods: Ninety extracted human premolar teeth were selected and examined at x3 magnification for any enamel defects. Three types of brackets and one orthodontic adhesive were used. One half of the sample was tested in a universal testing machine to determine the shear bond strength. The other half was debonded with the appropriate pliers and the tooth surface examined at x5 magnification. The site of failure was scored with the modified Adhesive Remnant Index (ARI). Teeth with an ARI grade of zero were examined in a SEM to determine any enamel fracture. Results: No statistically significant differences in bond strength among the samples were found (p > 0.159). The modes of failure after debonding with pliers were predominantly at the bracket-adhesive interface. The mean shear bond strength of the Clarity bracket was 10.78 2.74 MPa, the InVu bracket was 12.43 2.40 MPa and the metal bracket was 11.89 1.83 MPa. There were significant differences in the mean rank of the ARI grade between the three groups (p = 0.006). The Clarity and InVu (p = 0.011) and the Clarity and metal brackets (p = 0.005) were significantly different, but there was no difference between the InVu and metal brackets (p = 0.187). Conclusions: All three samples had similar bond strengths. The risk of ceramic fracture on debonding was greatest for the InVu ceramic bracket. (Aust Orthod J 2010; 26: 134140)
Submitted for publication: January 2010 Accepted: May 2010 Katia Lemke: klemkedmd@yahoo.com Xiaoming Xu: xxu@lsuhsc.edu Joseph Hagan: jhagan@lsuhsc.edu Paul C. Armbruster: parmbr@lsuhsc.edu Richard W. Ballard: Rball1@LSUHSC.EDU
Introduction
In orthodontic practices today, there is a strong demand for ceramic brackets due to the fact that approximately 20 per cent of all orthodontic patients are adults.1,2 With the change in the treatment population there is a greater demand for aesthetic orthodontics.3 Ceramic brackets are more aesthetic and retain important physical properties such as torque control.4 Many new ceramic brackets have been introduced to the profession; however, the bonding characteristics
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of all have not been tested. The first generation ceramic brackets had chemically-bonded ceramic bases.5 Several studies have shown that these brackets had significantly higher bond strengths compared with conventional metal brackets68 and bond failure occurred at the enamel-adhesive interface.810 Because these brackets were more rigid and brittle, complications such as enamel fracture, cracks and flaking occurred during mechanical removal.5,11 Consequently, tooth damage was a concern to many practitioners. Furthermore, the debonding force often resulted in ceramic fragments remaining on the
BOND STRENGTHS AND DEBONDING CHARACTERISTICS OF CERAMIC BRACKETS
Figure 1. Tooth mounted in acrylic in the Instron machine.
groove designed to produce a consistent mode of failure during debonding.6 The Clarity bracket, which is a polycrystalline, mechanically retained ceramic bracket with a metal-lined archwire slot, requires a special plier for optimal debonding.20 The InVu bracket (TP Orthodontics, La Porte, IN, USA) is another polycrystalline ceramic bracket with, according to the manufacturer, a fracture point on the mechanical polymer base that should flex during debonding. According to the manufacturer, the main advantages of the InVu bracket are its aesthetic appearance and ease of debonding, which can be done with a ligature cutter. The bond strength and debonding characteristics of InVu brackets have not yet been reported. A shearing force delivers a higher debonding force and transmits more force to the enamel than the force applied by bracket removal pliers.12 For this reason, we investigated the shear bond strength and the Adhesive Remnant Index (ARI) after debonding with bracket removal pliers. We also compared the shear bond strengths of a polycrystalline ceramic bracket, a collapsible polycrystalline bracket and a metal bracket after debonding with bracket removal pliers, and the modes of failure of the brackets at the enamel-adhesive-bracket interfaces.
teeth, which then had to be removed with a bur: a procedure that could be stressful to both patient and clinician.12 To address this problem, different methods of bracket removal were introduced in order to minimise enamel damage. Initially, the instruments used to debond ceramic brackets applied heavy shear-torsion forces that could cause enamel fractures and/or cracks.13 Swartz suggested that the debonding force should be applied by a sharp-edged instrument on opposite sides of the enamel-adhesive interface, so that failure occurred through the adhesive rather than at the adhesiveenamel interface.8 Storm suggested that there would be less enamel damage if ceramic brackets were debonded with a rotational motion using a speciallydesigned instrument.14 Alternative methods of debonding ceramic brackets included ultrasonic, electrothermal and laser techniques.11,15 In order to serve the increasing demand for ceramic brackets and improve their physical and bonding properties, a second generation ceramic bracket with a mechanical base was introduced in 1991.16,17 These brackets had significantly lower bond strengths and caused less enamel fracture than the first generation brackets, but special debonding instruments were needed and the tie wings frequently fractured during debonding.17 Several studies reported that mechanically retained brackets had adequate bond strengths and there was minimal enamel damage during debonding.15,18,19 A third generation of ceramic brackets was introduced in 1997. The Clarity collapsible bracket (3M Unitek, Monrovia, CA, USA) incorporated a vertical

Ninety extracted human maxillary first premolars were selected for bonding. The teeth were kept in distilled water at 37 C for 48 hours. All teeth were examined under x3 magnification to screen for any enamel fractures prior to the research, and teeth with visible fractures were excluded from the study. The teeth were mounted in acrylic before testing in the Instron 5566 universal testing machine (Instron Corporation, Norwood, MA, USA) (Figure 1). The brackets tested were the Clarity collapsible polycrystalline bracket, the InVue polycrystalline ceramic bracket and, as a control, the Miniature Twin metal bracket (3M Unitek, Monrovia, CA, USA). All brackets were maxillary first premolar brackets with 0.022 x 0.028 inch slot size and mechanical retention bases (Figure 2). Transbond XT Light Cure Adhesive and Primer were used (3M Unitek, Monrovia, CA, USA). The teeth were pumiced, etched with 37 per cent phosphoric acid for 20 seconds, rinsed with water and then air dried for 5 seconds. The primer was rubbed on the tooth surface and each tooth then
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(a)
(b)
(c)
Figure 2. (a) Clarity polycrystalline bracket base. (b) InVu polycrystalline bracket base. (c) Miniature Twin (metal) bracket base.
Table I. Shear bond strengths of ceramic and metal brackets (MPa).
Table II. Weibull moduli (m) and 95 per cent confidence intervals and
Bracket
Mean
SD
Maximum
Minimum
adjusted R2. Bracket m (95% CI) Adjusted R2
Metal Clarity InVu
15 15 15
11.89 10.78 12.43
1.83 2.74 2.40
15.63 15.60 16.08
8.5 7.08 7.78
Metal InVu Clarity
6.42 (5.42 7.42) 5.15 (4.68 5.61) 4.03 (3.34 4.73)
0.94 0.98 0.92
ANOVA, p = 0.159
received a two second air blast. Adhesive was applied to the bracket base, and the bracket was placed on the buccal surface of each premolar tooth. Excess resin was carefully removed. The brackets were cured for 10 seconds with an Ortholux LED curing light (3M Unitek, Monrovia, CA, USA). The samples were stored in distilled water at 37 C for 48 hours. Forty-five teeth (N = 15 per group) were bonded with Clarity ceramic brackets, InVu ceramic brackets and Miniature Twin metal brackets, respectively. The shear bond strengths were tested using the Instron universal testing machine at a crosshead speed of 1 mm/minute. This technique is frequently used in this type of research.21 The average surface areas of the bases were 12.45 mm2 for the Clarity ceramic brackets, 16.13 mm2 for the InVu ceramic brackets and 9.08 mm2 for the metal brackets. The shear bond strength values in MPa were obtained by dividing the maximum load (N) by the base area (mm2). In the other 45 teeth, the brackets were removed with pliers, as recommended by the respective manufacturers (Figure 3). The locations of failure were examined in all 45 teeth with a Nikon Microphot SA microscope at x5 magnification. The amount of residual adhesive was assessed according to the modi136
fied Remnant Index (ARI).22 This index has four grades, ranging from 0 to 3 (0, no adhesive left on tooth; 1, less than half of the adhesive left on tooth; 2, more than half of the adhesive left on tooth; 3, all adhesive left on tooth with distinct impression of the bracket base). An additional grade of 4 was added for samples that had ceramic material left on the teeth. This method is frequently used to quantify the amount of adhesive left on the tooth. The teeth with an ARI score of 0 were evaluated with a SEM at x35 magnification. One operator performed the entire experiment. ANOVA was used to determine whether or not there were significant differences in the mean shear bond strengths between the three groups (Clarity, InVu and the Miniature Twin metal brackets). The KruskalWallis test was used to determine if there were significant differences in the mean rank of the ARI between the three groups. Post-hoc pairwise comparisons were made using the Wilcoxon-Mann-Whitney U test with a Bonferroni correction (adjusted = 0.017). The Weibull modulus (m), was computed to compare brackets variabilities in tension at failure, where m is the slope coefficient obtained from regressing ln(ln(1/survival probability)) on ln(shear
(a)
(b)
Figure 3. (a) Clarity debonding pliers. (b) Plier used to debond the InVu and metal brackets.
Table III. Comparison of ARI of ceramic and metal brackets when removed with pliers.
ARI grade Bracket N 0 1 2 3 4 p
Clarity vs InVu p
Metal vs Clarity p
Metal vs InVu p
Metal Clarity Invu
15 15 15
1 0 3
3 0 5
2 3 0
9 11 1
0 1 6
0.006 0.006 0.006
}
0.011
0.005
0.187
Grade: 0, no adhesive left on tooth; 1, less than half of the adhesive left on tooth; 2, more than half of the adhesive left on tooth; 3, all adhesive left on tooth with distinct impression of the bracket base; 4, ceramic left on tooth Because there was a statistically significant difference, pairwise analysis was used to compare the differences between the samples Significant values in bold
bond strength). A high value of m indicates that the tensile strength of the material is defined more precisely than a material with a small m value.23
Results
The mean shear bond strengths are given in Table I. The mean shear bond strengths of the Clarity, Invu and metal brackets were 10.78 2.74 MPa, 12.43 2.40 MPa and 11.89 1.83 MPa, respectively (p = 0.159). The Weibull analysis showed that the metal bracket had the highest m value and thus its failure could be defined in a more narrow range, followed by the InVu bracket and then the Clarity bracket (Table II). The modes of failure during debonding with pliers were predominantly between the bracket and the adhesive. There were significant differences in the mean rank of the ARI between the three groups (p = 0.006). Pairwise comparisons revealed that there were significant differences in mean rank between the
Clarity and InVu brackets (p = 0.011) and between the Clarity and metal brackets (p = 0.005), but there was no significant difference in mean rank between the InVu and metal brackets (p = 0.187). The majority of the Clarity brackets had an ARI score of 3. The ARI scores for the metal brackets were also mostly within the adhesive: only one metal bracket failed at the adhesive and enamel interface. The InVu bracket failures were more toward the extreme scores, being either 0 and 1 or 3 and 4. In six out of 15 InVu brackets the brackets fractured. When debonding with pliers, three InVu and one metal bracket debonded between the enamel and the adhesive. These four teeth were examined in the SEM to determine if enamel fracture had occurred. There were no enamel fractures of the teeth bonded with the three InVu brackets, but there was a small fracture on the tooth bonded with the metal bracket (Figure 4). An examination with the SEM at a magnification of x250 confirmed our findings (Figure 5). The ARI scores after debonding are shown in Table III.
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(a)
(b)
(c)
(d)
Figure 4. SEM photomicrographs. (a) InVu bracket, specimen 2. (b) InVu bracket, specimen 10. (c) InVu bracket, specimen 12. (d) Metal bracket, specimen 12. Original magnification x35.
Discussion
While determinations of shear bond strength are frequently reported, one should remember that this type of force is not always the force applied to a bracket during function or debonding in vivo. In the laboratory, shear bond strength is tested by applying a unilateral load at the bracket-adhesive interface, and provides an acceptable method to compare the bond strengths of different brackets.24 Retief reported enamel fractures on debonding with bond strengths of 13.73 MPa, leading Bishara and Fehr to suggest that bond strengths lower than 12.75 MPa would be safe for the enamel.11,25 The mean shear bond strength of the Clarity brackets reported by Theodorakopoulou et al. was 21.67 MPa, which is much higher than the previously reported values of 10.4 and 13.27 MPa.20,26 Webster et al. evaluated the bond strengths of metal brackets bonded to enamel with Transbond XT adhesive and found that, under ideal conditions, the mean shear bond strength was as high as 26.9 6.9 MPa, but when the XT primer was contaminated with artificial saliva, the bond strength was 23.7 5.3 MPa.27 These values are higher than
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those reported by Theodorakopoulou and coworkers, although metal brackets were used.26 Bishara et al. tested the bond strength of Clarity ceramic brackets bonded to enamel with Transbond XT adhesive and reported a value of 10.4 4.1 MPa.28 We used the same adhesive and found similar results. Mundstock et al. also used Clarity ceramic brackets with Transbond XT adhesive and reported a slightly higher bond strength value of 13 5.39 MPa.20 In agreement with Bishara et al., we found no significant differences between the forces needed to debond Clarity and metal brackets.6 In-vitro studies have shown that acceptable bond strengths can be achieved for collapsible ceramic brackets and removal of the bracket should not cause any enamel fracture.6,20,26 Liu noted enamel fracture in four out of 20 specimens with Inspire brackets and five out of 20 for both the Clarity and the metal brackets after shear bond strength testing: six out of 14 of these fractures occurred below the bracket bonding areas.21 Our results indicated that debonding collapsible ceramic brackets with pliers is a safe method of bracket removal: we found only two
Tel: +504 941 8245 Fax: +504 941 8410 Email: Rball1@LSUHSC.EDU
References
1. Keim RG, Gottlieb EL, Nelson AH, Vogels DS. 2009 JCO Orthodontic Practice Study. Part 1. Trends. JCO 2009;43: 62534. Scott P, Fleming P, DiBiase A. An update in adult orthodontics. Dent Update 2007;34:4278, 4314, 436 passim. Rosvall MD, Fields HW, Ziuchkovski J, Rosenstiel SF, Johnston WM. Attractiveness, acceptability, and value of orthodontic appliances. Am J Orthod Dentofacial Orthop 2009;135:276 e112. Sinha PK, Nanda RS. Esthetic orthodontic appliances and bonding concerns for adults. Dent Clin North Am 1997;41: 89109. Birnie D. Ceramic brackets. Br J Orthod 1990;17:714. Bishara SE, Olsen ME, Von Wald L. Evaluation of debonding characteristics of a new collapsible ceramic bracket. Am J Orthod Dentofacial Orthop 1997;112:5529. Wang WN, Li CH, Chou TH, Wang DD, Lin LH, Lin CT. Bond strength of various bracket base designs. Am J Orthod Dentofacial Orthop 2004;125:6570. Swartz ML. Ceramic brackets. J Clin Orthod 1988;22:828. Odegaard J, Segner D. Shear bond strength of metal brackets compared with a new ceramic bracket. Am J Orthod Dentofacial Orthop 1988;94:2016. Chaconas SJ, Caputo AA, Niu GS. Bond strength of ceramic brackets with various bonding systems. Angle Orthod 1991;61:3542. Bishara SE, Fehr DE. Ceramic brackets: something old, something new, a review. Semin Orthod 1997;3:17888. Bishara SE, Fonseca JM, Fehr DE, Boyer DB. Debonding forces applied to ceramic brackets simulating clinical conditions. Angle Orthod 1994;64:27782. American Association of Orthodontists. Summary of AAO ceramic bracket survey. The Bulletin Supplement 1989;7 (4)(Winter). Storm ER. Debonding ceramic brackets. J Clin Orthod 1990;24:914. Bishara SE, Trulove TS. Comparisons of different debonding techniques for ceramic brackets: an in vitro study. Part I. Background and methods. Am J Orthod Dentofacial Orthop 1990;98:14553. Redd TB, Shivapuja PK. Debonding ceramic brackets: effects on enamel. J Clin Orthod 1991;25:47581. Forsberg CM, Hagberg C. Shear bond strength of ceramic brackets with chemical or mechanical retention. Br J Orthod 1992;19:1839. Viazis AD, Cavanaugh G, Bevis RR. Bond strength of ceramic brackets under shear stress: an in vitro report. Am J Orthod Dentofacial Orthop 1990;98:21421. Eliades T, Viazis AD, Eliades G. Bonding of ceramic brackets to enamel: morphologic and structural considerations. Am J Orthod Dentofacial Orthop 1991;99:36975. Mundstock KS, Sadowsky PL, Lacefield W, Bae S. An in vitro evaluation of a metal reinforced orthodontic ceramic bracket. Am J Orthod Dentofacial Orthop 1999;116: 63541. Liu JK, Chung CH, Chang CY, Shieh DB. Bond strength and debonding characteristics of a new ceramic bracket. Am J Orthod Dentofacial Orthop 2005;128:7615; quiz 802.
2. 3.
Figure 5. Small fracture found on a tooth bonded with a metal bracket. Original magnification x250.
4.
enamel fractures when removing the InVu and one tooth with an enamel fracture in the Clarity group. Several studies confirm our finding of a high incidence of ARI scores of 3 (all adhesive on the enamel) with the Clarity bracket.20,26,28 Three InVu brackets failed at the adhesive-enamel interface, five had an ARI of 1 and six InVue brackets fractured. In our study, the modes of failure of the Clarity and metal brackets during debonding with pliers were predominantly at the bracket-adhesive interface, whereas 40 per cent of the InVu brackets fractured. In a clinical setting, it is harder and takes longer to remove ceramic remnants from the enamel than adhesive remnants. With some methods of removing ceramic remnants there is a chance of overheating the teeth and possible pulpal damage.29
5. 6.
7.
8. 9.
10.
11. 12.
13.
Conclusion
There were no statistically significant differences in the shear bond strengths among the three bracket types. The mode of failure with pliers was predominantly at the adhesive-bracket interface in all three samples. No enamel fractures occurred in the teeth bonded with either ceramic bracket. The Clarity collapsible ceramic brackets had similar bond strength and near-zero bracket failure rate compared with the metal brackets, while the InVu ceramic brackets had a higher failure rate than metal brackets.
14. 15.
16. 17.
18.
19.
Dr Richard W. Ballard LSUHSC School of Dentistry 1100 Florida Avenue (Box 230) New Orleans, LA, 70119 United States of America
20.
21.
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22. David VA, Staley RN, Bigelow HF, Jakobsen JR. Remnant amount and cleanup for 3 adhesives after debracketing. Am J Orthod Dentofacial Orthop 2002;121:2916. 23. Burrow MF, Thomas D, Swain MV, Tyas MJ. Analysis of tensile bond strengths using Weibull statistics. Biomaterials 2004;25:50315. 24. Armstrong S, Geraldeli S, Maia R, Raposo LH, Soares CJ, Yamagawa J. Adhesion to tooth structure: a critical review of micro bond strength test methods. Dent Mater 2010;26: e5062. 25. Retief DH. Failure at the dental adhesive-etched enamel interface. J Oral Rehabil 1974;1:26584. 26. Theodorakopoulou LP, Sadowsky PL, Jacobson A, Lacefield W Jr. Evaluation of the debonding characteristics of 2 ceramic brackets: an in vitro study. Am J Orthod Dentofacial Orthop 2004;125:32936.
27. Webster MJ, Nanda RS, Duncanson MG Jr, Khajotia SS, Sinha PK. The effect of saliva on shear bond strengths of hydrophilic bonding systems. Am J Orthod Dentofacial Orthop 2001;119:548. 28. Bishara SE, Olsen ME, VonWald L, Jakobsen JR. Comparison of the debonding characteristics of two innovative ceramic bracket designs. Am J Orthod Dentofacial Orthop 1999;116:8692. 29. Vukovich ME, Wood DP, Daley TD. Heat generated by grinding during removal of ceramic brackets. Am J Orthod Dentofacial Orthop 1991;99:50512.
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Skeletal and dental changes after rapid maxillary expansion: a computed tomography study
Ahmed Ghoneima, * Ezzat Abdel-Fattah, * Francisco Eraso, David Fardo, Katherine Kula and James Hartsfield +
Department of Orthodontics, Al-Azhar University Faculty of Dental Medicine, Cairo, Egypt;* Department of Orthodontics and Oral Facial Genetics, Indiana University School of Dentistry, Indianapolis, Indiana, United States of America; Department of Biostatistics, University of Kentucky College of Public Health, Lexington, Kentucky, United States of America and the Department of Oral Health Science, University of Kentucky College of Dentistry, Lexington, Kentucky, United States of America+
Objectives: To investigate the skeletal and dental changes induced by rapid maxillary expansion, using computed tomography (CT) scans and three-dimensional (3-D) reconstructed images. Methods: Twenty patients (Mean age: 12.3 1.9 years) who required rapid maxillary expansion as a part of their comprehensive orthodontic treatment underwent pretreatment (T1) and post-treatment (T2) CT scans. The T2 T1 differences between selected skeletal and dental measurements on the coronal CT and 3-D volumetric images were compared using the Wilcoxon signed ranks test. Results: At T2 the Maxillary alveolar width (4.5 3.5 mm) was greater than the Maxillary base width (1.7 0.9 mm). The greatest transverse dental change was in the Intermolar width (6.3 2.1 mm and 2.7 1.9 mm at the crown and the apex, respectively). On the 3-D volume, significant increases occurred in the Bicondylar width (1.2 1.3 mm), Bimaxillo-mandibular width (2.1 2.3 mm) and the Maxillary width (2.5 1.6 mm). The greatest change in the dental measurements was in the Maxillary first molar width (6.4 0.1 mm). The Maxillary central incisor angle decreased significantly (-7.9 8.4 mm), indicating an increase in the distance between the apices of the central incisors. Conclusion: Volumetric 3-D CT scanning provides a useful method for assessing skeletal and dental changes after rapid maxillary expansion. Although significant increases occurred in most skeletal and dental measures, it appears that dental tipping explains most of the expansion. (Aust Orthod J 2010; 26: 141148)
Received for publication: December 2009 Accepted: June 2010 Ahmed Ghoneima: aghoneim@iupui.edu Ezzat Abdel-Fattah: ezzat_barakat@hotmail.com Francisco Eraso: francisco@omfic.com David Fardo: david.fardo@uky.edu Katherine Kula: kkula@iupui.edu James Hartsfield: jkha222@uky.edu
Introduction
Rapid maxillary expansion (RME) is a routine orthodontic procedure used to normalise a constricted maxillary dental arch. It increases the width of the maxillary dental arch by separating the maxillae at the midpalatal suture and allows the maxillary and mandibular dental arches to match transversely.1,2 Traditionally, two-dimensional planar radiographic images have been used to identify specific anatomic landmarks from which vertical and anteroposterior
skeletal and dental dimensions can be measured. Within the past few years, three-dimensional (3-D) radiographic images have been used for the same purposes with many advantages. Computed tomography (CT) allows fast and precise acquisition of multiple thin slices and has the potential for multiplanar, 3-D reconstruction. These capabilities greatly increase the utility of CT as a diagnostic method. It also facilitates precise measurements to evaluate surgical and orthodontic outcomes,
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GHONEIMA ET AL
Figure 1. Hyrax appliance.
for example, following rapid maxillary expansion.3,4 Diagnosis and treatment planning are more precise and predictable with the use of CT technology in combination with the available software. Clinicians can take advantage of 3-D planning for many applications.5 For all these reasons, CT has become an acceptable, accurate and readily accessible tool for todays clinical practice. Multislice CT is a powerful craniofacial measurement tool with several advantages: true volumetric 3-D representation of the hard and soft tissues of the skull; real-size (1:1 scale) and volumetric 3-D cephalometric analysis; and high accuracy and reliability with no superimposition of anatomic structures.6 Therefore, the aim of this prospective, clinical study was to investigate the changes in the craniomaxillary complex and dental arches after rapid maxillary expansion using multislice CT scans and 3-D reconstructed images.
Figure 2. Coronal diagrams showing the landmarks and measurements. A, Molar level: 1-2, line tangent to the base of the nose; 3-4, Maxillary base width; 5-6, Intermolar width (apex); 7-8, Maxillary alveolar width; 9-10, Intermolar width (crown); 11 and 12, Right and Left molar angulations. B, Premolar level: 1-2, line tangent to the base of the nose; 3-4, Interpremolar width (apex); 5-6, Interpremolar width (crown); 7 and 8, Right and Left premolar angulations. C, Canine level: 1-2, line tangent to the base of the nose; 3-4, Intercanine width (apex); 5-6, Intercanine width (crown); 7 and 8, Right and Left canine angulations.
Material and methods

The study included 20 patients (Mean age: 12.3 1.9 years; Age range: 815 years) with bilateral posterior crossbites who required RME prior to comprehensive orthodontic treatment. The exclusion criteria included: presence of a premature contact; previous orthodontic or orthopaedic treatment; systemic disease; congenital abnormality; TMJ disorder; carious, gingival and/or periodontal lesions; and a metallic restoration(s). The study was approved by the Ethical Committee of the Dental Faculty, Al-Azhar University, Cairo, Egypt, and the parents of each patient gave their informed consent.
142
The Hyrax appliance design was used, which required banding either the maxillary first premolars or the maxillary first primary molars and the maxillary first permanent molars (Figure 1). The appliance screw was activated two quarter turns twice per day until the palatal cusps of the maxillary first molars contacted the buccal cusps of the mandibular first molars. The appliance was left in situ as a passive retainer for three months, after which it was removed. The multiplanar spiral CT machine (X vision EX, General Electric GE Corporation Medical Systems Company, NY, USA) was used to obtain pre-RME (T1) and post-RME (T2) CT images. The latter were taken the day after the Hyrax appliance was removed.
SKELETAL AND DENTAL CHANGES AFTER RAPID MAXILLARY EXPANSION
Figure 3. CT coronal images. A: 1, Maxillary base width; 2, Intermolar width (apex); 3, Maxillary alveolar width; 4, Intermolar width (crown). B: 1 and 2, Right and Left molar angulations; C: 1, Interpremolar width (apex); 2, Interpremolar width (crown); D: 1 and 2, Right and Left premolar angulations; E: 1, Intercanine width (apex); 2, Intercanine width (crown); F: Right and Left canine angulations.
Figure 4. Frontal diagram showing the landmarks and measurements: 1-2, Bilatero-orbital width; 3-4, Bicondylar width; 5-6, Bizygomatic width; 7-8, Bizygomatico-mandibular width; 9-10, Bimaxillo-mandibular width; 11-12, Maxillary width; 13-14, Bigonial width; 15-16, Biantegonial width; 17-18, Maxillary central incisor apex width; 19-20, Maxillary first intermolar width; 21-22, Maxillary central incisor mesial width; 23-24, Maxillary intercanine width; 25-26, Mandibular intercanine width; 27-28, Mandibular first intermolar width; 29, Maxillary central incisor angle.
The CT scans were performed at 120 kV and 20 mA (low dose), with a scanning time of 2 s/section. The machines perpendicular light beams were used to standardise the head position in all three planes, allowing comparison of the images before and after expansion. The scans were taken with the patients in the supine position and the palatal plane perpendicular to the floor. Each subject was positioned so that the longitudinal light beam passed through the centre of glabella and the philtrum, and the transverse light beam passed through the lateral canthi of the eyes. One-millimetre thick axial sections were made parallel to the palatal plane. The digital images (Imaging and communications in medicine, DICOM) were assessed and measured using the InVivoDental Imaging software programme (Anatomage Incorporated, San Jose, CA, USA). Multiplaner reformatting and 3-D postprocessing of the DICOM images were carried out with the software used to create the 3-D volumetric skull models. Linear and angular parameters were measured to the nearest 0.1 mm and 0.1 degree
respectively, on both the coronal sections of the CT images and on the 3-D volumetric scans (Figures 2 to 6).7,8 The Maxillary base width (MBW) and Maxillary alveolar width (MAW) were measured on the coronal sections that included the furcations of the maxillary first permanent molars. The same procedure was repeated for the T2 measurements. The amounts of skeletal expansion at the Maxillary base and the Maxillary alveolar process and dental expansion at the Intermolar, Interpremolar and Intercanine widths at the crowns and root apices were the differences between the T1 and T2 widths (T2 minus T1). Positive values indicated expansion. Dental angulations were measured on the coronal sections as the angles between the line tangent to the base of the nose (representing the lower limits of the nasal cavity on the right and left sides, respectively) and lines passing through the buccal cusps and the apices of the palatal roots of the maxillary first permanent molars, through the buccal cusps and apices
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GHONEIMA ET AL
Figure 6. 3-D volume. The Maxillary central incisor angles before (A) and after (B) RME.
Figure 5. 3-D volume. A: 1, Bilatero-orbital width; 2, Bicondylar width; 3, Bizygomatic; 4, Bizygomatico-mandibular width; 5, Bimaxillo-mandibular width; 6, Maxillary width; 7, Bigonial width; 8, Biantegonial width. B: 1, Maxillary central incisor apex width; 2, Maxillary first intermolar width; 3, Mandibular first intermolar width; 4, Maxillary central incisor mesial width. C: 1, Maxillary intercanine width; 2, Mandibular intercanine width.
of the first premolars, and the cusp tips and apices of the canines. The same procedure was repeated for the T2 measurements. An increase in the value (T2 T1) indicated buccal tipping of the maxillary dental arch. From the 3-D volume of each patient, 14 distances and one angle were measured at T1 and T2. To improve the reliability and validity of the measurements of the 3-D volume, the selected skeletal and dental landmarks were defined on each model by two investigators. The following skeletal landmarks were used: Latero-orbitale point the intersection of the lateral wall of the orbit and the greater wing of the sphenoid (the oblique line); Condylion the superior point of the condyle; Zygomatic point the most lateral point of the zygomatic arch; Zygomandibulare intersection between the lower margin of the zygomatic bone and the lateral contour of the mandibular ramus; Maxillomandibulare the intersection between the lower margin of the maxilla and the medial contour of the mandibular ramus; Maxillare the depth of the concavity of the lateral maxillary contour, at the junction of the maxilla and the zygomatic buttress; Gonion the gonial angle of the mandible; Antegonion the antegonial notch. The following dental landmarks were located on the 3-D volume: Maxillary first molar the most
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prominent lateral point on the buccal surface of the maxillary first molar; Mandibular first molar the most prominent lateral point on the buccal surface of the mandibular first molar; Maxillary central incisor mesial the most mesial point of the maxillary central incisor crown; Maxillary central incisor apex the tip of the root apex of the maxillary central incisor; Maxillary central incisor edge the incisal edge of the maxillary central incisor, centred mediolaterally. The amount of dental expansion was determined as the difference between the T1 and T2 widths. For the Maxillary incisal angle, a positive value for T2 T1 indicated flaring of the maxillary central incisors crowns, while a negative value indicated flaring of the maxillary central incisor apices. In addition, the buccal aspects of all involved teeth were scanned to determine if the roots fenestrated or dehisced the buccal cortical plate.
Statistical analyses
All parameters were measured twice by the same examiner with a fortnight between the measurements.9 The errors were assessed by Dahlbergs method and the intra-examiner reliability was assessed with the intraclass correlation coefficient (ICC). Since the data were not normally distributed, the change in each variable was tested with the Wilcoxon signed rank test.
Results
We found no statistically significant differences between the first and second measurements and high intra-examiner reliability (ICC > .97). The Dahlberg values fell between 0.13 mm for the Maxillary central incisor width at T1 and 0.91 mm for the Maxillomandibular width at T2, and 0.38 and 0.88 degree for the Maxillary central incisor angle at T1 and T2, respectively. The majority of the ICC values were .98
Table I. Comparison of the T1 and T2 measurements on the coronal CT sections (N = 20).
T1 Mean SD Mean
T2 SD
Change Mean SD
Maxillary base width (MBW, mm) Maxillary alveolar width (MAW, mm) Intermolar width (crown, mm) Intermolar width (apex, mm) Interpremolar width (crown, mm) Interpremolar width (apex, mm) Intercanine width (crown, mm) Intercanine width (apex, mm) Right molar angulation (degrees) Left molar angulation (degrees) Right premolar angulation (degrees) Left premolar angulation (degrees) Right canine angulation (degrees) Left canine angulation (degrees)
Statistically significant at p < 0.01
59.7 52.8 50.3 29.3 40.6 26.5 31.4 23.5 118.9 119.5 107.6 110.0 100.5 100.7
2.7 4.0 3.4 2.2 2.9 3.3 5.0 3.3 5.6 7.5 5.1 6.5 7.8 9.2
61.5 57.3 56.6 32.0 46.6 29.2 34.5 25.9 126.0 125.9 114.1 115.5 105.6 104.1
2.6 4.1 3.6 2.8 3.2 3.6 4.4 3.0 4.7 6.6 5.2 6.4 6.6 6.8
1.7 4.5 6.3 2.7 6.0 2.8 3.1 2.4 7.2 6.3 6.5 5.5 5.1 3.5
0.9 3.5 2.1 1.9 2.6 1.7 2.0 1.4 4.2 4.7 3.4 4.2 5.1 4.3
0.01 0.01 0.01 0.01 0.01 0.01 0.01 0.01 0.01 0.01 0.01 0.01 0.01 0.01
and .99 and only four values (Maxillary alveolar width T1; Mandibular first molar width T1 and T2; Maxillary central incisor mesial width T1) had an ICC of .97, confirming the reliability of our method of measurement. The results are given in Tables I and II. The changes T2 minus T1 are the overall treatment effect. All skeletal and dental measurements on the coronal CT sections increased significantly from T1 to T2, indicating that the appliance had expanded the maxillary dentition and upper facial skeleton (Table I). The increase in Maxillary alveolar width was 4.5 3.5 mm, which was greater than that seen at the Maxillary base width (1.7 0.9 mm). Greater transverse changes occurred at the molar crowns than the molar apices (Intermolar crown width: 6.3 2.1 mm: Intermolar apical width: 2.7 1.9 mm). In addition, the right and left molars were tipped buccally 7.2 4.2 degrees and 6.3 4.7 degrees, respectively. Dental tipping was not identical on the right and left sides. The premolar and canine widths also increased and the premolars and canines tipped buccally, but to a lesser degree than the molars. There were nine significant increases in 3-D volume between T1 and T2 (Table II). The Bicondylar width, Bimaxillo-mandibular width and the Maxillary width increased between 1.2 and 2.5 mm. The greatest
increase in the linear measurements was seen in the Maxillary first intermolar width (6.4 0.1 mm). The Maxillary intercanine width (3.3 0.9 mm), Maxillary central incisor apex width (3.4 0.4 mm), Mandibular first intermolar width (1.7 1.8 mm) and Mandibular intercanine width (0.6 0.9 mm) also increased significantly. The Maxillary central incisor angle reduced significantly from T1 to T2 (-7.9 8.4 mm), indicating that the distance between the root apices increased (Figure 6).
Discussion
Rapid maxillary expansion appliances are used to obtain a normal transverse relationship between the maxilla and the mandible and to relieve crowding in mild cases. The magnitude of the expansion varied greatly in different individuals and at different parts of the craniomaxillary complex. We found the Maxillary alveolar width increased more than the Maxillary base width and that the amount of skeletal and dental tipping gradually increased from the anterior region to the molar region. Technical advances in CT have increased its utility as a diagnostic aid and as a method of evaluating the treatment outcome. Since CT can be used for multiplanar 3-D reconstructions and as it has few artifacts and superimposed structures (both of which can hinder measurement),
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Table II. Comparison of T1 and T2 measurements on the 3-D volumes (N = 20).
T1 Mean SD Mean
T2 SD
Change Mean SD
Bilatero-orbital width (mm) Bicondylar width (mm) Bizygomatic width (mm) Bizygomatico-mandibular width (mm) Bimaxillo-mandibular width (mm) Maxillary width (mm) Bigonial width (mm) Biantegonial width (mm) Maxillary central incisor apex width (mm) Maxillary first intermolar width (mm) Mandibular first intermolar width (mm) Maxillary central incisor mesial width (mm) Maxillary intercanine width (mm) Mandibular intercanine width (mm) Maxillary central incisors angle (degrees)
Statistically significant at p < 0.01
85.0 91.8 113.6 94.2 77.3 56.2 83.8 77.4 5.5 49.7 51.0 0.5 30.9 26.6 10.3
4.2 6.8 5.0 6.9 9.7 4.2 5.7 5.3 1.7 3.5 2.6 0.8 3.7 1.9 5.3
85.1 92.9 113.7 94.2 79.3 58.7 83.8 77.5 8.9 56.1 52.7 0.9 34.2 27.2 2.4
4.2 6.6 5.0 6.8 9.8 3.7 5.7 5.3 4.1 3.6 2.7 1.3 3.8 2.2 10.5
0.1 1.2 0.0 0.1 2.1 2.5 0.0 0.0 3.4 6.4 1.7 0.4 3.3 0.6 -7.9
0.1 1.3 0.1 0.1 2.3 1.6 0.1 0.1 0.4 0.1 1.8 1.5 0.9 0.9 8.4
1.96 4.20 1.63 2.26 4.05 7.16 2.60 1.33 3.82 29.59 4.41 1.32 16.50 2.89 4.20
0.06 0.01 0.12 0.04 0.01 0.01 0.02 0.20 0.01 0.01 0.01 0.20 0.01 0.01 0.01
evaluation of the skeletal and dental changes after rapid maxillary expansion is possible. In addition, the new software added to the CT workstation provides reproducible images over time, thereby increasing the possibility of a longitudinal investigation.6 In the present study, all linear and angular measurements on the coronal sections increased significantly, indicating that RME increased the transverse dimensions of the maxillae. The increase in the Maxillary base width, however, was considerably less than the increase in the Maxillary alveolar width. This finding is in agreement with previous studies conducted on frontal cephalograms,1015 with the use of implants,16 and on CT scans.1720 Despite the heterogeneous sample regarding age, sex and amount of expansion, Krebs reported similar outcomes, with a mean increase in intermolar distance three times larger than expansion at the zygomatic processes.16 Wertz and Dreskin reported a 2.5 mm widening of the maxillary base compared with a 6.5 mm increase in the intermolar distance.10 Our results also showed that the greatest increase in the width of the dental arch occurred opposite the first molars and the effect gradually decreased towards the canines, indicating that the posterior dentition underwent the greatest expansion as a result of RME
146
therapy. This was further confirmed by our finding on the 3-D volume, that the greatest variation in the linear measurements was found in the Maxillary intermolar width. The increase in the Intermolar width reflects the total amount of dental and dentoalveolar expansion produced by the appliance. In agreement with Garrett et al.,19 we found that RME tipped the maxillary teeth buccally with the greatest effect at the first permanent molars, indicating increased alveolar bone bending posteriorly. In this regard, when tooth movement becomes the most significant response to expansion, care should be taken not to cause a fenestration or dehiscence in the cortical plate overlying the buccal roots of the first molars. We used the 3-D data to examine the cortical plates from the canines to the first molars, and we found no cases with alveolar fenestration. The results from the coronal sections were confirmed by measurements of selected skeletal and dental parameters on the 3-D volumes. Skeletal parameters such as Bicondylar width, Bimaxillo-mandibular width and Bimaxillary width increased significantly, whereas the Bilatero-orbital width, Bizygomatic width, Bizygomatico-mandibular width, Bigonial width, and Biantegonial width did not change, presumably because the latter were located some
distance from the maxillae and not directly affected by the expansion. In addition, the Mandibular first intermolar and Mandibular intercanine widths increased significantly following RME although there was no appliance in the mandibular arch during this time, confirming that RME indirectly expands the mandibular dental arch.2,8,13,21 When we compared the radiographic and clinical findings we found that the median maxillary diastema closed at the end of active expansion as the central incisor crowns tipped mesially. This was accompanied by a significant reduction in the angle between the central incisors and an increase in the distance between the incisor apices, while the distance between the mesial surfaces of the central incisors did not change significantly. Compared to current cephalometric methods, CT scans and 3-D reconstructed images provide a more comprehensive and accurate assessment of the dental and skeletal changes associated with RME. Furthermore, the use of CT scans for diagnosis and follow-up is becoming accepted by clinicians as a substitute for conventional cephalometry, but analysis of long-term data and a larger clinical series will be necessary to determine the application of this method in the clinical practice. Future studies will examine the long-term treatment effects of RME on this group of subjects.
Acknowledgments
The authors would like to thank Dr Ayman Kamel for his skilled radiographic and technical assistance, Dr Ashraf El-Bedwehi for his critical advice and Mr George Eckert for the statistical assistance.
Dr Ahmed Ghoneima Department of Orthodontics and Oral Facial Genetics Indiana University School of Dentistry 1121 W. Michigan St. RM 270B Indianapolis, IN 46202 United States of America Tel: (+317) 278-1653 Fax: (+317) 278-1438 Email: aghoneim@iupui.edu
References
1. McNamara JA. Maxillary transverse deficiency. Am J Orthod Dentofacial Orthop 2000;117:56770. 2. Bishara S, Staley R. Maxilary expansion: clinical implications. Am J Orthod Dentofacial Orthop 1987;91:314. 3. Goldenberg D, Alonso N, Goldenberg F, Gebrin E, Amaral T, Scanavini M, Ferreira M. Using computed tomography to evaluate maxillary changes after surgically assisted rapid palatal expansion. J Craniofac Surg 2007;18:30211. 4. Baumrind S, Carlson S, Beers A, Curry S, Norris K, Boyd R. Using three-dimensional imaging to assess treatment outcomes in orthodontics: a progress report from the University of the Pacific. Orthod Craniofac Res 2003;6:13242. 5. Scarfe W, Farman A, Sukovic P. Clinical applications of cone-beam computed tomography in dental practice. J Can Dent Assoc 2006;72:7580. 6. Swennen G, Schutyser F. Three-dimensional cephalometry: Spiral multi-slice vs cone-beam computed tomography. Am J Orthod Dentofacial Orthop 2006;130:41016. 7. Podesser B, Williams S, Bantleon H, Imhof H. Quantitation of transverse maxillary dimensions using computed tomography: a methodological and reproducibility study. Eur J Orthod 2004;26:20915. 8. Baccetti T, Franchi L, Cameron C, McNamara JA. Treatment timing for rapid maxillary expansion. Angle Orthod 2001; 71:34350. 9. Suomalainen A, Vehmas T, Kortesniemi M, Robinson S, Peltola J. Accuracy of linear measurements using dental cone beam and conventional multislice computed tomography. Dentomaxillofac Radiol 2008;37:1017. 10. Wertz R, Dreskin M. Midpalatal suture opening: A normative study. Am J Orthod 1977;71:36781. 11. Frank S, Engel G. The effects of maxillary quad-helix appliance expansion on cephalometric measurements in growing orthodontic patients. Am J Orthod 1982;81:37889. 12. da Silva Filho O, Montes L, Torelly L. Rapid maxillary expansion in the deciduous and mixed dentition evaluated through posteroanterior cephalometric analysis. Am J Orthod Dentofacial Orthop 1995;107:26875.
Conclusions
RME produced a significant overall increase in maxillary transverse dimensions, with increasing magnitude from the base of the maxilla to the dental arch. Although significant increases occurred in most skeletal and dental parameters, it appears that bone bending and tipping might explain most of the expansion. The amount of tipping gradually increased from the anterior region to the molar region. Computed tomography is an effective and reliable method for evaluating the changes induced by RME. It also allows multiplanar and volumetric 3-D reconstruction of the image and a comprehensive evaluation of changes in the skeletal and dental structures. In addition, the volumetric images allow better examination of the treatment outcomes than conventional methods.
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13. Cameron C, Franchi L, Baccetti T, McNamara JA. Long term effects of rapid maxillary expansion: a posteroanterior cephalometric evaluation. Am J Orthod Dentofacial Orthop 2002;121:12935. 14. Lamparski D, Rinchuse D, Close J, Sciote J. Comparison of skeletal and dental changes between 2-point and 4-point rapid palatal expanders. Am J Orthod Dentofacial Orthop 2003;123:3218. 15. Davidovitch M, Efstathiou S, Sarne O, Vardimon A. Skeletal and dental response to rapid maxillary expansion with 2versus 4-band appliances. Am J Orthod Dentofacial Orthop 2005;127:48392. 16. Krebs A. Midpalatal suture expansion studies by the implant method over a 7-year period. Rep Congr Eur Orthod Soc 1964:40;13142. 17. Garib D, Henriques J, Janson G, Freitas M, Coelho R. Rapid maxillary expansion-tooth tissue-borne versus toothborne expanders: a computed tomography evaluation of dentoskeletal-effects. Angle Orthod 2005;75:54857.
18. Podesser B, Williams S, Crismani A, Bantleon H. Evaluation of the effects of rapid maxillary expansion in growing children using computer tomography scanning: a pilot study. Eur J Orthod 2007;29:3744. 19. Garrett B, Caruso J, Rungcharassaeng K, Farrage J, Kim J, Taylor G. Skeletal effects to the maxilla after rapid maxillary expansion assessed with cone-beam computed tomography. Am J Orthod Dentofacial Orthop 2008;134:8e18.e11. 20. Ballanti F, Lione R, Fanucci E, Franchi L, Baccetti T, Cozza P. Immediate and post-retention effects of rapid maxillary expansion by computed tomography in growing patients. Angle Orthod 2009;79:249. 21. Adkins M, Nanda R, Currier G. Arch perimeter changes on rapid palatal expansion. Am J Orthod Dentofacial Orthop 1990;97:1949.
148
Strength of attachment between band and glass ionomer cement

Elahe Vahid Dastjerdie, * Houman Zarnegar, Mohammad Behnaz and Massoud Seifi *
Department of Orthodontics, Dental School, Shahid Beheshti University of Medical Sciences* and Private practice, Tehran, Iran
Aim: To determine the strength of attachment between plain stainless steel band material and glass ionomer cement. Methods: Seventy-five extracted upper premolars, free of visible structural defects, were used. The teeth were divided randomly into three groups and embedded in acrylic resin blocks. A short length of plain, stainless steel band material with a welded stainless steel standard edgewise 0.022 inch bracket was adapted to the buccal surface of each tooth. The bracket-stainless steel pads were then cemented to the teeth with either Bandtite (Group 1), Granitec (Group 2) or Ariadent (Group 3) glass ionomer cement and stored in an incubator at 37 C for 30 days. The shear bond strengths of the specimens were measured and compared. Results: The mean shear bond strengths (SBS) were significantly different: Bandtite 0.7331 0.056 Mpa; Granitec 0.3869 0.047 Mpa; Ariadent 0.2931 0.033 Mpa (ANOVA, p < 0.001). Tukey HSD post-hoc tests also showed significant differences between Bandtite and Granitec, Bandtite and Ariadent, and Granitec and Ariadent (p < 0.001). All specimens failed at the band-cement interface. Conclusion: The highest and lowest SBS were related to Bandtite and Ariadent cements, respectively. All cements had bond strengths less than the range of bond strengths considered to be clinically acceptable for bonded orthodontic attachments. Mechanical factors are important for band retention. (Aust Orthod J 2010; 26: 149152)
Received for publication: January 2009 Accepted: June 2010 E. Vahid Dastjerdie: elahevahid@dent.sbmu.ac.ir H. Zarnegar: zarnegar@yahoo.com M. Behnaz: behnaz1357@yahoo.com M. Seifi: mseifi@dent.sbmu.ac.ir
Introduction
Band retention is essential for successful and effective orthodontic treatment.1,2 Furthermore, plaque retention under loose bands can result in carious lesions in a few weeks.3 The consensus is that bands cemented with glass ionomer cements are retained longer, and less decalcification occurs under a loose band than under bands cemented with either zinc phosphate or zinc silico-phosphate cements.4,57 Band retention is improved when the band is welladapted to the tooth, if it is rigid and if the anatomical surface is roughened. A luting agent should seal the gap between the band and tooth, reduce the risk of caries should the band loosen and be easily removed at the end of treatment. Although one in 10 bands cemented with glass ionomer cements can be expected to fail over the course of orthodontic treat Australian Society of Orthodontists Inc. 2010
ment, glass ionomer cements generally fail at the cement-band interface, leaving a protective layer of cement on the tooth.4,5,8,9 Bond strength, which is the load required to dislodge an attachment from the surface of a tooth, is used as a guide to the retention of a band in vivo. A high bond strength is assumed to translate into a high band retention rate. The retention of a band is dependent on the properties of the cement and factors that influence mechanical retention of the band. In this preliminary in-vitro study, we aim to determine the strength of attachment between a stainless steel pad and glass ionomer cement. We excluded the contributions to band retention made by surface treatment of the anatomical surface of the band material, such as microetching, and mechanical locking of an intact band on the tooth.
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Seventy-five extracted upper premolars were used in this in-vitro study. The teeth were caries-free, had no restorations, no visible dentinal or enamel defects and were not malformed. They were stored in normal saline before the experiment. Soft tissue and blood debris were removed by washing the teeth with water and the crowns were cleaned with a fluoride-free prophylaxis paste and rubber cup. Following cleaning, the teeth were randomly assigned to three groups: Group 1, Bandtite (American Orthodontics, WI, USA) a true glass ionomer cement containing silicon oxide, calcium fluoride, aluminium oxide, barium sulfate, aluminium phosphate, aluminium fluoride, polyacrylic acid and water; Group 2, Granitec (OrthoTechnology, FL, USA) a true glass ionomer cement containing fluoro-alumina-silica glass as a powder and an aqueous solution of polyacrylic acid as the liquid; Group 3, Ariadent (ApadanaTak, Tehran, Iran) a true glass ionomer cement containing fluorosilicate as a powder and an aqueous solution of polyacrylic acid as the liquid. The teeth were embedded in acrylic resin blocks (Acropars, Tehran, Iran) to within 2 mm of the cemento-enamel junctions, placed in water to dissipate heat from the polymerising resin and then stored in normal saline for 24 hours. Standard 0.022 inch slot, edgewise brackets (Dentaurum, Ispringen, Germany) were welded to short lengths (5 x 7 mm) of 0.006 inch thick stainless steel band material and adapted to the buccal surface of each tooth. The band material was not microetched. The cements were mixed according to the manufacturers directions, loaded on the stainless steel pads, pressed on the dry buccal surfaces of the teeth with a burnisher and left undisturbed for 15 minutes. The specimens were transferred to distilled water and stored in an incubator with 100 per cent humidity and a temperature of 37 C for 30 days. The teeth were mounted in an Instron Universal Testing Machine (Model 1195, Instron Ltd, High Wycombe, England) with the aid of a purpose-built jig. A shear force was applied to each bracket slot by a length of 0.021 x 0.025 inch wire welded to a 2 x 20 mm wide stainless steel blade at a crosshead speed of 0.5 mm/min. The groups were compared with a one-way analysis of variance and Tukey post-hoc multiple comparison tests.
Results
The observed force at fracture (N) was divided by the mean area of the band material surface (35 mm2) to obtain the shear bond strength in megapascals (MPa). The results are given in Table I. The SBSs were: Group 1, Bandite, Mean: 0.7331 0.056 MPa, Range: 0.63-0.83 MPa; Group 2, Granitec Mean: 0.3869 0.047 MPa, Range: 0.3-0.47; Group 3, Ariadent Mean: 0.2931 0.033 MPa, Range: 0.230.36. The one-way ANOVA revealed a significant difference in the SBS (p < 0.001). Tukey post-hoc tests also showed significant differences between Bandtite and Granitec, Bandtite and Ariadent, and Granitec and Ariadent (p < 0.001).
Discussion
We set out to determine the strengths of attachment between the cement, the tooth and a plain stainless steel pad. Previous studies have shown what appears to be a threshold in the shear-peel band strength of microetched orthodontic bands.10,11 A coarse factoryetched surface aided retention, while a finer in-office pattern reduced the shear-peel band strength to almost half that of the factory-etched band. We aimed to exclude any contribution to retention by either surface treatment of the anatomical surface of a band or by mechanical locking of the band on the tooth. As expected, the bond strengths of all three cements were markedly less than the bond strengths of composite resins used to bond orthodontic attachments to teeth, and the strength of attachment between an intact band and the tooth.12 We were surprised that the cement remained attached to the plain stainless steel pads for 30 days and at least 0.23 MPa was required to dislodge the pads from the teeth. Of the cements tested, Bandtite had the highest shear bond strength (approximately 10 per cent of the clinically acceptable range for individual bonded attachments) and Ariadent the lowest bond strength. Following debonding, no remnants of cement remained on the band material and no specimens failed cohesively. We are at a loss to explain the differences between the cements and postulate that the different particle sizes, moisture contamination during storage, the powder/liquid ratio, solvent concentration, mixing procedure and different acidities may have contributed to our findings.4,8
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Table I. The shear bond strengths of glass ionomer cements.
Group
Mean (MPa)
SD
Range
SE
95 per cent CI Upper Lower
Bandtite Granitec Ariadent
25 25 25
0.73 a,b 0.38 a,c 0.29 b,c
0.05 0.04 0.03
0.63 0.83 0.30 0.47 0.23 0.36
0.010 0.009 0.006
0.75 0.40 0.30
0.70 0.36 0.27
ANOVA, p < 0.001 Tukey HSD test, groups with the same letters were significantly different from each other at p < 0.001
Glass ionomer cements are mixtures of an acid, frequently an aqueous solution of polyacrylic acid, and an acid soluble calcium fluoro-alumina-silica powder. During bonding, polyacrylic acid reacts with the enamel, replacing phosphate and/or calcium ions from the enamel and the cement bonds to the tooth and, in our study, the band material.13 As a rule glass ionomer cements with higher concentrations of acid and thinner films produce stronger bonds to enamel.14 As the companies did not provide full information of the composition of their cements, we can only speculate that different concentrations of polyacrylic acid, different solubilities and powder:liquid ratios may be responsible for the different strengths of attachment between the cements and the stainless steel pad. The ideal luting agent should fill the gap between the band and the tooth for the length of treatment and offer some protection from decay should the band loosen. It could be argued that cohesive failure or failure at the band-glass ionomer cement interface is preferable, as an intact cement film and release of fluoride ions from the cement protect the tooth from decay. The thickness of the cement layer is also an important factor that may compromise the bond strength at the cement-tooth interface. Thick layers of cement are more prone to dissolve in fluids over time and influence the longevity of the bond between the band and the tooth.2,3 Thin cement films, of the order of 1319 m, produce strong bonds.15,16 Although we did not measure the thickness of the cement layer, we used well-adapted 7 x 5 mm stainless steel pads and held them in place for 15 minutes while the cement set. The debonding sites for all cements occurred at the band-cement interfaces and intact cement layers remained attached to the teeth. The specimens were
stored in distilled water, not saliva, for 30 days and were not subjected to the temperature changes encountered in the mouth. Nor were they subjected to the corrosive effects of some foods and drinks or to physical stress: factors that may promote early loosening and failure at the tooth-cement interface.
Conclusions
The glass ionomer cements failed at the cement-pad interface and all had bond strengths below the value considered to be clinically acceptable for a bonded attachment. The importance of mechanical factors for band retention is stressed.
Acknowledgments
The authors wish to thank Dr Mina Mahdian for help revising and editing the manuscript.
Dr Elahe Vahid Dastjerdie Dental School Shahid Beheshti University of Medical Sciences Evin 1983969411 Tehran I.R. Iran Tel/Fax: +98 21 2242 1814 Email: elahevahid@dent.sbmu.ac.ir
References
1. Millett DT, MacCabe JF, Bennett TG, Carter NE, Gordon PH. The effect of sandblasting on the retention of first molar orthodontic bands cemented with glass ionomer cement. Br J Orthod 1995;22:1619. Fricker JP. A 12-month clinical comparison of resin-modified light-activated adhesives for the cementation of orthodontic molar bands. Am J Orthod Dentofacial Orthop 1997; 112:23943. Melrose CA, Appleton J, Lovius BB. A scanning electron microscopic study of early enamel caries formed in vivo beneath orthodontic bands. Br J Orthod 1996;23:437.
2.
3.
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4.
Durning P, McCabe JF, Gordon PH. A laboratory investigation into cements used to retain orthodontic bands. Br J Orthod 1994;21:2732 5. Norris DS, McInnes-Ledoux P, Schwaninger P, Weinberg R. Retention of orthodontic bands with new fluoridereleasing cements. Am J Orthod 1986;89:20611. 6. Clark RJ, Phillips RW, Norman, RD. An evaluation of silicophosphate as an orthodontic cement. Am J Orthod 1977; 71:1906. 7. Kvam E, Broch J, Nissen-Meyer IH. Comparison between a zinc phosphate and a glass ionomer for cementation of orthodontic bands. Eur J Orthod 1983;5:30713. 8. Shaver RL, Siegel IA, Nicholls JI. Effect of ultrasonic ZnPO4 cement removal on band adhesion and cement solubility under orthodontic bands. J Dent Res 1975;54: 20611. 9. Stirrups DR. A comparative clinical trial of a glass ionomer and a zinc phosphate cement for securing orthodontic bands. Br J Orthod 1991;18:1520. 10. Grabouski JK, Staley RN, Jakobsen JR. The effect of microetching on the bond strength of metal brackets when bonded to previously bonded teeth: an in vitro study. Am J Orthod Dentofacial Orthop 1998;114:45260.
11. Aggarwal M, Foley TF, Rix D. A comparison of shear-peel band strength of 5 orthodontic cements. Angle Orthod 2000;70:30816. 12. Millett DT, Duff S, Morrison L, Cummings A, Gilmour WH. In vitro comparison of orthodontic band cements. Am J Orthod Dentofacial Orthop 2003;123:1520. 13. Sturdevant CM, Roberson TM, Heymann HO, Sturdevant JR. The Art and Science. 3rd edn. St Louis: Mosby, 1995: 2637. 14. Bagheri J. Glass ionomer cements. (D. Wilson). 1st edn. Astane Ghods Razavi Publishing Co. 1373:289310. 15. Craig R, Powers J. Restorative Dental Materials. 11th edn. St. Louis: Mosby, 2002:61416. 16. Zachrisson BU. Direct bonding in orthodontic treatment and retention: a post-treatment evaluation. Eur J Orthod 2007;29 (suppl.1):12834.
152
Lip - tooth relationships during smiling and speech: an evaluation of different malocclusion types
Roozbeh Rashed and Farzin Heravi
Department of Orthodontics, School of Dentistry, Mashhad University of Medical Sciences, Mashhad, Iran
Background: Few studies have focused on the impact of malocclusion on lip tooth relationships during smiling and speech. Aim: To evaluate the impact of different malocclusions on lip tooth relationships during smiling and speech, using video images. Methods: One hundred and three subjects with Class I (N = 31), Class II division 1 (N = 26), Class II division 2 (N = 16) and Class III malocclusions (N = 30) were asked to repeat the same sentence and then smile in front of a video camera. Nine frames were extracted from each subjects video clip: at rest, posed smile, unposed smile and during the pronunciation of the sounds: che, fa, se, chee, tee and mee. On each frame, up to 10 parameters describing the lip tooth relationships were measured. Results: In all frames, there were no statistically significant differences in the upper central incisor display ratios among the malocclusion groups (p > 0.05). The buccal corridor ratio in the posed and unposed smiles did not differ significantly among the malocclusions (p > 0.05). The most frequently visible last maxillary tooth was the first premolar in the posed smile, and the second premolar in the unposed smile. In each malocclusion group, the upper central incisor display ratio varied significantly among the nine frames and the buccal corridor ratio during the unposed smile was less than the ratio during the posed smile; although this was only significant in the Class II division 2 subjects. The smile arc was similar in all malocclusions. Conclusions: In each malocclusion the upper central incisor display ratio varied significantly among the nine frames. In each group, the buccal corridor ratio during the unposed smile was less than that during the posed smile, but only the Class II division 2 group was significantly different. The smile arc did not differ among the malocclusions. (Aust Orthod J 2010; 26: 153159)
Received for publication: December 2009 Accepted: June 2010 Roozbeh Rashed: rashedr@mums.ac.ir, roozberashed@yahoo.com Farzin Heravi: heravif@mums.ac.ir
Introduction
Psychological studies have shown that facial attractiveness affects the way an individual is regarded by others. Infants considered to be unattractive by the general population and their own mothers tend to be perceived more negatively than attractive infants.1 The attractiveness halo extends from home to school. It can affect teacher student and student peer relations and academic attainment.2 The benefits of physical attractiveness also extend to the workplace, where attractive individuals tend to fare better than unattractive individuals with regard to perceived job qualifications, hiring decisions and future career success.3 In modern society, a pleasant smile is an
advantage in job interviews, social interactions and even in the selection of a spouse.35 An unattractive dental appearance during childhood can lead to teasing by age peers that may result in a profound psychological impact, which may continue into adult life.68 Both adolescent patients and their parents expect orthodontic treatment to improve oral and dental function, health and aesthetics and to enhance self-confidence and the quality of their social life.9,10 Needless to say, the goal of modern orthodontics is to improve the quality of life which, in part, is achieved through the enhancement of the patients smile and facial appearance. Oral health related quality of life (OHRQoL) has been defined as the
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Figure 1. Smile Analyzer software. This picture shows five windows for the operators use, and the patients personal information, loading the desired image, measuring the desired parameter (here, the width of the right upper central incisor) and the table of measured variables.
Figure 2. (a) Maximum upper central incisor display. (b) Outer commissure width (smile width). (c) Inner commissure width. (d) Visible maxillary dentition width.
absence of negative impacts of oral conditions on social life and a positive sense of dentofacial selfconfidence. Thus, orthodontic treatment should carefully consider the patients facial appearance and particularly his/her smile. Patients will not be satisfied with the treatment outcome if aesthetics are sacrificed for the sake of a good occlusion, even if all the functional goals are met. Improvement in facial aesthetics is a powerful motivation for seeking treatment.11 Lip tooth relationships during speech and smiling are important aspects of facial aesthetics. However, few studies have focused on lip tooth relationships during speech and only one study has considered the impact of malocclusion on these relationships during speech and smiling. Our aim was to evaluate the lip tooth relations in subjects with different types of malocclusion, using video images taken during smiling and speech.
The study was explained to each participant and/or his/her parent or guardian and all agreed to participate in the study. The subjects were seated facing a mirror positioned two metres in front of them. To obtain the natural head position (NHP), each subject was asked to pitch his/her head up and down until a positon of balance was obtained and to look at the reflections of their eyes in the mirror. Video images were captured by means of a video camera recorder (Sony Video Camera Recorder, Model CCD-TR311E, Sony Corporation, Japan) mounted on a tripod 1.5 metres in front of each subject, and aimed at the mouth. Each subject was then asked to repeat a sentence which included words containing the sounds: che, fa, se, chee, tee and mee. The subject was then asked to smile voluntarily (posed smile) and spontaneously (unposed smile), while the movements of the lips were recorded. After calculating the magnification of the recorded images, a vernier caliper was used to measure the width of an upper central incisor. The captured images were then downloaded to a personal computer. Using the Windows Movie Maker software (Windows XP Professional, Microsoft Corporation, USA), nine frames were extracted from each video clip: the subject at rest, during the posed smile, during the unposed smile and during pronunciation of the sounds: che, fa, se, chee, tee and mee. Measurements were made using a software programme designed by the author and called Smile
Material and methods Subjects and video recording

The experimental sample consisted of 37 male and 66 female subjects who presented for orthodontic treatment. The mean ages of the male and female subjects were 19.0 6.7 years and 18.1 4.9 years, respectively. Of the 103 subjects, 31 had a Class I malocclusion, 26 a Class II division 1 malocclusion, 16 a Class II division 2 malocclusion and 30 a Class III malocclusion.
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SPEECH AND SMILE CHARACTERISTICS IN DIFFERENT MALOCCLUSIONS
60 50 40 30 20 0 Posed Unposed Lateral Canine 1st Premolar 2nd Premolar 1st Molar
Figure 4. (a) Posed smile. (b) Unposed smile. In an unposed smile, despite the greater smile width, because the lips are stretched more, a larger part of the modiolus becomes visible and the inner commissures get more distinct and closer to each other. Thus, the buccal corridor ratio during an unposed smile is less than that of a posed smile.
Figure 3. Frequency distribution of the last visible maxillary tooth during posed and unposed smiles.
Analyzer (Figure 1). In this software, all measurements were saved in the integrated database, and could be transferred to other Windows-based software, such as Microsoft Excel or SPSS.
2. Inner commissure width (the inner commissure is formed by the mucosa overlying the buccinator muscle where it inserts with the orbicularis oris muscle fibres at the modiolus).12 3. Visible maxillary dentition width, which is the distance between most lateral left and right points of the maxillary dentition during smiling.13 4. Left and right buccal corridors, measured from the inner commissure to the last visible maxillary tooth. This measurement was divided by the visible maxillary dentition width. The result was a ratio of the maxillary teeth while smiling, minus the buccal corridor. For example, 0.92 means that the maxillary dentition occupied 92 per cent of the inner intercommissure width. Therefore, the buccal corridor would then occupy 8 per cent (100 minus 92 per cent) of the smile.14 5. Smile arc, which may be in one of three forms: consonant (i.e. parallel), flat or reverse.15 6. Most posterior maxillary tooth visible. In case of a discrepancy between the two sides, the most posterior tooth was entered.14 For the frames in which the subject was speaking the following were measured: 1. Maximum upper central incisor display and the upper central incisor display ratio. 2. Gingival display of the upper central incisor. 3. Interlabial gap.
Measured parameters
For each subject, the height and width of an upper central incisor was measured on a frame that showed all of the central incisor crown, and the height-towidth ratio calculated (Figure 2). The following measurements were taken from a representative frame with the subject at rest: 1. Maximum upper central incisor display and the upper central incisor display ratio. These are the percentage and ratio of the crown height on the frame. 2. Gingival display of the upper central incisor. The amount of gingival tissue displayed above the long axis of the incisor, in millimetres. 3. Interlabial gap. 4. Philtrum height. 5. Left and right commissure heights. The distances between the outer commissures and a horizontal line passing through the subnasal point. In addition to the first three parameters measured on the at rest frame, the following parameters were measured on representative frames of the posed and unposed smiles (Figures 2 and 4): 1. Smile width or outer commissure width, as delineated by the outermost confluences of the vermilion borders of the lips at the corners of the mouth,12 and the smile index, that is, the smile width divided by the smile height (interlabial gap).13
Statistical analyses were performed with SPSS 15.0 for Windows (SPSS Inc., Chicago, IL, USA). OneAustralian Orthodontic Journal Volume 26 No. 2 November 2010
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Table I. Comparisons of the buccal corridor ratios.
Class I Mean (SD)
Class II div 1 Mean (SD)
Class II div2 Mean (SD)
Class III Mean (SD)
p*
Posed smile Unposed smile p
0.13 (0.06) 0.12 (0.06) 0.27
0.14 (0.07) 0.13 (0.08) 0.77
0.18 (0.07) 0.14 (0.06) 0.04
0.14 (0.08) 0.13 (0.07) 0.50
0.14 0.68
* One-way ANOVA Paired t-test, significant value in bold
Table II. Frequency distributions of the smile arc during posed and unposed smiles.
Unposed smile arc Non definable Consonant Flat Reverse
Total
Posed smile arc
Non definable Consonant Flat Reverse Total
Number % of total Number % of total Number % of total Number % of total Number % of total
4.0 4.4 0.0 0.0 0.0 0.0 0.0 0.0 4.0 4.4
6.0 6.6 24.0 26.4 3.0 3.3 0.0 0.0 33.0 36.3
5.0 5.5 8.0 8.8 23.0 25.3 2.0 2.2 38.0 41.8
2.0 2.2 0.0 0.0 3.0 3.3 11.0 12.1 16.0 17.6
17.0 18.7 32.0 35.2 29.0 31.9 13.0 14.3 91.0 100.0
Contingency coefficient: .716, p < 0.001
way ANOVA and paired-t tests were used to analyse the parametric data and the nonparametric tests: the Friedman, Wilcoxon, Mann-Whitney and KruskalWallis were used to analyse the quantitative data. The qualitative data were analysed with the chi-squared test. A significance level of 0.05 was used for all tests.
Results
The mean upper central incisor display ratio or the per cent of the visible crown height was 23 per cent at rest, 78 per cent during the posed smile and 99 per cent during the unposed smile. On average, the highest ratio of incisor display during speech occurred during the pronunciation of che or chee (70 per cent) and the lowest ratio during pronunciation of mee (47 per cent). Using Tjan et al.s classification of incisor display during the posed smile, we found 41.7 per cent of the subjects had an average smile, 13.6 per cent had a high smile and 44.7 per cent a low smile.16 There
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were fewer subjects with high smiles in all of the malocclusion groups, although there was no statistically significant difference in the type of smile among the malocclusion groups (p = 0.12). When incisor display in the boys and girls were compared, 12.1 per cent of the girls and 16.2 per cent of the boys had a high smile, but the difference was not statistically significant (p = 0.76). There was no statistically significant difference in the upper central incisor display ratio among the malocclusion groups (p > 0.05). However, this ratio was significantly different among nine frames taken at rest, during the posed and unposed smiles, and for the frames taken during the speech exercises (p < 0.001). When frames of the speech exercises were paired up, the pairs were statistically different (p < 0.001), except for the che - chee and fa - se pairs. We found a significant positive correlation between the upper central incisor display ratio during the posed and unposed smiles (Spearman rank correlation:
r = .59, p < 0.001). Furthermore, during speech, the highest positive correlation was between chee and tee (r = .92, p < 0.001) and the lowest correlation was between che and mee (r = .69, p < 0.001). A positive correlation was found between the upper central incisor display ratio during the posed smile and pronunciation of chee (Pearson correlation coefficient: r = .60, p < 0.001). Although the buccal corridor ratio was greater during the posed smile than during the unposed smile, the difference was not statistically significant (p > 0.05), except for subjects with a Class II division 2 malocclusion (p = 0.04) (Table I). This ratio did not differ significantly among the malocclusion groups (p > 0.05). A significant positive correlation was found between the interlabial gap at rest and incisor display during the posed smile (r = .41, p < 0.001). Within each malocclusion group, the smile indices during the posed and unposed smiles also varied significantly (p < 0.05). However, neither during the posed nor during the unposed smile was this difference significant among the malocclusions (p > 0.05). Table II depicts a significant contingency in the smile arc type between the posed and unposed smiles (Contingency coefficient: .716, p < 0.001). This means that the smile arc was the same among the posed and unposed smiles in about 70 per cent of the subjects. As shown in Figure 3 during the posed smile, the most frequently visible last maxillary tooth was the first premolar, whereas during the unposed smile it was the second premolar.
III malocclusion displayed less of their upper incisors during speech and smile than subjects with Class I and Class II malocclusions.20 Age-related and ethnic variations in lip tooth relationships may exist, as white North American adolescents with a Class I skeletal pattern had different lip tooth relationships between a posed smile and articulation of chee.21 A possible explanation for the similarity in the upper incisor display ratio among the malocclusions is that the soft tissues contribute more to incisor display than the underlying skeletal form.21 At present, we have no effective method of classifying dynamic movements of the lips that will allow us to investigate differences in lip tooth relationships. The upper incisor display ratio differed significantly among the nine frames because each facial animation resulted from different soft tissue movements. During a posed smile, the lip commissures move more superiorly and laterally compared with lip movement during pronunciation of chee.21 We found positive correlations between incisor display during the posed smile and during the pronunciation of chee and between pronunciation of chee and tee. These findings lend support to the belief that sole consideration of the lip tooth relations in smiling may be misleading. Observing the patient during normal speech gives the most valuable aesthetic information for planning treatment. Tooth display during smiling cannot provide the same information, since the upper lip is raised by three different muscle groups when a person is smiling.22 In addition, certain consonant sounds may be more reproducible than smiles.23 Consonant sounds are certainly language specific and, hence, not universal. More research is needed to relate speech sounds to the amount of incisor exposure. In social interactions, people mostly talk to each other rather than just exchanging smiles, thus making the consideration of lip tooth relationships during speech of prime importance. However, such analysis of the patients speech is not possible unless dynamic records are obtained before treatment. It is also necessary to define specific words or letters which represent the patients lip tooth relationships. This area is fertile ground for further research. No study has assessed the buccal corridor spaces in different malocclusions. In our study, the buccal corridor ratio both during the posed smile (p = 0.14) and
Discussion
Undoubtedly, patients expect to have an attractive and pleasing appearance at the end of orthodontic treatment. Important components of an attractive face are an attractive smile and appropriate lip tooth relationships during speech: both contribute to social interaction. We measured the upper central incisor display ratio and found no gender difference in the type of smile in our Iranian sample. Other investigators have reported higher smile lines in women than in men, selected from non-Iranian groups.1719 We found that the upper central incisor display ratio in young adult Iranians during speech and a smile did not differ significantly among the malocclusions, although we reported that male subjects with Class
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the unposed smile (p = 0.68) did not differ significantly among the malocclusions. This may be due to specific soft tissue features in each malocclusion, such as the thickness of the lips, the amount of lip movement, the position and movement of the modiolus.24 An important and interesting observation in this study was that the buccal corridor ratio during an unposed smile was less than that during a posed smile (although this difference was only significant in Class II division 2 subjects). As Ackerman and Ackerman stated, the buccal corridor should be measured from the inner rather than the outer commissures.12 In an unposed smile, despite the greater smile width, because the lips are stretched more, a larger part of the modiolus becomes visible and the inner commissures become more distinct and closer to each other (Figure 4). Burstone attributed the variability of this space among different types of smiles to the buccinator muscle.23 We found a positive correlation between the interlabial gap at rest and the upper incisor display ratio during the posed smile. This confirms the notion that the interlabial gap at rest may be a good estimate of incisor display during a smile, underlining the importance of taking the interlabial gap into account during treatment planning.13,25,26 We also found that the smile index differed significantly between the posed and unposed smiles, and attribute this to variability of soft tissue movements and different smile widths (i.e. outer commissure width) and smile heights (i.e. interlabial gap). Is iksal and his colleagues reported that the smile index had little impact on smile aesthetics.13 In nearly 70 per cent of our subjects, we found the smile arc was the same during the posed and unposed smiles, which suggests that if a consonant smile is present during a posed smile before and/or after treatment then a consonant smile during an unposed smile will be similarly affected. In agreement with Maulik and Nanda,14 we found that the most frequently visible last upper teeth were the first and second premolars during the posed and unposed smiles, respectively. It is believed that the muscles of facial expression may account for more than 10,000 visible facial configurations and at least 18 different types of smile.27 We found that the upper central incisor display ratio was significantly different among the nine frames we used, which supports our proposal that dynamic records should be an
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integral part of orthodontic diagnosis and treatment planning.21,26,28,29
Conclusions
There was no significant difference in the upper central incisor display ratio among the malocclusion groups. The buccal corridor ratio during posed and unposed smiles did not differ significantly among the malocclusion groups. In each malocclusion group, the buccal corridor ratio during an unposed smile was less than that during a posed smile, but only in the Class II division 2 group the difference was significant. The smile arc did not differ significantly among different malocclusions.
Acknowledgment
This research was supported by a grant from ViceChancellor for Research, Mashhad University of Medical Sciences.
Associate Professor Farzin Heravi Department of Orthodontics and Dental Research Center School of Dentistry Mashhad University of Medical Sciences Mashhad Iran Tel: +98 511 8419814 Fax: +98 511 8423073 Email: heravif@mums.ac.ir
References
1. Langlois JH, Ritter JM, Casey RJ, Sawin DB. Infant attractiveness predicts maternal behaviours and attitudes. Dev Psychol 1995;31:46672. Clifford M, Walster E. The effects of physical attractiveness on teacher expectation. Sociol Educ 1973;46:24858. Hosoda M, Stone-Romero EF, Coats G. The effects of physical attractiveness on job-related outcomes: a meta-analysis of experimental studies. Personnel Psychol 2003;56:43162. Buss DM, Schmitt DP. Sexual strategies theory: an evolutionary perspective on human mating. Psychol Rev 1993; 100:204232. Stevenage SV, McKay Y. Model applicants: the effect of facial appearance on recruitment decisions. Br J Psychol 1999;90:22134. Shaw WC, Meek SC, Jones DS. Nicknames, teasing, harassment and the salience of dental features among school children. Br J Orthod 1980;7:7580.
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Helm S, Kreiborg S, Solow B. Psychosocial implications of malocclusion: a 15-year follow-up study in 30-year-old Danes. Am J Orthod 1985;87:110118. Kilpelinen PV, Phillips C, Tulloch JF. Anterior tooth position and motivation for early treatment. Angle Orthod 1993;63:1714. Gosney MB. An investigation into some of the factors influencing the desire for orthodontic treatment. Br J Orthod 1986;13:8794. Cunningham SJ, OBrien C. Quality of Life and Orthodontics. Semin Orthod 2007;13:96103. Jacobson A. Psychological aspects of dentofacial aesthetics and orthognathic surgery. Angle Orthod 1984;54:1835. Ackerman MB, Ackerman JL. Smile analysis and design in the digital era. J Clin Orthod 2002;36:22136. Is iksal E, Hazar S, Akyaln S. Smile aesthetics: perception and comparison of treated and untreated smiles. Am J Orthod Dentofacial Orthop 2006;129:816. Maulik C, Nanda R. Dynamic smile analysis in young adults. Am J Orthod Dentofacial Orthop 2007;132:30715. Sarver DM. The importance of incisor positioning in the esthetic smile: the smile arc. Am J Orthod Dentofacial Orthop 2001;120:98111. Tjan AH, Miller GD, The JG. Some esthetic factors in a smile. J Prosthet Dent 1984;51:248. Vig RG, Brundo GC. The kinetics of anterior tooth display. J Prosthet Dent 1978;39:502504. Mikami I. An evaluation of the functional lip posture. Shigaku 1990;78:33976.
19. van der Geld PA, van Waas MA. The smile line, a literature search. Ned Tijdschr Tandheelkd 2003;110:3504. 20. Heravi F. Assessment of lip line in different malocclusions with video images. World J Orthod 2005;6:501. 21. Ackerman MB, Brensinger C, Landis JR. An evaluation of dynamic lip-tooth characteristics during speech and smile in adolescents. Angle Orthod 2004;74:4350. 22. Rubin LR. The anatomy of a smile: Its importance in the treatment of facial paralysis. Plast Reconstr Surg 1974;53: 3847. 23. Nanda R, Burstone CJ. JCO Interviews: Part 1 Facial Esthetics. J Clin Orthod 2007;41:7987. 24. Jacobs RM, Brodie AG. The analysis of perioral muscular accommodation in young subjects with malocclusion. Angle Orthod 1966;36:32534. 25. Peck S, Peck L, Kataja M. The gingival smile line. Angle Orthod 1992;62:91100. 26. Frindel F. Sixteen keys for building a youthful smile. Orthod Fr 2003;74:83102. 27. Ekman P, Davidson RJ, Friesen WV. The Duchenne smile: emotional expression and brain physiology II. J Pers Soc Psychol 1990;58:34253. 28. Sarver DM, Ackerman MB. Dynamic smile visualization and quantification: part 1. Evolution of the concept and dynamic records for smile capture. Am J Orthod Dentofacial Orthop 2003;124:412. 29. Tarantili VV, Halazonetis DJ, Spyropoulos MN. The spontaneous smile in dynamic motion. Am J Orthod Dentofacial Orthop 2005;128:815.
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Effects of orthodontic treatment and premolar extractions on the mandibular third molars
Mevlut Celikoglu, * Hasan Kamak, * Ismail Akkas and Husamettin Oktay
Departments of Orthodontics* and Oral and Maxillofacial Surgery, Faculty of Dentistry, Ataturk University, Erzurum, Turkey, and Department of Orthodontics, Faculty of Dentistry, Medipol University, Istanbul, Turkey
Background: The space available for an unerupted mandibular third may depend on the choice of premolar extracted. Aims: To investigate the effects of orthodontic treatment and premolar extractions on the inclinations of the mandibular third molars and the space available for their eruption, and to compare these changes with a nonextraction group. Methods: The pre- and post-treatment panoramic radiographs of 54 subjects (20 males, 34 females) were used. Eighteen of these subjects had the four first premolars extracted, 16 subjects had four second premolars extracted and 20 subjects were treated nonextraction. Changes in the inclinations and spaces available for the unerupted third molars were compared. Results: In the nonextraction group the third molars uprighted approximately 1 degree and in the second premolar extraction group the third molars uprighted 10 degrees. The spaces available for the third molars increased significantly in the first and second premolar extraction groups as compared with the space available in the nonextraction group. Conclusions: Orthodontic treatment and extraction of the second premolars improved the inclinations of unerupted third molars and the space available for their eruption into the arch. The changes in inclination and eruption space were less marked following first premolar extractions. (Aust Orthod J 2010; 26: 160164)
Received: February 2010 Accepted for publication: July 2010 Mevlut Celikoglu: mevlutcelikoglu@hotmail.com Hasan Kamak: hkamak@gmail.com Ismail Akkas: i_akkas@hotmail.com Husamettin Oktay: husamoktay@yahoo.co.uk
Introduction
Third molars are more frequently impacted than any other tooth in the dental arches. Incomplete eruption of mandibular third molars may be accompanied by infection, pain, cysts, tumours, caries and root resorption of the second molars.13 The prevailing view is that extraction of lower second premolars followed by orthodontic treatment improves the positions and angulations of unerupted third molars so that some third molars erupt fully. Factors under the control of the clinician include the premolar extracted and the mechanics used e.g. Class II traction vs molar uprighting. First premolar extractions are thought to provide less space for unerupted third molars and nonextraction treatment the least amount of space. A number of biological factors also play a part in determining whether a third molar becomes impacted or whether it erupts into position. Some of these include: growth in the length of
160
mandible, the direction of condylar growth, the pattern of eruption of the mandibular dentition, the path of eruption of the third molars and the retromolar space.46 Previous studies have investigated the angulations of the mandibular third molars after either second molar or first premolar extractions, but there have been few reports of the effects of different premolar extractions on the positions and angulations of the mandibular third molars.7,8 The aims of this study were to investigate the effects of orthodontic treatment and premolar extractions on the inclinations of the mandibular third molars and the space available for their eruption, and to compare these changes with a nonextraction group.

This retrospective study used the standardised panoramic radiographs of 54 subjects (20 males,
EFFECTS OF PREMOLAR EXTRACTIONS ON MANDIBULAR THIRD MOLARS
Nasal septum
1
Z point 2 8 RIGHT 7
ANS
Reference plane (RP) 1 Z point 2 8
LEFT
Z point
Figure 2. 1, third molar angulation to the reference plane (RP); 2, eruption space measured between the Z point and the most distal point on the outline of the second molar.
8 7
appliances were removed or within two weeks of debonding. All radiographs were taken by an experienced X-ray technician using an orthopantomograph (Planmeca Proline CC 2002, Helsinki, Finland) with a magnification factor of 1.2. The outlines of the mandible, nasal septum, hard palate and the mandibular second and third molars were traced. The outline of the nasal septum was bisected and a horizontal reference plane (RP) was drawn perpendicular to the midline bisector and through the outline of the hard palate. The angles between RP and the long axes of third molar buds and the distances between the most distal points of the second molars and the right and left Z points were measured on the pre- and post-treatment films by the same investigator (Figures 1 and 2). Three weeks after the first set of measurements, 30 films were randomly selected, remeasured and intraclass coefficients were calculated to estimate the method errors. The coefficients for all measurements fell between .92 and .96, and were considered acceptable. The changes in the eruption spaces and inclinations of the third molars to RP were compared with one-way ANOVA and Tukey post-hoc tests. The significance level was set at p < 0.05 for all tests.
Figure 1. Definition of Z point: the constructed point on the retromolar outline and the bisector of the angle between the tangents to anterior border of ramus and superior surface of the body of mandible.
34 females) treated in the Department of Orthodontics, Ataturk University. All subjects had Class I skeletal and dental relationships with moderate anchorage requirements (crowding between 6 and 9 mm) prior to orthodontic treatment. Eighteen subjects (7 males, 11 females) had four first premolars extracted (Group I), 16 subjects (6 males, 10 females) had four second premolars extracted (Group II) and 20 subjects (7 males, 13 females) had nonextraction treatment (Group III). The subjects were agematched at the start to ensure that each group started with the same potential for resorption on the anterior border of the ramus. All subjects were treated with upper and lower straight-wire appliances for at least 24 months and the second molars were not banded or bonded. Mechanics that could either hold or tip the lower first molars distally (e.g. uprighting bends, lingual arches) or mesially (e.g. Class II elastics) were not used. All pretreatment panoramic radiographs were taken within one month prior to the start of the orthodontic treatment. The post-treatment radiographs were taken either on the day the active orthodontic
Results
The subjects ages ranged from 14.20 to 15.20 years and the observation periods from 2.04 to 2.30 years. As there were no statistically significant gender differences in either the mean ages or the observation periods, the data for the males and females were
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Table I. Comparisons of the pretreatment ages and periods between the pre- and post-treatment radiographs.
Sex
Mean age (years)
SD
Observation period (years)
SD
Group I Group II Group III Group I Group II Group III
Male Female Male Female Male Female
7 11 6 10 7 13 18 16 20
14.76 14.20 14.57 15.17 14.73 15.37 14.42 14.94 15.15
1.59 2.22 0.85 0.96 1.15 0.87 1.97 0.94 0.99
0.574 0.215 0.177 0.264
2.09 2.30 2.13 2.13 2.04 2.15 2.22 2.13 2.12
0.19 0.58 0.28 0.24 0.11 0.27 0.47 0.24 0.23
0.365 0.980 0.311 0.615
Group I: first premolar extraction; Group II: second premolar extraction; Group III: nonextraction
Table II. Comparisons of the pre- and post-treatment angulations and positions of the mandibular third molars.
Group
Pretreatment Mean SD
p*
Post-treatment Mean SD
Mean difference SD
P Group I vs II
P Group I vs III
P Group II vs III
Third molar angulation (degrees) Third molar eruption space (mm)
I II III I II III
45.22 8.98 43.13 8.18 40.43 6.78 6.69 3.03 5.00 3.66 4.85 2.98
0.188
49.44 11.93 53.03 10.34 41.30 7.04 9.78 2.57 10.31 2.80 5.28 3.00
4.22 9.44 9.91 11.26 0.88 2.08 3.08 1.31 5.31 2.39 0.43 0.73
0.123
0.433
0.006
0.167
0.000
0.000
0.000
Group I: first premolar extraction; Group II: second premolar extraction; Group III: non-extraction Significant values in bold * ANOVA Tukey HSD test
combined (Table I). The pretreatment angulations of the mandibular third molars and the pretreatment space available for their eruption among the groups were also compared and no statistically significant differences were found (Table II). The Group I third molars uprighted approximately 4 degrees, the Group II molars uprighted 10 degrees and the angulations of the Group III molars unchanged (Table II). Only the difference between Group II and III was statistically significant. Extraction of the first premolars resulted in 3 mm of space for the unerupted third molars, and extraction of the second premolars provided 5 mm additional space for the third molars. The eruption space in Group III was less than 1 mm. There were significant group differences in the eruption spaces (Table II).
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Discussion
Measurements of third molar angulations on lateral cephalograms may be biased due to the difficulty in measuring the angulations of the molars on superimposed images, but these problems can be overcome if 60-degree cephalometric films are used.914 The angulations and positions of the third molars can be accurately measured on panoramic radiographs providing the same equipment is used for the entire study.1519 We used panoramic radiographs taken with the same equipment. Although some previous investigators have used the occlusal plane and/or the mandibular plane as the reference planes to assess the changes in the angulation and position of the third molars during orthodontic treatment, the occlusal plane may change during treatment and the mandibular plane may be affected by remodelling.5,16,17,2023
EFFECTS OF PREMOLAR EXTRACTIONS ON MANDIBULAR THIRD MOLARS
The palatal plane is a more stable option to these planes as it is not usually affected by orthodontic treatment.23 The treatment mechanics, in this study, were not so complex as to cause the palatal plane to tip. Our subjects had skeletal Class I malocclusions treated by levelling and aligning the arches and closing the extraction spaces. Some orthodontists2426 believe that extraction of the second molars will improve the angulation of the third molars and will cause their eruption into the arch. According to some authorities, the mandibular third molars upright between 7 and 10 degrees following extraction of either the first or second mandibular premolars.8,10,11,13,15 We found less than 7 degrees uprighting in our first premolar extraction group (4 degrees), but a similar amount of uprighting (10 degrees) in our second premolar extraction group. In the nonextraction group, there was no change in the angulation of the third molars. The greatest increase in eruption space for the third molars was found in the second premolar extraction group and the smallest increase in the nonextraction group. As the additional space for the third molars in the nonextraction group was less than 1 mm, mesial movement of the first and second molars in the second and, to a lesser extent, first premolar extraction groups must have been responsible for increasing the eruption space, and not growth changes in the retromolar area as claimed by Capelli.9 The third molars erupt between 17 and 21 years of age, but their roots are not fully formed until 18 to 25 years of age. Because our subjects were less than 20 years of age at the end of treatment we could not determine the final outcome of the third molars. It is quite possible that some third molars in unfavourable positions at the end of treatment may erupt into position and that some molars with favourable positions and angulations may become impacted.10 In a recent study, the prevalence of third molar impaction was found to be 40 per cent for the nonextraction group and 22 per cent for the first premolar extraction group.10 As expected, low rates of third molar impaction occur following first and second molar extractions.18,21,27,28 The closer an extraction is to an impacted/unerupted third molar the less likely the third molar will become impacted.20 Third molars that become impacted may be useful replacements for heavily filled and carious first or second molars.13
The types of the mechanics used during treatment appear to have an important bearing on eruption of mandibular third molars. Mechanics that move the first and second molars mesially are likely to create space for unerupted third molars, and mechanics that hold or tip the first or second molars distally are likely to result in unerupted third molars becoming impacted. In the present study, Class II elastics were not required since the subjects had Class I skeletal and dental relationships with moderate anchorage requirements. Although we did not randomly allocate our subjects to the groups or match the subjects third molar eruption status, we attempted to reduce selection bias by matching the ages of our subjects in the groups at the outset.
Conclusions
1. Orthodontic treatment and extraction of the second premolars improved the inclinations of unerupted third molars and the space available for their eruption into the arch. 2. The changes in inclination and eruption space were less marked following first premolar extractions. 3. Nonextraction treatment had little effect on the positions and angulations of the third molars.
Acknowledgment
We would like to express our sincere gratitude to Professor Zekeriya Aktrk for his help with the statistical evaluation.
Dr Mevlut Celikoglu Department of Orthodontics Faculty of Dentistry Ataturk University Erzurum, 25240 Turkey Tel (Bus.): +90.442.231 1820 Fax: +90.442.236 0945 Email: mevlutcelikoglu@hotmail.com
References
1. Halmos DR, Ellis E, 3rd, Dodson TB. Mandibular third molars and angle fractures. J Oral Maxillofac Surg 2004;62: 107681. Polat HB, Ozan F, Kara I, Ozdemir H, Ay S. Prevalence of commonly found pathoses associated with mandibular impacted third molars based on panoramic radiographs in Turkish population. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;105:417.
2.
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3.
4. 5.
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9. 10.
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12.
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Celikoglu M, Miloglu O, Kazanci F. Frequency of agenesis, impaction, angulation and related pathologies of third molar teeth in orthodontic patients. J Oral Maxillofac Surg 2010; 68:9905. Kaplan RG. Some factors related to mandibular third molar impaction. Angle Orthod 1975;45:1538. Saysel MY, Meral GD, Kocadereli I, Tas ar F. The effects of first premolar extractions on third molar angulations. Angle Orthod 2005;75:71922. Bjork A, Jensen E, Palling M. Mandibular growth and third molar impaction. Acta Odontol Scand 1956;14:23172. Dierkes DD. An investigation of the mandibular third molars in orthodontic cases. Angle Orthod 1975;45:20712. Guo XH, Qian YF, Feng QP. Effects of different premolar extraction on lower third molar eruption. Shanghai Kou Qiang Yi Xue 2007;16:3703. Capelli J, Jr. Mandibular growth and third molar impaction in extraction cases. Angle Orthod 1991;61:2239. Kim TW, Artun J, Behbehani F, Artese F. Prevalence of third molar impaction in orthodontic patients treated nonextraction and with extraction of 4 premolars. Am J Orthod Dentofacial Orthop 2003;123:13845. Erdem D, Ozdiler E, Memikoglu UT, Bas pinar E. Third molar impaction in extraction cases treated with the Begg technique. Eur J Orthod 1998;20:26370. Behbehani F, Artun J, Thalib L. Prediction of mandibular third-molar impaction in adolescent orthodontic patients. Am J Orthod Dentofacial Orthop 2006;130:4755. Artun J, Thalib L, Little RM. Third molar angulation during and after treatment of adolescent orthodontic patients. Eur J Orthod 2005;27:5906. Richardson ME. The early developmental position of the lower third molar relative to certain jaw dimensions. Angle Orthod 1970:22630. Jain S, Valiathan A. Influence of first premolar extraction on mandibular third molar angulation. Angle Orthod 2009;79: 11438.
16. Larheim TA, Svanaes DB. Reproducibility of rotational panoramic radiography: mandibular linear dimensions and angles. Am J Orthod Dentofacial Orthop 1986;90:4551. 17. Elsey MJ, Rock WP. Influence of orthodontic treatment on development of third molars. Br J Oral Maxillofac Surg 2000;38:3503. 18. Bayram M, Ozer M, Arici S. Effects of first molar extraction on third molar angulation and eruption space. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;107:1420. 19. Olive RJ, Basford KE. Transverse dento-skeletal relationships and third molar impaction. Angle Orthod 1981;51: 417. 20. Ay S, Agar U, Biaki AA, Ks ger HH. Changes in mandib ular third molar angle and position after unilateral mandibular first molar extraction. Am J Orthod Dentofacial Orthop 2006;129:3641. 21. Cavanaugh JJ. Third molar changes following second molar extractions. Angle Orthod 1985;55:706. 22. Staggers JA, Germane N. Clinical considerations in the use of retraction mechanics. J Clin Orthod 1991;25:3649. 23. Nanda RS. Reappraising Wits. Am J Orthod Dentofacial Orthop 2004;125:18A. 24. Gaumond G. Second molar germectomy and third molar eruption. 11 cases of lower second molar enucleation. Angle Orthod 1985;55:7788. 25. Huggins DG, McBride LJ. The eruption of lower third molars following the loss of lower second molars: a longitudinal cephalometric study. Br J Orthod 1978;5:1320. 26. Rindler A. Effects on lower third molars after extraction of second molars. Angle Orthod 1977;47:558. 27. Orton-Gibbs S, Crow V, Orton HS. Eruption of third permanent molars after the extraction of second permanent molars. Part 1: Assessment of third molar position and size. Am J Orthod Dentofacial Orthop 2001;119:22638. 28. Gooris CG, Artun J, Joondeph DR. Eruption of mandibular third molars after second-molar extractions: a radiographic study. Am J Orthod Dentofacial Orthop 1990;98:1617.
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Cephalometric analysis of Malay children with and without unilateral cleft lip and palate
Lillybia Emily Ebin, * Norzakiah Mohamed Zam Zam and Siti Adibah Othman
Oral Health Division, Federal Government Administrative Centre, Putrajaya* and the Department of Childrens Dentistry and Orthodontics, Faculty of Dentistry, University of Malaya, Malaysia
Objective: To investigate the craniofacial morphology of Malay children with repaired UCLP and compare the data with non-cleft Malay children. Methods: Twenty Malay children with repaired UCLP (12 boys, 8 girls; Mean age: 10.5 years) and 20 normal Malay children (8 boys, 12 girls; Mean age: 9.72 years) were recruited from the Combined Cleft Lip and Palate Clinic and the Department of Childrens Dentistry and Orthodontics, Faculty of Dentistry, University of Malaya, Malaysia. Lateral cephalometric radiographs were taken with the head orientated parallel to the floor. Thirty-one linear and angular variables were measured on the lateral cephalometric radiographs with Dolphin Imaging Software Version 10.0 (Dolphin Imaging, Chatsworth, CA, USA). The data were analysed with the Mann-Whitney U test and the level of significance was set at p < 0.05. Results: In the UCLP group, the girls had deeper overbites than the boys (p = 0.011), and in the Control group the girls had a significantly more acute cranial base angle (NSBa, p = 0.017) and a less protrusive lower lip (LL-E line, p = 0.21). The data for the boys and girls were combined. Subjects in the UCLP group had a more acute cranial base angle, shorter and more retruded maxillae and were more skeletal III than the subjects in the Control group. In the UCLP group, the upper and lower incisors were less proclined than in the Control group, the interincisal angle was more obtuse and the overjet reduced by 6 mm. There were no significant facial height differences. The nasolabial angle (Col-Sn-UL) was significantly more obtuse and the upper lip relative to the E line more retrusive in the UCLP group. There was no significant difference between the groups in facial heights or the maxillo-mandibular planes angle. Conclusion: Malay children with repaired UCLP have small, retrusive maxillae. The mandible in this group of children was of normal size and position, relative to the cranial base. Pressure from the repaired upper lip may be responsible for the retruded maxillae, retroclined incisors and obtuse nasolabial angle. (Aust Orthod J 2010; 26: 165170)
Received for publication: December 2009 Accepted: July 2010 Lillybia Emily Ebin: lillyemilyebin@yahoo.co.uk Norzakiah Mohamed Zam Zam: norzack@gmail.com Siti Adibah Othman: sitiadibah@um.edu.my
Introduction
The incidence of cleft lip, cleft palate and combinations of both conditions in Malay children is 1 in 941 live births.1 Unilateral cleft lip and palate (UCLP) is the most common type of cleft lip and palate deformity. Children with repaired cleft lip and palatal deformities have an irregular dental arch, a Class III malocclusion, a retrusive maxillae and, to a lesser extent, a retrusive mandible. Some of children with UCLP also have a marked facial deformity and masticatory dysfunction.28 Lateral cephalometric analysis is a convenient method to appraise the post-
surgery craniofacial morphology of children with UCLP, and serial cephalometric records enable the impact of treatment on the growing face to be assessed. As there have been no cephalometric studies of the Malay children with UCLP, we aimed to investigate the craniofacial morphology of Malay children with repaired UCLP and compare the data with noncleft Malay children.

Twenty Malay children (12 boys, 8 girls; Mean age: 10.5 1.79 years) with UCLP who attended the
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4. No previous orthodontic treatment. 5. Second generation Malay. Ethical and written approvals for this study were obtained from the Research Committee of the Dental Faculty of the University Malaya and from the participants and their parents. A questionnaire was used to confirm that all parents and grandparents were Malay and there had been no inter-racial marriages.
Radiographic procedures
All lateral cephalometric radiographs were taken with the same machine with the Frankfort horizontal plane parallel to the floor, with the lips in a relaxed position and the teeth in the retruded contact position. Thirty-one linear and angular variables were measured directly on the radiographs with Dolphin Imaging Software Version 10.0 (Dolphin Imaging, Chatsworth, CA, USA). The landmarks identified on the cephalometric films are shown in Figure 1.5 All measurements were carried out by the same investigator.
Figure 1. Cephalometric landmarks.
Combined Cleft Lip and Palate Clinic at the University of Malaya were selected for this study. The following criteria were used for selection: 1. Children between 7 and 13 years of age. 2. Repaired, non-syndromic complete unilateral cleft of the lip and palate. Primary surgical repair of the lip was carried out at 3 months of age and palatal surgery at 9 months of age. 3. No major orthodontic treatment and/or orthognathic surgery prior to the cephalometric examination. Subjects had palatal expansion with a quadhelix appliance prior to the alveolar bone graft 4. Second generation Malay. Twenty non-cleft subjects (8 boys, 12 girls) were selected from the patients receiving dental treatment in the Department of Childrens Dentistry and Orthodontics, Faculty of Dentistry, University Malaya. The subjects in the Control group were 9.72 1.70 years of age. The following selection criteria were used: 1. Children between 7 and 13 years of age. 2. No facial clefts and/or other facial abnormality. 3. Skeletal Class 1 malocclusion or mild skeletal Class II malocclusion with either well-aligned arches or mild crowding. The arch length discrepancy was less than 4 mm.
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Ten lateral cephalometric radiographs were selected randomly from the UCLP and Control groups, measured and remeasured a month later by the same investigator. Reproducibility was determined using the intraclass correlation coefficient (ICC). The result demonstrated that the method was highly reliable for the majority of measurements (Cronbachs alpha value > 0.8), except for Li-MP and Ar-Go, where Cronchbachs alpha values were 0.57 and 0.70, respectively. Since the Cronchbachs alpha values exceeded 0.4, Li-MP and Ar-Go were considered to have acceptable reproducibilities. A Mann-Whitney U test was used to determine if there were gender differences in each group or if the children in the UCLP and Control groups differed from each other. All calculations were made using the Statistical Package for the Social Sciences (SPSS 12.0 for Windows) and the level of significance was set at p < 0.05.
Results
There were only three gender differences in both groups. In the UCLP group, the girls had deeper overbites than the boys (p = 0.011), and in the Control group the girls had a significantly more acute
CEPHALOMETRIC ANALYSIS OF MALAY CHILDREN WITH UCLP
Table I. Comparisons of the skeletal, dental and soft tissue variables in Malay boys and girls with and without unilateral cleft lip and palate.
UCLP group (N = 20) Variables Male Mean Female Mean p Male Mean
Control group (N = 20) Female Mean p
Dentoskeletal measurements N-S-Ba (degrees) N-S-Ar (degrees) S-Ar (mm) S-N (mm) SNA (degrees) SNB (degrees) SNpg (degrees) S-Ar-Go (degrees) A-N-B (degrees) A-N-pg (degrees) SN-Mxp (degrees) MMPA (degrees) N-ANS (mm) ANS-Me (mm) N-Me (mm) S-Go (mm) Ar-Go (mm) ANS-Me/N-Me (per cent) S-Go/N-Me (per cent) Ui/Mxp (degrees) Li/Mp (degrees) Ui/Li (degrees) OJ (mm) OB (mm) ANS-PNS (mm) Ar-Go-Me (degrees) Go-Me (mm) Soft tissue measurements Col-Sn-UL (degrees) Pn-N-Sn (degrees) UL-E Line (mm) LL-E Line (mm)
Significant values in bold
128.2 124.2 35.1 64.0 77.0 77.8 78.2 145.0 -0.9 -1.2 8.8 22.0 47.7 62.7 109.3 72.9 41.3 55.9 66.4 105.3 90.3 140.1 -3.0 0.7 45.4 123.1 60.7 88.5 18.4 -1.4 2.9
126.2 120.7 31.9 60.8 79.5 80.9 80.3 149.4 -1.4 -0.8 5.8 38.4 45.1 59.2 103.4 66.8 37.6 55.9 64.6 104.4 88.6 138.7 -3.2 4.1 43.4 124.1 60.8 85.6 19.7 -1.6 4.3
0.355 0.203 0.105 0.643 0.113 0.280 0.487 0.355 0.877 0.877 0.123 0.123 0.487 0.487 0.758 0.396 0.700 0.758 0.537 0.700 0.728 0.396 0.728 0.011 0.787 0.969 0.908 0.700 0.375 0.589 0.440
131.4 126.5 30.7 61.4 81.5 76.9 76.5 145.5 4.6 4.9 8.8 25.1 45.0 58.4 101.1 66.1 39.4 55.2 65.3 112.0 98.2 124.7 3.1 2.1 43.4 121.7 57.7 100.9 17.9 3.4 3.9
128.0 124.9 31.7 59.6 83.4 79.5 79.5 144.7 4.0 4.1 7.0 25.8 44.5 57.6 100.4 66.8 37.7 55.2 66.5 113.9 96.4 123.8 3.1 2.7 45.0 122.6 59.5 105.4 18.1 1.2 1.7
0.017 0.616 0.562 0.247 0.463 0.263 0.142 0.758 0.396 0.396 0.121 0.121 0.512 0.728 0.616 0.643 0.512 0.616 0.396 0.375 0.537 0.969 0.537 0.296 0.758 0.817 0.563 0.247 0.699 0.076 0.021
cranial base angle (N-S-Ba, p = 0.017) and a less protrusive lower lip (LL-E line, p = 0.21) than the boys (Table I). In light of the few differences, data for the boys and girls were combined. There were 12 statistically significant differences between the UCLP and Control groups. Subjects in the UCLP group had a more acute cranial base angle (N-S-Ba, N-S-Ar), shorter and more retruded
maxillae (ANS-PNS, S-N-A) and were more skeletal III (A-N-B, A-N-Pg) than the subjects in the Control group. In the UCLP group, the upper and lower incisors (Ui-Mxp, Li-Mp) were less proclined than in the Control group, the interincisal angle (Ui-Li) was more obtuse and the overjet (OJ) reduced by 6 mm. There were no significant facial height differences. The nasolabial angle (Col-Sn-UL) was significantly
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Table II. Comparisons of the skeletal, dental and soft tissue variables in Malay children with and without unilateral cleft lip and palate.
UCLP group (N = 20) Variables Mean SD Mean
Control group (N = 20) SD p
Skeletal N-S-Ba (degrees) N-S-Ar (degrees) S-Ar (mm) S-N (mm) S-N-A (degrees) ANS-PNS (mm) S-N-B (degrees) S-N-Pg (degrees) S-Ar-Go (degrees) Ar-Go-Me (degrees) Go-Me (mm) A-N-B (degrees) A-N-Pg (degrees) S-N-Mxp (degrees) MMPA () N-ANS (mm) ANS-ME (mm) N-Me (mm) S-Go (mm) Ar-Go (mm) ANS-Me/N-Me (per cent) S-Go/N/Me (per cent) Dental Ui/Mxp (degrees) Li/Mp (degrees) Ui/Li (degrees) OJ (mm) OB (mm) Soft tissue Col-Sn-UL (degrees) Pn-N-Sn (degrees) UL-E Line (mm) LL-E Line (mm)
127.3 122.8 33.8 62.7 78.0 44.6 79.0 79.1 146.8 123.5 60.7 -1.1 -1.1 7.6 26.9 46.7 61.3 106.9 70.4 39.8 55.9 65.7 105.0 89.6 139.5 -3.1 2.1 103.6 18.9 -1.5 3.5
4.7 4.9 7.6 10.3 3.3 7.9 5.1 5.0 8.0 8.1 12.0 3.9 4.3 5.1 6.0 7.7 10.9 17.8 14.5 8.3 2.4 4.9 6.9 8.1 10.7 3.3 2.9 9.7 2.9 2.7 2.8
129.3 125.6 31.3 60.3 82.7 45.4 78.4 78.3 145.0 122.3 58.8 4.2 4.4 7.7 25.5 44.7 57.9 100.7 66.5 38.4 55.2 66.0 113.1 97.1 124.1 3.1 2.4 87.3 18.0 2.1 2.6
3.5 4.1 2.2 2.6 3.8 2.9 3.7 4.3 5.8 7.5 7.0 1.5 2.3 2.4 5.0 2.2 4.5 4.5 5.6 5.6 2.2 4.0 5.7 5.8 8.5 0.9 1.4 15.6 1.7 2.4 2.0
0.038 0.022 0.194 0.310 0.000 0.030 0.839 0.705 0.766 0.588 0.715 0.000 0.000 0.685 0.245 0.925 0.850 0.903 0.914 0.989 0.291 0.507 0.001 0.003 0.000 0.000 0.304 0.001 0.159 0.000 0.180
more obtuse in the UCLP group. The upper lip relative to the E line was more retrusive than in the Control group.
Discussion
In agreement with previous studies, we found the maxillae in children with UCLP were more retrusive than the maxillae in the non-cleft children.27,9 Many
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authorities attribute most or all of the deformity to the contraction of scar tissue following surgery. This view is supported by the findings that children with UCLP had normal maxillary growth before palatal surgery and that unoperated subjects with UCLP had normal anteroposterior maxillary growth.3,10 The SN-A angle in our UCLP subjects was 4.7 degrees less than S-N-A in the non-cleft subjects, but maxillary
CEPHALOMETRIC ANALYSIS OF MALAY CHILDREN WITH UCLP
length in the UCLP subjects was only 1 mm shorter than maxillary length in the non-cleft subjects. Bearing in mind that the subjects in our study were not randomly allocated to their respective groups and that we did have longitudinal records, we were unable to say how much of the deformity in our UCLP subjects was due to the morphogenetic pattern (i.e. early developmental disturbance of the maxillary growth due to the cleft) and how much was due to scar tissue contraction following surgery.4 We found small, but statistically significant, reductions in the saddle angle (N-S-Ba, N-S-Ar) in the UCLP group as compared with the Control group. This finding differs from several previous studies57 that reported cranial base angulation was increased in cleft subjects, and in other studies that it did not differ significantly from non-cleft groups.9,10 Some investigators have argued that post-surgical scarring is unlikely to affect the cranial base, and have attributed differences in the size and angulation of the limbs of the cranial base to genetic influences. Subjects with Class III malocclusions, with and without cleft palates, tend to have a smaller cranial base angle that may contribute to the mandibular prognathism.1113 Although our UCLP subjects were skeletal III (the mean ANB angle was 1.1 degrees), the skeletal relationship appears to be due to maxillary retrognathism, as demonstrated by the S-N-A angle and short maxillae rather than the size and/or position of the mandible relative to the cranial base. In agreement with Dogan et al.7 we found no statistically significant group differences in the length of the cranial base (S-N, S-Ar). Furthermore, the anterior and posterior vertical heights of our UCLP subjects were similar to those in our non-cleft group. The upper and lower incisors were retroclined, the interincisal angle obtuse and the overjet significantly less in the UCLP group as compared with the Control group. Pressure from the repaired upper lip is generally considered to be the most likely cause of the upper and lower incisor retroclination and the negative overjet.3,5,7,8 In agreement with others, an increased nasolabial angle (Col-Sn-UL) and retrusive upper lip relative to the E line accompanied the retrusive maxillae in the UCLP group. Again pressure from the repaired upper lip is believed to be responsible for the upper lip changes in this group.3 On the other hand, the projection of the nose, as indicated by
the Pn-N-Sn angle, was not significantly different between the groups.
Conclusions
Malay children with repaired UCLP have small, retrusive maxillae. The mandible in this group of children was of normal size and position, relative to the cranial base. Pressure from the repaired upper lip may be responsible for the retruded maxillae, retroclined incisors and obtuse nasolabial angle.
Acknowledgments
We would like to express our gratitude to Dr Marhazlinda Jamaludin for her statistical help and Mrs Zuraini Ghazali from the Cleft Lip and Palate Association of Malaysia (CLAPAM). This study was supported by grant from the Institute of Postgraduate Studies, University Malaya, Grant number (PPP)/P0217/ 2007A.
Dr Siti Adibah Othman Department of Childrens Dentistry and Orthodontics Faculty of Dentistry University of Malaya 50603 Kuala Lumpur Malaysia Email: sitiadibah@um.edu.my Tel: +6 03 79674567 Fax: +6 03 79674530
References
1. Oral Health Division, Ministry of Health, Malaysia. National Oral Health Survey of School Children 1997. Ministry of Health, Malaysia; 1998, p 30. Hayashi I, Sakuda M, Takimoto K, Miyazaki T. Craniofacial growth in complete unilateral cleft lip and palate:a roentgenocephalometric study. Cleft Palate J 1976;13: 21537. mahel Z, Mllerov Z. Craniofacial morphology in uniS lateral cleft lip and palate prior to palatoplasty. Cleft Palate J 1986;23:22532. Ross RB. Treatment variables affecting facial growth in complete unilateral cleft lip and palate. Part 7: An overview of treatment and facial growth. Cleft Palate J 1987;24:717. Semb G. A study of facial growth in patients with unilateral cleft lip and palate treated by the Oslo CLP Team. Cleft Palate Craniofac J 1991;28:121. ztrk Y, Cura N. Examination of craniofacial morphology in children with unilateral cleft lip and palate. Cleft Palate Craniofac J 1996;33:236.
2.
3.
4.
5.
6.
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7.
Dogan S, Onag G, Akin Y. Craniofacial development in children with unilateral cleft lip and palate. Br J Oral Maxillofac Surg 2006;44:2833. 8. Bishara SE. The influence of palatoplasty and cleft length on facial development. Cleft Palate J 1973;10:3908. 9. Bishara SE, Sierk DL, Huang KS. A longitudinal cephalometry study on unilateral cleft lip and palate subjects. Cleft Palate J 1979;16:5971. 10. Mars M, Houston WJ. A preliminary study of facial growth and morphology in unoperated male unilateral cleft lip and palate subjects over 13 years of age. Cleft Palate J 1990;27: 710.
11. Hopkin GB, Houston WJ, James GA. The cranial base as an aetiological factor in malocclusion. Angle Orthod 1968;38: 2515. 12. Moss ML. Correlation of cranial base angulation with cephalic malformations and growth disharmonies of dental interest. N.Y. State Dent J 1955;24:4524. 13. Moss ML. Malformations of the skull base associated with cleft palate deformity. Plast Reconstr Surg 1956;17:22634.
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Factors contributing to stability of protraction facemask treatment of Class III malocclusion

Yan Gu
Department of Orthodontics, Peking University School and Hospital of Stomatology, Beijing, Peoples Republic of China
Aim: To identify the craniofacial characteristics that contribute to long-term stability of protraction facemask treatment of Class III malocclusion. Methods: Fifty subjects who met the following criteria were recruited: subjects with an anterior crossbite and Wits appraisal < -3.5 mm; subjects who had been successfully treated with a protraction facemask (at the end of active orthopaedic treatment the overjet was overcorrected by more than 4 mm); the facemask treatment was started at either CS1 or CS2 and the subjects were followed until CS4; no subject had a congenital craniofacial deformity. Based on the occlusal status at CS4, three groups were identified: Stable group (SG), Unstable group (USG) and a Failed group (FG). One-way analysis of variance and Scheffes post-hoc multiple comparisons were used to analyse the differences between the groups. Stepwise discriminant analysis was used to identify the craniofacial characteristics able to predict the stability of protraction facemask treatment. Results: There were no statistically significant differences between USG and FG. The N-S-Ar was significantly larger and Co-Gn, Wits and LAFH significantly smaller in the SG group as compared with the USG and FG groups. The critical score between SG and USG was 0.368 and between USG and FG it was -0.981. Individuals with scores higher than 0.368 showed relatively stable occlusions at CS4, whereas anterior crossbites returned in individuals with scores less than -0.981 at CS4. The overall percentage of correctly classified cases was 74 per cent, with 90.0 per cent in SG and 73.3 per cent in FG. Conclusions: A severe maxillo-mandibular discrepancy, an increased vertical dimension and a prognathic mandible were unfavourable factors for long-term stability following early treatment of severe Class III subjects with protraction facemasks. (Aust Orthod J 2010; 26: 171177)
Received for publication: May 2010 Accepted: August 2010 Yan Gu: guyan99@yahoo.com
Introduction
The treatment options for Class III malocclusions include orthopaedic treatment, camouflage treatment with comprehensive fixed orthodontic appliances and orthognathic surgery. Early orthopaedic treatment may include chin cup therapy to inhibit forward mandibular growth, facemask therapy to protract the maxillae and treatment with a functional regulator.13 The timing of early orthopaedic treatment depends to some extent on the nature and severity of the skeletal discrepancy and the amount of facial growth remaining. Some clinicians are convinced that early orthopaedic treatment is often a waste of time and resources because the correction relapses, while others believe that treatment in the mixed dentition will eventually normalise a skeletal Class III disharmony.49
It is generally agreed that the treatment option chosen should address the patients particular skeletal and/or dentoalveolar discrepancy. In population groups with Class III malocclusions predominately due to maxillary skeletal retrusion, early treatment with a protraction facemask may be an effective method of treatment.1015 The major concern of protraction facemask treatment for this type of malocclusion is that the treatment may not be stable in the long-term and, eventually, surgical correction will be required. Obviously, it would be helpful to be able to identify patients with Class III malocclusions that are likely to be stable in the long-term following early orthopaedic treatment with a facemask. The aim of the current study was to identify the craniofacial features that contribute to long-term stability of protraction facemask treatment. This
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GU
(a)
(b)
Figure 1. (a) A 10 year-old girl with a protraction facemask. (b) The upper appliance, showing the protraction hooks.
study was based on 50 subjects who had orthopaedic treatment prior to the adolescent growth spurt.
2. Unstable group (USG): 15 subjects (8 females, Mean age: 9.4 1.1 years; 7 males, Mean age: 9.4 1.9 years) with an overjet and overbite between 0 and 2 mm. 3. Failed Group (FG): 15 subjects (9 females, Mean age: 9.4 1.9 years; 6 males, Mean age: 9.0 1.6 years) with an anterior crossbite i.e. overjet 0 mm.
Materials and methods Sample

Fifty subjects (28 females, Mean age: 9.3 1.7 years; 22 males, Mean age 9.3 1.4 years) who met the following criteria were recruited: 1. The subjects had an anterior crossbite with a Wits appraisal less than -3.5 mm and no functional shift. 2. The negative overjet was overcorrected with a protraction facemask and more than 4 mm of overjet was present at the end of orthopaedic treatment (Figure 1). 3. Facemask treatment was started at cervical vertebral maturation stage CS1 or CS2 and, on average, lasted 12 months. All subjects were followed until CS4.16 4. Subjects with congenital craniofacial deformities were excluded. At CV4 the subjects were classified into the following groups: 1. Stable group (SG): 20 subjects (11 females, Mean age: 9.2 2.1 years; 9 males, Mean age: 9.5 1.3 years) who had 2 mm of overjet and overbite.
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Cephalometric analysis
The cephalometric variables were measured on lateral cephalometric radiographs taken at the start of treatment (i.e. CV1 or CV2) by one investigator and then verified by another investigator (Table I). Skeletal maturation was assessed by examiners experienced in the CVM method of Baccetti and coworkers.16 Any disagreements between the two investigators were resolved to the satisfaction of both investigators.
All statistical analysis was performed with SPSS 14.0 (SPSS Inc., Chicago, IL, USA). Because of the small number of subjects available, the data from the female and male subjects were pooled. One-way analysis of variance and Scheffes post-hoc multiple comparisons were performed to compare the groups. Stepwise discriminant analysis was performed to identify the cephalometric variables able to predict the stability of protraction facemask treatment of Class III malocclusion.
STABILITY OF FACEMASK TREATMENT
Table I. Comparison of the cephalometric variables.
Measurements
SG (N = 20)
USG (N = 15)
FG (N = 15)
p*
p SG vs USG
p SG vs FG
p USG vs FG
Craniofacial N-S-Ar Maxilla A-NFH Co-A Mandibular Pg-NFH Ar-Go Go-Me Co-Gn Go angle
124.7 5.1 -4.5 2.3 80.2 4.6 -5.8 46.9 63.8 108.3 125.1 6.7 5.6 4.4 6.5 5.4
119.0 4.1 -3.3 1.8 80.6 4.6 -2.6 50.4 66.6 114.0 128.9 4.4 5.5 4.9 6.4 5.2
120.3 3.9 -5.2 2.4 81.7 3.6 -7.1 48.5 67.4 114.3 130.5 6.2 4.1 6.6 5.7 5.6
0.001 0.057 0.619 0.111 0.161 0.125 0.010 0.015 0.001 0.000 0.794 0.066 0.749 0.434 0.262 0.238 0.104
0.002 0.261 0.973 0.290 0.421 0.325 0.040 0.129 0.007 0.009 0.796 0.443 0.749 0.466 0.791 0.505 0.990
0.014 0.648 0.631 0.829 0.933 0.163 0.028 0.021 0.003 0.000 1.000 0.069 0.949 0.982 0.262 0.271 0.174
0.809 0.062 0.794 0.130 0.674 0.925 0.991 0.743 0.959 0.106 0.806 0.596 0.919 0.617 0.663 0.911 0.171
Maxilla-mandibular relationship Wits -7.8 2.5 Vertical LAFH S-Go FH-MP Dental U1-SN L1-FH Soft tissue UL E Line LL E Line Nasolabial angle 60.0 3.4 75.5 5.9 26.9 5.8 104.2 9.2 63.2 8.4 -1.6 2.4 1.9 2.9 103.0 12.9
-11.6 3.2 63.8 4.1 76.8 6.3 29.3 4.9 106.8 12.7 64.8 8.4 -1.1 2.0 3.0 2.6 102.4 10.9
-11.9 4.1 66.5 2.6 75.5 3.9 31.4 5.8 105.3 6.4 63.9 7.0 -0.4 2.0 3.5 3.3 110.6 10.3
* ANOVA Significant values in bold (p < 0.05)
Method error
Thirty randomly chosen lateral cephalometric radiographs were digitised and remeasured two weeks apart and Dahlbergs method errors calculated.17 The combined error did not exceed 0.3 mm for the linear variables and 0.5 degree for the angular variables.
Results
The cranial base angle (N-S-Ar) was significantly larger in the SG group (Mean: 124.7 degrees) as compared with the USG (Mean: 119.0 degrees) and FG (Mean: 120.3 degrees) groups. There were no statistically significant differences between the FG and USG groups (Table I).
There were no significant differences in maxillary position, as evaluated by the perpendicular distance from A point to the perpendicular to Frankfort horizontal through N (A-NFH) and the mandibular condyle to A point distance (Co-A). In the mandible, the gonial angle (Go angle) was significantly larger in FG than that in SG (Table I). Mandibular length (Co-Gn) was significantly larger in the USG and FG as compared with SG. The mean values for SG, USG and FG were 108.3 mm, 114.0 mm and 114.3 mm, respectively. However, the mean values of Ar-Go and Go-Me were similar among the three groups (Table I). The maxillo-mandibular discrepancy in the SG was significantly smaller (-7.8 mm) than the
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Table II. Discriminant analysis.
Table III. Group classification based on the discriminant analysis.
Predictive variables
Standardised canonical discriminant function coefficients
Unstandardised canonical discriminant function coefficients
Group
Predicted group membership SG USG FG Total
N-S-Ar Wits LAFH Constant
0.633 0.494 -0.753
0.141 0.151 -0.218 -1.859
Individual score = 0.141 x (N-S-Ar) + 0.151 x (Wits) - 0.218 (LAFH) - 1.859 Group centroids: SG = 1.471; USG = -0.735; FG = -1.227
Original count 1 18 2 2 3 0 Per cent 1 90.0 2 13.3 3 0
2 8 4 10.0 53.3 26.7
0 5 11 0.0 33.3 73.3
20 15 15 100.0 100.0 100.0
74 per cent of the original cases were correctly classified
maxillo-mandibular relationships in both the USG (-11.6 mm) and FG (-11.9 mm) groups (Table I). The mean lower anterior facial height (LAFH) in SG, USG and FG were 60.0 mm, 63.8 mm and 66.5 mm, respectively. Significant differences were noted when SG was compared with USG and the FG (Table I). There were no significant differences in the Frankfort mandibular plane angle (FH-MP) between the groups. There were no statistically significant group differences in the inclinations of the incisors (U1-SN, L1-FH) or the soft tissue measurements (UL E line, LL E Line, Nasolabial angle).
In the present study, the percentage of correctly classified cases based on the above equation was 74 per cent, with 90.0 per cent in the Stable Group and 73.3 per cent in the Failed Group (Table III).
Discussion
Previous studies have reported that Class III malocclusions become more pronounced with growth.18 Therefore, orthopaedic treatment of skeletal Class III malocclusions in either the mixed or the deciduous dentition has received increasing attention. Treatment timing is, however, complicated due to the variability in craniofacial growth and the different responses to this form of treatment. Confidence in early treatment of these difficult malocclusions has been shaken by malocclusions that, although successfully corrected in childhood, relapsed in adolescence. Discriminant analysis had been used in previous studies to predict the outcomes to different forms of Class III treatment.1926 Some previous studies have graded the treatment outcomes into two groups: a successfully treated group and a failed or relapse group. In our experience a twopoint method does not include all responses to early orthopaedic treatment. We found a borderline group of cases with close to zero overbite and overjet that were not covered by a simple two-point scheme, so we graded the occlusal outcomes at CV4 into Stable, Unstable and Failed groups. We also decided to use cervical vertebral maturation to describe the developmental status of our subjects because chronological age is associated with wide variation in the timing of
Discriminant analysis
Stepwise analysis was performed to generate three variables: Cranial base angle (N-S-Ar), Wits and lower anterior facial height (LAFH). Unstandardised canonical discriminant function coefficients of the selected variables, along with a constant, led to the following equation: Individual Score = 0.141 x (N-S-Ar) + 0.151 x (Wits) - 0.218 (LAFH) - 1.859 (Table II). The critical score between the SG and USG was 0.368 and the critical score between USG and FG was -0.981. The results suggest if a patients score is higher than 0.368, early treatment with a protraction facemask would result in a relatively stable occlusion at the cervical vertebral maturation stage CV4. On the other hand, if an individuals score is less than -0.981, the incisors are likely to relapse into a crossbite by the end of adolescent growth spurt (CV4).
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spurts in facial growth. Cervical vertebral maturation, on the other hand, is regarded as an acceptable indicator of skeletal maturity and the adolescent growth spurt.16,2728 A protraction facemask has become an accepted method of early orthopaedic treatment of skeletal Class III malocclusions because the majority of these malocclusions have a maxillary skeletal retrusion.1415 However, as treatment with a facemask usually ceases in the mixed dentition and further facial growth will occur, these subjects should be followed to determine if additional orthodontic and/or surgical treatment is needed. The stability of protraction facemask treatment depends, to a large extent, on the magnitude and direction of late growth in the face. Previous longitudinal studies have demonstrated that the adolescent peak in mandibular growth in Class III subjects occurs between cervical vertebral maturation stages 3 and 4 (CS3 to CS4). Between the late maturation stages of CS4 and CS6, increases in mandibular length in females and males with Class III malocclusions were two to three times more than in subjects with normal occlusion. Furthermore, increases in the vertical dimension become apparent at late maturation stages.29 In the present study, an anterior crossbite at follow-up did not automatically mean that surgical intervention was required: some of these patients were treated with additional orthodontic treatment. We used skeletal, dental and soft tissue measurements that may influence the outcome of treatment. The first variable extracted by the discriminant analysis was the cranial base angle (N-S-Ar). We found that an acute N-S-Ar angle was associated with a prognathic mandible and was a good indicator that protraction facemask treatment was unlikely to be successful in the long-term. Others have reported that the cranial base angle becomes more acute in growing Class III subjects and, as a result, a prognathic profile develops with age.13,3033 It is interesting to note that neither maxillary position nor maxillary size significantly influenced the longterm treatment outcome with a protraction facemask. Some investigators have reported that the mandible in skeletal Class III malocclusions is larger, but similar in shape, to an average-size mandible.3435 Other investigators have reported that although mandibular length was increased in Class III malocclusions, an obtuse gonial angle was the major contributor to the
prognathism.911,13,36 Our findings are in agreement with this latter view: we found small, but statistically significant, differences in the gonial angle and the length of the mandibular body (Co-Gn) between SG and FG. In the present study, no parameters describing the position and size of the mandible were identified in the discriminant model. Although our findings indicated that mandibular shape (Co-Gn, Go angle) were important factors in occlusal stability, the discriminant analysis disclosed that the maxillomandibular relationship, as assessed by the Wits appraisal, was a more important factor for long-term stability of facemask treatment. In agreement with previous studies, we confirmed that increases in lower anterior face height during and following adolescence are likely to lead to unfavourable occlusal changes following facemask treatment.911,13,29,37 The mean lower anterior facial height in the FG was signicantly larger than the lower anterior face height in the SG. The predictive model developed in the present study primarily identifies the good responders to early treatment with a protraction facemask, but it does not distinguish between surgical and non-surgical patients. In the Failed and Unstable groups alternative orthodontic therapies should be considered. Class III malocclusion is a heterogeneous and complex anomaly with a distinct craniofacial pattern, established early in development. It often becomes more severe with age, leading to a marked skeletal sagittal imbalance. Due to the fact that some Class III malocclusions deteriorate over time, there is a need to identify patients who would benefit from early treatment of the discrepancy. Although this study indentified some cephalometric measurements that can be used to predict the outcome of facemask treatment, the model would be improved with a larger sample. This suggests that a multicentre study and the addition of transverse parameters, which are often features of maxillary hypoplasia, may improve the predictive power of the discriminant model.
Conclusions
A severe maxillo-mandibular discrepancy, an increased vertical dimension and a prognathic mandible were unfavourable factors for long-term stability following early treatment of severe Class III subjects with protraction facemasks.
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The ability to predict the outcome of facemask treatment at the mixed dentition stage is an important advance for orthodontists.
Dr Yan Gu Department of Orthodontics Peking University School and Hospital of Stomatology No. 22 ZhongGuanCun Nandajie HaiDian District, Beijing 100081 Peoples Republic of China Email: guyan99@yahoo.com
References
1. Frnkel R. Maxillary retrusion in Class III and treatment with the function corrector III. Trans Eur Orthod Soc 1970: 24959. Sakamoto T, Iwase I, Uka A, Nakamura S. A roentgenocephalometric study of skeletal changes during and after chin cup treatment. Am J Orthod 1984;85:34150. Macdonald KE, Kapust AJ, Turley PK. Cephalometric changes after correction of Class III malocclusion with maxillary expansion/facemask therapy. Am J Orthod Dentofacial Orthop 1999;116:1324. Campbell PM. The dilemma of Class III treatment. Early or late? Angle Orthod 1983;53:17591. Joondeph DR. Early orthodontic treatment. Am J Orthod Dentofacial Orthop 1993;104:199200. 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;121:8492. Tollaro I, Baccetti T, Franchi L. Mandibular skeletal changes induced by early functional treatment of Class III malocclusion: a superimposition study. Am J Orthod Dentofacial Orthop 1995;108:52532. Sugawara J, Asano T, Endo N, Mitani H. Long-term effects of chincap therapy on skeletal prole in mandibular prognathism. Am J Orthod Dentofacial Orthop 1990;98: 12733. Jacobson A, Evans WG, Preston CB, Sadowsky PL. Mandibular prognathism. Am J Orthod 1974;66:14071. Guyer EC, Ellis E, McNamara JA Jr, Behrents RG. Components of Class III malocclusion in juveniles and adolescents. Angle Orthod 1986;56:730. Tollaro I, Baccetti T, Bassarelli V, Franchi L. Class III malocclusion in the deciduous dentition: a morphological and correlation study. Eur J Orthod 1994;16:4018. Williams S, Andersen C. The morphology of the potential Class III skeletal pattern in the growing child. Am J Orthod 1986;89:30211. Battagel JM. The aetiological factors in Class III malocclusion. Eur J Orthod 1993;15:34770. Ngan P, Hagg U, Yiu C, Wei H. Treatment response and long-term dentofacial adaptations to maxillary expansion and protraction. Semin Orthod 1997;3:25564.
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15. Westwood PV, McNamara JA, Baccetti T, Franchi L, Sarver DM. Long-term effects of Class III treatment with rapid maxillary expansion and facemask therapy followed by xed appliances. Am J Orthod Dentofacial Orthop 2003;123: 30620. 16. Baccetti T, Franchi L, McNamara JA. The cervical vertebral maturation (CVM) method for the assessment of optimal treatment timing in dentofacial orthopedics. Semin Orthod 2005;11:11929. 17. Dahlberg G. Statistical methods for medical and biological students. London: Allen and Unwin, 1940;12232. 18. Mitani H, Sato K, Sugawara J. Growth of mandibular prognathism after pubertal growth peak. Am J Orthod Dentofacial Orthop 1993;104:33036. 19. Battagel JM. Predictors of relapse in orthodontically treated Class III malocclusions. Br J Orthod 1994;21:113. 20. Franchi L, Baccetti T, Tollaro I. Predictive variables for the outcome of early functional treatment of Class III malocclusion. Am J Orthod Dentofacial Orthop 1997;112:806. 21. Tahmina K, Tanaka E, Tanne K. Craniofacial morphology in orthodontically treated patients of Class III malocclusion with stable and unstable treatment outcomes. Am J Orthod Dentofacial Orthop 2000;117:68190. 22. Moon YM, Ahn SJ, Chang YL. Cephalometric predictors of long-term stability in the early treatment of Class III malocclusion. Angle Orthod 2005;75:74753. 23. Stellzig-Eisenhauer A, Lux CJ, Schuster G. Treatment decision in adult patients with Class III malocclusion: Orthodontic therapy or orthognathic surgery? Am J Orthod Dentofacial Orthop 2002;122:2738. 24. Baccetti T, Franchi L, McNamara JA. Cephalometric variables predicting the long-term success or failure of combined rapid maxillary expansion and facial mask therapy. Am J Orthod Dentofacial Orthop 2004;126: 1622. 25. Tahmina K, Tanaka E, Tanne K. Craniofacial morphology in orthodontically treated patients of Class III malocclusion with stable and unstable treatment outcomes. Am J Orthod Dentofacial Orthop 2000;117:68190. 26. Ghiz MA, Ngan P, Gunel E. Cephalometric variables to predict future success of early orthopedic Class III treatment. Am J Orthod Dentofacial Orthop 2005;127:3016. 27. Flores-Mir C, Burgess CA, Champney M, Jensen RJ, Pitcher MR, Major PW. Correlation of skeletal maturation stages determined by cervical vertebrae and hand-wrist evaluations. Angle Orthod 2006;76:15. 28. Gu Y, McNamara JA. Mandibular growth changes and cervical vertebral maturation a cephalometric implant study. Angle Orthod 2007;77:94752. 29. Baccetti T, Reyes BC, McNamara JA. Craniofacial changes in Class III malocclusion as related to skeletal and dental maturation. Am J Orthod Dentofacial Orthop 2007;132: 171.e1171.e12. 30. Ellis E, McNamara JA, Jr. Components of adult Class III malocclusion. J Oral Maxillofac Surg 1984;42:295305. 31. Bjrk A. Some biological aspects of prognathism and occlusion of teeth. Acta Odontol Scand 1950;9:140. 32. Rakosi T. The significance of roentgenographic cephalometrics in the diagnosis and treatment of Class III malocclusions. Trans Eur Orthod Soc 1970:15570. 33. Baccetti T, Antonini A, Franchi L, Tonti M, Tollaro I. Glenoid fossa position in different facial types: a cephalometric study. Br J Orthod 1997;24:559.
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34. Stapf W. A cephalometric roentgenographic appraisal of the facial pattern in Class III malocclusions. Angle Orthod 1948;18:203. 35. Smith A, Chambers F. Mandibular prognathism corrected by newly devised ostectomy of the ramus. Am J Dent Assoc 1962;64:32844.
36. Chang HP, Kinoshita Z, Kawamoto T. Craniofacial pattern of Class III deciduous dentition. Angle Orthod 1992;62:13944. 37. Miyajima K, McNamara JA, Jr., Sana M, Murata S. Iizuka T. An estimation of craniofacial growth in the untreated Class III female with anterior crossbite. Am J Orthod Dentofac Orthop 1997;112:42534.
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Effects of rapid-slow maxillary expansion on the dentofacial structures

Nihat Kilic* and Hsamettin Oktay
Department of Orthodontics, Faculty of Dentistry, Atatrk University, Erzurum, Turkey* and Department of Orthodontics, Faculty of Dentistry, Istanbul Medipol University, Istanbul, Turkey
Background: To date, no study has determined if rapid followed by slow maxillary expansion (also termed semi-rapid expansion) has the same effects on the dentofacial skeleton as rapid maxillary expansion. Objective: To determine the vertical and sagittal changes in the facial skeleton during and following rapid then slow maxillary expansion (R-SME). Methods: Bonded maxillary expansion appliances were used to separate the maxillae over six days by activating the midline screws twice a day. The screws were then activated three times a week until sufficient expansion was obtained (Mean: 3.4 months) and used as retainers for six months. Cephalometric measurements at the start of expansion (T1), end of expansion (T2) and end of retention (T3) were compared with paired t-tests. Pearson correlation coefficients were used to determine the associations between the expansion (dental and skeletal) and the cephalometric changes. Results: The maxillae moved forward a small, but statistically significant, extent during expansion. The upper molars were extruded and the mandible rotated downward and backward. Although the vertical height of the facial skeleton (SN/GoMe, S-Go, N-Me, ANS-Me) increased significantly during expansion, the changes were small and highly variable. Some dimensions (SN/GoMe) relapsed during retention, while others (S-Go, N-Me) increased. Conclusions: Rapid then slow maxillary expansion caused a small, but statistically significant, forward movement of the upper facial skeleton, a small downward and backward rotation of the mandible and a small increase in face height. The changes were similar to those found during rapid maxillary expansion. (Aust Orthod J 2010; 178183)
Received for publication: March 2010 Accepted: August 2010 Nihat Kilic: drnkilic@yahoo.com Husamettin Oktay: hoktay@atauni.edu.tr
Introduction
Transverse constriction of the maxillae with an accompanying posterior crossbite is frequently treated by rapid maxillary expansion (RME).1 The prevalence of a posterior crossbite ranges from 2.7 to 23.3 per cent depending on the population group,15 but not all posterior crossbites are accompanied by a narrow upper facial skeleton and deep palatal vault.6 Rapid maxillary expansion separates the maxillae over a few days and the expanded midpalatal suture eventually fills with new bone. This procedure increases the widths of the maxillary arch and the upper facial skeleton.7 Rapid maxillary separation is usually carried out with an appliance attached to the maxillary first molars and premolars or deciduous molars, and activated by a screw.7,9 The force produced by the RME appliance
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is applied to the teeth, which act as handles separating the maxillae and bending the alveolar processes outwards before the anchor teeth have time to move through the alveolar bone.8 While significant relapse may be found in cases treated by conventional maxillary expansion appliances, RME is claimed to be more stable.7,10,11 It has also been claimed that slow separation of the maxillae produces less tissue resistance in the nasomaxillary complex and a more stable result.8,12 Iseri and Ozsoy separated the maxillae over a few days and then used slow expansion until adequate dental expansion had been obtained.13 They called this method of rapid expansion followed by slow expansion semi-rapid expansion. They reported that this simple method of varying the activation rate of the appliance resulted in significant skeletal and dental expansion in older adolescents and adults, and satisfactory stability in the long-term.13
RAPID-SLOW MAXILLARY EXPANSION
Figure 1. The bonded acrylic R-SME appliance.
Conventional banded RME appliances are widely used, and lateral cephalometric studies indicate that during expansion the maxillae move anteriorly, the maxillary posterior teeth move downward and the mandible rotates downward and backward. These changes are usually accompanied by an increase in the height of the face, an increase in the overjet and reduced overbite.7,10,11,14 In this preliminary study we aim to determine the sagittal and vertical changes in the facial skeleton following rapid-slow expansion (R-SME). The underlying hypothesis is that a short period of rapid expansion followed by slow expansion will result in similar sagittal and vertical skeletal changes as rapid maxillary expansion.

Lateral cephalometric radiographs of 20 subjects (15 females, 5 males), treated with bonded maxillary expansion appliances in the Department of Orthodontics, Faculty of Dentistry, Atatrk University, were used in this study. All subjects had a severe maxillary arch deficiency, a bilateral posterior crossbite and a deep palatal vault. No subject had previous orthodontic treatment. The subjects had a mean age of 13.44 0.98 years at the start of the study. Informed consent was obtained from the parents of all subjects. The acrylic bonded expansion appliance and the activation schedule used in this study were identical to
those used by Iseri and Ozsoy (Figure 1).13 In brief, the appliance was a tooth- and tissue-born rigid, acrylic appliance with posterior bite planes, bonded to the upper posterior teeth. The appliances were activated twice a day for 57 days, i.e. one quarter turn in the morning and a quarter turn in the evening, until the midpalatal suture had opened. Each quarter turn of the screw produced 0.2 mm expansion. When the midpalatal suture had opened (this was confirmed with an occlusal radiograph), the appliance was debonded and used as a removable expansion appliance. The appliance was then activated three times a week (i.e. 0.6 mm per week) until adequate expansion was achieved. It was then used as a retainer. The mean period of expansion was 3.41 0.81 months and the mean length of retention was 6.02 0.17 months. The maxillary intermolar distance was measured on stone casts taken before expansion (T1), after expansion (T2) and after retention (T3). Lateral and posteroanterior cephalometric radiographs were taken with a Siemens Nanodor 2 cephalostat (Siemens AG, Munich, Germany). During the exposure the subjects adopted a habitual, unstrained body posture with the teeth in the intercuspal position and the lips at rest. The cephalometric radiographs were taken before expansion (T1), after 3.41 0.81 months expansion (T2) and after 6.02 0.17 months retention (T3). The radiographs were scanned at 144 dpi with an Epson Expression 1860 Pro scanner (Seiko Epson Corp., Nagano-Ken, Japan) and the parameters shown in Figure 2 measured with
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(PP/SN). We concluded that the method of measurement met the requirements of the study. The mean maxillary dental expansion was 7.53 1.47 mm and mean skeletal expansion was 2.80 1.06 mm. The cephalometric measurements at T1, T2 and T3 are given in Table I and comparisons of the T2-T1, T3-T1 and T3-T2 measurements in Table II. Statistically significant changes were observed for all measurements except OP/SN and U1-SN angles after maxillary expansion. The SNB, PP/SN, interincisal angles and overbite decreased significantly during maxillary expansion (T2-T1), and the remaining measurements increased significantly during this period. During the retention period (T3-T2), SNA, ANB, SN/GoMe and overjet decreased significantly, whereas SNB, S-Go, and L1-GoMe and overbite increased significantly. There were no statistically significant changes T3-T2 in the remaining measurements. According to the overall changes (T3-T1), the maxillae moved forward (SNA), the mandible rotated downward and backward (SN-GoMe, SNB), the vertical dimensions of the face (N-Me, ANS-Me) and the overjet increased, the overbite decreased, the palatal plane rotated counterclockwise (PP/SN), the lower incisors protruded (L1-GoMe) and distance of the maxillary first molar from the palatal plane (Ms-PP) increased significantly. No significant correlations were found between the amounts of expansion (maxillary dental and skeletal expansion) and either the sagittal or the vertical changes. The correlation coefficients ranged from -.325 to .301.
Figure 2. The measurements used in this study.
Quick Ceph 2000 (Quick Ceph Systems Incorporated, San Diego, CA, USA). The basal maxillary width, the distance between right and left maxillare points (the points located at the depths of the concavities on the lateral maxillary contours, at the junctions of the maxillae and the zygomatic buttresses) was measured on the T1, T2 and T3 posteroanterior cephalometric films.
Statistical methods
Fifteen radiographs were randomly selected and remeasured two weeks later by the same investigator. Intraclass correlation coefficients were calculated to assess the reliability of the method.15 The T2-T1, T3T1 and T3-T2 differences were compared with paired t-tests and associations between the amounts of expansion (dental and skeletal) and the vertical and sagittal changes were determined with Pearsons correlation coefficients. All statistical analyses were performed using the SPSS software package (SPSS for Windows 98, version 10.0, SPSS Incorporated, Chicago, IL, USA).
Discussion
We aimed to determine the vertical and sagittal changes in the facial skeleton during and following R-SME. We found the maxillae moved forward a small, but statistically significant, extent during expansion and the mandible rotated downward and backward. Although the vertical height of the facial skeleton increased significantly during expansion, the changes were small and variable, and may not be clinically significant. Some of the height dimensions relapsed during retention, while others increased, possibly the result of continued vertical growth in the dentofacial skeleton. The sagittal and vertical changes following R-SME were similar to those following RME.
Results
The coefficients of reliability for the cephalometric measurements ranged from .994 (N-Me) to .932
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Table 1. The cephalometric measurements before expansion (T1), after expansion (T2) and after retention (T3).
T1 Mean SD Mean
T2 SD Mean
T3 SD
Skeletal measurements SNA SNB ANB SN/GoMe OP/SN PP/SN S-Go N-Me ANS-Me Dental measurements Ms-PP Mi-GoMe U1-SN L1- GoMe Interincisal Overjet Overbite Soft tissue measurements Ls-E Line Li-E Line
78.09 74.63 3.46 39.93 19.95 9.26 75.46 123.35 72.58 24.76 31.82 100.98 89.79 129.31 3.85 0.93 -3.68 -1.59
4.01 3.99 2.53 6.61 5.06 3.16 5.23 5.54 5.02 2.04 1.84 7.31 5.46 7.97 2.52 1.39 2.89 3.64
79.37 73.68 5.67 41.08 20.10 8.54 76.31 125.88 75.11 25.37 32.21 101.56 90.18 127.20 4.98 -0.69 -3.14 -1.04
4.38 4.02 2.50 6.71 5.02 2.53 5.34 5.73 5.10 2.26 1.81 6.82 5.57 8.07 2.53 1.73 3.45 4.09
79.15 74.16 5.00 40.59 19.74 8.52 77.00 126.27 75.09 25.46 32.08 101.42 90.49 127.25 4.48 0.02 -3.20 -1.56
4.28 4.43 2.52 7.00 5.05 3.16 4.72 5.82 4.76 2.22 1.97 7.06 5.62 7.79 2.75 1.50 3.44 3.95
The SNA angle increased approximately 1.3 degrees after maxillary expansion and relapsed 0.22 degree during the retention period: the net change was 1.06 degree. The increase in the SNA angle indicates that the maxillae moved forward during R-SME. The majority view is that RME produces significant forward movement of the maxillae,10,14,1620 although some researchers have reported less forward movement after RME21 and R-SME.22 Our finding that SNA remained unchanged during retention is similar to the findings reported by others who used rigid acrylic bonded expansion appliances and either slow expansion or rapid followed by slow expansion.12,13 According to these authors, there is less tissue resistance in the nasomaxillary complex during R-SME, anteroposterior movement of maxillae is controlled and the results are relatively stable. The SNB angle decreased 1 degree after R-SME, but approximately 0.5 degree returned during the retention period, resulting in a net decrease of only 0.5 degree.7,20,23,24 When this reduction and the
increases in the ANB angle, SN/GoMe, N-Me and ANS-Me are considered, it appears the mandible had moved downward and backward after maxillary expansion.7,10,16,17,20,2428 The changes in mandibular position were small and may not be permanent. The vertical increases in the facial skeleton (e.g. N-Me and ANS-Me) and backward rotation of the mandible also resulted in a small, but statistically significant increase in the overjet and decrease in the overbite: confirming what others have observed at the end of maxillary expansion.4,7,10,16,1719,21,28,29 Our subjects had an anterior open bite at the end of expansion. During retention, however, the overjet reduced to 4.48 mm (from 4.98 mm) and the overbite increased to an edge-to-edge occlusion. During expansion we observed significant increases in the positions of the maxillary (Ms-PP) and mandibular molars (Mi-GoMe), confirming Ozsoys observation of similar changes after R-SME in older adolescents and adults.30 Buccal tipping of the maxillary teeth during expansion and contact with the opposing
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Table II. Comparison of the cephalometric measurements.
T2-T1 Mean difference SD difference Mean difference
T3-T1 SD difference Mean difference
T3-T2 SD difference
T2-T1
T3-T1
T3-T2
Skeletal measurements SNA 1.28 SNB -0.95 ANB 2.21 SN/GoMe 1.16 OP/SN 0.15 PP/SN -0.72 S-Go 0.85 N-Me 2.53 ANS-Me 2.53 Dental measurements Ms-PP 0.61 Mi-GoMe 0.39 U1-SN 0.58 L1- GoMe 0.39 Interincisal -2.11 Overjet 1.13 Overbite -1.61 Soft tissue measurements Ls-E Line 0.54 Li-E Line 0.55
0.82 0.91 0.99 1.25 1.53 1.37 1.28 1.48 1.70 0.84 0.74 2.20 0.43 2.45 1.25 1.15 1.18 1.16
1.06 -0.47 1.54 0.66 -0.21 -0.74 1.55 2.92 2.51 0.70 0.26 0.44 0.69 -2.06 0.64 -0.91 0.48 0.03
0.55 0.87 0.75 1.24 1.58 1.38 1.73 1.93 1.75 0.85 0.99 2.02 0.48 2.66 1.08 0.80 1.23 1.72
-0.22 0.48 -0.68 -0.49 -0.36 -0.02 0.70 0.39 -0.02 0.09 -0.13 -0.14 0.31 0.05 -0.50 0.70 -0.06 -0.53
0.35 0.80 0.81 0.99 1.20 1.20 1.29 1.76 1.17 0.72 1.11 0.83 0.37 1.44 0.84 0.87 0.77 1.15
0.000 0.000 0.000 0.001 0.645 0.029 0.008 0.000 0.000 0.004 0.030 0.254 0.001 0.001 0.001 0.000 0.049 0.047
0.000 0.027 0.000 0.027 0.559 0.027 0.001 0.000 0.000 0.002 0.254 0.336 0.000 0.003 0.017 0.000 0.099 0.949
0.010 0.015 0.001 0.040 0.197 0.956 0.026 0.334 0.940 0.585 0.608 0.476 0.002 0.878 0.016 0.002 0.711 0.054
teeth is the most likely reason for the increases in the vertical measurements during R-SME.26 There were no significant changes in the inclinations of the upper incisors during expansion or during retention, however there were small but significant increases in the inclinations of the lower incisors to the mandibular plane. Similar changes were reported by Ozsoy after R-SME.30 We attribute the changes in the lower incisors to the development of an anterior open bite and a lower tongue position after expansion.18 We used adolescents for this study because this is the usual age group for orthodontic treatment and we wanted the permanent molars and premolars to be fully erupted. We also used bonded expansion appliances with occlusal coverage because some authorities consider that bonded appliances may have a greater orthopaedic effect and less tipping of the anchor teeth than conventional RME appliances.
182
Conclusions
R-SME caused a small, but statistically significant, forward movement of the upper facial skeleton, a small downward and backward rotation of mandible and a small increase in face height. The changes were highly variable and no significant associations were found between the amount of expansion and the sagittal and vertical changes. R-SME produced similar dentofacial changes to those found during and following conventional RME.
Dr Nihat Kilic Atatrk niversitesi Dis Hekimligi Fakltesi Ortodonti Anabilim Dal 25240 Erzurum
Turkey Email: drnkilic@yahoo.com Tel: +90.442.3411807 Fax: +90.442.2360945 - 2312270
References
1. 2. McNamara JA. Maxillary transverse deficiency. Am J Orthod Dentofacial Orthop 2000;117:56770. Thilander B, Pena L, Infante C, Parada SS, de Mayorga C. Prevalence of malocclusion and orthodontic treatment need in children and adolescents in Bogot, Colombia. An epidemiological study related to different stages of dental development. Eur J Orthod 2001;23:15367. Kurol J, Berglund L. Longitudinal study and cost-benefit analysis of the effect of early treatment of posterior crossbites in the primary dentition. Eur J Orthod 1992;14: 1739. Sandikcioglu M, Hazar S. Skeletal and dental changes after maxillary expansion in the mixed dentition. Am J Orthod Dentofacial Orthop 1997;111:3217. Thilander B, Lennartsson B. Study of children with unilateral posterior crossbite, treated and untreated, in the deciduous dentition-occlusal and skeletal characteristics of significance in predicting the long-term outcome. J Orofac Orthop 2002;63:37183. Allen D, Rebellato J, Sheats R, Ceron AM. Skeletal and dental contributions to posterior crossbites. Angle Orthod 2003;73:51524. Bishara SE, Staley RN. Maxillary expansion: clinical implications. Am J Orthod Dentofacial Orthop 1987;91:314. Memikoglu TU, seri H. Effects of a bonded rapid maxillary expansion appliance during orthodontic treatment. Angle Orthod 1999;69:2516. Kilic N, Oktay H. Effects of rapid maxillary expansion on nasal breathing and some naso-respiratory and breathing problems in growing children: a literature review. Int J Pediatr Otorhinolaryngol 2008;72:1595601. Velazquez P, Benito E, Bravo LA. Rapid maxillary expansion. A study of the long-term effects. Am J Orthod Dentofacial Orthop 1996;109:3617. Gurel HG, Memili B, Erkan M, Sukurica Y. Long-term effects of rapid maxillary expansion followed by fixed appliances. Angle Orthod 2010;80:59. Mew JR. Semi-rapid maxillary expansion. Br Dent J 1977; 143:3016. seri H, zsoy S. Semirapid maxillary expansion a study of I long-term transverse effects in older adolescents and adults. Angle Orthod 2004;74:718. Oliveira NL, Da Silveira AC, Kusnoto B, Viana G. Threedimensional assessment of morphologic changes of the maxilla: a comparison of 2 kinds of palatal expanders. Am J Orthod Dentofacial Orthop 2004;126:35462.
3.
4.
5.
6.
7. 8.
9.
10.
11.
12. 13.
14.
15. Houston WJ. The analysis of errors in orthodontic measurements. Am J Orthod 1983;83:38290. 16. Haas AJ. Rapid expansion of the maxillary dental arch and nasal cavity by opening the midpalatal suture. Angle Orthod 1961; 31:7390. 17. Akkaya S, Lorenzon S, cem TT. A comparison of sagittal and vertical effects between bonded rapid and slow maxillary expansion procedures. Eur J Orthod 1999;21:17580. 18. Erverdi N, Sabri A, Kucukkeles N. Cephalometric evaluation of Haas and Hyrax rapid maxillary appliances in the treatment of the skeletal maxillary transverse deficiency. J Marmara Univ Dent Fac 1993;1:3616. 19. Taspinar F. The computerized tomographic and cephalometric evaluation of the changes resulted from rapid maxillary expansion. (Dissertation). Ataturk University, Health Sciences Institute, Department of Orthodontics, Erzurum, 2002. 20. Klc N. Investigation of the changes at dentofacial structures and tonus of masticatory muscles induced by semi rapid and rapid maxillary expansion (Dissertation). Ataturk University, Health Sciences Institute, Department of Orthodontics, Erzurum, 2005. 21. Chung CH, Font B. Skeletal and dental changes in the sagittal, vertical, and transverse dimensions after rapid palatal expansion. Am J Orthod Dentofacial Orthop 2004;126: 56975. 22. Ramoglu SI, Sari Z. Maxillary expansion in the mixed dentition: rapid or semi-rapid? Eur J Orthod 2010;32:1118. 23. McNamara JA, Brudon WL. Orthodontic and orthopedic treatment in the mixed dentition. Ann Arbor: Needham Press Inc., 1996:13169. 24. Sari Z, Uysal T, Usumez S, Basciftci FA. Rapid maxillary expansion. Is it better in the mixed or in the permanent dentition? Angle Orthod 2003;73:65461. 25. Kilic N, Kiki A, Oktay H, Erdem A. Effects of rapid maxillary expansion on Holdaway soft tissue measurements. Eur J Orthod 2008;30:23943. 26. Kilic N, Kiki A, Oktay H. A comparison of dentoalveolar inclination treated by two palatal expanders. Eur J Orthod 2008;30:6772. 27. Oktay H, Kilic N. Evaluation of the inclination in posterior dentoalveolar structures after rapid maxillary expansion: a new method. Dentomaxillofac Radiol 2007;36:3569. 28. Mossaz-Joelson K, Mossaz CF. Slow maxillary expansion: a comparison between banded and bonded appliances. Eur J Orthod 1989;11:6776. 29. Haas AJ. Palatal expansion: just beginning to dentofacial orthopedics. Am J Orthod 1970;57:21955. 30. zsoy FS. Evaluation of the effects of semirapid maxillary expansion on dentofacial structures. (Dissertation). Ankara University, Health Sciences Institute, Department of Orthodontics, Ankara, 2001.
183
Shear bond strengths of buccal tubes

Kathiravan Purmal and Prema Sukumaran
Dental Faculty, University Malaya, Kuala Lumpur, Malaysia
Aims: To investigate the shear bond strengths of buccal tubes and to determine the sites of failure. Method: Four orthodontic buccal tubes were selected: A, American Orthodontics; B, 3M Unitek - small base; C, 3M Unitek large base; D, Hangzhou Dentop. Twenty buccal tubes from each group were bonded to the buccal surfaces of lower right first molars with the same light-cured composite resin. The buccal tubes were debonded with a universal testing machine and the data analysed. The amount of adhesive remaining on the teeth after debonding was classified with the modified adhesive remnant index (ARI). Results: The groups ranked from the highest to lowest bond strength (MPa) were: B, A, D and C. The bond strengths of the buccal tubes, except Groups A and B, were significantly different (p < 0.05). The majority of the buccal tubes (63 per cent) had modified ARI scores of 1 and 2 and 25 per cent of the tubes had scores of 4 and 5. After debonding, no adhesive remained on 40 per cent of the teeth in Groups B and D. Conclusions: The shear bond strengths of the buccal tubes fell below the value considered to be clinically acceptable. There were no differences between the shear bond strengths of the buccal tubes with photoetched and microetched bases. The buccal tubes with the largest base failed prematurely, possibly because the unsupported bonding pad flexed during debonding. (Aust Orthod J 2010; 26: 184188)
Received for publication: March 2009 Accepted: September 2010 Kathiravan Purmal: drkathi@myjaring.net Prema Sukumaran: sk_prema@hotmail.com
Introduction
The practice of bonding attachments to molars has not been widely accepted because it is believed that bonded buccal tubes have inadequate bond strengths.1,2 The failure rate of bonded buccal tubes has been reported to be as high as 21 per cent.3 The bond strength of buccal tubes can be improved by increasing the etch time to 30 seconds,4 use of foil mesh bonding pads,5,6 sand blasting the attachments7 and using different resin adhesives.8 According to one authority, bond strength is influenced by the size and design of the bonding pad, but others consider that shear bond strength is independent of the surface areas of bonding pads between 6.82 and 12.32 mm2.9,10 The limitations in previous studies are the use of bovine teeth, use of premolars rather than molars, use of attachments with different surface areas and different types of bonding pad. Our aims were to compare the in-vitro shear bond strengths of different buccal tubes bonded to human molars, and to determine the sites of failure using the modified adhesive remnant index (ARI).
184

Eighty lower right first molar teeth were collected, sterilised with 0.5 per cent chloramine for one week and stored in distilled water for 24 hours. The buccal surfaces of all teeth were sound. The teeth were randomly assigned to four groups and mounted in acrylic resin blocks to facilitate debonding in a universal testing machine. Lower right MBT prescription buccal tubes from the following sources were used: A (American Orthodontics, Sheboygan, WI, USA); B (Small base; 3M Unitek, Monrovia, CA, USA); C (Large base; 3M Unitek, Monrovia, CA, USA); D (Hangzhou Dentop, Zhejiang, Hangzhou, China). The buccal surface of each tooth was polished with fluoride-free pumice powder for 20 seconds, sprayed with water and dried with a blast of air. The buccal surfaces were then etched for 30 seconds with 35 per cent phosphoric acid gel (Transbond XT etchant gel, 3M Unitek, Monrovia, CA, USA), rinsed for 30 seconds with distilled water and dried with air for 20 seconds. A thin layer of Transbond XT primer
SHEAR BOND STRENGTHS OF BUCCAL TUBES
Table I. Base sizes and shear bond strengths of the buccal tubes.
Group
Mean size (mm2)
Mean SBS SD (MPa)*
95 per cent CI
A B C D
20 20 20 20
26.50 18.20 32.60 22.70
3.88 4.32 1.71 3.34
0.34 0.73 0.60 0.66
3.73, 3.98, 1.43, 3.03,
4.04 4.66 1.99 3.65
A: American Orthodontics, 80 gauge photoetched foil mesh base B: 3M Unitek (small base), 80 gauge microetched foil mesh base C: 3M Unitek (large base), 80 gauge microetched foil mesh base D: Hangzhou Dentop, 80 gauge microetched foil mesh base * One-way ANOVA, p = 0.00
Figure 1. A specimen ready for debonding.
(3M Unitek, Monrovia, CA, USA) was then brushed on the etched surface. Transbond XT light-cured composite resin (3M Unitek, Monrovia, CA, USA) was placed on the bonding pad and the attachment pressed on the buccal surface by an experienced orthodontist. Surplus resin was removed with a sharp, dental instrument. The resin was cured with an Optilux 400 curing light (Demetron Research Corp, Danbury, CT, USA) at 400 MW/cm2 by placing the light 10 mm from the mesial (20 seconds) and distal edges (20 seconds) of each bonding pad. The samples were stored in distilled water at 37 C for 24 hours before debonding. Each specimen was mounted in a Shimadzu Universal Testing Machine (Shimadzu Corporation, Kyoto, Japan) so that the middle of the buccal surface was parallel to the long axis of the blade used to debond the tubes (Figure 1). The universal testing machine had a load cell of 1 kg and crosshead speed of 1 mm/min. The shear load was applied on the occlusal side of the buccal tube, as close as possible to the base. The force required to debond a buccal tube was recorded in newtons (N) and converted to force per unit area (MPa), by dividing the force by the surface area of the base. The latter was measured by tracing the base on graph paper and counting the number of squares enclosed by the outline (Table I). To determine the sites of failure, the teeth and buccal tubes were examined at x10 magnification (Leica Image Analyzer, Houston, TX, USA) and the amount of adhesive on the tooth surface was scored with the modified adhesive remnant index (ARI): 1, all of the adhesive remained on the enamel with an impression
of the base of the buccal tube; 2, more than 90 per cent of the adhesive remained on the tooth surface; 3, less than 90 per cent but more than 10 per cent of the adhesive remained on the tooth surface; 4, less than 10 per cent of the adhesive remained on the tooth surface; 5, no adhesive remained on the tooth surface.11,12
One-way analysis of variance (ANOVA) was used to compare the shear bond strengths of the buccal tubes. Tukey HSD post-hoc tests were employed to analyse the shear bond strength data. The distributions of residual adhesive (ARI) were compared using the chisquared test. A significance level of 0.05 was used for all tests.
Results
The 3M Unitek small base buccal tubes were slightly more than half the area of the large base 3M Unitek buccal tubes and 80 per cent of the area of the Hangzhou Dentop tubes. The mean base area of the Hangzhou Dentop tubes was approximately 85 per cent of the mean base area of the American Orthodontics tubes (Table I). The highest mean shear bond strength was observed in Group B (4.32 0.73 MPa) and the lowest mean bond strength in Group C (1.71 0.60 MPa) (Table I). The mean shear bond strengths of the tubes were significantly different, except for the tubes in Groups A and B (Table II). The largest mean difference of 2.61 MPa occurred between the Group B and Group C buccal tubes.
185
PURMAL AND SUKUMARAN
Table II. Comparisons of the shear bond strengths.
Shear bond strength (MPa) Group, Manufacturer Comparison Mean difference p*
A, American Orthodontics
B, 3M Unitek, small base C, 3M Unitek, large base D, Hangzhou A, American Orthodontics C, 3M Unitek, large base D, Hangzhou A, American Orthodontics B, 3M Unitek, small base D, Hangzhou A, American Orthodontics B, 3M Unitek, small base C, 3M Unitek, large base
-0.44 2.18 0.54 0.44 2.61 0.98 -2.18 -2.61 -1.63 -0.54 -0.98 -1.63
0.11 0.00 0.03 0.11 0.00 0.00 0.00 0.00 0.00 0.03 0.00 0.00
B, 3M Unitek, small base
C, 3M Unitek, large base
D, Hangzhou
* Tukey HSD, significant differences in bold
Table III. Comparisons of the modified ARI scores.
ARI A B
Group count (Per cent) C D Total
1 2 3 4 5 Total
12 4 2 2 0
(60) (20) (10) (10) (0)
6 4 2 0 8
(30) (20) (10) (0) (40)
14 6 0 0 0
(70) (30) (0) (0) (0)
2 2 6 2 8
(10) (10) (30) (10) (40)
34 16 10 4 16
(43) (20) (13) (5) (20)
20 (100) 20 (100) 20 (100) 20 (100) 80 (100)
Chi-squared test, p < 0.05
largest bonding pads had the lowest bond strengths. The buccal tubes with the smallest pad area had the highest bond strength, but it fell below the value considered to be clinically acceptable. The ARI scores for buccal tubes with the smallest bonding pad were more-or-less evenly distributed between the extreme scores, whereas most of the adhesive remained on the teeth when the buccal tubes with the largest bonding pads (Groups A and C) were debonded. The buccal tubes we tested had different base areas and different types of retentive meshes, but we considered them a single independent variable in our analysis. Several investigators have proposed that increasing the surface area of the bonding pad increases the load carrying capacity of an attachment and, presumably, results in a higher shear bond strength.9,13 However, MacColl et al.10 reported that shear bond strength was independent of the surface area of bonding pads above 6.82 mm2. We found the smallest attachments had the highest bond strength, and postulate that the multilayer bases of the largest buccal tubes were not uniformly rigid. In our view, if the periphery of the bonding pad is not supported by the actual attachment it would be somewhat flexible and relatively easily deformed by a shear force (Figure 2). On the other hand, when the buccal tube covered the bonding pad the tube-pad combination was more rigid and, therefore, less likely to fail (Figure 3).14
The distributions of ARI scores are given in Table III and were significantly different (p < 0.05). In Groups A and C most of the resin remained on the surfaces of the teeth, whereas in Groups B and D there was no adhesive on 40 per cent of the teeth. The ARI scores in Group D were variable: all of the resin remained on 10 per cent of the teeth, a further 10 per cent of the teeth retained 90 per cent of the resin, and 30 per cent of the teeth retained between 90 and 10 per cent of the resin (Table III).
Discussion
We compared the shear bond strengths of four different buccal tubes under standardised in-vitro conditions and found that the buccal tubes with the
186
SHEAR BOND STRENGTHS OF BUCCAL TUBES
Layer 1 Layer 2
Layer 3
Figure 2. A multilayer buccal tube with a large base (Group C), showing the unsupported flange.
Figure 3. A buccal tube with a small base (Group B). The attachment extends almost to the edge of the bonding pad.
Other factors that may have influenced our findings are the closeness of fit of the bonding pads, the extent of polymerisation and the effect of immersion in water before testing.15 A buccal tube with a large base area is likely to be less well-adapted to the surface of the tooth, leading to an uneven and, in parts, thick layer of adhesive.14 The latter may include small inclusions of air and is more likely to develop cracks as the concentration of stress increases proportionally with the thickness of the resin layer.16 Maximum conversion of monomer to polymer is necessary for composite resin to achieve optimal physical properties.17 Complete polymerisation of the resin beneath a buccal tube relies on the polymerising light reaching all parts of the resin. Recent studies have reported that there was no significant difference in the shear bond strengths when the tip of the curing light was positioned between 1 and 10 mm from the bases of the brackets.18,19 We followed the manufacturers directions and placed the light 10 mm from the mesial and distal edges of the metal bonding pads, but it is possible that resin in the most inaccessible parts of the mesh base was not completely polymerised.20,21 The storage media used may have influenced the bond strength. We sterilised the teeth before using them in a 0.5 per cent solution of chloramine, which according to Jaffer and coworkers15 should not affect the shear bond strengths. After bonding, however, we simulated the oral environment by storing the teeth in water, which may have contributed to a loss of bond strength.22 The Group B buccal tubes may have had the highest bond strength and smallest base area, but in 60 per cent of the teeth much of the resin still remained attached to the teeth. The area of unsupported base is greater in Groups A and C (26.50 mm2 and 32.60
mm2, respectively) and most of the resin remained attached to the teeth in these groups, strengthening our belief that the peripheries of the buccal tubes flexed when subjected to the shear force and contributed to early failure.
Conclusions
Within the limitations of this study the conclusions are: 1. None of the buccal tubes had sufficient shear bond strength for clinical use. 2. Increasing the area of the base did not increase the shear bond strength. The area of unsupported base may flex when subjected to a shear force and contribute to early failure. 3. There were no differences in bond strength between photoetched or microetched bases. 4. The buccal tubes in Groups B and D had the highest bond strengths and more tubes failed at the toothresin interface.
Acknowledgment
We thank The University of Malaya for providing the financial support for this study (Grant No: FS253/2008A).
Dr Kathiravan Purmal Department of General Dental Practice and Oral and Maxillofacial Imaging Dental Faculty University Malaya 50603 Kuala Lumpur Malaysia Tel: +603 7967 4555 Fax: +603 7967 4575 Email: drkathi@myjaring.net
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PURMAL AND SUKUMARAN
References
1. Knoll M, Gwinnett AJ, Wolff MS. Shear strength of brackets bonded to anterior and posterior teeth. Am J Orthod 1986; 89:4769. 2. Banks P, Macfarlane TV. Bonded versus banded first molar attachments: a randomized controlled clinical trial. J Orthod 2007;34:12836; discussion 11112. 3. Millett DT, Hallgren A, Fornell AC, Robertson M. Bonded molar tubes: a retrospective evaluation of clinical performance. Am J Orthod Dentofacial Orthop 1999;115:66774. 4. Johnston CD, Burden DJ, Hussey DL, Mitchell CA. Bonding to molars the effect of etch time (an in vitro study). Eur J Orthod 1998;20:1959. 5. Maijer R, Smith DC. Variables influencing the bond strength of metal orthodontic bracket bases. Am J Orthod 1981;79:2034. 6. Regan D, van Noort R. Bond strengths of two integral bracket-base combinations: an in vitro comparison with foilmesh. Eur J Orthod 1989;11:14453. 7. Johnston CD, McSherry PF. The effects of sandblasting on the bond strength of molar attachments: an in vitro study. Eur J Orthod 1999;21:31117. 8. Millett DT, Letters S, Roger E, Cummings A, Love J. Bonded molar tubes: an in vitro evaluation. Angle Orthod 2001;71:3805. 9. Wang WN, Li CH, Chou TH, Wang DD, Lin LH, Lin CT. Bond strength of various bracket base designs. Am J Orthod Dentofacial Orthop 2004;125:6570. 10. MacColl GA, Rossouw PE, Titley KC, Yamin C. The relationship between bond strength and orthodontic bracket base surface area with conventional and microetched foilmesh bases. Am J Orthod Dentofacial Orthop 1998;113: 27681. 11. Artun J, Bergland S. Clinical trials with crystal growth conditioning as an alternative to acid-etch pretreatment. Am J Orthod 1984;85:33340.
12. Bishara SE, VonWald L, Olsen ME, Laffoon JF. Effect of time on the shear bond strength of glass ionomer and composite orthodontic adhesives. Am J Orthod Dentofacial Orthop 1999;116:61620. 13. Cozza P, Martucci L, Toffol LD, Penco SI. Shear bond strength of metal brackets on enamel. Angle Orthod 2006; 76:8516. 14. Matasa CG, Eng C, Sci T. Buccal tubes bond strength: a comparison reveals unexpected differences. Orthod Mat Insider 2009;21:18. 15. Jaffer S, Oesterle LJ, Newman SM. Storage media effect on bond strength of orthodontic brackets. Am J Orthod Dentofacial Orthop 2009;136:836. 16. Patrick RL, Minford JD. Treatise on Adhesion and Adhesives. In: Raton B, ed. CRC Press, 1991:3378. 17. Ruyter IE, Oysaed H. Conversion in different depths of ultraviolet and visible light activated composite materials. Acta Odontol Scand 1982;40:17992. 18. Gronberg K, Rossouw PE, Miller BH, Buschang P. Distance and time effect on shear bond strength of brackets cured with a second-generation light-emitting diode unit. Angle Orthod 2006;76:6828. 19. Bennett AW, Watts DC. Performance of two blue light-emitting-diode dental light curing units with distance and irradiation-time. Dent Mater 2004;20:729. 20. Oesterle LJ, Messersmith ML, Devine SM, Ness CF. Light and setting times of visible-light-cured orthodontic adhesives. J Clin Orthod 1995;29:316. 21. Oesterle LJ, Shellhart WC, Belanger GK. Effect of tacking time on bond strength of light-cured adhesives. J Clin Orthod 1997;31:44953. 22. Murray SD, Hobson RS. Comparison of in vivo and in vitro shear bond strength. Am J Orthod Dentofacial Orthop 2003;123:29.
188
The effect of a Clark twin block on mandibular motion: a case report

Catherine OShea, * Andrew Quick, Gillian Johnson, + Allan Carman + and Peter Herbison
Royal Childrens Hospital, Brisbane, Queensland, Australia;* Schools of Dentistry, Physiotherapy+ and Medicine, University of Otago, Dunedin, New Zealand
Aims: To investigate mandibular motion in six degrees of freedom before, during and after twin block treatment in one individual. Methods: The appliance was worn for eight months, and motion recordings, using a 12-camera opto-electric system, were captured prior to placement of a twin block appliance and 2, 4, 14 and 52 weeks after insertion. Results: The wide variations in mandibular motion that accompany twin block wear disappeared post-treatment, except for an increase in anteroposterior movement of the mandible. Conclusion: Twin block therapy appears to affect mandibular motion temporarily. (Aust Orthod J 2010; 26: 189194)
Received for publication: February 2010 Accepted: May 2010 Catherine OShea: catherineloshea@gmail.com Andrew Quick: andrew.quick@stonebow.otago.ac.nz Gillian Johnson: gill.johnson@otago.ac.nz Allan Carman: allan.carman@otago.ac.nz Peter Herbison: peter.herbison@otago.ac.nz
Introduction
Movement of the mandible has been investigated and documented for over a century,1 and as technology advanced, so has our ability to accurately capture mandibular motion in three planes of space. Of late, magnetic and opto-electric camera systems have been employed to track human movement, including the translation and rotation of the mandible in the three planes of space.26 In dentistry, kinematic studies have been used to investigate normal jaw physiology and function,710 and the changes associated with temporomandibular dysfunction11,12 and orthognathic surgery.1315 To our knowledge no studies have examined condylar motion in patients using functional appliances. Functional appliances, including the design popularised by William Clark,16 are used to treat Class II malocclusions characterised by mandibular retrognathia. The dentoalveolar effects of functional
appliances are well-documented,17 but there is less certainty of their effects on the condyle and the articulating surface. Primate studies have indicated that there is some remodelling of the condylar heads in a posterior direction and that the glenoid fossae are remodelled by a combination of bone deposition posteriorly and resorption anteriorly.18,19 Furthermore, there is evidence to suggest that the retrodiscal tissue becomes increasingly vascularised during prolonged mandibular advancement,20 indicating an inflammatory response in that region. Whilst these changes have not been confirmed in human subjects, we postulate that local adaptations within the human condylar joint during anterior posturing of the mandible may produce functional changes in mandibular kinematics. The aim of this study was to describe the mandibular motion in an individual undergoing growth modification orthodontic treatment using a Clark twin block appliance.
189
OSHEA ET AL
Figure 1. Pretreatment intra-oral photographs. Figure 2. A model showing the arrangement of reflective markers attached to the cranial cap, the lateral pole of the right condyle and the splint.
Methods
An 11 year-old male subject with a Class II division 1 malocclusion and a retrusive mandible was referred to the Orthodontic Clinic, University of Otago. The ANB angle was 10 degrees and the Wits value was +9 mm. The pretreatment intra-oral photographs of the subject are shown in Figure 1. The study was approved by the University of Otago Human Ethics Committee and informed consent was obtained for the mandibular motion study. The proposed intervention consisted of two phases: a twin block appliance followed by fixed appliances. The twin block appliance, which incorporated an upper labial bow to retract the upper incisors, was relieved to allow exfoliation of the remaining deciduous canines and molars and eruption of the permanent molars. The method of capturing mandibular motion was similar to that described previously.12 Briefly, a vacuum-formed occlusal splint was fabricated to fit the subjects lower dentition, to which was attached a wire frame that supported seven reflective markers: three anterior and two on each side. A new splint was manufactured for each recording to accommodate teeth that may have moved in the interim. Six cranial reference markers were attached to a tight fitting latex swim cap worn by the subject and two markers were placed over the condylar heads, determined by palpation (Figure 2). Motion was captured using a 12 camera infra-red Motion Analysis System (Motion Analysis Corporation, Santa Rosa, CA, USA) at a sampling rate of 60 Hz and supported by EvaRT 4.0 software (Motion Analysis Corporation). Recordings of condylar motion were made prior to twin block therapy, after 2, 4 and 14 weeks treatment,
190
and 12 months from the start of treatment. The subject was instructed to wear the twin block appliance full-time, although compliance was not monitored. He was treated for 8 months and during this time the overjet reduced from 11 mm to 3 mm (Figure 3). At the end of this phase of treatment a modified Hawley retainer with a lower anterior bite plane was fitted. The subject declined the second phase of fixed appliance treatment. At each recording, the subject was orientated in a natural head position and the static position (with the teeth in maximum intercuspation) recorded for 6 seconds. He was then asked to perform a comfortable open and closing movement of his mouth within a 6second time frame and this was repeated six times at each recording. A custom-written programme was then used to identify the opening and closing parts of each recording and each cycle was normalised to 100 points. During the 6-second static recording the mandibular (MP) and cranial (CP) axes were located while the jaw was closed (Figure 4). The origin of the mandibular axes (MP) was located at the midpoints of markers overlying the right and left condyles. An orthogonal axes system was then constructed with the Z-axis passing through MP and the midpoint of the jaw device, and the X-axis passing through the left and right condylar markers. The Y-axis was perpendicular to the X- and Z-axes. Similarly, the origins of the cranial axes (CP) were located at the midpoints of the left and right temporal markers. A second orthogonal axes system was then constructed with Z-axis passing through CP and the frontal head marker, and the X-axis passing through the left and right temporal markers. The local coordinates of all mandibular and cranial markers were then calculated with respect to
TWIN BLOCK THERAPY AND MANDIBULAR MOTION
Figure 3. Intra-oral photographs after 8 months treatment.
Figure 4. The cranial global axes (CP) and mandibular global axes (MP) are calculated from the cranial and mandibular markers, respectively.
Table I. Mean differences (95% CI) between the mean maximum rotation pretreatment and the four post-insertion recordings in the X, Y and Z axes.
Rotation (degrees)
Post-insertion 2 weeks Mean (95% CI)
Post-insertion 12 months Mean (95% CI)
X Y Z
3.60 (0.92, 6.28)* 0.17 (-0.64, 0.417)* -0.65 (-1.19, -0.09)*
1.46 (-1.33, 4.27)** -5.05 (-5.30, 4.79)** 4.07 (3.49, 4.65)**
8.09 (5.42, 10.77)** -5.16 (-5.40, 4.92)** 1.70 (0.59, 1.75) **
8.08 (5.26, 10.87)** -2.16 (-2.41, 1.91)** -0.84 (-1.23, -.045)**
ANOVA, * p < 0.05, ** p < 0.01
each axes system. During the movement trials, the mandibular and cranial axes were reconstructed from local and global coordinates of the corresponding markers using a least squares fitting procedure. The relative rotation and translation between the MP and the CP were calculated in degrees and millimetres respectively along three axes: X, left-right; Y, vertical; Z, anteroposterior (Figure 5). The error of detection of an individual reflective marker by the camera under dynamic conditions was less than 0.4 mm, which is considered insignificant with respect to the total movement recorded by the two points. The error in rotation within and between the recording sessions had previously been calculated by Johnson et al. as less than 1 degree.12
Results
The results were based on the means of six repeat measures during each recording session with the exception of the 4-week and 12-month recordings, where on both occasions the results of one of the six measures was discarded due to technical difficulties. The mean rotation data about each of the three axes and the mean translation data for the pretreatment and final (12-month) recordings are shown in Figure 6. Statistically significant differences were found between the mean maximum rotation pretreatment and the 2-week, 14-week and 12-month recordings in the X-axis, between the mean maximum rotation pretreatment and the 4-week, 14-week and 12month recordings in the Y-axis, and between the mean maximum rotation pretreatment and the 2week, 4-week, 14-week and 12-month in the Z-axis (Table I). Significant differences were also found between the mean maximum translation pretreatment and the 2week, 14-week and 12-month recordings in the Xaxis, between the mean maximum rotation pretreatment and the post-insertion recordings in the Y-axis
A one-way analysis of variance (ANOVA) was used to compare the mean differences in the dependent variables of mean maximum rotation (degrees) and mean maximum translation (mm) between the pretreatment and the four post-insertion recordings (the last being the post-treatment 12-month recording).
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Table II. Mean differences (95% CI) between the mean maximum translation pretreatment and the four post-insertion in the X, Y and Z axes.
Translation (mm)
Post-insertion 2 weeks
Post-insertion 12 months
X Y Z
1.06 (0.61, 1.51)** -5.11 (-6.98, 3.24)** 2.09 (0.98, 3.20)**
-0.39 (-0.86, 0.08)** -8.40 (-10.36, -0.17)** -8.78 (-9.94, 7.62)**
1.10 (0.63, 1.58)** -2.12 (-4.08, 1.06)** 6.42 (5.26, 7.58)**
-0.88 (-1.35, -0.40)** -0.88 (-2.84, 1.06)** 6.52 (5.36, 7.68)**
ANOVA, * p < 0.05, ** p < 0.01
Figure 5. The axes and planes of mandibular movement. In this model the centre of the mandible is the midpoint of the condylar markers.
at 2-weeks, 4-weeks and 12-months, and between the mean maximum pretreatment translation and all post-insertion values (Table II).
resting position when teeth are in contact, which can approximate, but not necessarily coincide with centric relation. Centric relation has been loosely defined as the position when the condyles are in their most anterosuperior positions against the slopes of the articular eminences.22 The method of determining condylar position by palpation has been criticised in the past because it is subjective, and has a location error that can vary up to 5 mm.23 We attempted to limit errors in location by using the same operator to locate the points in one subject. It has also been shown that the overall pattern of jaw movement is the same despite variations in location of the condyles, although some differences in the shape of the path of jaw motion can be expected.24 In our study, the use of a single representative point, located between the condyles, further reduced any error due to inaccurate marker placement over a condyle. In patients undergoing twin block therapy, the condyles may not necessarily be in centric relation as the mandible is encouraged to posture anteriorly. Figure 7 shows the approximate tracking of point MP over the five recordings in the anteroposterior and superior-inferior planes, relative to the automatic origin generated at each recording and with approximate envelopes of error. Minimal variation in mandibular opening occurred at the pretreatment and 2-week recordings, although a slightly greater opening was observed after two weeks of appliance wear. The 4-week recording was statistically different from the two initial recordings: MP was positioned more posteriorly and inferiorly than initially. A possible explanation for this difference is that the condyle started from a more anterior position as a result of posturing, and in order to achieve opening, the condyles had to move in a posterior direction relative to CP. Mandibular motion in both planes was very variable, as indicated by the large standard deviations. Furthermore, absolute opening was
Discussion
Although not specifically assessed using a clinical outcome measure such as the PAR Index,21 there was an overall improvement in the occlusion at the end of phase one treatment, which suggests that compliance was adequate (Figures 1 and 3). The kinematic model used in this study reduces mandibular motion to a single condyle equivalent, a point situated midway between the lateral poles of the right and left condyles, referred to as MP. The kinematics of this point were tracked relative to a static reference point, midway between the stable cranial markers (CP). The system can accurately track relative movement between these points with six degrees of freedom, but it is unable to locate the starting position of MP relative to anatomical cranial structures. The assumption made in previous kinematic studies is that condylar movement begins at the
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TWIN BLOCK THERAPY AND MANDIBULAR MOTION
Per cent of movement
Figure 6. Graphs depicting the mean rotation (A) and translation (B) (dashed lines, 95% CI) in the X, Y and Z planes. Each line is based on six repetitive trials from the pretreatment and post-treatment sessions.
-7 -6 -5 -4 -3 -2 -1 1 -1 -2 -3 -4 -5 -6 -7 -8 -9 -10 -11 -12 -13 -14 -15 -16 -17 -18 -19 -20 -21 -22 -23 -24
5 6
9 10 11 12 13 14
Pretreatment
14 weeks 12 months 2 weeks
4 weeks
Figure 7. Trajectories of MP in the anterior-posterior and superior-inferior planes at the initial and four post-insertion recordings, together with the standard deviation envelopes (not to scale).
approximately double the initial value, although this may be partly due to a training effect, despite measures taken to minimise this. The 14-week recordings indicated that MP moved anterior-inferiorly, although this was also accompanied by large variability in jaw kinematics in both the A-P and the superior-inferior planes. The final recording at the end of treatment (12 months) shows that mandibular motion became more consistent in the vertical plane, with average opening values similar to those obtained at the first recording. Point MP translated anteriorly approximately two and a half times more than in the initial recording, with more variation in the horizontal plane. Table I indicates significant rotation within the mandible between the initial and final recordings (approximately 8 degrees), but this may not have clinical significance. The results indicate that mandibular opening and closing during twin block therapy undergo a phase of dramatic fluctuation, accompanied by forward posturing, but these return to a more consistent motion post-treatment that
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largely resembles the pretreatment pattern, except for a greater anteroposterior movement.
8. 9.
Conclusions
During treatment the twin block appliance changed mandibular function from the usual anterior movement on opening to a distal movement of the mandible. Mandibular movement during therapy was very variable, but these changes largely disappeared after removal of the appliance: the condylar trajectories tended to return to the pretreatment curves.
10.
11.
12.
Acknowledgment
Funding for this study was supported by the New Zealand Association of Orthodontists.
13.
14.
Dr Andrew Quick School of Dentistry University of Otago PO Box 647 Dunedin New Zealand Tel: +64 3 479 7480 Fax: +64 3 479 7070 Email: andrew.quick@stonebow.otago.ac.nz
15.
16. 17.
18.
19.
References
1. 2. Luce CE. The movements of the lower jaw. Boston M Surg J 1889;121:811. Mongini F, Tempia-Valenta G. A graphic and statistical analysis of the chewing movements in function and dysfunction. J Craniomandibular Pract 1984;2:12534. Mesqui F, Palla S. Real-time non-invasive recording and display of functional jaw movements. J Oral Rehabil 1985;12: 5412. Proeschel P. An extensive classification of chewing patterns in the frontal plane. Cranio 1987;5:5563. Airoldi R, Gallo LM, Palla S. Precision of the jaw tracking system JAWS-3D. J Orofac Pain 1994;8:15564. Naeije M, Van der Weijden JJ, Megens CC. OKAS 3D: an opto-electric jaw movement analysis system with six degrees of freedom. Med Biol Eng Comput 1995;33:6838. Zafar H, Nordh E, Eriksson PO. Temporal coordination between mandibular and head-neck movements during jaw opening-closing tasks in man. Arch Oral Biol 2000:45; 67582.
20.
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7.
Gallo LM, Fushima K, Palla S. Mandibular helical axis pathways during mastication. J Dent Res 2000:79;156672. Lewis RP, Buschang PH, Throckmorton GS. Sex differences in mandibular movements during opening and closing. Am J Orthod Dentofacial Orthop 2001:120;294303. Proeschel PA. Chewing patterns in subjects with normal occlusion and with malocclusions. Semin Orthod 2006:12;13849. Miyawaki S, Tanimoto Y, Inoue M, Sugawara Y, Fujiki T, Takano-Yamamoto T. Condylar motion in patients with reduced anterior disk displacement. J Dent Res 2001:80; 14305. Johnson GM, Coe H, Wirawan R, Wong L, Lee C, MacFadyen E. Objective discrimination between mandibular open/close excursion patterns: a clinical case report. Cranio 2007:25;21824. Athanasiou AE. Electrognathographic patterns of mandibular motion after bilateral vertical ramus setback osteotomy. Int J Adult Orthodon Orthognath Surg 1992:7;239. Ehmer U, Broll P. Mandibular border movements and masticatory patterns before and after orthognathic surgery. Int J Adult Orthodon Orthognath Surg 1992:7;1539. Throckmorton GS, Ellis E. Recovery of mandibular motion after closed and open treatment of unilateral mandibular condylar process fractures. Int J Oral Maxillofac Surg 2000: 29;4217. Clark WJ. Twin block functional therapy. 1995. MosbyWolfe, Turin, Italy. Dermaut LR, Aelbers CMF. Orthopedics in orthodontics: fiction or reality. A review of the literature Part II. Am J Orthod Dentofacial Orthop 1996:110;66771. Adams CD, Meikle MC, Norwick KW, Turpin DL. Dentofacial remodelling produced by intermaxillary forces in Macaca mulatta. Arch Oral Biol 1972:17;151935. McNamara JA, Carlson DS. Quantitative analysis of temporomandibular joint adaptations to protrusive function. Am J Orthod 1979:76;593611. Woodside DG, Metaxas A, Altuna G. The influence of functional appliance therapy on glenoid fossa remodelling. Am J Orthod Dentofacial Orthop 1987:92;18198. Richmond S, Shaw WC, OBrien KD, Buchanan IB, Jones R, Stephens CD et al. The development of the PAR index (Peer Assessment Rating): reliability and validity. Eur J Orthod 1992:14;12539. Rinchuse DJ, Kandasamy S. Centric relation: a historical and contemporary orthodontic perspective. J Am Dent Assoc 2006;137:494501. Zwinjenburg A, Megens CC, Naeije M. Influence of choice of reference point on the condylar movement paths during mandibular movements. J Oral Rehab 1996:23;8327. Ostry DJ, Munhall KG. Control of jaw orientation and position in mastication and speech. J Neurophysiol 1994:71; 152845.
194
Orthodontic treatment of a transmigrated mandibular canine: a case report

Gksu Trakyal, * Sule Kavaloglu ldr and Nket Sandall
Departments of Orthodontics* and Pedodontics, Faculty of Dentistry, Yeditepe University, Istanbul, Turkey
Background: Intraosseous migration of a lower canine across the midline is a rare dental anomaly. The treatment options include: forced eruption of the unerupted tooth using orthodontic traction, autotransplantation, extraction followed by prosthetic replacement. Aim: To report the management of a transmigrated lower right canine. Method: The treatment involved surgical, orthodontic and cosmetic dental treatment. No permanent teeth were extracted. Results: The transmigrated canine was placed between the left central and lateral incisors and the crown recontoured to simulate a lateral incisor. An acceptable aesthetic and functional outcome was gained. Conclusion: Transmigration is a rare dental condition that can be treated successfully with a collaborative effort from several dental disciplines. (Aust Orthod J 2010; 26: 195200)
Received for publication: December 2009 Accepted: May 2010 Gksu Trakyal: goksu.trakyali@yeditepe.edu.tr S Kavaloglu ldr: sulecildir@hotmail.com ule Nket Sandall: nuketsandalli@yeditepe.edu.tr
Introduction
The failure of a tooth to emerge into the dental arch is usually due to crowding or the presence of an obstruction, such as another tooth, in the path of eruption.1,2 Occasionally, an unerupted tooth migrates to the opposite side of the arch. This is referred to as transmigration.4 Transmigration usually involves a lower tooth, such as a lateral incisor, a second premolar or a canine, and on rare occasions the upper canines.3,5,6 Migrated canines typically remain impacted.7,8 Occasionally, they may erupt ectopically in the midline or on the opposite side of the arch.911 In some cases, canines have erupted next to the contralateral canine, in a mirror image fashion.12 The first sign that a canine is transmigrating may be failure of a lower permanent canine to erupt, or retention of a lower primary canine.7,13 Absence of a developing permanent lower canine under a deciduous canine is associated with slow resorption of the root of the deciduous canine.14
Tooth migration in the mandible is unlikely to be detected during a routine clinical examination. It is rarely discovered on a routine periapical radiographic examination because the tooth is generally impacted under the apices of the permanent teeth, and lies adjacent to the mandibular border. Therefore, when a permanent tooth is missing a panoramic radiograph should be taken. The female to male ratio of transmigrated teeth is 1.6:1.15 The treatment options for a transmigrated lower canine are: surgical removal of the impacted canine and retention of the deciduous canine for as long as possible; transplantation; surgical exposure, forced eruption and orthodontic alignment; and extraction followed by prosthetic replacement.16 Surgical extraction is the most favoured form of treatment, especially when the lower arch is crowded and space is needed to align the lower teeth.16,17 If the lower incisors are in a normal position and there is sufficient space in the arch for the transmigrated canine, transplantation may be undertaken.18 Surgical
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(a)
(b)
Figure 1. (a) Frontal view before orthodontic treatment. (b) Lower occlusal view before orthodontic treatment.
Table I. Pre- and post-treatment cephalometric measurements.
Cephalometric variables
Before treatment
After treatment
U1/L1 (degrees) U1/NA (degrees) L1/NB (degrees) SNA (degrees) SNB (degrees) ANB (degrees) Maxillary depth (degrees) GoMeSN (degrees) Saddle angle (degrees) FMA (degrees) SN/OccP (degrees) Jaraback (ratio) ANSMe/NMe (ratio)
144.0 23.0 35.0 75.5 70.5 5.0 86.0 35.0 136.0 28.0 20.0 65.7 58.0
126.0 19.0 29.0 76.5 72.5 4.0 87.0 31.0 137.0 21.0 15.0 72.0 58.4
lower right canine and retained lower right deciduous canine. She was in good health and had no history of dental trauma. The intra-oral examination revealed Angle Class II molar and canine relationships, an overbite of 2 mm, an overjet of 5 mm, no upper or lower arch crowding and the lower left permanent canine was rotated mesio-lingually (Figure 1). Analysis of the pretreatment lateral cephalometric radiograph revealed normal vertical values and a skeletal Class II relationship (Figure 2, Table I). Radiographic examination also revealed that the lower right canine was positioned vertically with the tip of the crown labial to the roots of the lower left central and lateral incisors (Figure 2). There were carious lesions in the occlusal surfaces of upper right first molar and lower left first molar.
exposure, combined with orthodontic alignment, can be performed for labially impacted transmigrated canines. When the crown of a transmigrated canine has migrated past the contralateral incisors or if the apex of the transmigrated canine has migrated past the apex of the ipsilateral lateral incisor, it is usually impossible to move the unerupted tooth into its correct place in the arch. The purpose of this article is to report multidisciplinary treatment of a transmigrated lower right canine. The tooth was positioned between the roots of the left central and lateral incisors and the crown recontoured to simulate a lateral incisor.
Treatment plan
The treatment plan called for extraction of the lower right deciduous canine and closure of the extraction space by moving the right lateral incisor and the both central incisors to the right side. Surgical exposure and forced eruption of the unerupted right canine were planned in order to place the transmigrated canine between the contralateral central and lateral incisors. A Jasper Jumper appliance was used to establish bilateral Class I molar relationships and to correct the overbite and overjet.
Treatment progress
Before active orthodontic treatment, the paedodontist responsible for the patients dental care restored both carious teeth. The treatment objectives and alternatives were explained to the patient and her parents and informed consent was obtained.
Case report Pretreatment evaluation

An 11 year-old girl was referred to the Orthodontic Department at Yeditepe University with an impacted,
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TRANSMIGRATED MANDIBULAR CANINE
(a)
(b)
Figure 2. (a) Pretreatment lateral cephalometric radiograph. (b) Pretreatement panoramic radiograph.
(a)
(b)
Figure 3. (a) The 0.016 x 0.016 inch stainless steel archwire used to correct the lower midline. (b) Forced eruption of the transmigrated canine with the sectional archwire.
Upper and lower 0.022 inch metal Roth brackets were bonded to the teeth in both arches (Victory Series, 3M Unitek, Monrovia, CA, USA) and the lower right deciduous canine was extracted. The upper arch was aligned and the lower arch levelled. The rotated left canine was corrected with a 0.016 inch and 0.016 x 0.016 inch NiTi archwires. A 0.016 x 0.016 inch stainless steel archwire was used to move the lower incisors towards the right side (Figure 3). Five months later, an open coil spring was used to create space between the left central and lateral incisors for the transmigrated canine. After four months treatment, the transmigrated lower right canine was surgically exposed and a bracket bonded to the crown. At the next appointment traction was applied to the transmigrated canine with
a 0.016 inch NiTi segmental wire between the left central and lateral incisors. The main archwire was a 0.016 x 0.016 inch stainless steel wire with an offset between the left central and lateral incisors (Figure 3). After forced eruption of the transmigrated canine, which took 5 months, a Jasper Jumper fixed functional appliance and upper and lower 0.017 x 0.025 inch stainless steel archwires were used to correct the Class II malocclusion. The Jasper Jumper appliance was activated once a month for 4 months. Finishing archwires were used to torque teeth in both arches and were left in place for 4 months. The fixed appliances were removed after 2 years and 5 months of active orthodontic treatment. The tip and labial surface of the transmigrated right canine were reshaped to simulate a lateral incisor. The lower
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(a)
(b)
Figure 4. (a) Frontal view after orthodontic treatment. (b) Lower occlusal view after orthodontic treatment.
(a)
(b)
Figure 5. (a) Post-treatment lateral cephalometric radiograph. (b) Post-treatment panoramic radiograph.
arch was retained with a 0.0175 inch sectional wire bonded to the lingual surfaces of the lower incisors and canines.
Treatment results
During treatment, the upper (U1/NA) and lower incisors (L1/NB) were proclined 4 degrees and 6 degrees, respectively. As a result, the interincisal angle (U1/L1) decreased from 144 degrees to 126 degrees (Figure 4, Table I). The post-treatment panoramic radiograph revealed resorption of the distal root of the lower right first permanent molar, possibly due to the asymmetric Class I forces used to move the incisors to the right side (Figure 5). The lower right molar was root-filled by her paedodontist. Currently, the patient is recalled for retention checks.
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Multidisciplinary treatment involving surgical exposure and orthodontic traction of the transmigrated canine, alignment and correction of the Class II malocclusion and cosmetic reshaping of the canine to simulate a lateral incisor, provided this patient with an acceptable aesthetic and functional result.
Discussion
Developing teeth move within the jaws before emerging into the mouth. It is not known why a tooth deviates from its normal path of eruption and erupts in an abnormal position. The lower canines are the most likely teeth to migrate to the opposite side.5,7,19 The angle between the long axis of an unerupted canine and the midsagittal plane indicates whether a canine is displaced (between 25 and 30 degrees) or likely to migrate across the midline (30 and 95 degrees).18
TRANSMIGRATED MANDIBULAR CANINE
According to Joshi, when the angle between the midsagittal plane and the dental axis exceeds 50 degrees, transmigration is predictable; if the angle falls between 30 and 50 degrees transmigration may develop, and if the angle if less than 30 degrees transmigration is unlikely to occur.14 In our patient the angle between the impacted canine and the midsagittal plane was about 80 degrees and the tooth had migrated across the mandibular midline. If a migrating tooth can be diagnosed early, it may be possible to surgically expose the tooth and move it into the arch. We elected to treat our patient with a combination of surgery and orthodontic treatment. Alternative treatment options are to transplant the tooth to a space in the arch, extract the unerupted tooth and use the deciduous canine as a replacement for the permanent canine or leave the transmigrated canine in situ.16,18 Some clinicians prefer to transplant teeth with immature roots, so only a short period of time is available for the tooth to be detected and transplanted. Furthermore, it may be difficult to remove the impacted tooth intact and avoid damage to the root and/or adjacent teeth: situations that reduce the likelihood of a successful long-term outcome. In our case, the root of the lower canine was completely formed and the tooth was accessible. Our patient had a deep overbite, upright incisors and minimal crowding and did not require the extraction of any permanent teeth. The second and most common option would have been to extract the transmigrated canine. This option is generally favoured when the arch is crowded and a tooth needs to be extracted as part of the orthodontic treatment.16,17 Wertz noted that surgical repositioning of an impacted tooth can be attempted before the tooth is extracted.20 A third option would be to leave the transmigrated canine in situ, but this approach can lead to long-term complications. Impacted teeth have the potential to become ankylosed, making future surgical removal difficult, and they can continue to erupt, leading to resorption of overlying roots and, if they erupt, crowding. The deciduous canine could have been left in position and the appearance of the crown enhanced with composite resin. In our case the transmigrated canine could have been extracted, the extraction space closed and the occlusion adjusted with the aid of temporary anchorage devices. We rejected the latter treatment plan because treatment would have taken longer and required an additional surgical procedure.
There were some disadvantages to our treatment. Firstly, the incisors were proclined between 4 and 6 degrees, due to the Jasper Jumper appliance. Secondly, we detected a slight colour difference in the lower left canine after the cosmetic reshaping procedures and, thirdly, the transmigrated canine had a slightly longer clinical crown than the adjacent lateral incisor. The latter was not considered a great aesthetic disadvantage. Finally, there was no contact between the right lower lateral incisor and upper right canine during lateral excursions of the mandible. This was not considered to be a problem.
Summary
Transmigration of a mandibular canine is a rare event. Early diagnosis of an impacted tooth likely to migrate across the midline allows the orthodontist to present multiple treatment options to the patient and his/her family. Surgical exposure and forced eruption of the transmigrated canine, combined with non-extraction orthodontic treatment and good patient cooperation can give an acceptable orthodontic result.
Dr Gksu Trakyal Yeditepe niversitesi Dishekimligi Fakltesi Ortodonti Anabilim Dal Barbaros Bulvar S akir Kesebir Sokak, No: 26, Balmumcu-Besiktas, 34349 I stanbul Turkey Tel: +90 212 347 71 37 Email: goksu.trakyali@yeditepe.edu.tr
References
1. 2. 3. 4. Daskalogiannakis J. Glossary of Orthodontic Terms, ed 1. Berlin, Germany: Quintessence 2000:2142. Bishara SE. Impacted maxillary canines: a review. Am J Orthod Dentofacial Orthop 1992;101:15971. Shapira Y, Kuftinec MM. Intrabony migration of impacted teeth. Angle Orthod 2003;73:73843. Ando S, Aizawa K, Nakashima T, Sanka Y, Shimbo K, Kiyokawa K. Transmigration process of the impacted mandibular cuspid. J Nihon Univ Sch Dent 1964;6:6671. Aydin U, Yilmaz HH. Transmigration of impacted canines. Dentomaxillofac Radiol 2003;32:198200. Shapira Y, Kuftinec MM. Unusual intraosseous transmigration of a palatally impacted canine. Am J Orthod Dentofacial Orthop 2005;127:3603. Javid B. Transmigration of impacted mandibular cuspids. Int J Oral Surg 1985;14:5479.
5. 6.
7.
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8.
9.
10.
11. 12. 13.
14.
Miranti R, Levbarg M. Extraction of a horizontally transmigrated impacted mandibular canine: report of case. J Am Dent Assoc 1974;88:60710. Brezniak N, Ben-Yehuda A, Shapira Y. Unusual mandibular canine transposition: a case report. Am J Orthod Dentofacial Orthop 1993;104:914. Kaufman AY, Buchner A, Gan R, Hashomer T. Transmigration of mandibular canine. Report of a case. Oral Surg Oral Med Oral Pathol 1967;23:64850. Pratt RJ. Migration of canine across the mandibular midline. Br Dent J 1969;126:4634. Batra P, Duggal R, Parkash H. Canine ectopia: report of two cases. J Indian Soc Pedod Prev Dent 2003;21:11316. Tarsitano JJ, Wooten JW, Burditt JT. Transmigration of nonerupted mandibular canines: report of cases. J Am Dent Assoc 1971;82:13957. Joshi MR. Transmigrant mandibular canines: a record of 28 cases and a retrospective review of literature. Angle Orthod 2001;71:1222.
15. Peck S. On the phenomenon of intraosseous migration of nonerupting teeth. Am J Orthod Dentofacial Orthop 1998; 113:51517. 16. Camilleri S, Scerri E. Transmigration of mandibular canines-a review of the 21literature and a report of five cases. Angle Orthod 2003;73:75362. 17. Thoma KH. Oral Surgery, ed 2. St Louis: Mosby,1952:623. 18. Howard RD. The anomalous mandibular canine. Br J Orthod 1976;3:11721. 19. Mupparapu M. Patterns of intra-osseous transmigration and ectopic eruption of mandibular canines: review of literature and report of nine additional cases. Dentomaxillofac Radiol 2002;31:35560. 20. Wertz RA. Treatment of transmigrated mandibular canines. Am J Orthod Dentofacial Orthop 1994;106:41927.
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Non-surgical treatment of mandibular deviation: a case report

Abdolreza Jamilian * and Rahman Showkatbakhsh
Department of Orthodontics, School of Dentistry, Islamic Azad University* and Shahid Beheshti University of Medical Sciences, Tehran, Iran
Background: Mandibular deviation due to premature contact of teeth in crossbite may be associated with facial asymmetry. Aim: To describe the non-surgical treatment of mandibular deviation associated with a marked facial asymmetry. Methods: A 13.5 year-old girl presented with a unilateral posterior crossbite, noticeable facial asymmetry, anterior crossbite and displacement of the mandible on closure. She had no history of head injury or significant medical problems and her parents rejected surgical correction. A removable appliance was used to correct the crossbite followed by fixed appliances to complete treatment. Results: Treatment resulted in a marked improvement in facial symmetry and elimination of the mandibular displacement. Conclusions: Early correction of a functional deviation associated with a unilateral facial asymmetry may avoid the need for surgery. (Aust Orthod J 2010; 26: 201205)
Received for publication: April 2010 Accepted: June 2010 Abdolreza Jamilian: info@jamilian.net Rahman Showkatbakhsh: showkatbakhsh@hotmail.com
Introduction
Mandibular deviation is the deviation of the mandible as it moves from a postural position into the intercuspal position. It may be due to intermediate or initial tooth contacts deflecting the mandible and it may be associated with a facial asymmetry, which may worsen if the cause of the deviation is left untreated. Congenital anomalies and environmental factors, such as condylar fracture, may lead to the development of facial asymmetry.1,2 Other causes are believed to be: internal derangements in the temporomandibular joint,3 rheumatoid arthritis,4 osteoarthritis,46 condylar hyperplasia or hypoplasia,7,8 temporomandibular ankylosis,9 tumours in the temporomandibular region10 and lateral crossbite.11 Untreated fractures of the mandible can display varying degrees of facial asymmetry.2 There have been several long-term studies of children with fractured mandibular condyles, and the consensus is that many fractured condyles are undiagnosed and regenerate spontaneously.1214 Children with a mandibular deviation due to premature tooth contacts should be treated as soon as convenient to avoid the development of a skeletal
asymmetry. Often orthodontic treatment to eliminate the crossbite is all that is required. We report treatment of a child with anterior and unilateral posterior crossbites, a mandibular deviation to the left side during closure of the jaws and a marked facial asymmetry.
Case report Diagnosis

A 13.5 year-old girl with a unilateral posterior crossbite and noticeable facial asymmetry was referred to a private practice office for orthodontic treatment. Her parents gave no history of head injury or significant medical problems. At the time of examination she had a full permanent dentition, except for the third molars. The extra-oral examination revealed that she had an obvious suborbital hypoplasia of the left side of her face (Figure 1). The mandible was displaced to the left side and the lower dental midline was displaced 6 mm to the left of the facial and upper dental midlines. During closure of the jaws into occlusion, initial contacts occurred between the upper right premolars and first molar and the opposing teeth. The buccal surface of the lower right first molar had wear
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(a)
(b)
(c)
Figure 1. Pretreatment facial and intra-oral photographs. (a) Frontal view. (b) Frontal view with smile. (c) Intra-oral.
Table I. Cephalometric analysis.
Pretreatment
Post-treatment
SNA (degrees) SNB (degrees) ANB (degrees) U1 to MxPl (degrees) L1 to MnP1 (degrees) Intercisal angle (degrees) MMPA (degrees) Facial proportion (per cent) L1 to A-Pog line (mm) SN to MxP1 (degrees)
81.1 79.8 1.3 122.0 102.0 119.0 11.0 67.0 3.2 16.0
78.7 77.6 1.1 128.0 101.0 118.0 10.0 69.0 2.4 15.0
The pretreatment radiographs are shown in Figure 2. The posteroanterior cephalometric radiograph showed a conspicuous left side suborbital hypoplasia. The lateral cephalometric radiograph showed a skeletal Class III relationship and proclined upper and lower incisors (Table I).
Treatment objectives and alternatives

The treatment objectives were to eliminate the anterior and posterior crossbites and achieve a normal buccal occlusion with an ideal overbite and overjet. The treatment plan accepted by the patient and her parents was to extract the upper and lower right second premolars, correct the anterior crossbite with a removable appliance with a posterior bite plane, and then correct the unilateral posterior crossbite, align the teeth and close any residual extraction spaces with a fixed appliance. It was estimated that treatment would take 3 years. Alternative treatment plans using rapid maxillary expansion and miniscrews were rejected. The possibility of future surgery to correct the skeletal asymmetry was discussed with the patients parents and rejected by them.
facets from contact with the palatal surface of the upper first molar. In the intercuspal position the upper right first and second premolars and the first molar were in buccal crossbite and the upper left central incisor, lateral incisor and canine were in palatal crossbite. On the right side the canine and molar relationships were Class III, but on the left side the molar relationship was Class I and the canine relationship was Class II (Figure 1). There was no evidence suggesting a fractured mandibular condyle and the patient and her parents could not recall an accident likely to result in a condylar fracture.
Treatment progress
The anterior crossbite was corrected with a removable appliance with a screw behind the upper left incisors
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NON-SURGICAL TREATMENT OF MANDIBULAR DEVIATION
(a)
(b)
(c)
Figure 2. Pretreatment radiographs. (a) Panoramic radiograph. (b) Posteroanterior radiograph. (c) Lateral cephalometric radiograph.
(a)
(b)
(c)
Figure 3. Post-treatment photographs. (a) Frontal view. (b) Frontal view with smile. (c) Intra-oral.
and canine and a posterior bite plane to disocclude the teeth in crossbite. This appliance was retained with Adams clasps on the first molars and the first premolars and C-clasps on the upper canines and central incisors. The patient was instructed to wear the appliance full-time except for eating, contact sports and toothbrushing. The appliance corrected the anterior crossbite and was used for 6 months.
A standard 0.018 inch edgewise appliance was then placed (American Orthodontics, Sheboygan, WI, USA) and the teeth levelled and aligned with a 0.012 inch stainless steel wire and then a 0.016 inch stainless steel wire. The remaining extraction spaces were closed with stainless steel 0.016 inch round archwires. Three intermaxillary elastics were used for 16 months to correct the posterior crossbite, mandibular
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JAMILIAN AND SHOWKATBAKHSH
(a)
(b)
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Figure 4. Post-treatment radiographs. (a) Panoramic radiograph. (b) Posteroanterior radiograph. (c) Lateral cephalometric radiograph.
procedures were undertaken. The appliance was removed after 3 years and 4 months treatment and an upper Hawley retainer placed.
Treatment results
The extra-oral photographs show the patient has an improved facial profile and less marked facial asymmetry (Figure 3). The intra-oral photograph shows that the crossbites have been eliminated, the midlines are coincident and a normal occlusal relationship has been established. No root resorption was found on the post-treatment panoramic radiograph (Figure 4). At the end of treatment the upper and lower incisors were proclined (Figure 5, Table I).
Figure 5. Pre- and post-treatment tracings superimposed on S-N, at sella.
deviation and the midlines: one diagonal elastic from the upper right canine to the lower left canine; one cross elastic from the buccal surface of the upper right first molar band to the lingual surface of the lower right first molar band; one cross elastic from the lingual surface of the upper left first molar band to the buccal surface of the lower left first molar band. Following correction of the mandibular midline, a Class III elastic was used to correct the right molar and the canine relationships. After a good occlusal relationship was obtained, detailing and finishing
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Discussion
When our patient presented we were concerned about the obvious facial asymmetry and our first thoughts were that the asymmetry would eventually need surgical correction. The patient and her parents rejected a surgical solution, which led us to propose a more conservative line of treatment. We set out to correct the crossbites and midline discrepancy using a removable appliance followed by a fixed appliance. The treatment took longer than we anticipated because we asked the patient to remove the removable
NON-SURGICAL TREATMENT OF MANDIBULAR DEVIATION
appliance during eating and for some sporting activities, and it may have been left out of the mouth for longer periods than desirable. Furthermore, because we did not use a bite plane with the fixed appliance occlusal interferences slowed correction of the posterior crossbite. After correction of the anterior crossbite the upper and lower right second premolars were extracted to enable the lower midline to be corrected and to establish Class I canine and molar relationships. At this stage a full fixed appliance with continuous archwires was placed and the removable appliance with the bite plane discontinued. On reflection, an upper removable appliance with posterior bite planes and fly-over clasps and waxed out over the upper right premolar and molars may have allowed the treatment to proceed more quickly because it would have prevented occlusal interferences from the right premolar and molar. Further correction and better interdigitation were achieved by the fixed appliances with the help of the diagonal and cross elastics. The mandibular deviation and midlines were corrected and normal overbite and overjet were achieved. The dental and facial aesthetics were improved to a great extent. Facial asymmetry is a difficult deformity to correct. Orthognathic surgery along with orthodontics is the first treatment plan for severe mandibular deviation, especially in non-growing patients. It has also been reported that facial asymmetries in children are frequently due to undiagnosed fractured condyles and that the majority of the condyles regenerate spontaneously.12 Asymmetries can be classified according to the structures involved into dental, skeletal and functional. Dental asymmetries can be due to local factors such as early loss of deciduous teeth or thumb sucking. Skeletal asymmetries may involve the maxilla, mandible or both bones. Functional asymmetries arise when a malposed tooth deflects the mandible during closure into occlusion or by a constricted upper arch.2
Associate Professor Abdolreza Jamilian No. 2713 Jam Tower Next to Jame Jam Vali Asr St Tehran 1966843133 Iran Tel: 0098 21 2201 1892 Fax: 0098 21 2202 2215 Email: info@jamilian.net
References
1. 2. 3. Proffit WR, White RP. Surgical-orthodontic Treatment. St Louis, Mosby Year Book; 1991:2470. Bishara SE, Burkey PS, Kharouf JG. Dental and facial asymmetries: a review. Angle Orthod 1994;64:8998. Trpkova B, Major P, Nebbe B, Prasad N. Craniofacial asymmetry and temporomandibular joint internal derangement in female adolescents: a posteroanterior cephalometric study. Angle Orthod 2000;70:818. Gynther GW, Tronje G, Holmlund AB. Radiographic changes in the temporomandibular joint in patients with generalized osteoarthritis and rheumatoid arthritis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;81: 61318. Dibbets JM, Carlson DS. Implications of temporomandibular disorders for facial growth and orthodontic treatment. Semin Orthod 1995;1:25872. Kjellberg H. Craniofacial growth in juvenile chronic arthritis. Acta Odontol Scand 1998;56:3605. Westesson PL, Tallents RH, Katzberg RW, Guay JA. Radiographic assessment of asymmetry of the mandible. AJNR Am J Neuroradiol 1994;15:9919. Tallents RH, Guay JA, Katzberg RW, Murphy W, Proskin H. Angular and linear comparisons with unilateral mandibular asymmetry. J Craniomandib Disord 1991;5:13542. Subtelny JD. The degenerative, regenerative mandibular condyle: facial asymmetry. J Craniofac Genet Dev Biol Suppl 1985;1:22737. Hall HD. Facial asymmetry. In: Bell WH, editor. Surgical correction of dentofacial deformities: new concepts. Philadelphia: WB Saunders; 1985:15368. Pirttiniemi PM. Associations of mandibular and facial asymmetries: a review. Am J Orthod Dentofacial Orthop 1994;106:191200. Harkness EM, Thorburn DN. Hemifacial microsomia label questioned. Angle Orthod 1990; 60:56 (Letter). MacGregor AB, Fordyce GL. The treatment of fractures of the neck of the mandibular condyle. Br Dent J 1957:102:3517. Proffit WR, Vig KW, Turvey TA. Early fracture of the mandibular condyles: frequently an unsuspected cause of growth disturbances. Am J Orthod 1980:78:124.
4.
5.
6. 7.
8.
9.
10.
11.
12. 13.
14.
Conclusion
A patient with mandibular deviation and marked facial asymmetry was successfully treated nonsurgically. Early treatment of crossbites with an associated facial asymmetry may reduce the facial asymmetry.
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Editorial
Effective orthodontics
This issue is one of the largest so far and covers a wide range of topics from bonding (and debonding) to lip tooth relationships during smiling and speech to forces and moments with reverse curve NiTi archwires. It opens with a randomised clinical trial of the utility of custom bases for indirect bonding by Peter Miles. Peters interesting study has important information for the increasing number of clinicians who use indirect bonding. Exogenous opioids reduce macroscopic tooth movement in rats, according to Drs Akhoundi, Dehpour, Rashidpour, Alaeddini, Kharazifard and Noroozi. They suggest that opiate-based analgesics, which are readily available and may be used by patients for pain relief, may do the same in humans. Chromatic adhesives are an attractive proposition because they aid flash clean-up. June Lee, George Georgiou and Steven Jones report there were no differences in the unfatigued and fatigued bond strengths of chromatic and light-cured adhesives, but urge caution before their results are confirmed by clinical tests. The intrusive forces exerted on the upper incisors by NiTi reverse curve archwires are very high regardless of the type of bracket, according to Drs Sifakakis, Pandis, Makou, Eliades and Bourauel. Lighter archwires may be more effective than the NiTi archwire they used and, presumably, result in less tissue damage. Debonding ceramic brackets can be a stressful procedure, particularly if ceramic remnants are left behind or the enamel fractures. Drs Lemke, Xu, Hagan, Armbruster and Ballard compared the bond strengths and modes of failure of ceramic and metal brackets and their findings will be of interest to clinicians using ceramic brackets. Drs Ghoneima, Abdel-Fattah, Eraso, Fardo, Kula and Hartsfield used CT imaging to investigate the skeletal and dental changes during rapid maxillary expansion. They consider 3-D volumetric reconstruction gives a better evaluation of treatment outcomes than traditional radiographic methods. In their study of glass ionomer cements, Drs Dastjerdie, Zarnegar, Behnaz and Seifi tell us that the cements contributed little to band retention, and
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imply that well-adapted bands are the key to good retention. Many orthodontists (and professional associations) use the word smile in their literature. Roozbeh Rashed and Farzin Heravi look at the impact of various types of malocclusion on lip tooth relationships during smiling and speech. They suggest that dynamic records during smiling and speech should be part of our diagnosis and treatment planning and have designed a software programme to facilitate these. Many clinicians will agree that extraction of lower second premolars provides more space for unerupted third molars than extraction of the first premolars, but is it sufficient to allow the lower third molars to erupt into the arch? Drs Celikoglu, Kamak, Akkas and Oktay give us data of the actual space gained and the extent of third molar uprighting following either premolar extractions or nonextraction treatment. Drs Ebin, Zam and Othman tell us Malay children with repaired unilateral cleft lip and palate have normal mandibles, but retrusive maxillae. They postulate that pressure from the repaired lip may be responsible for the retrusive maxillae and retroclined incisors. In this latest investigation of facemask therapy, Dr Gu identifies the craniofacial features contributing to long-term stability of this type of treatment. Dr Gu also calls for a multicentre study to improve the predictive power of the discriminant model. A few days of rapid maxillary expansion followed by a period of slow opening has the same effects on the facial skeleton as rapid maxillary expansion alone, according to Drs Kilic and Oktay. The sagittal and vertical changes were small and variable and may not be clinically significant, according to Nihat Kilic and Hssamettin Oktay. Somewhat surprisingly, buccal tubes with large bonding pads had lower shear bond strengths than tubes with small bonding pads. Drs Purmal and Sukumaran think the periphery of the large pads may have flexed during debonding, leading to early dislodgement. If they are correct, a design change should improve the retention of bonded buccal tubes. The Clark twin block is the appliance of choice for many Class II division 1 malocclusions. Catherine
EDITORIAL
OShea, Andrew Quick, Gillian Johnson, Allan Carman and Peter Herbison combine to analyse mandibular motion in this case report, and tell us that appliance-induced changes in condylar trajectories may be temporary. In this case report Drs Trakyal, ldr and Sandall describe their treatment of a lower transmigrated canine. They used a combination of forced eruption and orthodontic treatment and obtained an excellent result. Drs Jamilian and Showkatbakhsh describe their nonsurgical treatment of a young girl with mandibular deviation. The case was beautifully treated and Abdolreza Jamilian and Rahman Showkatbakhsh point out the advantage of combining a bite plane with the fixed appliances. Associate Professor Craig Dreyer will take over editorship of the Journal in January 2011. Craig is a senior staff member in orthodontics, the Assistant Dean of Clinical Services at the University of Adelaide and has been acting-Dean on several occasions. He has been Chairman of the Appeals Committee of the Australian Society of Orthodontists for many years, which speaks highly of the Societys confidence in his fairness and dedication. Many of you know him through his excellent reviews for the Recent publication section of the Journal, his publications on tissue reactions and excellent chapters in recent orthodontic textbooks. He is an experienced editor having supervised many theses from honours to doctorate level. A/Prof Dreyer has been invited to speak at many universities and conferences: most recently as a keynote speaker at the World Federation of Orthodontists Conference in Sydney. He has also used his skills and extensive knowledge of orthodontics to teach postgraduate students at Khon Kaen University, to review articles for numerous journals, to provide curriculum advice for the Batchelor of Oral Health programme at the University of Adelaide and coordinate the Fourth year undergraduate programme at the University. As external examiners our paths have crossed and the postgraduate students he examined spoke highly of his knowledge and fairness. I am confident you will find him an excellent editor for the Journal. Finally, I would like to thank those who have contributed to the Journal and supported me during my term as editor. Michael Harkness
Retirement of Michael Harkness

Aimee deCathelineau, as current senior editor of the Journal of Cell Biology, recently said, . . . when you read 100 papers you find out what a journal is really about . . .. When you read 100 papers from the Australian Orthodontic Journal, you gain the impression that the Journal is about, well, orthodontics. What Aimee deCathelineau has inferred is that an editor has a crucial role in determining the nature of a journal and the emphasis and the direction that editorial content and manuscripts should take. Writing in Nature, Kendall Powell1 described an editors role as the Gatekeepers burden, as submitted papers are chaperoned through the peer-review and editorial processes and, ultimately, in deciding whether a paper is published. Over almost a decade, Michael Harkness has been the shepherd of our Journal and the overseer of its development. A glance at the last issue published in May 2010 reveals the extent of his contribution. In it there are articles on growth and development, orthodontic materials, therapy, treatment planning, prevention and more. The direction that the Journal has taken has been topical, relevant and of intense interest to the readership. The responsibilities of liaising with authors, chasing referees and the editing of manuscripts can seem a never-ending task. Like his predecessors, Michael has dedicated considerable time, untiring effort and remarkable expertise to the publication of a journal that is increasing in its academic value and its popularity. His strong and broadly-based foundation in science has been applied to the Journals content. His creative and imaginative view of orthodontics and its future prospects has enabled the Journal to grow under his leadership, whilst maintaining a historical perspective of the profession. The Journals readership has basked in an intellectual atmosphere sustained by Michaels honesty and integrity in all aspects of the editing and publishing process. Upon his retirement as editor, Michael Harkness leaves a legacy of service and dedication to the Journal for which the Australian Society of Orthodontists is proud and thankful. Its continued success has been because of his devotion. The Society wishes Michael a happy and long retirement, doing the things that he, heretofore, has been unable to do. Best wishes and thank you from a grateful Society. Craig Dreyer, on behalf of the Journal readership
Reference
1. Powell K. Gatekeepers burden, Nature 2010;464:8001.
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Letter
Letters and brief communications are welcomed and need not concern what has been published in the Australian Orthodontic Journal. We will print experimental, clinical and philosophical observations, reports of work in progress, educational notes and travel reports relevant to orthodontics. We reserve the right to edit all Letters to meet our requirements of space and format. All financial interests relevant to the content of a Letter must be disclosed. The views expressed in Letters represent the personal opinions of individual writers and not those of the Australian Society of Orthodonticts Inc., the Editor, or BPA Print Group Pty Ltd.
Optimal force
Sir, I read with interest the article, The dimensions of the roots of the human permanent dentition as a guide to the selection of optimal orthodontic forces by Dr Brian Lee in the May 2010 issue of the Journal. This thought-provoking and challenging article provided data on the dimensions of roots of teeth, which allowed us to estimate the optimal forces for orthodontic tooth movement. This is a significant contribution for orthodontists seeking a more objective method of assessing the force requirements to move teeth. He also demonstrated that the product of root length and width gives a better estimate of root area than length alone. Current technology, such as threedimensional imaging, may allow the dimensions of the roots of individual teeth to be measured accurately and more conveniently than the manual methods used by Dr Lee. The next technological step will be to design and manufacture stress-breaking brackets. To a limited extent these are available in active self-ligating brackets where the self-ligating latch exerts a force on the archwire. Other stress-breaking designs have been proposed, but alas none are widely available. When
the force is greater than optimal, a stress-breaking bracket is able to reduce the applied force acting via the bracket slot.1 If the manufacturers of brackets can make the intricately designed self-ligating brackets with ever more complex mechanisms, surely a calibrated stress-breaking bracket is not beyond their capabilities? An assessment of the optimal forces required to move the teeth and use of a stress-breaking bracket should result in less tissue damage during orthodontic tooth movement, more patient comfort, more rapid tooth movement and less chair-side time. The challenge is for the profession and manufacturers to explore these possibilities and produce a truly stress-breaking bracket. Felix Goldschmied PO Box 187 Kings Meadows Tasmania 7249 Australia Email address: goldschm@bigpond.net.au
Reference
1. Goldschmied F. A new bracket system. Part I. Aust Orthod J 2001;17:1-7.
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Book reviews
Head and Neck Anatomy for Dental Medicine

Edited by Eric W Barker. Based on the work of Michael Schuenke, Erik Schulte and Udo Schumacher Publisher: Thieme 2010 (www.thieme.com) ISBN: 978 1 604 06209 0 Price: USD $64.95
The final interesting chapter on sectional anatomy correlates the diagrams to MRI images (Magnetic Resonance Imaging), which clarify and enhance understanding of the complex relationships between different structures. An understanding of this information is of paramount importance for 21st century imaging. Overall, the book has many excellent illustrations, particularly for visual learners, that should enhance the retention of information. A criticism would be the lack of detailed text accompanying the illustrations and legends. It is essentially an atlas that attempts to highlight some clinical associations. The book allows one-off registration for the internet/interactive teaching tools, however the registration process is through WinkingSkull.com and this could prove to be a tedious process. Shazia Naser-ud-Din
Bruxism: Theory and Practice
Author: Daniel A. Paesani Publisher: Quintessence 2010 (www.quintpub.com) ISBN: 978 1 85097 191 7 Price: USD $248.00
This is an impressively illustrated atlas with colourcoded tabs for easy referencing to the different chapters. The 14 chapters are recommended as an efficient study tool, not only for students, but also for a broader practitioner-based audience. The important facts and figures are tabulated into several aspects, such as embryonic origins and ossification timelines. The information in the tables is referenced in the number/codes to the illustrations, which should enhance understanding. The excellent artwork and colour-coded illustrations are based on large diagrams that correspond to simulated dissections. The emphasis is on transverse and lateral views and the illustrations show the overlying layers peeled away. Embryonic development and neuroanatomy are comprehensively covered, and an exceptionally clear illustration of the biomechanics of the temporomandibular joint is provided. The clinical relevance of features important to future applications, such as LeFort I - III fractures, is given. These are particularly useful for undergraduate students. In addition, embryological anomalies have been clearly depicted and in-depth details provided. With special reference to oral cavity, the landmarks of various soft and hard tissue components on orthopantomograms are provided. These establish spiral learning as the students can revisit these as they move through the clinical years of their courses.
Bruxism is a complex phenomenon that has both intrigued and mystified the dental profession for many years. The aetiology has been the subject of debate with some believing that it is a centrally driven process, while others believe that it is peripherally generated activity that is mediated by tooth contacts. Dentists appear to believe that all patients brux for a certain period each night and that over a certain threshold this activity, rather than being a normal habit, becomes a pathological process that can lead to
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BOOK REVIEWS
significant tooth wear. Dental treatments vary from preventative measures through to occlusal adjustment with adjunctive appliances. This text is an evidence-based volume providing comprehensive information and a thorough overview of bruxism. There are 25 chapters divided into three sections, written by multiple contributors from around the world. The text is edited by Dr Daniel Paesani who has been the Professor of Stomatognathic Physiology in the School of Dentistry, Universidad del Salvador/AOA, Buenos Aires, Argentina for 12 years. It is clearly written, has excellent photographs and a detailed review of the literature. According to Dr Paesani, the premise was that the information should be based on scientific evidence, thus removing ambiguity from the subject and providing a sound basis for clinical practice. The volume is divided into three sections: the first comprises eight chapters and provides an overview of bruxism, the second comprises nine chapters and deals with the effects of bruxism on the masticatory system and the final (third) section comprises eight chapters describing clinical approaches to the treatment of bruxism. Part 1 introduces the reader to bruxism and has chapters that provide guidelines for diagnosis, sleep physiology, the main aetiological theories, influence of peripheral sensory factors and emotional factors, movement disorders and bruxism in children. Chapter 1 introduces us to bruxism and contains an excellent summary of the prevalence of bruxism by collating studies and presenting the results in tables. Chapter 2 deals with the diagnosis of bruxism and Chapter 3 discusses sleep physiology and bruxism. The latter details the different phases of sleep and sleep architecture. Chapter 4 is an excellent summary of the aetiology of bruxism. It reviews the literature on the aetiology of bruxism and tries to establish the most important aetiological factors that are implicated in the phenomenon. Establishing these factors is thought to be clinically important as they ultimately may determine the treatment that is undertaken by the clinician. Chapters 5 and 6 deal with peripheral sensory factors and emotional factors in the aetiology of bruxism. These are particularly interesting chapters because they provide insights into how occlusal interferences are thought to provide a neuromuscular stimulus capable of triggering bruxism. Currently, most authors lean towards a central aetiology;
210
however, the theory of peripheral influences has not been abandoned. Chapter 7 gives an overview of movement disorders and how they impact on dentistry. Chapter 8 will be of interest to orthodontists, as it gives an excellent summary of bruxism in children. Despite bruxism being common in children, the literature is not extensive enough to provide a firm basis for evidence-based clinical practice. Interestingly, this chapter cites a study that shows that occlusal splints are not useful in reducing the symptoms of bruxism in children. Part 2 provides a detailed analysis of the effect of bruxism on the components of the masticatory system. Chapters 9, 10 and 11 describe tooth wear, dental erosion and reflux as a cause of dental erosion, respectively. Tooth wear is commonly encountered in dental practice and orthodontists are often asked to comment on the relationship between bruxism, malocclusion and tooth wear. Importantly, tooth wear is not exclusively caused by bruxism and may have several different aetiologies. This chapter provides detailed descriptions on tooth wear patterns and is well supplemented by excellent clinical photographs. The chapters on erosion are very detailed and clearly describe various aetiologies. Chapter 11 is solely devoted to discussion of gastroesophageal reflux as a cause of dental erosion. Chapter 12 discusses controversies on the effect of bruxism. This chapter describes some of the controversies and reviews the literature relating to them. It starts by discussing the effect of bruxism on progressive dental crowding. Periodontists have dealt with the effect of bruxism on the disruption of the dental occlusion and do not agree whether bruxism should be considered as a cause of pathologic tooth migration. Other areas discussed are the effects of bruxism on the soft tissues and bone. Chapter 13 deals with the effect of bruxism on teeth and its relationship with endodontics. Chapter 14 discusses the influence of trauma from the occlusion on the periodontium. The relationship between occlusal force and periodontal disease is controversial. This chapter comprehensively reviews the literature and concludes that occlusal trauma per se will not lead to periodontal disease. Chapter 15 describes the effects of bruxism on muscles. Chapter 16 explores TMJ dysfunction and bruxism. It details TMD and has an extensive literature review. It has been suggested that there is a causal relationship between TMD, bruxism and stress, though more data needs to be collected to support this theory. The final
BOOK REVIEWS
chapter in this section discusses craniofacial pain and bruxism. Although there is a potential relationship, it tends to be non linear and it is suggested that craniofacial pain and bruxism should be treated as separate problems in patients. Part 3 provides chapters dealing with clinical approaches to the treatment of bruxism. Chapter 18 provides a description of pharmacological effects of drugs (both central-action and peripheral-action) on bruxism. Chapter 19 will be of significant interest to the dental clinician as it discusses the criteria for selection of dental materials, analyses of wear mechanisms and relates both to the bruxing patient. There is a discussion of posterior composite resin restorations, which is particularly relevant in this aesthetic era of restorative dentistry. Regardless of the restorative material used, all show increased wear in the bruxing patient. Chapter 20 outlines evidence related to the treatment of bruxism. It describes treatments including occlusal splints, mandibular anterior repositioning appliances and behaviour modification treatments. Chapters 21 to 23 deal with oral restoration and its relationship to bruxism. Chapter 21 is an introduction to complex oral restoration and describes centric relation, RP, rotation of the mandible and the anterior bite plane method. Chapter 22 focuses on restoration of the worn dentition. It outlines general management and rehabilitative strategies. Rehabilitative techniques are described and are well supported with excellent clinical photographs. Chapter 23 deals with the effect of bruxism on implant restorations. Implants are an important part of restorative dentistry and it is important to explore the relationship between bruxism and implants. Although the literature generally considers bruxism to be a contraindication for dental implant treatment, there is no clear evidence that implant failure is caused by bruxism. Chapter 24 examines the use of botulinum toxin in the treatment of bruxism. The last chapter describes the clinical treatment of bruxism. It includes a discussion on canine guidance, bruxism splints and treatments with botulinum toxin. Different types of splints are described and detail is provided on the fabrication of the splints. Excellent photographs supplement the text. In summary, this book provides comprehensive information on bruxism. It is clearly written and relatively easy to read. I found it provides a good balance between being concise and providing detail in the
various topics related to bruxism. The literature has been reviewed in detail and each chapter is well referenced. This text serves both as an academic reference and a clinical guide in the treatment of bruxism, and should have a place in the libraries of all dental clinicians and orthodontists. Andrew Barry
Microimplants in Orthodontics
Authors: Jae-Hyun Sung, Hee-Moon Kyung, Hyo Sang Park, Seong-Min Bae and Oh-Won Kwon Publisher: Dentos Australia Pty Ltd (Email: dentos1@optusnet.com.au) ISBN: 89 956605-0-3-93510 Price: AUD $200
This hardcover book, published by Dentos, is a fullcolour volume written by several South Korean pioneers and leaders in the field of microimplant technology as well as Professor James McNamara from Ann Arbor. Well-illustrated and laid out, the book is divided into seven chapters. The first summarises the history of skeletal anchorage in orthodontics, commencing with the early work of Brnemark and colleagues in osseo-integration in the 1970s, through to the more recent studies of this decade. Several illustrations are a little unclear, but this quality may be due to their reproduction from original publications. A comprehensive reference list is cited at the end of each chapter. The second chapter deals with guidelines, including illustrations, for implant size and site selection. Anatomical areas in both the mandible and maxilla are discussed with respect to proposed orthodontic movements, surgical considerations and suggested microimplant size. A short third chapter outlines the development of new smaller orthodontic microimplants and their clinical applications. These fixtures (Absoanchor, Dentos Inc.), designed by one of the authors, can thus be placed in any area of the mouth, including the interradicular areas. Various designs, selected according to site and function, are illustrated together with recommended elastomers. Surgical procedures for implant insertion and removal are comprehensively described in Chapter 4.
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BOOK REVIEWS
These include the surgical armamentarium, operative procedures, pitfalls and the timing of force application. This section is comprehensively illustrated with high quality photographs and diagrammatic representations of clinical procedures. Chapter 5 describes and illustrates biomechanical considerations in anchorage, and addresses techniques for control in all dimensions ranging from molar intrusion in open bite cases to achieving unilateral maxillary constriction with an implant at the midpalatal suture. Clinical case reports are presented in the following and largest chapter. The authors aim to demonstrate a wide variety of applications for microimplant anchorage, and commence with a classification of their cases, ranging from skeletal malocclusions to minor tooth movement. Extensive clinical photographs and pre- and post-treatment superimpositions are included with each case. Other interesting uses include placement for intra- or intermaxillary elastics (also following orthognathic surgery for fixation) and potential anchor units for fixed functional appliances. The concluding chapter evaluates success and failure rates of implants, referring to recent published studies. This reference guide provides a clear and well-illustrated overview of microimplant usage for orthodontic anchorage based on directional force mechanics, and would be a valuable addition to the library of any orthodontist or oral and maxillofacial surgeon with an interest in implant technology as an adjunct to routine orthodontic protocols. Denise Lawry
Change Your Smile. Fourth Edition
Author: Ronald E. Goldstein Publisher: Quintessence 2009 (www.quintpub.com) ISBN: 978 0 86715 466 5 Price: USD $29.50
what can be achieved with the latest techniques in cosmetic dentistry. The book also attempts to list some of the limitations of cosmetic dentistry. Chapter 1 begins with a list of questions to be answered by the patient, to see if the patient really needs and wants to change their smile. It reminds the patient that their smile does not only consist of the six front teeth, but all the teeth and gum tissue that show when the patient is speaking or in the maximum smiling position. He also advises patients to look at their facial proportions. The Smile Analysis, which is another list of questions, points out the different dental problems that can affect the smile. This analysis asks the patient to look at the size, shapes and positions of his or her teeth and the condition of the gums, the patients facial appearance and lip positions when smiling. There are lots of photos illustrating the problems listed. This chapter also tells the patient how to select a good cosmetic dentist. The author advises that it is very important to have good communications with the dentist, stating exactly what the patients concerns are and to discuss the treatment options and their costs before making a final decision.The next nine chapters are about the actual problems and detailed treatment options: Chapter 2, Staining and discolouration of teeth; Chapter 3, Decay and old fillings; Chapter 4, Fractured teeth; Chapter 5, Spaces between teeth; Chapter 6, Missing and lost teeth; Chapter 7, Crooked teeth; Chapter 8, Bite problems; Chapter 9, How your smile can make you look younger and Chapter 10, How the gums affect the overall appearance of your smile. The types of treatment recommended are cosmetic contouring, bonding, porcelain veneers, crowns, orthodontics, fixed and removable bridges, implants and dentures. At the end of each chapter there is a table summarising the treatment solutions, treatment time, maintenance needed, costs, advantages, disadvantages and treatment longevity. In Chapter 6, on the treatment of missing teeth, the author recommends the use of a fixed bridge, removable bridge, complete denture or implants as treatment options, but orthodontics is not listed as a treatment option. Chapter 10 tells the patients everything they need to know about keeping their gums healthy and, hence, improving their smile. The author explains what healthy gums look like and the causes of gum disease, and how to prevent it or treat it. He also gives a few solutions on how to mask bone loss
28001_aoj_ortho_jnl_26.2_dec15:06:24
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Yellow Black Cyan Magenta
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Front
This is a comprehensive book about cosmetic dentistry for patients, and for dentists to show patients what can be done to correct common dental aesthetic problems, in order to improve their smiles and enhance their facial appearance. It is written in laymans language and is full of before and after photographs and diagrams to illustrate to patients
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BOOK REVIEWS
and gingival recession and how to treat a gummy smile. Chapter 11 is about making changes to the patients facial features to make them look better. The first half of this chapter is written by a maxillofacial surgeon, Dr Louis S. Belinfante and the second half is by two plastic surgeons Drs Farzad Nahai and Foad Nahai. Dr Belinfante explains in simple terms what orthognathic surgery involves, the costs, and what orthognathic surgery can correct. He emphasises that good communication between surgeon and patient is necessary for success. He also gives advice on how to select a good maxillofacial surgeon. There are before and after photos of pre- and post-orthognathic surgery. Unfortunately, the photograph on page 177 is upside down. He finishes with a table summarising treatment options, risks and costs. The plastic surgeons warn patients that cosmetic surgery should be carried out for the right reasons, and list questions to determine if a patient is a candidate for plastic surgery. They give advice on how to select an appropriate surgeon and show the patient what type of things can be achieved with plastic surgery and/or minimally invasive procedures, such as Botox and facial fillers. They also give a summary table at the end. The last chapter, Finishing touches, gives advice on health, skin and lip care, diet, beauty and hairstyle. The book ends with an appendix. This is a quick look at the major cosmetic dentistry techniques presented in the book and how they are carried out. It gives the patient a description of what is to be done to their teeth. The procedures covered are bonding, crowns, veneers, bridges, implants and orthodontics. Again, this section is well-illustrated. The section on orthodontics mentions braces (metal and tooth-coloured), but advises the patient to ask about Invisalign, lingual braces and spring aligners. He lists the disadvantages of lingual braces and the spring aligners, but doesnt give any disadvantages of Invisalign for orthodontic treatment. Throughout the book the author recommends Invisalign for orthodontic treatment. Overall, the book is a bit repetitive, but it is comprehensive. It is a useful book for cosmetic dentists to have in their surgeries or waiting rooms to show patients what cosmetic dentistry can do to change their appearances. The photographs and illustrations make it easier for the dentist to explain their treatment procedures to the patient. Some of the solutions
suggested do not correct the problem but mask it nicely, hence patients may be tempted to select a compromise or easy solution. Kit Chan
Dental Implants: The Art and Science
Authors: Charles A. Babbush, Jack A. Hahn, Jack T. Krauser and Joel L. Rosenlicht Publisher: Elsevier Australia 2010 (http://shop.elsevier.com.au) ISBN: 9781416053415 Online price: AUD $283.50
This is a review of the second edition of this book, which aims to provide a comprehensive review of the principles and concepts in the constantly changing field of implant dentistry. The book outlines the basic concepts in implant dentistry, but has a very North American focus in its discussion of fee structures, practice set-up and demand for treatment. Furthermore, there is a distinct bias towards the implants and treatment modalities proposed by Nobelbiocare. The initial chapters focus on diagnosis and treatment planning of the implant patient. This seems to be largely surgically driven and there is limited discussion of the prosthetic treatment planning involved in these cases. The latter half of the book focuses on surgical anatomy, soft and hard tissue grafting procedures, nerve repositioning and immediate loading of implants in single tooth and full arch rehabilitations. Again, there is a very limited discussion about the prosthetic aspects of the management of treatment. There is a discussion limited to two pages about the placement of implants in young patients and this is followed by several case studies. There is no discussion at all about the use of implants as orthodontic anchorage. Of interest is that three of the four authors are maxillofacial surgeons. As such I suspect that this has influenced the overall direction and tone of this book as it has a strong surgical bias. Where I find the book further lacking is in discussions of implant soft tissue aesthetics, long-term maintenance and the success of these modalities of treatment.
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I must conclude that this book may prove interesting to readers who seek greater knowledge in some of the more advanced and controversial surgical implant techniques. However, the book as a whole is disjointed, and does not inform individuals who have a limited knowledge of implant dentistry; they would probably be better to look elsewhere to attain a more comprehensive discussion of the topic. Eric Tan
Implant Dentistry: A Practical Approach. Second Edition
Author: Arun K. Garg Publisher: Mosby Elselvier 2010 (http://shop.elsevier.com.au) ISBN: 9780323055666 Online price: AUD $160.20
This second edition is well set out and illustrated. Professor Garg has presented a fairly concise, welldocumented and an easy-to-read contemporary text. This is a comprehensive text with 19 chapters and four appendices. It begins with a chapter on the historical development of dental implants, which is well compiled and is helpful in understanding the history of implants and how implant design has changed with time and our knowledge of biology. This gives an excellent history of the development of implants from bone to titanium and the evolution of endosteal and periosteal dental implant designs. Professor Garg then moves on to the armamentarium required for implant dentistry. He includes the use of an implant guiding system to assist with implant to tooth and inter-implant spacing during surgical placement. This chapter is a good reference for the basic and extended use of surgical instruments. His discussion of medical history and anatomic considerations for implant dentistry are practical. Often anatomic considerations are not practically related to implant dentistry, but this chapter is well-written and illustrated and is a useful review of the vital structures and landmarks that the implantologist needs to grasp for surgical practice.
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One of the highlight chapters is on surgical templates in implant dentistry. The transfer of our proposed treatment from diagnostic wax-up to imaging and then to surgery is critical. This chapter takes us through the manufacture of simple single tooth templates, to fully edentulous situations. He also discusses the various com-puterised template systems available and their applications. The chapters on sterilisation, disinfection and asepsis; medical history; generalised surgical techniques and wound healing; and suturing techniques provide adequate information, but could go into more detail as these are all vitally important to the practical aspects of surgery. The chapter on anterior single tooth implants presents a classification of immediate extraction and immediate placement, but does not present a solidified philosophy of technique. Articles and techniques from the literature are presented, when clear clinical techniques and guidelines would be useful. The description of implant properties desirable does not yet include the technique of laser etching of the implant surface for soft and hard tissue attachment. The highlight of this book is his chapter on bone biology, osseointegration and bone grafting. Understanding bone biology and physiology enables the implant clinician to adequately engineer treatment plans with an understanding of the effect of force on the proposed prosthesis. The author has concisely summarised the salient points of this expanding field of knowledge. The chapters on considerations for implants in the geriatric patient, peri-implantitis and guidelines for handling complications associated with implant procedures are useful short summaries on these aspects of implant dentistry. The final third of the book contains a glossary of implant terminology and appendices on American item number use, consent forms, surgical trays, a useful appendix on post-operative instructions and dietary menus for patients of implant surgery. In this final appendix, he includes a suggested lifestyle change for patients that may not be well received by the Australian patient psyche. A useful inclusion would be a chapter on the surgical placement and use of implants and mini-implants in orthodontics. In summary, this is a useful addition to the implantologists library. Dan Brener
BOOK REVIEWS
Orthodontic and Dentofacial Orthopedic Treatment

Authors: Thomas Rakosi and Thomas Graber Publisher: Thieme 2010 Distributor: Elsevier Australia (http://shop.elsevier.com.au) ISBN: 978313127761 9 Online price: AUD $278.10
appliances. The first discusses the principles, scope and limitations of functionals, together with a discussion of the activator and the bionator. The second chapter (written by Dr Clark) is about his twin block appliance and the third chapter explores the use of rare-earth magnets to help in mandibular propulsion. There follows chapters on early maxillary expansion and inter-arch compression springs, which introduce the reader to a number of systems including the Herbst, Jasper jumper, Forsus and Twin Force. The next section of the book is related more to fixed appliance systems and has chapters exploring anchorage control, segmented arch mechanics, the Alexander discipline, implants and orthodontics, and treatment with the Invisalign system. A comprehensive chapter on tooth stripping by Zachrisson follows, and the book concludes with chapters on active retention procedures and treatment planning for mandibular distraction osteogenesis respectively. As a treatment manual it does well, but could have been so much more. In the preface the editors comment that for this new treatment textbook they have chosen orthodontic topics that they consider to be the most important for rendering the highest level of service, in the safest, most practice-efficient way. A big call. You cannot please everyone, but perhaps some chapters on the straight-wire appliance which is arguably the most commonly practiced technique in the world at the current time in one guise or another, self-ligating bracket systems, aesthetic bracket systems, lingual orthodontics and orthognathic surgery would add that little bit more depth to make it the definitive text it deserves to be. It would sit well as a reference guide in dental libraries and for postgraduate s tudents, but will have limited appeal to the more experienced orthodontist. Andrew Toms
This book adds to the burgeoning collection of compilation texts that are now available for the orthodontic and dental professions. It is meant to be a treatment book and a companion volume to Orthodontic Diagnosis, which was first published in 1993. Edited by Drs Thomas Graber and Thomas Rakosi it has 14 contributors who are well-known academics and clinicians from around the world. Unfortunately, Dr Graber was unable to see the completed work and the book is dedicated to his memory. There are 16 chapters, each of which is very well illustrated and generally read well. Each chapter is well-referenced, but a few need to give more current references. The reviewer acknowledges that there is a lag period between the writing of a textbook and its publication, and it is often difficult to cite contemporary references. Three chapters have no references more current than 2000 and five no more recent than 2001. The first few chapters introduce the reader to therapeutic diagnosis, preventive orthodontics and early treatment; interceptive guidance of the occlusion, including serial extraction followed by mechanotherapy. The next three chapters consider functional
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Recent publications
Abstracts of recently published papers reviewed by the Assistant Editor, Craig Dreyer
Effectiveness of a lower lingual arch as a space holding device

A.I. Owais, M.E. Rousan, S.A. Badran and E.S. Abu Alhaija
Longitudinal changes in microbiology and clinical periodontal parameters after removal of fixed orthodontic appliances
J. van Gastel, M. Quirynen, W. Teughels, W. Coucke and C. Carels
The early loss of primary teeth has the potential to create an arch length discrepancy leading to crowding or tooth impaction. The greatest space loss has been attributed to mesial movement of the first permanent molars, and a lower lingual arch has been accepted as a standard component of preventive orthodontic space maintenance. Despite widespread use, little is known regarding the efficiency of the lingual arch and its effect on the dimensions of the mandibular arch. This study therefore examined the effectiveness of the lingual arch and compared two different wire gauges. The authors identified 67 subjects from an orthodontic centre into which 44 lingual arches were placed and monitored. Selected subjects who were in the mixed dentition, possessed a Class I or mild Class II malocclusion, a normal or slightly increased overbite and had primary second molars earmarked for extraction. Subjects were randomly divided into two groups, which either had an arch made from 0.9 mm or 1.25 mm wire. A group of 23 patients who received no treatment served as controls. Arch assessments were made from pretreatment cephalograms, dental pantograms and study casts taken and retaken at six months and at the end of treatment. In both treatment groups, the lower incisors proclined and moved forward, and space loss in the area of the extracted primary second molar occurred. While arch length preservation occurred, it was at the expense of lower incisor proclination and the loss of primary molar extraction space. The lingual arch made from 0.9 mm wire was found to be superior for arch length preservation. The preference for the smaller gauge wire was determined by the fewer breakages and clinical problems compared with the more rigid 1.25 mm wire.
European Journal of Orthodontics doi:10.1093/ejo/cjq022
It is well known that the placement of orthodontic bands and brackets influences plaque accumulation and growth. In addition, there are significant differences in biofilm formation and periodontal reaction between different bracket types and between bonded and control teeth. The aim of this longitudinal study was to monitor patients microbiological and clinical parameters from bracket placement up to 3 months post-treatment. Twenty-four patients (10 males and 14 females, aged 14.6 1.0 years) were investigated for the microbiology of sub- and supra-gingival flora, periodontal probing depth, bleeding on probing and gingival crevicular fluid flow, and assessed upon the placement of orthodontic appliances, upon their removal and three months post-treatment. All patients received standardised oral hygiene instructions and were selected to be free of extensive dental work and periodontal disease, to be non-smokers and not taking antibiotics. The statistically evaluated results demonstrated that sub- and supra-gingival colony-forming unit ratio of aerobic to anaerobic bacteria decreased significantly from the time appliances were placed until their removal. Microbial levels did not recover in the three months after treatment, which meant a sustained increase in the levels of anaerobes. Clinical parameters for periodontal probing depth, bleeding on probing and gingival crevicular fluid showed significant increases while appliances were in place, but decreased following debanding/debonding to still remain higher than original levels. The authors concluded that fixed appliances altered microbial and periodontal parameters, which did not recover to pretreatment levels over the examination period. It was
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RECENT PUBLICATIONS
suggested that the prospect of any required periodontal treatment best be left until at least three months after orthodontic therapy.
European Journal of Orthodontics doi:10.1093/ejo/cjq032
Relationship between initial crowding and interproximal force during retention phase
K. Okazaki
Long-term stability of tooth alignment has been stated as an aim of orthodontic treatment, but often there is disappointment in the poor patient response. It has been shown that most of the treatment collapse occurs in the two years after the cessation of retention, and that contact point displacement was related to the level of interproximal force in treated and untreated cases. The present study chose to examine the change in interproximal force (IPF) between lower anterior teeth during the retention phase, its relationship between the irregularity index before orthodontic treatment, and the total IPF. In addition, the effects of erupting third molars on the total IPF were recorded. Forty patients who underwent orthodontic treatment with premolar extractions in the Department of Orthodontics of Nihon University Dental Hospital were selected after applying the following criteria. Cases in which the overbite fell in the range of 0.5 to 4.0 mm, an overjet of 1.0 - 4.0 mm or crowding of 0.5 - 10.0 mm in the lower anterior teeth, were chosen. Following fixed appliance treatment, corrected incisors were retained by a wrap-around retainer without any interproximal reduction of tooth substance. Interproximal force was measured by the placement of a 30 mm-thick titanium strip between the mandibular anterior teeth and with the patient seated upright, the strip was withdrawn using a digital force gauge at 10 mm/sec. Five anterior contact points were measured, each three times, and values averaged and then added. This sum produced a total IPF for each patient and the procedure was performed at each visit until 18 months after active treatment. The IPF effects of third molars were assessed by comparison of patients with impacted third molars and their relationship with second molars as determined by panoramic radiology. One-way analysis of variance and intergroup comparisons were statistically determined.
The total interproximal force increased during the retention phase study period. There was a positive correlation between the pretreatment irregularity index and the total IPF. The effects of the third molars were not statistically significant. The authors suggested that the total increase in IPF may be an indication of relapse in mandibular anterior crowding. Although other relapse factors need consideration, it was suggested that clinicians pay special attention to the relapse potential of increasing IPF, particularly if severe irregularity existed prior to treatment.
Journal of Oral Science 2010; 52: 197-201
Adult orthodontics whos doing what?

M.K. Cedro, D.R. Moles and S.J. Hodges
A United Kingdom Adult Dental Health Survey in 1998 indicated that 27 per cent of adults were dissatised with the appearance of their teeth. A more recent British Dental Health Foundation Survey revealed that one in two adults approaching middleage would consider having dental treatment purely to improve their smile. In addition, adults in the 36 to 45 year age group were much more likely to consider cosmetic treatment to improve the appearance of their dentition. While it has been revealed that adults in the 18 to 30 age group make up approximately 17 per cent of the average orthodontists workload, the aim of this study was to assess the factors and estimate the number of adults currently being treated by specialist orthodontists in the UK, within the NHS and privately. After a small pilot study, three postings of a questionnaire yielded 724 usable responses, out of a total of 1034 sent to registrants on the General Dental Councils Specialist List in Orthodontics, on 1 September 2007. The nal response rate was 70 per cent. Respondents had worked as orthodontists for a mean of 15.7 years, although there was a wide distribution ranging from six months to 51 years. The main workplace for the majority of respondents was specialist orthodontic practice (62.3 per cent), followed by the hospital service (29.2 per cent). A minority worked in university (academic) posts (1.8 per cent). The most commonly reported adult age groups treated were 26 - 35 years (73.9 per cent of respondents) and 36 - 45 years (64.6 per cent of respondents). The age group least frequently treated were those aged 55 years and older (16.9 per cent of respondents).
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Slightly more than half (55.1 per cent) indicated that the majority of their NHS adult patients were referred by general dental practitioners and 61.3 per cent stated that general dental practitioners were their main source of private patient referrals. In addition, a substantial proportion of orthodontists stated that the majority of their private adult patients were selfreferred (25.7 per cent of respondents). The mean percentage of adults undergoing orthodontic-only treatment was 72.5 per cent and adjunctive multidisciplinary treatment was 22.8 per cent. The most common appliance type used was the pre-adjusted edgewise appliance followed by selfligating systems. Concerns regarding the appearance of the appliances were cited as the most common complicating factor expressed by the adult patients. In the previous financial year, the total number of adult cases started by all questionnaire respondents within the NHS was 14,099 and privately was 18,511. While it has been reported that the number of adult orthodontic patients is increasing, no previous data from specialist orthodontic providers are available by which to compare these results. Therefore, the authors suggest that this information be viewed as a baseline for comparison with future studies.
Journal of Orthodontics 2010; 37: 107117
vention groups, both of which were treated with EMD/DFDBA, but only one group of 24 patients received orthodontic care. Patients had either a 2- or 3-walled infrabony defect of at least 6 mm, which was managed with EMD and DFDBA for four weeks prior to the application of an orthodontic extrusive force. Probing depth and the clinical attachment level were recorded prior to treatment and again at one year. The primary outcome measure was an absolute change in probing depth and attachment level. A secondary outcome was an absolute change in open probing attachment level gain and percentage defect resolution from the commencement of surgical treatment to re-entry surgery six months later. Results indicated that both groups showed a significant improvement following treatment. The group that received the orthodontic extrusion had statistically significant probing attachment level gain related to 2wall defects. The authors concluded that both treatments were effective in managing all infrabony defects, but limited orthodontics provided an additional benefit in 2-wall defects. The authors contend that the results should be viewed with a degree of caution because of inherent limitations of the study, but at least the work highlighted that there are other benefits of orthodontic care apart from the expected aesthetic improvement.
Journal of Periodontology doi: 10.1902/jop.2010.100127
Periodontal regeneration with or without limited orthodontics for the treatment of 2- or 3- walled infrabony defects
S. Ogihara and H-L. Wang
Orthodontic extrusion of the lower third molar with an orthodontic mini-implant

W. Park, J-S. Park, Y-M. Kim, H-S. Yu and K-D. Kim
Past studies on forced eruption of teeth in a healthy periodontium have generally indicated a beneficial effect on alveolar bone levels. Unhealthy periodontium has been treated and subjected to the application of enamel matrix derivative (EMD) or the use of demineralised freeze-dried bone allograft (DFDBA) in order to recover lost bone. The results have been equivocal. The authors of this study therefore aimed to compare the clinical efficacy of limited orthodontics combined with EMD/DFDBA in the treatment of 2- or 3-walled infrabony pockets. A randomised, parallel clinical trial was undertaken in a private periodontal practice over a 4-year period. The treatment duration was one year with a one-year follow-up. Forty-seven patients (Mean age: 53.0 10.7 years) were randomly allocated into two inter218
Lower third molar extraction is one of the most common surgical procedures in oral and maxillofacial surgery. Damage to the inferior alveolar nerve and subsequent neurological changes are the most serious complications associated with third molar removal. The introduction of cone beam computed tomography has allowed the 3-D visualisation of third molars and their relationship with the inferior alveolar nerve, but has not entirely removed the risk of nerve damage due to surgery. Two techniques have been introduced to minimise the risk of post-third molar extraction paraesthesia. Coronectomy has been advocated but remains controversial while extraction of the third molar following orthodontic extrusion occurs only rarely. However, the advent of the miniscrew has provided
RECENT PUBLICATIONS
anchorage possibilities in regional orthodontic treatment and the use of simple orthodontic appliances. The authors describe two cases in which orthodontic extrusion of an impacted third molar was undertaken because of its close approximation to the inferior alveolar nerve. In both cases, miniscrews were placed in the lower premolar region and segmental appliances attached to the buccal teeth. An elevating archwire was inserted back to the third molar while vertical anchorage was reinforced by the attachment of the premolars to the mini-screw. Six and nine months after the commencement of extrusion, the third molars were uneventfully extracted and the inferior alveolar nerve left intact. While the complications with this approach were reportedly minimal, the foreseen difficulty is the bonding of an attachment to the third molar.
Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontics doi:10.1016/j.tripleo.2010.04.031
Orthodontic therapy and gingival recession: a systematic review

I. Joss-Vassalli, G. Grebenstein, N. Topouzelis, A. Sculean and C. Katsaros
Long-term epidemiological studies have indicated that despite a reasonable level of oral hygiene, gingival recession is found in 60 per cent of the younger population ( 20 years) and more than 90 per cent of those older. The occurrence of recession has been found to be much higher in a population who experience no dental care. The reasons for gingival recession have been associated with mechanical, periodontal or to inflammatory disease. This study therefore aimed to assess the effects of orthodontic treatment on the occurrence of gingival recession by a systematic review the gingival effects of incisor inclination change. The study comprised a literature search undertaken by two of the authors who accessed the PubMed, EMBASE Excerpta Medica and CENTRAL of the Cochrane Library databases. Appropriate MeSH searches were conducted using the terms gingival recession, orthodontics, gingival disease and articles in any language were considered. The inclusion criteria were human or animal studies, controlled or randomised clinical trials and the occurrence of gingival recession associated with anterior teeth. Exclusion criteria identified medically compromised
patients, studies of injured or traumatised anterior teeth and studies in which periodontal disease was evident. Of the 1925 articles initially identified, only 17 were finally included. Eleven articles were retrospective clinical studies in humans, while six were animal studies. The authors results and conclusions indicated that there were no high-quality animal or clinical studies on gingival recession. The major reason for the low level of evidence in the animal as well as in the human studies was the lack of diagnostic reliability tests. Animal studies tended to suggest more gingival recession in displaced incisors than in control teeth. Clinical studies showed that more proclined teeth compared with less proclined teeth or untreated teeth, and movement of the incisors out of the osseous envelope of the alveolar process, may be associated with a higher tendency for developing gingival recession. Because of the low level of evidence of the included studies, the authors suggest that the results be considered with caution. In addition, the amount of recession found in studies with statistically significant differences between proclined and upright incisors is small and the clinical consequence questionable. It was suggested that further prospective, randomised clinical studies, including clinical examination of oral hygiene and the gingival condition before, during and after treatment, were needed to clarify the effect of orthodontic changed incisor inclination and the occurrence of gingival recession.
Orthodontics and Craniofacial Research 2010; 13: 127-141
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In appreciation Reviewers for the Australian Orthodontic Journal

Over the past year the following individuals have generously contributed their time, knowledge and expertise reviewing articles for the Journal. We sincerely thank them and acknowledge their considerable contributions which have improved the quality of the Journal.
Rola Al Habashneh, Irbid, Jordan Kazem Al Nimri, Irbid, Jordan Michael Anderson, Ashgrove, Q Paul Armbruster, Louisiana, United States of America John Armitage, Melbourne, Vic David Armstrong, Coffs Harbour, NSW Stephen Atkin, Redcliffe, Q Saeed Banabilh, Kelatan, Malaysia Matthew Barker, Wellington, New Zealand Derek Barwood, Auckland, New Zealand Donna Batchelor, Christchurch, New Zealand Phillip Benson, Sheffield, United Kingdom Eduardo Bernabe, London, United Kingdom Jim Bokas, Burwood, Vic Pierre Bourdiol, Clermont-Ferrand, France Guy Burnett, Adelaide, SA Barbara Carach, North Ringwood, Vic Luke Chapman, Louisiana, United States of America Tony Collett, Ferntree Gully, Vic John Coolican, Chatswood, NSW Angela Coombe, Pymble, NSW Amy Counts, Florida, United States of America Michael Courtney, Palmerston North, New Zealand Marguerite Crooks, Christchurch, New Zealand Paul Crowther, Christchurch, New Zealand Ali Darendeliler, Sydney, NSW Saxton Dearing, Napier, New Zealand Craig Dreyer, Adelaide, SA Bernadette Drummond, Dunedin, New Zealand Peter Dysart, Dunedin, New Zealand Carlos Flores-Mir, Alberta, Canada Matthew Foo, Pymble, NSW Peter Fowler, Christchurch, New Zealand Elissa Freer, Mt Ommaney, Q Terry Freer, Bardon, Q John Fricker, Manuka, ACT Shane Fryer, Wollongong, NSW George Georgiou, London, United Kingdom Allahyar Geramy, Tehran, Iran Peter Gilbert, Dunedin, New Zealand Keith Godfrey, Sutherland, NSW Urban Hgg, Hong Kong, Peoples Republic of China Fiona Hall, Mount Lawley, WA Winifred Harding, Dunedin, New Zealand James Hartsfield, Kentucky, United States of America James Hawkins, Sydney, NSW
David Healey, Dunedin, New Zealand Farzin Heravi, Mashhad, Iran Junichiro Iida, Sapporo, Japan Hideki Ioi, Fukouka, Japan Brooke Jolly, New Plymouth, New Zealand Viral Kachiwala, Muscat, Oman Brett Kerr, Ashgrove, Q Elias Kontogiorgos, Texas, United States of America Budi Kusnoto, Chicago, United States of America Eden Lau, Lower Mitcham, SA Igor Lavrin, Melbourne, Vic Gavin Lenz, Brisbane, Q Kerry Lester, Woollahra, NSW Pei-Ti Lin, Parkville, Vic Eric Liou, Taipei, Taiwan Lombardo Luca, Ferrera, Italy Erin Mahoney, Sydney, NSW Sameh Malek, Burwood, NSW Montien Manosudprasit, Khon Kaen, Thailand Ken Marshall, Blaxland, NSW Domingo Martin, San Sebastian, Spain Brendan McCane, Dunedin, New Zealand Ana Claudi Melo, Curitiba, Brazil Stephen Moate, Forestville, NSW Rachel Moore, Dargaville, New Zealand Andrea Motta, Rio de Janeiro, Brazil Jose Nelson Mucha, Rio de Janeiro, Brazil John Muir, Auckland, New Zealand Shazia Naser-ud-Din, Brisbane, Q Daniel Ngan, Sydney, NSW Rick Olive, Brisbane, Q Kieran ONeill, Invercargill, New Zealand Desmond Ong, Helensvale, Q Lynne Opperman, Texas, United States of America Stephen Papas, New Farm, Q Ian Patrick, Epping, NSW Timo Peltomaki, Tampere, Finland Ajith Polonowita, Bendigo, Vic Maryam Poosti, Mashhad, Iran Zainul Rajion, Kelantan, Malaysia Sarbin Ranjitkar, Adelaide, SA Morris Rapaport, Bondi Junction, NSW Henry Rawls, Texas, United States of America Mike Razza, Booragoon, WA David Rogers, Highgate, WA Wayne Sampson, Adelaide, SA
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Australian Orthodontic Journal Volume 26 No. 2 November 2010-
IN APPRECIATION
Philip Sanford, Invercargill, New Zealand Seyed Safavi, Tehran, Iran Martyn Sherriff, London, United Kingdom Steven Singer, Kingsley, WA Jane Spark, Epping, NSW John Stamatis, Booragoon, WA Steve Stramotas, Chatswood, NSW Michael Swain, Dunedin, New Zealand Arzu Tezvergil-Mutluay, Turku, Finland Guilherme Thiesen, Florianpolis, Brazil Abi Thomas, Punjab, India Murray Thomson, Dunedin, New Zealand Marcus Tod, Upper Mount Gravatt, Q Martin Tyas, Melbourne, Vic
Christine Underhill, Edgecliff, NSW Oktay Uner, Ankara, Turkey Tancan Uysal, Kayseri, Turkey Jan Van Gastel, Leuven, Belgium Vicky Vlaskalic, Hawthorn East, Vic Jeffrey Watts, Auckland, New Zealand Willliam Weekes, Gosford, NSW Tony Weir, Corinda, Q Geoff Wexler, Toorak, Vic Greg White, Camberwell, Vic Dilshan Wijayaratne, Sandy Bay, Tas Peter Wilkinson, Benowa, Q Matthew Williams, Wellington, New Zealand
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New products
Lava digital model

The new 3M Lava digital model tools make it easy for doctors to display models for new patients and analyse models for treatment planning. According to the manufacturer, the Lava treatment management portal has new features including upgraded analytical tools such as occlusal mapping, bite adjustment, grid measurement and email capability. For further information contact your 3M Unitek Territory Manager Tel: 136 136 484
Medical Indemnity Protection Society
Medical Indemnity Protection Society (MIPS) provides extensive indemnity cover for the dental profession. Members have access to knowledgeable, professional and confidential advice from an experienced and sympathetic colleague on all medico-legal matters. For further information contact MIPS Tel: 1800 061 113 Website: www.mips.com.au Email: info@mips.com.au
Cinch-back plier
The new cinch-back plier from Dentaurum can bend NiTi wire in the mouth, eliminating the need to remove the archwire. The manufacturer states it can be used to form indentations (dimples) at the midline to lock the archwire between the central incisor brackets. To order, please quote product number 003-355. For further information contact Dentaurum Tel: Australia: 1300 880 782; NZ: 0800 336 828 Website: www.dentaurum.com Email: dmacpherson@dentaurum.com.au
topsOrtho version 4.0 released

The latest version of this Macbased practice management and imaging programme offers near instant retrieval of data and patient charts with no loss of quality even from satellite and home offices as well as enhanced image editing. Users no longer need buy or pay support fees for a separate imaging programme. For further information contact tops Software Email: sales@topsOrtho.com Website: topsOrtho.com
Invisalign
Invisalign uses a series of clear, removable, active appliances and 3-D modelling software to design a series of custom-made aligners that occlude the patients teeth in an aesthetic and comfortable manner. The company states that Invisalign can be used alone for comprehensive orthodontic treatment or as a key component of restorative or cosmetic dental work. ClinCheck, the virtual 3-D modelling software, allows the doctor to view the initial malocclusion and virtual final result, as well as the stages of movement in between. For further information contact Invisalign Tel: 1800 468 472 Website: www.invisalign.com.au Email: support@invisalign.com.au 222
InVu aesthetic brackets with Readi-Base pre-applied adhesive

The InVu aesthetic brackets with ReadiBase pre-applied adhesive were developed to help orthodontists meet the rising demand for aesthetic orthodontics. Features include exclusive colour-matching technology that allows the brackets to blend naturally with individual teeth, and a pre-applied adhesive that makes bracket placement easy and precise and reduces chair time, according to the manufacturer. For more information contact TP Orthodontics Tel: 1800 643 055 Website: www.InVu-Ortho.com New products are presented as a service to our readers, and in no way imply endorsement by the Australian Orthodontic Journal.
Orthodontic
calendar
2011
January 21-23 International Meeting of the Egyptian Orthodontic Society, Alexandria, Egypt. Email: azaher@idsc.net.eg March 2-5 Mexican Association of Orthodontists Annual Congress, Cancn, Mexico. Email: orthorea@hotmail.com Website: www.amo.org.mx March 4-6 Australian Society of Orthodontists Foundation for Research and Education Meeting, Melbourne, Australia. Website: www.aso.org.au March 18-20 Association of Orthodontists, Singapore, Biennial Conference, Conrad Centennial Hotel, Singapore. Email: aso_secretariat@yahoo.com.sg May 13-17 American Association of Orthodontists 111th AAO Annual Session, McCormick Place, Chicago, Illinois, United States of America. Website: www.aaomembers.org June 2-4 Societe Francaise dOrthopedie Dento-Faciale Scientific Congress, Lyon, France. Website: www.sfodf.org June 19-23 87th Congress of the European Orthodontic Society, Istanbul, Turkey. Website: www.eso2011.com November 3-5 44th Annual Scientific Congress of the Korean Association of Orthodontists, COEX Convention and Exhibition Center, Seoul, Korea. Email: kao100@chol.com Website: http://www.kao.or.kr
2012
February 11-14 23rd Australian Orthodontic Congress, Perth, Western Australia, Australia. Website: aso2012perth.com November 23-26 8th Asian Pacific Orthodontic Society and the 8th Asian Pacific Orthodontic Conference, New Delhi, India. Website: www.ap-os.org
Orthodontic position
An opportunity exists for a new graduate or experienced orthodontist to join our state-of-the-art group practice in Newcastle, Australia. Newcastle is a progressive coastal city 160 km North of Sydney. The practice has a comprehensive range of modern treatment facilities using modern materials and techniques. It is fully computerised, has an in-house laboratory, a continuing education facility and the philosophy of clinical autonomy with a work/leisure balance. For further information, please contact Mari-Ann Phillips; mphillips@hvortho.com.au
For a list of meetings and links to websites of national and international orthodontic societies, visit the World Federation of Orthodontics, www.wfo.org For inclusion in the Australian Orthodontic Journal please contact Dr Tony Collett Tel: (+61 3) 9756 0519. Email: tonycol@netspace.net.au
Australian Orthodontic Journal Volume 26 No.2 November 2010
223
Index to Volume 26
The Australian Orthodontic Journal
Author index
Abdel-Fattah E, 141 Akhoundi M, 113 Akkas I, 160 Alaeddini M, 113 Amasyali M, 10, 49 Ang H, 66 Armbruster P, 134 Ballard R, 134 Behnaz M, 149 Bhalla N, 38 Bolognese A, 27 Bosco A, 90 Bourauel C, 127 Carman A, 189 Cash A, 38 Catal G, 33 Celikoglu M, 160 ldr S, 195 Cobourne M, 42 Cuoghi O, 90 da Luz Fontes J, 78 Dastjerdie E, 149 Dause R, 42 de Souza Arajo M, 16 Dehpour A, 113 dos Santos R, 16, 73 Dreyer C, 66, 207 Ebin L, 165 Eliades T, 61, 127 Eraso F, 141 Fardo D, 141 Georgiou G, 119 Ghoneima A, 141, Goldschmied F, 208 Good S, 38 Gu Y, 171 Guerra C, 27 Gunhan O, 49 Hagan J, 134 Harkness M, 95, 206 Hartsfield J, 141 Heravi F, 153 224
Herbison P, 189 Jamilian A, 201 Johnson G, 189 Jones S, 119 Kamak H, 160 Karsliogu Y, 49 Kharazifard M, 113 Kilic N, 33, 56, 178 Koyuturk A, 10 Kula K, 141 Kusakabe S, 84 Lee B, 1 Lee J, 119 Lemke K, 134 Makou M, 61, 127 Martins F, 16 May N, 78 McDonald F, 38, 42 Mendona M, 90 Miles P, 21, 109 Miranda-Zamallou Y, 90 Motta A, 27 Mucha J, 27 Noroozi H, 113 OShea C, 189 Oktay H, 160, 178 Olmez H, 49 Othman S, 165 Ozcan S, 10 Pandis N, 16, 127 Pithon M, 16, 73 Polychronopoulou A, 61 Purmal K, 184 Quick A, 189 Rashed R, 153 Rashidpour M, 113 Romanos M, 16 Sagdic D, 10 Sandall N, 195 Scougall-Vilchis R, 84 Seifi M, 149 Sherriff M, 38 Showkatbakhsh R, 201
Sifakakis I, 61, 127 Souza M, 27 Sukumaran P, 184 Thiesen G, 78 Tondelli P, 90 Trayal G, 195 Uysal T, 10, 49 Weyant R, 21 Xu X, 134 Yamamoto K, 84 Yoldas T, 49 Zam Zam N, 165 Zrate-Daz C, 84 Zarnegar H, 149 Zastrow D, 78
Subject index
3-D evaluation
Skeletal and dental changes after rapid maxillary expansion: a computer tomography study, 141
Adhesive Remnant Index (ARI)
Bond strengths of different orthodontic adhesives after enamel conditioning with the same self-etching primer, 84 Does ozone water affect the bond strengths of orthodontic brackets? 73 Shear bond strength of buccal tubes, 184
Alignment
Porcelain brackets during initial alignment: are self-ligating cosmetic brackets more efficient? 21
Amorphous calcium phosphate-containing composites
Amorphous calcium phosphatecontaining orthodontic composites. Do they prevent demineralisation around orthodontic brackets? 10
Band retention
Strength of attachment between band and glass ionomer cement, 149
INDEX
Biocompatibility
Cephalometric norms
Dental bonding
Cytotoxicity of orthodontic separating elastics, 16

Bond strength
McNamara norms for Turkish adolescents with balanced faces and normal occlusion, 33
Cephalometric variables
Bond strengths and debonding characteristics of two types of polycrystalline ceramic brackets, 134
Dental changes
Does ozone water affect the bond strengths of orthodontic brackets? 73 Strength of attachment between band and glass ionomer cement, 149
Book reviews
Factors contributing to stability of protraction facemask treatment of Class III malocclusion, 171
Ceramic brackets
A comparison of dental changes produced by mandibular advancement splints in the management of obstructive sleep apnoea, 66
Dental trauma
Bruxism: Theory and Practice, 209 Change Your Smile. Fourth Edition, 212 Current Therapy in Orthodontics, 97 Dental Practice: Get in the Game, 100 Dental Implants: The Art and Science, 213 Head and Neck Anatomy for Dental Medicine, 209 Implant Dentistry: A Practical Approach. Second Edition, 214 Introduction of Innovative Orthodontic Concepts Using Microimplant Anchorage, 101 Microimplants in Orthodontics, 211 Minor Tooth Movement with Microimplants for Prosthetic Treatment, 98 Orthodontic and Dentofacial Orthopedic Treatment, 215 Self-ligation in Orthodontics, 98
Buccal tubes
Clinical trial
Multidisciplinary treatment of fractured root: a case report, 90

Dentofacial changes
Compression
Effects of rapid-slow maxillary expansion on the dentofacial structures, 178

Discriminant analysis
Response of the expanded inter-premaxillary suture to intermittent compression. Early bone changes, 49
Computer tomography
Dolphin imaging
Crossbite
Cephalometric analysis of Malay children with and without unilateral cleft lip and palate, 165
Duoblock
Non-surgical treatment of a mandibular deviation: a case report, 201

Curve of Spee
Editorials
Shear bond strengths of buccal tubes, 184

Case reports
Effects of levelling of the curve of Spee on the proclination of mandibular incisors and expansion of dental arches: a prospective clinical trial, 61
Custom base
Can an optimal force be estimated? 95 Effective orthodontics, 206 Retirement of Michael Harkness, 207
Efficiency
Non-surgical treatment of mandibular deviation: a case report, 201 Orthodontic treatment of a transmigrated mandibular canine: a case report, 195 The effect of a Clark twin block on mandibular motion: a case report, 189
Cephalometric analysis
Indirect bonding do custom bases need a plastic conditioner? A randomised clinical trial, 109
Cytotoxicity
Elastics

Demineralisation

Electromyography
Amorphous calcium phosphatecontaining orthodontic composites. Do they prevent demineralisation around orthodontic brackets? 10
Associations between upper activity and incisor position, 56
lip
225
INDEX
Enamel microhardness
Indirect bonding
Amorphous calcium phosphatecontaining orthodontic composites. Do they prevent demineralisation around orthodontic brackets? 10
Eruption space
Intercanine width
Mandibular advancement splint
Effects of orthodontic treatment and premolar extractions on the mandibular third molars, 160
Facial asymmetry
Intermolar width
Mandibular deviation

Mandibular displacement

Fatigue testing orthodontic adhesives
Initial and fatigue bond strengths of chromatic and light-cured adhesives, 119
Forced eruption
Intrusion

Mandibular incisor inclination
Orthodontic treatment of a transmigrated mandibular canine: a case report, 195

Friction
A comparative assessment of the forces and moments generated at the maxillary incisors between conventional and self-ligating brackets using a reverse curve of Spee NiTi archwire, 127
Korkhaus Analysis
Mandibular motion
The effect of a Clark twin block on mandibular motion: a case report, 189
Maxillary expansion
Glass ionomer cement
Space planning sensitivity and specificity: Royal London Space Planning and Korkhaus Analyses, 42
Letter
Effects of rapid-slow maxillary expansion on the dentofacial structures, 178 Response of the expanded interpremaxillary suture to intermittent compression. Early bone changes, 49
Maxillary protraction
Strength of attachment between band and glass ionomer cement, 149

Image analysis
Optimal force, 208

Lips at rest
Response of the expanded inter-premaxillary suture to intermittent compression. Early bone changes, 49
Incisor display
Display of the incisors as functions of age and gender, 27

Lower incisors
Incremental effects of facemask therapy associated with intermaxillary mechanics, 78

Methyl methacrylate monomer

McNamara analysis
Midline

Incisor inclination

Incisor torque
lip
Malay children

Monobloc
A comparative assessment of the forces and moments generated at the maxillary incisors between conventional and self-ligating brackets using a reverse curve of Spee NiTi archwire, 127 226
Malocclusion
Morphine
Lip tooth relationships during smiling and speech: an evaluation of different malocclusion types, 153
The effect of morphine on orthodontic tooth movement in rats, 113
INDEX
Naltrexone
Orthopaedic treatment

Nickel titanium

Overbite
Rapid-slow maxillary expansion
Non-surgical treatment

Overjet
lip

Rats

Ozonized water
lip
Response of the expanded inter-premaxillary suture to intermittent compression. Early bone changes, 49 The effect of morphine on orthodontic tooth movement in rats, 113
Reverse curve archwires

Opioid antagonist
Does ozone water affect the bond strengths of orthodontic brackets? 73

Permanent dentition

Optimal force
The dimensions of the roots of the human permanent dentition as a guide to the selection of optimal orthodontic forces, 1
Orbicularis oris muscle
Plastic conditioner
Root lengths
Porcelain

Orthodontic adhesive
lip
Royal London Space Planning
Bond strengths of different orthodontic adhesives after enamel conditioning with the same self-etching primer, 84
Orthodontic brackets
Premolar extractions
Self-etching primer
Projected root areas
Orthodontic extrusion
Bond strengths of different orthodontic adhesives after enamel conditioning with the same self-etching primer, 84
Self-ligating brackets

Orthodontic tooth movement
Protraction facemask

Orthodontics
Randomised clinical trial
A comparative assessment of the forces and moments generated at the maxillary incisors between conventional and self-ligating brackets using a reverse curve of Spee NiTi archwire, 127 Assessment of slot sizes in self-ligating brackets using electron microscopy, 38 Porcelain brackets during initial alignment: are self-ligating cosmetic brackets more efficient? 21
Shear bond strength
Cytotoxicity of orthodontic separating elastics, 16 Space planning sensitivity and specificity: Royal London Space Planning and Korkhaus Analyses, 42
Rapid maxillary expansion
Bond strengths and debonding characteristics of two types of polycrystalline ceramic brackets, 134 227
INDEX
Bond strengths of different orthodontic adhesives after enamel conditioning with the same self-etching primer, 84 Initial and fatigue bond strengths of chromatic and light-cured adhesives, 119 Shear bond strengths of buccal tubes, 184
Six degrees of freedom
Space analysis
Transmigration
Space planning

Turkish adolescents
Speech
Twin block
Skeletal Class III malocclusion
Stability
Unilateral cleft lip and palate

Slot dimensions
Third molar angulations
Upper incisors
28001_aoj_ortho_jnl_26.2_dec15:06:24
Assessment of slot sizes in self-ligating brackets using electron microscopy, 38

Slow maxillary expansion

Smile
Transmigrated mandibular canine

Upper lip activity

Video imaging
lip
10-11-08
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Front
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Australian

Australian Orthodontic Journal Volume 26 No. 2 November 2010

Allocated to Group 1 (N = 20) Received allocated intervention (N = 17)

Allocated to Group 2 (N = 20) Received allocated intervention (N = 19)

Analysed (N = 17) Excluded from analysis (N = 0)

Analysed (N = 19) Excluded from analysis (N = 0)

Figure 1. Study design.

Materials and methods

DO CUSTOM BASES NEED A PLASTIC CONDITIONER?

Table I. Bracket failures over the 6-month observation period.

Total brackets (N = 828)

Failed Failure (Per cent)

1.4 1.2 0.74 1.5 2.0 0.71 1.4 0.5 0.32

13. 14. 15. 16.

Australian Orthodontic Journal Volume 26 No. 2 November 2010

The effect of morphine on orthodontic tooth movement in rats

Orthodontic appliance and measurement of tooth movement

Figure 1. Schematic view of the appliance.

Materials and methods Animals

EFFECT OF MORPHINE ON ORTHODONTIC TOOTH MOVEMENT

Tooth movement (mm)

0.0 Groups Morphine Naltrexone-saline Naltrexone-morphine Control

Table I. Molar separation over 14 days.

Morphine Naltrexone - morphine Naltrexone - saline Control

0.081 0.164 0.162 0.170

0.029 0.069 0.061 0.089

0.009 0.022 0.019 0.028

0.060 0.114 0.119 0.106

0.102 0.214 0.205 0.233

0.05 0.10 0.08 0.10

0.15 0.30 0.25 0.35

Australian Orthodontic Journal Volume 26 No. 2 November 2010

EFFECT OF MORPHINE ON ORTHODONTIC TOOTH MOVEMENT

Australian Orthodontic Journal Volume 26 No. 2 November 2010

Australian Orthodontic Journal Volume 26 No. 2 November 2010

Initial and fatigue bond strengths of chromatic and light-cured adhesives

Materials and methods

SHEAR BOND STRENGTHS OF TWO ADHESIVES

Fatigued Composite resin

Figure 3. Kaplan-Meier plot for unfatigued brackets.

Figure 4. Kaplan-Meier plot for fatigued brackets.

SHEAR BOND STRENGTHS OF TWO ADHESIVES

Table I. Shear bond strength values (MPa) for test groups.

Transbond Transbond Transbond Transbond

XT Initial PLUS Initial XT Fatigued PLUS Fatigued

15.11 16.72 15.87 15.33

14.13, 15.87, 14.85, 14.38,

16.10 17.56 16.89 16.29

4.29 3.66 4.42 4.15

8.26 9.13 7.54 7.75

24.19 23.91 24.85 22.97

0.49 0.42 0.51 0.48

Table II. Survival percentiles for all test groups.

25 per cent Initial/Fatigued Composite Resin Estimate SE

50 per cent Estimate SE

75 per cent Estimate SE

Transbond Transbond Overall Transbond Transbond Overall Overall

18.67 19.57 19.29 19.01 18.67 18.89 19.01

0.966 0.629 0.454 0.462 0.832 0.426 0.308

14.64 16.96 15.86 17.04 15.17 15.43 15.78

0.534 0.654 0.601 0.953 0.554 0.865 0.502

11.50 14.50 12.84 11.90 11.55 11.74 12.02