EDITORIAL

JOURNAL OF THE MASSACHUSETTS DENTAL SIMPLE TRUTHS SOCIETY

E WRITE THESE WORDS AS OUR GOVERNMENT AND CITIZENS BATTLE (SOMETIMES LITERALLY) EDITOR Wover health care reform and as our state and nation have lost two Kennedy sib- David B. Becker, DMD lings, one the longtime “Lion of the Senate” and the other the founder of the Special ASSISTANT EDITOR Olympics Program. Arthur I. Schwartz, DMD Since 1968, the Special Olympics has raised the quality of life and self-esteem of EDITOR EMERITUS countless people with special needs. Eunice Kennedy Shriver also understood the ben- Norman Becker, DDS efi ts of good oral health. She paved the way for dentistry to be a part of the Special Olympics competitions, opening doors to dental care to a truly underserved popula- MANAGING EDITOR OF tion, many of whom had never received even rudimentary dental evaluation. One of PUBLICATIONS AND WEB SITE our own members, Dr. Steve Perlman, spearheaded this effort, which has grown to Melissa Carman worldwide dimensions and brought higher respect to all of us as a profession. MANAGER, GRAPHIC DESIGN Senator Edward M. Kennedy was a champion for public health causes. Ironically, Jeanne M. Burdette while it often seemed popular among our peers to oppose anything he said, far more GRAPHIC DESIGNER often than not he fought for many of the same causes we, as a profession, also sought. Shelley Padgett Ted Kennedy and Eunice Kennedy Shriver were people of privilege who used their inherited advantages and natural talents to do what they could to improve the world around them. Whether or not we agree with all that they did, it cannot be argued that Editorial Board they left the world a better place. Bruce Donoff, DMD, MD However, this is not meant to be a political treatise. Your editors recently lost a mutual friend who was also one of our colleagues. He, like all of us, strived to provide Robert Faiella, DMD the best care that he could to the people who entrusted their oral health to him. He was Russell Giordano, DMD a consummate clinician. He, like any of us, was not perfect. He lived with the day-to- day challenges we all face. His passing, all too sudden, all too soon, is a reminder that Shepard Goldstein, DMD we, as professionals, as family members, as citizens, and as friends, do not have infi nite Stephen McKenna, DMD time to accomplish all we hope to do in any of the facets of our lives. John McManama, DDS By the time you read this, national health care reform may be an accomplishment, Noshir Mehta, DMD a quagmire, or a total failure. No matter where we stand in the progress of any of the multitude of public efforts to improve the health of our society, some simple truths Charles Millstein, DMD remain. Philip Millstein, DMD Our time allotment to accomplish our goals is unknown. Maria Papageorge, DMD We are given the expectations of those who come to us for care to do our best to Michael Sheff, DMD restore and maintain health. Steven Tonelli, DMD Whether we are a senator, a philanthropist, or a dentist, we are obliged to try to leave the world a better place. Copyright © 2009 Massachusetts Dental Society Our friend did. issn: 0025-4800 The JOURNAL OF THE MASSACHUSETTS DENTAL Let’s hope that in the very distant future, the same is said for each of us. SOCIETY [usps 284-680] is owned and published quarterly by the Massachusetts Dental Society, Our lives, individually and collectively, are precious. What really matters is how we Two Willow Street, Suite 200, Southborough, live the life each of us is given, and what we do to leave the world a better place.  MA 01745-1027. Subscription for nonmembers is $15 a year in the United States. Periodicals postage paid at Southborough, MA, and additional mailing offi ces. Postmaster: Send address changes to: Journal of the Massachusetts Dental Society, Two Willow Street, Suite 200, Southborough, MA 01745. Contributions: Contact the Communications Department, or visit www.massdental.org for author’s guidelines. Display ad closing dates: February 1, May 1, August 1, November 1. For more information, contact Rachel Marks, Exhibits Coordinator, at (508) 480-9797, ext. 259, or email [email protected].

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4 Journal of the Massachusetts Dental Society FINANCIAL SERVICES CORNER

Securities offered through NEXT Financial Group, Inc., Member FINRA/SIPC. EDFS is not an affi liate of NEXT Financial Group, Inc. EDFS/Eastern Dental Financial Services, LLC, 200 Friberg Parkway, Suite 2002, Westborough, MA 01581. Phone: (800) 898-3342. Fax: (508) 870-2897. Copyright 2009 Forefi eld Inc. All Rights Reserved. INVESTING IN A LOW-INTEREST-RATE ENVIRONMENT

OW INTEREST RATES CREATE A DILEMMA: DO YOU ACCEPT A LOW RE- Read the prospectus carefully before investing. If you prefer in- Lturn because you feel you must protect your principal, or do dividual stocks, keep an eye on trading costs. you take on greater investment risk in order to try for a higher return? In balancing these two concerns, there are some factors Think About Your Real Return to consider. Low interest rates may not be quite as problematic as they seem. Even if you’re earning a low interest rate, your real return might Laddering Your CDs not suffer too much if infl ation is also low. Real return represents When yields on Treasury bonds began dropping last year, many what your money earns once the impact of infl ation is taken into investors were attracted to certifi cates of deposit (CDs) offered account. With an annual infl ation rate of 0.1 percent—the De- by banks that needed to attract capital. However, interest rates cember 2008 Consumer Price Index fi gure—a bond that pays won’t stay low forever, and at some point you may want access 3 percent would produce the same real return as a bond that to your money before a CD matures. One way to achieve higher pays 5 percent when annual infl ation is running at 2.1 percent. rates while retaining fl exibility to adjust your strategy over time is to ladder CDs. Laddering involves Compare Interest Rate investing in CDs with varying matu- and Yield Spreads rity dates. As the shorter-term CDs When market instability drove many mature, you can reinvest in one with investors to the safety of Treasury a longer term and higher rate. Over bonds, their prices rose and yields time, laddering can give you both fell. As a result, the spreads between the higher rates typically offered by Treasury yields and those of corpo- longer-term CDs and the ability to ad- rates and municipals have been rela- just as interest rates change. tively high over the last year because For example, Susan wants to non-Treasury bonds have to offer invest $60,000 in CDs. She puts higher yields to compensate for inves- $20,000 in a six-month CD that pays tors’ anxiety about the safety of their 2.6 percent, another $20,000 in a principal and possibility of default. three-year CD that pays 3 percent, and the fi nal $20,000 in a fi ve-year CD that pays 3.5 percent. When the six-month CD ma- Consider Small Changes tures, she reinvests that money in another fi ve-year CD. When You may not need to remake your portfolio completely to seek her two-year CD matures, she reinvests it in still another fi ve- a higher return. For example, if you’re in Treasury bonds, you year CD. At that point, funds from a maturing CD will be avail- could move part of that money to municipal bonds, which may able roughly every other year, but will earn the higher fi ve-year involve greater risk of default but whose net returns are boosted rate. If rates are lower when a CD matures, she has the option of by their exemption from federal income tax. Or you could shift investing elsewhere. (This is a hypothetical example and doesn’t a portion of your stock allocation to dividend-oriented stocks represent the results of any specifi c investment.) and exchange-traded funds (ETFs), or preferred stock.

Pay Attention to Expenses Look for Buying or Selling Opportunities Low returns magnify the impact of high investing expenses. Let’s Interest rates also can be used to help evaluate equities. Some say a mutual fund has an expense ratio of 1.00, meaning that analysts like to determine the relative value of the stock market 1 percent of its net asset value each year is used to pay operating using the so-called Fed market valuation model. (Though not expenses such as management and marketing fees. That 1 per- offi cially endorsed by the Federal Reserve Board, the method cent represents a bigger relative bite out of your return when the evolved based on a 1997 Fed report.) The model compares the fund is earning 3 percent than it does if it’s earning 10 percent. earnings yield on the S&P 500 to the 10-year Treasury bond’s At the higher number, you’re losing only about 10 percent of yield. If the S&P’s yield is higher than the T-bond’s, the model your return; at 3 percent, almost a third of your return goes to considers the market undervalued relative to bonds. If the Trea- expenses. Before investing in a mutual fund, carefully consider sury yield is higher, the market is overvalued. However, this is its fees and expenses as well as its investment objective and risks, only one of many valuation models and shouldn’t be the sole which can be found in the prospectus available from the fund. factor in your decision. 

14 Journal of the Massachusetts Dental Society MDS INSURANCE SERVICES

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Vol. 58/No. 3 Fall 2009 17 pened to be sitting next to Dr. Wells. His sidered to be safer.3 Dr. Wells continued References name was Samuel Cooley, a young drug to have much success with using nitrous 1. Twain, M. Happy memories of the dental chair. In: Hirst RH, editor. Who is Mark Twain? New Horace Wells and 6 clerk. oxide on his patients, and then he set his York (NY): HarperCollins; 2009. p. 77-85. The masterful American author sights on Boston. Boston was a medical 2. Goldsmith D. The discovery of anesthesia. Samuel Clemens (better known by his hub of great importance, with the pres- Anesth Prog. 1974;174-180. His Significant pseudonym, Mark Twain) describes in ence of Harvard Medical School and 3. Carranza, FA. The discovery of anesthesia: the tragic history of Wells and Morton. 2009. his short story “Happy Memories of the Massachusetts General Hospital. Available from: http://www.dent.ucla.edu/pic/ Dental Chair” this momentous and his- members/carranza/anesthesia.html toric event.1 Clemens wrote, “They vis- Boston Bound 4. Pierre Fauchard Academy International Hall Contributions to the ited a traveling laughing-gas exhibition On January 20, 1845, Dr. Wells lectured of Fame of Dentistry. Dr. Horace Wells. 2009. Available from: http://www.fauchard.org/ one winter night, and were consumed to the senior medical students of Dr. John awards/fame3.htm with laughter over the grotesque perfor- Warren at the Massachusetts General 5. Jacobsohn PH. Horace Wells: discoverer of Discovery of Anesthesia mances of some of the Hartford youth Hospital.5 Dr. Wells then proceeded to anesthesia. Anesth Prog. 1995;42:73-75. while under the happy dominion of the extract a tooth from a volunteer. The ad- 6. Finder, SG. Lessons from history: Horace Wells gas. Presently one of them, a young chap ministration of the gas went well, and the and the moral features of clinical contexts. Anesth Prog. 1995;42:1-6. named Cooley, went sprawling over a extraction was performed quickly, but as 7. Shklar G, Carranza FA. The historical back- chair or a table, and reached the stage the tooth came out, the patient groaned. ground of periodontology. In: Newman MG, WILLIAM J. MALONEY, DDS with a crash, but immediately jumped up The audience laughed and hissed.2 A for- Takei HH, Carranza FA, editors. Carranza’s MAURA P. MALONEY, DDS clinical periodontology, 9th ed. Philadelphia and plunged into the fun again with no mer student of Dr. Wells’s, Dr. William (PA): W.B. Saunders; 2002. P. 7. Dr. William Maloney is group 1 diminution of spirit.” Morton, was in the audience. 8. Wildsmith JAW, Menczer LF. A British footnote practice clinical coordinator at New Clemens did not make his residence Unfortunately, after this demonstra- to the life of Horace Wells. Br J Anaesthes. York University College of Dentistry. in Hartford until many years after that tion Dr. Wells felt ridiculed and was never 1987;59(9):1067-1069. He also maintains a private general fateful evening—well after Dr. Wells had the same person from that point on. He 9. Colton GQ. Deposition of G.Q. Colton, of the city of New York. In: Smith T, editor. An exami- dentistry practice in Ossining, NY. passed on, but his vivid description of the would go on to practice dentistry only on Dr. Maura Maloney is a general nation of the question of anaesthesia, arising events of the evening of December 10, a sporadic basis.8 On October 16, 1846, on the memorial of Charles Thomas Wells, dentist in Westchester County, NY. “Science brought a miracle for its relief 1844, were based on direct conversations Dr. Morton, that former student, success- presented to the United States Senate, second session, Thirty-Second Congress, and referred worth more than all the miracles that with his own dentist and personal friend, fully anesthetized a patient with ether to a select committee, of which the Hon. Isaac had ever preceded it; and had placed Dr. John Riggs. Dr. Riggs would later be- at the Massachusetts General Hospital. P. Walker is chairman. New York (NY). John A. it, as her generous custom is, within come the fi rst individual to limit his prac- Soon after, Dr. John Warren proceeded to Gray, Printer; 1858. p. 22-23. Wells played an extremely signifi cant role tice to periodontics and is considered to remove a small tumor from the neck of 10. Riggs JM. Extract from the deposition of John the reach of every sufferer, instead of M. Riggs, dentist of Hartford, Connecticut. In: 7 restricting it to a pious half dozen, in the discovery of anesthesia. be the fi rst specialist in this fi eld. a young man who experienced no pain Smith T, editor. An examination of the question after the old way.” Horace Wells was born in the town of Dr. Wells contacted Colton after the during the surgery. Dr. Warren declared, of anaesthesia, arising on the memorial of Hartford, Vermont, on January 21, 1815.4 nitrous oxide exhibition and asked him “Gentlemen, this is no humbug.”2 Charles Thomas Wells, presented to the United 1 States Senate, second session, Thirty-Second —Samuel Clemens He is descended from very aristocratic to bring the nitrous oxide to his offi ce After Dr. Morton’s success, Dr. Wells Congress, and referred to a select committee, of New England stock: His grandfather was the next morning. Wells then contacted fell into a deep depression and tried for which the Hon. Isaac P. Walker is chairman. New Captain Hezekiah Wells, who served in the American Revolu- Dr. Riggs to discuss his experience at the the remainder of his life, in an obsessive York (NY). John A. Gray, Printer; 1858. p. 21-22. tion and was prominent in affairs of state.5 His grandmother nitrous oxide exhibition. The two dis- manner, to prove his very signifi cant role was related to Jonathan Trumbull, the governor of Connecticut cussed the possibilities of a nitrous oxide in the discovery of anesthesia. On Janu- ince the dawn of human consciousness, man during the American Revolution.5 anesthetic. They decided that Dr. Riggs ary 21, 1848, Dr. Wells was arrested in has continuously sought various means of alle- Dr. Wells trained as a dentist in Boston under a preceptor.3 would extract one of Dr. Wells’s badly New York City for throwing sulfuric In 1836, he opened his own dental practice in Hartford, Con- decayed molars the next morning.8 acid in the faces of two females. While in S viating pain. Until the 19th century, these efforts necticut. His offi ce was immediately successful, and he counted So it was that on December 11, prison, at the age of 33, he committed had generally yielded poor results and could be viewed among his patients the more affl uent and infl uential individuals 1844, at 10 a.m., history was made suicide by slashing his femoral artery.8 of Hartford society.3 Dr. Wells was soon married to Elizabeth in Hartford. Present at the time in Ironically enough, he anesthetized him- today as being quite primitive. Galen and Hippocrates Wales and the couple had one child, Charles Thomas. Dr. Wells’s offi ce were fi ve individuals— self with chloroform prior to this act.5 employed the “soporifi c sponge” as an inhalation anes- Despite his young age, Dr. Wells had two students of his Drs. Wells and Riggs, Colton, Colton’s Dr. Horace Wells had many hon- own: John Mankey Riggs and William T. G. Morton,3 who brother, and Sam Cooley.3 Dr. Riggs ex- ors bestowed upon him posthumously. thetic. The sponge was impregnated with opium, hen- would fi nd immense notoriety and fame for their own achieve- tracted the tooth as soon as Dr. Wells Among these honors is the inclusion of bane, and mandrake.2 The Assyrians used strangulation ments years later. was under the infl uence of the nitrous Dr. Horace Wells in the Pierre Fauchard December 10, 1844, was a day which would change the oxide. Dr. Wells did not exhibit any signs Academy International Hall of Fame of 2 as a method of pain relief for circumcisions. The early course of Dr. Wells’s life forever. It would also be an extremely of pain or discomfort.5 When Dr. Wells Dentistry. He deserves the praise of both 18th-century patient who required the amputation of a important day in the timeline of the development of anesthe- awoke from the anesthesia, he exlaimed, members of the scientifi c community and sia. Dr. Wells read in the December 10, 1844, edition of the “It is the greatest discovery ever made! grateful patients worldwide. limb usually received a stiff dose of alcohol before the Hartford Courant that there would be “a Grand Exhibition of I didn’t feel it so much as the prick of a Today, a magnifi cent statue of procedure.3 the effects produced by inhaling nitrous oxide” that evening in pin! A new era in tooth-pulling!”9,10 Dr. Wells stands in the east section of Union Hall to be presented by Mr. G. Q. Colton.5 Dr. Wells and Dr. Wells began experimenting with Bushnell Park in Hartford. The statue Dentistry could not have become the profession that it is his wife decided to attend the exhibition that night. nitrous oxide and other gases for use as gazes peacefully and proudly across the today without the development of consistently safe and effective Colton invited members of the audience to inhale the gas anesthetics. He experimented with ether green landscape, giving no indication as anesthetic drugs and techniques. The contributions of Dr. Horace to experience its effects. One young man who volunteered hap- but favored nitrous oxide, which he con- to Wells’s tumultuously short life. 

18 Journal of the Massachusetts Dental Society Vol. 58/No. 3 Fall 2009 19 movements produced by uncontrolled Root Resorption and Irreversible tipping of teeth.6,7 The Straight Wire Technique has similar shortcomings. This compara- tively rigid method of mechanotherapy Damage to the Paradental added rectangular wire roundtripping to round wire roundtripping. As rect- angular archwires engage pretorqued Edgewise brackets, Newton’s third law Structures Associated with of physics applies, since incisor lingual root torque, often an integral compo- Figure 3. A similar excessive uncontrolled tip- nent of orthodontic treatment, inevitably ping with Edgewise brackets (arrow points to Figure 4. Diagram depicting controlled tipping creates buccal premolar and molar root Orthodontic Treatment location of potential fenestration). Poor bio- versus uncontrolled tipping, sagitally and mechanics, not the appliance, is responsible transversely. Uncontrolled tipping requires torque (see Figure 5). This latter conse- for this tissue damage. subsequent uprighting. Outlines of Edgewise quential movement of the roots risks the and Begg brackets are shown. occurrence of buccal plate fenestrations. VINCENT DEANGELIS, DMD Wehrbein et al. reported evidence of this Dr. DeAngelis has served as the editor of the Northeastern Society correction was not an objective of the Begg dictable and unavoidable negative side damage to the roots and paradental tis- of Orthodontics, associate clinical professor of orthodontics at treatment. The Class II molar relationship effect of orthodontic treatment, and it sues in their gross and histological analy- Harvard School of Dental Medicine, president of the Massachusetts was resolved primarily by dentoalveolar remains a concern of dentistry today. It sis of a deceased 19-year-old orthodontic Society of Orthodontics, and president of the Edward H. Angle means. Therefore, treatment characteris- seems apparent to many that root resorp- patient, a traffi c accident victim who had Society of Orthodontists, Eastern Component. He is a recipient of tically did not begin until the late mixed tion is an inevitable consequence of orth- been treated for approximately one year the Outstanding Teacher Award from the Harvard Society for the dentition or the early permanent dentition odontic treatment. Current orthodontic with the Straight Wire Appliance. From Advancement of Orthodontics and the Frederick Moynihan Award period of dental development. literature is replete with research on the their fi ndings, they stated that “the buc- from the Massachusetts Association of Orthodontists, and he is a Variations of the Begg appliance etiology and pathogenesis of this irrevers- cal periosteum draped like an awning Fellow of the International College of Dentistry. were introduced in the Tip-Edge tech- ible damage to the root apices. The Begg over the exposed, severely resorbed mo- Figure 1. Edgewise brackets. Arrow designates nique by Kesling, where the brackets system, with its reliance on uncontrolled lar root apices and the palatal roots per- labial slot for archwire insertion. were modifi ed for more control, incor- tipping of all teeth, employed the ineffi - forated the maxillary sinus.”9 Correla- Introduction porating an Edgewise component to the cient practice of roundtripping—redun- tion of treatment duration with the Roth In the early 1900s, the Edgewise Technique was the predomi- previous Begg pin-in-tube design.3 The dant movement of root apices in one di- Straight Wire Appliance to irreversible nant orthodontic treatment of choice. This appliance was then Edgewise bracket edges were chamfered rection only to require later movement in tissue damage was further revealed by and is still now practiced worldwide, and has been extensively to facilitate uncontrolled tipping of the the opposite direction during treatment the 1991 Kaley and Phillips study of 200 described by Thurow.1 teeth in keeping with the Begg treatment of a malocclusion (see Figure 4). The Kes- consecutively treated patients where 90 The Edgewise bracket design accommodates both round philosophy (see Figure 3). Elastomeric ling modifi cation did little to resolve this percent of these patients were found to and rectangular cross-section archwire (see Figure 1). The lat- ties to fi x the archwires to the bracket re- problem. Irreversible damage to the root exhibit varying degrees of incisor apical ter’s capability permits torqueing—exerting control over the labio- placed the vertical pin connection of the apices in the form of root resorption and root resorption. Moreover, they found a lingual movement of dental roots while maintaining stationary Begg appliance. production of fenestrations and dehis- strong positive correlation between the crown positions. The rectangular-shaped archwire engages the In 1976, Andrews modifi ed the Edge- cences in the alveolar bone often resulted amount of resorption and the length of rectangular Edgewise slot to achieve this essential form of tooth wise bracket design, incorporating torque, from these superfl uous, redundant root time the patient was treated by intraslot Figure 2. Begg brackets. Note the excessive tipping of the movement. Round cross-section archwires are unable to produce angulations, and varied dimensions of the incisors, which likely produced fenestrations of the labial this important form of dental manipulation. slot, obviating the need for adding these plate, indicated by the yellow arrow. The red arrow desig- nates gingival slot access for archwire insertion. In the 1950s, Dr. P. Raymond Begg of Adelaide, Australia, features by previously required archwire introduced a then-revolutionary method of orthodontic treat- manipulation.4 In reducing the archwire Abstract ment, solely utilizing round cross-section archwires, which were bending requirement, this innovation was odifi cations of orthodontic appliances and inserted into a narrow, gingivally accessible bracket, versus the an attempt to facilitate treatment, reduce common labially accessible bracket.2 Vertical pins to affi x the chair time, and gain greater precision in mechanotherapy have evolved continually archwires to the bracket replaced the wire ligation of the Edge- the treatment outcome. Later, Roth modi- 5 over the past several decades. General prac- wise appliance. This technique heralded rapid treatment results fi ed the Andrews bracket. The resulting M requiring fewer visits and longer intervals between appoint- Straight Wire Appliance of Andrews and titioners have observed the changes in appliance design ments. Through a series of uncontrolled tipping movements, bite Roth has been universally adopted by the in their own patients in treatment by local orthodon- opening, dental alignment, and protrusions were resolved rela- international orthodontics community for tively quickly (see Figure 2). In the Begg technique, torque was decades and its popularity continues today. tists. This article discusses state-of-the-art orthodontic achieved with an auxiliary “piggy back” sectional round wire. Discussion biomechanics and appliance design, and the impetus Another advantage of the technique purported by Begg was the elimination of the need for headgear for correction of As these various disparate treatment mo- Figure 5. Diagram demonstrates that incisor palatal root that has led many clinicians to adopt biomechanically the ubiquitous Class II malocclusion. Consequently, this method dalities evolved, problems inherent in all torque produces buccal root torque of posterior teeth as the sound treatment innovations that avoid damage to den- relied heavily on four premolar extractions and often the ex- became evident. Radiographic evidence rectangular archwire (yellow) is twisted to engage the Edge- traction of maxillary permanent fi rst molars, as well—six tooth of root resorption, reported by Ketcham wise attachments. Newton’s third law of physics applies. Wehrbein et al. show the severe adverse effects of these 6 tal roots and their supporting tissues. extractions—since distalization of the maxillary arch for Class II in 1927, has been viewed as an unpre- mechanics in a human subject.9 20 Journal of the Massachusetts Dental Society Vol. 58/No. 3 Fall 2009 21 by both the Wehrbein and Kaley and Phillips studies.9,10 In fact, Thurow advo- cates the total elimination of this popular NO HASSLES. NO WORRIES. THE RESOURCE FOR DENTAL HIRING. 1 rectangular archwire intraslot torque www.rdhtemps.net (see Figure 5). This principle can be ac- 1-800-462-TEMP OR 1-888-RDH-TEMP complished by the use of torqueing aux- Serving CT, MA, NH and RI iliaries as employed in the Amalgamated a Technique (AT)11 (see Figure 8). b

Figure 6. Radiographs reveal moderate to severe incisor root resorption In the AT, the clinician carefully following Straight Wire Appliance treatment. Subsequent alveolar bone aligns the clinical crowns without any 10 loss can result in loss of these teeth. Image from Kaley and Phillips. redundant root movements, utilizing a combination of round and rectangular archwires. With the round cross-section Flexibility. archwire utilized early in AT treatment, controlled versus uncontrolled tipping • Temporary and permanent Figure 7. Severe incisor root resorption follow- of teeth is attained to prevent superfl u- ing the Straight Wire orthodontic treatment ous movement of root apices. (see Fig- staffing exclusively for the of a 25-year-old patient. A splint is in place to dental industry. stabilize the extremely short roots. Extent of ure 4). Moreover, the rectangular wires root resorption is designated by the arrows. employed later in treatment do not en- c d Risk of tooth loss is increased, particularly if • Dentists, Dental Hygienists, there is subsequent periodontal breakdown. gage the rectangular Edgewise bracket Dental Assistants and slots since, unlike in the Straight Wire Administrative Staff. Technique and the many other methods that rely on intraslot engagement of the Figure 8. Warren spring auxiliaries utilized Figures 9a–9f. Class II, Division 1 pa- • Centrally owned and in the Amalgamated Technique apply gen- bracket for torque, these wire dimensions tient treated for 18 months with con- operated since 1979 with tle torque force to move the incisor roots are considerably smaller (.016" x .018") trolled light continuous biomechanics palatally. Posterior teeth are not adversely (Amalgamated Technique), thus avoid- local specialists. affected with this method, as the narrow than the wider-dimension Edgewise slot ing roundtripping in three planes (Fig- rectangular archwire does not engage the (.022" x .028") of the AT. Instead, torque ures 9a–9d). Pre- and posttreatment • Flexible temporary rates; wider posterior attachments, which would periapical radiographs reveal the total create buccal plate fenestrations. The pos- with the AT is achieved with the gentler absence of root resorption (Figures 9e– proportional rebates should terior archwire extensions “roll” within the auxiliary torqueing springs that avoid the 9f). Controlled root apex movements a permanent placement fail wider attachments, avoiding roundtripping, roundtripping of posterior teeth because throughout treatment also eliminate to last. vis-á-vis intraslot torque, with the Straight e f the likelihood of fenestrations of the Wire Technique. the posterior archwire extensions, ow- labial and buccal plates. ing to their undersize, do not engage the • All dental auxiliary and posterior attachments to attain the nec- administrative temps are torqueing with rectangular archwire10 occurrences that lead to the premature essary incisor torque. These extensions our employees. (see Figure 6). aging of the dentition and the risk of in- “roll” within the slots while the torque- measured only by posttreatment dental 5. Roth RH. The straight wire appliance 17 years • Recently, the trend toward self- cisor loss when compounded by reduced ing auxiliaries apply light, continuous casts, photographs, and gross examina- later. J Clin Orthod. 1987;21:632-642. Personnel are interviewed ligating brackets has eliminated the prac- alveolar bone level with time.10 Root api- force to the incisors, thereby avoiding tion while ignoring a thorough exami- 6. Ketcham AH. A preliminary report of an inves- in person and are pre- tigation of apical root resorption of permanent tice of wire ligation entirely, to reduce ces must be moved in one direction only the adverse affects (i.e., buccal fenestra- nation of radiographic evidence of ir- teeth. Int J Orthod. 1927;13:97-127. screened. chair time. This innovation, however, once, whether round or rectangular arch- tions and apical root resorptions of the reversible root and paradental soft- and 7. Ten Hoeve A, Mulie RM. The effect of antero- • Extensive live phone does little to improve treatment out- wires are utilized. This essential rule is at- posterior teeth) described by Wehrbein9 hard-tissue destruction directly related to postero incisor repositioning on the palatal cortex as studied with laminography. J Clin coverage by a large team of comes and possibly even exacerbates the tainable if the clinician carefully applies (see Figure 5). orthodontic treatment. Only after includ- Orthod. 1976;11:804-822. staffing experts. root resorption problem. sound biomechanics to the dentition, and In essence, the brackets utilized in ing fi nal periapical radiographs in post- 8. Goldson L, Hendrickson CO. Root resorption does not allow the appliance to dictate all appliances should simply be consid- treatment records that confi rm the ab- during Begg treatment: a longitudinal roent- • RDH Temps carries genologic study. Am J Orthod. 1975;73:55-66. Conclusions and the mechanotherapy for expedience. ered as handles made available to move sence of irreversible damage to the roots professional liability Recommendations Techniques that focus on the elimi- teeth, just as the golf club is the instru- and periodontium can the orthodontic 9. Wehrbein H, Fuhrmann RAW, Deidrick PR. Human histological tissue response after long- (malpractice) insurance on Some lessons learned from a critical re- nation of root roundtripping by avoiding ment that moves the golf ball. The bio- result be deemed truly successful (see term tooth movement. Am J Orthod Dentofac all Dental Hygienists & view of the evolution of orthodontic ap- all superfl uous root apex movement are mechanical application to these instru- Figures 9a–9f).  Orthop. 1995;107:360-371. Assistants. pliances are clear and simple. The clini- currently practiced by many discerning ments determines the fi nal outcome. In 10. Kaley J, Phillips C. Factors related to root cian must avoid roundtripping of teeth clinicians. Roots of anterior and poste- the absence of sound biomechanics, the References resorption in Edgewise practice. Angle Ortho- dont. 1991;61:125-132. New! in all three planes (vertical, sagittal, rior teeth must be carefully moved only bracket and golf club are irrelevant and 1. Thurow R. Edgewise orthodontics. St. Louis Flex (MO): Mosby; 1966. 11. DeAngelis V. Begg-Edgewise: an amalgamated ible rates! and transverse); use light, physiologic once to their fi nal position in all three may even be detrimental in determining technique. Am J Orthod. 1976;69:301-317. Propo 2. Begg PR, Kesling PC. Begg orthodontic rtio continuous forces; and keep treatment planes. Accomplishing this objective the result. 12. DeAngelis V. The amalgamated technique: a manag nal practice and technique. Philadelphia (PA): ement time as short as possible, particularly curtails irreversible damage to roots and Basically, root resorption in ortho- W.B. Saunders; 1977. mechanically and biologically effi cient method No dai fees! of controlled tooth movement. Angle Ortho- ly overtime! 3. Kesling PC. Expanding the horizons of the 70% o with rectangular archwires that engage paradental structures associated with dontics is analogous to the dreaded dont. 1980; L(1):1-15. f customers will 11-13 Edgewise arch wire slot. Am J Orthod Dent save an av the Edgewise slots. In fact, total elimi- orthodontic treatment (see Figure 7). shanked shot in golf. If one employs Facial Orthop. 1988;94:27-37. 13 DeAngelis V, Davidovitch Z. Optimal orthodon- erage of tics: an achievable target. In: Krishan V, Davi- $1 nation of that form of incisor torque is Moreover, elimination of intraslot torque sound mechanical and biological tech- 4. Andrews LF. The straight-wire appliance: 9 per d dovitch Z,editors. Biological methods of tooth ay! prudent.1 By adhering to these tenets, where the rectangular archwire fi lls or niques, both potentially devastating origin, controversy, commentary. J Clin Orthod. movement. Oxford (UK): Wiley-Blackwell. 1976;10(2):99-114. the orthodontist limits irreversible dam- engages the Edgewise slot to some degree outcomes can be avoided. The success 2009. p. 180-200. age to teeth and supporting structures, avoids the severe adverse effects reported of orthodontic treatment should not be

22 Journal of the Massachusetts Dental Society Vol. 58/No. 3 Fall 2009 23 General Manifestations of Behçet’s Syndrome and

the Success of CO2-Laser as Treatment for Oral Lesions: A Review of the Literature and Case Presentation Figure 1. Ulcerative lesions on the right fl oor of the mouth. Figure 2. Ulcerative lesions on the right lateral pharyngeal wall.

NEOPHYTOS DEMETRIADES, DMD, FROMS HOPE HANFORD, BA drome. Furthermore, clinical and labo- The patient had a medical history The patient was referred to our CONSTANTINOS LASKARIDES, DMD, PHARMD ratory diagnosis of Behcet’s Syndrome of hypercholesterolemia and depression. service for laser ablation of prodromal Dr. Demetriades is an instructor in the department of oral and will be presented, and the more common The patient also suffered from dilated lesions. On clinical examination, four maxillofacial surgery, Ms. Hanford is a dental student, and manifestations of the disease will be dis- cardiomyopathy due to the involvement regions were dominated by ulcerative Dr. Laskarides is an assistant professor in the department of oral and cussed. of the myocardium by the disease; se- lesions: the right fl oor of the mouth maxillofacial surgery at Tufts University School of Dental Medicine. vere pain in the legs and feet as a result (see Figure 1), the right lateral pharyn- Case Report of joint lesions; burning sensation in geal wall (see Figure 2), the right lateral Abstract A 53-year-old male patient presented to the eyes due to ocular lesions; and in- tongue, and the alveolar mucosa buccal the department of oral and maxillofa- creased peripheral neuropathy and tin- to tooth #6 (see Figure 3). The signifi cant RAS lesions are localized, painful, shallow ulcers that affl ict cial surgery at Tufts University School nitus consistent with Behçet’s Syndrome. pain and discomfort of the patient, in his article reviews the oral manifestations of the soft mucosa of the oral cavity.1 According to the literature, of Dental Medicine. The patient’s oral The patient had a 35-year history of re- combination with the failure of the cur- Behçet’s Syndrome that have been discussed in the anywhere from 5 to 25 percent of the population is affected by condition had been consistently problem- current major aphthous stomatitis with rent treatments, led to the decision to use T RAS ulcerations.2 The precise etiology and pathophysiology of atic since 1981. His clinical symptoms high frequency, severity, and duration. the CO -laser as a treatment for the RAS. literature and presents the success of the use of CO - 2 2 RAS are unknown. However, many predisposing circumstances included persistent oral and oropharyn- Many unsuccessful treatments had been The patient was treated in the out- laser for recurrent aphthous stomatitis (RAS). Behçet’s are known, such as genetic factors, immunological problems, geal ulcerations (major apthae), which attempted, including administration of patient setting under local anesthesia (see Syndrome is a multisystem infl ammatory disease that hypersensitivity to food and drugs, hormonal changes, trauma, impeded daily functions, including swal- steroids and thalidomide. The only mar- Figure 4). All appropriate laser safety and environmental and psychological stresses.2 Recurrent aph- lowing, drinking fl uids, eating, talking, ginally successful treatment for the le- measures were observed. The involved has the capacity to affect nearly every human system. It thous lesions may also be the manifestation of more complicated and sleeping. He also suffered from ocu- sions has been a high dosage of cortico- areas were infi ltrated with a minimal is characterized by a wide range of clinical features. In diseases such as Behçet’s Syndrome. While the most common lar and genital lesions, which were clini- steroids, which have had signifi cant side amount of lidocaine 2% with 1:100,000 clinical feature of Behçet’s Syndrome is RAS in the oral cavity, cally consistent with Behçet’s Syndrome. effects. epinephrine. A CO2-laser set at low-power particular, the defi ning symptom in most cases is recur- the clinical manifestations may extend to the skin, genital area, rent aphthous stomatitis present in the oral cavity. RAS and eyes; in severe cases, Behçet’s Syndrome may also include vascular and neurological involvement (see Table 1). Table 1. Manifestations of Behçet’s Syndrome is the most common infl ammatory ulcerative condition There is no cure for RAS, so the majority of treatments Article Authors Journal Manifestations Presented in Article to affect the oral cavity and is characterized by local- focus on relief of localized symptoms. Remedies for aphthous ized, painful ulcers that may be a manifestation of more ulcerations include topical corticosteroids, mouthrinses, antibi- Adamantiades-Behçet Disease: An Enigmatic Eguia A, et al. Med Oral Recurrent oral ulcers, genital lesions, ocular lesions, 2 4 otics, or local anesthetic gels. More recently, CO2-lasers have Process with Oral Manifestations Patol Oral joint lesions, neurological lesions, vascular lesions, complicated diseases, such as Behçet’s Syndrome. There been used to treat the localized symptoms of RAS. Zand et al. Cir Bucal gastrointestinal lesions, and other complications is no effective treatment for RAS. In most cases, RAS proved in a randomized control study of 15 patients where all (cardiac, renal, pulmonary, and pleurae)

of the patients treated with a nonablative, nonthermal CO2- is managed by anesthetic topical treatments, topical or laser reported a signifi cantly lower level of pain in comparison Recurrent Aphthous Stomatitis in the Diagnosis Rogers Yonsei Oral recurrent aphthous stomatitis, genital ulcers, 1 systemic steroids, or antibiotics. More recently, though, to placebo ulcerations and following treatment, and 100 per- of Behçet’s Disease RS 3rd Med J and ocular infl ammation cent of patients required no postoperative medication.2 A similar there has been evidence of possible benefi t from Diagnostic Criteria of Behçet’s Disease: Lee S Yonsei Oral, ocular, and genital lesions, arthritis, study completed by Colvard and Kuo used an ablative CO -laser 6 2 Problems and Suggestions Med J gastrointestinal lesions, epididymitis, vascular lesions, treatment of aphthous lesions with CO2-lasers. Our requiring anesthesia and was able to eradicate pain in 88.8 per- and central nervous system symptoms cent of the cases.3 Much of the literature indicates that CO -laser experience treating a patient who suffered from 2 treatment could be considered as an alternative relief for RAS. Behçet’s Disease5 Kontogiannis V, Postgrad Oral ulcers, genital ulcers, skin lesions, arthritis, fatigue, Behçet’s Syndrome and RAS showed transient pain relief In this article, we will review the existing literature and Powell R Med J widespread vasculitis, arterial aneurysms, and neurological, gastrointestinal, brain, and audiovestibular symptoms with the use of CO ablative laser as a monotherapy. present a case in which CO2-laser ablation was used to treat 2 aphthous ulcerations on a patient diagnosed with Behçet’s Syn-

24 Journal of the Massachusetts Dental Society Vol. 58/No. 3 Fall 2009 25 tal ulcers, ocular lesions, cutaneous le- Table 2. Previous CO -laser Studies Completed sions, or a positive patergy test.4 Despite 2 the fact that numerous other classifi ca- Number of Success tion schemes have been developed over Article Authors Journal Study Completed Patients Rate the years, no consistent model exists to- Relieving Pain in Minor Aphthous Stomatitis Zand N, Lasers Med Single-session non-thermal 15 100% day.4,6 Therefore, it is essential to develop by a Single Session of Non-thermal Carbon et al. Sci CO2-laser on relieving pain in a comprehensive clinical history of the Dioxide Laser Irradiation2 minor recurrent ulcers patient in order to establish differential diagnosis along with the potential diag-

nosis of Behçet’s Syndrome. Managing Aphthous Ulcers: Colvard M, JADA Ablative CO2-laser on relieving 18 88.8% According to Kondogiannis and Laser Treatment Applied3 Kuo P pain in recurrent ulcers Powell, oral ulcers are the defi ning feature Figure 3. Lesions on the alveolar mucosa. Figure 4. CO -laser set at low-power (2W) 2 in 97 to 100 percent of the cases and the superpulse mode with a 0.4 mm ceramic tip Oral Surg initial symptom in most cases.5 Clinically, was used to lightly char the surface. CO -laser Treatment of Ulcerative Lesions7 Sharon- Oral Med CO -laser therapy for relieving pain 2 100% the oral lesions of Behçet’s Syndrome 2 2 Buller A, Oral Path in large lesions in the oral cavity 4 are indistinguishable from RAS. There- et al. Oral Radiol fore, the clinician must be cognizant of Endod defi ning characteristics of associated RAS systemic disorders.1 The oral ulcers found in Behçet’s Syndrome are typi- cally limited to the nonmasticatory oral 1 mucosa. Eguia et al. classifi ed the oral The distinct difference between the by which CO2-lasers are able to effectively drome before any recommendation can

ulcers of Behçet’s Syndrome into three ulcers of RAS and Behçet’s Syndrome re- reduce pain is unknown. However, Zand be made for the use of CO2-lasers on main categories: minor ulcers (less than mains unclear. RAS is the most common et al. provide some of the explanations: Behçet’s Syndrome ulcerations. Our expe- 1 cm), major ulcers (larger than 1 cm), infl ammatory ulcerative condition of the blockage of action potential and con- rience follows existing literature (see Ta- 4 1 and herpetiform (1–3 mm). In many cases, the oral mucosa. RAS lesions are typi- duction of nociceptive signals in affer- ble 1) and shows that CO2-lasers can offer oral ulcers may appear one to three years cally shallow, painless, round-to-oval ul- ent neurons; a decrease in the release of a transient relief of symptoms when used 1  Figure 5. Ulcerative lesions immediately fol- Figure 6. Lesions at one-week follow-up, at before any other symptoms. cers. Rogers states that the presence of chemical mediators; and an increase in the as monotherapy for treatment of RAS. 1 lowing CO2-laser ablation. which time the patient reported considerable Less common manifestations of RAS lesions is critical in the diagnosis of amount of natural analgesics. relief of symptoms. Behçet’s Syndrome include genital, cu- Behçet’s Syndrome.1 However, Eguia et References taneous, ocular, joint, neurological, and al. indicate the disparity between RAS Conclusion 1. Rogers RS 3rd. Recurrent aphthous stomatitis in the diagnosis of Behçet’s disease. Yonsei vascular lesions. According to Eguia et and Behçet’s Syndrome ulcers, explain- In the three studies considered, the re- Med J. 1997;38:370-379. (2W) superpulse mode with a 0.4 mm ce- Discussion al., genital lesions occur in 60 to 80 per- ing that Behçet’s Syndrome ulcers tend duction in pain was signifi cantly greater 2. Zand N, et al. Relieving pain in minor aphthous ramic tip was used, after calibration, in a Behçet’s Syndrome is a multisystem in- cent of patients, cutaneous lesions occur to appear in unusual places and in higher immediately following laser treatment of stomatitis by a single session of non-thermal defocused way to lightly char the surface fl ammatory reaction that has the capac- in 80 percent, ocular lesions occur in 20 numbers.4 Nevertheless, both forms of aphthous lesions (see Table 2). However, carbon dioxide laser irradiation. Lasers Med Sci. 2008;24:515-520. of the ulcers (see Figures 4 and 5). The ity to affect any human organ or system. to 50 percent, joint lesions occur in 40 to ulcers appear to be aphthous in nature the studies did not indicate whether the 3. Colvard M, Kuo P. Managing aphthous ulcers: patient tolerated the procedure well. On The disease is characterized by recurrent 50 percent, and neurological lesions oc- and are managed with similar techniques. decrease in pain was long lasting. In a laser treatment applied. JADA. 1991;122: subsequent follow-up, one week after the cycles of remission and relapse, as well cur in 5 to 20 percent.4 Genital lesions In the past, oral aphthous lesions randomized, controlled study of 15 pa- 51-53. procedure, the patient reported consider- as a wide range of clinical features. At are extremely painful and can result in have been treated with anesthetic pastes tients, Zand et al. proved a signifi cant de- 4. Eguia A, et al. Adamantiades-Behçet disease: an enigmatic process with oral manifestations. able relief of symptoms on most of the one time, the Pathergy Test was used as diffi culty with walking. Ocular lesions and mouthwashes, topical or systemic crease in pain among the treated lesions Med Oral Patol Oral Cir Bucal. 2006;11: treated ulcers (see Figure 6). The oro- a diagnostic tool for the disease; how- may result in conjunctivitis, vasculitis, or steroids, and antibiotics.7 Topical and in comparison to the placebo lesions; E6-E11. pharyngeal ulcer displayed only moder- ever, in many cases it can give a false retina atrophy or loosening. According to systemic treatments help to reduce the however, pain measurements were only 5. Kontogiannis V, Powell R. Behçet’s disease. ate response, but the patient reported an negative result.4,5 To date, there is no Kontogiannis and Powell, ocular involve- symptoms and duration of the ulcers, taken up to 96 hours after treatment.2 Postgrad Med J. 2000;76:629-637. overall improvement of his quality of life. conclusive diagnostic test for Behçet’s ment can result in vision loss for 25 per- but are not effective in preventing recur- In a separate study by Colvard and Kuo, 6. Lee S. Diagnostic criteria of Behçet’s disease: problems and suggestions. Yonsei Med J. 4 On long-term observation, two months Syndrome, so diagnosis relies solely on cent of patients who experience ocular rences. Immunosuppressive drugs, such pain measurements were only taken im- 1997;38:365-369. after the procedure, most ulcers had dis- the wide range of clinical features. Oral manifestations.5 as thalidomide, are effective in decreasing mediately after resolution of anesthesia; 7. Sharon-Buller A, et al. CO2-laser treatment appeared and the oropharyngeal area, and genital aphthous ulcerations are the In general, Behçet’s Syndrome is the number of lesions and the length and however, it was reported that all lesions of ulcerative lesions. Oral Surg Oral Med Oral although clinically improved, remained most common manifestation of Behçet’s characterized by a widespread vasculi- severity of ulcers, as well as in increasing had healed within 7 to 10 days.3 Pathol Oral Radiol Endod. 2004;97:332-334. mildly symptomatic. Six months after his Syndrome. However, alone they are not tis, which can result in a tendency the latency period.4 However, these drugs All three studies indicate evidence original treatment, the patient developed evidence enough for diagnosis of Behçet’s toward thrombosis in many patients. can have severe side effects. that lesions are less likely to occur at the 2,3,7 more intraoral aphthous ulcers. Syndrome. While neurological involvement is less Most of these remedies only help treated site. In addition, the studies Have a Question or Overall, the CO -laser helped to de- According to Eguia et al., the In- common, it can result in brain and spinal to provide temporary pain relief to local- excluded patients who had any systemic 2 Comment? crease the sensitivity and control the pain ternational Study Group for Behçet’s cord damage or emotional and sensory ized symptoms and do not help to prevent disease, including Behçet’s Syndrome, for a short period of time. No healing of Syndrome established a classifi cation in changes.4,5 Arterial aneurysms can result future occurrences. Recently, CO -lasers that may have predisposed them to RAS. To contact our editorial department, write 2 to JOURNAL OF THE MASSACHUSETTS DENTAL SOCIETY, the ulcerative lesions was appreciated. In 1990 that would provide evidence for the from vasculitis and can be potentially have been considered in order to relieve Although there is signifi cant evidence Two Willow Street, Suite 200, Southborough, our experience, CO2 ablative lasers can disease based on at least three episodes lethal. Gastrointestinal lesions are rare the symptoms of aphthous lesions. Studies that recurrent aphthous ulcerations re- MA 01745, fax (508) 480-0002, or email be used for pain control in Behçet’s Syn- of oral ulcers within a 12-month period and may result in a variety of symptoms, have proven that CO2-laser therapy has spond positively to CO2-laser treatment, Managing Editor Melissa Carman at drome patients with some transient ben- and the presence of at least two of the including abdominal pain, dysphagia, been effective in relieving pain from aph- more research must be completed in re- [email protected]. efi ts. following manifestations: repeated geni- and diarrhea. thous lesions.2,3,7 The precise mechanism gard to aphthous lesions in Behçet’s Syn-

26 Journal of the Massachusetts Dental Society Vol. 58/No. 3 Fall 2009 27 Case Report Treatment of a Skeletal Class III Malocclusion with Mandibular Asymmetry Using a Single Miniscrew

STEPHEN M. WEISNER, DMD Dr. Weisner is a diplomate of the American Board of Orthodontists and former instructor in clinical orthodontics in the division of postdoctoral orthodontics at Harvard School of Dental Medicine. He maintains a private orthodontics practice in North Andover.

Editors’ Note: This article has been reprinted with permission from the Journal of Clinical Orthodontics. Please visit www.jco-online.com for more information on the Journal of Clinical Orthodontics.

nce a patient’s growth is complete, a mal- occlusion caused by skeletal dysplasia of one or Table 1. Cephalometric Data both jaws can be treated in one of two ways. African American Pre- Post- O Norm2,3 treatment treatment The fi rst option is to correct the skeletal deformity with a SNA 84.7° 82.5° 83.5° combination of orthodontics and orthognathic surgery; SNB 79.2° 82.5° 84.5° the other is to camoufl age the malocclusion with ortho- ANB 5.5° 0.0° –1.0° FMA 30.0° 27.0° 25.0° 1 dontic tooth movement. The severity of the skeletal GoGn-SN 38.2° 31.0° 29.0° disharmony is a major factor in the decision, but such Occlusal plane-SN — 14.0° 12.0° issues as the patient’s chief complaint and desires, the U1-NA 7.4 mm 10.0 mm 10.5 mm U1-NA 24.1° 22.0° 23.0° potential risks and complications of orthognathic sur- U1-SN 109.0° 104.0° 106.5° gery, the cost and time involved, and the potential for L1-NB 11.4 mm 8.0 mm 6.0 mm L1-NB 36.7° 25.0° 16.5° relapse must also be carefully weighed. IMPA 100.0° 91.0° 83.5° This article describes orthodontic treatment of a U1-L1 113.8° 127.0° 140.0° patient with a skeletal Class III malocclusion using a single Upper lip-E line — –2.0 mm –3.5 mm Lower lip-E line — 6.0 mm 3.0 mm miniscrew.

Diagnosis premolars, which were congenitally missing. The mandibular A 17-year-old male patient was referred to our offi ce with the second deciduous molars were still present. chief complaints of “an underbite and crowded lower teeth.” He Diagnostic casts demonstrated 3.5 mm of mandibular reported that his impacted maxillary and mandibular third mo- crowding. The anterior maxilla was slightly narrow. The right lars had been removed within the preceding six months. Clinical canine and lateral incisor were in crossbite with the mandibular examination revealed Class III molar and canine relationships right fi rst premolar, canine, and lateral incisor; the maxillary left on the left side and Class I relationships on the right (see Figure 1a lateral incisor and mandibular left canine were also in crossbite. and Table 1). The patient’s mandibular dental midline was devi- The mandibular dental midline was deviated 3.5 mm to the right ated to the right of his maxillary dental midline, which coincided of the maxillary dental midline.

with his facial midline. All permanent teeth were present except Radiographic evaluation showed that the roots of the man- Figure 1a. A 17-year-old male patient with Class III malocclusion on left side, mandibular crowd- for the third molars and the mandibular left and right second dibular second deciduous molars were short, but intact. The ing, midline deviation, and anterior crossbite (continued on page 30).

28 Journal of the Massachusetts Dental Society Vol. 58/No. 3 Fall 2009 29 1a 1b

Figure 1a (cont.). A 17-year-old male patient with Class III malocclusion on left side, mandibular crowding, midline deviation, and anterior crossbite. Figure 1b. Facial asymmetry evaluated according to Dahan’s protocol.4 extraction sites of the mandibular third Oblique osteotomies would carry a lower lationship on both sides, bring the man- molars had not completely ossifi ed. A risk of alveolar nerve damage, but would dibular dental midline into alignment cursory evaluation of the frontal digital require six weeks of intermaxillary fi xa- with the maxillary midline, correct the photograph according to the protocol de- tion. Sagittal osteotomies would allow anterior crossbite, and address the man- scribed by Dahan4 demonstrated a mild rigid fi xation, but posed a greater risk to dibular crowding. This approach would mandibular deviation to the patient’s the inferior alveolar nerve. Either surgical avoid the need for implant replacement right (see Figure 1b). Cephalometrically, intervention would correct the mild man- of the congenitally missing left second the patient exhibited a Class III skel- dibular asymmetry and the malocclusion, premolar, but would not correct the skel- etal tendency (ANB = 0°), regardless of and would also improve the contact be- etal asymmetry or improve the contact of whether norms for African-Americans tween the mandibular left second molar the left second molars. An implant would or the general population were used. A and its maxillary antagonist. Dental im- still be needed after exfoliation of the hand-wrist radiograph demonstrated plants would eventually be needed after mandibular right second deciduous mo- that all epiphyses were closed and that exfoliation of the mandibular second de- lar, and one might also be needed distal the patient’s growth was virtually com- ciduous molars. to the mandibular left second molar. plete (see Figure 2). The purely orthodontic treatment An alternative orthodontic approach plan called for removal of the mandib- would involve extraction of the mandib- Treatment Options ular left second deciduous molar and ular right second deciduous molar, fol- Two surgical procedures were consid- placement of a temporary anchorage de- lowed by mesial movement of the man- Figure 3. Patient after extraction of mandibular left second deciduous molar and placement of miniscrew, with 150g Sentalloy closed-coil spring ered: oblique osteotomies and sagittal vice (TAD) between the mandibular left dibular right fi rst and second permanent attached to hook crimped onto .018" round archwire. osteotomies, both of which would in- fi rst and second molars. Treatment goals molars. This could be accomplished with volve a mandibular setback and rotation. would be to establish a Class I canine re- anchorage from a TAD in the extreme mesial portion of the extraction site. Al- though it would leave the Class I canine relationship on the right side intact, the molar movement would cause a loss of contact between the right second per- manent molars, requiring a dental im- plant distal to the mandibular molar. In essence, this plan would exchange one Figure 4. Attachment of 200g Sentalloy closed-coil spring six weeks after miniscrew placement. implant for another; moreover, the addi- tional mechanotherapy might jeopardize ized 6.5 mm. Anchorage loss is affected Class I space-closing mechanics used, Strategic placement of a miniscrew could the occlusal relationship on the right side. by numerous factors, including the de- 4.5 mm of the extraction space would avoid this anchorage loss and the unde- After careful consideration of the gree of crowding, the type of mechanics, be lost through mesial movement of the sirable side effects. risks and complications of orthognathic the patient’s age, the size of the extrac- mandibular left molars. Additional pos- surgery, the patient and parents chose the tion space, and the overjet.5 Creekmore’s terior anchorage loss would result from Treatment Progress fi rst orthodontic treatment plan. “rule of thumb” states: “Ordinarily when correcting the mandibular crowding and Brackets were bonded in both arches, mandibular second bicuspids [or, in this moving the mandibular midline 3.5 mm and leveling and alignment were carried Anchorage Evaluation case, mandibular second deciduous mo- to the patient’s left. Although a Class III out with .016" round nickel-titanium The mandibular left second deciduous lars] are extracted, you can expect the elastic worn on the left side would not archwires. The archform was then devel- molar had a mesiodistal dimension of posterior teeth to come forward about tax the anchorage units, its vertical vec- oped with .018" stainless steel archwires. 9 mm. Establishing a Class I canine re- half the extraction site.”6 Therefore, if tor would cant the occlusal plane. In ad- Under local anesthesia, the man- lationship on the left side would require the mandibular left second deciduous dition, the elastic would cause the maxil- dibular left second deciduous molar was Figure 2. Hand-wrist radiograph indicating closure of epiphyses and completion of growth. the mandibular left canine to be distal- molar were extracted and conventional lary midline to shift to the patient’s right. removed, and a miniscrew* (8 mm long, 30 Journal of the Massachusetts Dental Society Vol. 58/No. 3 Fall 2009 31 5a 5b

Figure 5a (cont.). After 25 months of treatment, Class I canine relationship achieved on left side; mandibular dental midline coincident with maxillary midline. Figure 5b. Superimpositions of pre- and posttreatment cephalometric tracings, demonstrating continued Class III growth, retraction of mandibular incisors, and slight mesial movement of mandibular left fi rst molar.

1.5 mm in diameter) was inserted. Place- side, only 1 mm of extraction space ment of a self-drilling screw in the at- remained to be closed with an elastic tached gingiva avoided damage to the chain. Cephalometric analysis indicated mucosa and eliminated the need for pilot that additional mandibular growth had drilling. The TAD was inserted at a right occurred in a counterclockwise direc- angle to the buccal cortical bone between tion (see Table 1); since the right side the mandibular left fi rst and second mo- remained in a Class I relationship, the 5b lars, close to the center of resistance of mandibular growth continued to be the teeth. asymmetrical. This not only necessi- A 7 mm crimpable hook** was tated more canine and incisal retraction placed on the archwire between the man- than originally anticipated, but also re- dibular left canine and lateral incisor to duced the contact between the left sec- allow application of a horizontal force ond molars. References vector from the hook to the miniscrew The brackets were debonded after 1. Turpin DL. Camoufl age might not mean compromise. Am J Orthod. 2003;123:241. (see Figure 3). Vertical skewing forces 25 months of treatment, one week be- 2. Drummond RA. A determination of cephalo- were eliminated because the vector was fore the patient was to return to college metric norms for the Negro race. Am J Orthod. parallel to the occlusal plane. The di- (see Figures 5a and 5b). A thermoformed 1968;54:670-682. rection of force through the center of maxillary retainer was fabricated to pre- 3. Alexander TL, Hitchcock HP. Cephalometric standards for American Negro children. resistance of the teeth allowed bodily vent supereruption of the maxillary left Am J Orthod. 1978;74:298-304. movement of the dentition and reduced second molar and the maxillary right fi rst 4. Dahan J. A simple digital procedure to assess frictional forces as the archwire moved and second premolars. When the patient facial asymmetry. Am J Orthod. 2002;122: through the mandibular left molar tube. returns home during a break from col- 110-116. The right side of the lower archwire was lege, he will be evaluated for a compos- 5. Geron S, Shpack N, Kandos S, Davidovitch M, Vardimon AD. Anchorage loss—a multifactorial tied back to the mandibular right fi rst ite buildup of the occlusal surface of the response. Angle Orthod. 2003;73:730-737. molar, and the arch was coligated. The mandibular right second deciduous mo- 6. Creekmore TD. Where teeth should be posi- miniscrew was loaded immediately with lar, along with an implant distal to the tioned in the face and jaws and how to get a relatively light force to facilitate primary mandibular left second molar. them there. J Clin Orthod. 1997;31:586-608. 7,8 7. Mah J, Bergstrand F. Temporary anchor- stabilization; a 150g Sentalloy*** age devices: a status report. J Clin Orthod. closed-coil spring was used to apply a Conclusion 2005;39:132-136. constant and long-acting force. Miniscrew anchorage simplifi ed the bio- 8. Melsen B, Costa A. Immediate loading of Six weeks later, the mandibular mechanics involved in this case and led implants used for orthodontic anchorage. Clin Orthod Res. 2000;3:23-28. archwire was replaced with an .016" × to a satisfactory outcome without the 9. Carano A, Velo S, Leone P, Siciliani G. Clinical .022" stainless steel wire, and a 200g need for orthognathic surgery. The use of applications of the Miniscrew Anchorage Sentalloy closed-coil spring was placed TADs allows the application of force vec- System. J Clin Orthod. 2005;39:9-24. between the miniscrew and the archwire tors that were previously diffi cult or im- hook (see Figure 4). Correction of the possible to achieve. This enables the clini- * OrthoAnchor is a trademark of KLS Martin (Jacksonville, FL) canine and crossbite relationships took cian to produce the desired dentoalveolar ** Ortho Organizers (Carlsbad, CA) eight months. After the Class I canine or skeletal changes without detrimental Figure 5a. After 25 months of treatment, Class I canine relationship achieved on left side; *** Registered trademark of GAC International, 7,9 mandibular dental midline coincident with maxillary midline (continued on page 33). relationship was established on the left side effects.  Inc. (Bohemia, NY) 32 Journal of the Massachusetts Dental Society Vol. 58/No. 3 Fall 2009 33 CLINICIAN’S CORNER A Clinico-Pathologic Correlation MATTHEW R. WIMMER, DMD RYAN A. ABDOOL, DMD LYNN W. SOLOMON, DDS, MS WILLIAM C. GILMORE, DMD, MS Dr. Wimmer is currently in a one-year oral and maxillofacial surgery internship with the St. John Health System/ John D. Dingel Detroit V.A. Medical Center; Dr. Abdool maintains a private practice in Quincy; and Dr. Solomon is an associate professor in the department of oral and maxillofacial pathology and Dr. Gilmore is a professor Figures 2a–2c. Low-, medium-, and high-power views demonstrate the architectural diversity of the tumor. Original magnifi cations of 2x, 4x, and 10x, in the department of oral and maxillofacial surgery at Tufts University School of Dental Medicine. respectively.

Figures 1a–1b. Clinical photos taken at the time of presentation show views of the lesion with and without the acrylic bent- wire partial denture in place.

History Differential Diagnosis 48-year-old African American male was Minor salivary gland tumor • Mucoepidermoid carcinoma referred to the Oral and Maxillofacial Surgery • Pleomorphic adenoma Clinic at Tufts University School of Dental • Adenoid cystic carcinoma A • Carcinoma ex pleomorphic adenoma Medicine for evaluation of an intraoral swelling on the • Non-Hodgkin’s lymphoma Figures 3a–3d. These high-power photomicrographs demonstrate why the pleomorphic ad- left posterior hard palate. The patient reported that the enoma is also known as a “mixed tumor.” Figure 3a shows an area of ductal differentiation Biopsy containing a wispy mucoid luminal product. In Figure 3b, a paucicellular area of myxo- hyaline material resembling chondroid is illustrated. In Figure 3c, deposits of amorphous lesion had been slowly increasing in size for the past Local anesthesia was obtained and needle aspiration yielded a eosinophilic hyaline separate neoplastic epithelial cells. Figure 3d depicts amorphous ba- negative result. An incisional biopsy, down to the periosteum, sophilic “stromal” material separating narrow, anastamosing epithelial strands. Original eight to nine months. The patient fi rst became aware magnifi cation of all photomicrographs is 40x. was performed. The specimen was fi xed in formalin and sent of the swelling when he noted increasing pain when for histopathologic evaluation by Tufts Oral and Maxillofacial Discussion wearing his maxillary partial denture. His medical Pathology Services. Minor salivary glands are distributed throughout the oral cavity, although in minor gland tumors the capsule may be incomplete. except for the anterior two-thirds of the tongue, the attached Histologically, PA consists mainly of glandular epithelium and history was signifi cant for pharmacologically controlled Histolopathologic Examination gingiva, and the anterior hard palate.1 The worldwide annual myoepithelial cells in a mesenchyme-like background.1,2 hypertension. Clinical examination showed a single, pink, Microscopic examination of tissue sections showed a wedge incidence of salivary gland tumors is 1 in 6.5 cases per 100,000 In the original Greek, pleomorphic means “many formed.” of palatal mucosa surfaced by stratifi ed squamous epithelium. population; of these, minor glands are involved in 9 to 23 percent PA is still commonly known as a “mixed tumor,” thus named dome-shaped nodule, measuring 2.0 cm in diameter, on The fi brous connective tissue stroma was replaced by a prolif- of cases.2 According to Ellis et al. in their report on 3,355 minor because it may contain many histologically different cell types, the left posterior hard palate. The lesion was fi rm and eration of mucoserous glands and ducts in a myxomatous and gland tumors, 44 percent were located in the palate, 21 percent including ductal, keratinizing squamous, mucous, adipose, and chondromatous background. In addition, mild infl ammation in the lips, and 12 percent in the buccal mucosa; 51.3 percent myoepithelial cells. In addition, materials such as mucin, osteoid, non-tender on palpation, with a smooth, intact mucosal was noted, as well as scattered lobules of minor salivary glands. were found to be benign and 48.7 percent were malignant.1 hyalinized cartilage, and a tyrosine-rich crystalloid material can surface and faint spider-web telangiectasias. Of note is The islands, nests, and strands of the neoplastic proliferation Clinically, the PA presents as a painless, slow-growing, fi rm be present within isolated areas or widespread throughout the extended to the lateral and deep specimen margins (see Figures mass. In the palate, PA accounts for 47 percent of the minor sali- tumor.1,2,4 Tyrosine-rich crystals are most common in PAs that the alteration of the acrylic bent-wire partial denture to 2a–2c and 3a–3d). vary gland tumors. The most common location is the posterior occur in African American patients, and have been observed in 1,4 1,4 accommodate the swelling, in response to the patient’s lateral hard palate, and it usually does not cross the midline. 21 percent of tumors from this population. The ductal cells Diagnosis PA is most common in adults ages 30–50 and has a predilec- appear as normal intercalated ducts whose lumina are lined complaint of pain (see Figures 1a–1b). Pleomorphic adenoma (PA) tion for females.2,4 This tumor is contained in a fi brous capsule, with a single layer of ductal epithelium. These ducts are in turn

38 Journal of the Massachusetts Dental Society Vol. 58/No. 3 Fall 2009 39 minor glands, the palate is the most common site. ACC con- without ulceration. The most common locations are the pos- stitutes 8–15 percent of all palatal salivary tumors.2 ACC is terior hard palate, buccal vestibular areas, or gingiva.2,3 It is most common in the fourth to sixth decades of life and does important to note that at the time of intraoral presentation not have a predilection for either gender.4 This malignancy often of non-Hodgkin’s lymphoma, there is often evidence of dis- presents as a slow-growing swelling of the posterior-lateral pal- ease in distant sites. However, an intraoral swelling may be ate.2,5 Histologically, ACC can present in four forms: cribriform, the presenting sign of disease with no other signs elsewhere in tubular, solid, or a combination of the three. The cribriform the body, although disseminated disease may develop in the pattern is the most common and well-recognized form with a future.4 Histopathologic studies of non-Hodgkin’s lymphoma “Swiss cheese” appearance. This unique appearance stems from show minor salivary glands invaded by lymphocytes that can islands of basaloid epithelial cells surrounded by many cylindrical be monomorphic, pleomorphic, and both well or poorly differ- spaces, which contain either a basophilic mucoid material or an entiated.2,4 Treatment consists of radiation and adjuvant che- eosinophilic hyalinized substance. The tubular pattern appears motherapy. Palatal lesions, in particular, have been shown to as many small ducts in a hyalinized stroma, and the solid form resolve with 8–10 Gy of radiation.4 contains large sheets or islands of cells that have a low propensity to form ducts.2,5 Because ACC is prone to local recurrence in up Conclusion to 32 percent of cases, wide surgical excision is recommended.2 With early detection, pleomorphic adenoma can be removed

Figure 4. An obturator was fabricated to fi ll the defect between the hard Carcinoma ex pleomorphic adenoma is the most common with minimal consequence while the tumor is still small. Un- palate and nasal fl oor caused by the surgical tumor removal. form of malignant mixed tumor. The tumor arises from the ma- fortunately, in this patient’s case the tumor had reached consid- lignant transformation of a neglected pleomorphic adenoma. erable size and its surgical removal led to a fi stula in the hard The chance of malignant transformation is low (approximately palate, creating a communication between the oral and nasal 5 percent of all PA cases) but increases with the patient’s age and cavities. This case demonstrates the importance of regular oral duration of the tumor.1,2 Carcinoma ex pleomorphic adenoma soft-tissue examinations by dentists and the need to have suspi- has peak prevalence from ages 60 to 80, approximately 15 years cious oral lesions surgically biopsied as soon as possible.  later than diagnosis of benign PA. Two-thirds of the cases re- ported in minor salivary glands arise in the palate. A clinical sign References of malignant transformation is recent rapid growth or pain in a 1. Ellis GL, Auclair PL, Gnepp DR. Surgical pathology of the salivary glands. Philadelphia (PA): W.B. Saunders; 1991. mass that has been present for many years. Histological features 2. Neville BW, Damm DD, Allen CM, Bouquot JE. Oral and maxillofacial pa- of carcinoma ex pleomorphic adenoma show the presence of thology. 3rd ed. Philadelphia (PA): W.B. Saunders; 2009. cellular pleomorphism and abnormal mitotic fi gures in conjunc- 3. Koloktronis A, Konstantinou N, Christakis I, Papadimitriou P, Matakis A, tion with evidence of benign PA. Treatment for carcinoma ex Zaraboukas T, Antoniades D. Localized B-cell non-Hodgkin’s lymphoma of oral cavity and maxillofacial region: a clinical study. Oral Surg Oral Med Oral pleomorphic adenoma is wide surgical excision with local lymph Pathol Oral Radiol Endodont. 2005;99:303-310. node dissection, if nodal metastases are present, and adjunctive 4. Eversole LR. Clinical outline of oral pathology: diagnosis and treatment. Figures 5a–5b. These clinical photos show the postoperative palatal defect that connects the oral cavity with the nasal radiation therapy.2 Philadelphia (PA): Lea & Febiger; 1992. cavity. Figure 5a was taken using a mirror two months postoperatively. Figure 5b shows a considerable reduction in size of the defect one year postoperatively, although an obturator is still necessary to close off the oral and nasal cavities. Approximately 58,000 cases of non-Hodgkin’s lym- 5. Yih WY, Kratochvil FJ, Stewart JCB. Intraoral minor salivary gland phoma occur annually in the United States, with a mortality neoplasms: review of 213 cases. J Oral Maxillofac Surg. 2005;63:805-810. surrounded by myoepithelial cells that often have a layer of Mucoepidermoid carcinoma (MEC) accounts for 10 per- rate of approximately 33 percent.2 Lymphoma is most com- 6. Rapidis AD, Givalos N, Gakiopoulou H, Stavrianos SD, Faratzis G, Lagogiannis GA, Katsilieris I, Patsouris E. Mucoepidermoid carcinoma of the 1,2 mucoid material surrounding them. Myoepithelial cells make cent of all major salivary gland tumors and 15–21 percent of mon in patients with underlying immune system conditions, salivary glands. Review of the literature and clinicopathological analysis of up a large portion of pleomorphic adenomas.1 The tumor all minor salivary gland tumors in the United States.4 The most such as AIDS, organ transplants, or various autoimmune dis- 18 patients. Oral Oncol. 2007;43:130-136. epithelium often presents with cells in the form of sheets, nests, common site for MEC of the minor salivary glands is the hard eases.2 Non-Hodgkin’s lymphoma usually presents in lymph 7. Wood NK, Goaz PW. Differential diagnosis of oral and maxillofacial lesions. or anastomosing cords. palate, which is also the second-most-common site overall.2,4,5 nodes, but in the United States, 20–40 percent of cases develop 5th ed. New York (NY): Mosby; 1997. p. 149-153. 8. Triantafi llidou K, Dimitrakopoulos J, Iordanidis F, Koufogiannis D. Manage- Pleomorphic adenoma is a benign tumor; however, with This lesion is also the second-most-common malignant salivary in extranodal sites. In the oral cavity, non-Hodgkin’s lym- ment of adenoid cystic carcinoma of minor salivary glands. J Oral Maxillofac neglect it can become quite large and may undergo malignant tumor. MEC has a slight female predilection and is the most phoma presents in soft tissues as a painless swelling with or Surg. 2006;64:1114-1120. transformation into carcinoma ex pleomorphic adenoma. A common salivary gland neoplasm affecting children.2 It affects a clinical sign of transformation is a period of rapid growth of a wide age group, and patients range from the second to seventh previously indolent tumor. The treatment of pleomorphic ade- decades of life. MEC presenting in the palate appears as a slow- noma is surgical excision, making sure to remove the tumor with growing, painless, and sometimes fl uctuant swelling, usually Take Advantage of the adequate margins of healthy tissue. With good surgical margins, without ulceration. The color of the lesion may be blue or MDS Discount the tumor has an extremely low propensity for recurrence and reddish, and MEC may demonstrate surface telangiectasia.2,4 often has a 95 percent cure rate.1,2 Histologic examination reveals a lack of encapsulation and a Looking for a Job? Based on the combined buying In the present case, a partial maxillectomy was performed mixture of squamous, intermediate, and mucous cells. The Have a Position to Fill? power of its membership, the MDS under general anesthesia in an ambulatory surgical setting. The mucous cells have cytoplasm that is “foamy” in appearance. has secured a variety of business margins of the surgical resection were tumor free. The patient The squamous, or epidermoid, cells have a polygonal shape The Massachusetts Dental Society and was fi tted with an obturator at the time of the surgery (see Figure 4). and contain intercellular bridges and occasionally demonstrate Boston University Henry M. Goldman School of Dental Medicine discounts for its members. The procedure was well tolerated and healing was uneventful keratinization.2,4 Intermediate cells are commonly seen and are have joined forces to offer the Dental Career Network, New England’s 2 most comprehensive online job database for dental professionals. (see Figures 5a–5b). thought to differentiate into both mucous and epidermoid cells. A full list of MDS business Other neoplasms to be considered in the differential diag- Treatment of mucoepidermoid carcinoma of the minor salivary Open to all dental personnel, the Dental Career Network is free for job services is available at nosis of a fi rm, slow-growing nodule of the hard palate include glands is surgical excision.2,4,5 seekers and available at minimal cost to employers. mucoepidermoid carcinoma, adenoid cystic carcinoma, carci- Adenoid cystic carcinoma (ACC) may occur in any major www.dentalcareernetwork.com www.massdental.org/atyourservice. noma ex pleomorphic adenoma, and non-Hodgkin’s lymphoma. and minor salivary gland. For the 50 percent occurring in the

40 Journal of the Massachusetts Dental Society Vol. 58/No. 3 Fall 2009 41 Oral and Maxillofacial Radiology Case Report 1 A new name and a new look… A CBCT scan was obtained in a 70-year-old male for treatment planning for dental implants. The CBCT scan revealed a well- but the same great service. defi ned radiolucency with dense corticated margin in the lingual Incidental Findings on Dental aspect of left mandibular molar region. The lesion was located inferior to the IAN canal, and the lesion measured 5.77 mm x 4.02 mm x 5.41 mm. The radiographic diagnosis for the lesion was Stafne bone defect. In the absence of any signs and symp- Radiographs: Stafne Bone Defect toms, no further evaluation was suggested. The radiographic appearance of the lesion in multiple planes is shown in Figures ARUNA RAMESH, BDS, DMD, MS 1a–1d. Implant Systems TARUNJEET PABLA, BDS, MS N All implant systems Dr. Ramesh is head and associate professor for the Case Report 2 ™ department of general dentistry in the division of oral and A CBCT scan on a 68-year-old female revealed a well-defi ned N Authorized NobelGuide Dental Laboratory

maxillofacial radiology at Tufts University School of Dental corticated left mandibular radiolucency measuring 10.5 mm x N Radiographic and surgical guides

Medicine. Dr. Pabla is an oral and maxillofacial radiologist. 11.29 mm x 12.5 mm in size. The lesion was causing interrup- ® ™ N Distributor for 3i , AstraTech, Nobel Biocare They are both diplomates of the American Board of Oral tion in the lingual mandibular cortex and was located inferior and Straumann implant components and Maxillofacial Radiology. to the IAN canal. The radiographic diagnosis was Stafne bone defect, or developmental salivary gland depression. No inter- Removable Prosthetics vention was recommended. The radiographic appearance of the ® lesion in multiple planes is shown in Figures 2a–2c.  N Ivocap injected complete dentures N Ticonium cast partial frameworks References N Night guards – hard/soft laminated Figure 1a. Panoramic view generated from the CBCT data shows the sub- 1. Chen CY, Ohba T. An analysis of radiological fi ndings of Stafne’s idiopathic mandibular gland depression in the left mandible. bone cavity. Dentomaxillofac Radiol. 1981;10:81. N Denture relines and laser-welded repairs 2. D’Eramo EM, Poidmore SJ. Developmental submandibular gland defect of the mandible: review of the literature and report of a case. Oral Surg Oral Med Oral Pathol. 1986;61:213. Conventional Services N Full-mouth reconstruction

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N Temporaries – heat cured – cast reinforced

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Figure 1c. CBCT coronal view Ceramic Systems shows the submandibular gland depression in the left mandible. N CAD/CAM technologies

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Cresco™ Precision evelopmental salivary gland depressions and Figure 1d. CBCT axial view shows the submandibular Figure 2a. CBCT axial view shows the submandibu- gland depression in the left mandible. lar gland depression in the lingual aspect of the Implant Frameworks Stafne bone defects or cysts have been inci- left mandible. “Precision Laboratory” Ddental fi ndings in many panoramic radiographs and sometimes in periapical radiographs. The average The typical radiographic presentation is a defi ned cor- ticated radiolucency along the inferior cortex of the mandible Call today for your free “new doctor” kit incidence is reported to be between 0.1 and 1.8 per- below the inferior alveolar nerve (IAN) canal. This radiolucency 781.828.2808 cent in the general population.1,2 is usually located in the posterior mandible in the second molar to the mandibular angle region. Developmental salivary gland Figure 2b. CBCT sagittal view shows the subman- dibular gland depression in the left mandible Many believe that these depressions form to accommo- depressions are usually not treated. The rationale is that after inferior to the IAN canal. Quality N Service N Expertise date the submandibular salivary gland tissue and, hence, are a period of fi ve to eight years, the lesions achieve their mature considered developmental in origin. In 1981, a study by Chen presentation and remain stable. The destruction of well-defi ned and Ohba found the content of these developmental cavities cortex of the defect may be indicative of a neoplasm and would to be mostly salivary gland tissue and sometimes fatty or lym- require intervention. phatic tissue and muscle.1 Very rarely, benign tumors like pleo- Most of the cases described in literature are based on pan- Figure 2c. CBCT cross-sectional view shows the submandibu- morphic adenoma and hemolymphangioma have been found. oramic radiographs. Two cases with radiographic presentations N N lar gland depression in the left 76 Pond St. P.O. Box 355 Sharon, MA 02067 There have also been cases where these depressions were empty of developmental salivary gland depressions in 3-D cone-beam mandible. 781.828.2808 N www.dickermandental.com cavities.1 computed tomography (CBCT) are presented here.

42 Journal of the Massachusetts Dental Society Vol. 58/No. 3 Fall 2009 43 PATHOLOGY SNAPSHOT

VIKKI NOONAN, DMD, DMSC SADRU KABANI, DMD, MS Drs. Noonan and Kabani are oral and maxillofacial pathologists in the department of oral pathology at Harvard Vanguard Medical Associates.

GINGIVAL MALIGNANCY

ALIGNANT LESIONS INVOLVING THE GINGIVA ARE UNCOMMON; Mhowever, when such lesions occur, the clinical appearance often resembles commonly encountered infl ammatory lesions such as focal reactive gingival hyperplasia or endoperiodontic lesions.1 Although metastatic disease may involve the gingival soft tissues, in most instances gingival malignancy represents primary squamous cell carcinoma. Approximately 10 to 25 per- cent of all oral squamous cell carcinomas involve the gingival, Low-power view of H&E-stained section shows a well-differentiated and the mandibular gingiva or alveolar ridge is most frequently squamous cell carcinoma. The asterisk affected.2,3 represents surface mucosa, while ar- Equally found to involve both the dentate gingiva and the rows indicate invasive tumor islands. edentulous alveolar ridge,4 the intimate relationship between the gingival mucosa and underlying alveolar bone may explain References the high propensity of bony invasion at the time of diagnosis.5 1. Heller AN, Klein A, Barocas A. Squamous cell carcinoma of the gingiva presenting as an endoperiodontic lesion. J Periodontol. 1991;62(9):573-575. Common clinical presentations for gingival malignancy include 2. Yoon TY, Bhattacharyya I, Katz J, Towle JH, Islam MN. Squamous cell evidence of tooth mobility with a radiographic appearance that carcinoma of the gingiva presenting as localized periodontal disease. mimics localized periodontitis or a poorly healing extraction Quintessence Int. 2007;38(2):97-102. socket. 3. Makridis SD, Mellado JR, Freedman AL, Salkin LM, Stein MD, Leal D, Miller AS. Squamous cell carcinoma of gingiva and edentulous alveolar ridge: a clinico- While the condition typically affects adults, it is important to pathologic study. Int J Periodontics Restorative Dent. 1998;18(3):292-298. note that squamous cell carcinoma involving the gingival tissues 4. Barasch A, Gofa A, Krutchkoff DJ, Disenbert E. Squamous cell carcinoma has been reported with some frequency in young patients.5,6 In of the gingiva. A case series analysis. Oral Surg Oral Med Oral Pathol Oral instances of suspected infl ammatory gingival lesions that are Radiol Endod. 1995;80(2):183-187. unresponsive to conventional therapy, a high index of suspicion 5. Bill TJ, Reddy VR, Ries KL, Gampper TH, Hoard MA. Adolescent gingival squamous cell carcinoma; report of a case and review of the literature. for malignancy should exist. A thorough examination as well as Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2001;91(5):682-685. a biopsy with submission of lesional tissue for histopathologic 6. Alsharif MJ, Jiang WA, He S, Zhao Y, Shan Z, Chen X. Gingival squamous cell evaluation is requisite for ensuring timely diagnosis and carcinoma in young patients: report of a case and review of the literature. management.  Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2009;107(5):696-700.

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44 Journal of the Massachusetts Dental Society CLINICAL CASE STUDY

DAVID LEADER, DMD Dr. Leader is assistant clinical professor at Tufts University School of Dental Medicine. He maintains a private practice in Malden. BUCCAL OBJECT RULE

47-YEAR-OLD MALE PATIENT PRESENTED WITH AN INTERESTING examination of the parotid gland revealed a fi rm inclusion about A lesion, which is easily visible radiographically but is not 1 cm distal to Stinson’s duct. Figure 3 is a radiograph of the area apparent on visual inspection. Thorough radiographic interpre- taken with a fi lm placed buccal to the teeth. This image revealed tation is an essential component of diagnosis in dentistry, and that the radiopacity is in the soft tissue of the cheek. the buccal object rule is an important tool of such interpreta- Further discussion with the patient did not reveal any tion. Dentists use the buccal object rule to determine the loca- symptomatology that one may expect with a sialolith. However, tion of restorations, lesions, and objects in relation to the teeth. the patient related an interesting story. Thirty years ago, the pa- The buccal object rule also has an important application in tient’s father lifted weights for exercise. To support his barbells, victim identifi cation. he hung a series of chains and sharp hooks from the basement Figure 1 is a periapical radiograph that reveals a radi- rafters. As a young teenager, the patient suffered injury when opacity that appears lodged in the maxillary alveolus, project- a hook accidentally stabbed through his cheek in that same ing through the masticatory mucosa in the area of the distal area. The correct differential diagnosis based on history, exam- root of the missing tooth #2. Based on the information in this ination, and radiology includes sialolith, phlebolith, calcifi ed image alone, the differential diagnosis includes retained root of lymph node, and calcifi ed scar;1 none of the possibilities are life- #2, odontoma, or a supernumerary tooth. Figure 2, from the threatening or dangerous. Without symptoms, this calcifi cation, same full-mouth survey, includes the hamular notch. Film place- deep in the parotid gland, does not require treatment.  ment for this image is more distal than that of the fi rst. Note that in Figure 2, the radiopacity is superimposed over the distal Reference of the fi rst molar. 1. Carter, LC. Soft tissue calcifi cation and ossifi cation. In: White SC, Pharoah MJ. Oral radiology: principles and interpretation. St. Louis (MO): Mosby; The acronym that radiologists use to teach the buccal ob- 2004. p. 576-596. ject rule is Same Lingual Opposite Buccal (SLOB). The opacity is more mesial in the image that is more distal. Therefore, the unidentifi ed opacity is buccal to tooth #3. Acknowledgment Visual inspection of the area did not reveal the opacity The author wishes to thank Dr. Lynn Solomon of the department projecting from the buccal surface of the alveolus as expected. of oral pathology at Tufts University School of Dental Medicine Digital inspection of the area had the same fi nding. Bidigital for assistance in researching this article.

Figure 1. Periapical radiograph reveals a radi- Figure 2. From the same full-mouth survey as Figure 3. Radiograph taken with a fi lm opacity that appears lodged in the maxillary Figure 1, this radiograph includes the hamu- placed buccal to the teeth reveals that alveolus. lar notch. Note that the radiopacity is super- the radiopacity is in the soft tissue of the imposed over the distal of the fi rst molar. cheek.

About Clinical Case Study A Clinical Case Study is defi ned as a written and visual assessment of a clini- Please address your correspondence to Clinical Case Study, JOURNAL cal case wherein the author presents before-and-after radiographs and/or OF THE MASSACHUSETTS DENTAL SOCIETY, Two Willow Street, Suite 200, South- photographs as a means to discuss the diagnosis, treatment plan, and actual borough, MA 01745. Include your name, address, and phone number or treatment of a particular situation. The purpose of this study is to encourage email address so that we may contact you for follow-up. Responses may be JOURNAL readers to contribute a clinical response to the cases presented. published in a future issue of the JOURNAL.

46 Journal of the Massachusetts Dental Society BOOK REVIEWS

NORMAN BECKER, DDS, EDITOR EMERITUS

Osseointegration: On Continuing Wheeler’s Dental Anatomy, Physiology, Synergies in Surgery, Prosthodontics, and Occlusion—Ninth Edition and Biomaterials STANLEY J. NELSON, GEORGE A. ZARB, TOMAS ALBREKTSSON, MAJOR M. ASH JR. (EDITORS) GERALD BAKER, STEVEN E. ECKERT, Saunders Elsevier CLARK STANFORD, DENNIS P. TARNOW, he ninth edition of this text not only ANN WENNERBERG (EDITORS) Tcontinues with the subject matter and Quintessence Publishing basic information of the previous editions, n an almost novel-like textbook, the editors but the editors have added new features, Ihave gathered many of the pioneers in os- such as colorization of previously black- seointegration to cover this fi eld of study and and-white illustrations, an expanded clinical use. The text prepares the readers for and updated section on Forensic Odon- the past, present, and future of osseointegra- tology, and the inclusion of “fl ash tion in clinical practice. cards” that can be used as quick study guides. Ad- It was fun reviewing this text. A para- ditionally, this edition includes “help sites” for faculty and graph in the fi rst chapter sets the tone for the students, a collection of 300 test questions, and an ancillary book and indicates how un-textlike the edi- DVD that features 3-D animation, electronic fl ash cards, label- tors are in approaching this book: “This fi rst ing exercises, and a virtual reality tooth identifi cation quiz. The chapter employs the metaphor to refl ect the editors’s editors use DVD icons in the text margins to point readers to perception of where we have been and where we are currently, in the appropriate sections of the DVD, which may be used as an the context of osseointegration’s impact on the management of interactive simulation and learning aid. partial and complete edentulism. Subsequent chapters sum up our Even without the bells and whistles of the DVD, the text convictions as to how far we have come and speculate on where itself is a good teaching tool. It is well-organized and uses we are heading. We welcome readers to join us in the journey. photographs, fi gures, and attractive design to maintain reader We promise prudent speed and a more than cursory interpretative interest.  glance at the panorama we travel through.” Writing like this made for an enjoyable and informative read. MDS Roster Available Online

Guidelines for Adhesive Dentistry— Do you need to fi nd a colleague’s address, The Key to Success offi ce phone, or email address? Use the Find FRANCESCO MANGANI, a Member function on the MDS Web site at ANGELO PUTIGNANO, ANTONIO CERUTTI (EDITORS) www.massdental.org/fi nd-a-dentist. You Quintessence Publishing can fi nd members by last name, specialty, ith the goal of simplifying teaching or city/town, and the list- methods and facilitating the educa- W ings are updated daily so tion of students and colleagues, the edi- tors have prepared more of a multimedia you are sure to have the presentation in the form of a textbook to be used in conjunction with a DVD. most recent information. Studying seems to become more fun Log in and you can also through the course of the text, even if more effort may be needed to play access members’ email the accompanying DVD. However, in addresses. Log in to this text, the authors use great photo- graphs (with an almost 3-D appearance) to the Web site today at emphasize the teaching points. It is a most attractive, col- orful, and well-designed text that could fi t in many art libraries. www.massdental.org/login. I enjoyed studying the teaching goals of the authors.

Vol. 58/No. 3 Fall 2009 51 DENTAL EDUCATION

MELISSA CARMAN, MANAGING EDITOR Highlighting key events taking place in dental education in Massachusetts.

Forsyth Institute genome sequencing research will foster a greater understanding he Forsyth Institute has found a of the several hundred bacteria that live in the human oral cavity Tnew home. In early August, For- and can cause tooth decay, periodontal disease, and infections syth signed a long-term lease for a elsewhere in the body. research facility located at 245 First Dr. Bartlett’s two-year grant was for his project, “The Role Street in Cambridge. Forsyth is leas- of ER-stress and pH in Fluorosis.” The project’s goal is to defi ne ing 73,317 square feet to accommo- the role of endoplasmic reticulum (ER) stress responses in den- date its state-of-the-art laboratories, tal fl uorosis, a condition that results in discolored and/or pitted a new research clinic, meeting spaces, teeth due to overexposure to fl uoride. This work will identify and administrative offi ces. In 2007, the genes and molecular pathways that respond to fl uoride ex- Forsyth sold its present building at posure. 140 The Fenway in Boston to the Museum of Fine Arts, and remained there as a tenant while completing its Tufts University search for a permanent location. ofi gh Raayi, DMD, MScD, was Despite its relocation, the orga- Trecently named president of the nization will maintain a strong com- Tufts University Dental Alumni Asso- mitment to the city of Boston through ciation for 2009–2010. A past recipi- its community programs, including ent of the Volunteer Hero recognition ForsythKids, an oral health program for at-risk children that from the JOURNAL OF THE MASSACHU- provides dental care at elementary schools and at Boston’s SETTS DENTAL SOCIETY and past chair Camp Harbor View, and the Educational Outreach Program, of the East Middlesex Dental Society, which offers paid summer science internships to Boston Public Dr. Raayi has previously served as School children. president of the American Association “We are very excited about our new location, which will of Women Dentists and the Women’s enable Forsyth to establish additional collaborations and thrive Dental Society of Massachusetts, as well as the American Acad- into its second century,” says Dr. Philip Stashenko, Forsyth pres- emy of Dental Science. ident and CEO. The institute will celebrate its centennial in its • new headquarters in 2010. Michael A. Kahn, DDS, was installed as vice president of the • American Academy of Oral and Maxillofacial Pathology on In June, three Forsyth Institute scientists were among the fi rst May 19, 2009, during the organization’s annual meeting in in the country to receive stimulus funding for their research Montreal. Dr. Kahn is professor and chair of the department of from the National Institutes of Health through the American oral and maxillofacial pathology. Recovery and Reinvestment Act of 2009. Drs. Nikos Soukos, Floyd Dewhirst, and John Bartlett received funds totaling $1,881,788 to help develop potential therapies for oral diseases Boston University that cause pain, fi nancial hardship, and long-term systemic eorge Huang, DDS, has been health problems for millions of Americans. In addition, these Gnamed the Herbert Schilder pro- grants from the National Institute of Dental and Craniofacial fessor in endodontics and director of Research will help sustain laboratory positions and create new the postdoctoral program in endodon- jobs. tics at Henry M. Goldman School of Dr. Soukos’s project, “Nanoparticle-based Antimicrobial Dental Medicine. Dr. Huang has exten- Photochemotherapy in Biofi lms,” aims to develop a clinically sive experience teaching in both clini- appropriate way to enhance the penetration and effectiveness cal and didactic settings. Since begin- of photoactive compounds into human dental plaque by encap- ning his academic career, Dr. Huang sulating them in biodegradable and biocompatible polymeric has held faculty positions at Boston nanoparticles. When combined with exposure to visible light, University, the University of California this leads to the killing of disease-causing bacteria, in particular (San Diego and Los Angeles), the University of Maryland, Kaoh- those that are responsible for periodontitis. siung Medical University, and most recently Columbia University, Dr. Dewhirst received a two-year grant for his work, “A where he was associate professor and director of the division of Foundation for the Oral Microbiome and Metagenome.” This endodontics. 

52 Journal of the Massachusetts Dental Society ART OF DENTISTRY

ERIC K. CURTIS, DDS, MAGD, ELS Dr. Curtis is past president of the American Association of Dental Editors. In 2006, he received the American Dental Association’s Distinguished Editor Award. FORGET IT

F COURSE YOU WILL REMEMBER THAT THIS TIME YOU WANT TO GIVE The Russian psychologist Alexander Luria wrote about a OJulie Larkin 3% mepivacaine without a vasoconstrictor, man who remembered too much. The man could hold on to and that the gingival hyperplasia you noticed last week on Tom seemingly unlimited facts and mental pictures of people and Elfman could be related to his nifedipine regimen. You have no places he had seen. He was deeply unhappy; his extraordinary problem recalling, either, that you need to be done to- memory for minute details of the past overwhelmed and night before 6:00 so you can get to the school play interfered with his experience of the present. on time. At least you’d better remember. So although our entire personal and pro- From the fi rst time we gazed into our fessional lives are arranged around what we mother’s eyes to the continuing education remember, or want to remember, I pro- course we took last week, our lives are pose that we dedicate a modest slice of defi ned by the demands of memory. our energies to doing just the opposite. Memory—our ability to draw wisdom Forgetting is not always an embarrass- from experience—shapes and infl u- ment, an annoyance, or an indication ences every aspect of our lives. Mem- of the onset of Alzheimer’s. It can be ory creates identity and animates our extremely benefi cial. There are some surroundings. Memory builds mean- things that we ought to actually try ing. Our shared memories become to forget. As dentists, for example, culture. “The very essence of civili- we would be better off forgetting at zation consists of purposefully build- least three things: dogma, anger, and ing monuments so as to not forget,” insularity. wrote L. S. Vygotsky, a Soviet psy- Forget dogma. There are standards chologist and the founder of cultural- of care in dentistry, and a lot of talk historical psychology. about formulating parameters and in- But we forget all the time. dicators. Certainly, we must agree on Memory is not a documentary of the thresholds of what constitutes acceptable events we experience but an interpretation. care. But dentistry is not a religion. There has Our memory for faces, facts, songs, events, pic- to be room for thoughtful experimentation for tures, smells, and skills seems both vast and mostly progress to occur. And there is usually room in a trustworthy. Yet research on memory affi rms that we con- given treatment plan for several approaches. tinually edit, distort, forget, and recast the past as we create Forget anger. It’s time to cool off. Anger must not distort meaningful stories about ourselves. We fi lter and shade memory, our relationship with patients, who must not become enemies enhancing some remembrances and blocking out others. “Just or fodder in third-party tugs-of-war. Nor should we allow anger wait until now becomes then,” Susan Sontag wrote slyly. “You’ll to interfere with our relationship with colleagues, with whom see how happy we were.” Author Francois de la Rochefoucauld camaraderie diminishes stress and improves communication and called attention to our inevitably selective memory more bluntly: patient care. It’s time to put away anger for that certain dental “Everyone complains of his memory, and no one complains of school professor—you know who I mean. And it’s certainly time his judgment.” to shelve the anger for organized dentistry. This is a democracy, We hate that we forget. “I just had it on the tip of my vibrant and messy, full of give-and-take. It will only improve if tongue,” we say, apologizing in conversation. Forgetting is you make it improve. Which brings me to the next point: clumsy, frustrating, and frightening; it can ruin a date, an exam, Forget insularity. That’s isolation. Dentists are the sover- or a career. But at the same time, forgetting is a crucial mental eigns of solitude. So get out. Get involved in the community. process. Ironically, we must forget in order to remember. Forget- Sign on for a project. Don’t just do the things you’re paid for. ting is clearly an important part of effective remembering. “If we Volunteer somewhere. Go to work on a committee at the dental remembered everything,” the philosopher William James noted, association. “we should, on most occasions, be as ill off as if we remembered As you struggle to remember everything in your busy nothing. It would take as long for us to recall a space of time as schedule, leave a little space in the day planner for a small shift it took the original time to elapse and we should never get ahead in your point of view. Don’t forget to forget. Your memory may in our thinking.” not improve, but your memories will. 

56 Journal of the Massachusetts Dental Society