A Simplified Method for Crimping Double-Back Bends

Ayman El Nigoumi Department of Orthodontics and Dentofacial Orthopaedics, Cairo University, Cairo, Egypt Abstract

Sakha Ahil Many orthodontic appliances such as the Quad Helix, Transpalatal Department of Orthodontics and arch, Pendulum and Nance appliance utilize double-back bends Dentofacial Orthopaedics, Cairo that are inserted in lingual sheaths typically bonded to, or welded University, Cairo, Egypt on, banded posterior teeth. These bends are advantageous because of ease of removal and reinsertion of the appliance for modification or activation without the need for debanding and Seif El Din Hegab recementation, and because there is no need to drop to a softer Department of Orthodontics and wire after appliance modification. Dentofacial Orthopaedics, Cairo Some problems encountered when making a double-back University, Cairo, Egypt bend include poor adaptation of the wire sections preventing passive insertion into the lingual sheaths, a weakened joint due to multiple attempts to approximate the two sections, and hand Correspondence: injury due to slippage of the wire during this tedious procedure. e-mail: [email protected] The modified pliers developed by Hashir requires permanent welding or soldering of a 19-gauge stainless steel wire to a utility Article history: plier1. Received: 19/04/2016 Thus we propose a new, simplified approach to making a double- Accepted: 20/06/2016 back bend with ease and precision. Published online: 22/08/2016 Keywords Conflict of interest: double back bend, lingual sheath, goshgarian sheath, TPA The authors declare that they have no conflicts of interest related to this research.

How to cite this article: El Nigoumi A, Ahil S, Hegab S. A simplified method for crimping double-backPROOF bends. EJCO 2016;doi: PROOF 10.12889/2016_T00257

PROCEDURE

A 0.036” wire is roughly bent into a double-back bend. 1

All three sections of the wire are all held securely with a mosquito forceps and PROOF 2PROOFlocked firmly.

A well-adapted double-back bend is seen. 4 PROOF PROOF

REFERENCE LIST

1. Hashir YM. A modified plier for crimping a double-back bend. J Clin Orthod 2012;46:26.

Modified Palatine Arch: An Option for Traction of Impacted Maxillary Central Incisors in the Presence of Odontomas

Matheus Melo Pithon Department of Pediatric Dentistry and Orthodontics, Universidade Federal do Rio de Janeiro UFRJ, Rio Abstract de Janeiro, Brazil Department of Health, I Universidade Estadual do Sudoeste A new appliance for applying traction to impacted teeth is da Bahia UESB, Bahia, Brazil described. The appliance is supported on rings fitted to the maxillary first molars (16 and 26) and extends to the anterior Correspondence: region, where lingual tubes are fixed, supporting the molars e-mail: [email protected] which will traction the impacted teeth. In the present case, the maxillary central incisors were disimpacted and mixed occlusion, Article history: normal for the age of the patient, was re-established. Received: 29/07/2016 Accepted: 09/11/2016 Published online: 02/12/2016

Conflict of interest: The authors declare that they have no conflicts of interest related to this research.

How to cite this article: Pithon MM. Modified palatine arch: an option for traction of impacted maxillary central incisors in the presence of odontomas. EJCO 2016; 4 doi: 10.12889/2016_C00266 Keywords Odontoma, tooth, unerupted, orthodontics, corrective

INTRODUCTION represented, and which are caused general health. He was at the stage Impaction of a permanent tooth is by a series of factors6–8. of mixed dentition, with an absence uncommon in mixed dentition. An Treatment for tooth impaction due to of maxillary central incisors. In the impacted central incisor is usually the presence of odontomas consists mandibular arch, crowding of the diagnosed when the tooth fails to of the removal of the odontoma, teeth and various primary teeth in the erupt1. Although the maxillary canine followed by orthodontic traction of mouth were noted . (Figs. 1 and 2) is the most frequently impacted the impacted teeth. There are various Initially, complete orthodontic anterior tooth, impaction of the ways to disimpact impacted teeth documentation was requested. The maxillary central incisor poses a using mobile or fixed appliances. panoramic radiograph confirmed the problem at an earlier age2. This tooth The authors describe a new method presence of odontomas close to the usually erupts several years before the consisting of the fabrication and use maxillary central incisors . (Fig. 3a,b) canine, when the child is between 8 of an appliance to traction impacted Because of the lack of clarity of the and 10 years of age, and its impaction teeth in the presence of odontoma. radiograph, computed tomography is more obvious to parents3–5. Use of this appliance resulted in dental was requested which (Fig. 3c,d) Impaction of the maxillary central traction with easy biomechanics and showed impaction of the incisors incisors may be due to the presence without aesthetic compromise. and the presence of odontomas. It of supernumerary teeth, odontomas was therefore decided to perform or trauma4. Odontoma is the most CLINICAL CASE orthodontic traction of the incisors common type of odontogenic The patient arrived at the orthodontic and remove the odontomas. tumour1–3, representing up to 70% dental office, accompanied by his of all such lesions2,4,5. However, guardian, having been referred by his APPLIANCE DESIGN some authors consider odontogenic paediatric dentist with the complaint Initially, orthodontic rings were fitted tumours to be developmental that his maxillary permanent central to the patient’s maxillary first molars. malformations (hamartomas), incisors had not erupted. Lingual tubes for the transpalatine in which all dental tissues are The patient had satisfactory oral and bar from the palatine and a triple

a b c

d e f

a b c

d e Figure 2: Initial orthodontic models.

a b Figure 3: Initial radiographic exams.

c d

tube from the vestibular region were canine. After the palatine arch was segment of the palatine arch was welded to these rings. Impressions contoured, anterior rods were welded acrylized. The appliance was polished were then taken and the rings were with silver solder to obtain a surface and finished after the acrylic resin visible in the cast. A stainless steel to which the lingual tubes could be was polymerized . (Fig. 4) 0.032″ archwire was placed along welded. After this, the palatine tubes The rings were cemented to the the contour of the palatine arch. were welded onto the wire segment, maxillary first molars (16 and 26) This wire was adapted to the lingual and the palatine arch was removed before surgery for odontoma removal. tube and followed the contour in the from the model and placed in the It was not possible to bond the anterior region close to the distal spot-welding machine. The palatine buttons for traction on the vestibular region of the left maxillary primary tubes were repaired and the anterior surface of the teeth during surgery

because they significantly projected arch and springs for traction of the between the springs and the chain, and so the buttons were bonded to incisors were fitted. The springs were which wasjoined to the tubes bonded the lingual surface. fabricated with a 0.032″ stainless to the teeth, was made with ligature Seven days after accessories were steel wire with a bend to fit in the wire . The fabricated appliance (Fig. 4) bonded and the odontomas were lingual tubes, and helicoid in shape would cause an extrusion movement removed, the patient returned to to facilitate activation by the chain of and movement inside the dental office and the palatine bonded accessories. The connection Complete traction of the impacted

a b c

d e f

g h i

incisors was achieved over 4 months incisor poses a problem at an earlier of the impacted teeth8, followed by . The palatine arch was age and affects the child’s aesthetic multidisciplinary treatment. However, (Figs. 5 and 6) then removed, and the rings were used appearance, giving parents cause for extraction of impacted teeth must be to support a transpalatine bar in order concern6,7. a last resort because the development to prevent mesial migration of the When impacted teeth are associated and maintenance of the premaxilla permanent first molars, maintaining with odontomas, these pathologies depends on the development and the leeway space. The patient’s must be removed in order to eruption of the incisors7. dental development is currently being provide space for the teeth to erupt Various appliances for applying monitored . spontaneously or after orthodontic traction to impacted teeth are (Figs. 7 and 8) traction. described In the literature7–9. Traction DISCUSSION In cases of impacted teeth, it is may be applied to impacted teeth The authors have described the important to inform the patient and using mobile or fixed appliances. Fixed clinical case of a young patient who their parents of the possibility of appliances are more commonly used presented with impacted maxillary treatment failure before extensive for practical reasons and because central incisors due to the presence measures are implemented to they can also be used to correct other of compound odontomas. Although save severely impacted teeth6,8. malpositioned teeth. However, in a the maxillary canine is the most Depending on the position of the patient in mixed dentition, placement frequently impacted tooth in this teeth, alternative treatments must of a fixed orthodontic appliance may region, an impacted maxillary central be considered, including extraction result in radicular correction, which

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Figure 5: (a) Tying the springs with ligature wire. d e (b-d) Intra-oral photographs after placement of traction springs.

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d Figure 6: Intra-oral photographs after appearance of the teeth in the mouth.

Figure 7: Intra- and extra-oral photographs after traction of the central incisors.

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d e Figure 8: Photograph of models after completion of traction of incisors. is usually undesirable at this stage of impossible when the springs are unwanted side effects. dental development. welded to the palatine arches9. The main side effect of traction of Our appliance differs from others Another treatment possibility in anterior impacted teeth using a fixed because the traction springs are this case would be to weld fixed appliance bonded on molars is the coupled to lingual tubes welded cantilever tubes to the rings of molars intrusion and mesial tipping of the in an anterior region of the dental using 0.018×0.025″ TMA cantilever molars, even in the presence of a arch, allowing easier activation and wire, which would reduce the low- transpalatal arch. However, extension replacement of springs, which is deflection rate, decreasing the risk of of the device associated with the doi:10.12889/2016_C00266 © 2016 SIDO CLINICAL ARTICLE

presence of a button reduced this in eruption, which could lead to anchorage was to bone tissue in the effect in the apparatus described resorption of their roots. region of the palatine rugosities. here. Considering this problem, Giancotti Vaid et al.13 developed a modified Recently, Chandhoke et al.10 et al.12 described a modified lingual lingual arch for the traction of described a clinical case where a arch with coupled hooks to apply impacted mandibular teeth, which system composed of a rectangular traction to an impacted maxillary was supported on lingual tubes. This arch associated with crossed tubes central incisor. The disadvantage of arch was effective but was difficult that supported another more flexible this appliance is the impossibility to insert or remove. The spring in the arch was inserted into the slot of of changing the hook to which the appliance described here was easily the tooth to undergo traction. This elastic used to traction the tooth is inserted and removed, thereby saving system appears to be very similar to attached. However, the appliance clinical time. the method proposed by Ruellas11. used in the present case does not have A limitation of the use of this device is This method was shown to allow this problem because the traction the fact that biofilm can accumulate good control but was difficult to springs can easily be removed from around the acrylic button, potentially use in patients in the initial stages the tubes during activation. Another infecting the surgically exposed area. of mixed dentition, as previously possible problem with the appliance discussed. However, the appliance described by Giancotti et al. was CONCLUSION described here was suitable for that the vertical anchorage of the The modified palatine arch was such cases because it uses posterior appliance applied to the occlusal effective for applying traction anchorage and mucosa in the anterior regions/surface of the primary to impacted maxillary incisors in region of the palate. Avoiding the teeth could lead to a change in the the presence of odontomas. This use of anterior teeth as anchorage process of rhizogenesis. However, appliance is therefore a new tool at reduces the chances of these teeth the appliance described by us avoids the disposal of the orthodontist. being moved towards the canines this disadvantage because vertical

REFERENCE LIST

1. Troeltzsch M, Liedtke J, Troeltzsch V, 6. Brand A, Akhavan M, Tong H, Kook 10. Chandhoke TK, Agarwal S, Feldman Frankenberger R, Steiner T. Odontoma- YA, Zernik JH. Orthodontic, genetic, J, Shah RA, Upadhyay M, Nanda R. An associated tooth impaction: accurate and periodontal considerations in the efficient biomechanical approach for the diagnosis with simple methods? Case treatment of impacted maxillary central management of an impacted maxillary report and literature review. J Oral incisors: a study of twins. Am J Orthod central incisor. Am J Orthod Dentofacial Maxillofac Surg 2012;70:e516–520. Dentofacial Orthop 2000;117:68–74. Orthop 2014;146:249–254. 2. Becker A. Early treatment for impacted 7. Sant’Anna EF, Marquezan M, Sant’Anna 11. Ruellas AC. An interview with: Antonio maxillary incisors. Am J Orthod CF. Impacted incisors associated with Carlos de Oliveira Ruellas. Dental Press J Dentofacial Orthop 2002;121:586–587. supernumerary teeth treated with a Orthod 2013;18:15–25. 3. Crawford LB. Impacted maxillary central modified Haas appliance.Am J Orthod 12. Giancotti A, Mozzicato P, Germano F. A incisor in mixed dentition treatment. Am Dentofacial Orthop 2012;142:863–871. new device for traction of dilacerated J Orthod Dentofacial Orthop 1997;112:1–7. 8. de Oliveira Ruellas AC, de Oliveira AM, maxillary central incisors. J Clin Orthod 4. Pinho T, Neves M, Alves C. Impacted Pithon MM. Transposition of a canine 2009;43:709–714. maxillary central incisor: surgical to the extraction site of a dilacerated 13. Vaid NR, Doshi VM, Kulkarni PV, exposure and orthodontic treatment. maxillary central incisor. Am J Orthod Vandekar MJ. A traction arch for Am J Orthod Dentofacial Orthop Dentofacial Orthop 2009;135(4 impacted mandibular canines and 2011;140:256–265. Suppl):S133–139. premolars. J Clin Orthod 2014;48:191–195. 5. Choi SC, Park JH, Kwon YD, Yoo EK, 9. Kuroda S, Yanagita T, Kyung HM, Takano- Yoo JE. Surgical repositioning of the Yamamoto T. Titanium screw anchorage impacted immature maxillary central for traction of many impacted teeth in incisor. Quintessence Int 2011;42:25–28. a patient with cleidocranial dysplasia. Am J Orthod Dentofacial Orthop 2007;131:666–669.

A Case of Bi-Maxillary Protrusion with Ankylosed Incisors Treated with a Multidisciplinary Approach

Hiroo Kuroki Orthodontic Dentistry, The Nippon Dental University Niigata Hospital, Niigata, Japan Abstract

Masutaka Mizutani This case report describes a multidisciplinary approach in a Oral & Maxillofacial Surgery, patient with maxillary protrusion and ankylosed upper incisors. The Nippon Dental University The patient was a 15-year-old boy with the chief complaint of Niigata Hospital, Niigata, Japan maxillary protrusion and superiorly positioned upper incisors. The patient had maxillary protrusion with an overjet of 6 mm. Cephalometric analysis showed a skeletal class II relationship. Yoshihiro Sugawara Presurgical orthodontic treatment was performed with lower Comprehensive Dental Care Unit, bicuspid extractions followed by a Wassmund segmental The Nippon Dental University osteotomy and then prosthetic treatment. A good aesthetic and Niigata Hospital, Niigata, Japan functional result which included an acceptable facial profile and occlusal relationship was achieved. When planning similar cases, a multidisciplinary approach can be considered as one treatment Yoshiki Kobayashi alternative. Orthodontic Dentistry, The Nippon Dental University Niigata Hospital, Niigata, Japan

Toshiya Endo Department of Orthodontics, Keywords The Nippon Dental University Bi-maxillary protrusion, ankylosed teeth, wassmund segmental School of Life Dentistry at Niigata, osteotomy Niigata, Japan

David PC Rice Oral and Maxillofacial Diseases, Correspondence: How to cite this article: University of Helsinki and e-mail: [email protected] Kuroki H, Mizutani M, Sugawara Y, Helsinki University Hospital, Kobayashi Y, Endo T, Rice DPC. A Helsinki, Finland Article history: case of bi-maxillary protusion with Received: 04/08/2016 ankylosed incisors treated with a Accepted: 12/12/2016 multidisciplinary approach. EJCO 2017;5: Published online: 23/02/2017 doi:10.12889/2017_C00269

Conflict of interest: The authors declare that they have no conflicts of interest related to this research.

INTRODUCTION problematic, external root resorption bicuspid teeth into their place5–7, Maxillary protrusion may be caused occurs and results in ankylosis2. bone distraction in combination by trauma to the maxillary anterior In the case presented here, the with alveolar osteotomy8–13, and teeth during the growth phase1. In correction of malocclusion was more aesthetic improvement using cases of complete tooth dislocation, complicated due to the presence of prosthetic treatment alone2. A the periodontal ligament is torn over ankylosed teeth. Several different multidepartmental approach with the entire root surface and the pulp treatments were considered including orthodontic treatment, oral surgery, is severed. Survival of the periodontal orthodontic traction following periodontal and prosthetic dentistry ligament cells before replantation is subluxation of the ankylosed teeth3,4, was adopted. Treatment involved important for long term success. If extraction of the ankylosed teeth and pre- and post-surgical orthodontics, repair of the periodontal ligament is autologous transplantation of lower a maxillary alveolar osteotomy and prosthetic treatment, and resulted in functional and aesthetic improvement. We report a case of maxillary protrusion with ankylosed incisors successfully treated using a multidisciplinary approach.

HISTORY The patient was a 15-year-old boy with the chief complaint that he could not bite as his front teeth protruded and the upper right central and lateral a

Figure 1: Before treatment (15 years 0 month). (a) Facial photographs; (b) intraoral photographs; (c) panoramic radiograph; (d) lateral cephalometric radiograph; (e) dental x-rays.

incisors were superiorly positioned. length discrepancy of 0 mm in the and ankylosed upper right central The patient’s siblings had received upper jaw and –2 mm in the lower jaw. and lateral incisors, and mild skeletal orthodontic treatment for crowding. The panoramic radiograph confirmed class II malocclusion with a high The patient’s medical history was that endodontic treatment of the mandibular plane angle. unremarkable. upper right central incisor and At 12 years of age, the patient’s upper upper right lateral incisor had been TREATMENT PLAN AND PROGRESS right central and lateral incisors completed. Periapical radiographs Surgical orthodontic treatment had been completely dislocated by revealed that the upper right central with a Wassmund osteotomy with trauma. These teeth were replanted, and lateral incisors had lost lamina upper left and right first bicuspid but ankylosis and external resorption dura, indicating root ankylosis. A extractions was planned to improve had occurred in both. As a result, the reduction was noted in the alveolar the maxillary protrusion and was patient was introduced to the Nippon bone height. to be followed by an advancement Dental University Niigata Hospital, Lateral cephalometric analysis genioplasty. Orthodontic treatment Japan. showed that SNA (84.5°) was was to be employed using an upper On clinical examination, the patient’s increased but within normal variation and lower multi-bracket system after face was symmetrical except for the (standard deviation), SNB (78.5°) extraction of the lower first bicuspid right corner of his mouth which was was reduced, and ANB (6°) indicated teeth. The preoperative orthodontic slightly elevated. He had a convex a class II relationship. The Frankfurt treatment was designed to align profile due to retrognathia of the chin plane to the mandibular plane angle and level the teeth in the anterior and protrusion of the upper lip. There (FMA; 37°) was increased and was and buccal segments. The lower was strong muscular tension in the greater than +1 SD. The upper incisor anterior teeth were to be retracted. chin during lip closure. The overbite angle (U1 to SN; 111.5°) and lower Cephalometric analysis indicated was +2 mm, while the overjet was incisor angle (L1 to Md; 96°) were that the upper anterior teeth would +6 mm. Molars were in Angle class both within the standard deviation, move back by 8.5 mm after the I relationships. The crowns of the but the inter-incisor angle (U1 to L1; Wassmund procedure and the lower upper right central incisor and 105.5°) was reduced by more than 3 anterior teeth would move back by 6 lateral incisor were discoloured. SD. The upper lip was +5.5 mm and mm. Postoperative orthodontics was The percussion sounds of the two the lower lip was +12 mm in relation planned to improve the stability of teeth were high, and the teeth were to the E line. The nasolabial angle was the occlusion. positioned superiorly compared to 104° . The bilateral first lower bicuspids (Fig. 1, Table 1) neighbouring teeth . The diagnosis was maxillary were extracted and a multi- (Fig. 1) Model analysis revealed a tooth-arch protrusion with superiorly positioned bracket appliance was fitted on the

Normative mean Pre-treatment Pre-operation Post-treatment Post-retention (adult) (15 years 0 (18 years 1 (18 years 11 (21 years 7 Measurement Mean SD months) months) months) months) Angle, degrees SNA 84.5 82 79 79 82.6 3.5 SNB 78.5 76.5 76.5 76.5 80.3 3.3 ANB 6 5.5 2.5 2.5 2.2 2.2 FMA 37 37.5 37.5 37.5 26 5.5 IMPA 96 77 77 77.5 94.7 5 FMIA 47 65.5 65.5 65 59 6.7 U1SN 115 108.5 100 103.5 105.8 6.8 OP 9 9 9 9 9.4 3.9 II 105.5 129 135.5 133 127.6 6.2 Nasolabial angle 104 104 113 118 93.8 11.3 Linear, mm Overjet 6 11.5 1.5 3 Overbite 2 2 2 2 Upper lip to the E line 5.5 5.5 –1.5 –2.5 Lower lip to the E line 12 8.5 6 2 Standard by Sakamoto, Miura, Iizuka, Yamanouchi et al.

Table 1: Cephalometric analysis at the pre-treatment, pre-operation, post-treatment and post-retention stages

Figure 2: Before surgery (18 years 1 month). (a) Facial photographs; (b) intraoral photographs; (c) panoramic radiograph; (d) lateral cephalometric radiograph.

the patient’s graduation from high school. Changes during the preoperative orthodontic phase included an increase of 5.5 mm in the overjet. The upper right central and lateral incisor teeth were not covered by the upper lip in the resting position. Pre-Wassmund lateral cephalometric analysis showed that SNA decreased by 2.5° to 82°, and SNB decreased by 2.0° to 76.5°. FMA increased by 0.5° to 37.5°, U1 to SN decreased by 6.5° c to 108.5°, and L1 to Md decreased by 19° to 77°. The upper lip’s relationship to the E line was unchanged, while the lower lip position was decreased by 3.5 mm to +8.5 mm. The nasolabial d angle was unchanged. The panoramic radiograph indicated that the upper right third molar mandibular teeth (0.018×0.025-in upper jaw, sectional mechanics was was poorly developed, and that slot). After 16 months of preoperative employed with the upper arch wire both upper third molar teeth were orthodontic treatment, the extraction divided into an anterior section unerupted and mesially inclined (Fig. sites had almost closed and a which incorporated the incisor and . 2, Table 1) multibracket appliance was fitted to canine teeth. The posterior section During the Wassmund procedure, the the upper teeth. incorporated the second bicuspids upper first bicuspids were removed Cephalometric analysis at the end together with the first and second as well as the lower third molars of the preoperative orthodontic molar teeth . Preoperative which were partially erupted and (Fig. 2b) treatment showed maxillary surgery orthodontic treatment took 23 mesially impacted. Following surgery, had caused the maxillary anterior months to complete. Surgical a fixation splint was placed for 2 incisor to move by 9.5 mm. In the treatment was delayed because of weeks. Postoperative orthodontic doi:10.12889/2017_C00269 © 2017 SIDO CLINICAL ARTICLE

treatment was performed for 12 3° to 79°, and SNB was unchanged. Changes from the end of months followed by prosthetic ANB was decreased to 3° due to the orthodontic treatment to the end of treatment of the upper right central improved anteroposterior position of prosthetic treatment and lateral incisors. The patient did the maxilla. U1 to SN was decreased U1 to SN increased by 3.5° to 103.5°, not want to receive an advancement by 8.5° to 100°. The upper lip was –1.5 while L1 to Md increased by 0.5° to genioplasty. mm and the lower lip was +6 mm in 77.5° . (Fig. 4, Table 1) relation to the E line. The symmetry of the corners of the Changes from before surgery to the The nasolabial angle had improved mouth was improved. The incisor end of orthodontic treatment from 104° to 113°. There did not seem edges of the upper right central and The overjet was decreased by 10 mm to be any additional root resorption lateral incisors were adjusted to be in to +1.5 mm, SNA was decreased by . harmony with adjacent teeth. (Fig. 3, Table 1) The upper right central and lateral incisors showed root resorption on the dental x-ray but this (Fig. 4e) did not appear to differ greatly from the previous assessment , and clinically there were (Fig. 3c) no problems with regard to tooth mobility or inflammation. Following this appointment, the patient left his home town to enter university and did not attend further follow- up appointments for additional prosthetic rehabilitation. a

Figure 3: After treatment (18 years 11 month). (a) Facial photographs; (b) intraoral photographs; (c) panoramic radiograph; (d) lateral cephalometric radiograph.

Figure 4: After retention (21 years 7 month). (a) Facial photographs; (b) intraoral photographs; (c) panoramic radiograph; (d) lateral cephalometric radiograph; (e) dental x-ray.

c With regard to autologous transplantation, when bicuspids are transplanted to the maxillary anterior teeth positions, the transplanted d teeth should be extruded to the level of the adjacent teeth so that the gingival margins are at the same level. DISCUSSION have involved orthodontic traction Furthermore, following implantation, Treatment alternatives following subluxation3,4 or autologous lingual root torque would have been In this report, we describe transplantation5–7. However, in this needed and this combined with the treatment combining orthodontics case, traction following subluxation large orthodontic tooth movement with prosthetics and a localized was not chosen as external root required and the disparate root osteotomy of the Wassmund type. resorption of the two ankylosed morphology of the incisor teeth Had there not been two ankylosed teeth was widespread across the compared to the bicuspid teeth, led teeth, this case could have been entire root. Also, the amount of to the conclusion that control of the treated as a bicuspid extraction post-dislocation orthodontic tooth teeth would be difficult14. In addition, with orthodontic treatment alone. movement was predicted to be too the height of the alveolar bone was Alternative treatment plans could large4. not sufficient to receive the bicuspid doi:10.12889/2017_C00269 © 2017 SIDO CLINICAL ARTICLE

Figure 5: Superimposition of cephalometric tracings on the S-N plane at S, on the palatal plane at ANS, on the mandibular plane at Me. __ Pre-treatment; __ pre-surgery; __ post-treatment; __ post-retention. tooth. Also, due to the advanced combination with an advancement After retention stage of the lower first bicuspid genioplasty was thought to be the An increase in the overjet was root development, the timing best option to improve the profile. observed at the end of the retention for autotransplantation was not Even so, the patient did not want the period. It was noted that the muscle considered to be optimal5,7. Therefore, genioplasty. tension around the mouth had as autologous transplantation was Anterior maxillary alveolar reduced. This mild relapse may have thought to carry a high risk, an osteotomy is a surgical technique been caused by tongue pressure on alternative plan was adopted. that can enhance the aesthetics of the incisors. Localized osteotomy with distraction protruding maxillary anterior teeth for the movement of ankylosed and improve lip competence15. In CONCLUSION teeth has been reported8–13. In this addition, improvement of ANB and This case report describes maxillary case, however, movement of the the nasolabial angle by backward protrusion with anterior teeth upper labial segment including the movement of point A can be ankylosis. Treatment consisted of a ankylosed teeth was thought to be expected, and so anterior maxillary combination of various disciplines technically risky, and it was considered alveolar osteotomy was considered to achieve an acceptable aesthetic that distraction osteogenesis would to be advantageous. and functional result, which further be unreliable. Achieving these improvements is underscores the effectiveness of a thought difficult with conventional multidisciplinary approach in such Wassmund local osteotomy orthodontic treatment16. The upper cases. Wassmund local osteotomy can anterior alveolus including point A move teeth en masse with the was sufficiently retracted, and the surrounding bone. Although E line and nasolabial angle were Wassmund local osteotomy is more improved. extensive compared to non-surgical Tooth replacement using implants alternatives, there is a reduced is generally performed after risk of damage to the adjacent orthodontic treatment. However, the teeth compared to distraction patient refused implant treatment osteogenesis, because the osteotomy due to its cost and changes in his cuts are made at the site of the upper living circumstances: he wanted bicuspid extractions. In addition to minimally invasive treatment rather local Wassmund osteotomies and than further surgery. Consequently genioplasty, more extensive treatment implants were not placed and an options combining orthodontics aesthetic solution was achieved with with orthognathic surgery were also enamel bonding. evaluated. Single jaw and two jaw After the prosthetic treatment options were considered to address and recontouring of the anterior the issues of the increased overjet, the teeth, the patient’s pronunciation class II profile, the local open bite and clearly improved. A small functional the inclination of the occlusal plane. improvement in chewing function However, Wassmund osteotomy in was also noted.

REFERENCE LIST

1. Eidenbauum IW. A correlation of 8. Agabiti I, Capparè P, Gherlone EF, 14. Aoyama S, Yoshizawa M, Niimi K, Sugai T, traumatized anterior teeth to occlusion. Mortellaro C, Bruschi GB, Crespi Kitamura N, Saito C. Prognostic factors J Dent Child 1963;30:239–236. R. New surgical technique and for autotransplantation of teeth with distraction osteogenesis for ankylosed complete root formation. Oral Surg Oral 2. Atabek D, Alaçam A, Aydintuğ I, dental movement. J Craniofac Surg Med Oral Pathol Oral Radiol 2012;114(5 Konakoğlu G. A retrospective study of traumatic dental injuries. Dent Traumatol 2014;25:828–830. Suppl):S216–228. 2014;30:154–161. 9. Senışık NE, Koçer G, Kaya BÜ. Ankylosed 15. Lu CH, Ko EW, Huang CS. The accuracy 3. Lin F, Sun H, Yao L, Chen Q, Ni Z. maxillary incisor with severe root of video imaging prediction in soft tissue Orthodontic treatment of severe anterior resorption treated with a single-tooth outcome after bimaxillary orthognathic open bite and alveolar bone defect dento-osseous osteotomy, vertical surgery. J Oral Maxillofac Surg complicated by an ankylosed maxillary alveolar distraction osteogenesis, and 2003;61:333–342. central incisor: a case report. Head Face mini-implant anchorage. Am J Orthod 16. Mise Y, Morita S, Yamaki M, Saito I. Med 2014;10:10–47. Dentofacial Orthop 2014;146:371–384. Hard and soft tissue profile changes 4. Paleczny G. Treatment of the ankylosed 10. Rodrigues DB, Wolford LM, Figueiredo before and after treatment in severe mandibular permanent first molar: a case LM, Adams GQ. Management of maxillary protrusion: comparison of study. J Can Dent Assoc 1991;57:717–719. ankylosed maxillary canine with single- surgical orthodontic treatment using tooth osteotomy in conjunction with maxillary anterior alveolar osteotomy 5. Cunha DL, Masioli MA, Intra JB, Roldi A, orthognathic surgery. J Oral Maxillofac and orthodontic treatment alone with Dardengo Cde S, Miguel JA. Premolar Surg 2014;72:2419.e1–6. extraction of maxillary molars. Orthod transplantation to replace a missing Waves 2010;69:181–191 [in Japanese]. central incisor. Am J Orthod Dentofacial 11. Ohkubo K, Susami T, Mori Y, Nagahama Orthop 2015;147:394–401. K, Takahashi N, Saijo H, et al. Treatment of ankylosed maxillary central incisors by 6. Choi YJ, Shin S, Kim KH, Chung single-tooth dento-osseous osteotomy CJ. Orthodontic retraction of and alveolar bone distraction. Oral Surg autotransplanted premolar to replace Oral Med Oral Pathol Oral Radiol Endod ankylosed maxillary incisor with 2011;111:561–567. replacement resorption. Am J Orthod Dentofacial Orthop 2014;145:514–522. 12. Im JJ, Kye MK, Hwang KG, Park CJ. Miniscrew-anchored alveolar distraction 7. Denys D, Shahbazian M, Jacobs R, for the treatment of the ankylosed Laenen A, Wyatt J, Vinckier F, et al. maxillary central incisor. Dent Traumatol Importance of root development in 2010;26:285–288. autotransplantations: a retrospective study of 137 teeth with a follow-up 13. Alcan T. A miniature tooth-borne period varying from 1 week to 14 years. distractor for the alignment of ankylosed Eur J Orthod 2013;35:680–688. teeth. Angle Orthod 2006;76:77–83.

Mohammed K. Al Shhab International Orthodontic Program, Future University, New Cairo, Egypt Abstract

Fouad A. El Sharaby The Ballista spring is frequently used for extruding impacted Department of Orthodontics and maxillary canines. Despite its the simple design and easy Dentofacial Orthopedics, Cairo fabrication, design details should be carefully considered in order University, Cairo, Egypt to avoid unexpected and sometimes undesirable reaction forces that might complicate treatment. The current article suggests some changes to the design of the spring that could improve the Yehya A. Mostafa final outcome. Department of Orthodontics and Dentofacial Orthopedics, Future University, New Cairo, Egypt

Correspondence: e-mail: [email protected]

Article history: Received 06/09/2016 Accepted: 28/10/2016 Published online: 13/12/2016

Conflict of interest: The authors declare that they have Keywords no conflicts of interest related to this Ballista spring, canine impaction, forced eruption, biomechanics research.

How to cite this article: Shhab MK, El Sharaby FA, Mostafa YA. Modifying the ballista spring for better clinical outcome. EJCO 2016; 4 doi: 10.12889/2016_T00265

doi:10.12889/2016_T00265 © 2016 SIDO INTRODUCTION and on the palatal side than labially inch stainless steel (st.st.) to resist Maxillary canines have the longest (85% and 15%, respectively)4,5. During possible deformation caused by the period and deepest area of orthodontic treatment, traction is applied traction forces has been development together with the applied to move the impacted canine recommended7. Various methods most difficult path of eruption of in proper alignment in a procedure have been described to move all the teeth1. Ectopic eruption and traditionally known as forced the impacted tooth in an occlusal impaction of the maxillary canine is eruption. Regardless of the method direction (vertically downwards) in a frequently encountered problem used, the direction of applied force order to avoid any interruption in the in orthodontics. The incidence of should initially move the impacted path, and then buccally towards its maxillary canine impaction is reported tooth away from the neighbouring final and desired location6. to be between 0.9% and 1.7%2,3 and it teeth roots6. Additionally, use of a One of the methods employed for is more common in females than in light force of 60–120 g and a stiff canine forced eruption is use of the males (1.1% and 0.5%, respectively) main archwire of 0.018×0.025- Ballista spring originally described by Harry Jacoby. The Ballista spring is made of round (0.014 or 0.016-inch st.st.) wire that induces a downwards and labial movement 8. (Fig. 1) Despite the simple design and easy fabrication of the Ballista spring, design details should be carefully considered in order to avoid unexpected and sometimes undesirable reaction forces that might complicate treatment. One problem Figure 1: Changing the angle of the Ballista spring relative to the anteroposterior position of the which might be encountered is impacted canine. expansion of the posterior segment on the same side of the impacted canine despite the use of 0.019×0.025-inch st.st. customized main arch wire. This problem could be related to spring design, the distance of the impacted canine from the alveolar ridge, and the depth of the palatal vault.

SPRING ANGLE DESIGN (THE Figure 2: Changing the length of the Ballista spring relative to the transverse position of the ANTEROPOSTERIOR CANINE impacted canine. POSITION) As the main purpose of using the Ballista spring is to forcefully erupt the impacted canine in order to make it accessible for levelling and alignment, the palatal arm of the spring should be measured and fabricated taking into consideration the location of the impacted a b

c d

Figure 3: (a,b) Accurate arm length with no impact on the posterior segment despite the absence of a base arch wire. (c,d) Mistakenly long arm length with undesired expansion at the posterior segment despite the use of a rigid base arch wire. (e) Analysis of forces and moments acting on the e canine and buccal segment teeth.

a b

Figure 4: Effect of palatal vault depth on the Ballista spring arm length. (a) Deep palatal vault. Figure 5: A ‘free to slide’ attachment between the (b) Shallow palatal vault. impacted canine and the Ballista spring arm. canine antero-posteriorly relative one resisted by the dense palatal movement in a labial direction . (Fig. 5) to its intended alignment position. bone in that area. In turn, the forces Modification of the angulation of the will be reciprocally transmitted to the CONCLUSIONS spring arms might be considered for buccal segment teeth in an occlusal 1. A better design of the Ballista easier canine engagement and direct and buccal direction resulting in both spring angle in view of the occlusal movement . extrusion as well as buccal tipping of anteroposterior canine position in (Fig. 1) the posterior segment which occurs the palate is described. Distance from the alveolar ridge more easily . 2. In cases with average palatal vault (Fig. 3) (transverse canine position) depth, the conventional Ballista As a normal step during spring Depth of the palatal vault (vertical spring design is recommended construction, the distance from canine position) but great attention must be the alveolar ridge to the site of the In cases with a deep palatal vault, paid to the arm length to avoid impacted canine is measured, and the length of the palatal arms of undesirable arch expansion or fabricating the palatal arms of the the Ballista spring is unavoidably contraction. spring according to this measurement increased compared to similar cases 3. In cases with deep palatal vault, is essential . Mistakenly long with normal or shallow palatal vaults a ‘free to slide’ arm design is (Fig. 2) spring arms might result in unwanted . The long spring arms in recommended to avoid adverse (Fig. 4) arch expansion, extrusion of the such cases might result in a similar transverse effects on the arch buccal segment on the same side of expansion scenario as the canine during canine eruption. the impacted canine, open bite as well erupts, especially if the attachment 4. In cases with pre-existing arch as canting of the occlusal plane. Such point between the spring and the expansion or constriction in the iatrogenic problems may complicate impacted canine is fixed. To avoid this premolar-molar region, the spring the case and unduly extend the side effect, the attachment between is intentionally fabricated shorter treatment time. These side effects the spring and the impacted canine or longer, respectively, than the may be related to the long spring could be modified so that it allows distance between the canine and arm pushing the impacted canine sliding of the canine along the spring the main arch wire in order to through the palate in the direction arm during eruption. A ‘free to slide’ benefit from the side effects of of the mid-palatal suture. This attachment would allow vertical the change in the arm length. movement is considered a difficult eruption of the canine together with

REFERENCE LIST

1. Jacoby H. The etiology of maxillary canine impactions. Am J 6. Moyers RE. Handbook of Orthodontics, 2nd ed. Chicago: Year Orthod 1983;84;125–132. Book Medical, 1963, pp. 83–88. 2. Dachi SF, Howell FV. A survey of 3874 routine full mouth 7. Bishara SE, Kommer DD, McNeil MH, Montagano LH, Oesterie LH, radiographs. Oral Surg Oral Med Oral Pathol 1961;14:1165–1169. Youngquist HW. Management of impacted maxillary canines. Am 3. Thilander B, Myrberg N. The prevalence of malocclusion in J Orthod 1976;69:371–387. Swedish school children. Scand J Dent Res 1973;81:12–20. 8. Roberts-Harry D, Harridane N. A sectional approach to the 4. Ericson S, Kurol J. Radiographic examination of ectopically alignment of ectopic maxillary canine. Br J Orthod 1995;22:67–70. erupting maxillary canines. Am J Orthod Dentofacial Orthop 1987;91:483–492. 5. Moss JP. The unerupted canine. Dental Pract 1972;22:241–248.

The Sea of Learning Has No End

Raffaele Schiavoni Editor-in-Chief

How to cite this article: I started working as an orthodontist the first to understand this Schiavoni R. The sea of learning has no in the early 70’s. At the time there phenomenon and get ownership end. EJCO 2017;5. was no internet and, obviously, no of it, thus somehow affecting our real-time communication via e-mail. profession; I perfectly remember when I first - In modern terms we could say discovered a collection of AJO issues that “hardware” and “software” in the library of the Bologna University have almost become synonyms; that I used to attend. materials have become more I can’t articulate my greed to read important than ideas or perhaps all these articles; withdrawing in ideas are no longer considered that place in the spare time from necessary? This situation can my clinical practice had become my often be misleading and doesn’t favourite pastime. benefit either newcomers or I soon decided to subscribe. I filled highly educated professionals. out a form I found in one AJO issue At this point a question clearly and immediately sent it with the arises: what is the future of our payment receipt. profession? What does the salvation Many years have elapsed since then of our profession depend upon? but nothing has changed as to my What is going to save us from this excitement in reading new articles as barbarization? well as their clinical and professional On a prestigious journal, the European usefulness... in the meanwhile I have Journal of Orthodontics, I found a subscribed to many other journals. publisher’s ad: “the sea of learning has no end!” Some considerations are necessary: It immediately provided me with food - In the early 70’s there were far for thought: in our profession there fewer continuous training courses are three things that really count: than nowadays; it cannot be denied reading, reading, reading... that their current proliferation presents, especially in certain I remember a sentence Marguerite cases, marketing aspects that Yourcenar wrote in her book don’t benefit our profession very “Hadrian’s memoirs”: much; “Dounding libraries was like - This process has been triggered constructing more public granaries, by a need for education that ammassing reserves against a universities often failed to meet; spiritual winter which by certain - Manufacturing companies were signs, in spite of myself, I see ahead...”

Considering Factors to Maximize Facial Profile in the Treatment of Patients With Hyperdivergent Skeletal Pattern Using Microimplants

Hyo-Sang Park Department of Orthodontics, School of Dentistry, Kyungpook National University, Daegu, South Abstract Korea

Correspondence: In the treatment of patients with severe hyperdivergent skeletal e-mail: [email protected] pattern, the counterclockwise autorotation of the mandible after intrusion of the posterior teeth has an essential role in Article history: improvement of the facial profile. However, there are many Received: 21/11/2016 factors affecting facial profile changes. These factors include Published online: 28/02/2017 the intrusion of the upper posterior teeth, the consideration of anteroposterior occlusal plane cant, bodily retraction of the Conflict of interest: upper incisors, intrusion of the upper incisors, intrusion of the The authors declare that they have lower posterior teeth, vertical position of the lower incisors, and no conflicts of interest related to this most importantly coordination of movement at the upper and research. lower posterior teeth and the upper and lower incisors. A case of profound facial profile change after intrusion of the upper How to cite this article: and lower molars and bodily retraction of the upper incisors and Park HS. Considering factors to maximize retraction and intrusion of the lower incisors is presented. facial profile in the treatment of patients with hyperdivergent skeletal pattern using microimplants. EJCO 2017;5. doi: 10.12889/2017_C00270

Keywords Profile change; hyperdivergent patients; microimplants

INTRODUCTION characteristics include mesially incisal tips down and causes With development and use of tipped molars, divergent upper and incisal contact. Therefore, bodily extradental skeletal anchorage such lower functional occlusal plane, and retraction of the upper incisors as the microimplants, clinicians can long anterior alveolar height . plays an essential role in profile (Fig. 1) move teeth according to the specific In order to improve the facial profile changes. planned goal without anchorage loss. with orthodontic treatment, we need - The fourth factor is the intrusion The teeth movement can also be to have autorotation of the mandible of the upper incisors. In open precisely controlled with the help of the after intrusion of the molars with bite with hyperdivergent microimplants three-dimensionally. microimplants. However, there are skeletal pattern, the intrusion After observing that microimplants many factors that influence the of the posterior teeth causes could provide anchorage for the profile changes. autorotation without incisal whole maxillary dentition distally in What follows is a list of factors that contact, but autorotation of the 19991, microimplants started to be affect the facial profile in patients with mandible causes incisal contact used in many clinical situations. There hyperdivergent skeletal pattern15: with normal overbite. In this case, are many clinical reports and studies - The first consideration is the the intrusion of the upper incisors on the treatment of various types of intrusion of the upper posterior should be considered to provide malocclusion, including bialveolar teeth. To achieve counterclockwise space for autorotation of the protrusion that required maximum rotation of the mandible, the first mandible. retraction of the anterior teeth2,3, thing to be considered is the - For the fifth factor, the lower whole-arch distal retraction4-7, and intrusion of the upper posterior posterior teeth also need to be intrusion of a tooth or teeth8,9, and on teeth. intruded in severe cases. The open bite treatment after intrusion - Second, the anteroposterior intrusion of only the upper teeth of the posterior teeth10,11. In addition, occlusal plane cant should be can induce extrusion of the lower microimplants could be used more checked. A large amount of posterior teeth, which should be efficiently in the correction of intrusion of the upper posterior prevented by microimplants, and mesially tipped molars12, crossbites13, teeth can make the occlusal plane the active intrusion of the lower and impacted canines14. steep and guide the mandible posterior teeth is required in Among all these treatment effects, backward, and this restricts the severe hyperdivergent cases. the intrusion of the tooth or teeth was amount of counterclockwise - The sixth factor is the vertical the only movement not obtained with autorotation of the mandible. position of the lower incisors. conventional orthodontic treatment. - The third factor is bodily retraction The lower incisors are retracted Therefore, there are many case of the upper incisors. If the upper by tipping in most cases, and reports and studies that evaluate incisors are tipped lingually tipping may bring the incisal tip treatment effects after intrusion of during retraction, this causes upward and cause incisal contact. the posterior teeth. The author has contact between the upper and Therefore, intrusion of the lower also focused on the treatment of open lower incisors and tends to open incisors is required in patients with bite with molar intrusion. Recently, the mandibular plane angle, severe hyperdivergent skeletal the intrusion of the posterior teeth thus reducing autorotation of pattern. in both arches became known as an the mandible. Lingual tipping - The seventh factor is the essential factor to improve the facial of the upper incisors moves the coordination of movement at profile. And the author has realized the upper and lower posterior the importance of coordination of teeth and the upper and lower retraction and intrusion movement incisors, which is very important. at the upper and lower incisors and In patients with hyperdivergent intrusion of the upper and lower skeletal pattern, interdigitation of posterior teeth. the teeth is not obtained easily. In this clinical report, the author If 1 cusp of a tooth has occlusal explains a way to maximize changes contact only, the occlusion stays in the facial profile in patients with with no contact at the other teeth. hyperdivergent skeletal patterns and Therefore, the coordination of presents a case in which the patient movement is most important. had maximum changes in their facial - For the eighth factor, the profile. extraction of the lower second The skeletal characteristics of premolars is better in terms of patients with severe hyperdivergent profile improvement, because skeletal pattern are high mandibular the mesial protraction of the plane angle, upcanted palatal plane, lower posterior teeth is helpful retropositioned mandible, and long in reducing vertical dimension or Figure 1: Skeletal and dental characteristics of lower anterior facial height relative autorotation of the mandible by a patient with severe hyperdivergent skeletal to posterior facial height. The dental moving the fulcrum forward. pattern. doi:10.12889/2017_C00270 © 2017 SIDO CLINICAL ARTICLE

Figure 2: Pre-treatment extraoral photographs.

THE CASE Extraoral Findings Patients with a hyperdivergent Lateral extraoral photos showed a skeletal pattern with a large convex profile with severe bilabial mandibular plane angle and with protrusion. A retruded mandible posteriorly positioned menton and compared with the maxilla was overeruption of the maxillary and observed, with a long distance from mandibular anterior teeth could only the stomodeum to the menton. be properly treated by orthognathic Moreover, a small nasolabial angle surgery with a very complicated and hyperactivity of the mentalis design. However, microimplants can muscle during lip closure were found be used in these patients. A 24-year- . The upper and lower lips were (Fig. 2) old female patient presented with protruded from the esthetic line by 5 anterior open bite and lip protrusion. mm and 9 mm, respectively. The patient was treated with microimplants, and improvement Cephalometric Analysis and of the facial profile was obtained Radiographic Findings after intrusion of the maxillary and In cephalometric analysis, the mandibular molars and simultaneous A point–nasion–B point angle intrusion of the anterior teeth. The (ANB) was 5.6°, and the Frankfort- mechanics using microimplants to mandibular plane angle (FMA) was intrude posterior teeth and retraction 38.6°, showing a dolichofacial pattern of the anterior teeth were applied to with long lower facial height . (Table 1) maximize anterosuperior rotation of The maxillary and mandibular anterior the mandible. teeth showed a severe labioversion. The patient was diagnosed with a skeletal Class II malocclusion caused Figure 3: Pre-treatment lateral cephalometric and panoramic radiographs. Measurements Pretreatment 14 months of treatment Posttreatment Skeletal SNA 83.2 81.9 81.4 SNB 77.6 77.6 77.6 ANB 5.6 4.3 3.8 FMA 38.6 37.8 37.8 Dental U1 to FH 125.3 115.7 106.8 IMPA 104.4 87.5 82.7 Soft tissue Z-ANGLE 64.9 52.2 59.7 Upper lip to esthetic line, mm 5 1 −1 Lower lip to esthetic line, mm 9 6 2.5 Data are presented as degrees unless otherwise indicated. Abbreviations: ANB, A point–nasion–B point angle; FH, Frankfort horizontal; FMA, Frankfort-mandibular plane angle; IMPA, incisor mandibular plane angle; SNA, sella–nasion–A point angle; SNB, sella–nasion–B point angle; U1, upper incisor.

Table 1: Cephalometric measurements.

Figure 4: Pre-treatment intraoral photographs.

Figure 5: Immediate light distal force applied from microimplants.

Figure 6: Intraoral photographs at 7 months of treatment. Tongue spur was bonded to the upper central incisors. by mandibular retrognathism and length discrepancies were moderate: reduction on the mandibular anterior open bite. In a panoramic radiograph, 3.5 mm in the maxillary arch and teeth was planned. Class II canine 4 third molars existed and there was 3 mm in the mandibular arch. The and molar relationships were seen on no sign of root resorption . curve of Spee was 0 mm. The anterior both sides . (Fig. 3) (Fig. 4) Bolton ratio was 79.5%, meaning that Intraoral Findings the mandibular anterior teeth were 1.1 DIAGNOSIS AND TREATMENT PLAN Anterior open bite was observed mm larger than the maxillary anterior Third molars that might interrupt with an overbite of −5 mm. The arch teeth. Therefore, interproximal vertical control were extracted. In doi:10.12889/2017_C00270 © 2017 SIDO CLINICAL ARTICLE

Figure 7: Extraoral photographs at 10 months of treatment. Facial profile change was minimal.

Figure 8: Intraoral photographs at 11 months of treatment. Intrusion force was applied to the upper and lower posterior teeth.

Figure 9: Intraoral photographs at 14 months of treatment. To obtain more intrusion of the maxillary posterior teeth, the palatal microimplant was placed, and palatal intrusion force was added. addition, to solve the lip protrusion were placed between the second treatment, Super thread (T-45; RMO, and crowing, the first premolars in all premolar and first molar in both the Denver, CO, USA) was connected 4 quadrants were also extracted. For maxilla and mandible . The from the maxillary microimplant to (Fig. 5) maximum retraction of the anterior square thread (045; Dentos, Daegu, the first molar hook to apply about teeth and vertical control of the South Korea) was connected to the 50 gm of light intrusion force to the posterior teeth, microimplants on canine immediately following the maxillary molars. both the maxilla and mandible were placement of the microimplant to At 7 months of treatment, positive planned. exert 50 gm of distalizing force. A 016 overbite was achieved. The crowding × 022 stainless steel (SS) archwire at the mandibular anterior teeth was Treatment Progress with long anterior hooks was inserted resolved. Thus, a 016 × 022 TMA 022 Roth straight wire brackets in the maxillary arch, and 150 gm archwire with hooks crimped in the were bonded, and initial alignment of retraction force was applied gingival direction was inserted. The was started. A transpalatal arch was with nickel-titanium coil springs. distal force to the anterior hooks was inserted in the maxillary arch, and To obtain the space for resolving applied from the gingivally extended microimplants (Absoanchor, upper anterior crowding in the mandibular hook on the mandibular first molars. arch, SH1312-08; lower arch, SH1413- arch, distal force was applied to the Because the patient had a tongue 06; Dentos, Daegu, South Korea) canine continuously. At 11 weeks of thrusting habit, tongue spurs were

bonded on the lingual surfaces of the of treatment, the microimplant treatment, Class I canine and molar mandibular anterior teeth . (Absoanchor, SH1312-10; Dentos, relationships were achieved with a (Fig. 6) At 10 months of treatment, lip Daegu, South Korea) was placed into satisfactory facial profile . (Fig. 10) protrusion was decreased, and the palatal alveolar bone between hyperactivity of the mentalis muscle the maxillary first and second molars, Treatment Results disappeared. However, the facial and intrusion force was applied to The total treatment time was 28 profile change was minimal, and the molars from the microimplants. months, and open bite was treated the lower facial height was still long The intrusion of the posterior teeth by retraction of the anterior teeth because of inherent retropositioned rotates the mandible forward and and counterclockwise rotation of the mandible . upward, and this may cause traumatic mandible resulting from the intrusion (Fig. 7) At 11 months, after space closure, a occlusion at the anterior teeth. of the maxillary posterior teeth 017 × 025 SS archwire was inserted Thus, intrusion and retraction of the and intrusion and uprighting of the in the mandibular arch, and intrusion mandibular incisors was required. To mandibular posterior teeth. By these of the mandibular molars was started enhance intrusion of the mandibular changes, anterior lower facial height to induce counterclockwise rotation incisors during retraction, the hooks was decreased, and hyperactivity of of the mandible . Unlike the were crimped in the incisal direction the mentalis muscle disappeared. (Fig. 8) maxillary arch, the mandibular arch . Finally, improvement of the facial (Fig. 9) does not require a lingual arch if light At 20 months of treatment, the profile was achieved . The (Fig. 10) intrusion force is applied because nasolabial angle was improved. anterior open bite was corrected, and there is a tendency toward lingual Thus, retraction of the maxillary Class I canine and molar relationships tipping in cases where premolars are anterior teeth was stopped, and were achieved. The coincident extracted. intrusion of the molars and intrusion maxillary and mandibular midline and The necessity of improving the facial and retraction of the mandibular favorable arch shape were obtained profile by anterosuperior rotation anterior teeth were continued for . (Fig. 11) of the mandible justified additional more autorotation of the mandible. On the cephalometric radiograph, intrusion of the maxillary molar Occlusal settling was done in the final uprighting of the molars on both with microimplants. At 14 months detailing procedure. At 28 months of arches could be found, and minor root resorption was found at the maxillary anterior teeth . The (Fig. 12) cephalometric superimpositions showed that the maxillary and mandibular anterior teeth were retracted by 12 mm and 11 mm, respectively, and this brought about a decrease in lip protrusion . (Fig. 13) The maxillary and mandibular molars were intruded by 3 mm and 1 mm, respectively, and counterclockwise rotation of the mandible was evident. Figure 10: Post-treatment (28 months) extraoral photographs.

Figure 12: Post-treatment lateral cephalometric Figure 13: Superimposition of lateral cephalometric radiographs. radiographs.

The ANB and FMA decreased by DISCUSSION the teeth in the opposite jaw are 1.8° and 0.8°, respectively. This is To intrude the posterior teeth extruded, and no decrease in vertical difficult to achieve in a patient with effectively, the microimplants dimension results. Simultaneous a dolichofacial pattern, and it is were placed in the maxillary and intrusion of the posterior teeth was believed to be achieved by intrusion mandibular posterior teeth. The performed in the patient, and this of the molars. At 4 years of retention, 50 gm of light force was applied to brought about improvement of the the profile and occlusion were stably minimize side effects. When intruding facial profile. In patients who have a maintained . the posterior teeth in one jaw only, long distance from the incisal edges (Fig. 14, 15) of the mandibular incisor to the menton, anterosuperior rotation of the mandible cannot be induced by intrusion of the posterior teeth only, but can be induced by combined intrusion of the anterior and posterior teeth. Elastic thread force was applied from the microimplant between the second premolars and first molars to the hook attached incisal to the archwire. This down and backward Figure 14: Extraoral force brought about intrusion of the photographs at 4 years of retention.

Figure 15: Intraoral photographs at 4 years of retention.

mandibular anterior teeth during tongue thrusting habit, and this was the maxillary sinus. retraction, enhancing autorotation of believed to be one reason for root Regarding retention, retention was the mandible. resorption. Another reason might be satisfactory, and the reasons might If space deficiency is not severe and the use of the 016 × 022 SS archwire be because of the changes in tongue the molar uprighting is needed more until the end of treatment. Distalizing posture after treatment and the than the anterior teeth intrusion, force after closing of the extraction patient’s excellent cooperation in extraction of the mandibular second space may act as jiggling force to performing clenching and swallowing premolars might be better. The anterior teeth, especially when there exercises. general position of the mandibular is no distal movement of the posterior microimplant is between the first teeth. Therefore, when applying CONCLUSION and second molars in microimplant intrusion or retraction force to the In the treatment of patients with anchorage sliding mechanics, and the dentition after extraction space is severe hyperdivergent skeletal main purpose of this microimplant closed, 019 × 025 SS archwire should pattern, the intrusion of the posterior is vertical control of the posterior be inserted. teeth is not enough to maximize teeth rather than the retraction of Basically, the maxillary posterior the facial profile, and many factors the anterior teeth. However, the teeth receive intrusion force when need to be considered to not restrict patient had a long height from the posterosuperior retraction force is the amount of autorotation of the mandibular anterior incisor tip to the applied from the microimplant to mandible. The factors include the menton, and intrusion of the anterior an anterior hook on the archwire. intrusion of the upper posterior teeth, teeth along with the molar intrusion If more intrusion is required at the the consideration for anteroposterior was necessary for anterosuperior maxillary posterior teeth, intrusion occlusal plane cant, bodily retraction rotation of the mandible. Therefore, force can be added to the archwire of the upper incisors, intrusion of the to apply down and backward force from the buccal microimplant during upper incisors, intrusion of the lower to the mandibular anterior teeth, the retraction of the anterior teeth. After posterior teeth, vertical position of the microimplant was placed between extraction space is closed, intrusive lower incisors, and most importantly the second premolar and first molar. force to the archwire at the premolar coordination of movement at the Root resorption occurring at the area from the buccal microimplant upper and lower posterior teeth and maxillary anterior teeth is believed may produce labial tipping of the the upper and lower incisors. to have been caused by the anterior anterior teeth and may be insufficient The Author presents a case in which a traumatic occlusion due to the to gain the maxillary molar intrusion. patient experienced a profound facial posterior open bite after molar Therefore, the microimplant should profile change after intrusion of the intrusion. Therefore, to minimize such be placed between the first and upper and lower molars and bodily traumatic occlusion, retraction of the second molars for suitable molar retraction of the upper incisors and anterior teeth and the intrusion of intrusion such as in nonextraction retraction and intrusion of the lower the molars should be coordinated. open bite treatment. This is highly incisors. The patient showed excellent The anterior teeth were believed recommended if the roots of the retention after 4 years. to receive jiggling force due to the maxillary posterior teeth are close to

REFERENCE LIST

1. Park HS. The skeletal cortical anchorage 7. Oh YH, Park HS, Kwon TG. The treatment 12. Park HS, Kyung HM, Sung JH. A simple using titanium microscrew implants. effects of microimplant aided sliding method of molar uprighting with Korean J Orthod 1999;29:699-706. mechanics on distal retraction of the Micro-implant anchorage. J Clin Orthod 2. Park HS, Bae SM, Kyung HM, Sung JH. posterior teeth. Am J Orthod Dentofacial 2002;36:592-596. Micro-implant anchorage for treatment Orthop 2011;139:470-481. 13. Park HS, Kwon OW, Sung JH. Uprighting of skeletal Class I bialveolar protrusion. J 8. Park YC, Lee SY, Kim DH, Jee SH. second molars with Micro-implant Clin Orthod 2001;35:417-422. Intrusion of posterior teeth using mini- Anchorage. J Clin Orthod 2004;38:100- 3. Park HS, Kwon OW, Sung JH. Microscrew screw implants. Am J Orthod Dentofacial 103. implant anchorage sliding mechanics. Orthop 2003;123:690-694. 14. Park HS, Kwon OW, Sung JH. Micro- World J Orthod 2005;6:265-274. 9. Park HS, Jang BK, Kyung HM. Molar Implant Anchorage for forced eruption 4. Park HS, Bae SM, Kyung HM, Sung intrusion with Micro-implant Anchorage. of impacted canine. J Clin Orthod JH. Simultaneous incisor retraction Aust J Orthod 2005;21:129-135. 2004;38:297-302. and distal molar movement with 10. Park HS, Kwon OW, Sung JH. 15. Park HS. Efficient use of microimplants in microimplant anchorage. World J Orthod Nonextraction treatment of an anterior orthodontics, openbite, deepbite, Class 2004;5:164-171. openbite with Microscrew Implant III treatment, nonextraction and various 5. Park HS, Kwon TG, Sung JH. Anchorage. Am J Orthod Dentofacial clinical applications. Daegu, South Korea: Nonextraction treatment with Orthop 2006;130:391-402. Dentos; 2015. microscrew implants. Angle Orthod 11. Park HS, Kwon TG, Kwon OW. Treatment 2004;74:539-549. of openbite with microscrew implant 6. Park HS, Lee SK, Sung JH. Group distal anchorage. Am J Orthod Dentofacial movement of teeth with microscrew Orthop 2004;126:627-636. implants. Angle Orthod 2005;75:510-517.

doi:10.12889/2017_C00270 © 2017 SIDO Carlo Bonapace WHO’S WHO Private Practice of Orthodontics, Turin, Italy In this section we introduce an influential orthodontist who has given a significant contribution to the specialty. An article by the author featuring his landmarks follows. Correspondence: Corso Re Umberto, 97 - 10128 Turin, Italy e-mail: [email protected]

How to cite this article: Bonapace C. Hyo-Sang Park. EJCO 2017;5: doi:10.12889/2017_B00271

Hyo-Sang Park yo-Sang Park was born in a small effect to obtain in treating high-angle patient support during his long travels country town in Kyungpook Class II cases. However, in patients to lectures. His son, Mick, is now HProvince, South Korea. He who don’t adhere to treatment, the studying for a PhD degree in biology received his dental education from results are less than desirable, and at Yale University in the United States Kyungpook National University and high-pull J-hook headgear use is a of America. Outside of orthodontics, completed his specialty as orthodontic very difficult task for patients. he loves playing golf with friends and resident in the Department of Since 1998, his interests moved to traveling with his wife, Jae-Eun. Orthodontics, Kyungpook National clinical studies and the use of surgical University Hospital under the screws for orthodontic anchorage supervision of his mentor professor, to overcome the need for high-pull Jae-Hyun Sung. He joined the J-hook headgear, publishing the army as captain in a military public first article on microimplants in the hospital for 3 years. He worked at the Korean Journal of Orthodontics. Dental Department, Medical College, In the article, he alleged that Keimyung University for 10 years, where microscrews can provide anchorage he completed his PhD in 1997. His PhD for distalization of the whole maxillary research topic was neurotransmitter dentition. Since then, he has lectured expression in response to orthodontic extensively at orthodontic meetings tooth movement. He moved to the and at universities in South Korea, Department of Orthodontics, School Japan, and Taiwan to communicate of Dentistry, Kyungpook National the technique. He developed simple University, where he is currently and efficient microimplant anchorage Professor and Chair. mechanics, using sliding mechanics He learned many orthodontic with microimplant anchorage, techniques during and after his retracting the 6 anterior teeth specialty education, such as the together or distalizing the dentition Ricketts technique, Broussard altogether. technique, and Tweed technique. The He has been using microimplants for technique that influenced him most 18 years, owns 10 patents, and has was the Tweed technique, which was written more than 70 international introduced in South Korea by Il-Bong articles, 6 textbooks, and 5 chapters Kim and Jae-Hyun Sung. Because on orthodontic microimplants. He South Korean patients mostly have has spoken more than 70 times at high-angle Class II malocclusion prestigious meetings, including the that requires vertical control to American Academy of Orthodontics improve facial features, the high-pull Annual Session, European Orthodontic J-hook headgear used in the Tweed- Society Congress, and International Merrifield technique can prevent Orthodontics Congress, as a keynote lingual tipping of the upper incisors speaker. He has provided more than during retraction and can produce 130 two- or three-day microimplant mandibular forward movement training courses internationally. response. This is the most important He is thankful to his family for their

10.12889/2017_B00271 © 2017 SIDO Vittorio Grenga X-RAY ODDITIES Private Practice of Orthodontics, Rome, Italy Many times, when we see in our practice a radiograph, we have the opportunity to note images that may or may not influence directly our diagnosis and our treatment plan. Correspondence: This column of EJCO gives us the opportunity to show these images and to make Via Apuania, 3 • 00162 Rome • Italy e-mail: [email protected] some brief observations about them. The style is concise: the images largely speak for themselves. How to cite this article: Your suggestions for future topics as well as your comments will be very welcome. Giordano L, Turatti G. The goldenhar syndrome. EJCO 2017; 5 doi:10.12889/2016_E00267

Lia Giordano Department of Odontostomatology and Orthodontics, The Goldenhar Syndrome Martini Hospital, Turin, Italy

Gaetano Turatti Department of Odontostomatology and Orthodontics, Martini Hospital, Turin, Italy

Goldenhar syndrome (GS) is a rare GS, also known as hemifacial A cleft lip and ogival palate are very condition with an estimated incidence microsomia and oculo-auriculo- common4,5. The mandibular ramus can of 1 per 5,800 births and a male:female vertebral dysplasia (OAVS), can be short or absent and the chin tends ratio of 3:2. It is presumed to be an have very different manifestations to be asymmetric. If the mandibular inherited condition and results in in affected subjects, with severe ramus and the mandibular condyle morphological abnormalities in the malformations varying between are absent, so too are the glenoid regions of the face that develop from patients. fossae . This phenomenon is (Figs. 2–5) the ﬁrst and second branchial arches. According to scientifc evidence, GS probably due to the absence of the A multifactorial aetiopathology has the following features: mandibular functional stimulus of mandibular is reported and nutritional and hypoplasia, hemifacial microsomia, movements and dental growth environmental factors seem to be tissue underdevelopment on one side which determines the development important1. The facial features of of the face, and underdevelopment of of the temporal bone as a functional a rare case of an 8-year-old male the lower and upper jaws2,3 . process. In this rare case, the absence (Fig. 1) patient with GS are described. Macrostomia, tracheal-oesophageal of the zygomatic arch makes the fstula, oesophageal atresia, facial asymmetry more obvious6,7. and structural and functional Moreover, oral abnormalities are malformations of the pharynx present and visible on panoramic and larynx increase the risk of x-ray, with supernumerary teeth in airway obstruction and impair the lower arch and a supernumerary communication and mobility. premolar in the upper arch (Fig. This syndrome may cause severe . Three-dimensional radiological 6) obstructive sleep apnoea, which, if left diagnosis is always required so the untreated, could lead to growth and, best treatment can be planned. in some cases, mental retardation.

doi:10.12889/2016_E00267 © 2017 SIDO Figure 1: CT - frontal view. Asymmetric Figure 2: CT - lateral right view. Normal Figure 3: CT - lateral left side. Absence of development of the maxillae and the mandible, anatomy of the skeletal structures. the mandibular ramus, hypoplasia of the deviation of the nasal septum and absence of maxillae and the third middle of the face the zygomatic arch. with alteration of the lower edge of the eye orbit and absence of the glenoid fossae and associated ligaments (temporomandibular, sphenomandibular, stylomandibular).

Figure 6: Orthopantomograph. Normal development of the mixed dentition on the right side but dental anomalies on the left side with supernumerary teeth in the upper Figure 4: MRI - horizontal view of the Figure 5: MRI - frontal view of the nasal jaw. There is multiple dental impaction in nasal region. Asymmetric development of region. Deviation of the nasal septum with the lower arch and absence of the mandibular the maxillary sinus. In particular, there is reduced patency of the ipsilateral nasal canal, a wide cleft palate and otodysplasia underdevelopment of left maxillary sinus fossa (interruption of the nasal cavity floor major. A bony formation with downward with pneumatisation at the retrobulbar level; bilaterally in the cranial portion). development is visible on the left side of the the ethmoid and sphenoid sinuses show no mandible. significant anomalies. Note the asymmetric vertical position of the maxillary tuberosity.

REFERENCE LIST

1. Dali M, Chacko V, Rao A. Goldenhar syndrome: a report of a rare 5. Yañez-Vico RM, Iglesias-Linares A, Torres-Lagares D, et al. case. Journal of Nepal Dental Association 2009;10:128–130. Diagnostic of craniofacial asymmetry. Literature review. Med Oral 2. Reddy P. Facio-auricular vertebral syndrome - a case report. Patol Oral Cir Bucal 2010;15:e494–e498. Indian Journal of Human Genetics 2005;13:156–158. 6. Kaban LB. Congenital abnormalities of the temporomandibular 3. Goldenhar M. Malformative associations of eye and ear, especially joint, in: Kaban LB, Troulis MJ, editors. Pediatric Oral and the dermoid syndrome and the epibulbar dermoidauricular Maxillofacial Surgery. 1. Philadelphia: Saunders; 2004, pp. appendix-preauricula fstula auris congenital syndrome and its 302–337. connections with mandibular-facial-dysostosis. J Genet Hum 7. Ostlere SJ, MacDonald B, Athanasou NA. Mesenchymal 1952;1:243–282. chondrosarcoma associated with Goldenhar’s syndrome. Arch 4. Vinay C, Reddy RS, Uloopi KS, et al. Craniofacial features in Orthop Trauma Surg 1999;119:347–348. Goldenhar syndrome. J Indian Soc Pedod Prev Dent 2009;27:121– 124.

Giorgio Cacciatore Department of Biomedical Sciences Workshop on Early Treatment, for Health, Università degli Studi di Milano, Milan, Italy. SIDO International Spring Meeting, Turin, Italy, March 6-8, 2014 Silvia Allegrini Private practice in Orthodontics, Pisa, Italy. questionnaire was given to all of the speakers who attended the SIDO International Spring Meeting in Turin, Italy on March 6-8, 2014. Each Aspeaker was asked to answer the following 7 questions:

Lorenzo Franchi 1. What are the most commonly known orthodontic problems usually addressed with one phase of early treatment? Department of Surgery and 2. Based on the answer to Question 1, do we have sufficient evidence Translational Medicine, regarding one phase of early treatment? Orthodontics, Università degli Studi 3. Do we have evidence on the cost-benefits of early treatment? di Firenze, Florence, Italy. 4. Does an early phase of treatment eliminate/reduce the need for a second phase of treatment in permanent dentition? Claudio Lanteri 5. Are treatment alternatives to early treatment possible? 6. If so, in your opinion, are treatment alternatives clearly and routinely Private practice in Orthodontics, provided to the patient? Turin, Italy. 7. Is information to the public about early treatment protocols and their evidence clear and exhaustive?

Answers to Questions 1 and 3 were divided into vertical, transverse, sagittal, Correspondence: dental, and functional/temporo-mandibular joint problems. Speakers were e-mail: [email protected] then asked to agree or disagree with the remaining questions according to the following scale: strongly agree; agree; neither agree nor disagree; disagree; Article history: and strongly disagree. The answers are shown in . All speakers Tables 1 and 2 Received: 25/07/2015 were invited to quote references supporting their answers. Published online: 14/12/2015 Out of the 33 speakers who attended the meeting, 19 (58%) answered the questionnaire and only 13 (39%) gave references. A scientific committee Conflict of interest: summarized the consensus of the workshop, based on the answers given to The authors declare that they have the 7 questions. no conflicts of interest related to this research. CONSENSUS SUMMARY OF THE WORKSHOP

How to cite this article: 1. What are the most commonly known orthodontic problems usually Cacciatore G, Allegrini S, Franchi L, addressed with one phase of early treatment? Lanteri C. Workshop on early treatment, SIDO International Spring Meeting Early, or phase I, orthodontic treatment is defined as treatment started in either in Turin, Italy, March 6-8, 2014. EJCO the primary or mixed dentitions1. The perceived benefits include improvement 2015;doi: 10.12889/2015_E00243 in the patient’s self-esteem2, greater ability to modify the growth process3, earlier resolution or interception of the developing malocclusion4, more stable results1, less extensive therapy, and shorter treatment time in the permanent dentition1,3. The most commonly known orthodontic problem addressed with one phase of early treatment was posterior crossbite (according to 92.31% of the speakers). When grinding alone is not effective, maxillary expansion will decrease the risk of a posterior crossbite from being perpetuated to the permanent dentition5,6. Banded or bonded rapid maxillary expanders (RME), Quad Helix (QH), and expansion plates (EP) provide a correction of posterior crossbite at a high success rate5-12, an anterior crossbite self-correction13, an increase in maxillary arch perimeter (approximately 4 mm, when RME is followed by fixed appliances), and a maintenance of mandibular arch perimeter (2.5 mm)9,10. Moreover, early treatment of functional unilateral posterior crossbite could optimize conditions for function and development14-19. It was unclear if RME could help Class II correction20.

Early orthodontic treatment was also proposed by 46.15% evidence concerns early treatment of posterior crossbite, of speakers for the correction of a mild to moderate dento- Class III malocclusion, and Class II malocclusion, when skeletal Class III or Class II malocclusions. Rapid maxillary attempted to reduce the incidence of incisor trauma52. expansion and facemask therapy21-27, Frankel’s function regulator-3 (FR-3)28, and reverse pull headgear29 are effective 3. Do we have evidence on the cost-benefits of early in the short- and long-term correction of Class III malocclusion. treatment? Better results could be obtained when the interventions are undertaken during mixed dentition (under 10 years of age). The answers on the cost-benefit of early orthodontic With regard to Class II malocclusion, the evidence suggests treatment were consistent with those for question 1, with that providing “two-phase treatment” is more effective in the exception of functional/tempo-mandibular disorders. reducing the incidence of incisor trauma than providing According to the speakers, there was evidence for transverse “one-phase treatment”. There are no other advantages to (84.62%), sagittal (53.85%), and functional problems, while providing early treatment when compared to treatment the early treatment of vertical (38.46%) and dental problems in adolescence. When functional appliance treatment is (38.46%) reached the lowest level of evidence. provided in early adolescence, it appears that there are According to the cited references, there is some evidence minor beneficial changes in skeletal pattern; however, these of the effectiveness of early treatment only for the posterior changes are probably not clinically significant30-37. crossbite53-55. Regarding the sagittal problem, although The third orthodontic problem (38.46%) addressed with providing early treatment for children with prominent one phase of early treatment was impacted or displaced upper front teeth (Class II malocclusion) is more effective permanent teeth. RME treatment following surgical removal in reducing the incidence of incisor trauma than providing of the obstacles to the eruption (supernumerary teeth, treatment in adolescence30,56, it appears that “two-phase odontomas) seems to be an efficient interceptive approach treatment” does not produce major differences in jaw leading to the eruption of impacted permanent incisors38. relationships or dental occlusion compared with “one-phase Meanwhile, interceptive protocols proposed for palatally treatment”30,57,58. None of the studies cited evaluated the displaced permanent canines include extraction of the cost-benefit of early treatment of Class III malocclusion and corresponding primary teeth (EC), orthodontic procedures other vertical, dental, and functional problems. to maintain or increase maxillary arch length or perimeter Generally, the most suitable ages for screening the child such as RME, transpalatal arch (TPA), and cervical-pull population for interceptive orthodontics is 9 years and headgear (HG), or a combination of these modalities 11 years59. The outcome of interceptive treatment is very (TPA+EC, RME+TPA+EC, RME+HG, EC+HG). There is favourable, both in terms of improvement in the presenting currently no evidence on the effects of EC with palatally condition and in reducing the need for subsequent displaced permanent canines39; meanwhile, the prevalence treatment60,61. The disadvantages of early treatment are of canine eruption is 65.7% for RME40, 79.0% for TPA+EC41, prolonged treatment time and a higher incidence of 80.0% for RME+TPA+EC41, 82.3% for HG42 and 85.7% for premature termination of treatment, which is attributed to RME+HG42 versus 28% for no treatment41. patient/parent “burn-out.” To avoid compliance problems Approximately one third (30.77%) of the speakers said they due to excessive treatment times, it is recommended that treated early anterior open bite43,44 and functional/temporo- early treatment with fixed appliances be limited to 12 months mandibular disorders45-47. of active phase I treatment and be reserved for patients where it is clearly indicated62. 2. Based on the answer to Question 1, do we have sufficient evidence regarding one phase of early treatment? 4. Does an early phase of treatment eliminate/reduce the need for a second phase of treatment in permanent Most of the speakers strongly agreed (38.46%) or agreed dentition? (38.46%) that there is evidence on one phase of early treatment48-50. Only two (15.39%) were undecided and one Most of the orthodontists (61.54%) did not perceive one- (7.69%) was in strong disagreement51. The highest level of phase treatment as prevention for the need for a second

Functional / Questions Vertical Transverse Sagittal Dental TMJ

1. What are the most commonly 4 12 6 5 4 known orthodontic problems usually addressed with one phase 30.77% 92.31% 46.15% 38.46% 30.77% of early treatment?

5 11 7 5 7 3. Do we have evidence on the cost-benefits of early treatment? 38.46% 84.62% 53.85% 38.46% 53.85%

Strongly Neither agree Strongly Questions Agree Disagree agree nor disagree disagree

2. Based on the answer to 5 5 2 - 1 Question 1, do we have evidence to one phase of early treatment? 38.46% 38.46% 15.39% - 7.69%

4. Does an early phase of 1 7 3 1 - treatment eliminate/reduce the need for a second phase of treatment in permanent 7.69% 53.85% 23.08% 7.69% - dentition?

- 3 4 3 3 5. Are treatment alternatives to early treatment possible? - 23.08% 30.77% 23.08% 23.08%

6. If so, in your opinion are they 1 - 6 2 2 clearly routinely provided to the patient? 7.69% - 46.15% 15.39% 15.39%

7. Is information to the public - - 3 3 5 about early treatment protocols and their evidence clear and exhaustive? - - 23.08% 23.08% 38.46%

Table 2: Answers to the questions 2, 4, 5, 6 and 7.

phase of treatment, or that it offered any particular advantage About half of the speakers (46.15%) were undecided on with respect to preventing the need for extractions or this point, while the remaining strongly agreed (7.69%); other skeletal treatments in the second phase. They viewed disagreed (15.39%); and strongly disagreed (15.39%). early treatment as effective in reducing the severity of Whether treatment alternatives are clearly and routinely and priority for a second phase of treatment61,63-68. Only 3 proposed to patients depends on the individual practitioner. speakers answered that they were undecided, while one It is clear that each practitioner should provide exhaustive was in disagreement. Although they have a wide theoretical verbal and written options of the different types of treatment, basis and an appealing rationale, preventive and interceptive illustrating both their advantages and disadvantages, so orthodontic procedures appear unable to successfully patients are facilitated in their choice of treatment72. manage more than 15-20% of developing malocclusions in children. Corrective orthodontic procedures, rather than 7. Is information to the public about early treatment preventive-interceptive ones, should be emphasized both protocols and their evidence clear and exhaustive? in public planning for the delivery of care and in dental education69. No, the public do not receive clear and exhaustive information about early treatment protocols and their 5. Are treatment alternatives to early treatment possible? evidence. Orthodontists should be encouraged to inform patients regarding the possible risks, benefits, costs, and The most common alternative to “two-phase treatment” alternatives of their chosen treatment73. All of the speakers is “one-phase treatment” with fixed appliances, with or agreed with this statement (23.08-38.46%). without the extraction of permanent teeth. The possibilities of not treating, camouflaging, or opting for orthognathic DISCUSSION surgery at the end of growth should be considered for correcting malocclusion, as well70-71. The distribution of the The aim of this workshop was to summarize the knowledge answers was quite similar (from 23.08 to 30.77%) for all of and experiences of the referenced speakers who attended the speakers. No one was in strong agreement. the SIDO International Spring Meeting on early orthodontic treatment. The speakers agreed in most of the answers, but 6. If so, in your opinion, are treatment alternatives clearly a consensus was not always found. Additionally, all of the and routinely provided to the patient? systematic reviews on early treatment were considered,

in order to reach the highest level of scientific evidence. the available studies have serious problems that range from According to the systematic reviews analysed, there is small sample size, bias and confounding variables to a lack moderate to low quality of evidence on one phase of of method error analysis, blinding in measurements, and early treatment. The highest level of evidence concerns deficient or lack of statistical methods. Better-controlled early treatment of posterior crossbite5,74,75, Class III randomized clinical trials, which follow the guidelines malocclusion76,77 and Class II malocclusion, when attempted produced by the Consolidated Standards of Reporting to reduce the incidence of incisor trauma30; meanwhile, the Trials (CONSORT), are needed to obtain reliable scientific quality of the rest of the evidence is very low39,78-80. Most of evidence75.

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Ayman El Nigoumi Department of Orthodontics and Dentofacial Orthopedics, Cairo University, Cairo, Egypt Abstract

Sakha Dawoud Ahil Evaluation of the dental midline in relation to facial midline is Department of Orthodontics key in diagnosing, treatment planning and tracking progress. and Dentofacial Orthopedics, We propose a unique method to clinically locate and quantify Cairo University, Cairo, Egypt maxillary dental midline deviations using a ‘midline guide,’ which can also be used to check for mandibular asymmetry and possible canting. Correspondence: e-mail: [email protected]

Article history: Received: 15/05/2016 Accepted: 27/07/2016 Published online: 11/11/2016

Conflict of interest: The authors declare that they have no conflicts of interest related to this research.

How to cite this article: El Nigoumi A, Ahil SD. The midline guide: a new method for evaluating midline Keywords deviation. EJCO;4 doi:10.12889/2016_ Dental midline, facial midline, midline guide, canting, asymmetry T00264.

Figure 3: A close-up view of a patient showing a 0.5 mm shift to the right side.

Figure 1: The midline guide is printed on Figure 2: The guide is placed over the patient’s a transparent sheet using a laser printer. face, and the orienting lines are aligned as The figure shows vertical and horizontal follows: (1) the horizontal lines are parallel to orientation lines and the nose cut-out region. the interpupillary line; (2) the vertical center line passes through two points, the center of the Glabella and Subnasale; and (3) the dental midline is compared with the vertical center line to determine deviation.

INTRODUCTION arbitrarily, require parallax to properly Clinical evaluation of dental midlines visualize them, and are affected in relation to the facial midline is by asymmetry6. However, the face troublesome. It has been shown that is never symmetrical, and many of 39% of patients receiving orthodontic the midline structures are not well care have maxillary midline deviation aligned on the face. The nose plays from the facial midline1. Many methods an important role in the perception Figure 5: Illustration showing dental midline have been proposed to localize and of facial symmetry7. In Korea, the shifted 2 mm to the left. quantify midline deviation. Some prevalence of nasal septal deviation of these methods include drawing was found to be 48%8. Nasal septal two vertical marks on the patient’s deviation may be apparent on the face with a soft pencil; one at the face; thus, it is essential to exclude a center of the philtrum and the other deviated nose in midline assessment 4. at the mid-chin region2. Another A deviated chin can also distort the method uses a piece of dental floss reference plane and lead to improper stretched and centralized from above midline assessment9. the forehead to below the chin None of the methods described with the patient supine or standing above are universally accepted, and up3. A third method includes visual no guidelines on properly clinically assessment by an imaginary line locating and quantifying midline passing through a single structure deviations without error exist. Thus, Figure 6: Illustration showing canting of such as the philtrum4 or, alternatively, there is a need for a quick, simple, and incisors. The dental midline crosses several two structures – the center of the reproducible way to check midline vertical orienting lines. Glabella and soft tissue Pogonion5. shifts at any stage of treatment. We Finally, one method utilizes the mid- herein propose a new method to find philtrum and the distance between and measure midline deviations. laser printer sheet and use a sharp the canine and corners of the mouth, knife or scalpel to remove the nose as suggested by Burstone6. TECHNIQUE cut-out region. The guide consists Some of the points used to establish To use the attached midline guide of vertical and horizontal orienting the facial midline are located , print it out on a transparent lines. The vertical center line should (Fig. 1)

coincide with the midline of the on the facial midline allows the guide CONCLUSION face – the center of the Glabella and to be placed closely to the face of A new method to clinically assess Subnasale are used as references and the patient to reduce parallax errors. shift in the dental midline using can be marked with a light pencil Additionally, no points are chosen on a transparent sheet marked with if necessary . The horizontal the chin region because it would be orientation lines was presented. The (Fig. 2) lines must be oriented parallel to the subject to change due to asymmetry advantages of this method include: interpupillary line. The two vertical or functional shifting. - It is simple, reproducible, and broken lines to the right and left of After determining the upper midline inexpensive; the vertical center line denote a 1 mm position , it can be used - It determines upper midline (Fig. 4, Fig. 5) deviation from the vertical center as a reference to quantify the lower deviation from the facial midline line, and the two solid lines denote a midline shift. However, it is important and lower midline shift in relation 2 mm deviation. If the dental midline to ensure that there is no functional to upper midline position; appears between any two lines, the shifting and that the patient bites - It indicates mandibular asymmetry value is 0.5 mm . in the correct position. The midline and possible dental/skeletal (Fig. 3) The nose, which if taken into guide can also be used to check for canting. account would result in erroneous canting. Dental or skeletal canting measurement, is cut out from the may be present if the maxillary dental midline guide. Excluding the effect midline is not parallel to the vertical of the nasal tip or septal deviation center line of the midline guide . (Fig. 6)

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