Dental Press International

ISSN 2176-9451Volume 16, Number 3, May / June 2011Dental Press International

v. 16, no. 3 May/June 2011Dental Press J Orthod. 2011 May-June;16(3):1-164ISSN 2176-9451

[abor abormgtwitter.com/abormgth8 CONGRESS OF THE BRAZILIAN ASSOCIATIONOF ORTHODONTICS AND DENTOFACIAL ORTHOPEDICSth12-15 october, 2011, Belo Horizonte, Minas Gerais, Brazil6parallel events of ALADO, BBO, GRUPO, ENAP, ABOL e CFO.15 courses with the highlights of national and international speakers.50 hours of activities to broaden your knowledge.152 lectures forming a diversified scientific grid.10002m of trade show full of attractions.And a city fullof warmthand entertainmentto welcome you!International Speakers confirmedMcNamara Course Freefor members registered before June 30, 2011 ABOR.Take advantage of special conditions related to ABOR.James McNamaraUSAAlbino TriacaGermanyEustáquio AraújoUSAGiuseppe ScuzzoItalyLeena PalomoUSAMarco RosaItalyMartim PalomoUSARolf BehrentsUSAStephen YenUSA[Register now!Special conditions related to ABOR.Submit your Scientific Paper:FREE THEME, POSTERS, or CASE STUDY.Achievement Sponsorship Organization Agency OfficialSupport

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Uma programação científica voltadapara Uma a prática programação avançada científica da Ortodontia voltadae da para Ortopedia a prática Funcional avançada da dos Ortodontia Maxilares.e da Ortopedia Funcional dos Maxilares.A scientific agenda focused on the advancedpractice A scientific of Orthodontics agenda focused and on the the Functional advancedpractice Orthopedics of Orthodontics of the and Maxillaries. the FunctionalOrthopedics of the Maxillaries.15 a 17 de setembro • 2011 • Anhembi • São PauloSeptember 15 a 17 15 de thru setembro 17, Anhembi • 2011 Convention • Anhembi Center, • Sao São Paulo, PauloBrazilSeptember 15 thru 17, Anhembi Convention Center, Sao Paulo, BrazilMódulo/module 1: Finalização ortodôntica: estética e oclusão / Orthodontic completion: esthetics and occlusionMinistradores/lecturers: Módulo/module 1: Finalização Ana Carla Nahás; ortodôntica: Flávio estética Vellini e Ferreira; oclusão Weber / Orthodontic Ursi; Flavio completion: Cotrim-Ferreira esthetics and occlusionMinistradores/lecturers: Ana Carla Nahás; Flávio Vellini Ferreira; Weber Ursi; Flavio Cotrim-FerreiraMódulo/module 2: Tratamento ortodôntico de más-oclusões assimétricas / Orthodontic treatment of bad asymmetric occlusionsMinistradores/lecturers:Módulo/module 2: TratamentoArno Locks;ortodônticoMarcos Janson;de más-oclusõesMaurício Sakima;assimétricasGuilherme/ OrthodonticJansontreatment of bad asymmetric occlusionsMinistradores/lecturers: Arno Locks; Marcos Janson; Maurício Sakima; Guilherme JansonMódulo/module 3: O estado da arte na Ortodontia – filosofia de tratamento ortodôntico MBT – uma Ortodontia ao alcance de todos /Módulo/module 3: O estado da arte na Ortodontia – filosofia de tratamento ortodôntico MBT – uma Ortodontia ao alcance de todos /The state-of-the-artThe state-of-the-artin Orthodonticsin Orthodontics– philosophy– philosophyofofthetheMBTMBTorthodonticorthodontic treatmenttreatment––OrthodonticsOrthodonticsthatthateveryoneeveryonecancanaffordaffordMinistradores/lecturers: Ministradores/lecturers: Ricardo Ricardo Moresca; Moresca; Reginaldo Reginaldo Zanelato Zanelato Trevisi; Trevisi; Cristina Cristina Domingues; Domingues; Hugo Hugo Trevisi TrevisiMódulo/module Módulo/module 4: Disgenesias: 4: visão visão contemporânea do do diagnóstico; bases biológicas para para compreensão, orientação orientação e tratamento e tratamento / /Dysgenesis, Dysgenesis, contemporary vision vision of the of the diagnosis; biological bases for understanding, guidance and and treatmentMinistradores/lecturers: Alberto Consolaro; Daniela Garib; Maurício Cardoso; Leopoldino Capelozza Filho Filho700 places320 already completed700 places320 already completedUm encontro para quem Mais. Participe. Virada de preço em 3/6.Um encontro para quem é Mais. Participe. Virada de preço em 3/6.A meeting for someone who is More. Participate. Enrollment fee will change on June 3 rd .A meeting for someone who is More. Participate. Enrollment fee will change on June 3 rd .Programação científica completa e adesões on-line / Complete scientific agenda and on-line enrollmentsProgramação científica completa e www.ortociencia.com.br/ortonewsadesões on-line / Complete scientific agenda and on-line enrollmentsPromoçãoPromotionPromoçãoPromotionRealizaçãoRealizationRealizaçãoRealizationwww.ortociencia.com.br/ortonewsInformações adicionais e adesões / Additional information and enrollmentsInformações 55 11 adicionais 2168-3400 e (Camila adesões Adrieli) / Additional – ortonews@ortociencia.com.brinformation and enrollmentsApoio 55 11 2168-3400 (Camila Adrieli) – ortonews@ortociencia.com.brInstitutional SupportApoioInstitutional Support

James McNamaraEstados UnidosAlbino TriacaAlemanhaEustáquio AraújoEstados UnidosGiuseppe ScuzzoItáliaLeena PalomoEstados UnidosMarco RosaItáliaMartim PalomoEstados UnidosRolf BehrentsEstados UnidosStephen YenEstados UnidosE v e n t s C a l e n d a r2º Congresso Internacional MBTDate: August 25, 26 and 27, 2011Location: Abzil - São José do Rio Preto /SP, BrazilInformation: (55 18) 3222-4285cursos@trevisi.com.br15º Encontro AOA - “De Volta Para o Seu Futuro”Date: August 26 and 27, 2011Location: Hotel Fazenda Salto Grande - Araraquara / SP, BrazilInformation: (55 16) 3397-4924gestos@gestos.com.br2º CIOMT – Congresso Internacional de Odontologia de Mato GrossoDate: September 15, 16 and 17, 2011Location: Hotel Fazenda Mato Grosso - Cuiabá / MT, BrazilInformation: (55 65) 3321-4428 / 3624-5212www.ipeodonto.com.brabor abormgtwitter.com/abormg8º Congresso da Associação Brasileira de Ortodontia e Ortopedia FacialDate: October 12 to 15, 2011Location: Belo Horizonte / MG, BrazilInformation: www.congressoabor2011.com.br/10 | 11 | 12 | NOV | 2011 | CENTRO DE CONGRESSOS DE LISBOA | PORTUGALCongresso Internacional de Ortodontia, Implantodontia e Cirurgia OrtognáticaDate: November 4 and 5, 2011Location: Vale do Paraíba / SP, BrazilInformation: (55 11) 4368-5678[Inscreva seu Trabalho Científico:Realização Patrocínio Organização Agência OficialApoio[XX Congresso OMD (Ordem dos Médicos Dentistas)Date: November 10, 11 and 12, 2011Location: Centro de Congressos de Lisboa - PortugalInformation: www.omd.pt/congressoGOLD SPONSORSCONFERENCISTA CONVIDADOJORGE FABER | BRORTODONTIAPATROCINADORES OFICIAIS1º Congresso Internacional FASURGS - Cirurgia Bucomaxilofacial,Implantodontia e OrtodontiaDate: November 12, 13 and 14, 2011Location: FASURGS - Passo Fundo / RS, BrazilInformation: (55 54) 3312-4121www.fasurgs.edu.br/congressoDental Press J Orthod 19 2011 May-June;16(3):19

News7 th Meeting Abzil/3M of Individualized OrthodonticsIt was held in Belém (PA, Brazil),between 26 and 28 of May, the 7 th Meeting of Individualized Orthodontics,with the presence of the speakers: Leopoldino Capelozza Filho, Laurindo Furquim, Jesus M. Pinheiro Jr.,Sílvia Braga Reis, Sérgio Luiz de Azevedo Silva, José Valladares Neto and David Normando. Prof. Capelozzapresented the book “Metas Terapêuticas Individualizadas (Individualized Therapeutic Goals)”, his secondpublication by the Dental Press Publishing Co.Drs. Diana A. Athayde Fernandes and Dr. LeopoldinoCapelozza.Drs. Thiene Normando and Sílvia Reis.Event organizers and professors.Drs. Mielli Teixeira e Silva and Mara Sandra FerraisTobias.Drs. Eduardo Maranhão, Eurico Correia, JesusMaués P. Junior and Theodorico Neto.Drs. Adriana V. M. da Silva and Edilson da Silva.Drs. Hellen G. A. Santos and Lucyana Azevedo. Drs. Roberta F. Marbá and Renata B. Neri. Drs. Carolina Lima and Leopoldino Capelozza.Drs. Marília Guimarães and Fernanda Pinheiro. Drs. Murilo Neves and Rafael Simas. Drs. Iara Reis, Yuri Sasai, Laurindo Furquim andSocene Veloso.Dental Press J Orthod 21 2011 May-June;16(3):20-1

W h a t ´ s n e w i n D e n t i s t r yCephalometry is an important predictor ofsleep-related breathing disorders in childrenJorge Faber*, Flávia Velasque**Sleep-related breathing disorders (SBD) havebeen studied and treated for a long time in adults,but little attention has been given to children, forwhom SBD may be as serious as for adults. Parents,guardians and healthcare personnel should payclose attention to these problems, which may betreated during childhood. Their effects on everydaylife, such as hyperactivity and poor school achievement,may have a severe impact on the developmentof an individual and may clearly affect health.The relevance of this problem has motivated authorsto evaluate the cephalometric characteristicsof children with SBD. 1 Cephalometry is an importantfacial morphometry tool available practicallyall over the world. This study sample included 70children (34 boys; mean age = 7.3±1.72 years) whousually snored and had symptoms of sleep-relatedobstructive breathing disorders for over 6 months.Nocturnal polysomnography was used to dividechildren into 3 groups: 26 children with a diagnosisof obstructive sleep apnea (OSA); 17 with signs ofupper airway resistance syndrome (UARS), and 27snorers. The control group had 70 children with nobreathing obstructions paired for age and sex. Lateralhead radiographs were obtained, and cephalogramswere traced and measured.Children with SBD had a shorter mandible (P= 0.001) and a greater inclination in relation to thepalatal plane (P = 0.01). Anterior face height (P =0.01) and lower face height (P = 0.05) were greaterthan in control children. Their soft palate was longer(P = 0.018) and thicker (P = 0.002). Airwayshad a smaller diameter in the nasopharyngeal region,but the oropharynx had a greater diameter atthe base of the tongue (P = 0.01). The hyoid bonewas placed at a more inferior position (P < 0.01),and craniospinal angles were greater than thosefound in the control group, in which children hadno breathing obstruction.When divided in subgroups according to diseaseseverity, children with OSA had significantdifferences from children in the control group, particularlyfor the oropharyngeal variables. Childrenwith UARS and snoring also had differences fromthe control groups, but subgroups with obstructionwere not reliably distinguished from each otherby cephalometric measures. Logistic regression revealedthat UARS and OSA were associated witha decrease in pharyngeal diameter in the adenoidand uvula tip regions, an increase in its diameter inthe region of the base of the tongue, and a thick softpalate. In addition, their maxilla had a more anteriorposition in relation to the cranial base.This is an important study because it shows thatcephalometry may be an important predictor ofSBD in children. Special attention should be givento the pharyngeal measures. Children with SBDshould undergo systematic orthodontic evaluationsbecause of the effects of OSA on the developmentof craniofacial bones. The orthodontist is the specialistwith the best knowledge of the diagnostictools for these cases and may substantially contributeto improving health and quality of life of childrenwith SBD.* Associate Professor, Orthodontics, Universidade de Brasília, Brazil.** Private practice, Orthodontics and Pediatric Orthodontist.Dental Press J Orthod 22 2011 May-June;16(3):22-4

Faber J, Velasque FShould teeth be extracted at the beginning ofprosthetic treatment?The usual first option for dentists and laypeoplewhen a tooth has problems is to treat andpreserve it. However, clinical management oftenhas to be less conservative. Therefore, dentistsoften face the difficult task of deciding aboutthe effect and importance of the multiple riskfactors of periodontal, endodontic or prostheticorigin that may affect the prognosis of an abutment.The relevance of this topic and the changesin concepts due to the development of newtechniques in the different dental specialties ledthe authors to conduct a review whose purposewas to summarize the critical factors involvedin decisions about whether a problematic toothshould be treated and preserved or extracted andpossibly replaced with an implant. 2A literature search was conducted for peerreviewed studies published in English and foundin MEDLINE (PubMed) from 1966 to 2009.Different keyword combinations were used,such as treatment plan and decision making,periodontics, endodontics, dental implants orprosthesis. In addition, the reference lists of allrelevant studies and reviews were surveyed.The study concluded that tooth preservationand the acceptance of risks are properly definedfor several situations. At first, the tooth shouldbe preserved if not extensively damaged andwhen it has a strategic value, either esthetic orfunctional. This applies especially for patientswith implant contraindications. Moreover, preservationis further recommended in case thetooth is in an intact arch, and when the preservationof the gingival structures is fundamental.In contrast, when restorations are planned forall the mouth, the strategic use of tooth implantsis recommended. In addition, several smallerfixed prostheses, either implants or abutments,may be used. In this case, teeth whose long-termprognosis is excellent should be selected. Theseprocedures ensure that the risk of failure of allthe restorations will be reduced.Dental Press J Orthod 23 2011 May-June;16(3):22-4

What’s New in DentistryObesity is associated withperiodontal infectionA common observation made by clinicaldentists is that obese patients seem to havemore frequent periodontal infections than therest of the population. This possible association,relevant because additional care should be providedfor obese people, has been recently analyzedin an adult population. 3The study included 2,784 dentate, non-diabeticindividuals aged 30 to 49 years. Obesity wasassessed according to body mass index (BMI),body fat percentage (BF%) and waist circumference(WC). The extension of periodontal infectionwas assessed using the number of teeth withperiodontal pockets (whose depth was equal toor greater than 4 mm) and was classified intofour categories 0; 1-3; 4-6; 7 or more.The authors found a significant positive associationbetween the number of teeth withdeep periodontal pockets and BMI. The associationwas found among both men and women,and also among those who never smoked. Thenumber of teeth with deep periodontal pocketswas also associated with BF% and WC amongindividuals who never smoked.This study results suggest that periodontalinfection, measured according to the number ofteeth with deep periodontal pockets, seems to beassociated with obesity. However, no causal inferencemay be made, and further studies should elucidatethe role of periodontal infection in obesity.However, findings suggest that the periodontalhealth of obese patients deserves special attention.ReferEncEs1. Pirilä-Parkkinen K, Löppönen H, Nieminen P, Tolonen U, PirttiniemiP. Cephalometric evaluation of children with nocturnal sleepdisorderedbreathing. Eur J Orthod. 2010;32(6):662-71.2. Zitzmann NU, Krastl G, Hecker H, Walter C, Waltimo T, Weiger R.Strategic considerations in treatment planning: deciding when totreat, extract, or replace a questionable tooth. J Prosthet Dent.2010;104(2):80-91.3. Saxlin T, Ylöstalo P, Suominen-Taipale L, Männistö S, Knuuttila M.Association between periodontal infection and obesity: results ofthe Health 2000 Survey. J Clin Periodontol. 2011;38:236-42.Contact addressJorge FaberE-mail: faber@dentalpress.com.brDental Press J Orthod 24 2011 May-June;16(3):22-4

O r t h o d o n t i c I n s i g h tIndirect bone resorption in orthodonticmovement: when does periodontalreorganization begin and how does it occur?Alberto Consolaro*, Lysete Berriel Cardoso**, Angela Mitie Otta Kinoshita***, Leda Aparecida Francischone***,Milton Santamaria Jr****, Ana Carolina Cuzuol Fracalossi*****, Vanessa Bernardini Maldonado******Tooth movement induced by orthodontic appliancesis one of the most frequent therapeuticprocedures in clinical dental practice. The searchfor esthetics and functionality, both oral and dental,demands orthodontic treatments, which areoften associated with root resorptions that may,in extreme cases, lead to tooth loss, periodontaldamage, or both.The knowledge of induced tooth movementbiology, based on tissue, cell and molecularphenomena that take place on each day duringmovement progression, enable us to act safelyand consciously when using drugs, proceduresand interventions to optimize orthodontic treatmentand patient comfort, to reduce or avoidroot resorptions and to treat systemically compromisedpatients.The experimental model of induced toothmovement described by Heller and Nanda 5 hasbeen widely adopted 3,10 because results can be extrapolatedto orthodontic clinical practice (Fig 1).Standardization and detailed descriptions of thisexperimental model ensure greater applicabilityand easier result extrapolations. The improvementof this model may provide further knowledgeabout the biology of induced tooth movement. 3,10In general, experimental times were 5 to 7 daysin the first studies. 7,8,9,13 However, it remains unclearwhat tissue phenomena take place in murinemaxillary first molar roots that received intenseforces and produce indirect bone resorption. Severalquestions raised in previous studies 4,6,10,11 usingthis model have not been answered to this date:» Is the root resorption associated with experimentalinduced tooth movement moreclosely related with frontal or underminingbone resorption?» How long does it take to eliminate the hyalineareas, and when does the periodontalligament begin its reorganization?» When and how is the reabsorbed corticalbone replaced to reinsert the periodontalligament?» Do the hyalinized areas of connective tissueundergo phagocytosis, resorption or circumscription?» Where does root resorption occur, immediatelynext to or away from hyaline areas?» When indirect bone resorption is suspected,do microscopic data suggest the adoption ofa greater interval for the reactivation of theorthodontic appliance?How to cite this article: Consolaro A, Cardoso LB, Kinoshita AMO, Francischone LA, Santamaria Jr M, Fracalossi ACC, Maldonado VB. Indirect bone resorptionin orthodontic movement: when does periodontal reorganization begin and how does it occur? Dental Press J Orthod. 2011 May-June;16(3):25-31.* Head Professor, School of Dentistry of Bauru (FOB) and Graduate Program of School of Dentistry of Ribeirão Preto (FORP), University of São Paulo (USP), Brazil.** Professor, Histology, Anhanguera School, Bauru, Brazil.*** Professor, Oral Biology Program, Sagrado Coração University, Bauru, Brazil.**** Professor, Orthodontics Program, Araras University, Araras, Brazil.***** MSc in Oral Pathology from FOB. PhD from Federal University of São Paulo, São Paulo, Brazil.****** MSc in Pediatric Dentistry from FORP-USP.Dental Press J Orthod 25 2011 May-June;16(3):25-31

Indirect bone resorption in orthodontic movement: when does periodontal reorganization begin and how does it occur?ICM1 st MABFIGURE 1 - Murine skull where molars and incisors (IC) are seen, particularly maxillary first molar (M1 st M) after movement by appliance designed by Hellerand Nanda. 5 Microscopic cross-section (B) shows tooth roots, particularly M1 st M, in cervical plane.Dental Press J Orthod 26 2011 May-June;16(3):25-31

Consolaro A, Cardoso LB, Kinoshita AMO, Francischone LA, Santamaria Jr M, Fracalossi ACC, Maldonado VBABCDBDLITMLMBFIGURE 2 - In A, murine first molar and its five roots. In the mesiobuccal(MB) root, forces dissipate along its larger and longer structure.In other roots (distobuccal, intermediate, distolingual and mesiolingual),delicate structures clearly show effects of forces onperiodontal tissues. In B, red lines show cross-sections at cervicallevel in schematic drawing of a longitudinal section of murine firstmolar. In C, red lines correspond to longitudinal views in crosssectionof murine maxillary first molar (A: modified from Alatli-Kutet al.1; B and C: of Fracalossi 4 ).» When palatal expansion is used, applianceanchorage in maxillary premolars promoteshyalinization of the periodontal ligamenton the buccal face. Forces dissipate and theprocess ends when the midpalatal sutureis separated. Does indirect bone resorptionbegin long before that? When does it actuallybegin, at 3, 5, 7 or 9 days?Few studies investigated the chronology andsequential events of indirect bone resorptionand the consequent periodontal reorganizationresulting from it. Microscopic analyses of theevents induced by intense forces on teeth thatundergo experimentally induced movement inmurine models contributed to answer some ofthe questions raised, such as in the study conductedby Cardoso, 2 together with Consolaro,Kinoshita, Francischone, Santamaria Jr., Fracalossiand Maldonado. Their most interesting findingswere the late results, when the periodontalligament is reorganized and root resorptions aremore active and intense (Figs 6, 7 and 8).In patients, delayed events and periodontalreorganization occur at each activation time,between 15 and 21 days. At the end of six totwelve years, the resulting sum of the severalorthodontic appliance activation times may bedemonstrated by radiographic and CT imagesof periodontal tissues and tooth roots. Knowingeach activation time and its beginning, middleand end substantially increases our chances ofacting to reduce unwanted consequences.Some of the interventions that orthodonticspecialists may choose, based on results of experimentalstudies, are:1) Defining plans to prevent root resorptionand bone loss.2) Distributing the application of forces ontooth structure to reduce patient pain and discomfort.Ligament hyalinization reduces or blockstooth movement and may also be associatedwith root resorption. Knowledge about tissue,Dental Press J Orthod 27 2011 May-June;16(3):25-31

Indirect bone resorption in orthodontic movement: when does periodontal reorganization begin and how does it occur?vBvPLCECMCbObvHBCHHDPLDFIGURE 3 - Normal periodontal structures on the mesial face of murineM1 st M distobuccal root, which received intense forces in the experimentalmodel designed by Heller and Nanda. 5 B = alveolar bone; PL = periodontalligament; C = cement; D = dentine; P = tooth pulp; V = vessels; Cb= cementoblasts; Ob = osteoblasts; ECM = extracellular matrix. (HE;10X).PPFIGURE 4 - Incipient indirect bone resorption on mesial face of murineM1 st M distobuccal root after application of intense forces for 3 days.Hyalinized periodontal ligament (H) and initial clastic activity (circle)surround it. B = alveolar bone; PL = periodontal ligament; C = cement;D = dentine; P = tooth pulp. (HE; 10X).MSMSMSMSBHHHPLCDPFIGURE 5 - Indirect bone resorption on mesial face of murine M1 st M distobuccal root after application of intense forces for 5 days. Hyalinized periodontalligament (H) and clastic activity (circle) surround it. B = alveolar bone; PL = periodontal ligament; C = cement; D = dentine; P = tooth pulp; MS = marrowspace. (HE; 10X).Dental Press J Orthod 28 2011 May-June;16(3):25-31

Consolaro A, Cardoso LB, Kinoshita AMO, Francischone LA, Santamaria Jr M, Fracalossi ACC, Maldonado VBMSMSMSMSHBCHPLDPPLFIGURE 6 - Indirect bone resorption (arrows) on mesial face of murine M1 st M distobuccal root after application ofintense forces for 7 days. Hyalinized periodontal ligament (H) and clastic interaction with hyalinized areas surroundit. Root surface exposure due to root resorption induced by death of cementoblasts; several associated bone remodelingunits (circles). B = alveolar bone; PL = periodontal ligament; C = cement; D = dentine; P = tooth pulp; MS= marrow space. (HE; 10X).MSMSBPLHCHHRRDRRFIGURE 7 - Indirect bone resorption (arrows) on mesial face of murine M1 st M distobuccal root after application of intenseforces for 9 days. Ligament is reorganizing and frontal bone resorption is already visible on periodontal surfaceof cortical plate (circle). Hyaline areas remaining from previously hyalinized periodontal segment (H) are associatedwith clastic activity. Root resorption (RR) is seen in cement and dentine, together with active bone remodeling units.B = alveolar bone; PL = periodontal ligament; C = cement; D = dentine; MS = marrow space. (HE;10X).Dental Press J Orthod 29 2011 May-June;16(3):25-31

Indirect bone resorption in orthodontic movement: when does periodontal reorganization begin and how does it occur?cell and molecular phenomena involved in inducedtooth movement may provide a basis forclinical procedures.Murine molars have 5 roots, 3,5,12 and the experimentalorthodontic appliance (Fig 1) designedby Heller and Nanda 5 applies intenseforces on four roots: distobuccal, intermediate,distolingual and mesiolingual (Fig 2). In the mesialor mesiobuccal root, the forces applied bythe appliance dissipate along larger and longerroot structures, which affect periodontal tissuessimilarly to the application of slight or moderateforces. Because of these characteristics, in theexperimental model the effects of two types offorces may be analyzed at the same time accordingto their intensity: mild/moderate or intense.The distolingual root, according to the studyby Cardoso, 2 may show morphological changesassociated with indirect buccolingual bone resorptionin cross-sections of the cervical regionof the root and the alveolar bone process, as illustratedin Figures 3, 4, 5, 6, 7 and 8.MSMSMSPLHCBPLDFIGURE 8 - Indirect or undermining bone resorption (arrows) on mesial face of murine M1 st M distobuccal root after application of intense forces for 9 days,and more advanced reorganization than in Figure 7. Periodontal ligament is reorganizing together with remnants of cortical bone. Hyaline areas remainingfrom previously hyalinized periodontal segment (H) are associated with clastic activity. B = alveolar bone; PL = periodontal ligament; C = cement; D = dentine;P = tooth pulp; MS = marrow space. (HE;10X).PDental Press J Orthod 30 2011 May-June;16(3):25-31

I n t e r v i e wAn interview withJames A.McNamara Jr.• Degree in Dentistry and Orthodontics, University of California, San Francisco.• PhD in Anatomy from the University of Michigan.• Professor of Thomas M. and Doris Graber Chair, Department of Orthodonticsand Pediatric Dentistry - University of Michigan.• Professor of Cell Biology and Development - University of Michigan.• Research Professor at the Center for Human Growth and Development at theUniversity of Michigan.• Author of the book “Orthodontics and Dentofacial Orthopedics.”• Milo Hellman Research Award (AAO - 1973).• Lecturer Sheldon E. Friel (European Society of Orthodontics -1979).• Award Jacob A. Salzmann (AAO - 1994).• Award James E. Brophy (AAO - 2001).• Lecturer Valentine Mershon (AAO - 2002).• Award Albert H. Ketcham (AAO - 2008).• Graduate of the American Board of Orthodontics - ABO.• Fellow of the American College of Dentists.• Former President of Edward H. Angle Society of Orthodontists - Midwest.• Editor of series “Craniofacial Growth Monograph” - published by University of Michigan.• Over 250 published articles.• Wrote, edited or contributed to more than 68 books.• Taught courses and conferences in 37 countries.I met James A. McNamara Jr. in the late 70’s when we both became full members of the Edward H. Angle Society ofOrthodontists - Midwest. Jim is one of the most active members, always looking on to break boundaries with new works.During over 30 years, I saw him being presented with all the existing awards and honors in the field of orthodontics.Knowing his ability and persistence, I’m sure that if in the future other awards are instituted, Jim will be there to, with allmerits, conquer them. It is fortunate to have a family that supports and encourages: his wife Charlene, who accompanieshim on every trip, and Laurie, his daughter and colleague, now a partner in his clinic. In addition to Orthodontics, he ispassionate about golf and photography.My sincere thanks to colleagues Bernardo Quiroga Souki, José Maurício Vieira de Barros, Roberto Mario Amaral LimaFilho, Weber Ursi, and Carlos Alexandre Câmara, who accepted the invitation to prepare questions that facilitated thedevelopment of the script of this interview. I hope that readers will experience the same pleasure and satisfaction I felt,when reading the answers. Jim was able to show growth and maturity of his clinical career, based on scientific evidence,with a clarity and simplicity that makes him, besides clinician and researcher emeritus, one of the best speakers of our time.I thank the Dental Press for the opportunity to conduct this interview and wish you all a good reading.Carlos Jorge VogelDental Press J Orthod 32 2011 May-June;16(3):32-53

McNamara JA Jr1) May I begin by asking you to tell us aboutyour general educational background andyour education in orthodontics?I began my collegiate education at the Universityof California Berkeley, where I majoredin Speech (today called Forensics), not scienceor biology. I then attended the School of Dentistryat the University of California San Francisco,where I received my dental degree and myspecialty education in orthodontics. In 1968, Itraveled 2000 miles east to Ann Arbor and beganmy doctoral studies in the Department of Anatomyat the University of Michigan. I also becameaffiliated with the Center for Human Growthand Development, an interdisciplinary researchunit on the Ann Arbor campus that was headedby Dr. Robert Moyers. I had many wonderfulmentors during my PhD years, including bonebiologist Donald Enlow as well as orthodontistsFrans van der Linden from the Netherlands, KaleviKoski from Finland, Takayuki Kuroda fromJapan and José Carlos Elgoyhen from Argentina.It was an exciting time for a young man like meto conduct research at the University of Michigan.My dissertation concerned the adaptationof the temporomandibular joints in rhesus monkeys,a study completed in 1972. 1,2 I then wasappointed to the University of Michigan faculty.I have been at Michigan ever since.In addition to my current appointments inthe School of Dentistry, the School of Medicine,and the Center for Human Growth and Development,I have maintained a part-time privatepractice in Ann Arbor, now sharing the practicewith my daughter and partner Laurie McNamaraMcClatchey. Given my 40 years experience inprivate practice (with my partners and I sharingthe same patients) as well as through my clinicalsupervision at the University of Michigan(and for eight years at the University of DetroitMercy), I estimate that I have participated in thetreatment of over 9,000 orthodontic patients.Thus, I have both academic and clinical perspectivesconcerning orthodontics and dentofacialorthopedics. Maintaining a private practicewhile being on the Michigan faculty has hadmany advantages.In addition, our research group, which includesTiziano Baccetti and Lorenzo Franchifrom the University of Florence, has addressedmany orthodontic conditions from a clinical perspective,providing data on treatment outcomes.In this interview, I will be referring primarily toclinical investigations conducted by our groupbecause the protocols used in our research effortsare consistent across studies.2) You have been in private practice for along time and have been an innovator ofmany orthodontic and dentofacial orthopedicstreatments. How has your practiceevolved over the years?If anything, my practice philosophy has becomesimpler as the years have passed. I was welleducated at UCSF in fixed appliance treatmentand even used some preadjusted appliances duringmy residency in the mid 1960s. Beginning inthe early 1970s, I began working with a varietyof appliances aimed at modifying craniofacialgrowth, including functional jaw orthopedics(FJO), rapid maxillary expansion (RME) andfacial mask therapy.In 1980, I began formulating and testingprotocols in the early mixed dentition for thecorrection of crossbites and of tooth-size/archsizediscrepancies, first with a bonded expanderand later adding a removable lower Schwarzexpansion appliance. As time passed, I beganto realize how important it is for the orthodontistto have patience during treatment, lettingnormal growth and development of the patienttake place after early intervention (for example,we will talk about creating an environment allowing“spontaneous improvement” in Class IImalocclusion later in this discussion).Today our treatment protocols are far lessDental Press J Orthod 33 2011 May-June;16(3):32-53

Interviewcomplex that they were 20 years ago. Our regimensare clearly defined and standardized forthe most part, 3 as they had to become when Ibegan sharing patient treatment with partnersin my practice beginning in 1989. We also haveplaced significant emphasis on using those protocolsthat are not dependant on required highlevels of patient compliance.3) You thus have been an advocate of earlyorthodontic and orthopedic treatment formuch of your professional career. Today,what are the most important issues relatedto early treatment?In my opinion, perhaps the critical issuetoday is treatment timing. 3 With the recentemphasis on “evidence-based” therapies in bothmedicine and dentistry, we now are gainingan appreciation concerning the nature of thetreatment effects produced by specific protocolsin patients of varying maturational levels.We are moving toward a better understandingconcerning the optimal timing of orthodonticand orthopedic intervention, depending on theclinical condition.In recent years, there has been considerablediscussion among clinicians and researchers alikeconcerning the appropriate timing of interventionin patients who have Class II malocclusions,as has been evidenced by the ongoing discussionsconcerning the randomized clinical trials ofClass II patients funded by the US National Institutesof Health (e.g., North Carolina, Florida).But the issue of “early treatment” is far broaderthan simply arguing about whether a Class IIpatient is better treated in one or two phases.A variety of other malocclusions also mustbe considered within this topic, including themanagement of individuals with Class III malocclusions,those with open and deep bites, and themany patients with discrepancies between thesize of the teeth and size of the bony bases (thelatter comprise about 60% of the patients in ourprivate practice in Ann Arbor). The managementof digital habits also falls within this discussion.4) What are your views about the extentto which a clinician can alter the growth ofthe face?In general, the easiest way for a clinicianto alter the growth of the face is in the transversedimension, orthopedically in the maxilla,orthodontically in the mandible. 4 Rapid maxillaryexpansion (Fig 1) has been shown to be anextremely efficient and effective way of wideningthe maxillary bony base. In the lower arch,however, there is no mid-mandibular suture—soit is virtually impossible to produce orthopedicchange in the mandible other than in combinationwith surgical distraction osteogenesisat the midline. The changes in the lower archessentially are dentoalveolar in nature, such asthose resulting from the use of a removablelower Schwarz appliance (Fig 2).5) How about the correction of Class II andClass III problems?As far as sagittal change is concerned, I thinkthere is a substantial amount of experimental 5,6and clinical evidence 7-10 that mandibular lengthcan be increased over the short-term in comparisonto untreated Class II controls, using a varietyof functional orthopedic appliances. It should benoted, however, that not all investigators havecome to this conclusion. The long-term effectof bringing the mandible forward functionallyis much more uncertain at this time; mostrecent research has shown that the long-termmandibular skeletal effect may be limited to 1-2mm over what would have occurred withouttreatment. 11,12The best data that I have seen that considersthe question of how much mandibular growthcan be influenced over the long term has beenderived from our recent study of Class II patientstreated with the Fränkel appliance. In thisDental Press J Orthod 34 2011 May-June;16(3):32-53

McNamara JA JrFIGURE 1 - The bonded acrylic splint type of rapid maxillary expander thatis used primarily in patients in the mixed dentition is representative of theorthopedic expansion appliances used during treatment. The acrylic portionof the appliance is made from 3 mm thick splint Biocryl. 3FIGURE 2 - The removable lower Schwarz appliance 3 can be usedprior to RME to upright the lower posterior teeth and gain a modestincrease in arch perimeter anteriorly. It produces orthodontic tippingof the teeth only.investigation by Freeman and co-workers, 13 weevaluated patients treated with the FR-2 applianceby Rolf Fränkel of the former GermanDemocratic Republic. Based on my experiencewith a variety of FJO appliances, I considerthe function regulator (FR-2) the best of thefunctional appliances in that it addresses neuromuscularproblems directly as well as skeletaland dental problems. A sample of 30 FR-2patients was compared to a matched group ofuntreated Class II patients. Over the long-term,the increase in mandibular growth in the treatedsample was 3 mm in comparison to controls.6) If mandibular growth can be increasedin length only by 1-2 mm with functionaljaw orthopedics under most circumstances,why use it?Hans Pancherz answered that question eloquentlyduring a seminar at the University ofMichigan when asked the same questions byour residents. 14 He stated simply that “you getthe growth when you need it.” Most studiesof the Herbst appliance have shown that thetreatment effect produced by this tooth-bornetype of FJO appliance is 50% dental and 50%skeletal. 8,15 In comparison to untreated Class IIcontrols, Herbst treatment produces about 2.5to 3.0 mm increased mandibular length duringthe first phase of treatment; our investigationof Twin Block therapy has shown even largershort-term gains in mandibular length. 9,16Normally Herbst or Twin Block wear resultsin the Class II patient having a Class I or super-Class I molar and canine relationship at theend of the first phase of treatment. Full fixedappliances then are used to align and detail thedentition. If the overall treatment outcomeis evaluated, some of the gains in mandibularlength observed during Phase I treatment maydisappear by the end of fixed appliance therapy.11,12 Thus, FJO helps the clinician correct theunderlying Class II malocclusion in a relativelyshort (9-12 months) and predictable manner.Some Class II patients with particularly favourablecraniofacial features before treatment (arelatively closed gonial angle, for instance) maypresent an appreciable improvement in theirDental Press J Orthod 35 2011 May-June;16(3):32-53

Interviewfacial profile due to mandibular advancementfollowing FJO. If a substantial change in theposition of the chin is the primary focus of thetreatment protocol, however, then correctivejaw surgery might be indicated, be it a mandibularadvancement or a simple advancementby genioplasty.Attempting to restrict the growth of themandible presents a significant clinical challenge,particularly in the management of ClassIII malocclusion. One such appliance is the chincup. I have not had extensive first-hand experiencewith the chin cup clinically, although atany given time we usually have one or two chincup patients in our practice or in the universityclinic, with the chin cup used primarily as along-term retention device following facial masktherapy. The chin cup is indicated in patientswho have mandibular prognathism and in whoman increase in lower anterior facial height is notdesirable. A chin cup is not indicated in a patientwho has maxillary retrusion.There have been many studies, especially inAsian populations such as the Chinese, Koreanand Japanese, that have shown over the shorttermthat there can be a restriction in mandibularprojection in comparison to untreated ClassIII individuals. 17,18 As of now, however, there islittle evidence to support the premise that thegrowth of the mandible can be restricted overthe long term (unless the patient wears the chincup continuously from age 6 to age 18, a levelof compliance that is difficult to attain).7) You said earlier that the midface is responsiveto treatment in the transverse dimension.How responsive is the maxilla tosagittal forces?The growth of the midface seems to beinfluenced more readily by treatment than isthe mandible. In the midface, restriction of theforward movement of the maxilla and maxillarydentition in Class II patients has been welldocumentedfor over 60 years, beginning withthe work of Silas Kloehn, 19 among others. Givengood cooperation in a growing patient, thereis no question that extraoral traction is effectivein changing the occlusal relationship fromClass II toward Class I. However our researchon the components of Class II malocclusion hasshown that true maxillary skeletal protrusion isrelatively rare in a Caucasian population. 20,21 Inaddition, good patient compliance is an essentialcomponent of this type of treatment.Regarding protraction of the maxilla with anorthopedic facial mask (Fig 3) in Class III patients,most clinical studies have shown that theamount of true maxillary skeletal protractionis only 1-2 mm over what would occur duringgrowth in untreated Class III subjects. 22,23 ClassIII correction still can occur as a consequenceof facial mask wear due mainly to mandibularmodifications, especially because of favorablechanges in the direction of condylar growth,also in relation to appropriate early treatmenttiming. Increased forward protraction amountsmay be produced if the facial mask is attachedto dental implants or if microimplants or boneanchors are used for skeletal anchorage. 24-268) What changes can be produced in thevertical dimension of the face of a growingpatient?Most orthodontists have found that thevertical dimension is the dimension that is themost difficult to correct therapeutically, andthat observation certainly has been substantiatedby my clinical experience. In a growingpatient, increasing a short lower facial heightis accomplished most effectively with a FJOappliance such as the Twin Block 9,27 or the FR-2of Fränkel, 7 less so with the Herbst appliance.In the long-face patient, controlling thevertical dimension has been particularly challenging.For example, a study by our groupevaluated modification in growth following theDental Press J Orthod 36 2011 May-June;16(3):32-53

McNamara JA JrFIGURE 3 - The orthopedic facial mask of Petit. 3FIGURE 4 - The vertical-pull chin cup typically is used in combinationwith an acrylic splint expander. 3use of a bonded rapid maxillary expander andvertical-pull chin cup 28 (Fig 4). The effect of thevertical-pull chin cup was evident only in themixed dentition, with little effect noted in thepermanent dentition even though the appliancewas worn at night for 5.5 years on average.9) In Class III cases in the deciduous or earlymixed dentition, what cephalometric parametersdo you use to differentiate amonga true Class III, true developing Class III,and a dentoalveolar Class III malocclusion?I typically do not perform a detailed cephalometricanalysis on a young patient with thosequestions in mind. Our approach to Class IIItreatment primarily is through the use of abonded acrylic splint expander to which havebeen attached hooks for elastics (Fig 5) and anorthopedic facial mask (Fig 3). Typically, thefirst appliance that we use is the bonded expander.29 In many patients (perhaps one-third ofmixed dentition Class III patients), we observea spontaneous improvement of the Class IIIor Class III tendency toward Class I simply byexpanding the maxilla. This favorable changeoccurs almost immediately after maxillary expansion.If further intervention is necessary, thenwe will incorporate an orthopedic facial maskinto the treatment protocol.Any time a patient has a Class III molarrelationship and we use this protocol, first anyCO-CR discrepancy is eliminated just by placingthe facial mask; so we do not try to make thedifferentiation between those three conditionsyou asked about, in that all three conditions aremanaged by the same treatment regimen.10) Do you still use the FR-3 Fränkel appliance?You previously have recommendedthe use of the FR-3, especially in maxillaryretrognathic cases. What are your contemporaryviews on its use?Currently, I actually use more FR-3 appliances30 (Fig 6) than I do FR-2s. Today, the FR-3Dental Press J Orthod 37 2011 May-June;16(3):32-53

InterviewFIGURE 5 - The acrylic splint expander to which have been attachedfacial mask hooks. 3FIGURE 6 - The Fränkel FR-3 appliance. 3 Fränkel 62 states that the distractingforces of the upper lip are removed from the maxilla by theupper labial pads. The force of the upper lip is transmitted through theappliance to the mandible because of the close fit of the appliance tothat arch.usually serves as a retainer, rather than as aprimary treatment appliance. The FR-3 is anappliance that has vestibular shields and alsoupper labial pads that free the maxilla fromthe forces of the associated musculature. 31 TheFR-3 produced similar treatment effects as doesa facial mask-expander combination, but the effectstake much longer to occur in FR-3 therapy. 3In the patient about whom we are suspiciousof a strong tendency for relapse toward aClass III malocclusion after facial mask therapy,we will use the FR-3 as a retainer to be wornat night and around the house during the day.This approach of using the FR-3 as a retainerafter successful facial mask therapy seems tobe a reasonable way of incorporating this typeof Fränkel appliance into our overall treatmentscheme. We do not use the FR-3 often, but itsuse is essential in patients with difficult ClassIII problems.11) Tell us more about the acrylic splint expanderused in combination with the orthopedicfacial mask. Can you elaborate on theuse of this treatment protocol in dentoalveolarClass III or mandibular prognathismcases?As stated before, we use the same basic protocolregardless of the etiology of the Class IIIproblem. When I first heard Henri Petit (then ofBaylor University in Dallas, Texas) speak aboutfacial mask therapy in 1981, I was somewhatcritical of his presentation because he did notdifferentiate among the various types of ClassIII malocclusions according to their etiology.I soon realized that the facial mask-expandercombination is effective regardless of the underlyingetiology of the Class III problem. I haveused essentially the same protocol for the last30 years, starting with the bonded expander.Typically we will deliver the expander and havethe patient expand the appliance 28 times. Ifwe need more turns, the patient is instructedto do so at the next appointment; then we willdeliver the face mask if the underlying Class IIImalocclusion has not corrected spontaneously.We usually recommend that the timing of facialmask therapy correspond to the eruption ofthe maxillary permanent central incisors. 29 I donot like to start much earlier than that because IDental Press J Orthod 38 2011 May-June;16(3):32-53

McNamara JA Jrwant to make sure that there is maximum verticaloverlap of the permanent upper and lowercentral incisors at the end of facial mask treatment.The establishment of substantial verticaloverlap of the incisors is critical in maintainingthe corrected Class III malocclusion during thetransition to the permanent dentition.12) Do you use as a rule the maxillary expansionappliance with a facial mask, irrespectiveof the transverse width of themaxilla?We use the bonded expander regardless ofwhether or not expansion is required. If thepatient would benefit from widening of themaxilla, we have them expand the appropriatenumber of times. If there is no need to expand,we still have the patient expand 8-10 times toloosen the circummaxillary sutural system. 29 Weand others have found that by mobilizing thesutures of the midface, we presumably affect thecircummaxillary sutural system and facilitatethe forward movement of the maxilla. 3,3213) In the RME/FM appliance, where do youplace the hooks for elastic attachment? Isit at the deciduous canines or deciduousfirst molars?We typically use hooks that extend abovethe upper first deciduous molars. A downwardand forward pull on the maxilla produced bythe elastics counteracts the reverse autorotationof the maxilla that might occur becauseof the direction of pull on the teeth, resultingin a counterclockwise rotation of maxillarystructures.14) What are the force levels of the elasticsthat you prefer?Three different elastics, the same elastics asoriginally recommended by Petit, 33 are used.The first elastic is 3/8” in length and is rated at8 ounces (e.g., Tiger elastics from Ormco Corp.).These elastic generate about 200 grams of forceagainst the maxillary RME appliance. After aweek or so, we switch to heavier elastics (1/2”,14 oz; Whale) that generate about 350 g of force.The final elastic is 5/16” and is rated at 14 oz(Walrus). These elastics generate about 600 gof force, so that by the time we use the thirdtype of elastics, there is a considerable amountof force generated against the maxillary andmandibular structures.15) Is there any particular method you recommendto remove the bonded expander?The debonding procedure is relativelystraightforward. First, one of my chairside assistantsapplies a topical anesthetic gel abovethe appliance in the region of the first andsecond deciduous molars bilaterally. We let thegel activate for a few minutes, and then I willuse a pair of ETM 349 pliers to remove thebonded expander. The ETM 349 plier actuallyis an anterior bond remover that has a sharpedge on one side and a Teflon cap on the other.The Teflon cap is placed on the occlusal surfaceof the appliance, and the sharp edge is insertedunder the gingival margin of the appliance betweenthe first and second deciduous molars.I then use a single strong pulling motion thattakes about half a second, debonding the leftand then the right side of the appliance in onecontinuous motion. Very little or no discomfortis felt by the patient.Obviously the ease of removal of the applianceis dependent on a number of technicalfactors. One of these factors is making sure thatthe proper material is used for the acrylic. I donot recommend the “salt and pepper” type ofcold cure acrylic application for expander constructionbecause the resulting type of acrylicis too rigid; rather, I strongly recommend theuse of 3 mm thick splint Biocryl (Great LakesOrthodontic Products) applied over the wireframework in a thermal pressure machine suchDental Press J Orthod 39 2011 May-June;16(3):32-53

Interviewas a Biostar. By using the latter material, theexpander is somewhat flexible; it then becomesvery easy to break the seal of the adhesive tothe teeth.I also recommend that the chemical cureadhesive Excel (Reliance Orthodontics) isused for the bonding procedure. This adhesiveis made specifically for the bonding of largeacrylic appliances. In addition, a sealer shouldbe placed on the teeth, and “plastic bracketprimer” should be painted inside the expanderprior to the bonding procedure. This primeractually is methyl methacrylate liquid; it softensthe inside of the expander so that it can acceptthe bonding agent. So when we remove theappliance, all the bonding agent comes out inthe appliance and none remains on the teeth,making clean-up easy.16) Do you favor the use of slow expansionor rapid expansion?I have not had much experience in dealingwith protocols that deliver so-called “slow expansion.”34 By that, I mean having the expanderturned every other day or every third day (asmight be used in some young adult patients). Inour practice, we use a one turn-per-day protocolin growing patients, which is not as rapid as theoriginal protocol of two turns-per-day advocatedby Andrew Haas. 35There are two distinct reasons why I havetaken the one-turn-per-day approach, one practicaland one based on long clinical experience.From a practice management standpoint, havinga patient activate the expander twice per daysimply means that I have to see the patient twiceas frequently. We now have almost all patientsactivate the expander once a day for 28 days,which means that I only need to see the patientevery four weeks, a more practical interval thanonce each week or once every two weeks.The second reason has to do with the speedof expansion. Orthodontists across the UnitedStates often contact me concerning problemsthey are experiencing that are associated withRME. One such problem is “saddle nose deformity,”a condition characterized by a loss ofheight of the nose because of the collapse of thebridge. This clinical problem can occur in youngchildren undergoing rapid maxillary expansion(if the expander is removed immediately theunwanted deformity usually resolves withouttreatment). I have heard of 10 instances of thisdeformity over the years. In each instance, theorthodontist was using a protocol of twice-perdayexpansion, a protocol that I do not recommend.It should be noted, of course, that thisclinical recommendation is based purely onanecdotal information and clinical intuition,not hard science.17) You have advocated expanding themaxilla using RME to alleviate moderatecrowding. What is the basis of this approach?This topic has been of great interest to mefor over 3 decades. I received my orthodonticeducation during a time that the extraction ofpermanent teeth was a common occurrence inorthodontics, with a national extraction rate of40% or greater observed during the 1960s and1970s. 36 Since then, the rate of extraction graduallyhas decreased in the United States today toabout 25% nationally. In our practice we extractabout 12-15% of the time in Caucasian patients;however, the extraction rate is substantiallyhigher in patients of Pacific Rim ancestry.In 2003, our research group published apaper in the Angle Orthodontist 37 that dealtwith an analysis of 112 individuals treatedwith a Haas-type expander (Fig 7) combinedwith fixed appliance therapy in the permanentdentition. We found that by using this treatmentprotocol, in comparison to a control samplefrom the University of Michigan Growth Studyand University of Groningen Growth Study, aDental Press J Orthod 40 2011 May-June;16(3):32-53

McNamara JA Jrresidual increase of about 6 mm in maxillaryarch perimeter and about 4.5 mm in mandibulararch perimeter was observed at age 21 years,value that are highly significant clinically. Thesedata are the “best” data that I have seen withregard to increasing arch perimeter expansionin adolescent patients over the long term.Subsequently, we have conducted many studiesof patients treated initially in the early mixeddentition, two of which I will highlight: one thatdealt with the bonded expander used alone 38 andone in which a mandibular Schwarz expansionappliance 39 that is intended to decompensate thelower arch and gain a modest amount of archperimeter anteriorly was used prior to expansion.In general, the difference in arch perimeterin these two studies over the long term (patientswere ~20 years of age) was slightly less than 4mm in the maxilla and 2.5-3.7 mm in mandiblein comparison to matched untreated controlgroups. Our investigations have shown thatin a borderline case of crowding (i.e., 3-5 mmmandibular tooth-size/arch-size discrepancy)these early expansion protocols are reasonableapproaches to treatment. On the other hand, ifa patient has 7-10 mm or more of crowding inthe mandible, an extraction approach (serial orotherwise) may be in order.18) Tell me about serial extraction as usedin your private practice? Do you advocateany particular sequence?In our private practice my daughter and Icurrently have about 800 active patients, about10 of whom are going through a protocol involvingserial extraction. We use the size ofthe teeth as a guide to patient who requiresserial extractions as the appropriate treatment.In a serial extraction protocol, extractions areindicated when there is at least 7 mm of archlength deficiency in the mandible; usually thisprotocol is undertaken in patients who have wellbalanced faces. If a patient has a severe man-FIGURE 7 - The Haas-type rapid maxillary expander that has both metaland acrylic components. 3dibular skeletal retrusion or severe mandibularprognathism, it is not a good idea to use a serialextraction approach.Our studies of the subjects in the Universityof Michigan Growth Study have shown that thesize of the maxillary permanent central incisorin males of European ancestry is about 8.9 mmand in females about 8.7 mm, with a standarddeviation of 0.6 mm for both sexes. 40 So, as aguideline, if we have a patient whose centralincisor is 10 mm or greater in mesiodistal diameter,he or she would be a potential candidatefor a serial extraction protocol. Obviously, theclinician has to take into account the size of allthe teeth as well as the size of the bony bases.But generally a serial extraction protocol isperformed in patients who have large tooth size(maxillary incisor ≥10 mm). In some instances,expansion of the maxilla followed by a serialextraction procedure ultimately is the treatmentof choice.Typically we order the extraction of all fourdeciduous canines, followed 6-12 months laterby all deciduous first molars. This protocolhopefully encourages the first premolars toerupt before the canines, so that they can beDental Press J Orthod 41 2011 May-June;16(3):32-53

Interviewremoved easily, later permitting the caninesto erupt into the available arch space. In ourserial extraction protocol, ultimately four firstpremolars almost always are removed.19) Let’s move on to the treatment of ClassII malocclusion. If you have a choice as tothe optimal timing of Class II intervention,at what stage is the best treatment outcomesachieved?Today, evidence seems to indicate that themost effective time in the maturation sequence ofthe “generic” Class II patient who does not have asevere skeletal problem is during the circumpubertalgrowth period. The maturational stage can bedetermined best by the level of cervical vertebramaturation 41 (CVM) (Fig 8), as observed routinelyin the lateral headfilm. This method originally wasdeveloped by Don Lamparski 42,43 when he was anorthodontic resident at the University of Pittsburgh.This system was not used widely for the next 25years. We discovered a copy of the Lamparskithesis serendipitously in the late 1990s and havebeen refining the CVM method ever since. 41,44,45Dentitional stage, meaning the late mixed or earlypermanent dentition, also can be used to determinethe best time to initiate definitive Class II therapy.So in most such individuals, if it is reasonable wewill defer any type of Class II correction until thecircumpubertal growth period.If a patient has a “socially debilitating” ClassII malocclusion, however, then I would not hesitateto intervene in a 7-9 year old child, eitherwith a functional appliance such as the TwinBlock (Fig 9), the MARA appliance (Fig 10) orperhaps the cantilever version of the Herbst appliance.I would not expect, however, to have anabundant increase in mandibular growth duringthat early developmental stage. Rather, I wouldbe attempting to make the patient socially acceptablefrom a psychological standpoint, hopefullyleading to an improvement in his or heroverall self image.FIGURE 8 - CVM maturational stages. The six stages in cervicalvertebrae maturation. Stage 1 (CS-1): The inferior borders of thebodies of all cervical vertebrae are flat. The superior borders aretapered from posterior to anterior. Stage 2 (CS-2): A concavity developsin the inferior border of the second vertebra. The anteriorvertical height of the bodies increases. Stage 3 (CS-3): A concavitydevelops in the inferior border of the fourth vertebra. One vertebralbody has a wedge or trapezoidal shape. Stage 4 (CS-4): A concavitydevelops in the inferior border of the fourth vertebra. Concavities inthe lower borders of the fifth and sixth vertebrae are beginning toform. The bodies of all cervical vertebrae are rectangular in shape.Stage 5 (CS-5): Concavities are well defined in the lower bordersof the bodies of all six cervical vertebrae. The bodies are nearlysquare and the spaces between the bodies are reduced. Stage 6(CS-6): All concavities have deepened. The vertebral bodies arenow higher than they are wide. The largest amount of mandibularlengthening normally occurs between CS-3 and CS-4. 4120) In your publications over the last 15years, little emphasis has been assignedto the use of the Fränkel devices, in contrastto your earlier studies. What broughtabout this change to favor the use of TwinBlock and Herbst appliances?As I said earlier in the interview, I still considerthe functional appliance system developedby Rolf Fränkel to be the most biologically basedof any fixed or removable appliance. However,the technical manipulation of the appliance andthe difficulties in having the function regulatorFR-2 appliance (Fig 11) constructed properlystill are daunting. In addition, appliance breakageand problems with patient compliance havecaused the FR-2 to not be used often by mostorthodontists in North America.A few years ago, I polled six of the majororthodontic laboratories in the United Statesabout FJO appliance fabrication. The resultswere startling—more Herbst appliances (Fig12) are made today than all other functionalDental Press J Orthod 42 2011 May-June;16(3):32-53

McNamara JA Jrappliances combined. Most popular among theother FJO devices are the Twin Block (Fig 9) andthe MARA (Fig 10) appliance and the bionator.About as many Fränkel appliances are made asbionators, but both are made less frequentlythan are the other appliances already mentioned.FIGURE 9 - The Twin Block appliance 3 shown here is the modifiedversion of the appliance that has a lower labial bow with acrylic toincrease the stability of the appliance during the transition to the permanentdentition.FIGURE 10 - The Mandibular Anterior Repositioning appliance (MARA). 63This appliance has stainless steel crowns on the first permanent molars.The attachments cause the patient to bite in a forward position.FIGURE 11 - The Fränkel Function Regulator FR-2. 3 This appliance ischaracterized by buccal shields that are connected by a series of wires.The lower labial pads are used to retrain the mentalis muscle in patientswith weak perioral musculature.21) For the last 20 or so years, you havetalked about the “spontaneous improvement”in Class II malocclusion followingmaxillary expansion in the mixed dentition.A study from the University of Illinois byTonya Volk et al, 54 published in 2010 in theAJO-DO, concluded that rapid maxillaryexpansion for spontaneous Class II correctiondoes not support “the foot in the shoetheory”. According to this study, improvementin Class II malocclusions occur inabout 50% of cases. What is your positiontoday in respect of the concept that whenthe mandible is free to move forward, positiveconditions are created for the mandibleto grow to its full extent?I have evaluated many treatments availablefor Class II malocclusion for over the last 40years and have participated in the evolution ofmany types of functional appliances includingthe FR-2 of Fränkel as well as the Bionator,Herbst and Twin Block appliances. In addition,my education at the University of California SanFrancisco was strong concerning the use of extraoraltraction. So I have substantial experiencewith different ways of correcting the sagittalposition of the maxillary and mandibular bonybases. I certainly did not anticipate finding thatClass II malocclusion improved spontaneouslyin many patients following expansion. A littlepersonal history is in order.We began using an acrylic splint expanderin 1981 (actually our protocol today remainsessentially unchanged from our early beginnings).We started by expanding the maxilla andplacing four brackets on the maxillary incisors,Dental Press J Orthod 43 2011 May-June;16(3):32-53

InterviewAFIGURE 12 - The Stainless Steel Crown Herbst appliance. 3 This design is used most commonly in our practice. A rapid maxillary expansion appliance always isadded to the design not only to allow for expansion of the maxilla but also to stabilize the appliance. A) Maxillary view. B) Mandibular view.Bif needed, to eliminate rotations and spacing.Treatment was completed and a removablemaintenance plate (Fig 13) was delivered at thestart of the retention period; some remarkablepositive changes were noted post-treatment.Remember that at the end of active treatment,the maxillary dental arch intentionally had beenoverexpanded relative to the mandibular dentalarch. This relationship encouraged the patientto posture his or her jaw forward in order toocclude in the most functionally efficient way.After 6-12 months when follow-up records weretaken, many patients had substantial improvementin their sagittal occlusal relationship. Itshould be noted that discrepancies betweencentric occlusion and centric relation typicallywere not observed in the long-term.Even though I thought that I had uncovereda previously unrecognized phenomenon, I laterdiscovered that the spontaneous improvementin Class II relationship in fact had been noted inthe German literature since the early 1900s byKörbitz, 46 who originally postulated the “footin-shoe”theory 47 mentioned in your question(Fig 14). Even Norman Kingsley, considered bymany the “grandfather” of modern orthodontics,alluded to the expansion of the maxilla as a wayof correcting an excessive overjet as far back at1880. 48 But until recently, no clinical studies hadbeen carried out that addressed the “spontaneousimprovement” issue.In your question, you mentioned the work ofVolk and co-workers on this topic, published in2010. 54 Regardless of the findings of their study,the sample size was unacceptably small (N=13)and no control group was included. The questionunder consideration had to be addressed by amuch larger prospective clinical study (as wasstated in the last sentence of the Volk article),which we completed and just recently published.49 We have gathered prospectively cephalometricand dental cast data on every patientin our practice who underwent an early expansionprotocol, beginning in 1981. We stoppedcounting at 1,135 patients, a group that servedas the original sample. We then applied severalexclusionary rules to make sure that the patientswere at the same stage of dental developmentand did not have any additional appliances used(e.g., FJO, lip bumper). The final sample size(by chance) was precisely 500 patients who hadlateral cephalograms prior to treatment (aboutDental Press J Orthod 44 2011 May-June;16(3):32-53

McNamara JA JrFIGURE 13 - A removable maintenance plate with ball clasps on either sideof the second deciduous molars is used to stabilize the treated occlusion. 3FIGURE 14 - Maxillomandibular relationship as indicated by the “footand shoe” analogy of Körbitz. 46 A) The foot (mandible) is unable to bemoved forward in the shoe (maxilla) due to transverse constriction.B) A wider shoe will allow the foot to assume its normal relationship.After Reichenbach et al. 478.5 years old) and prior to Phase II treatment(about 12.5 years of age). We then gathereddata on 188 untreated subjects at the same twotime intervals. Both the treated and untreatedgroups were separated into a Class II group, anend-to-end group, and a Class I group.The results of our research are most easilyunderstandable by looking at a more detailedanalysis of a subset of individuals 50 that focusedon 50 Class II and end-to-end patients who werematched to 50 untreated subjects. The findingsof the latter study are presented in Figure 15.Positive skeletal and dentoalveolar treatmenteffects of RME were observed routinely; theseeffects are important in the serendipitoussagittal improvement of a Class II malocclusionafter therapy. Forty-six of the 50 patientsshowed positive molar changes equal to orgreater than 1 mm, compared to only 10 of 50in the control group. On the other hand, 40 ofthe control subjects had neutral or unfavorablemolar changes (less than +1 mm) between themixed and permanent dentitions, comparedto only 4 in the treated group. In other words,92% of the treated group spontaneously improvedtheir Class II molar relationship by onemillimeter or more, and almost 50% of treatedpatients presented with improvement in molarrelationship of 2 mm or greater, without anydefinitive Class II mechanics incorporated intothe protocol except for the transpalatal archworn during the transition to the permanentdentition. There also were significant skeletalimprovements from RME treatment includingan increase in mandibular length, pogonion advancement,and a reduction in the ANB angleand the Wits appraisal value three and half yearsafter active expansion therapy was completed.Observations in the control group in thisstudy confirm previously published data onlongitudinal observations of untreated subjectswith Class II malocclusions. 51-53 Arya and coworkers,52 for example, observed that all patientspresenting with a distal-step relationship of thesecond deciduous molars ultimately demonstrateda Class II relationship of the permanentmolars. In the current study, only 20% of thecontrol subjects improved their molar relationshipby 1 mm or 1.5 mm, which indicatesthat once a subject has a Class II malocclusion,without treatment they likely will remain witha Class II malocclusion in subsequent years.Dental Press J Orthod 45 2011 May-June;16(3):32-53

InterviewThe favorable effects of RME therapy on anteroposteriorrelationships occur both in full-cusp ClassII and half-cusp Class II subjects. This expansionprotocol originally was recommended from clinicalanecdotal observations only in half-cusp ClassII subjects; 3 the results of the study by Guest andco-workers 50 indicate that spontaneous improvementof Class II malocclusion occurs equally in bothhalf-cusp and full-cusp Class II relationships. EvenVolk and co-workers 54 found improvement in ClassII relationship in 7 of their 13 subjects.The treatment protocol described above includesa Schwarz appliance (if needed), followed by anacrylic splint expander, and four brackets to align themaxillary incisors (if needed). The patient is given asimple maintenance plate (Fig 13) to maintain theachieved result. The lower arch is not maintainedfollowing the removal of the Schwarz appliance, butthe patient is evaluated for a lower lingual arch (Fig16) prior to the loss of the second deciduous molarsif an arch length deficiency is anticipated. The laststep in the protocol is the delivery of a transpalatalarch — TPA (Fig 17) — to maintain the leeway spaceduring the transition to the permanent dentition.22) Do you believe that the use of TPA inyour sample had an important role for thepositive outcome?Each component of this protocol serves a significantrole in improving the transverse and occlusalrelationships during the transition to the permanentdentition. Obviously the rotation of the uppermolars around the palatal root has a positive effect.23) What happen in those patients in whoman early expansion protocol is undertakenand spontaneous correction of the underlyingTotal molar change161412108642031516Untreated Control GroupRME Treated Group-4 -3 -2 -1 0 1 2 3 4Increments of Molar Change (mm)FIGURE 15 - Spontaneous improvement in Class II molar relationshipfollowing rapid maxillary expansion in the early mixed dentition. Comparisonof amount of molar change from T2 - T1 for both groups. Ascore of “0” means that there was no change (i.e., 0 mm) in sagittalrelationship of the maxillary and mandibular first permanent molarsfrom the first to the second observation, a period of about 4 years.From Guest et al, 2010. 50315109 9131132711FIGURE 16 - The lower lingual arch is used during the late mixed dentitionto maintain the “leeway” space in the region of the erupting secondpremolar. 3 It also can be used during any stage of orthodontic treatmentto help in transverse arch coordination, especially in patients who haveundergone rapid maxillary expansion.FIGURE 17 - The transpalatal arch is used not only to maintain leewayspace, but also to rotate the maxillary first molars around their palatalroots and apply buccal root torque to these teeth. 3Dental Press J Orthod 46 2011 May-June;16(3):32-53

McNamara JA JrClass II molar relationship does not occur?Then what do you do?All patients receive comprehensive edgewisetreatment in the early permanent dentition. If apatient reaches the end of the mixed dentition orthe early permanent dentition and still has a Class IImalocclusion, a decision is made. If the patient hasa reasonable growth potential and the canine relationshipsare within 1-3 mm of Class I, then routinefixed appliance treatment is undertaken includingaggressive Class II elastic (¼”, 6 oz.) use. On theother hand, if the patient still has an end-to-end orworse Class II relationship, a stainless steel crownHerbst appliance (Fig 12) is used if mandibularskeletal retrusion is present. If the anteroposteriorposition of the mandible is within normal limits,then a Pendulum 55,56 (Fig 18) or Pendex (Fig 19)appliance may be recommended. In a few instances,the extraction of 2 maxillary first premolars maybe indicated. In any event, full fixed appliances areused to align the permanent dentition.It seems that the use of a Herbst appliance tobring the mandible forward would be in sharpcontrast to the approach taken by distalizing themaxillary dentition with a Pendex or Pendulumappliance; presumably these seemingly oppositetreatment approaches would result in very differenttreatment outcomes. A study by our groupthat compared the Pendex appliance to 2 types ofHerbst appliances 10 showed that even though theexpected differences in response in mandibulargrowth were noted during Phase I, the overalllength of the mandible was not statistically differentamong groups at the end of treatment; aslightly greater increase in lower anterior facialheight, however, did result after Pendex therapycombined with fixed appliances. Thus the presumeddifferences in treatment approach do notappear to be a great as assumed as before theresults were made available, again showing theimportance of evidence based treatment.24) What are your views on the use of functionalappliances in patients with verticalproblems?Functional appliance therapy in a high angleClass II patient is something I consider. My currenttreatment of choice is the stainless steelcrown Herbst appliance (Fig 12), which I haveused fairly routinely since the early 1990s. 10 Wealso have had good success when using the acrylicsplint variety of the Herbst appliance. 30 I see nosignificant contraindication to using either typeof appliance in a high angle patient.FIGURE 18 - The Pendulum appliance is used to distalize the maxillaryfirst molars, typically one side at a time. 3 This treatment is followed by theplacement of a Nance holding arch that is left in place until the premolarsand canines are distalized.FIGURE 19 - The Pendex appliance incorporates an expansion screwinto the palatal acrylic that is activated as necessary prior to molardistalization. 3Dental Press J Orthod 47 2011 May-June;16(3):32-53

Interview25) Where do we stand when we are askedby parents whether this early treatment approachis going to result in better or morestable results? What is a safe answer to thisquestion?I started using the bonded expander protocol30 years ago, and although we now have treated1,500+ patients with this protocol, accumulatinglong-term data on patients who are 20 years ofage or older is challenging, especially when conductinga non-federally-funded project such asours. The data we have analyzed thus far indicatethat the protocols we have been using are reasonablystable in comparison to untreated controls.I would tell patients and parents that existingresearch indicates that the treatment protocolsseem to provide a stable result over the long-termas long as the patient wears the retainers at leaston a part-time basis after active treatment. Werecommend full-time wear of retainers for oneyear and then nighttime wear indefinitely, a protocolthat is prudent to use in all patients treatedorthodontically for any type of malocclusion.26) How do you look at the changes orthodonticshas gone through in the last 10years, such as the use of TADs, self-ligatingbrackets, SureSmile archwires, lingual bracketsand aligners (Invisalign and others)? Inthe next decade, what can we expect interms of new technologies in orthodontics?You certainly are correct with regard to theinfluence of technology on clinical practice, notonly how we practice but also how patients usesocial and business media to determine whichorthodontist to see. I am sure that this phenomenonis just as obvious in Brazil as it is in theUnited States.You have asked about some specific technologiesthat have emerged during the last decade orso, the first being microimplants or TADs. Myfirst exposure to TADs was in about ten yearsago when we interacted with Drs. Kyung, Sungand Park of Kyungpook National University inDaegu, Korea. In fact, I am the last author of atextbook on this subject published by the Daegugroup. 57 Microimplants have been shown to offernew treatment options in orthodontics, particularin patients requiring maximum anchorage duringtooth retraction and in managing problems in thevertical dimension. My own success rate with microimplantsin our practice and at the universityhas been mixed, with the biggest problem beingthe loosening of the TADs during treatment forno apparent reason. With increased experience, Iassume that our success rate will improve.The second subject to be considered concernsself-ligating brackets. I entered this experiencewith great expectations, having learned the methoddirectly from the developer of the particularsystem that I used. I then started 20 consecutivecases with the prescribed self-ligating brackets.Treatment progressed nicely at first with goodinitial leveling and aligning, but by the end I hadswitch 11 of the patients back to my originalpreadjusted bracket system. I could not finishthe cases to my usual standards. I have triedother self-ligating bracket systems since then,but I still prefer a more traditional approach tostraightening teeth.I will group the next two topics together,SureSmile archwires and lingual brackets. I havenot used either in our private practice, so I haveno experience and thus no opinions on either. Wenow are conducting a clinical study comparingpatients treated with the SureSmile approach toconventional treatment. In a year or two, we willhave some good data as to the efficiency and effectivenessof the SureSmile approach.One topic that I do know a lot about is invisibleretainers. When I went into practice in AnnArbor in 1971, I rented space for orthodontistJohn Mortell. He was a friend and colleagueof Robert Ponitz, who practiced orthodonticsthree blocks away. Bob Ponitz published thefirst paper in the orthodontic literature 58 onDental Press J Orthod 48 2011 May-June;16(3):32-53

McNamara JA Jrinvisible retainers. I literally have used invisiblesfor 40 years. In 1985, we published a paper inthe Journal of Clinical Orthodontics on how touse invisibles to move teeth. 59 I of course did notenvision the CAD CAM revolution that wouldoccur a decade later. We use invisible retainersfor 97% of our patients as our primary retentionmethod following the use of a tooth positionerin the vast majority of patients. I am not a fanof Hawley retainers in that Hawleys do notmaintain the position of the anterior teeth verywell, particularly the lateral incisors.As far as Invisalign is concerned, this approachhas been incorporated into our practice on a limitedbasis, so we have treated about 175 patientsthus far. My daughter Laurie usually tells patientsthat Invisalign can achieve about 80% of what canbe achieved with fixed appliances. We limit ourInvisalign cases primarily to those that could betreated with fixed appliances in a year or so andhave only minor skeletal discrepancies. For manyadult patients, Invisalign is their only acceptableoption and thus our treatment expectations mustbe limited by reality.27) In that you have brought up the topic ofretention, let’s finish the interview with yougiving us a description of your finishing andretention protocol.One of the basic principles espoused by StephenCovey in his popular book “The Seven Habitsof Highly Effective People” 60 is to “start with theend in mind.” Thus we place brackets and activatethe transpalatal arch with the end of treatment inmind. After 6-12 months, a panoramic film is takento evaluate bracket position; we reposition bracketsas necessary. We typically move from an initialleveling wire (.014” or .016” NiTi or .016x.022”copper NiTi) to a .016x.022” Bioforce NiTi wireand finish in a .016x.022” TMA wire.A few months before the end of treatment,we take what are called “debond evaluationmodels” to evaluate the occlusion in all threedimensions. If additional treatment is indicated,this is completed and the same models are sentto a commercial laboratory for the fabrication ofa positioner that is delivered as soon as the appliancesare removed.A week before debonding, all bands are removedincluding those that are part of the TPA(if still present). The archwires also are removedand the patient has .008” ligature wire placed ina serpentine configuration from second premolarto second premolar on the opposite side of thearch (Fig 20). The patient is instructed to chewgum for a week prior to appliance removal. Onthat day, all remaining appliances are removedand the patient is given the positioner (Fig 21),with instructions to wear it full-time for the next24 hours, as much as possible during the next 3-4days and then 4 hours a day plus sleeping hoursfor the next few weeks. At the next appointment,post-treatment records are taken as are impressionsfor invisible retainers (Fig 22). Up to onetooth per quadrant can be reset before the invisibleretainers are fabricated.I would like to make one final commentabout our finishing and retention protocol. Mostorthodontists finish treatment with fixed appliancesand then give Hawley retainers to allow“settling” of the occlusion. We have found thatour more complex protocol produces outstandingresults, as has been substantiated by the findingsof a prospective clinical trial conducted in ourpractice. 61 The positioner improves the qualityof the finished result substantially.28) You have covered a wide range of topicsin this interview. If our readers want additionalinformation concerning the treatmentprotocols that you recommend, where canthey find that information?I suggest that they go online at www.needhampress.comand find our book “Orthodontics andDentofacial Orthopedics” 3 and well as the booksfrom the Craniofacial Growth Series published byDental Press J Orthod 49 2011 May-June;16(3):32-53

InterviewFIGURE 20 - Serpentine wires are placed from second premolar to secondpremolar in both arches after all bands have been removed. 3 Inextraction patients, bands adjacent to extraction sites are left in place.FIGURE 21 - A tooth positioner is fabricated from the debond evaluationmodels. The teeth are reset ideally after all the brackets and bands havebeen carved away. The occlusal set-up is ideal. 3AFIGURE 22 - Maxillary and mandibular invisible retainers 3 1 mm in thickness are used as the preferred method of long-term retention in most instances. Up toone tooth per quadrant can be reset in wax prior to the fabrication of the retainers.Bthe University of Michigan. The reader also cango to Google and search for “James McNamaraMichigan.” That search will take them directly tomy webpage on our dental school website. If thereader then looks under “Selected Publications,”PDF files of almost all of our publications can bedownloaded without charge.Also, I want to recognize again my two colleaguesfrom the University of Florence, Italy,Lorenzo Franchi and Tiziano Baccetti, who haveworked with me since 1994. Our collaborationtogether and with other researchers throughoutthe world has enabled all of us to gain uniqueperspective as to how the face grows and how thecraniofacial structures respond to treatment. Ourresearch definitely has been a group effort.Finally, I would like to thank you for the invitationto be interviewed. Over the years, I have hada close relationship with many Brazilian orthodontistsand have lectured in Brazil many times,including a delightful experience sponsored byDental Press in Maringá a few years ago (2007).Just this past fall, we hosted a one-week intensivecourse for Brazilian orthodontists in AnnArbor, the third time that we have done so overthe years. We are planning another one-weekorthodontic experience again through the Universityof Michigan in 2012.Dental Press J Orthod 50 2011 May-June;16(3):32-53

McNamara JA JrReferEncEs1. McNamara JA Jr. Neuromuscular and skeletal adaptationsto altered orofacial function. Ann Arbor: Monograph 1,Craniofacial Growth Series, Center for Human Growth andDevelopment, The University of Michigan; 1972.2. McNamara JA Jr. Neuromuscular and skeletal adaptationsto altered function in the orofacial region. Am J Orthod.1973;64:578-606.3. McNamara JA Jr, Brudon WL. Orthodontics and dentofacialorthopedics. Ann Arbor: Needham Press; 2001.4. McNamara JA Jr. Maxillary transverse deficiency. Am JOrthod Dentofacial Orthop. 2000;117:567-70.5. Petrovic A, Stutzmann J, Gasson N. The final length of themandible: is it genetically determined? In: Carlson DS,editor. Craniofacial Biology. Ann Arbor: Monograph 10,Craniofacial Growth Series, Center for Human Growth andDevelopment, The University of Michigan; 1981.6. McNamara JA Jr, Bryan FA. Long-term mandibularadaptations to protrusive function: an experimental studyin Macaca mulatta. Am J Orthod Dentofacial Orthop.1987;92:98-108.7. McNamara JA Jr, Bookstein FL, Shaughnessy TG. Skeletaland dental changes following functional regulator therapyon Class II patients. Am J Orthod. 1985;88:91-110.8. McNamara JA Jr, Howe RP, Dischinger TG. A comparisonof the Herbst and Fränkel appliances in the treatment ofClass II malocclusion. Am J Orthod Dentofacial Orthop.1990;98:134-44.9. Toth LR, McNamara JA Jr. Treatment effects produced bythe twin block appliance and the FR-2 appliance of Frankelcompared to an untreated Class II sample. Am J OrthodDentofacial Orthop. 1999;116:597-609.10. Burkhardt DR, McNamara JA Jr, Baccetti T. Maxillary molardistalization or mandibular enhancement: a cephalometriccomparison of the Pendulum and Herbst appliances. Am JOrthod Dentofacial Orthop. 2003;123:108-16.11. Pancherz H. The Herbst appliance. Seville: EditorialAguiram; 1995.12. Lai M, McNamara JA Jr. An evaluation of two-phasetreatment with the Herbst appliance and preadjustededgewise therapy. Semin Orthod. 1998;4:46-58.13. Freeman DC, McNamara JA Jr, Baccetti T, Franchi L. Longtermtreatment effects of the FR-2 appliance of Fränkel. AmJ Orthod Dentofacial Orthop. 2008;133:513-24.14. Pancherz H. Personal communication; 2001.15. Pancherz H. Treatment of Class II malocclusions by jumpingthe bite with the Herbst appliance. A cephalometricinvestigation. Am J Orthod. 1979;76:423-42.16. Schaefer AT, McNamara JA Jr, Franchi L, Baccetti T. Acephalometric comparison of two-phase treatment withthe Twin Block and stainless steel crown Herbst appliancesfollowed by fixed appliance therapy. Am J OrthodDentofacial Orthop. 2004;126:7-15.17. Sugawara J, Asano T, Endo N, Mitani H. Long-term effectsof chincap therapy on skeletal profile in mandibularprognathism. Am J Orthod Dentofacial Orthop.1990;98:127-33.18. Mitani H, Sato K, Sugawara J. Growth of mandibularprognathism after pubertal growth peak. Am J OrthodDentofacial Orthop. 1993;104:330-6.19. Kloehn SJ. Orthodontics: force or persuasion. Angle Orthod.1953;23:56-65.20. McNamara JA Jr. Components of Class II malocclusion inchildren 8-10 years of age. Angle Orthod. 1981;51:177-202.21. Ellis E 3 rd , McNamara JA Jr, Lawrence TM. Components ofadult Class II open-bite malocclusion. J Oral Maxillofac Surg.1985;43:92-105.22. Turley PK. Orthopedic correction of Class III malocclusionwith palatal expansion and custom protraction headgear.J Clin Orthod. 1988;22:314-25.23. McGill JS, McNamara JA Jr. Treatment and post-treatmenteffects of rapid maxillary expansion and facial mask therapy.In: McNamara JA Jr, editor. Growth modification: whatworks, what doesn’t and why. Ann Arbor: Monograph 36,Craniofacial Growth Series, Center for Human Growth andDevelopment, University of Michigan; 1999.24. McNamara JA Jr. Implants, microimplants, onplants andtransplants: New answers to old questions in orthodontics.Ann Arbor: Monograph 44, Craniofacial Growth Series,Department of Orthodontics and Pediatric Dentistry andCenter for Human Growth and Development, The Universityof Michigan; 2005.25. De Clerck HJ, Cornelis MA, Cevidanes LH, HeymannGC, Tulloch CJ. Orthopedic traction of the maxilla withminiplates: a new perspective for treatment of midfacedeficiency. J Oral Maxillofac Surg. 2009;67:2123-9.26. Cevidanes L, Baccetti T, Franchi L, McNamara JA Jr,De Clerck HJ. Comparison of 2 protocols for maxillaryprotraction: bone anchors and face mask with rapid maxillaryexpansion. Angle Orthod. in press 2010.27. Clark WJ. Twin block functional therapy. London: Mosby-Wolfe; 1995.28. Schulz SO, McNamara JA Jr, Baccetti T, Franchi L.Treatment effects of bonded RME and vertical pull chincup followed by fixed appliances in patients with increasedvertical dimension. Am J Orthod Dentofacial Orthop.2005;128:326-36.29. McNamara JA Jr. An orthopedic approach to the treatmentof Class III malocclusion in young patients. J Clin Orthod.1987;21:598-608.30. Fränkel R, Fränkel C. Orofacial orthopedics with the functionregulator. Munich: Karger; 1989.31. McNamara JA Jr, Huge SA. The functional regulator (FR-3) ofFränkel. Am J Orthod. 1985;88:409-24.32. Baik HS. Clinical results of the maxillary protractionin Korean children. Am J Orthod Dentofacial Orthop.1995;108:583-92.33. Petit HP. Adaptation following accelerated facial masktherapy. In: McNamara JA Jr, Ribbens KA, Howe RP,editors. Clinical alterations of the growing face. AnnArbor: Monograph 14, Craniofacial Growth Series, Centerfor Human Growth and Development, The University ofMichigan; 1983.34. Hicks EP. Slow maxillary expansion. A clinical study of theskeletal versus dental response to low-magnitude force. AmJ Orthod. 1978;73:121-41.35. Haas AJ. Rapid expansion of the maxillary dental archand nasal cavity by opening the mid-palatal suture. AngleOrthod. 1961;31:73-90.36. Proffit WR. Forty-year review of extraction frequencies at auniversity orthodontic clinic. Angle Orthod. 1994;64:407-14.37. McNamara JA Jr, Baccetti T, Franchi L, Herberger TA.Rapid maxillary expansion followed by fixed appliances: along-term evaluation of changes in arch dimensions. AngleOrthod. 2003;73:344-53.38. Geran RG, McNamara JA Jr, Baccetti T, Franchi L, ShapiroLM. A prospective long-term study on the effects of rapidmaxillary expansion in the early mixed dentition. Am JOrthod Dentofacial Orthop. 2006;129:631-40.39. O’Grady PW, McNamara JA Jr, Baccetti T, Franchi L.A long-term evaluation of the mandibular Schwarzappliance and the acrylic splint expander in early mixeddentition patients. Am J Orthod Dentofacial Orthop.2006;130:202-13.40. Moyers RE, van der Linden FPGM, Riolo ML, McNamaraJA Jr. Standards of human occlusal development. AnnArbor: Monograph 5, Craniofacial Growth Series, Centerfor Human Growth and Development, The University ofMichigan; 1976.Dental Press J Orthod 51 2011 May-June;16(3):32-53

Interview41. Baccetti T, Franchi L, McNamara JA Jr. The CervicalVertebral Maturation (CVM) method for the assessment ofoptimal treatment timing in dentofacial orthopedics. SeminOrthod. 2005;11:119-29.42. Lamparski DG. Skeletal age assessment utilizing cervicalvertebrae. Pittsburgh: Unpublished Master’s thesis, Departmentof Orthodontics, The University of Pittsburgh; 1972.43. Lamparski DG, Nanda SK. Skeletal age assessment utilizingcervical vertebrae. In: McNamara JA Jr, Kelly KA, editors.Treatment timing: Orthodontics in four dimensions.Ann Arbor: Monograph 39, Craniofacial Growth Series,Department of Orthodontics and Pediatric Dentistry andCenter for Human Growth and Development, The Universityof Michigan; 2002.44. Franchi L, Baccetti T, McNamara JA Jr. Mandibular growth asrelated to cervical vertebral maturation and body height. AmJ Orthod Dentofacial Orthop. 2000;118:335-40.45. Baccetti T, Franchi L, McNamara JA Jr. An improvedversion of the cervical vertebral maturation (CVM) methodfor the assessment of mandibular growth. Angle Orthod.2002;72:316-23.46. Körbitz A. Kursus der systematischen Orthodontik. EinLeitfaden für Studium und Praxis. 2 nd ed. Leipzig: Hans Licht;1914.47. Reichenbach E, Brückl H, Taatz H. KieferorthopaedischeKlinik und Therapie, 6er aufl. Leipzig: Johan AmbrosiusBarth; 1967.48. Kingsley NW. A treatise on oral deformities as a branch ofmechanical surgery. New York: D. Appleton; 1880.49. McNamara JA Jr, Sigler LM, Franchi L, Guest SS, Baccetti T.Changes in occlusal relationship in mixed dentition patientstreated with rapid maxillary expansion: a prospective clinicalstudy. Angle Orthod. 2010;80:230-8.50. Guest SS, McNamara JA Jr, Baccetti T, Franchi L. ImprovingClass II malocclusion as a side-effect of rapid maxillaryexpansion: a prospective clinical study. Am J OrthodDentofacial Orthop. 2010;138(5):582-91.51. Baccetti T, Franchi L, McNamara JA Jr, Tollaro I. Earlydentofacial features of Class II malocclusion: a longitudinalstudy from the deciduous through the mixed dentition. Am JOrthod Dentofacial Orthop. 1997;111:502-9.52. Arya BS, Savara BS, Thomas DR. Prediction of first molarocclusion. Am J Orthod. 1973;63:610-21.53. Bishara SE, Hoppens BJ, Jakobsen JR, Kohout FJ. Changesin the molar relationship between the deciduous andpermanent dentitions: a longitudinal study. Am J OrthodDentofacial Orthop. 1988;93:19-28.54. Volk T, Sadowsky C, BeGole EA, Boice P. Rapid palatalexpansion for spontaneous Class II correction. Am J OrthodDentofacial Orthop. 2010;137:310-5.55. Hilgers JJ. The pendulum appliance for Class II noncompliancetherapy. J Clin Orthod. 1992;26:706-14.56. Hilgers JJ. The pendulum appliance: An update. ClinImpressions. 1993:15-17.57. Sung JH, Kyung HM, Bae SM, Park HS, Kwon OW,McNamara JA Jr. Microimplants in orthodontics. Daegu:Dentos; 2006.58. Ponitz RJ. Invisible retainers. Am J Orthod. 1971;59:266-72.59. McNamara JA, Kramer KL, Jeunker JP. Invisible retainers. JClin Orthod. 1985;19:570-8.60. Covey SR. The seven habits of highly effective people. NewYork: Simon and Schuster; 1989.61. Stock GM, McNamara JA Jr, Baccetti T. The efficacy of twofinishing protocols in the quality of orthodontic treatmentoutcome. Am J Orthod Dentofacial Orthop. in press.62. Fränkel R. Maxillary retrusion in Class III and treatmentwith the function corrector III. Rep Congr Eur Orthod Soc.1970:249-59.63. Berkman ME, Haerian A, McNamara JA Jr. Interarchmaxillary molar distalization appliances for Class IIcorrection: an overview. J Clin Orthod. 2008;42:35-42.Dental Press J Orthod 52 2011 May-June;16(3):32-53

McNamara JA JrBernardo Quiroga Souki- Specialist in Pediatric Dentistry, School of Dentistry ofRibeirão Preto - USP.- Specialist in Orthodontics, PUC Minas.- mSc in Pediatric Dentistry, UFmg.- PhD in Health Sciences (UFmg).- associate Professor III, Masters Course in Orthodontics atPUC Minas.José Maurício de Barros Vieira- Specialist and MSc in Orthodontics, PUC Minas.- associate Professor III, Masters Course in Orthodontics atPUC Minas.- Graduate, Brazilian Board of Orthodontics and DentofacialOrthopedics - BBO.- Former President of ABOR-mg.Carlos Alexandre Camara- Specialist in Orthodontics, State University of Rio deJaneiro - UERJ.- graduate, Brazilian Board of Orthodontics and DentofacialOrthopedics - BBO.- Editorial reviewer of the Revista Dental Press de Estética.Carlos Jorge Vogel- Postgraduate in Orthodontics, University of Illinois,Chicago, USA.- PhD in Orthodontics, University of São Paulo - USP.- member of the Edward H. Angle Society of OrthodontistsMidwest.- graduate, Brazilian Board of Orthodontics and DentofacialOrthopedics - BBO.- Former President of the Brazilian Board of Orthodonticsand Dentofacial Orthopedics - BBO.Roberto Mario Amaral Lima Filho- Post-graduate degree in Orthodontics, University ofIllinois, Chicago, USA.- mSc and PhD in Orthodontics, Federal University of Riode Janeiro - UFRJ.- graduate, American Board of Orthodontics - ABO.- member of the Edward H. Angle Society of Orthodontists,Midwest.- Former President of the Brazilian Board of Orthodonticsand Facial - BBO.- Editor of the book “Ortodontia: Arte e Ciência.”Weber Ursi- mSc and PhD in Orthodontics, University of São Paulo -USP, Bauru.- Professor at UNESP - São José dos Campos.- Coordinator of the Specialization Course in Orthodontics -APCD - São José dos Campos.- Interim Editor - Revista Clínica de Ortodontia DentalPress.Contact addressJames A. McNamara Jr.mcnamara@umich.eduDental Press J Orthod 53 2011 May-June;16(3):32-53

O n l i n e A r t i c l e *Imaging from temporomandibular jointduring orthodontic treatment: a systematicreviewEduardo Machado**, Renésio Armindo Grehs***, Paulo Afonso Cunali****AbstractIntroduction: The evolution of imaging in dentistry has provided several advantages for thediagnosis and development of treatment plans in various dental specialties. Examinations asnuclear magnetic resonance, computed tomography and cone beam volumetric tomography,as well as 3D reconstruction methods, have enabled a precise analysis of orofacial structures.Allied to this fact, the effects of orthodontic treatment on temporomandibular joint (TMJ)could be evaluated with the accomplishment of clinical studies with appropriate designs andmethodologies. Objective: This study, a systematic literature review, had the objective ofanalyzing the interrelation between orthodontic treatment and TMJ, verifying if orthodontictreatment causes changes in the internal structures of TMJ. Methods: Survey in research basesMEDLINE, Cochrane, EMBASE, Pubmed, Lilacs and BBO, between the years of 1966 and2009, with focus in randomized clinical trials, longitudinal prospective nonrandomized studies,systematic reviews and meta-analysis. Results: After application of the inclusion criteria14 articles were selected, 2 were randomized clinical trials and 12 longitudinal nonrandomizedstudies. Conclusions: According to the literature analysis, the data concludes that orthodontictreatment does not occur at the expense of unphysiological disc-condyle position.Some orthodontic mechanics may cause remodeling of articular bone components.Keywords: Temporomandibular joint. Temporomandibular joint dysfunction syndrome. Temporomandibularjoint disorders. Orthodontics. Magnetic resonance imaging. Tomography.How to cite this article: Machado E, Grehs RA, Cunali PA. Imaging from temporomandibular joint during orthodontic treatment: a systematicreview. Dental Press J Orthod. 2011 May-June;16(3):54-6.* Access www.dentalpress.com.br/revistas to read the full article.** Specialist in TMD and Orofacial Pain, UFPR. Graduate in Dentistry, UFSM.*** PhD in Orthodontics and Dentofacial Orthopedics, UNESP/Araraquara – SP. Professor of Graduate and Post-graduate Dentistry course, UFSM.**** PhD in Sciences, UNIFESP. Professor of Graduate and Post-graduate Dentistry course, UFPR. Head of the Specialization Course in TMD andOrofacial Pain, UFPR.Dental Press J Orthod 54 2011 May-June;16(3):54-6

Machado E, Grehs RA, Cunali PAEditor’s summaryThe effects of orthodontic treatment ontemporomandibular joint (TMJ) is the subjectof doubts and discussions until the current days.Many of those doubts persist because of the useof conventional radiographs which have limitations.With the advent of imaging examinationswith specificity, sensitivity and greater accuracyin the reproduction of joint anatomicalstructures, such as nuclear magnetic resonance(NMR), computed tomography (CT) and conebeam volumetric tomography (CBVT) as wellas methods of 3D reconstruction, this interrelationshipcan be assessed with greater accuracy.The authors’ proposal for this article wasto analyze within a context of an evidencebaseddentistry, which implications orthodonticshave on the TMJ and specifically to checkchanges in condylar and articular disc position,as well as joint morphological changes, that occurdue to orthodontic treatment.Thus the search was performed in MED-LINE, Cochrane, EMBASE, PubMed, Lilacsand BBO in the period from 1966 to February2009. Inclusion criteria for selecting articleswere: studies based on images from NMR, CTand/or CBVT that evaluated the effects of orthodontictreatment in TMJ; randomized clinicaltrials (RCTs), non-randomized prospective longitudinalstudies, systematic reviews and metaanalysis;studies in which orthodontic treatmentwas already concluded in the samples; studieswritten in English and Spanish.After applying the inclusion criteria 14studies were obtained, 2 randomized clinicaltrials and 12 longitudinal studies without randomizationcriteria. Among the selected studies,11 were based on magnetic resonance imagingand 3 in computed tomography imaging.The authors conclude, with this systematicreview, that orthodontics when correctly performeddoes not cause adverse effects to theTMJ. Yet, the application of forces during certainorthodontic mechanics, especially orthopedicsituations, can cause alterations in condylargrowth and in bone structures of the TMJ.The authors end the paper noting that furtherrandomized clinical trials are necessary,with longitudinal and interventional nature,for the determination of more precise causalassociations, within a context of a scientificevidence-based dentistry.Dental Press J Orthod 55 2011 May-June;16(3):54-6

Imaging from temporomandibular joint during orthodontic treatment: a systematic reviewQuestions to the authors1) The fact that most papers have used orthopedicappliances makes us think that thiskind of treatment has been performed ingrowing patients. Therefore I ask: in adultpatients the results would be the same?Studies involving adult patients in whomfollow-up with imaging examinations wereperformed also found that the correct occlusalrelationship after orthodontic treatment wasnot obtained at the expense of changes in thecondyle-articular disc complex. The findings ofclinical studies should be added to these results,based on imaging examinations, which have alsoprovided evidences that orthodontics is not aform of development, prevention and treatmentfor temporomandibular disorders (TMD).2) In the discussion you mention that in somecases of TMD, an improvement can be obtainedas a result of orthodontic treatment.What is the reason of this improvement?It is important to be noted that the findingsof these studies are only suggestive, since theprimary objective of the studies was not to evaluateorthodontics as possible therapy for TMD.Still, it is necessary to emphasize that the scientificevidences indicate that orthodontic treatmentdoes not consist in a form of preventionor treatment for signs and symptoms of TMD.In TMD patients, the treatment option is basedon conservative, minimally invasive and reversibletherapeutics.3) What are the major difficulties in conductinga randomized controlled clinical trialevaluating the interrelationship betweenTMD and orthodontic treatment?It is a consensus that treatment protocols fortemporomandibular disorders should be guidedby conservative, minimally invasive and reversibletherapeutics. Thus, the accomplishmentof randomized clinical trials shows ethical andpractical limitations, since some participantswould not receive a beneficial treatment, aswell as some situations would not be investigatedwith this methodology. Thus, therapies thatchange irreversibly the occlusal pattern, such asorthodontics, would provide the patient a treatmentthat has no scientific basis to support itand change occlusion irreversibly, consideringthat available conservative treatments are effectivefor the control and treatment of TMD.Submitted: February 2009Revised and accepted: May 2010Contact addressEduardo MachadoRua Francisco Trevisan 20, Nossa Sra. de LourdesCEP: 97.050-230 - Santa Maria / RS, BrazilE-mail: machado.rs@bol.com.brDental Press J Orthod 56 2011 May-June;16(3):54-6

O n l i n e A r t i c l e *Cytotoxicity of electric spot welding:an in vitro studyRogério Lacerda dos Santos**, Matheus Melo Pithon***, Leonard Euler A. G. Nascimento****,Fernanda Otaviano Martins*****, Maria Teresa Villela Romanos******, Matilde da Cunha G. Nojima*******,Lincoln Issamu Nojima*******, Antônio Carlos de Oliveira Ruellas*******AbstractObjective: The welding process involves metal ions capable of causing cell lysis. In viewof this fact, the aim of this study was to test the hypothesis that cytotoxicity is present indifferent types of alloys (CrNi, TMA, NiTi) commonly used in orthodontic practice whenthese alloys are subjected to electric spot welding. Methods: Three types of alloys wereevaluated in this study. Thirty-six test specimens were fabricated, 6 for each wire combination,and divided into 6 groups: Group SS (stainless steel), Group ST (steel with TMA),Group SN (steel with NiTi), Group TT (TMA with TMA), Group TN group (TMA withNiTi) and Group NN (NiTi with NiTi). All groups were subjected to spot welding andassessed in terms of their potential cytotoxicity to oral tissues. The specimens were firstcleaned with isopropyl alcohol and sterilized with ultraviolet light (UV). A cytotoxicityassay was performed using cultured cells (strain L929, mouse fibroblast cells), which weretested for viable cells in neutral red dye-uptake over 24 hours. Analysis of variance andmultiple comparison (ANOVA), as well as Tukey test were employed (p0.05). Cell viability was higher in the TT group, followed by groups ST, TN, SS, NSand NN. Conclusions: It became evident that the welding of NiTi alloy wires caused agreater amount of cell lysis. Electric spot welding was found to cause little cell lysis.Keywords: Toxicity. Cell culture techniques. Welding in dentistry.How to cite this article: Santos RL, Pithon MM, Nascimento LEAG, Martins FO, Romanos MTV, Nojima MCG, Nojima LI, Ruellas ACO. Cytotoxicityof electric spot welding: an in vitro study. Dental Press J Orthod. 2011 May-June;16(3):57-9.* Access www.dentalpress.com.br/revistas to read the full article.** Specialist in Orthodontics, Federal University of Alfenas - UNIFAL. Master and Doctor in Orthodontics, Federal University of Rio de Janeiro -UFRJ. Adjunct Professor of Orthodontics, Federal University of Campina Grande - UFCG.*** Specialist in Orthodontics, Federal University of Alfenas - UNIFAL. Master and Doctor in Orthodontics, Federal University of Rio de Janeiro -UFRJ. Assistant Professor of Orthodontics, State University of Southwestern of Bahia - UESB.**** Doctored Student in Orthodontics, Federal University of Rio de Janeiro - UFRJ.***** Graduated in Microbiology and Immunology, Federal University of Rio de Janeiro. Trainee of the Microbiology Institute of Prof. Paulo de Góes- UFRJ.****** PhD in Sciences (Microbiology and Immunology) by the Federal University of Rio de Janeiro - UFRJ. Adjunct Professor, Federal University of Riode Janeiro - UFRJ.******* MSc and PhD in Orthodontics, Federal University of Rio de Janeiro - UFRJ. Adjunct Professor of Orthodontics, Federal University of Rio deJaneiro - UFRJ.Dental Press J Orthod 57 2011 May-June;16(3):57-9

Cytotoxicity of electric spot welding: an in vitro studyEditor’s summarySome studies have shown that silver solder,although widely used in orthodontics, hassome cytotoxic potential. In view of this fact,clinicians turn to spot welding as the methodof choice for bonding orthodontic wires andaccessories to achieve the desired orthodonticmechanics. Thus, the purpose of this study wasto assess the cytotoxic potential of spot weldinginvolving stainless steel, nickel-titanium (NiTi)and titanium-molybdenum (TMA) wires. Usingrectangular 0.019x0.025-in wires welded togetherby means of an electric spot welder, sixspecimens were prepared for each of the followinggroups: SS (steel/steel), ST (steel/TMA), SN(steel/NiTi), TT (TMA/TMA), TN (TMA/NiTi)and NN (NiTi/NiTi). Copper amalgam was usedas positive control, glass as negative control andfor cell control, cells not previously exposed toany material. As negative control for each materialcylinders made from stainless steel, nickeltitaniumand TMA were utilized. After sterilizationwith ultraviolet light, the specimenswere exposed for 24 h to a culture medium ofL929 cells, i.e., mouse fibroblasts. Cytotoxicitywas evaluated by the neutral red dye-uptakeassay for viable cells. Data were subjected toANOVA followed by Tukey’s multiple comparisontest (p

Santos RL, Pithon MM, Nascimento LEAG, Martins FO, Romanos MTV, Nojima MCG, Nojima LI, Ruellas ACOlowest cell viability, but within acceptable limits,i.e., above 80%. Arguably, only those orthodonticmaterials with less than 50% viabilityshould be withdrawn from clinical use. Nickel’snotorious allergenic potential may be relatedto the lower viability found in this group. ForDavid and Lobner, 1 and Eliades et al 2 there isclear evidence of a direct relationship betweencytotoxicity and nickel but findings by Sestiniet al 3 showed that nickel and chromium causeda decrease in cell activity. Nickel’s role in theprocess of carcinogenesis still defies clarification,but these materials appear not to have asignificant heightening effect in the process,which depends on the duration and amount ofmaterial in contact with oral cavity cells.3) Given the results of your investigation,do you regard spot welding as a biologicallysafe orthodontic procedure?Electric spot welding has proven to be a practical,fast procedure and current machines haveshown great effectiveness, which is also crucial.After undergoing spot welding, orthodonticwires appear cleaner and aesthetically pleasant,which attests to a decreased release of cytotoxicions while facilitating polishing when necessary.Besides, there is certainly a direct relationshipbetween the release of these ions and the resultsachieved in this study. One essential conditionfor the use of metallic materials in the oral environmentis that these materials resist the corrosiveaction of saliva, as well as variations in pHand temperature. As an orthodontic material, silversolder is particularly susceptible to corrosion.Furthermore, the use of this solder for bondingorthodontic wires has been shown to cause therelease of cytotoxic metallic ions, in part becausesilver solder polishing is usually inadequate,which facilitates the release of these ions. Therefore,spot welding has been used as a feasible andsafe alternative in orthodontics.ReferEncEs1. David A, Lobner D. In vitro cytotoxicity of orthodonticarchwires in cortical cell cultures. Eur J Orthod. 2004Aug;26(4):421-6.2. Eliades T, Pratsinis H, Kletsas D, Eliades G, Makou M.Characterization and cytotoxicity of ions released fromstainless steel and nickel-titanium orthodontic alloys. Am JOrthod Dentofacial Orthop. 2004 Jan;125(1):24-9.3. Sestini S, Notarantonio L, Cerboni B, Alessandrini C,Fimiani M, Nannelli P, et al. In vitro toxicity evaluation ofsilver soldering, electrical resistance, and laser welding oforthodontic wires. Eur J Orthod. 2006 Dec;28(6):567-72.Submitted: February 2009Revised and accepted: October 2009Contact addressAntônio Carlos de Oliveira RuellasAv. Professor Rodolpho Paulo Rocco, 325 - Ilha do FundãoCEP: 21.941-617 - Rio de Janeiro / RJ, BrazilE-mail: antonioruellas@yahoo.com.brDental Press J Orthod 59 2011 May-June;16(3):57-9

O n l i n e A r t i c l e *In vitro study of shear bondstrength in direct bonding of orthodonticmolar tubesCélia Regina Maio Pinzan Vercelino**, Arnaldo Pinzan***, Júlio de Araújo Gurgel****,Fausto Silva Bramante*****, Luciana Maio Pinzan******AbstractObjective: Although direct bonding takes up less clinical time and ensures increasedpreservation of gingival health, the banding of molar teeth is still widespread nowadays.It would therefore be convenient to devise methods capable of increasing the efficiencyof this procedure, notably for teeth subjected to substantial masticatory impact, such asmolars. This study was conducted with the purpose of evaluating whether direct bondingwould benefit from the application of an additional layer of resin to the occlusal surfacesof the tube/tooth interface. Methods: A sample of 40 mandibular third molars was selectedand randomly divided into two groups: Group 1 - Conventional direct bonding,followed by the application of a layer of resin to the occlusal surfaces of the tube/toothinterface, and Group 2 - Conventional direct bonding. Shear bond strength was tested 24hours after bonding with the aid of a universal testing machine operating at a speed of0.5mm/min. The results were analyzed using the independent t-test. Results: The shearbond strength tests yielded the following mean values: 17.08 MPa for Group 1 and 12.60MPa for Group 2. Group 1 showed higher statistically significant shear bond strengththan Group 2. Conclusions: The application of an additional layer of resin to the occlusalsurfaces of the tube/tooth interface was found to enhance bond strength quality of orthodonticbuccal tubes bonded directly to molar teeth.Keywords: Tooth bonding. Shear strength. Molar tooth.How to cite this article: Vercelino CRMP, Pinzan A, Gurgel JA, Bramante FS, Pinzan LM. In vitro study of shear bond strength in direct bondingof orthodontic molar tubes. Dental Press J Orthod. 2011 May-June;16(3):60-2.* Access www.dentalpress.com.br/revistas to read the full article.** PhD in Orthodontics, FOB/USP. Assistant Professor, Masters Program in Dentistry (Area of Concentration: Orthodontics), UNICEUMA (São Luís, MA).*** Associate Professor, Department of Orthodontics, Bauru School of Dentistry, University of São Paulo.**** PhD in Orthodontics, FOB/USP. Coordinator and Professor, Masters Program in Dentistry (Area of Concentration: Orthodontics), UNICEUMA (SãoLuís, MA). Assistant Professor in Speech Therapy Program, FFC - UNESP/Marília.***** PhD in Orthodontics, FOB/USP. Assistant Professor, Masters Program in Dentistry (Area of Concentration: Orthodontics), UNICEUMA (São Luís, MA).****** Graduate, USC/Bauru. Student, Specialization Course in Orthodontics, APCD, Bauru/SP.Dental Press J Orthod 60 2011 May-June;16(3):60-2

Vercelino CRMP, Pinzan A, Gurgel JA, Bramante FS, Pinzan LMEditor’s summaryDirect bonding of tubes to posterior teeth hasseveral advantages over the use of bands: shorterclinical time; greater preservation of periodontaltissues because of easier hygiene and preservationof biological distances; and no need of previousinterdental separation. However, due to the incidenceof greater masticatory forces in the posteriorregion, there is a relatively higher rate of bondingfailures, which explains the greater prevalenceof banding in posterior teeth in orthodontic practice.To increase the efficacy of tubes bonded toposterior teeth, this study evaluated whether theapplication of an additional resin layer in thetube/tooth occlusal interface might increase itsadhesive resistance. Forty mandibular third molarswere included in the study and divided intotwo groups: Group 1 – tubes bonded conventionally,using Transbond XT resin (3M Unitek,Monrovia, CA), light cured for 20 seconds, andapplication of an additional composite resin layerin the tube/teeth occlusal interface, light curedfor 10 seconds; Group 2 – conventional tubebonding using the same resin, light cured for 20seconds at first and, 40 seconds later, light curedagain for 10 seconds. The specimens were storedin distilled water at 37º C for 24 h. After that,shear bond tests were performed using a universaltesting machine (Emic, São José dos Pinhais,Brazil). Adhesive strengths in each group werecompared using an independent t test (p

In vitro study of shear bond strength in direct bonding of orthodontic molar tubesconsideration clinically when applying an additionalresin layer to the tube/tooth occlusalinterface, as recommended in your study?In clinical practice, several factors should beanalyzed before making the decision of bandingor bonding to molars: the quality of the adhesivematerial, the type of surface material (amalgam,resin, porcelain, enamel, metal alloys), the clinicalneeds (type of movement, height of clinicalcrown, need of anchorage use), as well as thepatient’s age. If the choice is direct bondingusing the method described here, the amount ofadhesive material should be calculated so thatis does not affect the occlusal relation betweenmaxillary and mandibular molars and does notobstruct the space for ligatures with archwiresand elastic bands in the case of using convertibletubes. Clinically, we recommend that, after theapplication of this reinforcement, the patientshould be asked to occlude several times beforethe resin is light cured to avoid the occurrence ofocclusal interferences. This test may be repeatedalso after the procedure using articulating paper.3) Clinically, one of the greatest difficulties inbonding tubes to posterior teeth is the excessiveaccumulation of saliva in that region,which crucially affects the success of the procedure.What possible clinical solutions arethere for this problem?We often bond tubes directly on molars and,honestly, we have not found any great differencesin saliva accumulation in the molar regionthan in the region of second premolars, which areroutinely bonded in orthodontic practice. In additionto adequate relative isolation, molars shouldbe bonded one at a time, that is, the molar is firstbonded on one side and then on the other, andtubes should only be bonded to other teeth afterthe procedure is completed. In other words, bondingshould move from the posterior to the anteriorregion. Moreover, the procedure should beconducted with the help of a dental assistant andthe use of an oral evacuator and vacuum suction.We usually ask the patient to move the head tothe opposite side of the tooth to be bonded, whichreduces the accumulation of saliva in the region.Submitted: September 2009Revised and accepted: April 2010Contact addressCélia Regina Maio Pinzan VercelinoAlameda dos Sabiás, 58CEP: 18.550-000 - Boituva / SP, BrazilE-mail: cepinzan@hotmail.comDental Press J Orthod 62 2011 May-June;16(3):60-2

O r i g i n a l A r t i c l eEvaluation of the bone age in 9-12 years oldchildren in Manaus-am cityWilson Maia de Oliveira Junior*, Julio Wilson Vigorito**, Carlos Eduardo Nossa Tuma***AbstractObjective: This study evaluated bone age using the Greulich & Pyle method (1959) andpubertal growth according to the study conducted by Martins (1979). Methods: Hand andwrist radiographs of 201 children (103 boys) aged 9 to 12 years living in the state of Amazonas(Brazil) were analyzed. A chi-square test was used for statistical analysis at a level ofsignificance of 5% (p

Evaluation of the bone age in 9-12 years old children in Manaus-AM cityintroductionTwo thirds of orthodontic patients have malocclusionin which growth and development playan important role in the success or failure of treatmentand directly affect the decisions about theuse of extraoral mechanics, functional appliances,extractions or even orthognathic surgeries. Orthodontistsshould understand the events associatedwith growth because maturation stages have adecisive role in diagnosis, planning and length oftreatment, as well as in the prognosis of malocclusion.Orthodontists should understand the eventsassociated with growth because maturation stageshave a decisive role in diagnosis, planning andlength of the treatment, as well as in the prognosisof malocclusion. 13 Therefore, individual patternsof growth for each patient are fundamental factorsin the success of orthodontic treatment.Age may be defined in several ways: bone age,morphological age, age at development of secondarysexual characteristics, age at menarcheand dental age. These parameters have all beendescribed as means to define physiological age. 18The time when a patient will reach puberty andeven when the pubertal growth spurt (PGS) willoccur may be estimated. However, these differenttypes of age have a low correlation, and there areindividual variations according to sex, ethnicity,geographic location, genetic factors, climate, nutritionand socioeconomic status. Because of that,the determination of specific chronological agesas the beginning of puberty in male and femalepatients is no longer used. 2,11,18PGS occurs in adolescence, usually between10 years and 6 months and 15 years of age inthe Brazilian population, and girls reach it at anearlier age. This phase of height and craniofacialgrowth occurs at the same time as the physicalphenomena that follow maturation of the sexualsystem and the beginning of reproductive life. Theestimated age at which they occur is variable andseveral individuals reach specific stages of skeletalmaturation at different chronological ages. 11,12,13The most common methods to measure boneage using hand and wrist radiographs are the onesdescribed by Greulich and Pyle 7 (1959) and Tanner-Whitehouse22 (TW2) (1983), which are basedon the recognition of maturity indicators that arecharacterized by changes in the radiographic appearanceof the epiphysis of long bones from theearly mineralization stages to their fusion with thediaphysis. 6Several intrinsic and extrinsic factors areknown to directly affect an individual’s growthpattern. Brazil is a very large country and hasregional population differences; therefore, specificstudies should be conducted about nutrition,weight, height, and skeletal development patterns.The characteristics of each region should be takeninto consideration to establish regional standardsfor the use of hand and wrist radiographs, to evaluatethe growth of that population, and, thus, significantlycontribute to the practice of high qualityorthodontics. This study evaluated chronologicalage at the beginning and at the peak of PGS forboth sexes and correlated findings with bone agein individuals born in the city of Manaus in thestate of Amazonas, Brazil.Several authors conducted studies using handand wrist radiographs to determine bone age andPGS beginning and peak. Pubertal growth spurtoccurred at 11 to 12 years in their samples, andPGS peak was exactly at 12 years of age. 4 A studywith Swedish children found that PGS occurredat 10 to 12 years and was completed at 14.8among girls and 17.1 among boys. Height velocitypeaked two years after the beginning of PGS inboth sexes (12 years for girls and 14.1 for boys). 9In general, ossification of the ulnar sesamoid maybe used as an indicator of PGS beginning, which occursbetween 10 and 11 years in girls and 11 and 12years in boys. Other authors found similar chronologicalages for PGS beginning and peak. 8,10,17 However,another study found that mean age at heightvelocity peak for boys was 14 years, and there wasa 2 year range of variation, whereas the mean peakDental Press J Orthod 64 2011 May-June;16(3):63-9

Oliveira Junior WM, Vigorito JW, Tuma CENvelocity age for girls was 2 years earlier than for boysand ranged from 10 to 14 years.Data about bone age and PGS are not availablefor the population in the Northern regionof Brazil, particularly in the state of Amazonas.This epidemiological study analyzed hand andwrist radiographs to determine bone age usingthe Greulich and Pyle radiographic atlas 7 andto determine, according to the study conductedby Martins, 12 the standard height velocity curveand hand and wrist bone ossification stages.MATERIAL AND METHODSSample sizeFor a total of 127,133 children enrolled inpublic schools, a sample size of 132 individualswas calculated for a 95% confidence intervaland a 5% error. Therefore, data about 132 childrenwere included in the study.Sample size and method errorThe following equation was used to calculatesample size:n= ∂ 2 .p.q.Ne 2 .(N-1)+ ∂ 2 .p.qKey:N = universen = calculated sample∂ = confidence levele = sample size errorp.q = percentage whichphenomena occursWhere, from a total of 127,133 children enrolledin the public schools in Manaus, a city inthe Brazilian state of Amazonas, a sample of 132individuals was defined for 90%, 95% and 99%confidence intervals and 5.8%, 7.0% and 9.1%errors using the interobserver error method.A sample of 132 Brazilian boys and girls aged9, 10, 11 and 12 years, born in Manaus, whoseparents and grandparents were born in Amazonas,and who studied in municipal public schools wereincluded in the study and separated into groupsaccording to sex and age. According to the ManausEducation Department, 127,133 children in thisage group were enrolled in school in 2006. An informedconsent term was signed by the parents. Aspecial form was used to collect data about medicalhistory, which included place of birth, possibleabsence of one or more permanent teeth, malocclusion,systemic diseases, nutritional deficiencies,chronic infectious diseases and no previous orthodontictreatments. After data about clinical historywere recorded, the children were taken to aradiology center for hand and wrist radiographs.This study was previously approved by the Ethicsand Research Committee of the institution whereit was conducted under no. 05/093 and in agreementwith Resolution no. 196/1996 of the BrazilianNational Health Council, Ministry of Health,on April 20, 2006.Hand and wrist radiographs were acquiredusing 18 x 24 Kodak T-Mat G/RA film (Atlanta,GA, USA) usable for at least 6 monthsaccording to expiration date and an Orthoralix9200 Plus unit (X Gendex, Dentsply, York,PA, USA) calibrated to operate at 06 mA, 60KVp and exposure time of 0.16 seconds. Thefocus-to-film distance was 76 cm. Patients wereprotected with a lead apron. The radiographswere acquired with the participant’s open lefthand centered on the film to include the carpal,metacarpal and phalangeal regions.After acquisition, the radiographs were processedin a dark room using an automatic developmentmethod and an AT 2000 XR processor(Air Techniques, New York, NY, USA) accordingto film manufacturer’s recommendations.After fixing and drying, the radiographs wereanalyzed in a dimly-lit room using an X-ray box,a 0.5 mm lead pencil, a soft eraser and a formfor data recording. Hand and wrist radiographswere analyzed visually and each one was comparedwith the radiographic standards in theGreulich and Pyle 7 atlas (Fig 1), a widely usedmethod because the atlas is easy to use and thestructures are easy to identify and interpret. 20Dental Press J Orthod 65 2011 May-June;16(3):63-9

Evaluation of the bone age in 9-12 years old children in Manaus-AM cityage and sex. Linear regression analysis was usedto evaluate the correlation between variables. Thelevel of significance was set at 5% (p

Oliveira Junior WM, Vigorito JW, Tuma CEN% PatientsEarly maturationIntermediateLate1009080706050403020100MaleMaturation phase according to sexFemaleBone age15141312111098769 10 11 12 13Chronological ageFemaleMaleFigurE 3 - Types of maturation according to sex.FigurE 4 - Dispersion plot: chronological age and bone age accordingto sex.tablE 3 - Statistical data on bone age according to chronological ageand sex.Age(years)Sex Mean SD Min. Median Max.9 M 8.4 1.6 6 8.5 1310 M 9.8 1.1 8 10 12.511 M 10.8 1.0 9 11 1312 M 12.3 1.0 10 12.5 13.59 F 9.6 1.3 6.8 10 1110 F 11.2 1.5 8.8 11 1511 F 12.3 1.3 8.8 12 1512 F 13.2 1.1 11 13.3 15DISCUSSIONThe analysis of absolute and relative numberof boys and girls at the different PGS stages revealedthat girls were at a more advanced phasethan boys (Table 1). In the sample under study,44.7% of the boys and 19.4% of the girls were atthe beginning of PGS, and about 50% of the girlshad reached PGS peak, whereas only 11.6% of theboys were in the same phase. No boy had reachedthe final phase of PGS, whereas 24 girls (24.5%)were in this phase. The comparison between sexesusing a chi-square test revealed statistically significantresults (p

Evaluation of the bone age in 9-12 years old children in Manaus-AM citybefore boys, and PGS peak was 1.2 year earlierin girls than in boys. However, other studiesfound that PGS beginning and peak were a mean1 to 2 years later in their samples than in ourstudy. 5,8,9,10,17,21Figure 3 shows the comparison between thetype of maturation (early, intermediate or late)and sex. There was a greater prevalence of intermediatematuration (differences between boneand chronological age below 1 year) in both sexes(boys = 55.3%; girls = 46.9%). Early maturation,that is, bone age at least one year greater thanchronological age, was more frequent among girls(41.8%) than boys (5.8%). Late maturation, orchronological age at least one year greater thanbone age, had a greater incidence among boys(38.8%) than girls (11.2%). These results confirmdata reported in other studies, which foundthat girls reach all the skeletal maturation phasesat an earlier age than boys (p

Oliveira Junior WM, Vigorito JW, Tuma CENReferEncEs1. Bergensen EO. The male adolescent facial growth spurt: itsprediction and relation to skeletal maturation. Angle Orthod.1972;42(4):319-38.2. Bowden BD. Epiphysal changes in the hand/wrist areaas indicators of adolescent stage. Austr Orthod J Pediat.1976;4(3):87-104.3. Cerveira ARP, Silveira ID, Calmo JAF, Danesi OFP, Rosa RO,Karam LC, et al. Avaliação da idade óssea em adolescentesdo sexo masculino na faixa etária de 10 a 12 anos. RevOdonto Ciênc. 1990;5(10):36-46.4. Damante JH, Freitas JAS, Capelloza Filho L. Estirão decrescimento circumpuberal em meninas brancas, brasileiras,da região de Bauru. Ortodontia. 1982;15(3):221-30.5. Franco AA, Santana AH, Santana IS, Melo MFB, SantosJúnior JH. Determinação radiográfica da maturidadeesquelética e sua importância no diagnóstico e tratamentoortodôntico. Ortodontia. 1996;29(1):53-9.6. Gilli G. The assessment of skeletal maturation. Horm Res.1996;45(2):49-52.7. Greulich WW, Pyle SI. Radiographic atlas of skeletaldevelopment of the hand and wrist. Calif Med. 1950October; 73(4):378.8. Guzzi BSS, Carvalho LS. Estudo da maturação óssea empacientes jovens de ambos os sexos através de radiografiasde mão e punho. Ortodontia. 2000;33(3):49-58.9. Hägg V, Taranger J. Maturation indicators and the pubertalgrowth spurt. Am J Orthod. 1982;82:299-309.10. Iguma KE, Tavano O, Carvalho IMM. Comparative analysisof pubertal growth spurt predictors: Martins and Sakimamethod and Grave and Brown Method. J Appl Oral Sci.2005 Jan-Mar;13(1):58-61.11. Magnunsson TE. Skeletal maturation of the hand in Iceland.Acta Odontol Scand. 1979;37(1):21-8.12. Martins JCR. Surto de crescimento puberal e maturaçãoóssea em ortodontia [dissertação]. São Paulo: Universidadede São Paulo; 1979.13. Mercadante MMN. Radiografia de mão e punho. In: FerreiraFV. Ortodontia: diagnóstico e planejamento clínico. 6ª ed.São Paulo: Artes Médicas; 2004. p. 188-23.14. Midtgard J, Bjork G, Linder-Aronson S. Reproducibilityof cephalometric landmarks and errors of measurementsof cephalometric cranial distances. Angle Orthod. 1974Jan;44(1):56-61.15. Moraes LC, Moraes MEL. Verificação da assimetria bilateralde desenvolvimento por meio de radiografias de mão epunho, baseada na avaliação da idade óssea. Rev OdontolUNESP. 1996;25(n. esp.):183-94.16. Onishi S, Amaral IM, Carvalho LS. Identificação da menarcana curva de crescimento estatural: radiografia de mão epunho. Rev Assoc Paul Cir Dent. 2006;60(3):176-81.17. Peluffo PL. Indicadores de la maduración. Edad ósea yvértebras cervicales. Rev Odontol Interdisc. 2001;2(3):9-15.18. Prates NS. Crescimento crânio-facial e maturação óssea:estudo em crianças nascidas em Piracicaba, portadoras deoclusão dentária normal [tese]. Campinas: UniversidadeEstadual de Campinas; 1976.19. Pryor JW. The hereditary nature of variation in theossification of bones. Ana Rec. 1907;1:84-8.20. Siqueira VCV, Martins DC, Canuto CE. O emprego dasradiografias da mão e do punho no diagnóstico ortodôntico.Rev Dental Press Ortodon Ortop Facial. 1999;4(3):20-9.21. Sulivan PG. A estimativa do surto de crescimento puberal,por meio do osso sesamóide e da menarca. Rev da ABRO.2004;5(1):42-6.22. Tanner JM, Whitehouse RH, Cameron N. Assessment ofskeletal maturity and prediction of adult height (TW2method). London Academic Press; 1983.23. Todd TW. Atlas of skeletal maturation (hand). St. Louis: C.V.Mosby; 203 p.Submitted: January 2008Revised and accepted: October 2008Contact addressWilson Maia O. JrRua 6, 192, Conj. Castelo Branco - Parque DezCEP: 69.055-240 - Manaus / AM, BrazilE-mail: ortomaia@gmail.comDental Press J Orthod 69 2011 May-June;16(3):63-9

O r i g i n a l A r t i c l eTreatment effects on Class II division 1 highangle patients treated according to theBioprogressive therapy (cervical headgearand lower utility arch), with emphasis onvertical controlViviane Santini Tamburús*, João Sarmento Pereira Neto**,Vânia Célia Vieira de Siqueira***, Weber Luiz Tamburús****AbstractObjective: This study investigated vertical control and the effects of orthodontic treatmenton dolicofacial patients, using cervical headgear (CHG) and lower utility arch. Methods:Cephalometric assessment of 26 dolicofacial patients with Class II, division 1, and meanage of 114 months. Orthodontic treatment involved the use of cervical headgear (CHG) inthe maxillary arch, lower utility arch in the mandibular arch until normal occlusion of themolars was obtained and finished in accordance with Bioprogressive Therapy, with a meanduration of 56 months. The values of FMA, SN.GoGn, ANB, Fg-S, S-FPm, maxillary length,mandibular length, posterior facial height (PFH), anterior facial height (AFH), facial heightindex (FHI), occlusal plane angle (OPA), palatal plane angle (PPA), total chin (TC), upperlip (UL) and Z angle were evaluated. Results: The results showed that treatment promotedstability of the mandibular, occlusal and palatal planes. Anteroposterior correction of theapical bases occurred, verified by the significant reduction in the variable ANB. The maxillapresented slight anterior displacement and increase in the anteroposterior dimension.The mandible presented improvement in its position in relation to the cranial base and itsanteroposterior dimension increased significantly. The posterior and anterior facial heightsremained in equilibrium, with no significant alteration in FHI. The tegumental profile presentedsignificant improvement. Conclusion: The treatment performed produced correctionof the apical basis with control of the horizontal planes and facial heights, and waseffective for vertical control.Keywords: Extraoral cervical traction appliances. Cephalometry. Orthodontics. Vertical control. Malocclusion.Class II, division 1.How to cite this article: Tamburús VS, Pereira Neto JS, Siqueira VCV, Tamburús WL. Treatment effects on Class II division 1 high anglepatients treated according to the Bioprogressive therapy (cervical headgear and lower utility arch), with emphasis on vertical control. DentalPress J Orthod. 2011 May-June;16(3):70-8.* Professor and Coordinator of the Specialization Course in Orthodontics and Facial Orthopedics, Dental Association of Ribeirão Preto (AORP).** PhD, Assistant Professor of Orthodontics Area FOP / UNICAMP.*** Doctor, Associate Professor, Discipline of Orthodontics FOP / UNICAMP.**** Professor of the Specialization Course in Orthodontics and Facial Orthopedics, Dental Association of Ribeirão Preto (AORP).Dental Press J Orthod 70 2011 May-June;16(3):70-8

Tamburús VS, Pereira Neto JS, Siqueira VCV, Tamburús WLintroductionThe vertical growth pattern of Class II representsan unfavorable factor, since divergence fromthe horizontal plane generally indicates a mandiblepositioned more downwards and backwards,accentuating the skeletal and dental discrepancyof this malocclusion, 7,17 making vertical control inthe palatal, occlusal and mandibular planes essential,as well as of the posterior and anterior facialheights during dental treatment. 6,8,24The application of various forms of treatmentand mechano-therapy can be found in the dentalliterature, but the main objective of any strategyshould center on reestablishment of the physiologicalfunctions, whenever possible normalizingthe dentoalveolar and skeletal positions, and consequentlyproviding a more harmonious profileto the patient.One of the orthodontic appliances availablefor the correction of Class II, division 1 is theextraoral cervical traction appliance (CHG) developedby Silas Kloehn in 1947, 12 much usedand studied during various decades. Amongstthe advantages of the CHG one can highlightthe anteroposterior repositioning of the apicalbases, the attainment of a normal molar occlusion,modification of the occlusal and palatalplanes and reduction of horizontal overlapping.4,11,19 When the extraoral appliance is incorrectlyemployed, it causes an extrusive effecton the permanent upper molars, an increase inthe anteroposterior facial height and rotation ofthe mandibular plane in the clockwise direction,making the malocclusion even worse, especiallyin patients with a dolicofacial pattern. 14Only two papers were found in the literaturefocused on the treatment of Class II, division 1malocclusion with the Kloehn extraoral cervicalappliance and lower utility arch. 4,22According to Ricketts et al, 18 the CHG can stabilizethe mandibular plane and facial axis of thebrachyfacials, rotating the mandible in the anticlockwisedirection, and thus decreasing the anteroposteriorfacial height and the mandibular planeangle. The combined headgear (HG) should be usedin Class II, division 1 dolicofacial patients, so thatthe mandible does not rotate in a clockwise directionand does not increase the lower facial height.Based on the above aspects, the present studyproposed to make a cephalometric evaluation ofthe maxilomandibular changes occurring when applyingBioprogressive treatment using the KloehnCHG to the upper arch, together with the use ofa lower utility arch, for the correction of Class II,division 1 malocclusion in dolicofacial patients,mainly evaluating the vertical control.MATERIAL AND METHODSThis study was carried out to obtain the titleof Master in Orthodontics, and was only startedafter approval by the Ethics Commission for Researchwith Human Beings of FOP-UNICAMP,Brazil.SampleThe sample consisted of 52 lateral cephalometricradiographs obtained at two moments intime, before (T1) and at the end (T2) of an orthodontictreatment with 26 patients, 13 girls and13 boys, with Class II, division 1 malocclusionand dolicofacial skeletal patterns, with a mean ageof 114 months and mean treatment time of 56months. The patients were selected according tothe following inclusion criteria:» Brazilian white patients, submitted to orthodontictreatment at the Orthodontic Clinicof the Specialization Course offered by theRibeirão Preto Dental Association (AORP),Brazil;» Patients with absence of syndromes andgood oral health;» Class II molar and canine relationship;» Overjet > 2.5mm;» ANB angle > 4º;» FMA angle >25º;» SNGoGn > 35º.Dental Press J Orthod 71 2011 May-June;16(3):70-8

Treatment effects on Class II division 1 high angle patients treated according to the Bioprogressive therapy (cervical headgear and lower utility arch), with emphasis on vertical controlDescription of the orthodontictreatment according to RickettsBioprogressive PhilosophyThe treatment of Class II, division 1 malocclusionwas performed without any tooth extraction(except for the third molars, when necessary), andaccording to the Bioprogressive Philosophy, at theSpecialization in Orthodontics and Facial OrthopedicsClinic of the Ribeirão Preto Dental Association– AORP. To correct the anteroposterior relationshipof the apical bases, the Kloehn type extraoral cervicaltraction appliance (CHG) was used, which is characterizedby an internal arch fitted into triple tubes,welded to the braces on the maxillary first molars,and an external rigid arch, inclined 20º upwards withrespect to the internal arch (which is parallel to theocclusal plane), and a cervical band with elastics, preadjustedto generate a total force of 450g, adaptedto the external arch. The patients were instructedto use the CHG for a period of 12h/day, includingwhile asleep, with the objective of correcting themolar relationship. This period lasted approximately1 year, and after obtaining normal molar occlusion,the CHG was gradually removed, decreasing thenumber of hours of use until complete withdrawal.Concomitant with the use of the CHG on themaxilla, the lower utility arch (LUA), made of0.016x0.016-in Elgiloy Blue wire, was adapted tothe lower arch. The molar sector of the LUA wasfitted into the cervical tubes of the double tubeswelded onto the lower first molar bands, and theincisor sector of the LUA onto the brackets ofthe four mandibular incisors. Activations wereperformed both for verticalizing and anchoringthe mandibular molars in the cortical bone, withthe objective of limiting their eruption (caudalangle of 30-45º, caudal deviation of 10-20º, buccalroot torque of 30-45º and expansion of 10mm in the molar sector), as well as intruding oruprighting the mandibular incisors according tothe requirements of each case (in the incisor sector,a buccal root torque of 5-10º was incorporated).After uprighting of the mandibular molars,brackets were placed on the premolars, and a stabilizersegmented arch made of 0.016x0.016-inElgiloy Blue wire was adapted on each side ofthe occlusal tube of the double tubes welded tothe bands of the mandibular first molars, whichextended up to the first mandibular premolars,with the object of avoiding excessive inclinationof the mandibular molars in the distal direction,while the mandibular incisors were being intruded.The orthodontic treatment proceeded usingthe Bioprogressive Therapy until the cases werefinished, with a harmonious profile and characteristicsof normal occlusion.Cephalometric methodThe anatomic structures and cephalometricpoints were marked, the planes and lines drawn,and the following angular (Fig 1) and linear (Fig2) variables measured:1256 348 7 521463FigurE 1 - Angular variables: 1) FMA; 2) SNGoGn; 3) ANB; 4) Z Angle;5) OPA; 6) PPA.FigurE 2 - Linear variables. 1) AFH; 2) PFH; 3) TC; 4) UL; 5) Max L;6) Mand L; 7) S-FPm; 8) Fg-S.Dental Press J Orthod 72 2011 May-June;16(3):70-8

Tamburús VS, Pereira Neto JS, Siqueira VCV, Tamburús WLStatistical analysisThe statistical analysis consisted of a univariateanalysis to determine the distributionsand verify the outliers and normality tests(Shapiro-Wilkens).The “t” test was used for the comparisons ofmeans in normal distributions. When the “t” testwas performed, the equality of variances was testedusing the Levene test. When the variances ofthe groups were shown to be different, the Satterthwaiteadjustment was used.For normal distributions, when data dependenceoccurred (comparison of means from oneand the same individual), the paired “t” test wasused. For non normal distributions the Kruskal-Wallis comparison of means test was used, and forthe comparison of paired data with non normaldistribution, the signed-rank test was used.Method of ErrorThe same researcher traced each cephalometricradiograph twice, in an interval of 30 days,and obtained two values for each cephalometricvariable. The arithmetic mean of these values wasused in the statistical analysis. The Dahlberg indexwas used to interpret the casual error. 10tablE 1 - Characteristic of the patients with respect to age at the beginningand during orthodontic treatment.Total (n=26)Age (months)Girls(n=13)Boys(n=13)Mean 114.0 127.5 120.0Q1 105.0 105.0 105.0Q3 131.0 130.0 131.0Min - Max 96 - 201 100 -155 96 - 120Duration of Treatment (months)Mean 56.0 56.0 57.0Q1 45.0 45.0 48.0Q3 67.0 68.0 59.0Min - Max 27 - 169 27 - 169 36 -103*Value of P for comparison of means - Kruskal-Wallis test (P < 0.05 significant).p*0.81700.7192RESULTSSampleComparison between sexesNo statistically significant difference wasobserved between the sexes with respect to thealterations that occurred, when the two momentsin time were compared (Table 2) for thewhole sample.Comparison of the cephalometric variablesSince no statistical differences were foundbetween the sexes with respect to the initialages and alterations occurring with the treatment,the sexes were placed together in thesame group (Table 3).TABLE 2 - Comparison of the paired differences between sexes.Pair.diff.Girls (n=13)SDBoys (n=13)*P Value for the paired Student-t test (P < 0.05 – significant).SEPair.diff.SD SE p*FMA -1.88 3.04 0.84 -1.35 1.78 0.49 0.5877SN.GoGn -1.34 2.74 0.76 -2.19 3.61 1.00 0.5081ANB -2.21 1.30 0.21 -3.00 1.36 0.38 0.0810Fg-S 1.12 1.30 0.36 0.61 1.66 0.46 0.3955S-FPm 0.57 1.10 0.31 0.58 1.01 0.28 0.9854Maxillarylength2.18 1.70 0.47 1.53 1.62 0.44 0.3348Mandibularlength9.08 3.33 0.92 9.81 4.79 1.33 0.6547PFH 6.60 3.69 1.02 9.78 4.39 1.22 0.0582AFH 6.39 2.98 0.82 8.05 3.09 0.86 0.1754FHI 0.008 0.04 0.01 0.008 0.021 0.006 0.9458Occlusal Pl.Angle-0.77 3.03 0.84 0.61 3.24 0.90 0.2713Palatal Pl.Angle0.23 2.88 0.80 -1.40 2.06 0.57 0.1089TC 1.61 2.32 0.64 2.06 1.59 0.44 0.5629UL 1.33 3.38 0.94 1.84 2.34 0.65 0.6580Z Angle 9.69 5.78 1.60 6.96 4.23 1.18 0.1826Dental Press J Orthod 73 2011 May-June;16(3):70-8

Treatment effects on Class II division 1 high angle patients treated according to the Bioprogressive therapy (cervical headgear and lower utility arch), with emphasis on vertical controltablE 3 - Comparison of the paired differences of all variables.Beginning End Diff.Mean SD Mean SD Paired SD SEp*FMA 28.98 4.01 27.36 4.11 -1.62 2.96 0.48 0.0026*SN.GoGn 39.21 3.79 37.44 4.29 -1.77 3.18 0.62 0.0088*ANB 6.11 1.63 3.50 1.77 -2.61 1.15 0.22 < 0.0001**Fg-S 15.58 2.78 16.45 3.23 0.87 1.49 0.29 0.0064*S-FPm 18.59 1.93 19.17 2.33 0.57 1.03 0.20 0.0089*Maxillary Length 51.10 3.30 52.96 3.57 1.86 1.67 0.33 < 0.0001**Mandibular Length 103.05 4.54 112.49 5.16 9.44 4.06 0.80 < 0.0001**PFH 38.59 1.48 46.78 4.21 8.19 4.30 0.84 < 0.0001**AFH 62.90 3.48 70.12 4.5 7.22 3.09 0.61 < 0.0001**FHI 0.65 0.04 0.66 0.05 0.008 0.29 0.006 0.1830Occlusal Pl. Angle 7.48 4.26 7.40 3.03 -0.08 3.15 0.62 0.9020Palatal Pl. Angle 3.27 3.57 2.69 3.60 -0.59 2.59 0.50 0.2592TC 14.03 1.63 15.87 2.09 1.84 1.96 0.38 < 0.0001**UL 11.53 2.91 13.12 1.96 1.59 2.86 0.56 0.0090*Z Angle 61.98 6.36 70.31 6.49 8.33 5.16 1.01 < 0.0001***P Value for the paired Student-t test (*P < 0.05 and **P < 0.0001– significant).DISCUSSIONVertical control of the face during the use oforthodontic mechanics has been shown to be ofutmost importance in obtaining functional estheticbalance, essential for the final result of a treatmentaimed at facial harmony and post-treatmentstability. 6,8Various types of appliance have been studiedand developed for the correction of Class II, oneof which is the cervical headgear. 12 There is a greatdeal of controversy in the literature with respectto the changes occurring with the use of the cervicalheadgear. However, the considerations mostreported are correlated to the extrusive effect onthe permanent maxillary molars, downward inclinationof the anterior part of the palatal planeand the increase in inclination of the mandibularplane, aggravating the vertical problem evenmore. 14 According to Ricketts, 17 cervical tractionproduces favorable changes for patients withClass II, division 1, such as: retraction of the maxillarycomplex, decrease in maxillary convexityand rotation of the palatal plane in the clockwisedirection. Some studies have shown that maxillarymolar extrusion could be minimal when theCHG is used with the external arch inclined 20ºabove the internal arch. 4,11,22The sole purpose of this study was to investigatethe effectiveness of orthodontic treatmentand vertical control in a sample selected from theorthodontic documentation file belonging to theSpecialization Course in Dentistry and Facial Orthopedicsof the Ribeirão Preto Dental Association- AORP, Brazil.The data assessed were submitted to a statisticalanalysis by applying the paired Student-ttest. It was observed that no statistically significantdifferences occurred between the sexes forthe initial ages, treatment time or for the alterationsthat occurred with the orthodontic treatment(Tables 1 and 2). Thus both sexes wereassessed in a single group, only studying the alterationsoccurring between the two momentsin time (initial and final).Dental Press J Orthod 74 2011 May-June;16(3):70-8

Tamburús VS, Pereira Neto JS, Siqueira VCV, Tamburús WLAssessment of the craniofacial growth patternis very important, particularly during the growthphase, since selecting the direction of the applicationof forces depends directly on this evaluation,and can be low, straight or high. Accordingto some authors, 6,15 orthodontic treatment shouldnot alter the measurements related to verticalcontrol or cause significant mandibular rotationin a clockwise direction, especially in dolicofacialpatients. These patients normally have anincreased lower facial height, with the mandiblepositioned more backwards and downwards.If the orthodontic treatment causes clockwisemandibular rotation, there will be an increase inthe height, worsening the facial profile of thesepatients even more.In the present study carried out with dolicofacialpatients submitted to orthodontic treatmentwith a CHG (with activations of the externalarch) and a lower utility arch, there was a statisticallysignificant decrease in the variables that representthe facial pattern and vertical control: anglesFMA -1.62±2.96º and SNGoGn -1.77±3.18º(Table 3). This result showed that the mandibularplane was stabilized during orthodontic treatment,allowing for the reasoning that the clinicallyobserved alterations were not expressive, since thealteration remained at approximately 1.6º and thestandard deviation of around 3º. This result corroboratedthe results of Decosse and Horn, 6 whoreported that the values of these angles shouldbe maintained with the use of orthodontic mechanicsfor vertical control to occur. Other resultsfound in the literature showed the stability of thevariables referring to the facial pattern with treatment.3,4,11,12 Ricketts et al 18 reported that the useof the CHG together with the lower utility archcould cause anti-clockwise rotation of the mandiblein brachyfacial patients, which they 18 denominatedas the Inverse Reaction. According tothese authors, 18 when the upper molar (Fig 3A)is extruded and distalized in an intermittent way,its inclined planes act to upright and distalize thelower first molar. This occurrence is accentuatedby the distal degree of the utility arch (Fig 3B)and labial torque of the root of the lower incisor(Fig 3D). The vertical action of the masseter andpterygoid muscles (Fig 3C) functions in the stabilizationof the eruption of the lower molar (Fig3F) and also limits extrusion of the upper molar.The torque of the labial root on the lower utilityarch (Fig 3E) also allowed for the lower incisor toavoid the cortical one while being intruded. Thepresent study assessed dolicofacial patients andshowed that the treatment can also result in a tendencyfor anti-clockwise rotation of the mandible(tendency, since it was considered that the changethat occurred — about 1.6º — was not clinicallyexpressive). This alteration occurred due to theintermittent use (12h/day, including while asleep)of the CHG, with activation of the external archand use of a lower utility arch, which promotesanchorage of the lower molars. A 20º activationof the external arch above the internal arch madethe resulting force pass through the center of resistanceof the upper molar, promoting an actionthat controlled the extrusive effect on the uppermolars. This result corroborated the findings ofCook et al 4 and Ulger et al, 22 who carried out astudy using the CHG with activation of the externalarch and use of a lower utility arch, andreported that the mandibular plane remained unalteredeven in dolicofacial patients. 4 KirjavainenbAcdeFIGURE 3 - Inverse Reaction – Combined action of the the CHG andLUA. A) upper first molar, B) LUA distal degree, C) vertical action of themasseter and pterygoid muscles, D) buccal root torque of the lowerincisors, E) wire activation to generate buccal root torque on the lowerincisors, F) limited eruption of the lower first molars, G) lingual movementof the lower incisors and change the functional occlusion plane.Source: Ricketts et al. 18fgDental Press J Orthod 75 2011 May-June;16(3):70-8

Treatment effects on Class II division 1 high angle patients treated according to the Bioprogressive therapy (cervical headgear and lower utility arch), with emphasis on vertical controlet al 11 reported the occurrence of minimal extrusionof the upper molars in patients who used theCHG with activation of the external arch.The maxilla protruded slightly with respect tothe cranial base at the start of the dental treatment(Table 3), and at the end of the treatment a mild,but statistically significant, forward displacementcould be observed. The variable S-FPm showed anincrease of 0.57±1.03 mm (Table 3), suggestingthat the use of the CHG restricted forward displacementof the maxilla, the mean displacementbeing 0.57 mm in a period of 4.6 years. Its anteroposteriordimension (FPm-point A) showed astatistically significant increase of 1.86±1.67 mm.Siqueira 20 assessed Brazilian patients with normalocclusion and showed that the length of the maxillaincreased approximately 3.34 mm from 9 to10 years of age, and thus it is reasonable to considerthat the anteroposterior dimension of the maxillawas restricted by the use of the CHG, since itonly increased 2 mm in a period of 4.6 years.The mandible protruded in relation to thecranial base at the start of treatment (Table 3),but by the end of treatment, the variable Fg-Sshowed a value of 16.45±3.23 mm, indicating anapproximation to the standard value determinedby Wylie, 25 suggesting an improvement in the anteroposteriormandibular position in relation tothe cranial base. The anteroposterior dimensionincreased significantly during the assessment period,showing an expressive increase in length of9.44±4.06 mm (Table 3). According to Rickettset al, 18 this increase could have occurred due tomandibular unlocking or to decompression of thecondyle in the glenoid cavity, freeing the mandiblefor normal growth.According to Antonini et al, 1 Broadbent et al 2and Ricketts, 16 the relationship of the maxillarycomplex with the cranial base remains relativelyconstant during growth in patients with predominantlyvertical growth, and thus orthodontic and/or orthopedic intervention is necessary for the correctionof anteroposterior Class II, division 1 malocclusion.The anteroposterior discrepancy wasshown to be corrected by means of a highly significant(P < 0.0001) alteration in the ANB angle(Table 3). A reduction of 2.61±1.15º occurred, improvingthe relationship between the apical bases,confirming the results of other authors. 3,4,11,22,23 Thereduction in ANB was due mainly to the expressivegrowth of the mandible and to the possible skeletalalterations occurring in the maxilla.The facial heights increased significantly, PFH8.19±4.30 mm (P

Tamburús VS, Pereira Neto JS, Siqueira VCV, Tamburús WLorthodontic planning and treatment other thanachieving the basic objectives of obtaining goodocclusion, if the facial esthetics remain compromised.The alterations occurring to the profilewere statistically significant (Table 3). The cephalometricvariables TC and UL showed meanvalues increased by values of 1.84±1.96 mm and1.59±2.86 mm, respectively, maintaining theproportionality between them (TC≥UL) fromstart to finish of the treatment.The Z angle relates the tegumental profile ofthe patient with the horizontal and vertical senses.8 At the start of the orthodontic treatment (Table3), the patients showed a decreased mean valueof the Z angle, confirming the convex profile,and one of the objectives of the orthodontic treatmentwas centered on increasing this angle, thusmaking the profiles of the patients more harmonious.The results of the present study showed a significantincrease in the Z angle (+8.33±5.16º andP

Treatment effects on Class II division 1 high angle patients treated according to the Bioprogressive therapy (cervical headgear and lower utility arch), with emphasis on vertical controlReferEncEs1. Antonini A, Marinelli A, Baroni G, FranchI L, Defraia E. ClassII maloclusion with maxillary protrusion from the deciduoustrhough the mixed dentition: a longitudinal study. AngleOrthod. 2005;75(6):980-98.2. Broadbent BH, Broadbent BH Jr, Golden WH. Boltonstandards of dentofacial developmental growth. St. Louis:Mosby; 1975.3. Ciger S, Aksu M, Germeç D. Evaluation of posttreatmentchanges in Class II, division 1 patients after nonextractionorthodontic treatment: Cephalometric and model analysis.Am J Orthod Dentofacial Orthop. 2005;127(2):219-23.4. Cook AH, Sellke TA, Begole EA. Control of the verticaldimension in Class II correction using a cervical headgearand lower utility arch in growing patients. Part I. Am JOrthod Dentofacial Orthop. 1994;106(4 Pt 1):376-88.5. Decker WB. Tweed occlusion and oclusal function. J CharlesH. Tweed Int Found. 1987;15:59-83.6. Decosse M, Horn AJ. Controle céphalométrique etdimension verticale. Introduction aux forces directionalles deTweed. Revue Orthop Dentofacial. 1978;12(2):123-36.7. Drelich RC. A cephalometric study of untreated Class II,division 1 malocclusion. Angle Orthod. 1948;18(3-4):70-5.8. Horn A, Jégou I. La philosophie de Tweed aujourd’hui. RevOrthop Dento-faciale. 1993;27:163-81.9. Horn A. Facial height index. Am J Orthod DentofacialOrthop. 1992;102(2):180-6.10. Houston WJB. Analysis of errors in orthodonticmeasurements. Am J Orthod Dentofacial Orthop.1983;83(5):382-9.11. Kirjavainen M, Kirjavainen T, Hurmerinta K, Haavikko K.Orthopedic cervical headgear with an expanded inner bowin Class II correction. Angle Orthod. 2000;70(4):317-25.12. Kloehn SJ. Guiding alveolar growth and eruption of teethto reduce treatment time and produce a more balanceddenture and face. Angle Orthod. 1947;17(1-2):10-33.13. Leichsenring A, Invernici S, Maruo IT, Maruo H, Ignácio AS,Tanaka O. Avaliação do ângulo Z de Merrefield na fase dedentição mista. Rev Clín Pesq Odontol. 2004;1(2):9-14.14. Melsen B. Effects of cervical anchorage during and aftertreatment: an implant study. Am J Orthod. 1978;51(5):526-40.15. Ricketts RM. The influence of orthodontic treatment on facialgrowth and development. Angle Orthod. 1960;30:103-33.16. Ricketts RM. Cephalometric analysis and synthesis. Am JOrthod. 1961;31(3):141-56.17. Ricketts RM. A four-step method to distinguish orthodonticfrom natural growth. J Clin Orthod. 1975;9(4):208-15, 218-28.18. Ricketts RM, Bench RW, Gugino CF, Hilgers JJ, Schulhof RJ.Técnica bioprogressiva de Ricketts. Buenos Aires: EditorialMédica Panamericana; 1983.19. Siqueira DF. Estudo comparativo, por meio deanálise cefalométrica em norma lateral, dos efeitosdentoesqueléticos e tegumentares produzidos peloaparelho extrabucal cervical e pelo aparelho de protraçãomandibular, associados ao aparelho fixo, no tratamento daClasse II, 1ª divisão de Angle [tese]. Bauru: Universidade deSão Paulo; 2004.20. Siqueira VCV. Dentição mista: estudo cefalométrico deestruturas craniofaciais em indivíduos brasileiros, dotadosde oclusão clinicamente excelente [dissertação]. Piracicaba:Universidade de Campinas; 1989.21. Tamburús WL, Teixeira C, Garbin AJI. Classe II divisão1. In: Baptista JM, Baptista LT, Manfredini M. CiênciaBioprogressiva. [CD-ROM]. Curitiba: Editek; 2000.22. Ülger G, Arun T, Sayinsu K, Isik F. The role of cervicalheadgear and lower utility arch in the control of thevertical dimension. Am J Orthod Dentofacial Orthop.2006;130(4):492-501.23. Üner O, Dinçer M, Türk T, Haydar S. The effects of cervicalheadgear on dentofacial structures. J Nihon Univ Sch Dent.1994;36(4):241-53.24. Vaden LJ, Harris EF, Sinclair PM. Clinical ramifications offacial height changes between treated and untreated Class IIsamples. Semin Orthod. 1996;2(4):237-40.25. Wylie WL. The assessment of facial dysplasia in the verticalplane. Angle Orthod. 1952;22(3):165-82.Submitted: July 2008Revised and accepted: February 2009Contact addressViviane Santini TamburúsRua Visconde de Inhaúma, nº 580, sala 611 - CentroCEP: 14.010-100 - Ribeirão Preto / SP, BrazilE-mail: vicatamburus@hotmail.comDental Press J Orthod 78 2011 May-June;16(3):70-8

O r i g i n a l A r t i c l eAnalysis of the correlation between mesiodistalangulation of canines and labiolingual inclinationof incisorsAmanda Sayuri Cardoso Ohashi*, Karen Costa Guedes do Nascimento*, David Normando**AbstractObjective: To assess the degree of correlation between canine angulation and incisorinclination. Methods: Mesiodistal angulation of canines and labiolingual inclination ofincisors were obtained by means of digital graphics software (ImageTool ® ) from standardizedphotographs of the casts of 60 patients. Incisor inclination was also assessed by lateralcephalometric radiographs. Results: Random error showed a variation of around 2° inmeasurements made on the casts (1.8-2.5), while systematic error, measured by the intraclasscorrelation test, displayed excellent reproducibility for both methods used in thisstudy (p

Analysis of the correlation between mesiodistal angulation of canines and labiolingual inclination of incisorsorthodontic treatment. Andrews noted that thelong axes of all teeth were mesially tipped tovarying degrees, depending on the group of teethexamined, and termed this feature as the 2 nd keyto normal occlusion. The 3 rd key outlined by Andrewswas crown inclination (torque), defininga positive value for the upper incisors (buccalcrown torque) and negative, or lingual for theremaining teeth. The angulation and inclinationvalues observed in the Andrews study 2 wereinstrumental for the invention of the Straight-Wire appliance.A few years later, changes were made to theinclination of incisor brackets to compensate forthe skeletal discrepancies that were not addressedin its entirety during orthodontic treatment. 2 Inthe case of Class III malocclusion, incisors weretipped more buccally in the maxillary arch andmore lingually in the mandibular arch, while inClass II the opposite was implemented. It laterbecame evident that, in fact, lower incisor inclinationwas strongly influenced by the relationshipbetween apical bases in the sagittal plane, whichplayed an important role in achieving a normal 8incisal relationship in the same manner thatchanges in upper incisor inclination significantlyaffect posterior occlusion. 12In addition to the compensatory inclinationsdesigned for the incisor region, 2 whose effects onthe arch length were eventually scientifically proven10 a few years later, changes were incorporated incanine angulation with the purpose of monitoringthe compensations built into incisor brackets. 4Thus, the mesiodistal angulation of canines wouldbe increased whenever orthodontic treatmentaimed to incline incisors labially, and be decreasedwhen the goal was either to incline incisors linguallyor maintain an existing lingual compensation.The impact exerted by changes in incisor angulationon arch length had been previously assessedby a mathematical model, 7 which showedthat these alterations caused only small changes inthe dental arch. However, no study seems to haveexamined the effects of mesiodistal angulation ofcanines on incisor inclination (torque).In an orthodontic treatment geared toward caseindividualization, such as skeletal malocclusioncases treated with compensations, it is extremelyimportant to recognize the natural features of eachpatient’s compensations. As well as the role playedby incisors, canine angulation needs to be investigatedsince these teeth are positioned in an importantarea within the geometric design of the dentalarch. The first step seems to consist in examiningwhether such canine angulation compensationsare indeed present in the several skeletal alterationsin the face — a fact which was confirmed ina previous study 9 — and also whether or not suchcompensations and changes exhibit a significantcorrelation, which is the purpose of this study.MATERIAL AND METHODSThis study comprised a sample of 60 patientsin the stage of permanent dentition, fromthe private practice of one single orthodontist,with the aim of establishing a correlation analysisbetween mesiodistal canine angulation andlabiolingual incisor inclination and anteroposteriorposition.The sample comprised individuals with differenttypes of malocclusion as determined by molarrelationship: Class I (n=20), Class II (n=20) andClass III (n=20) without previous orthodontictreatment. Patients who presented with toothloss, agenesis, moderate or severe crowding and/or syndromes were immediately excluded sincethese factors might interfere with canine and incisorinclination.Canine and incisor inclination were evaluatedwith the aid of scanned, standardized photographs.To determine canine angulation all quadrants ofthe patients’ casts were photographed, while forincisor inclination only the upper and lower rightsides of the same models were photographed. Thephotographs were taken with a digital camera(Canon Rebel XT 8.0 Megapixel, f=22). The castsDental Press J Orthod 80 2011 May-June;16(3):79-86

Ohashi ASC, Nascimento KCG, Normando DFigurE 1 - Plaster casts of an individual with Class I malocclusion used in the sample.were placed on a glass plate (Fig 2a), at a distanceof 20 cm from the camera (Fig 2b). At the bottomof each model a black device was placed with amarking in the center, used as reference to centralizethe teeth that would be photographed (Fig2c), as described in a previous study. 9The camera lens was propped on a utility waxplate to optimize lens direction (Fig 2d). Caninesand incisors were clearly centered at the time thephotographs were taken. To better visualize thelong axes of canines, these teeth were positionedso that their labial surface faced the examiner (Fig3A). Incisors were positioned in lateral view so asto render visible their inclination (Fig 3B).A total of 360 photographs were taken andlater exported to a computer program (AdobePhotoshop 7.0 ® ) where the occlusal plane wastraced (Fig 4). Those images were subsequentlyimported into an image editing program (ImageTool ® – www.imagetool.com) where canine angulationand incisor inclination were measured.dFigurE 2 - Method used to standardize how photographs of plastermodels were taken to determine canine angulation.When necessary, photograph brightness andcontrast were adjusted in order to enhance visualizationof structures, thereby providing a sharperoutline of the teeth. The occlusal plane was tracedfrom the incisal surface of the central incisors tothe mesiobuccal cusp of the first permanent molarto determine both canine and incisor inclination.Canine angulation measurements were thenbacFigurE 3 - Photograph of plaster study model exported to image editing program to obtain measurementsof canine angulation (A) and incisor inclination (B).Dental Press J Orthod 81 2011 May-June;16(3):79-86

Analysis of the correlation between mesiodistal angulation of canines and labiolingual inclination of incisorsperformed using the same graphics software usedfor tracing the long axes of canine crowns. Basedon the intersection of these two lines the value ofthe angle of the clinical crown of the canine wasobtained in the plaster casts. The same programwas used to measure incisor inclination by drawinga line tangent to the center of the right centralincisor crown, which intersected the previouslyoutlined occlusal plane (Fig 3B).Incisor inclination was measured using lateralcephalometric radiographs of the sample (Fig 4).The angle formed between the long axis of mandibularincisors and the mandibular plane (IMPA)and the angle formed between the long axis ofthe maxillary incisors and the palatal plane (1.PP)were also examined. Incisor inclination was alsoassessed using measures 1.NA and 1.NB and distances1-NA and 1-NB.Radiographs were traced manually and pointswere digitized using an 1812 series Genius Tablet.Tracings were performed by one of the researchersand checked by an orthodontist. Measurementswere obtained by means of SMTC(Sistema de Medição e Traçado Cefalométrico)computer software.Statistical analysisAfter obtaining cephalometric and dentalcast measurements, the D’Agostino-Pearson testwas employed to analyze normal data distribution.Method error study was performed by reassessing20 cases. Random error was reviewedby Dahlberg’s formula while systematic errorwas analyzed by intraclass correlation test. Correlationanalysis between the measurements wasperformed using Pearson’s linear correlation test.The confidence level used throughout the analysiswas 5% (P0.05). Itwas also noted that the variation coefficient wasapproximately 10% for measurements made onthe dental casts, and cephalometric angles of theincisors relative to the basal bone (1.PP, IMPA).These values, however, were higher than 25%when the cephalometric measurements relatedthe incisors to a reference line joining their respectivebasal bones to the nasion point (1.NA,1-NA, 1.NB, 1-NB).Random error analysis of measurements madeon the casts ranged from 2% to 2.9% of the mean.Cephalometric measurements that examined theincisors relative to a reference line on the cranialbase (1.NA, 1-NA, 1.NB, 1-NB) showed a randomerror greater than 5% of the mean, while for theangle formed between the long axis of the teethand their apical base (IMPA and 1.PP) error wasabout 2%. However, for all measures examinedby analysis of systematic error using intraclassGoSIMPA1.PPN1.NA1.NBMeBA1-NB1-NAFigurE 4 - Cephalometric tracing used to obtain cephalometric measurementsin this study.Dental Press J Orthod 82 2011 May-June;16(3):79-86

Ohashi ASC, Nascimento KCG, Normando Dcorrelation coefficient, the level of replicabilitywas excellent (Table 1).The results in Table 2 show no significant correlationbetween the position of the incisors, as measuredon the radiographs (1.NA, 1.PP and 1-NA),and canine angulation, as examined on the casts. Ascan be observed, there was a weak but significantpositive correlation between the position of theincisors, as measured on the casts, and canine angulation(P

Analysis of the correlation between mesiodistal angulation of canines and labiolingual inclination of incisorstablE 2 - Pearson’s correlation matrix (r) and P value (in parentheses) for measurements made in the upper arch.Upper Inc (Cast) 13 23 1.NA 1-NA 1.PPr (P) r (P) r (P) r (P) r (P) r (P)Maxillary Incisor (Cast) 1.00 --- --- --- ---Angulation 13 0.30 (0.018)* 1.00 --- --- --- ---Angulation 23 0.31 (0.017)* 0.62 (0.00)** 1.00 --- --- ---1.NA -0.72 (0.00)** -0.16 (0.24) -0.05 (0.71) 1.00 --- ---1-NA -0.61 (0.00)** -0.06 (0.67) 0.03 (0.80) 0.87 (0.00)** 1.00 ---1.PP -0.72 (0.00)** -0.21 (0.11) -0.11 (0.39) 0.91 (0.00)** 0.71 (0.00)** 1.00* P

Ohashi ASC, Nascimento KCG, Normando Dspecifically for this study, which also showed anexcellent level of replicability and a random errorof about 2% (Table 1).The correlation between canine angulationand incisor inclination yielded different results dependingon whether the incisors were examinedcephalometrically or on the casts. The maxillaryarch (Table 2) exhibited a weak (r=0.3/0.31) butsignificant correlation (P0.05).The lower arch (Table 3) showed a statisticallysignificant correlation every time that canine angulationwas correlated with incisor inclination,as measured on the casts (r=0.46/0.52, P

Analysis of the correlation between mesiodistal angulation of canines and labiolingual inclination of incisorsReferEncEs1. Andrews L. The six keys to normal occlusion. Am J Orthod.1972;62(3):296-309.2. Andrews L. The diagnostic system: occlusal analysis. DentClin N Am. 1976;20(4):671-90.3. Angle EH. The latest and best in orthodontic mechanism.Dent Cosmos. 1928;70:1143-58.4. Capelozza Filho L, Silva Filho OG, Ozawa TO, Cavassan AO.Individualização de bráquetes na técnica de straight wire:revisão de conceitos e sugestões de indicações para uso.Rev Dental Press Ortodon Ortop Facial. 1999;4(4):87-106.5. Capelozza Filho L, Fattori L, Maltagliati LA. Um novométodo para avaliar as inclinações dentárias utilizando atomografia computadorizada. Rev Dental Press OrtodonOrtop Facial. 2005;10(5):23-9.6. GhahferokhI AE, Elias L, Jonssons S, Rolfe B, RichmondS. Critical assessment of a device to measure incisorcrown inclination. Am J Orthod Dentofacial Orthop.2002;121(2):185-91.7. Hussels H, Nanda RS. Effect of maxillary incisor angulationand inclination on arch length. Am J Orthod DentofacialOrthop. 1987;91(3):233-9.8. Ishikawa H, Nakamura S, Kim C, Iwasaki H, Satoh Y, YoshidaS. Individual growth in class III malocclusions and itsrelationship to the chin cap effects. Am J Orthod DentofacialOrthop. 1998;114(3):337-46.9. Azevedo LR, Torres TB, Normando ADC. Angulação doscaninos em indivíduos portadores de má oclusão de ClasseI e de Classe III: análise comparativa através de um novométodo utilizando imagens digitalizadas. Dental Press JOrthod. 2010;15(5):109-17.10. Ohigiins EA, Kirschen RH, Lee RT. The influence ofmaxillary incisor inclination on arch length. Br J Orthod.1999;26(2):97-102.11. Richmond S, Klufas ML, Syawany M. Assessing incisorinclination: a non-invasive technique. Eur J Orthod.1998;20(6):721-6.12. Sangcharearn Y, Ho C. Maxillary incisor angulation and itseffect on molar relationships. Angle Orthod. 2007;77(2):221-5.13. Zanelato ACT, Maltagliati LA, Scanavini MA, Mandetta S.Método para mensuração das angulações e inclinações dascoroas dentárias utilizando modelos de gesso. Rev DentalPress Ortodon Ortop Facial. 2006;11(2):63-73.Submitted: August 2008Revised and accepted: November 2008Contact addressDavid NormandoRua Boaventura da Silva, 567- apt. 1201CEP: 66.060-060 - Belém / PA, BrazilE-mail: davidnor@amazon.com.brDental Press J Orthod 86 2011 May-June;16(3):79-86

O r i g i n a l A r t i c l eEvaluation of shear strength of lingualbrackets bonded to ceramic surfacesMichele Balestrin Imakami*, Karyna Martins Valle-Corotti**,Paulo Eduardo Guedes Carvalho**, Ana Carla Raphaelli Nahás Scocate**AbstractObjectives: The aim of this study was to evaluate the shear strength of lingual metalbrackets (American Orthodontics) bonded to ceramic veneers. Methods: A total of 40specimens were divided into four groups of 10, according to bonding material and ceramicspreparation: Group I - Sondhi Rapid-Set resin and hydrofluoric acid, Group II - SondhiRapid-Set resin and aluminum oxide, Group III - Transbond XT resin and hydrofluoricacid, and Group IV - Transbond XT resin and aluminum oxide. Prior to bonding, thebrackets were prepared with heavy-duty resin base (Z-250) and the ceramic veneers weretreated with silane. The shear test was conducted with a Kratos testing machine at a speedof 0.5 mm/min. Results: The results were statistically analyzed by the Tukey test (p

Evaluation of shear strength of lingual brackets bonded to ceramic surfaceslingual orthodontics, which was indicated forthose patients who value aesthetics and sometimesrefuse traditional orthodontic treatment. 9Besides the concern with aesthetics, anotherimportant factor to be considered in adultpatients is the presence of prosthetic ceramiccrowns. This fact raises the need for studieson the bonding of orthodontic brackets to lingualceramic surfaces. 15 Although the literaturecontains research on the bonding of bracketsto ceramic surfaces, their results were based ontechniques for bonding directly to the labialsurface. 4,8,15It is noteworthy that lingual bonding differsfrom labial bonding in many respects. Thefirst difference is the laboratory phase, whichconsists in positioning the brackets in a plastermodel with the teeth properly positionedin a setup model of the patient’s initial malocclusion.Each bracket receives a portion offiller resin on their base to regularize lingualsurface anatomy and the buccolingual widthof the teeth, thereby preventing the archwirefrom having inset/offset bends placed duringorthodontic treatment. Thus, bracket bonding(in the patient) occurs by adhesion betweenthe resin on the bracket base and the enamelor ceramic surface. 2Another difference is that the lingual surfacesof teeth exhibit different characteristicswhen compared to labial surfaces. The lingualsurface of posterior teeth is narrower mesiodistallyin the occlusocervical direction, showinga steep curvature relative to the labial surface.The upper incisors display concave surfaceswith compromised visibility while the lowerincisors are affected by tongue position, whichrequires a skilled professional. 3Thus, the lingual technique requires scientificstudies to assess and reduce the rateof bracket debonding. It further requires theuse of the best possible materials and bondingtechniques for preparation of ceramic surfacesmainly due to the fact that ceramic surfacesexhibit lower adhesion than dental enamel.OBJECTIVEBased on the reviewed literature, this studyintended to evaluate the shear strength of lingualbrackets bonded to ceramic surfaces usingtwo resins, i.e., Sondhi Rapid-Set A and Bself-curing resin (3M-Unitek) and TransbondXT light-curing resin (3M-Unitek), in additionto two ceramic surface preparation materials,namely, hydrofluoric acid and aluminum oxide.MATERIAL AND METHODSFor this experiment 40 lingual premolarmetal brackets of the Stealth brand (AmericanOrthodontics, Lot No.: 395-0023B) wereprepared and had their shear strength testedas follows:Bracket base resin preparationFor this research a maxillary arch model inideal occlusion was selected. The model wasduplicated with dental plaster and the lingualbrackets were bonded using resin Z-250 (3M,Lot No.: 5BX) to the maxillary right first molarsand premolars.To determine the exact position of the fortybrackets on the second premolars a rectangular0.017x0.025-in stainless steel archwire (AmericanOrthodontics) was adapted to the bondedbrackets bypassing the distal side of the secondmolars, resting on the occlusal surface of themolars and stabilized with self-curing acrylicresin (Ortho Cril yellow, Dental Vip). The mesiodistalposition of the brackets was standardizedwith a red mark on the wire which coincidedwith the mesial bracket tie wing (Fig 1).The surface of the second premolars received aninsulation layer (Cel-lac) to prevent the bracketsfrom adhering to the plaster.Single Bond 2 (3M) was applied to the secondpremolar bracket bases prior to Z-250 resinDental Press J Orthod 88 2011 May-June;16(3):87-94

Imakami MB, Valle-Corotti KM, Carvalho PEG, Scocate ACRNFigurE 1 - Model with brackets bonded and 0.017x 0.025-in stainlesssteel adapted with acrylic resin.FigurE 2 - Occlusal view of model with bracket positioned on secondpremolar and stabilized with occlusal support during resin base Z-250preparation.application. After placing the brackets in themodel all excesses was removed and the resinwas cured for 20 seconds (Fig 2).The resin bases of the 40 brackets receiveda jet of aluminum oxide (Bio-art, Lot No.:156,957) for 5 to 10 seconds at a distance of 10mm until they turned white and opaque. Subsequently,the resin was cleaned with a brush anda solution of ether at 50% (Removex), followedby acetone solution (5, Lutex AP at 58%, LotNo. 11256208), for removal of any oily resinlayer from the bracket bases.Fabrication of ceramic specimensThe second premolars in the model receiveda coat of waxing wax in order to compensate forany shrinkage in the ceramics caused by ovenheat (Fig 3). An impression of the model wasthen made with heavy condensation silicone(Zetalabor). On top of this new impression theceramic body was applied to the lingual half ofthe crown impression and subsequently driedwith an electric dryer to remove moisture fromthe ceramic.The ceramic body was placed in a vacuumoven at a temperature of 925°C for 1 minute.Finishing was accomplished with fine-graineddiamond stone and polishing was completedFigurE 3 - Plaster model with wax added to half of second premolar.with a special rubber made especially for thisprocedure. The piece was glazed and surfaceimperfections corrected. The ceramic body wasplaced in a non-vacuum oven at a temperatureof 880°C for 1 minute.Acrylic cylinder preparationA cylinder of Jet acrylic resin was fabricatedusing a silicone impression tray with 11.0 mmdiameter and 8.0 mm thickness to match theDental Press J Orthod 89 2011 May-June;16(3):87-94

Evaluation of shear strength of lingual brackets bonded to ceramic surfacesFIGURE 4 - Acrylic cylinder with ceramic specimen adapted withacrylic resin.FigurE 5 - Specimen bonded to ceramic veneer attached to acrylic resincylinder with bracket base parallel to cylinder surface (lateral distalview of bracket).size of the metal support on the KRATOS testingmachine. The ceramic specimen — in theshape of the second premolar — was attachedto the cylinder in such a manner as to allow themetal base of the bracket to be positioned parallelto the acrylic surface after bonding (Fig 4).Ceramics preparation and bracket bondingTwenty ceramic pieces, which had alreadybeen inserted in the acrylic cylinder, were preparedwith a jet of aluminum oxide (Bio-art,Lot No. 156,057) for 5 seconds at a distance of5 to 10 mm, rinsed thoroughly and dried withair. The other part of the sample was preparedwith 10% hydrofluoric acid (Dentsply, Lot No.579861) for 4 minutes, rinsed and dried for 15seconds as described by the manufacturer.All ceramic veneers received an application ofsilane (Dentsply, Lot No. 209,071) in a 1:1 ratio,mixed for 10 seconds, with a 5-minute rest.On twenty specimens (10 prepared with aluminumoxide and 10 with hydrofluoric acid)brackets were bonded with Sondhi Rapid-Set A(3M-Unitek, Lot: 051219), applied to the ceramicsurface; and Sondhi Rapid-Set B (3M-Unitek, Lot:0511114), applied to the resin base of the bracket.On the other twenty specimens (10 preparedwith aluminum oxide and 10 with hydrofluoricacid) brackets were bonded using Transbond XTadhesive (3M-Unitek, Lot: 6 CP) (Fig 5).Thus, taking into account ceramics preparationand bonding system, the samples were dividedinto four groups with 10 brackets each,as follows:» Group I - Sondhi and hydrofluoric acid.» Group II - Sondhi and aluminum oxide.» Group III - Transbond XT and hydrofluoricacid.» Group IV - Transbond XT and aluminumoxide.Specimen storage for shear strength testThe specimens were stored for seven daysprior to shear test in plastic containers withlids and water at room temperature. The containerswere kept in a thermal bag to maintainthe temperature.Shear strength testTensile shear strength tests were performedwith a KRATOS Universal Testing Machine atthe Department of Prosthodontics, Bauru Schoolof Dentistry, University of São Paulo (Fig 6), byapplying 50 Kgf of force at 0.5 mm/min. The valuesinitially obtained in kgf were converted intoMPa, a measure used for pressure evaluation.Dental Press J Orthod 90 2011 May-June;16(3):87-94

Imakami MB, Valle-Corotti KM, Carvalho PEG, Scocate ACRNRESULTSBased on the methodology used in this studycomparative results were obtained for the fourgroups. Table 1 shows the results of means andstandard deviations for the four groups.In checking the normal distribution ofdata, the Kolmogorov-Smirnov test showedno statistically significant difference (p>0.05).The Bartlett test, which was used to checkhomoscedasticity (homogeneity of variance)between groups showed no statistically significantdifference between variances (p =0.127). After the criteria of normality and homoscedasticityhad been applied, one-criterionvariance analysis was used to compare groups,disclosing a statistically significant differencebetween groups (Table 2).Tukey’s test for multiple comparisons onlyshowed statistically significant differences betweenGroup I and Group IV, and betweenGroup III and Group IV (Table 3).FigurE 6 - KRATOS Universal Testing Machine, Department of Prosthodontics,Bauru School of Dentistry, University of São Paulo.Statistical AnalysisThe test results were analyzed statistically.In order to check whether or not the data hadnormal distribution, the Kolmogorov-Smirnovtest was used, and to test for homogeneityof variance among groups, the Bartlett testwas used. 21 To compare differences betweengroups, one-criterion variance analysis (ANO-VA) was performed. When ANOVA showed asignificant difference, the Tukey test for multiplecomparisons was applied. In all tests, a significancelevel of 5% was adopted. 21 The testswere performed using the program Statisticsfor Windows v. 5.1 (StatSoft Inc., USA).tablE 1 - Shear strength means and standard deviations for the fourgroups, in Mpa.GroupmeanStrengthSDI 2.77 0.93II 4.30 1.74III 3.33 1.35IV 6.00 2.17TABLE 2 - One-criterion variance analysis (ANOVA) for comparing thefour groups.GL QM GL QMeffect effect error error3 19.444 35 2.663 7.302 0.001**Statistically significant difference (p < 0.05).TABLE 3 - Tukey’s test for multiple comparisons among the fourgroups.ComparisonI x III x III* Statistically significant difference (p < 0.05).ns = no statistically significant difference.Fp0.212ns0.886 nsI x IV 0.001*II x IIIII x IV0.552 ns0.110 nsIII x IV 0.004*pDental Press J Orthod 91 2011 May-June;16(3):87-94

Evaluation of shear strength of lingual brackets bonded to ceramic surfacesDISCUSSIONThe bonding of lingual brackets to a ceramicsurface was evaluated in this study by comparingtwo kinds of ceramics preparation and twobonding resins.The decision to use silane in this study wasbased on data from the literature that proveits effectiveness in the bonding of labial brackets.11,15,16,22 When applied to ceramic surfaces,silane increased the shear strength, regardless ofhow the ceramics was prepared. 15,16 Althoughthe use of silane is considered optional by someauthors 1,20 — due to difficulties inherent in lingualbonding combined with the inadequatebond strength shown by ceramic surfaces — thesilane used on all ceramic surfaces in this researchwas considered an important element.Although no research has hitherto been conductedon the bonding of lingual brackets toceramic surfaces, Wiechmann, 18 in a recent investigationrecommended the use of aluminumoxide and hydrofluoric acid prior to bondingceramic brackets.The bonding of lingual brackets, which consistsof two stages (clinical and laboratory), oftenwith indirect bonding, prompted the needto evaluate the difference in strength between achemically activated (self-curing) bonding resin(Sondhi Rapid-set A and B) and a light-curedresin (Transbond XT).The self-curing resin brand commonly foundin the literature is Concise which, when combinedwith hydrofluoric acid showed, respectively,mean values of 17.38 MPa, 15 9.52 MPa, 8and 4.17 MPa. 11 In this study, when preparationwas carried out using hydrofluoric acid andbonding performed with the self-curing resin(Sondhi) the mean value found was 2.77 MPa.Cochran et al 1 obtained a mean value of39.10 MPa when evaluating the shear bondstrength of Concise on a ceramic surface previouslyprepared with aluminum oxide and silane,while Gillis and Redlich 5 found a mean valueof 17.90 MPa. Sant’Anna et al 15 used a primer(Scotchprime - 3M) after the aluminum oxideand found a mean value of 18.64 MPa. Literaturevalues were found to be higher than those reportedin this paper. Group II (Sondhi resin andaluminum oxide) showed shear strength of 4.30MPa. However, the self-curing resin used was differentfrom those reported in the literature.The lower values of Groups I and II comparedto those observed in the literature may have occurreddue to differences between labial andlingual bonding techniques. In the lingual technique,adhesion between brackets and ceramicsurfaces occurs between the resin on the base(Z-250) and the bonding material, but in the labialtechnique adhesion takes place between themetal bracket base and the bonding material.Transbond XT is the most widely used selfcuringresin in the literature and was also selectedfor this research. Nebbe and Stein 12 alsoused this resin but prepared the ceramic surfacewith 37% phosphoric acid and silane, obtaininga mean value of 6.03 MPa. This result washigher than the one found in this study, whichyielded a mean value of 3.33 MPa in Group III.However, the acid used in this study was 10%hydrofluoric acid. The choice of acid also differsfrom the one used by Moreira et al, 11 whoapplied 35% phosphoric acid with silane to theceramic surface and found a mean value of 4.27MPa, also higher than the results of this study.Based on the methodology, the resultsshowed that the values of Groups I, II and IIIwere lower than would be clinically acceptable,i.e., between 6 and 8 MPa. 19 Group IV showedthe best result, with values near those indicatedfor clinical use.Group IV (Transbond XT + aluminum oxide)yielded a mean value of 6.00 MPa. This groupshowed the best overall results, demonstratingsuperior shear bond strength. Nebbe andStein 12 concluded that bonding with TransbondXT combined with silane achieves a bondingDental Press J Orthod 92 2011 May-June;16(3):87-94

Imakami MB, Valle-Corotti KM, Carvalho PEG, Scocate ACRNstrength comparable to bonding to enamel. Althoughthe literature reports the effectivenessof Transbond XT and aluminum oxide, no associationwas found with ceramics bonding.When the groups were subjected to analysisof variance a statistically significant differencewas found between groups (Table 2). Tukey’stest showed that this difference was found betweenGroups I and IV, and III and IV.The difference between Groups I and IV involvedall the factors studied in this research.The resin and preparation used in Group IV(Transbond XT aluminum oxide) showed greatershear strength than in Group I (hydrofluoricacid + Sondhi) (Table 3). Based on the methodologyused in this work, light-curing resinproved superior to chemically activated resin.This result differs from other studies in the literature,which did not use Sondhi resin. 4,10Groups III and IV, which were also statisticallydifferent, showed that aluminum oxide issuperior to hydrofluoric acid when bonding toceramic surfaces (Table 3). This result is in agreementwith Cochran et al, 1 who noted that whenceramics is treated with silane, aluminum oxideaffords greater strength than hydrofluoric acid.Some authors contradict the results reportedabove. Gillis and Redlich 5 conducted an electronmicroscopy analysis and revealed that erosioncaused by a diamond bur or jet of aluminum oxideproduced superficial wear while hydrofluoricacid produced deep wear. In a literature review,Vieira et al 16 concluded that hydrofluoric acidappears more effective than aluminum oxide forroughening the ceramic surface.Wiechmann 18 described the influence of ajet of aluminum oxide prior to etching withphosphoric acid. The author concluded that theadhesive strength between enamel and bondingmaterial can be significantly increased with a jetof aluminum oxide prior to etching. He recommendedthe same procedure when bonding toceramic surfaces.Due to difficulties involved in bonding lingualbrackets, an effective method has beensought to ensure a low debonding rate. Thecombination of hydrofluoric acid and aluminumoxide applied to the ceramic surface canincrease shear strength. In this study, the bestresult was obtained with Transbond XT lightcuringresin. Some professionals, however, stillprefer self-curing resins. It is therefore suggestedthat other chemically activated resins also beevaluated to meet this market demand.CONCLUSIONSBased on the methodology used and resultsachieved in this study, it can be concluded that:The bonding of lingual brackets to ceramicsurfaces exhibited greater shear strength whenaluminum oxide was used in association witheither of the two resins utilized in this study,although Transbond XT showed greater shearstrength than Sondhi Rapid-Set.Dental Press J Orthod 93 2011 May-June;16(3):87-94

Evaluation of shear strength of lingual brackets bonded to ceramic surfacesReferEncEs1. Cochran D, O’Keefe KL, Turner DT, Powers JM.Bond strength of orthodontic composite cement totreated porcelain. Am J Orthod Dentofacial Orthop.1997;111(1):297-300.2. Chumak L, Galil KA, Way DC, Johnson LN, Hunter WS.An in vitro investigation of lingual bonding. Am J OrthodDentofacial Orthop. 1989;95(1):20-8.3. Echarri P. Procedimiento para el posicionamiento debrackets em Ortodoncia lingual. Parte I. Ortod Clin.1998;1(2 Pt 1):69-77.4. Eustaquio R, Garner LD, Moore BK. Comparative tensilestrengths of brackets bonded to porcelan with orthodonticadhesive and porcelain repair systems. Am J OrthodDentofacial Orthop. 1988;94(5):421-5.5. Gillis I, Redlich M. The effect of different porcelainconditioning techniques on shear bond strength ofstainless steel brackets. Am J Orthod Dentofacial Orthop.1998;114(4):387-92.6. Huang TH, Kao CT. The shear bond strength of compositebrackets on porcelain teeth. Eur J Orthod. 2001;23(4):433-9.7. Jost-Brinkmann PG, Can S, Drost C. In-vitro study of theadhesive strengths of brackets on metals, ceramic andcomposite. Part 2: bonding to porcelain and compositeresin. J Orofacial Orthop. 1996;57(3 Pt 2):132-41.8. Kao EC, Johnston WM. Fracture incidence on debonding oforthodontic brackets from porcelain veneer laminates. J ProsthetDent. 1991;66(5):631-7.9. Kurz C, Romano R. Lingual Orthodontics: historicalperspective. In: Romano R. Lingual Orthodontics. Amilton:BC Decker; 1998.10. Major PW, Koehler JR, Manning KE. 24-hour shear bondstrength of metal orthodontic brackets bonded to porcelainusing various adhesion promoters. Am J Orthod DentofacialOrthop. 1995;108(3):322-9.11. Moreira NR, Sinhoreti MAC, Oshima HMS, Casagrande RJ,Consani RLX. Avaliação in vitro da resistência à tração debraquetes ortodônticos metálicos colados ao esmalte ou àcerâmica, com compósitos químicos ou fotoativados. BiosciJ. 2001;17(2):171-82.12. Nebbe B, Stein E. Orthodontic brackets bonded to glazedand deglazed porcelain surfaces. Am J Orthod DentofacialOrthop. 1996;109(4):431-6.13. Newman SM, Dressler KB, Grenadier MR. Direct bonding oforthodontic brackets to esthetic restorative materials using asilane. Am J Orthod. 1984;86(6):503-6.14. Pannes DD, Bailey DK, Thompson JY, Pietz DM.Orthodontic bonding to porcelain: a comparison ofbonding systems. J Prosthet Dent. 2003;89(1):66-9.15. Sant’Anna EF, Monnerat ME, Chevitarese O, Stuani MBS.Bonding brackets to porcelain – In vitro study. Braz Dent J.2002;13(3):191-6.16. Vieira S, Saga A, Wieler W, Maruo H. Adesão em Ortodontia– Parte 2. Colagem em superfícies de amálgama, ouro ecerâmica. J Bras Ortodon Ortop Facial. 2002;7(41 Pt 2):415-24.17. Wang WN, Tarng TH, Chen YY. Comparison of bond strengthbetween lingual and buccal surfaces on young premolars.Am J Orthod Dentofacial Orthop. 1993;104:251-3.18. Wiechmann D. Lingual orthodontics (Part 3): intraoralsandblasting and indirect bonding. J Orofac Orthop. 2000;61(4 Pt 3): 280-91.19. Winchester L. Direct orthodontic bonding to porcelain: an invitro study. Br J Orthod. 1991;18(4):299-30.20. Zachrisson BU. Orthodontic bonding to artificial toothsurfaces: clinical versus laboratory findings. Am J OrthodDentofacial Orthop. 2000;117(5):592-4.21. Zar JH. Biostatistical analysis. 3 rd ed. New Jersey: Prentice-Hall; 1996.22. Zelos L, Bevis RR, Keenan KM. Evaluation of the ceramic/ceramic interface. Am J Orthod Dentofacial Orthop.1994;106(1):10-21.Submitted: May 2007Revised and accepted: November 2007Contact addressMichele Balestrin ImakamiAvenida Vila Rica, 6 - CentroCEP: 87.250-000 - Peabiru / PR, BrazilE-mail: michele_bales@oi.com.brDental Press J Orthod 94 2011 May-June;16(3):87-94

O r i g i n a l A r t i c l eEducation and motivation in oral health —preventing disease and promoting health inpatients undergoing orthodontic treatmentPriscila Ariede Petinuci Bardal*, Kelly Polido Kaneshiro Olympio*, José Roberto de Magalhães Bastos**,José Fernando Castanha Henriques**, Marília Afonso Rabelo Buzalaf***AbstractIntroduction: It is incumbent upon dentists to prevent disease, minimize risks and promotehealth. Patients also need to be made aware of their role in oral health care. Patientsundergoing orthodontic treatment find it particularly difficult to maintain satisfactoryoral hygiene owing to the presence of bands, wires and ligatures. It is therefore crucialto establish preventive motivation and guidance methods to ensure mechanical controlof dental plaque. Objectives: This study investigated the effects of educational, preventiveand motivational actions on the oral health of patients undergoing fixed orthodontictreatment. Methods: Participants received free toothpaste and toothbrushes throughoutthe study and instructions on oral hygiene were provided and reinforced throughout thesix months of research. Physical examination was performed at baseline and after 6, 12and 24 weeks for verification of plaque, gingival and bleeding indices. Results: Initially, theoral hygiene of participants was inadequate. During the study, significant improvementin oral health occurred in all indices. Preventive, educational and motivational actionsundertaken in this study were statistically effective in improving the oral health of orthodonticpatients. Conclusion: Health promotion and disease prevention should be part andparcel of the care provided by orthodontists directly to their patients whereas oral healthcare guidance and motivation should be provided before and during treatment.Keywords: Prevention. Education. Motivation. Orthodontics. Oral health.How to cite this article: Bardal PAP, Olympio KPK, Bastos JRM, Henriques JFC, Buzalaf MAR. Education and motivation in oral health - preventing disease andpromoting health in patients undergoing orthodontic treatment. Dental Press J Orthod. 2011 May-June;16(3):95-102.* MSc in Orthodontics and Public Health Dentistry, FOB-USP. PhD in Public Health, FSP-USP.** Head Professor, Department of Pediatric Dentistry, Orthodontics and Public Health, Bauru School of Dentistry – FOB-USP.*** Head Professor, Department of Biological Sciences, FOB-USP.Dental Press J Orthod 95 2011 May-June;16(3):95-102

Education and motivation in oral health — preventing disease and promoting health in patients undergoing orthodontic treatmentintroductionPreventive dentistry has proved a landmarkin the health care field. Oral health care hasreached beyond aesthetic concerns. The newhealth paradigm has raised considerable awarenessregarding the need to maintain satisfactoryoral health, which in turn is reflected in theoverall health of individuals.Health professionals are responsible forpromoting disease prevention, minimizing risksand creating favorable conditions that enablepatients to achieve and maintain oral health.Moreover, patients also need to be made awareof their role in oral health care.One of the major and most common challengesin prevention within the field of oralhealth is the control of plaque and, consequently,the control of dental caries and gingivalinflammation. 10,32,36Mechanical methods such as the use oftoothbrush and dental floss, when applied effectively,can promote proper plaque control.30,38 Dentists and their staff play a key rolein guiding and encouraging patients to performproper oral hygiene frequently and effectively.Peculiarities of orthodontic treatmentDue to the declining prevalence of dentalcaries the population began to lose fewer teeth.Furthermore, racial mixing and improved preventivemethods have turned crowding into acommonplace cosmetic and occlusal problem,which ultimately boosts demand for orthodontictreatment. 5,28Patients undergoing fixed orthodontic treatmentare more prone to retaining dental plaque.Orthodontic accessories can lead to enamel demineralization,causing white spots, tooth decayand gingivitis. 15,19,20 Therefore, this group ofpatients is particularly compelled to take careof their oral hygiene since it is a challengingtask to maintain acceptable oral hygiene in thepresence of bands, wires and ligatures. 27Mechanical methods of plaque removal requiretime, motivation and manual skill. 13 Evenpatients who are properly trained and instructedto maintain satisfactory hygiene often seetheir compliance falter unless constant healtheducation reinforcement is provided. 3 In lightof these factors one cannot ignore that the domesticenvironment poses certain limitationson proper oral hygiene. 31According to Heintze 20 treatment with fixedappliances constitutes a substantial interventionin the oral cavity environment. Orthodonticaccessories involve a high risk of dental cariesand periodontitis. However, iatrogenic complicationsoccur due to patient unpreparednessbefore the orthodontic appliance is placed, inaddition to lack of motivation and reinforcementduring treatment.Microbiological studies have establishedthat after a fixed orthodontic appliance hasbeen placed the number of bacteria rises significantly,particularly lactobacilli and streptococci,subjecting the oral environment to animbalance that predisposes to the emergenceof diseases. 16Thus, successful orthodontic treatment liesin correcting occlusion in the best possiblemanner without, however, affecting the preexistinghealth of teeth and supporting tissues.Otherwise, treatment benefits may be calledinto question. 37Patients wearing orthodontic appliancesmust be encouraged to take good care of theiroral cavity as hygiene can prove difficult inthese cases. While problem areas in bandedteeth are located on the cervical side of theband, in teeth with bonded brackets the criticalsurfaces are those on the mesial and distal sidesof the bracket base. These areas are located underthe archwire “shadow” and are inaccessibleto toothbrush bristles. 20Perfect cleaning of teeth in patients withfixed appliance takes at least ten minutes,Dental Press J Orthod 96 2011 May-June;16(3):95-102

Bardal PAP, Olympio KPK, Bastos JRM, Henriques JFC, Buzalaf MARwhich requires considerable care and discipline.Preventive treatment remains the mosteffective weapon in the fight against dentalproblems. No doubt the only viable approachto address these issues is through awarenessand education of patients, who will as a resultbe encouraged to play an active role in preventiveprograms. 20,28Prevention in orthodonticsGiven the potential — and not uncommon— iatrogenic effects caused by orthodontictreatment, several authors agree that preventivemethods should be provided for all patientsundergoing orthodontic therapy. 4,14,17,18,20The type, frequency and quantity of measuresadopted to implement such methods will certainlydepend on the individual characteristicsof both professionals and patients. 4,18Dental plaque should be monitored beforesetting up the appliance and if patients are motivatedduring the course of treatment, one canprevent the gingival index from rising. 9The importance of conducting a motivationand guidance program for the mechanicalcontrol of dental plaque is emphasized byseveral authors. 34,35 Basically, the most efficientand simple method consists in the use of toothbrushand dental floss. 4,30,37Inglehart and Tedesco 22 reported that themodel of oral health promotion ushered in bythe 21 st century begins by examining the interactionbetween patient and oral health professional.Thus, issues related to cognitive, emotional,environmental and behavioral factorsmust be addressed concurrently.In dentistry, education is related to the cognitive,affective and psychomotor realms. Systematiceducation varies with individuals orthe target population as well as with the educationaltools to be employed. It is important thatteachers and learners maintain frequent contactto establish a framework of mutual trust,ensuring a successful communication process. 7The educational component is what enablespeople to assume their share of responsibilityfor their own oral health.Motivation, in turn, is a generic term thatrefers to needs, motives or desires that promptaction. Although some motives are innate andothers acquired, individual response is modifiedby learning and influenced by culture. 7Dentists should develop appropriate skills tobe able to persuade patients to change theirbehavior and thereby gain control over oraldiseases. Changing habits is a complex activityand requires effort, practice and building tieswith individuals. 23OBJECTIVEWithin the context of health promotion anddisease prevention, this study aimed to determinethe effects of educational, preventive andmotivational actions on the oral health of patientsundergoing fixed orthodontic treatment.MATERIAL AND METHODSSelection of participantsAfter approval by the Ethics in Human ResearchCommittee (FOB – USP), 27 patientsfrom the Clinic of Orthodontics, FOB-USP(master’s and specialization) and from the SpecializationCourse in Orthodontics at Bauru-APCD agreed to participate in this researchby signing a Term of Free and Informed Consent.Inclusion criteria were as follows: Beingunder fixed orthodontic treatment planned tolast at least six months beyond the beginningof the study, permanent dentition, good generalhealth condition, not having taken systemic antibioticswithin three months before the beginningof research, not being pregnant, not beinga smoker and exhibiting only minor gingivitis,verified by means of the Gingival Index. 25 Thegroup had a mean age of 16.9 years (14 subjectswere female and 13 male).Dental Press J Orthod 97 2011 May-June;16(3):95-102

Education and motivation in oral health — preventing disease and promoting health in patients undergoing orthodontic treatmentStudy protocolIn this longitudinal clinical study participantsreceived, after baseline examination, a hygienekit containing a toothbrush, dental floss, flossthreader and fluoridated toothpaste (SorrisoFresh Mint Red ® , 1100 ppm F, Kolynos Brazil).Verbal and written guidelines were providedprohibiting the use of other oral hygienechemical products during the experiment.Patients were instructed to brush their teeththree times a day.Toothpaste was supplied to the patients asneeded and the amount of tubes that each patientused during the experiment was recordedas used tubes had to be returned upon replacement.Three months into the study patients’toothbrushes were replaced.At the beginning of the research volunteerscompleted a questionnaire about their hygieneand any recommendations made by their orthodontists.ImplementationAll volunteers received professional prophylaxisafter baseline examination and were furtherexamined at intervals of 6, 12 and 24 weeks.During this examination a new professional prophylaxiswas performed.Instructions and reinforcement on correctoral hygiene and the importance of toothbrushingand proper flossing were provided after baselineexamination and after 6, 12 and 24 weeks.Issues were addressed pertaining to the preventionof diseases such as dental caries and periodontaldiseases, the fact that the orthodonticappliance required special individual efforts tomaintain oral hygiene, and the understandingthat plaque accumulates around the brackets,which requires additional care and the properuse of dental floss and a floss threader.To this end, when dental plaque became apparent,patients were shown in mirrors the regionsof greater plaque accumulation and theclinical characteristics of gingival tissue in theinflamed areas. Proper hygiene instructions werethen provided. Floss threader use was explainedwith the aid of manikins. Educational and preventiveactivities comprised a lecture at the beginningof the research attended by all patientsand their parents and subsequently verbal instructionswere given to patients after each clinicalexamination (baseline, 6, 12 and 24 weeks).A previously trained examiner 29 performedthe examinations in a dental office. Examinationswere made under artificial light and withcompressed air, using probes recommended bythe World Health Organization (WHO) and flatclinical mirrors. Two percent fuchsin was appliedin order to disclose supragingival dental plaque.The tests were as follows:1. Gingival index 25 to reveal the health conditionof gingival tissues and degree of inflammation.Mean GI values ranging from0.1 to 1.0 indicated mild gingivitis, from1.1 to 2.0, moderate gingivitis and from2.1 to 3.0, severe gingivitis.2. Bleeding index 1 to assess the percentage ofsites that bled and those that did not bleedon gentle probing.3. Orthodontic plaque index 21 to determinethe amount of plaque on the teeth. Indexvalues ranging from 0 to 25 representedgood oral hygiene, between 26 to 50points, moderate oral hygiene, and above50, poor oral hygiene.Statistical AnalysisAll data were recorded in individual chartsespecially developed for this study. Numericaldata were entered into Excel spreadsheets forindex calculation. Statistical analysis was performedusing the program InStat GraphPad.Data on gingival, bleeding and plaque indiceswere tested by analysis of variance with repeatedmeasures, and by Tukey’s test. A 5% significancelevel was adopted.Dental Press J Orthod 98 2011 May-June;16(3):95-102

Bardal PAP, Olympio KPK, Bastos JRM, Henriques JFC, Buzalaf MARRESULTSThe initial questionnaire filled out by theparticipants showed that 44.44% of them reporteda toothbrushing frequency of 3 timesa day, 22.22% more than three times a day,29.63% twice daily and 3.70% only once a day.Only 11.11% of the volunteers reported usinginterdental and end-tufted brushes.As regards the instructions provided to patientsby their respective orthodontists, 88.89%of participants reported receiving some sort ofguidance. The need to perform toothbrushingand flossing three times a day was the instructionmost often reported (66.67%), while otherinstructions concerned the use of interdentaland end-tufted brushes (14.81%) and the recommendationnot to ingest hard foods, chewinggum, candy and soft drinks (18.52%). None ofthe questionnaires comprised any reference tosupervised brushing or a more constant monitoringof the patients’ oral health.Table 1 presents mean values for PlaqueIndex (PI), Gingival Index (GI) and BleedingIndex (BI) at baseline examination, and after6, 12 and 24 weeks of follow-up. Initially, oralhygiene conditions were less than satisfactory,which can be attested by the fact that the PIand GI mean values, in their respective scales,reflect poor oral hygiene (PI>50) and moderategingivitis (GI = 1.0 to 2.0). During the study,the group reported significant improvement inoral health at all levels.tablE 1 - Mean values and standard deviation for Plaque Index (PI),Gingival Index (GI) and Bleeding Index (BI) at baseline examination, andafter 6, 12 and 24 weeks of follow-up.PI GI BIBaseline 83 (12.11) a 1.21 (0.31) a 33.33% (16.69) a6 weeks 65 (10.61 b 0.79 (0.25) b 12.49% (8.60) b12 weeks 55 (19.28) c 0.71 (0.28) b 12.39% (8.76) b24 weeks 51 (13.99) c 0.55 (0.19) b 6.52% (2.79) bThe different lowercase letters in the same column indicate significantdifferences, as analyzed by ANOVA and Tukey’s test.(p

Education and motivation in oral health — preventing disease and promoting health in patients undergoing orthodontic treatmentpoor oral hygiene. This fact demonstrates thatif hygiene instructions are not reinforced on acontinuous basis maintaining oral health canbe challenging. 20,35The instructions and encouragement offeredto participants during this research were reflectedin clinical and statistical improvement (Table1). Since the most common brushing frequencywas maintained, i.e., 3 times a day (according towhat was reported in the initial questionnaire),it is possible to demonstrate that toothbrushingquality is the decisive factor during oral hygiene.It is reasonable to assume that the distributionof free toothpaste throughout this 6-monthstudy also contributed to improving the group’soral health. Davies et al. 12 found that the freeand regular supply of fluoridated toothpastein a program conducted in England succeededin significantly reducing dental caries rates in5-year-old children.Control of plaque, gingivitis and bleedingshould be ongoing and effective in orthodonticpatients. Glans, Larsson, Ogaard 19 found thatafter installation of the orthodontic applianceall patients exhibited mild gingivitis, but afterremoval of the orthodontic appliance gingivalconditions returned to normal. This fact doesnot justify neglecting hygiene during treatment,especially when one is engaged in a philosophyof health promotion. Moreover, in the presenceof gingival inflammation, forces produced by theorthodontic appliance worsen tissue response,producing as a result increased destruction ofprotective and support tissues. 26Heintze 20 asserts that, especially in adolescents,gingival hyperplasias often emerge in responseto plaque accumulation, thereby hinderingoral hygiene and creating a vicious circle.Feliu 18 demonstrated that patients undergoingorthodontic treatment may have lower levelsof plaque and gingival inflammation than patientswho are not under orthodontic treatmentprovided that they first attend an educationalpreventiveprogram.Silva et al. 33 showed that one group of orthodonticpatients who received oral hygiene instructionsonly on the first day of treatment didnot change their habits while the other group,who was given instructions every fortnightthroughout the period with hygiene classes andmotivation and were monitored with a plaquecontrol chart, achieved a better oral hygiene indexgiven the additional encouragement.Motivation is based on understanding whatis normal and what is pathological in the oralcavity. Thus, one can change patient habitsand render them active participants in thecontrol, treatment and maintenance of theirown oral health. 24Well planned, evidence-based educationalprograms with a solid scientific background andan understandable terminology tailored to meetthe needs of the target group are highly likely toachieve planned results. 5,7CONCLUSIONSThe preventive, educational and motivationalactions undertaken in this study proved statisticallyeffective in improving the oral health oforthodontic patients.The current health paradigm requires thatpatients be regarded as one single whole. Healthpromotion and disease prevention should bepart of the philosophy adopted by orthodontistsin caring for their patients. Furthermore, professionalsshould provide guidance and motivationto their patients regarding oral health care beforeand during orthodontic treatment.Dental Press J Orthod 100 2011 May-June;16(3):95-102

Bardal PAP, Olympio KPK, Bastos JRM, Henriques JFC, Buzalaf MARReferEncEs1. Ainamo J, Bay I. Problems and proposals for recordinggingivitis and plaque. Int Dental J. 1975;25:229-35.2. Axelsson P. Current role of pharmaceuticals in prevention ofcaries and periodontal disease. Int Dental J. 1993;43(3):473-82.3. Axelsson P, Lindhe J. Efficacy of mouthrinses in inhibitingdental plaque and gingivitis in man. J Clin Periodontol.1987;14:205-12.4. Bacchi EOS, Prates NS, Attizzani A. Profilaxia buco-dentalem ortodontia. Rev Gaúcha Odontol. 1997;45(6):342-46.5. Bastos JRM, Henriques JFC, Olympio KPK. Prevenção decárie e doença periodontal em pacientes sob tratamentoortodôntico. Manual didático. Bauru: Universidade de SãoPaulo; 2001.6. Bastos JRM, Lopes ES, Ramires I. Odontologia social epreventiva. Manual didático. Faculdade de Odontologia deBauru, Universidade de São Paulo, Bauru, 2001.7. Bastos JRM, Sales-Peres SHC, Ramires I. Educação paraa saúde. In: Pereira AC. Odontologia em saúde coletiva:planejando ações e promovendo saúde. Porto Alegre:Artmed; 2003. p.117-39.8. Berglund LJ, Small CL. Effective oral higiene for orthodonticpatients. J Clin Orthod. 1990;24:315-20.9. Boyd RL. Enhancing the value of orthodontic treatment:incorporating effective preventive dentistry into treatment.Am J Orthod Dentofacial Orthop. 2000;117(5):601-3.10. Carvalho LEP, Granjeiro JM, Bastos JRM, Henriques JFC,Tarzia O. Clorexidina em Odontologia. Rev Gaúcha Odontol.1991;39(6):423-7.11. Couto JL, Couto RS, Duarte CA. A motivação do paciente:avaliação dos recursos didáticos de motivação paraprevenção da cárie e doença periodontal. Rev GaúchaOdontol. 1992;40:143-59.12. Davies GM, Worthington HV, Ellwood RP, Bentley EM,Blinkhorn AS, Taylor GO, et al. A randomised controlledtrial of the effectiveness of providing free fluoridetoothpaste from the age of 12 months on reducingcaries in 5-6 year old children. Community Dent Health.2002;19(3):131-6.13. Depaola IG. Chemotherapeutic inhibition of supragingivaldental plaque and gingivitis development. J ClinPeriodontol. 1989;16:311-5.14. Denes J, Gábris K. Results of a 3-year oral hygieneprogramme including amine fluoride products in patientstreated with fixed orthodontic appliances. Eur J Orthod.1991;13(2):129-33.15. Derks A, Katsaros C, Frencken JE, van’t Hof MA, Kuijpers-Jagtman AM. Caries-inhibiting effect of preventive measuresduring orthodontic treatment with fixed appliances. CariesRes. 2004;38(5):413-20.16. Diamanti-Kipioti A, Gusberti FA, Lang NP. Clinical andmicrobiological effects of fixed orthodontic appliances.J Clin Periodontol. 1987;14(6):326-33.17. Dubey R, Jalili VP, Garg S. Oral hygiene and gingival status inorthodontic patients. J Pierre Fauchard Acad. 1993;7(2):43-54.18. Feliu JL. Long-term benefits of orthodontic treatmenton oral hygiene. Am J Orthod Dentofacial Orthop.1982;82(6):473-7.19. Glans R, Larsson E, Ogaard B. Longitudinal changes ingingival condition in crowded and noncrowded dentitionssubjected to fixed orthodontic treatment. Am J OrthodDentofacial Orthop. 2003;124(6):679-82.20. Heintze SD. A profilaxia individual em pacientes comaparelhos fixos: recomendações para o consultório.Ortodontia. 1996;29(2):4-15.21. Heintze SD, Finke C, Jost-Brinkman PG, Miethke RR. Home-caremeasures for reducing oral bacteria. In: Heintze SD, Finke C,Jost-Brinkman PG, Miethke RR. Oral health for the orthodonticpatient. Illinois: Quintessence; 1998. Cap. 4. p. 66-70.22. Inglehart M, Tedesco LA. Behavioral research related tooral hygiene pratices: a new century model of oral healthpromotion. Periodontol 2000. 1995;8:15-23.23. Kay A. The prevention of dental disease: changing yourpatient´s behavior. Dental Update. 1991;7:245-8.24. Kon S. Controle da placa bacteriana. In: Garone Filho W.Atualização em odontologia clínica. São Paulo: Medisa;1980. p. 65-8.Dental Press J Orthod 101 2011 May-June;16(3):95-102

Education and motivation in oral health — preventing disease and promoting health in patients undergoing orthodontic treatment25. Löe H, Silness J. Periodontal disease in pregnancy. ActaOdontol Scand. 1963;21:533-51.26. Lucas GQ, Lucas ON. Efecto de la clohexidina em pacientescom aparatos de ortodoncia. Rev Assoc Odontol Argentina.1997;85(4):355-60.27. Lundströn F, Hamp SE. Effect of oral hygiene education onchildren with and without subsequent orthodontic treatment.Scand J Dental Res. 1980;88:53-9.28. Matos MS. Controle químico e mecânico de placa empacientes ortodônticos. Uma análise por grupos de dentesde acordo com o acessório ortodôntico empregado. RevDental Press Ortodon Ortop Facial. 2003;8(1):87-93.29. Oppermann RV, Rösing CK. Periodontia: ciência e clínica.São Paulo: Artes Médicas; 2001. p.5-9.30. Owens J, Addy M, Faulkner J, Lockwood C, Adair R. A shorttermclinical study design to investigate the chemical plaqueinhibitory properties of mouthrinses when used as adjunctto toothpastes: applied to chlorhexidine. J Clin Periodontol.1887;24(10):732-7.31. Santos A. Evidence-based control of plaque and gingivitis.J Clin Periodontol. 2003;30(5):13-6.32. Sekino S, Ramberg P, Uzel NG, Socransky S, Lindhe J.Effect os various chlorhexidine regimens on salivarybacteria and de novo plaque formation. J Clin Periodontol.2003;30(10):919-25.33. Silva Filho OG, Corrêa AM, Terada HH, Nary Filho H,Caetano MK. Programa supervisionado de motivação einstrução de higiene e fisioterapia bucal em crianças comaparelhos ortodônticos. Rev Odontol Univ São Paulo.1990;4(1):11-9.34. Souza FM. Prevenção de cáries e doenças periodontais emortodontia corretiva: métodos simples para serem usados noconsultório. Ortodontia. 1994;27(3):87-92.35. Souza NM, Falcão AFP, Araújo TM. Higiene bucal nopaciente ortodôntico. Rev Fac Odontol Univ Fed Bahia.1999;18:60-7.36. Sreenivasan PK, Tambs G, Gittins E, Nabi N, GaffarA. A rapid procedure to ascertain the antimicrobialefficacy of oral care formulations. Oral Microbiol Immuol.2003;18(6):371-8.37. Tamburus VS, Bagatin CR, Silva Netto CR. Higiene bucal notratamento ortodôntico: importância da motivação. Rev FacOdontol Lins. 1998;11(1):51-7.38. Torres MCM. Utilização da clorexidina em seus diversosveículos. Rev Bras Odontol. 2000;57(3):174-80.39. Uetanabaro T, Martins JES, Andrade JLF. Acúmulo de placabacteriana em pacientes portadores de colagem direta eanéis convencionais. Rev Gaúcha Odontol. 1984;32(2):161-6.Submitted: November 2006Revised and accepted: June 2008Contact addressPriscila Ariede Petinuci BardalRua Paes Leme, 1-41CEP: 17.013-180 - Bauru / SP, BrazilE-mail: priscilabardal@yahoo.comDental Press J Orthod 102 2011 May-June;16(3):95-102

O r i g i n a l A r t i c l eMicrobiological analysis oforthodontic pliersFabiane Azeredo*, Luciane Macedo de Menezes**, Renata Medina da Silva***, Susana Maria Deon Rizzatto****,Gisela Gressler Garcia*****, Karen Revers******AbstractObjective: To evaluate bacterial contamination of orthodontic pliers used in an academicsetting. Methods: Thirty-four pliers were selected — 17 band remover pliersand 17 bird beak pliers. The control group was composed of 3 previously autoclavedpliers of each model. After use, the pliers in the experimental group were immersed in10 ml of brain-heart infusion (BHI) culture medium for 2 minutes, incubated at 37ºC for 24 to 48 h and seeded in duplicates in different agar-based solid culture mediato detect and identify microbial agents. Results: Microbiological analyses revealed thatthere was contamination in both types of orthodontic pliers. Several bacteria were detected,predominantly staphylococcus and isolated Gram-positive (G+) cocci. The bandremover pliers had a greater contamination rate and mean values of 2.83 x 10 9 and 6.25x 10 9 CFU/ml, with variations according to the type of culture medium. The 139 pliersalso had all types of bacteria from the oral microbiota at values that ranged from1.33 x 10 8 to 6.93 x 10 9 CFU/ml. The highest mean value was found in the medium togrow staphylococci, which confirmed, in certain cases, the presence of Staphylococcusaureus, which are not part of the normal oral microbiota but are usually found in thenasal cavity and on the skin. Conclusion: Orthodontic pliers were contaminated as anyother dental instrument after use in clinical situations. Therefore, they should undergosterilization after each use in patients.Keywords: Dental instruments. Orthodontics. Infection control. Contamination. Microbiology.How to cite this article: Azeredo F, Menezes LM, Silva RM, Rizzatto SMD, Garcia GG, Revers K. Microbiological analysis of orthodontic pliers.Dental Press J Orthod. 2011 May-June;16(3):103-12.* Graduate student, Orthodontics, School of Dentistry, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Brazil.** MSc and PhD in Orthodontics, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil. Professor, Orthodontics, PUCRS, Porto Alegre, Brazil.*** MSc in Genetics and Molecular Biology, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil. PhD in Microbiology, Universidade deSão Paulo (USP), São Paulo, Brazil. Professor, Microbiology, School of Biosciences, PUCRS, Porto Alegre, Brazil.**** MSc in Orthodontics from PUCRS, Porto Alegre, Brazil. Professor, Orthodontics, PUCRS, Porto Alegre, Brazil.***** Undergraduate student, School of Biological Sciences, PUCRS, Porto Alegre, Brazil.****** Graduate in Biological Sciences from Universidade do Oeste Catarinense (UNOESC), São Miguel do Oeste, Brazil. Specialist in Applied Microbiology,UNOESC, São Miguel do Oeste, Brazil.Dental Press J Orthod 103 2011 May-June;16(3):103-12

Microbiological analysis of orthodontic pliersintroductionThe oral cavity has a large variety of microorganismsthat form a complex environmentand a diverse and often pathogenic microbiota.28 Therefore, special attention should be paidto infection control and biosafety in dentistry,and procedures should be adopted to preventand significantly reduce the chances of crossinfection between patients as well as betweenpatient and dentist. 14Infections may be transmitted by direct contactwith blood and oral fluids, or, indirectly,by contact with contaminated instruments orsurfaces. Some of the potentially transmissiblepathogens are hepatitis B and C (HBV andHCV), herpes simplex and human immunodeficiency(HIV) viruses, Mycobacterium tuberculosis,different Staphylococcus and Streptococcusstrains, and other microorganisms responsiblefor upper respiratory tract infections. 2Not all individuals with important diseases canbe identified before a procedure is performed;therefore, all patients, indiscriminately, shouldbe considered potentially contaminated, and,consequently, standard precautions should betaken in all procedures with all patients. 11The terms “sterilization” and “disinfection”,although clearly different, are often confusedand used incorrectly. The destruction of allforms of microbial life, including viruses, is obtainedby means of sterilization. Disinfection, inturn, destroys pathogenic microorganisms butdoes not eliminate sporebearers and resistantmicroorganisms, such as the etiological agentsof tuberculosis and hepatitis. 3,16,10The instruments used in medical and dentalpractice are classified into three categoriesaccording to the risk of infection, the need tosterilize them between uses, and their level ofcontamination: 20,29» Critical: They should be discarded or undergosterilization because they penetrate softtissue or bone.» Semicritical: Instruments that touch oraltissues but do not penetrate hard or soft tissues.They should be sterilized after each use; ifsterilization is not possible because the materialis not heat resistant, the instruments should atleast undergo high-level disinfection.» Noncritical: They touch only intact skinand should only be disinfected or cleaned.In orthodontics, concerns with infection controlhave intensified after the increase of casesof HIV infection, although hepatitis B and C infections,which have a high level of contamination,have been around for a long time. 14 Of alldental healthcare personnel (DHCP), the rateof hepatitis B infection among orthodontists isvery high, 10,13,27 second only to oral surgery specialists,7 as saliva is as infectious as blood. 13Clinical orthodontics, a specialty that usuallyhas more patients than other dental specialties,demands planning and organizationof sterilization and disinfection procedures toensure greater protection to both patients andDHCP. 18,30 Disinfection does not replace sterilizationand, therefore, all material that canundergo sterilization should never be only disinfected.9,10 However, a common error amongorthodontists is to see disinfection as an alternativeto sterilization. 10This study evaluated bacterial contaminationin the active tip of orthodontic pliers usedin patient care by orthodontics graduate studentsusing a microbiological method and theidentification of bacterial agents.MATERIAL AND METHODSSample selectionInstruments ready for clinical use were collectedto analyze the potential of microbialcontamination of orthodontic pliers. Sampleselection was random and took the students bysurprise during their clinical practice classes.Therefore, they had not time to perform proceduresthat might change statistical data orDental Press J Orthod 104 2011 May-June;16(3):103-12

Azeredo F, Menezes LM, Silva RM, Rizzatto SMD, Garcia GG, Revers Kmicroscopic findings. The sample comprised17 samples of bird beak pliers, type 139 and17 of band remover pliers, type 347. The controlgroup had 3 samples of 139 pliers and 3 ofthe 347 pliers, at a total of 6 previously sterilizedpliers (autoclave) not used in any clinicalprocedure. These instruments were chosenbecause they are widely used in everyday orthodonticprocedures: The 139 plier because it ismade of metal only, and the band remover pliers(347), because they have a plastic componentin its structure that, when pliers are used,is directly in contact with oral tissues.Culture mediaThe brain-heart infusion (BHI) medium usedfor the immersion of pliers is a liquid mediumfor the enrichment and proliferation of microbialcells to increase the number of bacteria inthe sample. After dilution, cultures were seededin duplicates in the following solid culture mediawith 2% agar: blood agar (BA) and nutrientagar (NA) for total count of grown colonies; eosinmethylene blue agar (EMB) for the selectionof gram-negative bacteria; mitis-salivariusagar (MS), for the selection of Streptococci; andmannitol salt agar (Chapman), for the selectionof Staphylococci. Culture media used in thisstudy were produced by Vetec Química FinaLtda (Duque de Caxias, Brazil).Microbiological analysisThe orthodontic pliers under analysis, as wellas the control instruments, had their active tipsimmersed for 2 minutes in 10 ml BHI. Immediatelyafter that, the samples were incubated for24 to 48 hours at 37ºC. The samples containingBHI inoculated by the pliers underwent successivedilutions in inert saline solution (0.9% NaCl)to obtain different concentrations for each sampleuntil a dilution of 10 -5 was obtained. The purposeof dilution was to reduce bacterial cell concentrationin liquid medium for later counting.Immediately after dilution, the samples wereseeded in the different solid media described beforeand later incubated for 24 to 48 hours at37ºC. After that, colony forming units (CFU) inthe Petri dishes were counted for comparisonsand statistical analyses. Dishes with very highbacterial growth, which made counting impossible,were classified as “uncountable” (>10 10 CFU/ml). The few cultures where no colonies werefound were called “null”. A final mean number ofbacterial cells per BHI milliliter was calculatedusing the two counts for each dilution, as longas there was no significant differences betweenthe duplicates. Counts for the same dilution andmedium that had great differences in the numberof colonies were excluded from the study.Therefore, only the duplicates whose scores wereequivalent were kept in the study, which ensuredthe reliability of results. Using the individualmean CFU/ml for each dilution, the generalmean for each culture medium was calculatedaccording to the type of pliers.The shape and color of colonies for each culturemedium were analyzed; bacteria in thosecolonies were examined under light microscopyand classified using Gram staining.Result analysisResults of total number of grown coloniesfor each instrument were recorded and comparedwith results of the different pliers understudy and between the different culture media.For those purposes, the Student t test and analysisof variance (ANOVA) were used. The levelof significance was set at 5%. The SPSS 15.0software was used for data analysis.RESULTSGrowth in enrichment and seeding mediumAfter the pliers were immersed in 10 ml ofBHI (enrichment medium), stored and incubatedat 37ºC for 24 to 48 hours, the liquid mediumwas turbid and microbial cells were depositedDental Press J Orthod 105 2011 May-June;16(3):103-12

Microbiological analysis of orthodontic plierson the bottom of the test tubes in 32 of the 34samples. This indicated that there was proliferationof the microorganisms collected fromthe instrument surfaces and that they hadmicrobial contamination. The fact that BHIremained clear and clean, as in the controlgroup, in two samples, one of the 139 plierand one of the 347 plier, indicated that the instrumentshad been previously sterilized. Afterdilution, the BHI samples were seeded induplicates in the Petri dishes containing agar.After the 24 to 48 h incubation time at 37ºC,colonies were found in most cultures.Number of CFU per milliliterFor statistical and comparative analyses, CFUwere counted whenever possible.Table 1 shows that the greatest discrepancyof mean CFU/ml values between instrumentswas found in NA, a nonselective and nondifferentialmedium. Band remover pliers had amean contamination rate 10 times greater thanthat of 139 pliers, and the differences betweenthe two types of pliers were statistically significant(p=0.008).In MS and Chapman media, differences werealso found in mean values between the pliers, andthese findings may be correlated with practical activities.The significantly greater mean (p=0.009)number of colonies in Chapman culture, a selectivemedium for Staphylococcus sp and a differentialmedium for S. aureus, obtained in the 139plier group suggests a greater contact of this typeof pliers with the skin. These bacteria colonize thesurface of human skin and the nasal cavity mucosa15 . Such findings may suggest that the plierswere used to produce other orthodontic devices,that is, in laboratory. Moreover, in the 139 group,ANOVA results revealed that the Chapman mediumwas the only one that had a significant differencefrom the NA medium, which had thelowest number of CFU/ml.In contrast, the MS medium had a high,but not significantly different, mean CFU/mlvalue for the band remover pliers, which indicatesa greater trend towards contamination ofthis type of pliers. As this medium is selectivefor Streptococcus and differential for S. mutans,this result may be explained by the directcontact of the instrument with the surfaces oftablE 1 - Mean CFU/ml in samples collected from 139 and 347 pliers, grown in BHI and seeded in different solid culture media.Culture mediaNutrient agar(NA)Blood agar(BA)Eosin methyleneblue agar(EMB)Mannitol salt agar(Chapman)Mitis salivarius agar(MS)Brief descriptionNumber of samplesCFU/mlmodel 139 model 347 model 139 model 347Rich medium 21 19 1.33 x 10 8 2.83 x 10 9 0.008*Rich medium 26 22 3.66 x 10 9 4.65 x 10 9 0.492Gram-negative selectivemediumGram-positive selectivemedium (Staphylococcus sp.)Gram-positive selectivemedium (Streptococcus sp.)t Test24 22 3.00 x 10 9 2.99 x 10 9 0.99226 22 6.93 x 10 9 3.19 x 10 9 0.009*6 8 3.34 x 10 9 6.25 x 10 9 0.317* Statistically significant results of comparisons between 139 and 347 models of pliers using t test (level of significance = 5%).Dental Press J Orthod 106 2011 May-June;16(3):103-12

Azeredo F, Menezes LM, Silva RM, Rizzatto SMD, Garcia GG, Revers Kteeth, gingiva and mucosa in the posterior regionof the oral cavity, where bacterial plaqueoften accumulates. These bacteria are part ofthe oral microbiota and are classified as substantiallymore carcinogenic. 6Finally, in the EMB, a selective medium forGram-negative bacteria, and the BS cultures, arich medium, mean number of CFU/ml in BHIwas similar for 139 pliers and band remover pliers.General morphological characteristics ofcolonies and microorganisms grown in eachculture mediumThe microbial colonies had variable shapes,sizes and colors. For the analysis under light microscopy,41 Petri dishes of all types of mediawere selected to include the greatest variety ofsamples of grown colonies. The Gram methodwas used for slide staining.Table 2 and Figure 1 describe the most frequentshape of the colonies and the type ofbacteria in them. In the dishes with NA, yellowcolonies were predominant. According tomicroscopic analysis, they were primarily composedof staphylococci or Gram-positive bacilli.In BA, the most common bacterial typeswere staphylococci and G+ streptobacilli,found in white and light yellow colonies withsmooth or rough surfaces. Moreover, some colonieshad microorganisms that could destroythe blood cells found in the BA cultures. Thetranslucent or greenish halos around the differentcolonies seen in dishes with that agarconfirmed the presence of hemolytic bacteria.Streptococci found in the oropharynx, in pharyngealinflammations and in skin infectionsare examples of hemolytic microorganisms. 19In EMB medium, several types of bacteria werevisualized, and there was a predominance ofisolated cocci and G+ streptobacilli. IsolatedG+ and G- bacilli were also found; they formedpurplish colonies with an irregular surface andtablE 2 - Colonies, shape organization and classification of most frequent bacteria in different culture media according to Gram staining.Culture media Most commom colony configuration Shape, organization and classification of bacteria according to Gram stainingNutrient agar(NA)Blood agar(BA)Eosin methyleneblue agar (EMB)Mannitol salt agar(Chapman)Mitis salivarius agar(MS)* G+ = Gram positive; ** G- = Gram negative.Yellow, smoothG+ staphylococci *, isolated G+ bacilliWhite, smooth Isolated G+ cocci, G+ coccobacilli, G- streptobacilli **Orange, smoothYellow, smoothWhite, smoothRough, whitePurple, roughPinkish, smoothYellow, smoothPinkish, smoothBlue, smoothClear, smoothG+ staphylococci, G+ coccobacilliG+ staphylococci, G- sarcinae, isolated G+ bacilli, G+ coccobacilliG+ staphylococci, G+ streptobacilli, isolated G+ cocci,G+ streptococciG+ streptobacilli, isolated G+ bacilli, isolated G+ cocci, G+ streptococci,G+ coccobacilli, G+ diplococciIsolated G+ cocci, isolated G+ and G- bacilli, G+ streptobacilliIsolated G+ cocci, isolated G+ bacilli, G+ diplococci, G+ diplobacilliG+ staphylococci, isolated G+ cocci, G+ streptobacilli, isolated G+ bacilli,G+ tetrad-forming organismsG+ staphylococci *, isolated G+ cocciIsolated G+ cocci, isolated G+ and G- bacilli, G- sarcinaeIsolated G+ cocci *, G+ streptobacilliDental Press J Orthod 107 2011 May-June;16(3):103-12

Microbiological analysis of orthodontic pliersNutrientG-StreptobacilliNutrientG+CocciBloodG+ StaphylococciBloodG+ StreptobacilliChapmanG+ BacilliChapmanG+ StaphylococciEMBG+ StaphylococciEMBG+ Streptobacilli and G+ CocciEMBG+ StreptobacilliEMBG+ Dipococci, G+ Bacilliand G+ CocciMitis-SalivariusG+ Diplobacilli and G+ CocciMitis-SalivariusG+ Cocci , G+ and G- BacilliFigurE 1 - Microbial colonies grown in different culture media and microscopic aspect (Gram staining; 1000 X magnification) of bacteria found in mostfrequent colonies of each medium.Dental Press J Orthod 108 2011 May-June;16(3):103-12

Azeredo F, Menezes LM, Silva RM, Rizzatto SMD, Garcia GG, Revers Koutline. In the Chapman cultures, G+ staphylococciwere prevalent in yellow and pinkishcolonies, which indicated, in several cases, thepresence of Staphylococcus aureus, confirmedby the change of agar color. MS had G+ cocci,and isolated G+ and G- bacilli; bluish, roundand small colonies were predominant.DISCUSSIONOver 300 bacterial species have already beendescribed in oral microbiota. 26 In healthy individuals,these microorganisms coexist in equilibriumwith the host, but environmental changesand microbial imbalances may originate infections.1 For example, brackets and orthodonticbands induce specific changes in the oral environment,such as a lower pH and an increase ofbacterial plaque, 1 higher levels of S. mutans 1,22and an increase in the number of Lactobacillispecies. 1,24This study found that biosafety proceduresadopted in academic settings are not efficient toreduce the risk of infection. The term “cross infection”refers to the transfer of microorganismsfrom one person or object to another personand the resulting infection. It should be distinguishedfrom cross contamination, which refersto the transfer of microorganisms from one personor object to another person which may ormay not result in infection.Of the several types of bacteria found in thisstudy using light microscopy, isolated G+ cocciand microorganisms arranged as staphylococciwere the most frequent. Such microorganismsmay belong to different bacterial species thatmay cause several diseases. As in several infectiousdiseases, immunodepression is an importantfactor in an individual’s susceptibility toinfection. 19 Both types of pliers under analysispresented bacterial contamination. Band removerpliers had the most contamination, andmost bacteria were those that are found in theoral microbiota. This may be assigned to thedirect contact of this instrument with intraoralstructures and to the presence of plastic materialin its tip, which may favor the retention ofmicroorganisms. The 139 pliers, in addition tocontamination by microorganisms found in theoral cavity, had a high rate of contamination bystaphylococci, which are bacteria that colonizethe nasal mucosa and the skin. This finding maybe explained by the use of this instrument duringthe manufacture of orthodontic appliances,because, in theory, these pliers are not supposedto be placed directly in the mouth.The Staphylococcus genus has more thanfifteen different species, and S. aureus, S. epidermidisand S. saprophyticus are the most importantin healthcare settings. 25 These microorganisms,responsible for nosocomial infections,are some of the most resistant pathogenicbacteria and may survive for months in drysurfaces at temperatures higher than 60ºC. 29Some of the diseases caused by staphylococcalenzymes and toxins are superficial infections,such as furuncles, carbuncles, pustules,abscesses, conjunctivitis and angular cheilitis,as well as more severe diseases, such as toxicshock syndrome, osteomyelitis, pneumonia, 25bacterial endocarditis and septicemia. 25,29Some of the important diseases caused byStreptococcus species are respiratory tractinfections, such as pharyngitis and tonsillitis,which may be accompanied by scarlet andrheumatic fever. 25 One of the complications ofacute pharyngitis may be the dissemination ofinfection into the ear (otitis media), the mastoids,the base of the tongue or the floor ofthe mouth. 25 Other diseases caused by streptococciare infections of soft tissues in the oralcavity or the skin, as well as caries, primarilycaused by mutans microorganims. 25Pathogens may be transmitted from one patientto another by direct or indirect contactwith reused instruments inadequately prepared,and with contaminated surfaces or hands. 21Dental Press J Orthod 109 2011 May-June;16(3):103-12

Microbiological analysis of orthodontic pliersSeveral studies found contamination after inadequatedisinfection of instruments used inpatients, which stresses the need to follow adequatedisinfection procedures. 14,23 Sterilizationor high-level disinfection is the recommendedprocedure against HBV and HIV. However,disinfection efficacy is affected by factors suchas the nature of the object (type of slots andhinges) and by duration of exposure to disinfectingproducts. 14 All materials that can besterilized should never be only disinfected.According to some authors, infection controlmethods currently adopted in some orthodonticoffices are not satisfactory, maybe becauseit is believed that this specialty has a low riskof contamination. 8,18A survey conducted with a group of orthodontistsfound that 49% sterilized their pliers,whereas 49% disinfected them. One reason forthe high usage of disinfection methods maybe the cost of sterilization, as the orthodontistshould have several pliers if each instrument isto be sterilized. Other reasons mentioned arethe fact that sterilization shortens the useful lifeof materials, the large number of patients perday, and the shorter duration of appointments.Moreover, orthodontists may be more flexiblein terms of infection control than dentists inother specialties because they may believe thattheir young population is less likely to be infectedwith HIV or HBV. 30 However, recentstudies showed that there has been an increasein HIV infection among individuals youngerthan 20 years. 17 Woo et al 30 reported that, of thetotal number of patients seen in orthodonticclinics, 21% were children, 52% were teenagers,and 27%, adults. Adolescents or adults accountfor the largest percentage of patients receivingorthodontic treatment. In addition, all patientsshould be treated as if they were potentially infective.Because most patients with HBV andHIV infection are asymptomatic, they may disseminatethe virus in offices. 10Of the many viral diseases that may be acquiredin a dental office, the most often mentionedare hepatitis (B, C and D), herpeticconjunctivitis, herpes simplex, herpes zoster,measles, chickenpox, rubella, mumps and AIDS.The most important infections caused by bacteria,according to the literature, are tuberculosis,syphilis, pneumonia, infections by streptococciand staphylococci. 12The incidence of hepatitis B after accidentalexposure to contaminated materials or dueto lesions caused by sharp instruments usedin patients that have HBsAg antigens is about20%. In the same circumstances, the risk ofHIV transmission is between 0 and 0.5%. 19 Anaggravating factor in HBV transmissibility is itshigh resistance and its high infectious capacity,as it has been shown to remain infectiveup to six months at room temperature and upto seven days when exposed to surfaces. 4,10 Inless than 0.00000001 ml of blood, hepatitis Bvirus is potentially infective for 7 days after thesurface is dried. 10This study showed orthodontic pliers havegreat contamination rates and that, by meansof contaminated instruments, several types ofmicroorganisms may be transmitted betweenindividuals. This is a truly relevant fact becauseof the immense number of bacteria and, particularly,viral particles that are secreted in oralfluids, and a small amount of saliva has the potentialto cause severe diseases, such as hepatitisB. Therefore, virus dissemination should not beoverlooked, although this study focused on theidentification of contaminating bacteria.The prevention and control of cross infectionin the dental office are current patient demandsand rights. Therefore, all dental healthcarepersonnel should be aware of these facts.Such knowledge will help them to change theirprocedures and adopt correct biosafety measuresfor all patients as a way to stop the propagationof infections.Dental Press J Orthod 110 2011 May-June;16(3):103-12

Azeredo F, Menezes LM, Silva RM, Rizzatto SMD, Garcia GG, Revers KCONCLUSIONThis study found high rates of bacterial contaminationin the two types of orthodontic pliersselected for investigation. Data showed thatband remover pliers had greater contaminationrates, probably because of their direct contactwith intraoral structures and tissues. The139 pliers also showed high contamination byagents found in the oral microbiota, but meanCFU/ml was relatively greater in the Chapmanagar cultures, a medium to grow staphylococci,which are microorganisms found not in the oralcavity, but, rather, on the surfaces of human skinand in the nasal mucosa.The disinfection procedures adopted did notseem to be effective to reduce contamination.More efficient measures should be adopted tocontrol infection, so that microorganisms arenot transmitted to patients or between patientsand the members of the orthodontic team.ReferEncEs1. Anhoury P, Nathanson D, Hughes CV, Socransky S, Feres M,Chou LL. Microbial profile on metallic and ceramic bracketmaterials. Angle Orthod. 2002;72(4):338-43.2. Araujo MW, Andreana S. Risk and prevention of transmissionof infectious diseases in dentistry. Quintessence Int.2002;33(5):376-82.3. Buckthal JE, Mayhew MJ, Kusy RP, Crawford JJ. Survey ofsterilization and disinfection procedures. J Clin Orthod.1986;20(11):759-65.4. Consolaro A, Pinzan A, Ursi WJS, Cuoghi AO, Pinto PRS,Diaz MCA. A hepatite B e a clínica ortodôntica. Ortodontia.1991;24(2):53-8.5. Cunha ACA, Zöllner MSA. Presença de microorganismos dosgêneros Staphylococcus e Candida aderidos em máscarasfaciais utilizadas em atendimento odontológico. Biociências.2002;8(1):95-101.6. De Lorenzo JL. Microbiologia para o estudante deOdontologia. 1ª ed. São Paulo: Atheneu; 2004.7. Feldman RE, Schiff ER. Hepatitis in dental professionals.JAMA. 1975;23(232):1228-30.8. Freitas MPM, Menezes LM, Rizzatto SMD, Feldens JA. Protocolobásico de biossegurança na clínica ortodôntica. Rev Clín OrtodDental Press. 2006;5(2):78-86.9. Gandini Júnior LG, Souza RS, Martins JC, Sakima T, GandiniMR. Controle da infecção cruzada em Ortodontia: Parte 2:processamento, esterilização e controle de corrosão. Rev DentalPress Ortodon Ortop Facial. 1997;2(3 Pt 2):80-7.10. Gandini LG Júnior, Souza RS, Martins JC, Sakima T, Gandini MR.Controle da infecção cruzada em Ortodontia: Parte 1: HepatiteB, desinfecção e aparatologia pessoal. Rev Dental Press OrtodonOrtop Facial. 1997;2(2):77-82.11. Hamory BH, Whitener CJ. Nosocomial infections in dental, oral,and maxillofacial surgery. In: Mayhall CG. Hospital Epidemiologyand Infection Control. 2 nd ed. Philadelphia: Lippincott Williams &Wilkins; 1999. p. 719-28.12. Jorge AOC. Princípios de biossegurança em Odontologia.[Acesso 2006 Jun 4] 2002. Available in: http://www.unitau.br/prppg/publica/biocienc/downloads/principiosbio-N1-2002.pdf.13. Kirchhoff ST, Sekijima RK, Masunaga MI, Alizadeh CM. Sterilizationin Orthodontics. J Clin Orthod. 1987;21(5):326-36.Dental Press J Orthod 111 2011 May-June;16(3):103-12

Microbiological analysis of orthodontic pliers14. Knorst ME, Asensi MD, Moraes BA, Yoshida CF, FinizolaFilho A, Salgado Júnior LP, et al. Desinfecção em ortodontia:estudo de um método alternativo utilizando o lenço BactiBuster Stepac L.A. em alicates ortodônticos e em superfíciedo mobiliário contra o vírus da hepatite B e a bactéria S.aureus meticilino-resistente. J Bras Ortodon Ortop Facial.1999;4(21):265-70.15. Marsh P, Martin MV. Microbiologia Oral. 4ª ed. São Paulo:Santos; 2005.16. Matlack RE. Instrument sterilization in orthodontic offices.Angle Orthod. 1979;49(3):205-11.17. McCarthy GM, Mamandras AH, MacDonald JK. Infectioncontrol in the orthodontic office in Canada. Am J OrthodDentofacial Orthop. 1997;112(3):275-81.18. Mulick JF. Upgrading sterilization in the orthodonticpractice. Am J Orthod. 1986;89(4):346-51.19. Nisengard RJ, Newman MG. Microbiologia oral e Imunologia.2ª ed. Rio de Janeiro: Guanabara Koogan; 1997.20. Orthodontic Instrument Sterilization: making the right choicein sterilization techniques. American Orthodontics - TheAssistant. 2002;1(1):2-7.21. Palenik CJ, Burke FJ, Miller CH. Strategies for dental clinicinfection control. Dent Update. 2000;27(1):7-15.22. Rosenbloom RG, Tinanoff N. Salivary S mutans levels inpatients before, during, and after orthodontic treatment. AmJ Orthod Dentofacial Orthop. 1991;100(1):35-7.23. Rutala WA. Draft APIC Guideline for selection and use ofdisinfectants. Am J Infect Control. 1990;18(2):99-117.24. Sakamaki ST, Bahn AN. Effect of orthodontic banding onlocalized oral lactobacilli. J Dent Res. 1968;47(2):275-9.25. Samaranayake LP. Essential microbiology for dentistry. 2 nded. London: Churchill Livingstone; 2002.26. Souto R, Andrade AF, Uzeda M, Colombo AP. Prevalenceof non-oral pathogenic bacteria in subgengival biofilm ofthe subjects with chronic periodontitis. Braz J Microbiol.2006;37:208-15.27. Starnbach H, Biddle S. A pragmatic approach to asepsis inthe orthodontic office. Angle Orthod. 1980;50(1):63-6.28. Thylstrup A, Fejerskov O. Cariologia Clínica. 2 a ed. SãoPaulo: Ed. Santos; 2001.29. Wichelhaus A, Bader F, Sander FG, Krieger D, Mertens T.Effective disinfection of orthodontic pliers. J Orofac Orthop.2006;67(5):316-36.30. Woo J, Anderson R, Maguire B, Gerbert B. Compliance withinfection control procedures among California orthodontists.Am J Orthod Dentofacial Orthop. 1992;102(1):68-75.Submitted: December 2007Revised and accepted: October 2008Contact addressFabiane AzeredoPontifícia Universidade Católica do Rio Grande do SulFaculdade de Odontologia – Departamento de OrtodontiaAv. Ipiranga, 6681CEP: 90.619-900 – Porto Alegre / RS, BrazilE-mail: fabianeazeredo@hotmail.comDental Press J Orthod 112 2011 May-June;16(3):103-12

O r i g i n a l A r t i c l eCephalometric evaluation of the effects of thejoint use of a mandibular protraction appliance(MPA) and a fixed orthodontic appliance onthe skeletal structures of patients with AngleClass II, division 1 malocclusionEmmanuelle Medeiros de Araújo*, Rildo Medeiros Matoso**,Alexandre Magno Negreiros Diógenes***, Kenio Costa Lima****AbstractObjective: This study aimed to perform a cephalometric evaluation of the skeletal responsestriggered by the joint use of a mandibular protraction appliance (MPA) and a fixedorthodontic appliance for correction of Class II, division 1 malocclusion in young Brazilianpatients. Methods: The sample consisted of 56 lateral cephalograms of 28 patients (16women and 12 men). The initial mean age was 13.06 years and mean duration of therapywith MPA was 14.43 months. The lateral radiographs were obtained before and after treatmentand were compared by two calibrated examiners to identify the skeletal changesinduced by the MPA using 16 linear and angular cephalometric measures. Some independentvariables (patient age, sex, facial pattern, MPA model, total use time, archwire andtechnique used during therapy with MPA) were considered and related to those measuresin order to demonstrate the influence of these variables on them. Responses to treatmentwere analyzed and compared by the Wilcoxon Signed Ranks test and Mann-Whitney test ata significance level of 5%. Results: The results showed restricted anterior displacement ofthe maxilla, increased mandibular protrusion, improved anteroposterior relationship of thebasal bones and stability of the mandibular plane relative to the cranial base. The influenceof variables age, facial pattern and MPA type was also noted. Conclusions: MPA proved aneffective alternative in the treatment of Class II, division 1 malocclusion, inducing changesin the skeletal component with satisfactory clinical results.Keywords: Cephalometry. Functional orthodontic appliances. Angle Class II malocclusion. Mandibularprotraction appliance.How to cite this article: Araújo EM, Matoso RM, Diógenes AMN, Lima KC. Cephalometric evaluation of the effects of the joint use of amandibular protraction appliance (MPA) and a fixed orthodontic appliance on the skeletal structures of patients with Angle Class II, division1 malocclusion. Dental Press J Orthod. 2011 May-June;16(3):113-24.* Specialist in Orthodontics, ABO-EAP/RN.** MSc in Orthodontics, USP. Head Professor of Orthodontics, UFRN. Professor of the Specialization Course, ABO-EAP/RN.*** Specialist in Orthodontics, ABO-EAP/RN.**** Professor, Department of Orthodontics and Graduated Course in Dentistry and Health Sciences, UFRN.Dental Press J Orthod 113 2011 May-June;16(3):113-24

Cephalometric evaluation of the effects of the joint use of a mandibular protraction appliance (MPA) and a fixed orthodontic appliance on the skeletal structures of patients with Angle Class II,division 1 malocclusionINTRODUCTION AND LITERATURE REVIEWAngle Class II, division 1 malocclusion is afrequent problem affecting about 55% of theBrazilian population. 2 It has a multifactorialetiology, and from a skeletal point of view, maybe due to maxillary protrusion, mandibular retrusionor a combination of both. 16The literature is rich in treatment methodsfor this malocclusion, which traditionallyrely on patient cooperation in wearing removablefunctional appliances (Activator, Balters’Bionator, Frankel appliance), using Class IIelastics and/or extraoral traction appliances.Among the appliances used in Class II, division1 cases are those which have as their keyobjective restricting the anterior displacementof the maxilla, those that push the mandibletowards a more anterior position in order toredirect growth and lead to an appropriatemorphological development, and those thatinduce changes in both arches. 12In recent decades, several authors began todevelop fixed intraoral orthopedic appliancescapable of correcting Class II molar relationshipwith mandibular retrognathism, sincethese appliances promote changes in mandibularposture, positioning it forward with the aimof stimulating its growth. 24,25 Since these appliancesare fixed (Herbst, 25 Jasper Jumper, 17,18Universal Bite Jumper, 4,28 Eureka Spring, 13MARA, 1 Churro Jumper 5 and Superspring 19 )they are instrumental in decreasing the needfor patient compliance during treatment.However, the lack of specialized laboratoriesto fabricate these appliances, their high costand scarcity of information about the installationof most of them led Coelho Filho 6 to designthe Mandibular Protraction Appliance 1,also known as MPA 1, whose characteristics, atfirst quite simple, soon evolved into a more advancedversion. In 1995, the inventor presentedthe clinical results achieved with his applianceas an alternative to Herbst, 6,20,21,22,23,26,27 reintroducedby Pancherz (1979), since the formeruses the same mechanical design as the latter.Some of the advantages of MPA over Herbstare that (a) it can be fabricated by professionalsthemselves, without the need for laboratorywork, (b) it is affordable, (c) it is easy to insert,and (d) as it is less bulky, it provides greaterpatient comfort. 10,11,30MPA 1 was initially made with 0.032-in(0.9 mm) wire and consisted of a steel rod witha round loop at each end. In this first version,rectangular wires had to be in place and due tothe conformation of the appliance only canineto canine brackets could be bonded. Moreover,the lower arch needed to have a strong torquein the anterior region to resist buccal displacementof lower incisors resulting from the protrusiveforces generated by the appliance. Additionally,bends had to be applied on the distalside of lower molar tubes to enhance anchorageand prevent mesial drift of lower teeth. 6,8Although the clinical results achieved withMPA 1 were extremely positive, limitations inmouth opening caused frequent breakages. 7Therefore, in 1997, the second MPA versionwas launched, featuring increased mouth opening,greater patient comfort and less frequentbreakages. Besides all the installation detailsdescribed for an MPA 1, the author emphasizedinsertion of anterosuperior buccal torqueand two circular loops positioned mesial to theupper molars and distal to the lower canines tofacilitate appliance installation. Also noteworthywas the fact that with this second versionbrackets could be bonded to premolars.In contrast to these upsides, MPA 2 alsoshowed some shortcomings. To address theseissues the author created a fully modifiedthird version termed MPA 3, 7,9,10 which hada completely different configuration fromearlier versions, including telescopic stainlesssteel tubes through which ran 0.9 mm wirerods. The method of insertion in the lowerDental Press J Orthod 114 2011 May-June;16(3):113-24

Araújo EM, Matoso RM, Diógenes AMN, Lima KCarch was redesigned. All these improvementsensured greater appliance balance when patientsopened and closed their mouth. Theauthor also discussed the use of the appliancein cases of Class III malocclusion and anteriorcrossbite. To do so would require reversingthe direction of the appliance. 7,9In 2001 and 2002, Coelho Filho introducedthe latest version: MPA 4. The author reportedthat this new model seemed to surpass all previousmodels in terms of both shear strength andease of installation. Furthermore, MPA 4 adaptationto the upper arch was modified to impartgreater functional stability to the appliance. 11The author also pointed out that MPA modeldid not determine differences in the outcome.All models feature the same mechanical principles.What makes each different is fabricationmethod, installation and patient comfort. 7Given their numerous advantages, as statedabove, in addition to being versatile and featuringa wide range of applications, orthodontistswere driven to study MPA treatment effects,prompting some to go as far as to proposeother appliance models with similar mechanisms.15,22 Thus, the purpose of this study wasto analyze and determine skeletal changes inpatients with Angle Class II, division 1 malocclusionresulting from treatment with MPAduring the phase of active growth.METHODSThis study can be defined as an uncontrolled,nonrandomized clinical trial. To conductit, a sample was selected comprising 56lateral cephalograms of 28 Brazilian youths ofboth sexes — 16 women and 12 men — accordingto the following criteria: Angle ClassII, division 1 malocclusion with mandibularretrognathism, as assessed by study models,photographs and radiographs with a clear visualizationof the structures of interest. Exclusioncriteria were as follows: Agenesis, extractionor loss of permanent teeth; patientsundergoing orthodontic treatment prior toMPA installation, since prior therapy wouldalter the Class II, division 1 malocclusion; andsignificant overjet.Clinical records included the following clinicalvariables: Patient age, sex, facial pattern(dolichofacial, mesofacial and brachyfacial, butthe latter was excluded during sample selectionas only one case had this facial type, whichmight yield statistical results with a highermargin of error), MPA model (types 1, 2, 3 and4; type 1 was associated with type 2, and type3 with type 4, since only one patient was treatedwith MPA 1, and only 5 cases with MPA3), total time of appliance use, archwires usedduring treatment with MPA (0.019x0.025-in,0.021x0.025-in and 0.018x0.025-in stainlesssteel wires, with the latter two grouped together,totaling 12 cases, compared to 16 patientswith 0.019x0.025-in stainless steel wire) andorthodontic technique (Standard Edgewiseand Straight Wire).The cephalograms used in this study wereselected from the archives of Professor CarlosMartins Coelho Filho’s private clinic (in thecity of São Luís, Maranhão state, Brazil), andobtained with Funk Orbital X15 X-ray device,with a magnification factor of 9%, and operatedby one and the same examiner.Two lateral cephalograms of each of the 28patients were used, referred to as T1 (initial) andT2 (final). The cephalograms were traced manuallyon a light box by two calibrated examinersin a darkened room at Professor Carlos Martins’private clinic in São Luís, Maranhão state.Examiner calibration was performed approximatelythree months earlier, when 30randomly selected cephalograms were retraceduntil minimum error was attained.To obtain the cephalograms the authors usedtransparent Ultraphan acetate paper (CephalometricTracing Paper, GAC), Pentel pencil holderDental Press J Orthod 115 2011 May-June;16(3):113-24

Cephalometric evaluation of the effects of the joint use of a mandibular protraction appliance (MPA) and a fixed orthodontic appliance on the skeletal structures of patients with Angle Class II,division 1 malocclusionwith a 0.3 mm tip, tape, soft rubber, template(Tracing Template, Unitek Corp.), and a lightbox. When double images of the anatomicaldesign of bony structures were visualized bothimages were traced and a mean value was foundbetween cephalometric points.In the next step the images were importedvia a scanner into a microcomputer containingthe Radiocef Studio Cephalometry program(No. 020576, version 4.0, release 3 - Belo Horizonte/MG,Brazil), where values were obtainedfor T1 and T2 and their respective repetitions.From then on, the following landmarkswere identified to obtain angular and linearmeasurements: S (sella turcica), N (nasion),A (subspinale), B (supramentale), Pog (pogonion),Me (menton), Go (gonion), Gn (gnathion),Ar (articulare), ANS (anterior nasal spine)and PNS (posterior nasal spine) (Fig 1).The reference planes used in this studywere, as shown in Figure 2: a modified FrankfortHorizontal Plane (FHP) 29 (1), composedof a line that forms with the SN line a 7° angledown through point S; Mandibular planes Go-Me (2) and Go-Gn (3); Palatal Plane (PP) (4),formed by points ANS and PNS; lines SN (5),NA (6), NB (7), APog (8) and S-HFp (9).Angular variables included, as shown in Figure3: SN.PP (10), SN.GoGn (11), SN.GoMe(12), SNA (13), SNB (14), ANB (15) andNAPog (16); and the linear variables were, asshown in Figure 4: Go-Gn (17), ANS-FHP (18),Pog-FHP (19), A-FHP (20), B-FHP (21), ASFH(22), PFH (23), LPFH (24) and LAFH (25).RESULTSThis study used a sample of 56 lateral cephalogramsof 28 young Brazilian of both sexescomprising 16 women (57.1%) and 12 men(42.9%) (Table 1).Mean age was 13.06 years, with a standarddeviation of 1.3 years, with a minimumof 10.33 years and a maximum of 16.58 years,respectively.As regards facial pattern, 39.3% (11 patients)were dolichofacial while 60.7% (17 patients)N51SArPNSANSASnUlPrn864GoMeBPogGnLl9732FigurE 1 - Cephalometric points (landmarks).FigurE 2 - Reference planes and lines.Dental Press J Orthod 116 2011 May-June;16(3):113-24

Araújo EM, Matoso RM, Diógenes AMN, Lima KC12111013141516242318202221 251719FigurE 3 - Skeletal angular variables.FigurE 4 - Skeletal linear variables.were mesofacial. As explained before, duringsample selection the brachyfacial pattern wasexcluded as only one case had this facial type,which might yield unreliable statistical results.Similarly, under variable MPA model, MPAtype 1 was associated with MPA type 2, andtype 3 with type 4, since only one patient(3.6%) had been treated with MPA 1 and 5cases (17.9%) with MPA 3. The remaining percentagescorresponded to 35.7% (10 cases) and42.9% (12 cases) of MPAs 2 and 4, respectively.For the variable archwire, the followingtypes were noted: 0.019x0.025-in stainlesssteel (57.1% or 16 patients), 0.021x0.025-in stainless steel (10.7% or 3 patients) and0.018x0.025-in stainless steel (32.1% or 9patients). The latter two archwires were alsogrouped into a total of 12 cases.The variable technique showed a frequencyof 12 cases (42.9%) for the Straight Wire techniqueand a total of 16 cases (57.1%) for theStandard Edgewise technique.The result achieved for the variable totalMPA use time was 14.43 months, with a minimumof 3 months and maximum of 33 months,and a standard deviation of 9.33 months.Table 2 shows the means for initial and finalcephalometric measurements of patients ofboth sexes, their medians, quartiles 25 and 75,and statistical significance value (p), obtainedwith the Wilcoxon Signed Ranks Test. As canbe observed, of all the skeletal cephalometricmeasures employed in this study, only SNA,SNB, ANB, NAPog, Go-Gn, Pog-FHP, FHP-B,ASFH, PFH, LPFH and LAFH were influencedby treatment with MPA, i.e., showed statisticallysignificant values (p

Cephalometric evaluation of the effects of the joint use of a mandibular protraction appliance (MPA) and a fixed orthodontic appliance on the skeletal structures of patients with Angle Class II,division 1 malocclusionAgeSexVariablesFacialPatternMPA TypeArchwireTechnique≤ 13.06 years≥ 13.06 yearsFemaleMaleDolichoMeso1+23+40.019x0.025-in SS0.021x0.025-in + 0.018x0.025-in SSStraight WireStandard EdgewiseFrequencyn %Table 1 - Relationship between variables and sample distribution. Natal,Rio Grande do Norte State, Brazil, 2005.141416121117111716121216505057.142.939.360.739.360.757.142.942.957.1tablE 2 - Medians and 25/75 quartiles of initial and final skeletal cephalometricmeasurements and value of statistical significance. (Natal, RioGrande do Norte state, Brazil, 2005).SkeletalcephalometricmeasuresInitial SN.PPFinal SN.PPInitial SN.GoGnFinal SN.GoGnInitial SN.GoMeFinal SN.GoMeInitial SNAFinal SNAInitial SNBFinal SNBInitial ANBFinal ANBMedian Q 25– Q 75P6.676.7729.4729.6931.1930.9989.8681.9577.2578.075.883.924.58 - 9.004.88 - 9.0327.74 - 34.3526.30 - 32.6329.53 - 36.1628.03 - 34.1080.07 - 86.0379.26 - 84.2475.74 - 78.9176.36 - 80.033.59 - 7.491.91 - 5.540.6080.3740.2190.018*0.032*0.000*Initial NAPogFinal NAPog11.007.173.95 - 14.153.03 - 9.630.009*Initial Go-GnFinal Go-Gn70.4476.3539.23 - 79.6245.30 - 84.190.000*and significance value (p) for each individualmeasure. For sex, only Go-Gn and LAFHshowed a statistically significant results, andfor age, only ANB. As for facial pattern, theonly quantities that showed significant differenceswere PFH and LPFH. Regarding MPAtype, statistical differences were found forGo-Gn, ANS-FHP, Pog-FHP, A-FHP, B-FHP,ASFH, PFH and LAFH.Tables 5 and 6 show the variables associatedwith the skeletal cephalometric measuresthat exhibited changes after treatment. Thevariables were related to these measures priorto treatment. This revealed the influence thatthey exerted on these measures and whetherdifferences existed in relation to these variableseven before starting therapy with MPA.To obtain these results, the Mann-WhitneyTest was employed.As can be seen in Tables 5 and 6, only Go-Gn and LAFH showed statistical relevanceeven before starting treatment, when relatedInitial ANS-FHPFinal ANS-FHPInitial Pog-FHpFinal Pog-FHpInitial A-FHpFinal A-FHpInitial B-FHpFinal B-FHpInitial ASFHFinal ASFHInitial PFHFinal PFHInitial LPFHFinal LPFHInitial LAFHFinal LAFH75.4977.6764.7865.7571.4571.9763.8463.8451.4853.4871.2476.2342.2645.1659.8562.7243.15 - 84.6344.79 - 86.1437.66 - 72.6838.80 - 77.3840.86 - 81.4041.70 - 82.3035.61 - 71.4436.75 - 72.9529.93 - 55.9030.79 - 57.6840.79 - 83.0243.15 - 83.9122.79 - 49.4224.94 - 51.8535.43 - 72.5636.25 - 71.05*Significant difference (p

Araújo EM, Matoso RM, Diógenes AMN, Lima KCtablE 3, 4 - Medians, 25/75 quartiles and significance of cephalometric measurements related to independent variables. (Natal, RN, Brazil, 2005).Differencebetween T1 andT2 cephalometricmeasurementsSex nANB Go-Gn ANS-FHP Pog-FHP A-FHPMedian Q 25/Q 75p Median Q 25/Q 75p Median Q 25/Q 75p Median Q 25/Q 75p Median Q 25/Q 75pFemale (16) 2.24 1.12/2.96-1.19 -3.76/-0.820.04 -1.76/1.27-1.15 -6.13/1.67-0.29 -1.02/1.190.246Male (12) 1.18 0.04/3.00 -4.20-11.44/-2.310.0290.1940.194-1.11 -6.48/0.75 -6.13 -10.26/0.51 -1.48 -4.75/0.440.114Age (n)≤ 13.06 (14) 2.65 1.07/3.45-3.72 -13.11/-1.14-0.42 -2.64/0.38-4.18 -9.66/1.65-0.40 -2.37/1.670.035*0.1830.7480.383>13.06 (14) 1.29 0.04/2.40 -1.66 -4.16/-0.80 -0.13 -4.89/1.02 0.79 -5.85/0.87 -0.34 -3.21/1.091.000Facial Pattern (n)Dolichofacial (11) 1.13 0.53/2.98-2.83 -17.47/-1.23-0.82 -4.66/0.78-5.09 -9.35/1.84-1.07 -3.58/1.240.4100.3120.3350.621Mesofacial (17) 2.37 0.78/3.03 -2.08 -6.31/0.83 0.06 -3.33/1.04 -1.20 -7.28/0.47 -0.37 -1.80/0.800.556MPA type (n)1 + 2 (11) 2.98 0.31/3.61-4.83 -17.47/-3.65-1.64 -5.02/-0.03-7.19 -10.58/-1.95-1.26 -3.74/-0.430.3350.003*0.018*0.001*3 + 4 (17) 1.74 0.75/2.44 -1.23 -3.13/-0.61 0.67 -1.89/1.21 0.39 -3.25/3.30 0.56 -1.27/2.150.006**Significant difference (p13.06 (14) -0.43 -5.15/1.01 -1.32 -2.50/-0.23 -2.33 -4.74/-0.01 -1.29 -4.35/-0.56 -2.57 -5.33/-0.470.566Facial Pattern (n)Dolichofacial (11) -4.59 -6.93/1.29-1.65 -4.84/-0.24-5.54 -11.09/-2.99-4.34 -8.00/-0.99-3.41 -5.71/-0.930.7240.3840.041*0.046*Mesofacial (17) -0.96 -6.37/0.70 -1.10 -2.38/0.16 -2.31 -5.38/0.28 -2.04 -4.53/-1.97 -2.62 -5.03/-0.580.371APM type (n)1 + 2 (11) -6.29 -10.85/-1.74-2.32 -6.09/-0.94-5.67 -11.09/-3.37-4.52 -8.00/-1.60-5.21 -7.57/-2.000.002*0.048*0.015*0.0630.041*3 + 4 (17) 0.49 -3.06/2.70 -0.85 -1.91/0.16 -2.31 -4.59/0.03 -0.99 -3.79/0.82 -1.12 -4.69/-0.47*Significant difference (p

Cephalometric evaluation of the effects of the joint use of a mandibular protraction appliance (MPA) and a fixed orthodontic appliance on the skeletal structures of patients with Angle Class II,division 1 malocclusiontablE 5, 6 - Values of cephalometric measurements that showed statistically significant changes after treatment - related to independent variables - beforestarting treatment with MPA. (Natal, RN, Brazil, 2005).ANB Go-Gn ANS-FHP Pog-FHP A-FHPSex (n)Median Q 25/Q 75p Median Q 25/Q 75p Median Q 25/Q 75p Median Q 25/Q 75p Median Q 25/Q 75pFemale (16) 44.14 27.51/66.57Male (12) 75.39 71.04/91.290.003*Age (n)≤ 13.06 (14) 5.57 3.26/7.23>13.06 (14) 6.04 3.95/7.840.730Facial Pattern (n)Dolichofacial (11)Mesofacial (17)MPA type (n)1 + 2 (11) 70.44 28.51/94.0978.39 28.55/102.2068.84 22.79/78.1674.68 27.14/97.741.0000.4100.6553 + 4 (17) 70.44 44.14/75.43 72.95 43.47/80.19 62.48 37.72/70.58 69.37 41.17/77.700.359*Significant difference (p13.06 (14)Facial Pattern (n)Dolichofacial (11) 78.12 39.86/89.0645.62 23.68/55.610.525Mesofacial (17) 70.66 40.83/80.62 40.50 22.42/47.090.269MPA type (n)1 + 2 (11) 66.90 23.38/76.3352.58 21.36/63.9177.53 27.53/89.0663.16 26.87/81.100.4660.4380.4663 + 4 (17) 61.15 35.53/68.08 44.20 30.02/55.04 69.16 40.83/82.33 53.83 35.54/69290.384*Significant difference (p

Araújo EM, Matoso RM, Diógenes AMN, Lima KCDISCUSSIONAngle Class II, division 1 malocclusion is afrequent problem since for its interception and/or correction a wide range of appliances havebeen proposed. Moreover, the literature is stillscarce in studies that pinpoint which changes resultfrom MPA use, be they skeletal, dental orcutaneous changes. Thus, this study sought toevaluate the skeletal changes triggered by the useof mandibular protraction appliances in patientswith Class II, division 1 malocclusion associatedwith a corrective orthodontic appliance.As for the sagittal maxillomandibular relationship,only measures ANB and NAPog wereverified. The following measures were used toobserve vertical changes: SN.PP, SN.GoGn,SN.GoMe, ASFH, PFH, LPFH and LAFH.According to the results shown in Table 2,only SNA showed statistical significance forthe maxillary component, suggesting that MPAacted by hindering anterior maxillary displacement,causing a reduction of 1.91°. It is knownthat during growth the maxilla moves forwardand downward. In patients with Class II growthpattern it is common for point A to be positionedmore anteriorly. Thus, when associatedwith the growth tendency observed in the maxillaof untreated patients, SNA often experiencesan increase. 14 In this study, reduction in thisskeletal cephalometric measurement can thereforebe attributed to the use of the appliancefavored by the growth factor, since the treatedgroup had a mean age of 13.06 years.Concerning mandibular changes, all measuresshowed significant differences and increased protrusionwhen MPA was used, but this fact doesnot warrant one to assert that protrusion wassolely due to the MPA as this age group showsa predominance of mandibular growth. Cephalometricmeasurements correspond to SNB, Go-Gn, B-FHp and Pog-FHp (Table 2).The measures used to verify the sagittal maxillomandibularrelationship yielded statisticallysignificant results. After using the appliance, animproved relationship was noted between themaxilla and mandible in the anteroposteriordirection, with a more posterior positioning ofthe maxilla and more anterior positioning ofthe mandible. There was a decrease in maxillomandibularrelationship values (ANB, NAPog)which resulted in the correction of the skeletalClass II (Table 2).In observing the vertical changes resultingfrom therapy with MPA, it was found thatthe angular measures SN.PP, SN.GoGn andSN.GoMe showed no statistically significantdifferences after MPA use. The former twomeasures remained fairly constant and the latterexperienced a slight downturn. Linear measuresASFH, PFH, LPFH and LAFH showedsignificant increases (Table 2). Once again theresults reinforce Coelho Filho’s finding that despiteincreases in anteroinferior and posteriorfacial height, the mandibular plane angle is notnegatively affected when treatment induces themandible to move to a more anterior position.Tables 3 and 4 show the difference ratio betweencephalometric initial and final measures,and independent variables. Only variablessex, age, facial pattern and MPA model influencedthe final cephalometric measures. Theother variables used in this research — totaluse time, archwire and technique used duringtreatment — showed no statistically significantresults and do not seem to exert any influenceon the skeletal cephalometric measures targetedin this study.Regarding sex, there was a significant differencefor Go-Gn and LAFH, and in both therewas a larger increase for males and smaller increasefor females since males exhibit greatergrowth potential (Tables 3 and 4). These measurements,however, were already different inrelation to sex before treatment, suggesting thatsex did not directly interfere with the outcomeof therapy using MPA (Tables 5 and 6).Dental Press J Orthod 121 2011 May-June;16(3):113-24

Cephalometric evaluation of the effects of the joint use of a mandibular protraction appliance (MPA) and a fixed orthodontic appliance on the skeletal structures of patients with Angle Class II,division 1 malocclusionAs regards age, the only measurement thatshowed significant alteration was ANB, and thedifference between T1 and T2 was higher inthe group aged ≤13.06 years and lower in thegroup aged >13.06 years, whose values correspondto 2.65 and 1.29, in the order given, dueto greater growth potential with more significantskeletal changes at younger ages (Tables 3and 4). However, this measure was not initiallyaltered, suggesting that age influenced thetreatment (Tables 5 and 6).According to Enlow, 14 during puberty thegrowth velocity curve rises to a peak and thenbegins to fall rapidly. Peak velocity is calledmaximum height growth speed. Pubertalgrowth spurt occurs on average two years earlierin girls than in boys. Spurt initiation, i.e., theage at which the curve shows a steady increase,represents an age of 10.04±1,26 years for girlsand 12.08±1.20 years for boys. As for spurt durationthere seems to be no significant differencebetween the sexes (4.73 and 4.91 yearsfor girls and boys, respectively). In this study,the group that exhibited the most significantchanges had a mean age ≤13.06 years, with adecrease in ANB, as can be seen in Table 4. Thiscan be explained both by the growth factor,since the group in question was experiencingmaximum spurt, but also by the mechanicsproduced by the MPA, confirming once againstudies by Coelho Filho which show satisfactoryresults from the use MPAs for facial convexityreduction and correction of the maxillomandibularrelationship.In analyzing facial pattern, only PFH andLPFH showed enhanced values, with dolichofacialpatients showing slightly more changesthan mesofacial patients (Tables 3 and 4).However, these measures showed no significantchanges before starting therapy with theMPA, which may lead one to reason that facialpattern exerted some influence on the treatment(Tables 5 and 6).Facial growth plays a significant role in theprognosis of patients treated orthodontically.A major goal in treating young patients duringthe active growth phase is to control facialgrowth direction. According to Björk, 3 Frankeland Frankel 15 and Vasconcelos 30 increasesin the vertical facial factor are deleterious forpatients with skeletal Class II malocclusion asthe mandible rotates posteriorly, further worseningthe sagittal malocclusion. In dolichofacialtypes, treatment of Class II should check anteroinferiorfacial height growth and posteriorfacial height growth. In this study, measuresPFH and LPFH — after treatment with MPA— showed increases that were higher for thedolichofacial than for the mesofacial group. Theother measures were correlated with the facialpattern and displayed no statistically significantresults. This finding has major clinical bearing asit shows an improved profile, control over verticalfacial increase and mandibular plane angle,or the latter’s anterior rotation, improving thesagittal maxillomandibular relationship.Regarding MPA type, in all that experiencedchanges (Go-Gn, ANS-FHP, Pog-FHP, A-FHP,B-FHP, ASFH, PFH, and LAFH) greater changesin measurements were observed in the groupusing MPA type 1 and 2 than in the secondgroup using MPAs 3 and 4 (Tables 3 and 4). Butthis difference was not present prior to treatment(Tables 5 and 6). Such changes may beassociated with the fact that MPAs type 1 and2 showed more limited mouth opening, greaterrigidity, longer-acting time and therefore greatereffectiveness.However, these findings cannot be consideredfully conclusive due to some limitationsin this study, among which are a small samplesize, absence of a control group and thefact that patients were not randomly assigned.Thus, further studies need to be conducted, includingassessment of variables that could influencethe results.Dental Press J Orthod 122 2011 May-June;16(3):113-24

Araújo EM, Matoso RM, Diógenes AMN, Lima KCCONCLUSIONSGiven the methods employed and the resultsobtained in this study, it can be concluded thattreatment with MPA:1. Worked by restricting anterior maxillarydisplacement, with decreased SNA.2. Influenced the anterior-most mandibularposition (SNB, Go-Gn, B-FHp and Pog-FHp).3. Was effective in reducing facial convexityand correcting the maxillomandibular relationship.4. Did not influence mandibular vertical growthsince the angular variables showed no significantposttreatment behavior (SN.PP, SN.GoGn,SN.GoMe). However, anterior and posterior facialheights increased significantly, despite the factthat the mandibular plane angle remained stable.The following influences were noteworthy: (a)variable age (the sample was experiencing pubertalgrowth spurt), (b) variable facial pattern(dolichofacial patients benefited most), and (c)variable MPA type (probably due to the greaterstiffness of types 1 and 2).ReferEncEs1. Allen-Noble, P. Clinical management of the MARA.Orthodontic CyberJournal, Auburn, ME, p.1-17, Feb. 1999.2. Almeida-Pedrin RR, Pinzan A, Almeida RR, Almeida MR,Henriques JFC. Efeitos do AEB conjugado e do Bionator notratamento da Classe II, 1ª divisão. Rev Dental Press OrtodonOrtop Facial. 2005;10(5):37-54.3. Björk A. Prediction of mandibular growth rotation. Am JOrthod. 1969;55(6):39-53.4. Calvez X. The universal bite jumper. J Clin Orthod.1998;32(8):493-500.5. Castanon R, Waldez M, White LW. Clinical use of the Churrojumper. J Clin Orthod. 1998;32(12):731-45.6. Coelho Filho CM. Mandibular Protraction Appliance for Class IItreatment. J Clin Orthod. 1995;29(5):319-36.7. Coelho Filho CM. Emprego do Aparelho de ProtraçãoMandibular. In: Grupo Brasileiro de Professores de Ortodontiae Odontopediatria. 9° Livro Anual do Grupo Brasileiro deProfessores de Ortodontia e Odontopediatria. 1ª ed. SãoPaulo: IMC- Image Maker Comunicações; 2000. p. 122-9.8. Coelho Filho CM. Clinical application of the MandibularProtraction Appliance. J Clin Orthod. 1997;31(2):92-102.9. Coelho Filho CM. The Mandibular Protraction Appliance n 3. JClin Orthod. 1998;32(6):379-84.10. Coelho Filho CM. Emprego clínico do aparelho para projeçãoda mandíbula. Rev Dental Press Ortodon Ortop Facial,1998;3(5):69-130.11. Coelho Filho CM. O Aparelho de Protração Mandibular IV. RevDental Press Ortodon Ortop Facial. 2002;7(2):49-60.12. Coelho Filho CM. O Aparelho de Protração Mandibular (APM)no tratamento de pacientes adultos. In: Sakai E. et al. Novavisão em Ortodontia-Ortopedia Facial. 1ª ed. São Paulo: Ed.Santos; 2002. p.457-63.13. De Vicenzo J. The Eureka Spring: a new interarch force deliverysystem. J Clin Orthod. 1997;31(7):454-67.14. Enlow DH. Crescimento facial. 3ª ed. São Paulo: Artes Médicas;1993.15. Fränkel R, Fränkel C. Ortopedia orofacial com o regulador defunção. 2ª ed. Rio de Janeiro: Guanabara Koogan; 1996.Dental Press J Orthod 123 2011 May-June;16(3):113-24

Cephalometric evaluation of the effects of the joint use of a mandibular protraction appliance (MPA) and a fixed orthodontic appliance on the skeletal structures of patients with Angle Class II,division 1 malocclusion16. Gandini Junior LG, Martins JCR, Gandini MREAS. Avaliaçãocefalométrica do tratamento da Classe II, divisão 1ª, comaparelho extrabucal de Kloehn e aparelho fixo: alteraçõesesqueléticas (Parte I). Rev Dental Press Ortodon Ortop Maxilar.1997;2(6 Pt 1):75-87.17. Garcia C. Jasper Jumper: alternativa para a correção da ClasseII. Ortodontia. 1998;3(2):93-100.18. Jasper JJ. The correction of interarch malocclusions usinga fixed force module. Am J Orthod Dentofacial Orthop.1995;108(6):641-50.19. Klapper L. The Superspring II: a new appliance for noncompliantpatients. J Clin Orthod. 1999;33(1):50-4.20. Konik M, Pancherz H, Hansen K. The mechanism of Class IIcorrection in late Herbst treatment. Am J Orthod DentofacialOrthop. 1997;112(1):87-91.21. Lai M. Molar distalization with the Herbst appliance. SeminOrthod. 2000;6(5):119-28.22. Loiola AV, Ramos E, Sakima MT, Sakima T. Aparelho para aprojeção da mandíbula modificado. Rev Clín Ortod DentalPress. 2002;1(4):31-7.23. Manfredi C, Cimino R, Trani A, Pancherz H. Skeletal changes ofHerbst appliance therapy investigated with more conventionalcephalometrics an European norms. Angle Orthod.2001;71(3):170-6.24. Pancherz H. The Herbst appliance: its biologic effects andclinical use. Am J Orthod Dentofacial Orthop. 1985;87(1):1-20.25. Pancherz H, Ruf S, Kohlhas P. Effective condylar growth andchin position changes in Herbst treatment: a cephalometriclong-term study. Am J Orthod Dentofacial Orthop.1998;114(4):437-46.26. Sakima MT, Pinto AS, Raveli DB, Martins LP, Ramos AL. Estudodo ângulo nasolabial em indivíduos Classe II 1ª divisão comdiferentes padrões faciais. Rev Dental Press Ortodon OrtopFacial. 2001;6(5):11-5.27. Silva Filho OG, Freitas SF, Cavassan AO. Prevalência deoclusão normal e má oclusão em escolares na cidade de Bauru(São Paulo). Parte I: relação sagital. Rev Odont USP. 1990;4(2 Pt1):130-7.28. Silva Filho OG, Ozawa TO, Ferrari Júnior FM, Aiello CA.Aparelho de Herbst: variação para uso na dentição mista. RevDental Press Ortodon Ortop Facial. 2000;5(2):119-28.29. Siqueira DF. Estudo comparativo, por meio de análisecefalométrica em norma lateral, dos efeitos dentoesqueléticose tegumentares produzidos pelo aparelho extrabucal cervicale pelo aparelho de protração mandibular, associados aoaparelho fixo, no tratamento da Classe II, 1ª divisão de Angle[tese]. Bauru: Universidade de São Paulo; 2004.30. Vasconcelos JCQ. Avaliação das alterações verticais daface proporcionadas pelo tratamento com o Bionator deBalters [monografia] Goiânia: Associação Brasileira deOdontologia; 2004.Submitted: September 2007Revised and accepted: February 2009Contact addressEmmanuelle Medeiros de AraújoAv. Lima e Silva, 1611, sala 206 - Lagoa NovaCEP: 59.075-710 - Natal / RN, BrazilE-mail: emmanuelle_rn@hotmail.comDental Press J Orthod 124 2011 May-June;16(3):113-24

B B O C a s e R e p o r tAngle Class II, division 2 malocclusion treatedwith extraction of permanent teeth*Sílvio Luís Dalagnol**AbstractThis study describes the orthodontic treatment of a woman with Angle Class II, division 2malocclusion, impacted maxillary third molars, periodontal pocket, gingival recession andtooth wear. Treatment consisted of extraction of maxillary second premolars and anchoragecontrol. This case was presented to the Committee of the Brazilian Board of Orthodonticsand Facial Orthopedics (BBO) in the Free Case category as part of the requisites to obtainthe BBO Diploma.Keywords: Angle Class II malocclusion. Adult. Impacted tooth. Periodontal pocket. Tooth extraction.Orthodontic anchorage.HISTORY AND ETIOLOGYThe patient, encouraged by her periodontist,sought orthodontic treatment at 28 years of age.Her main complaint was unsatisfactory dental esthetics.Her medical history was uneventful. Herdental history, however, reported by the periodontist,included a periodontal pocket in the mesialaspect of the right mandibular first molar (tooth#46), gingival recession in several teeth, toothwear, and an indication for extraction of impactedmaxillary third molars.DIAGNOSISFacial evaluation revealed a harmonious, slightlyconcave profile, retruded lips, mild facial asymmetry,mandible shifted to the left and gingival displayon the right side during smiling (Fig 1).She presented an Angle Class II, division 2malocclusion, with characteristic maxillary crowdingand less marked mandibular crowding, mesialspace in tooth #46 and a prosthesis, smaller whencompared with its contralateral tooth. The maxillarygingival margins were uneven, there was discretegingival recession in teeth #14, 22, 23 and 24,and the occlusal plane was uneven. Maxillary centralincisors were retruded, inclined lingually andexcessively worn, and lateral incisors were protrudingand malformed. Maxillary second premolarshad restorations and their size was disproportionatein comparison with the other teeth. The maxillaryand mandibular canines had an edge-to-edgerelation, marked overbite, and a functional displacementfrom centric relation (CR) to maximalintercuspation (MI). The upper part of the midlinewas shifted to the right in relation to the mid sagittalplane, and the lower, to the left (Figs 1 and 2).How to cite this article: Dalagnol SL. Angle class II, division 2 malocclusion treated with extraction of permanent teeth. Dental Press J Orthod. 2011 May-June;16(3):125-35.* Case Report, Free Choice Case Category, approved by the Brazilian Board of Orthodontics and Facial Orthopedics (BBO).** MSc in Orthodontics, Federal University of Rio de Janeiro State, Brazil. Diplomate, Brazilian Board of Orthodontics and Facial Orthopedics.Dental Press J Orthod 125 2011 May-June;16(3):125-35

Angle Class II, division 2 malocclusion treated with extraction of permanent teethFigurE 1 - Initial facial and intraoral photographs.FigurE 2 - Initial dental casts.Dental Press J Orthod 126 2011 May-June;16(3):125-35

Dalagnol SLRadiographs showed a mesial periodontalpocket in tooth #46; teeth #38 and 48 were missing,and teeth #18 and 28 were impacted (Fig 3).Cephalometric evaluation showed skeletalharmony: ANB was 3º, but the low values ofthe mandibular plane (SN-GoGn=29°andFMA=22°), the high value of the facial angle(89°) and the pogonion shape indicated abrachyfacial profile. Measurements to definedental pattern confirmed retrusion and lingualinclination of maxillary (1-NA=15° and 3 mm)and mandibular (1-NB=19° and 2.5 mm) incisors.Cephalometric measures are shown inFigure 4 and Table 1.TREATMENT OBJECTIVESAs the main complaint was esthetical, thepurpose of the treatment was to level maxillarygingival margins 5 for esthetical and functional rehabilitation,and to extrude tooth #46 to reestablishnormal periodontal space, as requested by theperiodontist.Specific objectives were to keep the harmoniousfacial profile, to improve maxillary occlusalplane by extrusion in the left side but not on theright side, and to obtain a Class II relationship betweenmolars and normal occlusion between caninesaccording to Andrew’s keys of occlusion, allunder maximal anchorage control, as well as tocorrect upper and lower midlines, overbite, incisortipping and leveling of the curve of Spee.Therefore, at the end of the treatment, facialharmony was expected to be preserved, smileesthetics improved, and centric relation (CR),maximal intercuspation (MI) and normal excursioncorrected.FigurE 3 - Initial panoramic radiograph.ABFigurE 4 - Initial cephalometric profile radiograph (A) and cephalometric tracing (B).Dental Press J Orthod 127 2011 May-June;16(3):125-35

Angle Class II, division 2 malocclusion treated with extraction of permanent teethTREATMENT RESULTSThe main treatment objectives were achieved,as confirmed by the patient’s final examinations(Figs 5-8).In the maxilla, the SNA angle was reducedin 1 degree because of bone remodeling resultingfrom the correction of incisor tipping. 1 Inthe mandible, the mandibular plane angles (SN-GoGn and FMA) and Y axis were reduced, andthe facial angle increased, although a Kloehnextraoral appliance was used. The analysis ofdental pattern confirmed that there were positivechanges in incisor position and tipping, aswell as a better leveling of gingival margins. Theevaluation of total cephalometric comparisonconfirmed profile, maxillary and dental changes.The partial comparison showed changes in Apoint 1 and dental changes (Fig 9).A Class II relation was achieved betweenmolars, together with intentional maxillary premolarand molar rotation to improve intercuspationand normal canine occlusion accordingto Andrew’s keys. Dental midlines coincidedwith the facial midline. Overbite was correctedas the maxillary and mandibular incisors wereintruded and the curve of Spee was leveled.Gingival recessions did not change becausetooth #22 recession did not allow for the definitionof a better contour for the gingival margins(Figs 5 and 6).FigurE 7 - Final panoramic radiograph.ABFigurE 8 - Final cephalometric profile radiograph (A) and cephalometric tracing (B).Dental Press J Orthod 130 2011 May-June;16(3):125-35

Dalagnol SLABFigurE 9 - Total (A) and partial (B) comparisons of initial (black) and final (red) cephalometric tracings.FigurE 10 - Facial and intraoral photographs four years and five months after treatment completion.Dental Press J Orthod 131 2011 May-June;16(3):125-35

Angle Class II, division 2 malocclusion treated with extraction of permanent teethIntercanine and intermolar distances remainedunaltered. Maxillary intercanine distanceincreased 3.7 mm as a result of caninedistal movement, and maxillary intermolar distancedecreased 4.1 mm due to the loss of anchorageand the intentional mesial rotation ofmolars (Table 2).The analysis of radiographs revealed boneleveling in tooth #46, and root dilacerations,mostly in the canines, which were visible onlyafter rotations were corrected. Despite these dilacerations,roots were parallel and root roundingwas compatible with the great amount ofmovement of maxillary central incisors. Rootresorption, more marked in tooth #12 6 , occurredprimarily in the last phase of the treatment,and will be followed up. The progressionof third molar eruption was small and will continueunder observation (Fig 7).Facial profile remained harmonious despiteslight lip retrusion, 3 the smile was significantlyimproved after the correction of the maxillaryocclusal inclination and the adequate alignmentand leveling of anterior teeth, and the esthetic andfunctional rehabilitation desired by the patientwas achieved.The evaluation of control examinations (Figs10-14) performed 4 years and 5 months aftertreatment completion showed esthetic and functionalresin restorations in the anterior teeth, themetal-ceramic prosthesis of tooth #46, and otherrestorations that had been made by her clinicaldentist. Occlusion remained balanced, there wereno shifts in CR or MI, and intercanine and intermolardistances remained stable. Cephalometricmeasures either remained stable or had minorchanges. Radiographs confirmed the apparent stabilityof root resorptions and the good progressionof maxillary third molar eruption. In this phase,the maxillary retainer was changed to includebuccal springs in teeth #18 and 28 to help correctingtheir position.FigurE 11 - Control dental casts four years and five months after treatment completion.Dental Press J Orthod 132 2011 May-June;16(3):125-35

Dalagnol SLFigurE 12 - Control panoramic radiograph four years and five months after treatment completion.ABFigurE 13 - Control cephalometric profile radiograph (A) and cephalometric tracing (B) four years and five months after treatment completion.ABFigurE 14 - Total (A) and partial (B) comparisons of cephalometric tracings at initial (black), final (red) and four years and five months after treatmentcompletion (green).Dental Press J Orthod 133 2011 May-June;16(3):125-35

Angle Class II, division 2 malocclusion treated with extraction of permanent teethTablE 1 - Summary of cephalometric measurements.MEASUREMENTS Normal A BA/BDIFFERENCECSNA (Steiner) 82° 81º 80° -1 80ºSNB (Steiner) 80° 78º 78° 0 78ºANB (Steiner) 2° 3° 2° -1 2ºSkeletal PatternConvexity angle (Downs) 0° 0.5° 0° -0.5 0.5ºY axis (Downs) 59° 59° 58° -1 58ºFacial angle (Downs) 87° 89° 90° 1 90ºSN–GoGn (Steiner) 32° 29° 28° -1 28ºFMA (Tweed) 25° 22° 20° -2 20ºIMPA (Tweed) 90° 93° 99° 6 99º–1 – NA (degrees) (Steiner) 22° 15° 23° 8 22º–1 – NA (mm) (Steiner) 4 mm 3 mm 4 mm 1 4 mmDental Pattern– 1 – NB (degrees) (Steiner) 25° 19° 25° 6 26º– 1 – NB (mm) (Steiner) 4 mm 2.5 mm 3 mm 0.5 3 mm– 1 1 – Interincisal angle (Downs) 130° 142º 128° -14 130º– 1 – APo (mm) (Ricketts) 1 mm -1.5 mm -0.5 mm 1 -0.5 mmFacialProfileUpper lip – S line (Steiner) 0 mm -3 mm -4.5 mm -1.5 -4.5 mmLower lip – S line (Steiner) 0 mm -2 mm -3.5 mm -1.5 -3.5 mmTablE 2 - Transverse distances of dental arches.MEASUREMENTS A BMandibularintercanine distanceMandibularintermolar distanceMaxillaryintercanine distanceMaxillaryintermolar distanceA/BDIFF.25.6 mm 25.6 mm 0 25.6 mm43.6 mm 43.6 mm 0 43.1 mm33 mm 35.6 mm +2.6 35.6 mm48.8 mm 44.7 mm -4.1 44.7 mmCFINAL CONSIDERATIONSAs the patient’s main complaint was aboutdental esthetics, the main treatment objectiveshave been achieved. Correct incisor alignmentand leveling resulted in the desired esthetic andfunctional rehabilitation.In adult patients, the plan to treat Angle ClassII, division 2 malocclusion often includes the extractionof the maxillary first premolars to facilitateanchorage and reduce treatment time. In thiscase, because of the size and clinical condition ofDental Press J Orthod 134 2011 May-June;16(3):125-35

Dalagnol SLthe second premolars, we chose to extract them,although we were aware that this would make anchoragemore difficult.The evaluation of total cephalometric comparison(Fig 14) confirmed the preservation ofthe skeletal pattern and the changes in dentalpattern and facial profile. Bone remodeling dueto the correction of maxillary incisor tipping andassociated with the marked retraction of maxillarylateral incisors was confirmed in the partialcomparison of the maxilla. As maxillary lateralincisors worked as support for the lips in the beginningof the treatment, those changes mighthave resulted in a slight lip retrusion and madethe profile more concave.Control examinations (Figs 10-14) showedthat the smile improved, the profile remainedharmonious and occlusion remained stable,which confirms that the treatment objectiveshave been achieved.ReferEncEs1. Tien An TL, Cuoghi OA, Mendonça MR, Bertoz FA. Oefeito da retração dos dentes anteriores sobre o pontoA em pacientes submetidos ao tratamento ortodônticocorretivo. Rev Dental Press Ortod Ortop Facial. 2008 marabr;13(2):115-23.2. Brandt S, Safirstein R. Different extractions for differentmalocclusions. Am J Orthod. 1975 Jul;68(1):15-41.3. Hershey HG. Incisor tooth retraction and subsequent profilechange in postadolescent female patients. Am J Orthod.1972 Jan;61(1):45-54.4. Kloehn SJ. Evaluation of cervical anchorage force intreatment. Angle Orthod. 1961 Apr; 31(2):91-104.5. Kokich VG. Esthetics: the orthodontic-periodontic restorativeconnection. Semin Orthod. 1996;2(1):21-30.6. Mirabella AD, Artun J. Risk factors for apical root resorptionof maxillary anterior teeth in adult orthodontic patients. AmJ Orthod Dentofacial Orthop. 1995 Jul;108(1):48-55.Submitted: April 2011Revised and accepted: May 2011Contact addressSílvio Luís DalagnolAv. Batel, 1230, Cj. 706, BatelCEP: 80.420-906 - Curitiba / PR, BrazilE-mail: silvio@dalagnolortodontia.com.brDental Press J Orthod 135 2011 May-June;16(3):125-35

S p e c i a l A r t i c l eCriteria for diagnosing and treatinganterior open bite with stabilityAlderico Artese*, Stephanie Drummond**,Juliana Mendes do Nascimento***, Flavia Artese****AbstractIntroduction: Anterior open bite is considered a malocclusion that still defies correction,especially in terms of stability. The literature reports numerous studies on the subjectbut with controversial and conflicting information. Disagreement revolves aroundthe definition of open bite, its etiological factors and available treatments. It is probablydue to a lack of consensus over the etiology of anterior open bite that a wide range oftreatments has emerged, which may explain the high rate of instability following thetreatment of this malocclusion. Objective: Review the concepts of etiology, treatmentand stability of anterior open bite and present criteria for diagnosing and treating thismalocclusion based on its etiology, and provide examples of treated cases that have remainedstable in the long term.Keywords: Open bite. Etiology. Treatment. Stability.introductionThe term “open bite” was coined by Caravelliin 1842 as a distinct classification of malocclusion1 and can be defined in different manners. 2Some authors have determined that open bite, ora tendency toward open bite, occurs when overbiteis smaller than what is considered normal.Others argue that open bite is characterized byend-on incisal relationships. Finally, others requirethat no incisal contact be present beforediagnosing open bite. For semantic reasons, andbecause it is in agreement with most definitionsin the literature, 2,3,4,5 anterior open bite (AOB) isherein defined as the lack of incisal contact betweenanterior teeth in centric relation.Given these different definitions for AOB, itsprevalence varies considerably among studies dependingon how authors define it. Prevalence inthe population ranges from 1.5% to 11%. 6 Theage factor, however, affects prevalence, sincesucking habits decrease and oral function matureswith age. At six years old 4.2% present withAOB whereas at age 14 the prevalence decreasesto 2%. 5 In the US population, differences in prev-How to cite this article: Artese A, Drummond S, Nascimento JM, Artese F. Criteria for diagnosing and treating anterior open bite with stability. Dental Press JOrthod. 2011 May-June;16(3):136-61.* MSc in Orthodontics, University of Washington. Associate Professor of Orthodontics, UFRJ (Retired).** Specialist and Masters Student in Orthodontics, UERJ.*** Specialist in Orthodontics, UERJ.**** MSc and PhD in Orthodontics, UFRJ. Associate Professor of Orthodontics, UERJ. Brazilian Board of Orthodonticsand Facial Orthopedics Diplomate.Dental Press J Orthod 136 2011 May-June;16(3):136-61

Artese A, Drummond S, Nascimento JM, Artese Falence were detected between the different ethnicities,with 3.5% occurring in Caucasian childrenand 16.5% in Afro-descendant children. 5Despite its low prevalence, the demand for treatmentof this malocclusion is very common as approximately17% of orthodontic patients haveAOB, 6 which means that professionals shouldtreat it in an effective and stable manner.AOB EtiologICAL FACTORS: FUNCTIONALOR SKELETAL?Teeth and alveolar bones are exposed to antagonisticforces and pressures stemming mostlyfrom muscle function, which may partly determinethe position of the teeth. On the otherhand, the intrinsic forces of the lips and tongueat rest generate the balance required to positionthe teeth (Fig 1). By definition, balanceFigurE 1 - Schematic illustrating balance between forces of lips andtongue (arrows), allowing contact of maxillary incisor and thereforeachieving normal overbite.occurs when a body at rest is subjected to forcesin various directions but does not undergoacceleration or — in the case of teeth — is notdisplaced. 7 Every time this balance is altered,changes occur, such as for example contractionof the dental arches in animals subjectedto glossectomy when compared to control animals.8 Thus, when a tooth is extracted its antagonistcontinues the process of passive eruption,indicating that the mechanism of eruptionremains basically unchanged throughoutlife and that the tooth seeks occlusal or incisalcontact until balance is reached. 7Based on this idea of balance several etiologicalfactors related to oral function have beenassociated with AOB. For example, sucking habits,presence of hypertrophic lymphoid tissues,mouth breathing, atypical phonation and swallowing,and anterior posture of the tongue atrest. 2,3,9,10,11 It should be noted, however, thatnot all of these etiological factors exhibit a perfectlyclear cause and effect relationship.The causal relationship between AOB andnonnutritive sucking habits, such as the suckingof fingers and pacifiers, has been very wellestablished. 12 In such cases, AOB self-correctsconsistently after removal of the sucking habit,provided that no other secondary dysfunctionshave set in 2 (Fig 2). These secondary dysfunctionsmay develop from maxillary incisor protrusiongenerated by the sucking habit, therebyhindering the lip seal required for swallowing,and causing the tongue to be abnormally positioned,especially at rest. 11During childhood the tongue is proportionallylarger than the oral cavity and it thereforeprotrudes beyond the alveolar ridges. The jawbones grow faster than the tongue during childhoodand eventually the size of the oral cavityadapts to tongue size. 10 In fact, longitudinalstudies in children showed that the prevalenceof tongue protrusion in speech and swallowingis significantly reduced starting at 8 years ofDental Press J Orthod 137 2011 May-June;16(3):136-61

Criteria for diagnosing and treating anterior open bite with stabilityABCDFigurE 2 - A) AOB in primary teeth caused by pacifier sucking and B) spontaneous correction afterremoval of habit. C) AOB in mixed dentition caused by thumb sucking. It is noteworthy how AOB morphologydiffers according to causative agent. Pacifier is soft and deformable, creating more elongatedand narrow open bite, whereas finger is stiffer and larger, creating wider, rounded open bite withprotruded maxillary incisors and deficient eruption in mandibular incisors. D) When thumb suckinghabit is so intense the back of the finger may become callous.age. It is approximately 51.7% at 4 years of ageand 38.9% at age 12. 14Some authors believe that the forces generatedduring swallowing and phonation cancause changes in the shape of the dental arches.4 Although these disorders are associated inthe literature with AOB etiology, other studiesshow that these functions are short livedand not sufficient to cause dental changes. 7,11Frequency of atypical speech and swallowing ismuch higher than AOB prevalence, which mayexplain the tenuous causal link between thepresence of atypical speech and swallowing,and the presence of this malocclusion. 11Hypertrophic adenoids and tonsils are themost common cause of nasal obstruction and,consequently, mouth breathing in children. 4The effect of airway obstruction on the occlusionwas demonstrated by Harvold et al 16 who,after placing acrylic blocks in the posterior regionof the palate of rhesus monkeys, found thatAOB had developed. Induced nasal obstructionwas also performed using nasal splints in rhesusmonkeys, which, in an attempt to secure an oralair passage, developed open mouth posture andprotruded tongue. 17Therefore, hypertrophic lymphoid tissuesand nasal obstruction may force the tongue toremain in a position designed to allow breathingto occur through the oropharyngeal ratherthan nasopharyngeal space. 12,18 In general,lymphoid tissues undergo involution duringpuberty, allowing the tongue to adopt a positionmore posterior than what is deemed normal.2 However, Linder-Aronson et al 19 foundthat dentoalveolar response to adenoidectomyis highly variable and therefore should not beconsidered as a prophylactic procedure for thedevelopment of AOB. Indeed, not all patientswith mouth breathing due to partial nasalblockage develop AOB. 4Most investigations of AOB etiology agree onthe existence of secondary dysfunctions, whichremain after the correction of an abnormal function,such as, especially, poor tongue posture atrest. 4,7,12 It is believed that a gentle but continuousDental Press J Orthod 138 2011 May-June;16(3):136-61

Artese A, Drummond S, Nascimento JM, Artese FABFigurE 3 - AOB caused by poor posture of the tongue at rest and lip interposition (A). Cephalometricradiograph contrast allows the tongue to be viewed in its resting position, supported by the mandibularincisors, preventing their proper eruption, and the interposition of the lower lip between the incisors,preventing the proper eruption of the maxillary incisors is also visible (B).pressure exerted by the tongue against the teethcan move such teeth, yielding significant effects.If a patient has a previous posture in which theyhave positioned their tongue, the duration of thispressure — even if very light — can affect theeruption process, or move anterior teeth, resultingin an open bite. 10,11Tongue posture at rest is long lasting (severalhours a day), which makes it clinically importantas it can prevent the eruption of incisors,thereby causing and maintaining AOB (Fig 3).In addition, a low tongue posture may encouragethe eruption of posterior teeth and constrictthe upper arch since the tongue does not touchthe palate. 7 This etiological factor has not beenstudied enough and is generally overlooked duringAOB treatment. Failure to eliminate this factormay be the primary reason of AOB relapse. 10In 1964, Subtelny and Sakuda 2 published anarticle on the diagnosis and treatment of AOB.Based on the premise that abnormal functionalhabits either decrease or are absent in adolescents,these authors sought out an explanationfor the existence of what they called “persistentopen bites,” i.e., those that persist after childhood.They conducted a cephalometric studyin 25 patients with “persistent open bite” andcompared them with 30 patients with normalocclusion. All subjects were over 12 years ofage. Basically, in cases of open bite the followingsignificant differences were found: Greatereruption of maxillary molars, extrusion of maxillaryincisors and overly increased mandibularplanes and gonial angles. This facial pattern wasnamed “skeletal open bite.” Its primary etiologicalfactor is an unfavorable growth pattern withdivergent basal bones and therefore no contactbetween the incisors. These etiological factorsare associated with growth and not function,and can thus be defined as skeletal factors.Over the years, vertical facial pattern wasultimately considered as the main risk factorfor AOB and its treatment instability. However,other studies 10,20 have reported that mosthyperdivergent patients exhibit a normal orexcessive overbite (Fig 4) while patients withnormal facial patterns display a “persistentopen bite” 4 (Fig 5).One can therefore infer that skeletal patternper se cannot be the cause of AOB. 7 In revisitingthe aforementioned idea of balance of forcesbetween teeth, the presence of a physical barrierprevents the incisors from coming into occlusalcontact. Since an abnormal posture of the tongueat rest may occur in different situations, 4,10 thismay be the key etiological factor in AOB.Dental Press J Orthod 139 2011 May-June;16(3):136-61

Criteria for diagnosing and treating anterior open bite with stabilityABCDEFFigurE 4 - Profile photograph (A), cephalometric radiograph (B), casts (C) and intraoral photographs (D, E and F) of a patient with hyperdivergent facialpattern (SNGoGn=49º), showing excessive overbite, which can be seen more clearly in a posterior view of the plaster casts in occlusion. The lower incisorstouch the palate seeking occlusal contact since there is no structure preventing its eruption.AOB TREATMENT AND STABILITYDue to numerous etiological factors describedin the literature various types of treatmenthave been postulated for correcting AOB.No consensus has been reached, however, as towhat would be the best treatment for this malocclusion:6 (a) Changes in behavior to eliminatehabits or abnormal functions, (b) Orthodonticmovement by extruding the anterior teeth orintruding the molars, or (c) Surgical treatmentof the basal bones. 21 The only consensus thatseems to exist is that AOB treatment is challenging3,6 and has poor stability. 6,9,22Functional treatmentsMyofunctional therapy is used to alter functionand consists of a set of exercises to reeducateorofacial muscles in swallowing, speech andresting posture. 11,12,15 It is believed that voluntaryactivities such as swallowing and speech areeasier to correct using myofunctional exerciseswhile involuntary activities such as tongue posturehabits are hard to automate. 11,14Another way to correct functional habits isthrough mechanisms that prevent the tonguefrom resting on the teeth. 23 The best known arepalatal or lingual cribs 24 and spurs 10,25 There isa consensus that these devices should be fixedwith the purpose of re-educating the functionuntil automatic movements are attained. 25,26Palatal or lingual cribs are aimed at correctingAOB by preventing the tongue from restingon the teeth. They must be long to prevent thetongue from positioning itself below them. 24However, such structures are smooth and deliberatelyallow the tongue to rest on them soDental Press J Orthod 140 2011 May-June;16(3):136-61

Artese A, Drummond S, Nascimento JM, Artese FABCDEFigurE 5 - Profile photograph (A), cephalometric radiograph (B) and intraoral photographs (C, D and E) of a patient with normal facial pattern (SNGoGn=34º),with AOB. The incisors are not in contact due to mechanical obstruction, possibly due to tongue posture since the patient reported no sucking habits.that in some cases this may prevent the functionalre-education of the tongue. In these cases,the tongue returns to its original position asshown by the cinefluoroscopic method, 28 thusleading to AOB relapse.The use of spurs was described by Rogers 28 in1927 in the treatment of three AOB cases. Thespurs were welded to a palatal arch and placedfrom canine to canine. All cases were correctedby normalizing the tongue posture. Several typesof similar devices were later described in whichspurs can be soldered to the lingual surfaces ofmaxillary incisor bands or attached to palatal 10or lingual 29 arches or, alternately, bonded to thelingual or palatal surfaces of the incisors. 26Despite their efficacy, treatments using spursare sometimes regarded as punitive, 1,2 althoughthere are no reports of pain or injury to thetongue. 10 Furthermore, Haryett et al 23 concludedthat any type of device used to break thefinger sucking habit, including spurs, can causepsychological disorders.Spurs induce a change in the resting positionof the tongue, thus allowing tooth eruptionand open bite closure. This change intongue position alters sensory perception bythe brain, thereby producing a new motor response.This response can be imprinted permanentlyin the brain, which explains the permanentchange in tongue posture producedby spurs. This is one of the factors responsiblefor AOB treatment stability. 10,25Huang et al 3 evaluated AOB treatment stabilityusing cribs or spurs in 33 patients dividedinto two groups, one with and one withoutgrowth. These authors found that AOBDental Press J Orthod 141 2011 May-June;16(3):136-61

Criteria for diagnosing and treating anterior open bite with stabilitycorrection occurred in both groups but 17.4% ofcases showed relapse. Since no comparison betweendifferent treatment types was performed,one could argue that patients whose overbite iscorrected with the use of cribs or spurs standa good chance of maintaining long-term treatmentoutcome. However, comparative studiesbetween these two types of treatment would beinvaluable for the prognosis of AOB treatment.Orthodontic treatmentsThere are several types of treatment involvingorthodontic movement for correction ofopen bite, with different therapeutic goals. Extraoralappliances, vertical chincups, bite-blocksand functional appliances are designed to reducethe extrusion of molars, allowing a counterclockwiserotation of the mandible. 6,9,22 More recently,the same mechanism was implemented withthe aid of anchorage to intrude molars. 6,21 Mechanicswith intraoral elastics are used both forincisor extrusion 2 and molar intrusion, as wellas for rotation of the occlusal plane combinedwith multiloop archwires. 30 Although there aremany successful reports of these therapies fewstudies have been conducted to investigate theirlong-term stability, which precludes any reliableprognoses for these treatments. 4,6,22Stability in the correction of AOB in patientstreated orthodontically with fixed appliancesassociated with high-pull and combinedheadgear was evaluated 10 years after treatment.9 AOB relapse was greater than 3 mm in35% of the cases. The sample was then stratifiedinto stable and relapse groups for comparisonof cephalometric variables. All variables weresimilar between the groups at the beginning oftreatment, except for anterior dental height inthe mandibular arch, which was lower in therelapse group at all treatment times.Zuroff et al 6 assessed AOB stability 10years after treatment. Sixty-four patients weredivided into three groups: One with incisalcontact, one with open bite and overlap, andone with open bite. All patients were onlytreated orthodontically. After treatment, 4%of the group with incisal contact had overjetrelapse; 20% of the group with open bite andoverlap had overjet relapse but preserved incisalcontact; and 40% of the open bite grouphad overjet, with 60% displaying no incisalcontact. These results indicate that a lack ofvertical overlap prior to treatment exerts agreater adverse effect on AOB stability comparedto open bite with overlap.Surgical TreatmentsSurgical treatments for AOB began in the70s and were indicated for extremely severecases with mandibular plane above 50 degrees.Thereafter, these treatments have become morecommon and usually include LeFort I osteotomyfor superior repositioning of the maxilla.This allows a counterclockwise rotation of themandible, thus correcting AOB. 22Denison et al 22 assessed the stability of AOBsurgical treatment in 66 adult patients followedup for at least 1 year after surgery. Thesepatients were stratified according to preoperativevertical overlap, namely: Open bite, openbite with overlap, and normal overlap. Openbite recurred in 42.9% of cases in the openbite group while the groups with open bite andoverlap, and normal overlap showed no changesin postoperative overbite. It was found thatthe instability found in patients in the openbite group was due to dentoalveolar changesand not to skeletal changes.Once it has been eliminated in surgical patients,one cannot claim that hyperdivergenceis an etiological factor since these patients areadults and exhibit little or no growth. Therefore,it is believed that the relapses found inthe study described above are of dentoalveolarorigin, generated by oral disorders overlookedin the pretreatment phase. 10Dental Press J Orthod 142 2011 May-June;16(3):136-61

Artese A, Drummond S, Nascimento JM, Artese FGreenlee et al 21 published a meta-analysiswhich evaluated AOB treatment stability insurgical and nonsurgical studies. A 75% stabilityrate was found in both types of treatment.However, these results should be viewed withcaution since these various treatments wereexamined in different studies and applied todifferent populations. Moreover, these studieslacked control groups.Nowadays there are not enough evidencebasedfindings to support the effectiveness ofAOB 21 treatment or stability of AOB correction.Randomized trials evaluating differenttherapies are thus necessary. 5 However, theoutcomes of the stability studies describedabove indicate that AOB relapse is linked totwo factors: Dentoalveolar changes and openbites with no vertical overlap prior to treatment.3,6,9,22 These data suggest that AOB relapseis generally caused by the anterior positionof the tongue at rest, an etiological factorthat has not merited due attention in bothorthodontic and surgical treatment. 3,10DIFFERENT POSTURES OFTHE TONGUE AT RESTAOB morphology is directly associated withetiological factors, 7 which differ for each type ofhabit (Fig 2). In AOB cases that do not resultfrom sucking habits one can use this logic to differentiatebetween the resting positions of thetongue, as there may be more than one type ofresting position.The position considered normal for thetongue at rest is one in which the tip of thetongue rests on the incisal papilla and its backlies along the palate (Figs 1 and 6A), keepingthe anterior teeth in balance while preservingthe transverse dimension of the upper arch. 7However, some AOBs show changes in thepositions assumed by maxillary incisors andothers display changes in the positions of mandibularincisors. Based on these morphologicalcharacteristics some different resting positionsof the tongue are suggested: High, horizontal,low and very low (Fig 6).A high posture of the tongue at rest is associatedwith slightly protruded maxillary incisors andAOB may exhibit vertical overlap and positivehorizontal overlap. Since the tongue rests on thepalatal surface of the incisors, beneath the incisalpapilla, upper incisors are positioned above theocclusal plane. Leveling of the mandibular arch isunaffected and displays a single occlusal plane (Fig7). Posterior crossbites are not present as the backof the tongue rests on the palate while maintainingthe transverse dimension of the upper arch.In the horizontal posture of the tongue atrest, the tongue appears lower than in the highposition, although with greater protrusion, restingon the palatal surface of the upper incisorsand on the incisal edges of the lower incisors.The major effect in this case can only be seen inthe upper arch, where protrusion of maxillaryincisors was more prominent, which preventedtheir extrusion, thereby causing AOB. Also dueto the greater protrusion of the incisors, a positiveand increased horizontal overlap was noted.As the tongue positions itself lower, its backturns away from the palate allowing transversechanges to occur in the maxillary arch, whichmay cause posterior crossbites (Fig 8).As the tongue assumes a lower position, pressurebegins to be exerted on mandibular teeth.In the low posture of the tongue, it rests onthe lingual surface of the crowns of mandibularincisors, thereby protruding these teeth andpreventing their eruption, which establishes amoderate open bite. Due to protrusion in thelower incisors, horizontal overlap may be zeroor negative. A gap can be seen between the occlusalsurfaces of posterior teeth and the incisalsurfaces of anterior teeth in the lower arch only,with lower incisors positioned below the occlusallevel. Posterior crossbites may be present forthe same reason mentioned above (Fig 9).Dental Press J Orthod 143 2011 May-June;16(3):136-61

Criteria for diagnosing and treating anterior open bite with stabilityA B CFigurE 6 - Classification for posture of thetongue at rest: (A) Normal, (B) high, (C) horizontal,(D) low and (E) very low.DEA B CFigurE 7 - Schematic (A) and photographs (B and C) of high posture of the tongue at rest, associated with a mild AOB; may exhibit vertical overlap. Themaxillary incisors are protruded and lower arch leveling is unchanged. No posterior crossbite was observed. The arrows represent the direction of theforce exerted by the tongue.Dental Press J Orthod 144 2011 May-June;16(3):136-61

Artese A, Drummond S, Nascimento JM, Artese FA very low tongue posture occurs when thetongue rests below the crowns of the mandibularincisors in the lingual region of the loweralveolar ridge. The direction of tongue pressureproduces retroclination of mandibular incisorsand prevents their eruption, positioning thembelow the occlusal level. The open bite is moresevere and associated with posterior crossbitedue to the fact that the tongue moves awayfrom the palate. The tongue sprawls across themouth floor, expanding the lower arch in thetransverse direction (Fig 10).TREATMENT CHOICE BASED ON TONGUEPOSITION AT REST: RESTRAINING ANDORIENTING TREATMENTSUnderstanding AOB etiology in each patientmay help in their treatment and long-term stability.4 These various postures of the tongue atrest will guide orthodontists in choosing thetreatment capable of bringing the tongue backto a correct resting posture, thus removing thecausative agent of the malocclusion.Once the AOB causative agent has been identifiedand ascribed to an abnormal posture ofthe tongue, orthodontists should classify tongueposture through an analysis of the morphologicalfeatures of the malocclusion.High and horizontal tongue postures arepositioned very close to normal posture and requirecontrol in the horizontal direction only. Itis suggested that blocking mechanisms such ascribs are sufficient to produce this tongue retractionand adapt it to its correct posture at rest.This type of treatment will be referred to as restrainingtreatment.However, in the low and very low tonguepostures, the tongue is not only protruded butit is positioned below its correct position andneeds to be retracted and elevated. This processis difficult to learn and automate, 25 requiring educatingdevices which force the direction of thetongue, such as spurs. This type of treatment willbe referred to as orienting treatment.To illustrate these types of treatment, and inparticular their stability, AOB cases caused byeach type of tongue posture at rest, which weremonitored in the long-term, will be presented.CA B DFigurE 8 - Schematic (A), radiograph (B) and photographs (C and D) of horizontal posture of the tongue at rest, associated with a moderate AOB; may exhibitvertical overlap. The maxillary incisors are markedly protruded and above the occlusal plane. Lower arch leveling is unchanged. Due to the distancebetween the back of the tongue and the palate, posterior crossbites may emerge. The arrows represent the direction of the force exerted by the tongue.Dental Press J Orthod 145 2011 May-June;16(3):136-61

Criteria for diagnosing and treating anterior open bite with stabilityCA B DFIGURE 9 - Schematic (A), radiograph (B) and photographs (C and D) of low posture of the tongue at rest, associated with a moderate AOB. The mandibularincisors display a pronounced protrusion. Lower arch leveling is changed, with mandibular incisors positioned below the occlusal level. Due to the distancebetween the back of the tongue and the palate, posterior crossbites may emerge. The arrows represent the direction of the force exerted by the tongue.CA B DFigurE 10 - Schematic (A), radiograph (B) and photographs (C and D) of very low posture of the tongue at rest, associated with a severe AOB. Themandibular incisors appear uprighted or retroclined. Lower arch leveling is changed, with mandibular incisors well below the occlusal level. Due to thedistance between the back of the tongue and the palate, posterior crossbites are bound to emerge. The arrows represent the direction of the force exertedby the tongue.APPLYING CRITERIA FOR AOB DIAGNOSISAND TREATMENT: CASE REPORTSCase 1: High Posture of Tongue at RestThis is an 8-year-old female patient in themixed dentition stage. She presented with anAngle Class I malocclusion with AOB, slightlyincreased overjet, protruded maxillary incisorsand interincisal diastemas in the upper arch. Thelower arch was normal. The face was symmetricalwith a slightly convex facial profile (Fig 11).Patient history did not reveal sucking habits,indicating that AOB was caused by an abnormalposture of the tongue at rest. AOB morphologicalcharacteristics indicated that the patienthad a high tongue posture as it did not changethe occlusal plane in the lower arch. However,Dental Press J Orthod 146 2011 May-June;16(3):136-61

Artese A, Drummond S, Nascimento JM, Artese Fthe maxillary incisors were protruded and positionedabove the occlusal plane (Figs 11C, Dand E). Since the treatment goal was to restrainthe tongue in the horizontal direction, placingit further back, restraining treatment was preferredand a Hawley retainer was therefore used,combined with a crib (Fig 12A).The retainer was used for a period of two yearsuntil the patient was in the final stage of mixeddentition (Fig 12B). She was monitored until thepermanent dentition phase. The open bite wasclosed, overjet and interincisal diastemas reduced(Figs 13C, D and E). No other treatment was performedon this patient, who achieved a stable resultas can be seen from the records obtained 32years after treatment (Fig 14).It was only thanks to the removal of a poortongue posture that establishing a normal horizontaloverlap became possible and, more importantly,the AOB etiological factor was eliminated,thus ensuring a stable result for manyyears (Fig 15).ABCDEFigurE 11 - Initial facial (A and B) and intraoral photographs (C, D and E).ABFigurE 12 - Hawley retainer with crib (A) usedto treat patients for a two-year period until anormal overbite was attained (B).Dental Press J Orthod 147 2011 May-June;16(3):136-61

Criteria for diagnosing and treating anterior open bite with stabilityABC D EFigurE 13 - Extraoral (A and B) and intraoral photographs (C, D and E) at the end of treatment. The patient was not subjected to any other type of orthodontictreatment.ABC D EFigurE 14 - Extraoral and intraoral photographs 32 years after treatment.Dental Press J Orthod 148 2011 May-June;16(3):136-61

Artese A, Drummond S, Nascimento JM, Artese FABCDFigurE 15 - A) Initial AOB condition, B) during treatment with Hawley retainer with crib, C) end oftreatment and D) 32 years after treatment, demonstrating stability of AOB correction.Case 2:Horizontal Posture of Tongue at RestA female patient aged 9 years, in the mixeddentition period presenting with an Angle ClassII, Division 1 malocclusion, 8 mm overjet, crossbite of teeth 16 and 46, AOB and less than 2mm midline shift to the right (Figs 16E, F andG). She had a Class II skeletal pattern with 10ºANB (SNA=88° and SNB=78°) and normalmandibular plane (SNGoGn=34º) (Fig 16D).Facial evaluation showed a symmetrical faceand convex profile (Figs 16A, B and C).Patient history revealed that she had nosucking habits, suggesting that AOB etiologywas related to abnormal tongue posture.To determine what sort of tongue posture thepatient had it was observed that lower archleveling was normal while the upper incisorswere protruded and positioned above the occlusallevel. These features suggest a horizontalposture of the tongue associated with markedoverjet. Therefore, restraining treatment wouldbe indicated in this case.It was decided the use of a modified Thurowappliance with expansion screw and palatalcrib (Fig 17), which was worn for six consecutivemonths. After this period, an AngleClass I molar relationship was attained with3 mm overjet, the crossbite was corrected aswell as the AOB (Figs 18E, F and G) and therewas improvement in the skeletal relationship(SNA=83°, SNB=78º and ANB=5º) (Fig 18D).The face remained symmetrical and the profileslightly convex (Figs 18A, B and C). The appliancewas then worn only at night for anothersix months for retention purposes.At age 12 the second phase of treatmentwas initiated with the placement of a fixedmetallic orthodontic appliance. Due to thecorrection of tongue posture the upper incisorsextruded (Fig 19), reaching a situation ofexcessive overbite, as shown in Figures 18E, Fand G. It was therefore necessary to employutility archwires to intrude the incisors andattain a normal overbite. The second phase oftreatment was completed by correcting thehorizontal and vertical overlaps, and the ClassI molar relationship was maintained (Figs 20D,E and F). The face remained symmetrical witha balanced facial profile (Figs 20A, B and C).Dental Press J Orthod 149 2011 May-June;16(3):136-61

Criteria for diagnosing and treating anterior open bite with stabilityABCDE F GFigurE 16 - Initial extraoral photographs (A, B, C), cephalometric radiograph (D) and intraoral photographs (E, F and G).FigurE 17 - Modified Thurow headgear usedin the first treatment phase containing aposterior maxillary splint with an expansionscrew, lingual crib and Hawley clasp.ABCDE F GFigurE 18 - Extraoral photographs (A, B, and C), cephalometric radiograph (D) and intraoral photographs (E, F and G) at the end of the first treatment phase.Dental Press J Orthod 150 2011 May-June;16(3):136-61

Artese A, Drummond S, Nascimento JM, Artese FABFigurE 19 - Total (A) and partial (B) cephalometricsuperimpositions comparing the beginningand end of the first treatment phase. It isnoteworthy that AOB correction occurred byextrusion of the maxillary incisors.A B CD E FFigurE 20 - Extraoral (A, B and C) and intraoral photographs (D, E and F) at the end of the second treatment phase.In this case, AOB correction occurred thanksto a spontaneous extrusion of the incisors (Fig19) after using a palatal crib and correcting thetongue posture. The results were stable as can beseen in the follow-up photographs 10 years aftertreatment (Fig 21). Stability of AOB correctionwas accomplished because the etiological factorwas eliminated and, in this case, it was curious tonote that the AOB evolved into an excessive overbite(Fig 22). This suggests that after removing theAOB etiological factor one can develop any degreeof overbite (normal or excessive) and, therefore, itis advisable to use plates with stops as a retentionmechanism like the ones used in this patient.Dental Press J Orthod 151 2011 May-June;16(3):136-61

Criteria for diagnosing and treating anterior open bite with stabilityA B CD E FFigurE 21 - Extraoral (A, B and C) and intraoral photographs (D, E and F) 10 years after treatment.ABCDFigurE 22 - Degrees of vertical overlap at the beginning of treatment showing AOB (A), after the firsttreatment phase with excessive overbite (B), at the end of treatment (C) and 10 years after treatment,with adequate vertical overlap (D).Dental Press J Orthod 152 2011 May-June;16(3):136-61

Artese A, Drummond S, Nascimento JM, Artese FCase 3: High Posture of Tongue at RestA 7-year-old female patient with mixed dentitionpresented with a Class I molar relationship,without horizontal overlap, with AOB andtendency toward posterior crossbite (Figs 23E, Fand G). No sucking habit was reported. She hada typical skeletal Class I (SNA=78°, SNB=77°and ANB=1º) with increased mandibular plane(SNGoGn=37) (Fig 23D). The face was balancedwith no apparent asymmetries, with lip incompetenceand a convex profile (Figs 23A, B and C).The morphological features of this AOBincluded slightly protruded maxillary incisorswith deficiently erupted and protruded mandibularincisors (IMPA=100º) (Figs 23D andF). These effects in the lower arch suggest alow posture of the tongue at rest. Since thistongue had to be retracted and elevated, it wasdecided to conduct orienting treatment withspurs on the lingual arch (Fig 24).The spurs were worn for a period of twoyears and the patient monitored for anothertwo years until the permanent dentition stage.By then the patient had developed a Class Imolar relationship, severe lack of space in botharches, posterior crossbite on the right side, andnormal overbite (Fig 25). The mandibular incisorswere uprighted and extruded through theuse of spurs (IMPA=92º) (Fig 26). The skeletalClass I relationship was maintained (ANB=1º).Corrective treatment was then initiated withextraction of first premolars.Corrective treatment was performed withcanine distalization followed by retraction ofthe incisors. No anchorage mechanism was used,nor any vertical elastics, which attests to the stabilityof the AOB correction. Dental alignmentwas attained as well as vertical and horizontaloverlaps, and adequate intercuspation. The profileremained balanced (Fig 27).ABCDE F GFigurE 23 - Initial extraoral photographs (A, B, C), cephalometric radiograph (D) and intraoral photographs (E, F and G).Dental Press J Orthod 153 2011 May-June;16(3):136-61

Criteria for diagnosing and treating anterior open bite with stabilityFigurE 24 - Panoramic radiograph of patient with spurs in place, reorientingthe tongue backwards and upwards.ABCDE F GFIGURE 25 - Extraoral photographs (A, B and C), cephalometric radiograph (D) and intraoral photographs (E, F and G) after use of spurs in permanent dentition.ABCFigurE 26 - Total (A) and partial (B) cephalometric superimpositions comparing the initial phase with the phase prior to corrective treatment. It is noteworthythat in the radiographs (C) uprighting and extrusion were attained in the lower incisors with the use of spurs alone, and the stable outcome wasmonitored over 5 years.Dental Press J Orthod 154 2011 May-June;16(3):136-61

Artese A, Drummond S, Nascimento JM, Artese FA B CD E FFigurE 27 - Extraoral (A, B and C) and intraoral photographs (D, E and F) at the end of corrective treatment after 7 years of spur use, showing stability ofAOB correction.Case 4: Very Low Posture of Tongue at RestA female patient aged 9 years, showing severeanterior open bite and severe lack of spacein the lower arch (Figs 28E, F and G). The patientwas a mouth breather and undergoingspeech therapy. She had a Class III skeletalpattern (ANB=-1°), a tendency toward verticalgrowth, and an increased mandibular plane(SNGoGn=49º) (Fig 28D). The face showedno clear asymmetry and had an adequate profile(Figs 28A, B and C).According to the morphological characteristicsof the open bite, the patient had a verylow position of the tongue at rest, clearly characterizedby retroclination of mandibular incisors(IMPA=70°) and posterior crossbite. Toperform the correction it would be necessaryto move the tongue upward and backward withorienting treatment. The appliance of choicewas a lower lingual arch with spurs. Firstly, asingle spur was placed in the midline region,then other spurs were gradually inserted in thecanine-to-canine region (Fig 29).Use of lingual arch with spurs was suspendedfour years later. At this time a significant improvementin vertical overlap was observed aswell as the presence of diastemas in the mandibularincisor region (Figs 30D, E and F) due to theprotrusion of these teeth. The profile remainedbalanced and the face symmetrical (Figs 30A, Band C). At this stage, it was decided to place afixed orthodontic appliance in the mandibulararch in order to close spaces.The upper arch received no appliances andwas monitored for a period of one year to assessstability of AOB correction. Should the AOBhave relapsed it would have meant that thetongue posture had not been corrected. An adequatevertical overlap was achieved and the posteriorcrossbite corrected (Figs 31C, D and E).Dental Press J Orthod 155 2011 May-June;16(3):136-61

Criteria for diagnosing and treating anterior open bite with stabilityABCDE F GFigurE 28 - Initial extraoral photographs (A, B, C), lateral cephalometric radiograph (D) and intraoral photographs (E, F and G).ABFigurE 29 - Spurs used on lingual arch, startingwith one spur at arch center (A) and increasingnumber and size of spurs (B) in orderto reorient tongue posture backwards andupwards.No expansion was performed in the upperarch and crossbite was corrected by positioningthe tongue higher, thus changing thetransverse dimension of the arch. The faceremained symmetrical with a balanced facialprofile (Figs 31A, B and C). At this stage,fixed appliances were installed in the upperjaw to finish the case.At the end of treatment an excellent occlusaloutcome was accomplished, with the establishmentof a Class I relationship and correcthorizontal and vertical overlap (Figs 32E, F andG). A skeletal Class I relationship was attained(ANB=1º) (Fig 31D). Despite the high mandibularplane (SNGoGn=50) the face was balancedwith a good profile and adequate lip seal (Figs32A, B and C).Correction of this AOB was achieved mostlyby a significant extrusion of the mandibular incisors(Figs 33A and B). The backward and upwardchange in tongue posture allowed eruptionof the incisors, thereby lengthening the alveolarprocess (Figs 33C, D, E and F), as reported byMeyer-Marcotty et al. 25 The skeletal features ofthis face would have one believe that the causeof the AOB might be an unfavorable growth pattern.2 However, this case suggests that AOB occurs— even in hyperdivergent faces — when theeruptive process is hampered by a mechanicalobstruction (in this case the tongue), and thus,Dental Press J Orthod 156 2011 May-June;16(3):136-61

Artese A, Drummond S, Nascimento JM, Artese FA B CD E FFigurE 30 - Extraoral (A, B and C) and intraoral (D, E and F) photographs after 4 years of spur use.A B CD E FFigurE 31 - Extraoral (A, B and C) and intraoral (D, E and F) photographs after placement of appliance in the lower arch.Dental Press J Orthod 157 2011 May-June;16(3):136-61

Criteria for diagnosing and treating anterior open bite with stabilityABCDE F GFigurE 32 - Extraoral photographs (A, B and C), lateral cephalometric radiograph (D) and intraoral photographs (E, F and G) at the end of treatment.ABC D E FFigurE 33 - Total (A) and partial (B) cephalometric superimpositions comparing initial and final treatmentphases. Radiographs (C, D, E and F) show protrusion and marked extrusion of incisors obtainedwith the use of spurs only.Dental Press J Orthod 158 2011 May-June;16(3):136-61

Artese A, Drummond S, Nascimento JM, Artese Fskeletal pattern would not play an etiologicalrole in AOB.Removal of the causative agent of this AOBensured outcome stability 10 years after treatment,as shown in Figure 34. Treatment of thesecases requires patience and the long-term useof spurs, which in this case lasted for 4 years.Due to AOB severity, the amount of extrusionrequired for incisors to attain vertical overlap isconsiderable (Fig 35). Moreover, the process ofautomating tongue posture is slow, demandingtime for neuromuscular restructuring. 10,25A B CD E FFigurE 34 - Extraoral (A, B and C) and intraoral (D, E and F) photographs 10 years after treatment.ABCDFigurE 35 - A) Initial open bite position, B)Intermediate treatment stage after adjustingoverbite with spurs and placement of appliancein the lower arch, C) Overbite achievedafter corrective treatment and D) Overbitestability 10 years after treatment.Dental Press J Orthod 159 2011 May-June;16(3):136-61

Criteria for diagnosing and treating anterior open bite with stabilityFINAL CONSIDERATIONSThe difficulties encountered in obtaining stableresults for AOB correction can be justified by thefact that their true etiology still defies understanding.The posture of the tongue at rest is not highlyregarded in AOB treatments. Some evidence suggeststhat the posture of the tongue may be oneof the most important etiological factors in AOB.Therefore, it must be analyzed and addressed whenit is abnormal.There is more than one possible resting positionfor the tongue. It can position itself on a higheror lower level, producing open bite with differentmorphological characteristics and severity.Appropriate treatment should be selected basedon these characteristics, and can be conducted byeither restraining or orienting the tongue. Oncethe posture of the tongue has been corrected, theetiological factor is extinguished and treatmentstability is ensured.Clinical studies of AOB are generally case-controlexperimental models with small samples andlack of control groups. This fact makes the informationavailable about this malocclusion incompleteand therefore inconclusive. Further researchis warranted, particularly to reassess whether or nottongue posture and a hyperdivergent facial growthcan be considered as an etiological factor of AOB.Dental Press J Orthod 160 2011 May-June;16(3):136-61

Artese A, Drummond S, Nascimento JM, Artese FReferEncEs1. Parker JH. The interception of the open bite in the earlygrowth period. Angle Orthod. 1971 Jan;41(1):24-44.2. Subtelny HD, Sakuda M. Open bite: diagnosis andtreatment. Am J Orthod. 1964 May;50(5):337-58.3. Huang GJ, Justus R, Kennedy DB, Kokich VG. Stability ofanterior openbite treated with crib therapy. Angle Orthod.1990 Jun;10(1):17-24.4. Shapiro PA. Stability of open bite treatment. Am J OrthodDentofacial Orthop. 2002 June;121(6):566-8.5. Cozza P, Mucedero M, Baccetti T, Franchi L. Earlyorthodontic treatment of skeletal open bite malocclusion: asystematic review. Angle Orthod. 2005 Sept;75(5):707-13.6. Zuroff JP, Chen SH, Shapiro PA, Little RM, Joondeph DR,Huang GJ. Orthodontic treatment of anterior open-bitemalocclusion: stability 10 years postretention. Am J OrthodDentofacial Orthop. 2010 Mar;137(3):302.e1-302.e8.7. Proffit WR. Equilibrium theory revisited: factors influencingposition of the teeth. Angle Orthod. 1978 July;48(3)175-86.8. Negri PL, Croce G. Influence of the tongue on developmentof the dental arches. Dental Abstr. 1965;10:453.9. Lopez-Gavito G, Wallen T, Little RM, Joondeph DR. Anterioropen-bite malocclusion: a longitudinal 10-year postretentionevaluation of orthodontically treated patients. Am J Orthod.1985 Mar;87(3):175-86.10. Justus R. Correction of anterior open bite with spurs: longtermstability. World J Orthod. 2001;2(3):219-31.11. Franco FC, Araújo TM, Habib F. Pontas ativas: um recursopara o tratamento da mordida aberta anterior. OrtodonGaúch. 2001 jan-jun;5(1):5-12.12. Miller H. The early treatment of anterior open bite. Int JOrthod. 1969 Mar;7(1):5-14.13. Andrianopoulos MV, Hanson ML. Tongue-thrust andthe stability of overjet correction. Angle Orthod. 1987Apr;57(2):121-35.14. Yashiro K, Takada K. Tongue muscle activity after orthodontictreatment of anterior open bite: a case report. Am J OrthodDentofacial Orthop. 1999 June;115(6):660-6.15. Subtelny JD, Subtelny JD. Malocclusion, speech, anddeglutition. Am J Orthod. 1962 Sept;48(9):685-97.16. Harvold EP, Vagervik K, Chierici G. Primate experiments onoral sensation and dental malocclusion Am J Orthod. 1973May;63(5):494-508.17. Harvold EP, Tomer BS, Vagervik K, Chierici G. Primateexperiments on oral respiration. Am J Orthod. 1981Apr;79(4):359-72.18. Brauer JS, Holt TV. Tongue thrust classification. AngleOrthod. 1965 Apr;35(2):106-12.19. Linder-Aronson S, Woodside D, Hellsing E, Emerson W.Normalization of incisor position after adenoidectomy. Am JOrthod Dentofacial Orthop. 1993 May;103(5):412-27.20. Dung J, Smith R. Cephalometric and clinical diagnosis ofopen bite tendency. Am J Orthod. 1998 Dec;94(6):484-90.21. Greenlee GM, Huang GJ, Chen SS, Chen J, Koepsell T,Hujoel P. Stability of treatment for anterior open-bitemalocclusion: a meta-analysis. Am J Orthod DentofacialOrthop. 2011 Feb;139(2):154-69.22. Denison TF, Kokich VG, Shapiro PA. Stability of maxillarysurgery in openbite versus nonopenbite malocclusions.Angle Orthod. 1989 Spring;59(1):5-10.23. Haryett RD, Hansen FC, Davidson PO, Sandilands ML.Chronic thumb-sucking: the psychologic effects and therelative effectiveness of various methods of treatment. Am JOrthod. 1967 Aug;53(8):569-85.24. Subtelny JD. Examination of current philosophies associatedwith swallowing behavior. Am J Orthod. 1965 Mar;51(3):161-82.25. Meyer-Marcotty P, Hartmann J, Stellzig-Eisenhauer A.Dentoalveolar open bite treatment with spur appliances.J Orofac Orthop. 2007 Nov;68(6):510-21.26. Nogueira FF, Mota LM, Nouer PRA, Nouer DF. Esporãolingual colado Nogueira ® : tratamento coadjuvante dadeglutição atípica por pressionamento lingual. Rev DentalPress Ortod Ortop Facial. 2005 mar-abr;10(2):129-56.27. Cleall JF. Deglutition: a study of form and function Am JOrthod. 1965 Aug;51(8):587-94.28. Rogers AP. Open bite cases involving tongue habits. Int JOrthod. 1927;13:837-44.29. Hickham JH. Maxillary protraction therapy: diagnosis andtreatment. J Clin Orthod. 1991 Feb;25(2):102-13.30. Kim YH, Han UK, Lim DD, Serraon ML. Stability of anterioropenbite correction with multiloop edgewise archwiretherapy: a cephalometric follow up study. Am J OrthodDentofacial Orthop. 2000 July;118(1):43-54.Submitted: April 2011Revised and accepted: May 2011Contact addressFlavia ArteseRua Santa Clara, 75/1110CEP: 22.041-011 - Copacabana / RJ, BrazilE-mail: flaviaartese@gmail.comDental Press J Orthod 161 2011 May-June;16(3):136-61

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Notice to Authors and Consultants - Registration of Clinical Trials1. Registration of clinical trialsClinical trials are among the best evidence for clinical decisionmaking. To be considered a clinical trial a research project must involvepatients and be prospective. Such patients must be subjectedto clinical or drug intervention with the purpose of comparingcause and effect between the groups under study and, potentially,the intervention should somehow exert an impact on the health ofthose involved.According to the World Health Organization (WHO), clinicaltrials and randomized controlled clinical trials should be reportedand registered in advance.Registration of these trials has been proposed in order to (a)identify all clinical trials underway and their results since not all arepublished in scientific journals; (b) preserve the health of individualswho join the study as patients and (c) boost communication andcooperation between research institutions and with other stakeholdersfrom society at large interested in a particular subject. Additionally,registration helps to expose the gaps in existing knowledge indifferent areas as well as disclose the trends and experts in a givenfield of study.In acknowledging the importance of these initiatives and sothat Latin American and Caribbean journals may comply with internationalrecommendations and standards, BIREME recommendsthat the editors of scientific health journals indexed in the ScientificElectronic Library Online (SciELO) and LILACS ( Latin Americanand Caribbean Center on Health Sciences) make public these requirementsand their context. Similarly to MEDLINE, specific fieldshave been included in LILACS and SciELO for clinical trial registrationnumbers of articles published in health journals.At the same time, the International Committee of MedicalJournal Editors (ICMJE) has suggested that editors of scientificjournals require authors to produce a registration number at thetime of paper submission. Registration of clinical trials can be performedin one of the Clinical Trial Registers validated by WHO andICMJE, whose addresses are available at the ICMJE website. To bevalidated, the Clinical Trial Registers must follow a set of criteriaestablished by WHO.2. Portal for promoting and registering clinical trialsWith the purpose of providing greater visibility to validatedClinical Trial Registers, WHO launched its Clinical Trial Search Portal(http://www.who.int/ictrp/network/en/index.html), an interfacethat allows simultaneous searches in a number of databases. Searcheson this portal can be carried out by entering words, clinical trialtitles or identification number. 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Dental Press Journal of Orthodontics - Statement and NoticeDENTAL PRESS JOURNAL OF ORTHODONTICS endorsesthe policies for clinical trial registration enforced by the WorldHealth Organization - WHO (http://www.who.int/ictrp/en/) andthe International Committee of Medical Journal Editors - ICMJE(# http://www.wame.org/wamestmt.htm#trialreg and http://www.icmje.org/clin_trialup.htm), recognizing the importance of these initiativesfor the registration and international dissemination of informationon international clinical trials on an open access basis. Thus,following the guidelines laid down by BIREME / PAHO / WHOfor indexing journals in LILACS and SciELO, DENTAL PRESSJOURNAL OF ORTHODONTICS will only accept for publicationarticles on clinical research that have received an identification numberfrom one of the Clinical Trial Registers, validated according tothe criteria established by WHO and ICMJE, whose addresses areavailable at the ICMJE website http://www.icmje.org/faq.pdf. Theidentification number must be informed at the end of the abstract.Consequently, authors are hereby recommended to registertheir clinical trials prior to trial implementation.Yours sincerely,Jorge Faber, DDS, MS, PhDEditor-in-Chief of Dental Press Journal of OrthodonticsISSN 2176-9451E-mail: faber@dentalpress.com.brDental Press J Orthod 164 2011 May-June;16(3):162-4

O r i g i n a l A r t i c l eImaging from temporomandibular jointduring orthodontic treatment: a systematicreviewEduardo Machado*, Renésio Armindo Grehs**, Paulo Afonso Cunali***AbstractIntroduction: The evolution of imaging in dentistry has provided several advantages forthe diagnosis and development of treatment plans in various dental specialties. Examinationsas nuclear magnetic resonance, computed tomography and cone beam volumetrictomography, as well as 3D reconstruction methods, have enabled a precise analysis of orofacialstructures. Allied to this fact, the effects of orthodontic treatment on temporomandibularjoint (TMJ) could be evaluated with the accomplishment of clinical studies withappropriate designs and methodologies. Objective: This study, a systematic literature review,had the objective of analyzing the interrelation between orthodontic treatment andTMJ, verifying if orthodontic treatment causes changes in the internal structures of TMJ.Methods: Survey in research bases MEDLINE, Cochrane, EMBASE, Pubmed, Lilacs andBBO, between the years of 1966 and 2009, with focus in randomized clinical trials, longitudinalprospective nonrandomized studies, systematic reviews and meta-analysis. Results:After application of the inclusion criteria 14 articles were selected, 2 were randomizedclinical trials and 12 longitudinal nonrandomized studies. Conclusions: According tothe literature analysis, the data concludes that orthodontic treatment does not occur atthe expense of unphysiological disc-condyle position. Some orthodontic mechanics maycause remodeling of articular bone components.Keywords: Temporomandibular joint. Temporomandibular joint dysfunction syndrome. Temporomandibularjoint disorders. Orthodontics. Magnetic resonance imaging. Tomography.How to cite this article: Machado E, Grehs RA, Cunali PA. Imaging from temporomandibular joint during orthodontic treatment: a systematicreview. Dental Press J Orthod. 2011 May-June;16(3):54.e1-7.* Specialist in TMD and Orofacial Pain, UFPR. Graduate in Dentistry, UFSM.** PhD in Orthodontics and Dentofacial Orthopedics, UNESP/Araraquara – SP. Professor of Graduate and Post-graduate Dentistry course, UFSM.*** PhD in Sciences, UNIFESP. Professor of Graduate and Post-graduate Dentistry course, UFPR. Head of the Specialization Course in TMD andOrofacial Pain, UFPR.Dental Press J Orthod 54.e12011 May-June;16(3):54.e1-7

Imaging from temporomandibular joint during orthodontic treatment: a systematic reviewIntroductionThe effects of orthodontic treatment on TemporomandibularJoint (TMJ) are still subject todoubts and discussions. The use of complementaryexams has always been a constant in the evaluationof this interrelation and can be exemplified byconventional radiographic examinations that werewidely used to assess the implications of orthodontictreatment on the TMJ. However, this modalityof imaging examination has limitations, because theTMJ is one of the structures of the human bodymore difficult to be well visualized radiographicallydue to overlapping of several adjacent bonystructures. Thus, the effects of orthodontics on TMJstructures are still controversial.With the advent of imaging examinations withspecificity, sensitivity and greater accuracy in thereproduction of articular anatomic structures,such as magnetic resonance imaging (MRI), computedtomography and cone-beam volumetriccomputed tomography as well as 3D reconstructionmethods, this interrelationship can be evaluatedwith greater exactness. Added to this fact,there was accomplishment of clinical studies withdesigns and more rigorous methodological criteria,generating higher levels of evidence.Thus, the general aim of this study, througha systematic literature review was to analyzewithin a context of a scientific evidence baseddentistry, the implications of orthodontics tothe TMJ and check specifically what changesin condylar and articular disc position and jointmorphological changes that occur due to orthodontictreatment.MATERIAL AND METHODSWe performed a computerized search in MED-LINE, Cochrane, EMBASE, PubMed, Lilacs andBBO in the period from 1966 through February2009. The research descriptors used were “orthodontics”,“orthodontic treatment”, “temporomandibulardisorder,” “temporomandibular joint”, “craniomandibulardisorder”, “TMD”, “TMJ”, “magneticresonance imaging” and “tomography”, which werecrossed in search engines. The initial list of articleswas submitted to review by two reviewers, who appliedinclusion criteria to determine the final sampleof articles, which were assessed by their title and abstract.If there was any disagreement between theresults of the reviewers, a third reviewer would beconsulted by reading the full version of the article.Inclusion criteria for selecting articles were:» Studies based on magnetic resonance imaging(MRI), computed tomography (CT) and/or volumetric cone-beam tomography, whichassessed the effects of orthodontic treatmentin TMJ. Studies based only on electromyography,cephalometric radiographs and conventionalradiographs were excluded, as well asstudies involving orthognathic surgery.» Randomized clinical trials (RCT), non-randomizedprospective longitudinal studies, systematicreviews and meta-analysis.» Studies in which orthodontic treatment is alreadycompleted in the assessed samples.» Studies written in English and Spanish, andpublished between 1966 and February 2009.Thus, we excluded cross-sectional studies, clinicalcase reports, case series, simple reviews and opinionspapers, as well as studies in which orthodontictreatment had not yet been completed.RESULTSAfter applying the inclusion criteria 14 studieswere selected and the Kappa index of agreement betweenreviewers was 1.00. Among these studies, twowere randomized clinical trials and 12 were longitudinalstudies without randomization criteria (Fig 1).Among the selected studies, 11 were based onmagnetic resonance imaging and 3 in computed tomographyimages, as shown in Figure 2. None of theselected studies used cone-beam computed tomographyfor evaluation of the TMJ.The sample of articles selected by the methodologicalcriteria of this systematic review is availablein Table 1.Dental Press J Orthod 54.e2 2011 May-June;16(3):54.e1-7

Machado E, Grehs RA, Cunali PA231211Randomized clinical trialsMagnetic resonance imagingLongitudinal studies without randomizationComputed tomography imagingfigure 1 - Design of included studies.figure 2 - Studies characteristics.TABLE 1 - Studies based on imaging examination of magnetic resonance imaging, computed tomography and/or cone-beam computed tomography.Authors Year of publication Design Sample sizeImagingExaminationsOrthodonticApplianceUsedChanges in TMJMajor et al. 23 1997 P, L 35 tt CT F Increase in An JSRuf, Pancherz 26 1998 P, L 15 tt MRI HerbstRuf, Pancherz 27 1999 P, L 39 tt MRI HerbstCarlton, Nanda 6 2002 P, L 106 tt CT F, FARemodeling ofcondylar andglenoid fossaRemodeling ofcondylar andglenoid fossaNo adverseeffectsFranco et al. 9 2002 RCT28 tt28 no ttMRIFANo adverseeffectsGokalp, Kurt 12 2005 P, L13 tt7 no ttMRICCCondylarremodelingKinzinger et al. 21 2006 P, L 20 tt MRI FAKinzinger et al. 22 2006 P, L 20 tt MRI FAKinzinger et al. 19 2006 P, L 15 tt MRI FAKinzinger et al. 20 2007 P, L 20 tt MRI FANo adverseeffectsNo adverseeffectsNo adverseeffectsNo adverseeffectsArici et al. 3 2008 RCT30 tt30 no ttCTFAChanges in An and Pojoint spacesArat et al. 1 2008 P, L 18 tt MRI F (RME)Arat et al. 2 2008 P, L 18 tt MRI F (RME)Wadhawan et al. 30 2008 P, L 12 tt MRI F, FANo adverseeffectsNo adverseeffectsNo adverseeffectsP= prospective; L= longitudinal; RCT= randomized clinical trial; tt= treatment; MRI= magnetic resonance imaging; CT= computed tomography;F= fixed appliances; FA= functional appliances; CC= chincup; JS= joint space; An= anterior; Po= posterior; RME= rapid maxillary expansion.Dental Press J Orthod54.e32011 May-June;16(3):54.e1-7

Imaging from temporomandibular joint during orthodontic treatment: a systematic reviewDISCUSSIONIt becomes increasingly important to analyzethe current literature in a critical and rigorousway to verify what level of scientific evidencethat the information generates. The applicationof methodological considerations for research— such as sample size calculation, randomization,calibration, blinding and control of involvedfactors —- are extremely important toqualify the level of evidence generated. And thisinformation must be available for examinationand discussion for the reader. 28Currently, the access to scientific evidences isavailable through many different ways. Because ofthis facility, the knowledge about the hierarchy ofthe scientific evidence levels is essential for assessingthe quality of the study. Thus, meta-analysis,systematic reviews and randomized clinical trialsreceive the best concepts. Being aware of this factis important, since the vast majority of articlespublished in Brazilian journals correspond to studiesof low potential for direct clinical application.Magnetic resonance imaging and computedtomography are methods with higher diagnosticaccuracy compared with conventional radiology,because of greater anatomic resolution they provide.CT is the ideal method for assessment ofbone structures, whereas MRI allows the studyof soft tissues, including intra-articular disc. Bothmethods often complement the study of abnormalitiesof the temporomandibular joint (TMJ),thus becoming important tools in the differentialdiagnosis of various diseases in this region. 11Computed tomography is the examination ofchoice to evaluate TMJ bony structures, especiallyfor the diagnosis of fractures, joint deformities, ankylosisand tumors. There is no overlapping of anyother structure, enabling assessment of the qualityand bone density. 5 Similarly, MRI is the gold standardfor the representation of soft tissue and positioningof the TMJ articular disc, 17 allowing informationabout the position, function and form ofthe articular disc and conditions of muscle tissuesand ligaments, as well as assessment of severity ofvarious disorders: trauma, arthritis, arthrosis andneoplastic degeneration. 10Also, the cone-beam computed tomographyallows visualization of structures of reduced dimensionswith minimal radiation exposure for patientsand less operating time than conventionalCT. This imaging modality has several applications,assisting in the diagnosis and in the treatmentplan in different dental specialties. 29 Thecone-beam tomography has a relevant importancein diagnosis, localization and reconstruction of tomographicimages with excellent precision, aidingin therapeutic decisions. 4Clinically, the scientific evidences indicatefor a tendency of no association between orthodontictreatment and temporomandibulardisorders (TMD), in other words, orthodonticsdoes not increase the prevalence of signs andsymptoms of TMD, with longitudinal and experimental-interventioniststudies, 7,8,13-16,25 systematicreview 24 and meta-analysis 18 corroboratingthat. Also, with the analysis of imagingstudies, according to the methodological criteriaadopted by this systematic review, it appearsthat orthodontic movement does not cause adverseeffects to the TMJ. 6,9,19-22The systematic literature review shows thatthe correct occlusal relationship between theteeth did not cause a change in the physiologicalposition of the condyles and articular discsin TMJ when MRI and CT were examined, 19,21,22whereas in some cases of TMD an improvementcan be obtained as a result of orthodontic treatment.9,19,22 Some studies found changes in condylarposition 3 and in the volumes of the anteriorand posterior joint spaces 3,23 due to appliedorthodontic mechanics. Furthermore, the use ofthe chincup caused a morphological change incondylar growth, which may be associated withcorrection of skeletal malocclusion in conjunctionwith remodeling in the jaw, 12 as well as theHerbst appliance. 26,27Dental Press J Orthod 54.e4 2011 May-June;16(3):54.e1-7

Machado E, Grehs RA, Cunali PAThe application of different orthodonticmechanics did not cause incorrect positioningon the articular disc-condyle relationship.Elastics mechanics, 6,23 headgear, 6 rapid maxillaryexpansion, 1,2 Frankel functional appliance,9 Bionator, 30 fixed functional orthopedicappliances, 20,21,22 Twin Block 30 and functionalmandibular advancement appliance 19 did notcause physiological changes in the positioningof the condyle and articular disc, whereas theimplementation or not of extraction protocolsdid not change this situation. 6,23Great provider of scientific evidence, randomizedclinical trials were found in low numberin this systematic review: only two studies.3,9 This fact is associated with difficulties inaccomplishment of this type of study in patientsundergoing orthodontic treatment due to ethicaland practical questions. 18 Likewise, therewere no selected meta-analysis and systematicreviews after application of the inclusion criteria.It is important to be noted that all theselected studies presented longitudinal assessments,which is the ideal study design to checkfor risk factors, due to its temporal component. 28The use of imaging examinations — CT, conebeamCT and MRI — in orthodontic practice, notonly for evaluating the occlusal criteria, but alsofor adjacent structures, tends to become a usefultool. Through 3D reconstruction of the surfacesof condyle and their overlaps, detailed views ofadaptive mechanisms and its non-invasive assessmentmay become possible in routine clinical orthodontics.20 Through these examinations modalities,allied to scientific knowledge, diagnosis andtherapeutic decision can be guided and based onscientific evidence, in order to provide most appropriateand safe treatment for patient.Dental Press J Orthod54.e52011 May-June;16(3):54.e1-7

Imaging from temporomandibular joint during orthodontic treatment: a systematic reviewCONCLUSIONS» This systematic literature review findsthat the correct occlusal relationship as aresult of orthodontic treatment is not obtainedat the expense of non-physiologicalpositioning of both the condyle and thearticular disc. Thus, when orthodontics isused correctly does not cause adverse effectsin the TMJ.» The application of forces during certainorthodontic mechanics, especially orthopedicsituations, can cause alterations in condylargrowth and bone structures of the TMJ.Thus, the mechanics application should beperformed properly and the professionalmust have knowledge of these impacts.» In some studies by analysis of imagingexaminations, it was observed that therewere improvements in situations of preexistingTMD at the beginning of orthodontictherapy. However, these data areonly suggestive and more randomizedclinical trials are necessary to obtain moreprecise conclusions.» Further randomized controlled clinicaltrials, with longitudinal and interventionalnature are necessary, for the determinationof more precise causal associations,within a context of a scientific evidencebased dentistry.ReferEncEs1. Arat FE, Arat ZM, Tompson B, Tanju S, Erden I. Muscular andcondylar response to rapid maxillary expansion. Part 2: magneticresonance imaging study of the temporomandibular joint.Am J Orthod Dentofacial Orthop. 2008;133(6 Pt 2):823-9.2. Arat FE, Arat ZM, Tompson B, Tanju S. Muscular and condylarresponse to rapid maxillary expansion. Part 3: magnetic resonanceassessment of condyle-disc relationship. Am J OrthodDentofacial Orthop. 2008;133(6 Pt 3):830-6.3. Arici S, Akan H, Yakubov K, Arici N. Effects of fixed functionalappliance treatment on the temporomandibular joint. Am JOrthod Dentofacial Orthop. 2008;133(6):809-14.4. Bissoli CF, Ágreda CG, Takeshita WM, Castilho JCM, MediciFilho E, Moraes ML. Importancia y aplicaciones del sistema detomografia computarizada cone-beam (cbct). Acta OdontolVenez. 2007;45(4):589-92.5. Bumann A, Lotzmann U. Disfunção temporomandibular:diagnóstico funcional e princípios terapêuticos. Porto Alegre:Artmed; 2003.6. Carlton KL, Nanda RS. Prospective study of posttreatmentchanges in the temporomandibular joint. Am J Orthod DentofacialOrthop. 2002;122(5):486-90.7. Egermark I, Carlsson GE, Magnusson T. A prospective longtermstudy of signs and symptoms of temporomandibulardisorders in patients who received orthodontic treatment inchildhood. Angle Orthod. 2005;75(4):645-50.8. Egermark I, Magnusson T, Carlsson GE. A 20-year follow-up ofsigns and symptoms of temporomandibular disorders and malocclusionsin subjects with and without orthodontic treatmentin childhood. Angle Orthod. 2003;73(2):109-15.9. Franco AA, Yamashita HK, Lederman HM, Cevidanes LH, ProffitWR, Vigorito JW. Fränkel appliance therapy and the temporomandibulardisc: a prospective magnetic resonance imagingstudy. Am J Orthod Dentofacial Orthop. 2002;121(5):447-57.10. Freitas A. Radiologia odontológica. 6ª ed. São Paulo: ArtesMédicas; 2004.11. Garcia MM, Machado KFS, Mascarenhas MH. Ressonânciamagnética e tomografia computadorizada da articulaçãotemporomandibular: além da disfunção. Radiol Bras.2008;41(5):337-42.12. Gokalp H, Kurt G. Magnetic resonance imaging of the condylargrowth pattern and disk position after chin cup therapy: apreliminary study. Angle Orthod. 2005;75(4):568-75.Dental Press J Orthod 54.e6 2011 May-June;16(3):54.e1-7

Machado E, Grehs RA, Cunali PA13. Henrikson T, Nilner M. Temporomandibular disorders and needof stomatognathic treatment in orthodontically treated anduntreated girls. Eur J Orthod. 2000;22(3):283-92.14. Henrikson T, Nilner M. Temporomandibular disorders, occlusionand orthodontic treatment. J Orthod. 2003;30(2):129-37.15. Henrikson T, Nilner M, Kurol J. Symptoms and signs of temporomandibulardisorders before, during and after orthodontictreatment. Swed Dent J. 1999;23(5-6):193-207.16. Imai T, Okamoto T, Kaneko T, Umeda K, Yamamoto T, NakamuraS. Long-term follow-up of clinical symptoms in TMDpatients who underwent occlusal reconstruction by orthodontictreatment. Eur J Orthod. 2000;22(1):61-7.17. Kamelchuk L, Nebbe B, Baker C, Major P. Adolescent TMJtomography and magnetic resonance imaging: a comparativeanalysis. J Orofac Pain. 1997;11(4):321-7.18. Kim MR, Graber TM, Viana MA. Orthodontics and temporomandibulardisorder: a meta-analysis. Am J Orthod DentofacialOrthop. 2002;121(5):438-46.19. Kinzinger G, Gulden N, Roth A, Diedrich P. Disc-condylerelationships during Class II treatment with the Functional MandibularAdvancer (FMA). J Orofac Orthop. 2006;67(5):356-75.20. Kinzinger G, Kober C, Diedrich P. Topography and morphologyof the mandibular condyle during fixed functional orthopedictreatment: a magnetic resonance imaging study. J OrofacOrthop. 2007;68(2):124-47.21. Kinzinger G, Roth A, Gulden N, Bucker A, Diedrich P. Effectsof orthodontic treatment with fixed functional orthopaedicappliances on the condyle-fossa relationship in the temporomandibularjoint: a magnetic resonance imaging study (Part I).Dentomaxillofac Radiol. 2006;35(5 Pt 1):339-46.22. Kinzinger G, Roth A, Gulden N, Bucker A, Diedrich, P. Effectsof orthodontic treatment with fixed functional orthopaedicappliances on the disc-condyle relationship in the temporomandibularjoint: a magnetic resonance imaging study (Part II).Dentomaxillofac Radiol. 2006;35(5 Pt 2):347-56.23. Major P, Kamelchuk L, Nebbe B, Petrkowski G, Glover K.Condyle displacement associated with premolar extraction andnonextraction orthodontic treatment of Class I malocclusion.Am J Orthod Dentofacial Orthop. 1997;112(4):435-40.24. Mohlin B, Axelsson S, Paulin G, Pietila T, Bondemark L, BrattstromV, et al. TMD in relation to malocclusion and orthodontictreatment. Angle Orthod. 2007;77(3):542-8.25. Mohlin BO, Derweduwen K, Pilley R, Kingdon A, Shaw WC,Kenealy P. Malocclusion and temporomandibular disorder: acomparison of adolescents with moderate to severe dysfunctionwith those without signs and symptoms of temporomandibulardisorder and their further development to 30 years ofage. Angle Orthod. 2004;74(3):319-27.26. Ruf S, Pancherz H. Temporomandibular joint growth adaptationin Herbst treatment: a prospective magnetic resonance imagingand cephalometric roentgenographic study. Eur J Orthod.1998;20(4):375-88.27. Ruf S, Pancherz H. Temporomandibular joint remodeling inadolescents and young adults during Herbst treatment: aprospective longitudinal magnetic resonance imaging andcephalometric radiographic investigation. Am J Orthod DentofacialOrthop. 1999;115(6):607-18.28. Susin C, Rosing CK. Praticando odontologia baseada emevidências. 1ª ed. Canoas: ULBRA; 1999.29. Xaves ACC, Sena LEC, Araújo LF, Nascimento Neto JBS.Aplicações da tomografia computadorizada de feixe cônico naodontologia. Int J Dent. 2005;4(3):80-124.30. Wadhawan N, Kumar S, Kharbanda OP, Duggal R, Sharma R.Temporomandibular joint adaptations following two-phasetherapy: an MRI study. Orthod Craniofac Res. 2008;11(4):235-50.Submitted: February 2009Revised and accepted: May 2010Contact addressEduardo MachadoRua Francisco Trevisan 20, Nossa Sra. de LourdesCEP: 97.050-230 - Santa Maria / RS, BrazilE-mail: machado.rs@bol.com.brDental Press J Orthod54.e72011 May-June;16(3):54.e1-7

O r i g i n a l A r t i c l eCytotoxicity of electric spot welding:an in vitro studyRogério Lacerda dos Santos*, Matheus Melo Pithon**, Leonard Euler A. G. Nascimento***,Fernanda Otaviano Martins****, Maria Teresa Villela Romanos*****, Matilde da Cunha G. Nojima******,Lincoln Issamu Nojima******, Antônio Carlos de Oliveira Ruellas******AbstractObjective: The welding process involves metal ions capable of causing cell lysis. In viewof this fact, the aim of this study was to test the hypothesis that cytotoxicity is presentin different types of alloys (CrNi, TMA, NiTi) commonly used in orthodontic practicewhen these alloys are subjected to electric spot welding. Methods: Three types of alloyswere evaluated in this study. Thirty-six test specimens were fabricated, 6 for each wirecombination, and divided into 6 groups: Group SS (stainless steel), Group ST (steelwith TMA), Group SN (steel with NiTi), Group TT (TMA with TMA), Group TNgroup (TMA with NiTi) and Group NN (NiTi with NiTi). All groups were subjectedto spot welding and assessed in terms of their potential cytotoxicity to oral tissues. Thespecimens were first cleaned with isopropyl alcohol and sterilized with ultraviolet light(UV). A cytotoxicity assay was performed using cultured cells (strain L929, mousefibroblast cells), which were tested for viable cells in neutral red dye-uptake over 24hours. Analysis of variance and multiple comparison (ANOVA), as well as Tukey testwere employed (p0.05). Cell viability was higher in the TT group,followed by groups ST, TN, SS, NS and NN. Conclusions: It became evident that thewelding of NiTi alloy wires caused a greater amount of cell lysis. Electric spot weldingwas found to cause little cell lysis.Keywords: Toxicity. Cell culture techniques. Welding in dentistry.How to cite this article: Santos RL, Pithon MM, Nascimento LEAG, Martins FO, Romanos MTV, Nojima MCG, Nojima LI, Ruellas ACO. Cytotoxicityof electric spot welding: an in vitro study. Dental Press J Orthod. 2011 May-June;16(3):57.e1-6.* Specialist in Orthodontics, Federal University of Alfenas - UNIFAL. Master and Doctor in Orthodontics, Federal University of Rio de Janeiro -UFRJ. Adjunct Professor of Orthodontics, Federal University of Campina Grande - UFCG.** Specialist in Orthodontics, Federal University of Alfenas - UNIFAL. Master and Doctor in Orthodontics, Federal University of Rio de Janeiro -UFRJ. Assistant Professor of Orthodontics, State University of Southwestern of Bahia - UESB.*** Doctored Student in Orthodontics, Federal University of Rio de Janeiro - UFRJ.**** Graduated in Microbiology and Immunology, Federal University of Rio de Janeiro. Trainee of the Microbiology Institute of Prof. Paulo de Góes- UFRJ.***** PhD in Sciences (Microbiology and Immunology) by the Federal University of Rio de Janeiro - UFRJ. Adjunct Professor, Federal University of Riode Janeiro - UFRJ.****** MSc and PhD in Orthodontics, Federal University of Rio de Janeiro - UFRJ. Adjunct Professor of Orthodontics, Federal University of Rio deJaneiro - UFRJ.Dental Press J Orthod 57.e12011 May-June;16(3):57.e1-6

Cytotoxicity of electric spot welding: an in vitro studyintroductionThe composition of most alloys used in orthodonticsis similar to that of stainless steel (18/8,i.e., 18% chromium and 8% nickel), and the manufacturingprocess of many devices such as facialmasks, orthodontic bands and brackets involvewelding of some kind. Research has shown thatsome ions can be released in welding 13,17,22,26,27,28and this exposure may trigger a variety of adverseeffects with direct toxic changes, be it acutely, orchronically. 1 The World Health Organization InternationalAgency for Research on Cancer andthe United States National Toxicology Programhave determined that metal components in silversolder such as cadmium, copper, silver and zincare potentially carcinogenic to humans. 1However, welding is widely used in orthodonticpractice as an aid in moving teeth. Electric spotwelding is a time saving procedure that providesease of use, lower cost, hygiene and pleasing aesthetics.5 However, this type of welding has beenavoided due to poor mechanical strength whencompared with silver solder. 14Type of welding machine, electrode shape andalloy wire are some of the factors that determinespot welding quality. 7 The first spot welding machinewas marketed in 1934. Currently, machineshave been reported that offer resistance weldsby means of functions that allow proper meltingof materials, reduction in the amount of oxidescapable of weakening wire joining, and absenceof heat around electrode contacts, which allowswires made from different types of alloys to notlose their mechanical properties.The use of stainless steel alloy (CrNi) prevailedin orthodontics for decades but the adventof new metal alloys diversified the universe ofweldable wires.Given the proven cytotoxic activity of silversolders, other joining methods, free from themetal ions found in silver solder, have been usedto reduce cytotoxic effects. The aim of this studywas to test the hypothesis that cytotoxicity ispresent in different types of alloys (CrNi, TMA,and NiTi) subjected to electric spot welding inorthodontic practice.MATERIAL AND METHODSCell cultureThis study used a culture of L929 cells (mousefibroblasts) obtained from the American TypeCulture Collection (ATCC, Rockville, MD, USA),maintained in Eagle minimum essential medium(MEM-Eagle) (Cultilab, Campinas, Brazil) plus0.03 mg/ml glutamine (Sigma, St. Louis, Missouri),50 mg/ml Gentamicin Sulfate (ScheringPlough, Kenilworth, New Jersey), 2.5 mg/ml fungizone(Bristol- Myers-Squibb, New York, USA),sodium bicarbonate solution at 0.25% (Merck,Darmstadt, Germany), 10 mM HEPES (Sigma,St. Louis, Missouri) and 10% fetal bovine serum(Cultilab, Campinas, Brazil) kept at 37°C in anenvironment containing 5% CO 2.Test specimen fabricationThree types of alloys were evaluated in thisstudy. The test specimens were fabricated withrectangular wires (0.019x0.025-in), cut into segmentsof 25 mm, which were welded using combinationsbetween stainless steel (CrNi), nickel-titanium(NiTi) and molybdenum-titanium (TMA)wires (Morelli, Sorocaba, Brazil). For the weldingprocedure the two wire segments were positionedone on top of the other forming an “X” and thenplaced in the electric spot welding machine (SMP-3000 Super Micro Point, Kernit, Indaiatuba, Brazil)and subjected to a single spot weld with powerset at 30 W for all samples. After each weld, theends of the electrodes were cleaned with 400 gritsandpaper (3M, Sumaré, São Paulo, Brazil).Thirty-six test specimens were fabricated,6 for each wire combination, and divided into:Group SS (steel with steel), Group ST (steel withTMA), Group SN (steel with NiTi), Group TT(TMA with TMA), Group TN (TMA with NiTi)and Group NN (NiTi with NiTi). After welding,Dental Press J Orthod 57.e2 2011 May-June;16(3):57.e1-6

Santos RL, Pithon MM, Nascimento LEAG, Martins FO, Romanos MTV, Nojima MCG, Nojima LI, Ruellas ACOtest specimen surfaces were cleaned with isopropylalcohol and then sterilized by exposureto ultraviolet light (Labconco, Kansas, Missouri,USA) for 30 minutes along with the positive andnegative controls. Preparation and welding of testspecimens were performed by a single examiner.ControlsTo observe cellular responses to extremes, sixadditional groups were included, Group CC (cellcontrol) where cells were not exposed to any material,Group C+ (positive control), consisting of acopper amalgam cylinder (Pratic NG 2, Vigodent,Rio de Janeiro, Brazil), group C- (negative control)consisting of a glass cylinder, and Group C-(steel), C- (TMA) and C- (NiTi) (negative controlfor each respective wire: stainless steel, TMAand NiTi) (Morelli, Sorocaba, São Paulo, Brazil),which remained in contact with the cells.Cytotoxicity assayAfter sterilization, the 6 samples of each materialwere placed in 24-well plates containingculture medium (MEM) (Cultilab, Campinas,São Paulo, Brazil). After 24 hours the culturemedium was collected and evaluated for toxicityto L929 cells. Supernatants were placed intriplicate in a 96-well plate containing L929confluent monolayer and incubated for 24hours at 37ºC in an environment containing 5%CO 2. After incubation, the effect on cell viabilitywas determined using the dye-uptake techniquedescribed by Neyndorff et al 16 with minormodifications. After 24 hours of incubation, 100µl of neutral red at 0.01% were added (Sigma,St. Louis, Missouri, USA), in a culture medium,to the microplate wells and these were incubatedat 37°C for 3 hours to allow penetration ofvital dye into the living cells. After this periodand after disposal of the dye, 100 µl of formaldehydesolution (Reagen) at 4% were addedin PBS (NaCl 130 mM; KCl 2 mM; Na 2HPO 42H 2O 6 mM; K 2HPO 41mM, pH 7.2) for 5 minutesto promote cell attachment to the plates.Next, in order to extract the dye, a solutionof 100 µl of acetic acid (Vetec, Rio de Janeiro,Brazil) at 1% was added along with methanol(Reagen, Rio de Janeiro, Brazil) at 50%. Twentyminutes later readings of the optical density ofthe experimental groups and positive and negativecontrols were performed in a spectrophotometer(Biotek, Winooski, Vermont, USA) at awavelength of 492 nm (λ = 492 nm).Statistical analyses were conducted with theaid of the SPSS 13.0 software program (SPSS Inc.,Chicago, Illinois). Data were compared by analysisof variance (ANOVA) and then Tukey’s test forassessment between groups, with reliability set at5% significance level.RESULTSThe results showed no statistically significantdifference between experimental groups (SS, ST,SN, TT, TN and NN) (P>0.05). A statistically significantdifference was found between groups CCand NN group (P

Cytotoxicity of electric spot welding: an in vitro studytable 1 - Dye-uptake technique. Statistical description of optical densityfor experimental groups (n=6).GroupsNTime (24 h)Mean Median SDViablecells (%)CC 6 1.107 a 0.989 0.119 100.0C+ 6 0.377 0.349 0.076 34.1C- 6 1.098 0.991 0.129 99.2C- (Steel) 6 1.052 0.960 0.076 95.1C- (TMA) 6 1.092 0.946 0.139 98.8C- (NiTi) 6 0.919 0.859 0.116 83.1SS 6 0.927 a 0.889 0.129 83.8ST 6 0.994 a 0.917 0.115 89.8SN 6 0.897 a 0.829 0.123 81.1TT 6 1.039 a 0.963 0.137 93.9TN 6 0.943 a 0.891 0.125 85.2NN 6 0.787 b 0.721 0.113 71.1Values followed by identical letters do not show a statistically significantdifference (p>0.05). SD= Standard deviation.experienced by the body appear to be due to theinfluence of ions on the mechanisms of bacterialadhesion caused by toxicity, subtoxic effects or allergyto metal ions. 15One of the fundamental conditions for the useof metallic materials in the oral environment isthat these materials resist the corrosive action ofsaliva and alkaline or acid foods 4,8 as well as variationsin pH and temperature. Silver solders areamong the materials used in orthodontics, whichare very susceptible to corrosion. 10 These soldersare used when one wishes to join stainless steelalloys or other alloys for the manufacture of orthodonticappliances.Upon analysis of the biological aspects of silversolder, the results suggest that, contrary to routineorthodontic practice, silver solder should be usedsparingly in the oral environment. 18,19Based on this premise, attempts have beenmade to replace it with other welding methods27,28 — such as electric spot welding — thatare free from the metal ions present in silversolder. 13,22,26,17,27,28 This study was conducted inorder to investigate the behavior of CrNi, NiTiand TMA alloys subjected to spot welding, usinga culture of fibroblasts.Cell cultures have been used as part of a seriesof recommended tests for assessing the biologicalbehavior of materials designed to be placed incontact with human tissue. In this study, copperamalgam was utilized as positive control, given itsproven cytotoxicity, 23 and glass as negative controlto validate the results.The findings of this study showed low cellcytotoxicity in the experimental groups comparedto the cell control groups and negativecontrol group, with the sole exception of theNN group, which showed a statistically significantdifference relative to the cell control group(p

Santos RL, Pithon MM, Nascimento LEAG, Martins FO, Romanos MTV, Nojima MCG, Nojima LI, Ruellas ACOIn view of the cytotoxicity observed in thegroups there seems to be a relationship betweenthe amount of nickel present in alloys and theamount of cell lysis caused by these alloys. For Davidand Lobner 6 and Eliades et al 9 there is clear evidenceof a direct relationship between cytotoxicityand nickel. But findings by Sestini et al 27 showedthat nickel and chromium caused a decrease in cellactivity. Although in vitro evaluations do not simulatethe oral environment, one should not assumethat the in vitro environment is clinically inert.The results of this study are consistent withthose found by Sestini et al, 27 who evaluatedtwo different alloys subjected to spot weldingand concluded that both were well tolerated bydifferent cell types, including fibroblasts and osteoblasts,which also agrees with the findings ofVande Vannet et al. 28Success in orthodontic practice involves notonly employing corrective techniques to achievethe ideal dental occlusion, but also requires materialsthat are inert to the oral environment.CONCLUSIONSElectric spot welding was found to cause littlecell lysis. Moreover, the welding of NiTi alloywires produced the greatest amount of cytotoxicitywhile TMA alloy wires were the least cytotoxic.Dental Press J Orthod57.e52011 May-June;16(3):57.e1-6

Cytotoxicity of electric spot welding: an in vitro studyReferEncEs1. Azevedo CRF. Characterization of metallic piercings. Eng FailAnal. 2003;10(2):255-63.2. Bass JK, Fine H, Cisneros GJ. Nickel hypersensitivity inthe orthodontic patient. Am J Orthod Dentofacial Orthop.1993;103(3):280-5.3. Blanco-Dalmau L, Carrasquillo-Alberty H, Silva-Parra J. Astudy of nickel allergy. J Prosthet Dent. 1984;52(1):116-9.4. Cadosch D, Chan E, Gautschi OP, Simmen HP, FilgueiraL. Bio-corrosion of stainless steel by osteoclasts-in vitroevidence. J Orthop Res. 2009;27(7):841-6.5. Correr DF Sobrinho, Nouer DF, Mendonça MR, ConsaniRLX, Sinhoretti MAC. Estudo comparativo da resistência àtração de soldas de prata e super micro ponto, utilizadasem ortodontia. Rev Fac Odontol Univ Passo Fundo.1997;2(1):51-7.6. David A, Lobner D. In vitro cytotoxicity of orthodonticarchwires in cortical cell cultures. Eur J Orthod.2004;26(4):421-6.7. Donovan MT, Lin JJ, Brantley WA, Conover JP. Weldabilityof beta titanium arch wires. Am J Orthod. 1984;85(3):207-16.8. El Safty A, El Mahgoub K, Helal S, Abdel Maksoud N. Zinctoxicity among galvanization workers in the iron and steelindustry. Ann NY Acad Sci. 2008;1140:256-62.9. Eliades T, Pratsinis H, Kletsas D, Eliades G, Makou M.Characterization and cytotoxicity of ions released fromstainless steel and nickel-titanium orthodontic alloys. Am JOrthod Dentofacial Orthop. 2004;125(1):24-9.10. Grimsdottir MR, Gjerdet NR, Hensten-Pettersen A.Composition and in vitro corrosion of orthodonticappliances. Am J Orthod Dentofacial Orthop.1992;101(6):525-32.11. Jacobsen N, Hensten-Pettersen A. Occupational healthproblems and adverse patient reactions in orthodontics. EurJ Orthod. 1989;11(3):254-64.12. Janson GR, Dainesi EA, Consolaro A, Woodside DG, FreitasMR. Nickel hypersensitivity reaction before, during, andafter orthodontic therapy. Am J Orthod Dentofacial Orthop.1998;113(6):655-60.13. Kalimo K, Mattila L, Kautiainen H. Nickel allergy andorthodontic treatment. J Eur Acad Dermatol Venereol.2004;18(5):543-5.14. Lopes MB, Correr L Sobrinho, Consani S, Sinhoretti MA,Cangiani MB. Resistência à fadiga de solda de prata e soldaelétrica a ponto utilizadas em ortodontia. Rev Dental PressOrtodon Ortop Facial. 2000;5(6):45-9.15. Morais LS, Guimarães GS, Elias CN. Liberação de íons porbiomateriais metálicos. Rev Dent Press Ortodon OrtopFacial. 2007;12(3):48-53.16. Neyndorff HC, Bartel DL, Tufaro F, Levy JG. Developmentof a model to demonstrate photosensitizer-mediated viralinactivation in blood. Transfusion. 1990;30(6):485-90.17. Oh KT, Kim KN. Ion release and cytotoxicity of stainless steelwires. Eur J Orthod. 2005;27(6):533-40.18. Pacheco MCT. Propriedades mecânicas, resistência àcorrosão e citotoxicidade de soldagens ortodônticas [tese].Rio de Janeiro: Universidade Federal do Rio de Janeiro;1995. 235 p.19. Pacheco MCT, Wigg MD, Chevitarese O. Biocompatibilidadedas soldagens ortodônticas. Rev SBO. 1995;2(8):233-38.20. Park HY, Shearer TR. In vitro release of nickel and chromiumfrom simulated orthodontic appliances. Am J Orthod.1983;84(2):156-9.21. Peltonen L. Nickel sensitivity in the general population.Contact Dermatitis. 1979;5(1):27-32.22. Saglam AM, Baysal V, Ceylan AM. Nickel and cobalthypersensitivity reaction before and after orthodontictherapy in children. J Contemp Dent Pract. 2004;5(4):79-90.23. Santos RL, Pithon MM, Oliveira MV, Mendes GS, RomanosMTV, Ruellas ACO. Cytotoxicity of intraoral orthodonticelastics. Braz J Oral Sci. 2008;24(4):1520-5.24. Schafer T, Bohler E, Ruhdorfer S, Weigl L, Wessner D,Filipiak B, et al. Epidemiology of contact allergy in adults.Allergy. 2001;56(12):1192-6.25. Schubert H, Berova N, Czernielewski A, Hegyi E, Jirásek L,Kohánka V, et al. Epidemiology of nickel allergy. ContactDermatitis. 1987;16(3):122-8.26. Schultz JC, Connelly E, Glesne L, Warshaw EM. Cutaneousand oral eruption from oral exposure to nickel in dentalbraces. Dermatitis. 2004;15(3):154-7.27. Sestini S, Notarantonio L, Cerboni B, Alessandrini C,Fimiani M, Nannelli P, et al. In vitro toxicity evaluation ofsilver soldering, electrical resistance, and laser welding oforthodontic wires. Eur J Orthod. 2006;28(6):567-72.28. Vande Vannet B, Hanssens JL, Wehrbein H. The use of threedimensionaloral mucosa cell cultures to assess the toxicity ofsoldered and welded wires. Eur J Orthod. 2007;29(1):60-6.Submitted: February 2009Revised and accepted: October 2009Contact addressAntônio Carlos de Oliveira RuellasAv. Professor Rodolpho Paulo Rocco, 325 - Ilha do FundãoCEP: 21.941-617 - Rio de Janeiro / RJ, BrazilE-mail: antonioruellas@yahoo.com.brDental Press J Orthod 57.e6 2011 May-June;16(3):57.e1-6

O r i g i n a l A r t i c l eIn vitro study of shear bondstrength in direct bonding of orthodonticmolar tubesCélia Regina Maio Pinzan Vercelino*, Arnaldo Pinzan**, Júlio de Araújo Gurgel***,Fausto Silva Bramante****, Luciana Maio Pinzan*****AbstractObjective: Although direct bonding takes up less clinical time and ensures increasedpreservation of gingival health, the banding of molar teeth is still widespread nowadays.It would therefore be convenient to devise methods capable of increasing the efficiencyof this procedure, notably for teeth subjected to substantial masticatory impact, such asmolars. This study was conducted with the purpose of evaluating whether direct bondingwould benefit from the application of an additional layer of resin to the occlusal surfacesof the tube/tooth interface. Methods: A sample of 40 mandibular third molars was selectedand randomly divided into two groups: Group 1 - Conventional direct bonding,followed by the application of a layer of resin to the occlusal surfaces of the tube/toothinterface, and Group 2 - Conventional direct bonding. Shear bond strength was tested 24hours after bonding with the aid of a universal testing machine operating at a speed of0.5mm/min. The results were analyzed using the independent t-test. Results: The shearbond strength tests yielded the following mean values: 17.08 MPa for Group 1 and 12.60MPa for Group 2. Group 1 showed higher statistically significant shear bond strengththan Group 2. Conclusions: The application of an additional layer of resin to the occlusalsurfaces of the tube/tooth interface was found to enhance bond strength quality of orthodonticbuccal tubes bonded directly to molar teeth.Keywords: Tooth bonding. Shear strength. Molar tooth.How to cite this article: Vercelino CRMP, Pinzan A, Gurgel JA, Bramante FS, Pinzan LM. In vitro study of shear bond strength in direct bondingof orthodontic molar tubes. Dental Press J Orthod. 2011 May-June;16(3):60.e1-8.* PhD in Orthodontics, FOB/USP. Assistant Professor, Masters Program in Dentistry (Area of Concentration: Orthodontics), UNICEUMA (São Luís, MA).** Associate Professor, Department of Orthodontics, Bauru School of Dentistry, University of São Paulo.*** PhD in Orthodontics, FOB/USP. Coordinator and Professor, Masters Program in Dentistry (Area of Concentration: Orthodontics), UNICEUMA (SãoLuís, MA). Assistant Professor in Speech Therapy Program, FFC - UNESP/Marília.**** PhD in Orthodontics, FOB/USP. Assistant Professor, Masters Program in Dentistry (Area of Concentration: Orthodontics), UNICEUMA (São Luís, MA).***** Graduate, USC/Bauru. Student, Specialization Course in Orthodontics, APCD, Bauru/SP.Dental Press J Orthod 60.e12011 May-June;16(3):60.e1-8

In vitro study of shear bond strength in direct bonding of orthodontic molar tubesintroductionThere is currently a constant concern overthe efficiency of clinical procedures performedin orthodontic practice. Orthodontists andpatients alike, as well as their legal guardians,strive to attain the best possible results in theshortest possible treatment time. Among thefactors that affect treatment time are the rebondingof brackets and recementing of bands.Frequent rebonding and/or recementing of accessoriesoften hinders orthodontic mechanics,resulting in longer treatment time, higher costsand increased chair time. 12In many cases, orthodontists prefer to bandteeth, especially molars and second premolars,to avoid the need to rebond accessories in theseregions. However, it is a known fact that directbonding saves chair time as it does not requireprior band selection and fitting. Moreover, whenthe banding procedure is not performed with utmostcare it can damage periodontal tissues (encroachmentof biological width) 2 and/or dentaltissues (infiltration at the tooth/band interface).Current literature recommends that all teethbe bonded, underscoring the importance of assessingmalocclusion severity and the need foranchorage devices. 17 Low profile molar tubesare available on the market which allow a 2 mmgain of vertical space in the area of posteriorintercuspation. 17Despite its many advantages in terms ofpatient comfort, less periodontal damage andshorter chair time, direct bonding of molar teethis not commonly performed in fixed orthodontictreatment. A 2002 U.S. study showed a higherprevalence of banded vs. bonded molars. 7 Thisfinding is probably related to studies that evaluatedthe bonding of tubes, and demonstrated decreasedbond strength 8 and increased percentageof clinical failures 3 in these tubes than in bracketsbonded in the anterior region of the dentalarch. Tubes bonded to molars using self-cure 3,18or light-cure resins 9,10 showed around 14% offailure. According to the authors, these resultsmay be related to (a) difficulty in maintainingproper isolation of the region, (b) inadequateadaptation of the attachment base to the toothsurface, (c) stronger masticatory forces, (d) differentetching times, and (e) individual variationsrelated to enamel composition. 8Nowadays, however, given recent advancesin primer quality 4,16,17 and in the bases of orthodonticattachments 11 manufactured for directbonding, combined with awareness of the benefitsof this procedure, it would be convenientto devise methods capable of increasing theefficiency of traditional bonding, notably inteeth subjected to higher masticatory impact,such as lower molars. In reviewing the literature,only one study was found which evaluatedin vitro an alternative approach to reducethe percentage of failures in the direct bondingof molars. 6 Johnston and McSherry 6 evaluatedthe effect of sandblasting of tube bases andconcluded from the results that there was nosignificant increase in bond strength.This study was therefore conducted with thepurpose of evaluating whether direct bondingwould benefit from the application of an additionallayer of resin to the occlusal surfaces of thetube/tooth interface.MATERIAL AND METHODSA sample of 40 healthy third molars indicatedfor surgical removal were selected for this study.The teeth were obtained in a private clinicand were cleaned and stored in 1% chloramine-T. The material was then embedded in rigidPVC rings with acrylic resin, only the crownswere exposed. When adding the material, thebuccal surfaces of the crowns were positionedperpendicular to the base of the die with theaid of an acrylic square at an angle of 90º to ensurethat the mechanical tests were performedcorrectly. After the resin had cured all sampleswere stored in distilled water.Dental Press J Orthod 60.e2 2011 May-June;16(3):60.e1-8

Vercelino CRMP, Pinzan A, Gurgel JA, Bramante FS, Pinzan LMThe specimens were randomly divided intotwo groups according to different bonding protocols:Group 1 — conventional direct bondingwith subsequent application of a layer of resinto the occlusal surface of each tube/tooth interface,and curing for a further 10 seconds overthe reinforcement; Group 2 — conventionaldirect bonding, followed by application of anadditional 10 seconds of curing by placing thelight on the occlusal surface of the teeth.For the sake of standardization all procedureswere performed by a single orthodontist.Prophylaxis of the buccal surface of eachtooth was carried out with the aid of a rubbercup and extra-fine pumice prior to direct bonding,followed by rinsing with water and dryingwith compressed air. The teeth were thenetched with phosphoric acid in gel at 37% for30 seconds, after which the enamel was rinsedand dried. In Group 1, the etched area waslarger, because the region where the resin reinforcementwas applied needed etching. Inthe following step, Transbond XT primer (3MUnitek Orthodontic Products, Monrovia - CA,USA) was applied and the tubes (Morelli Ortodontia,Sorocaba - SP, Brazil) bonded directlyto the teeth over an area of 13.6 mm 2 , usingTransbond XT light-cured resin (3M UnitekOrthodontic Products, Monrovia - CA, USA).The tubes were stored in their containers untilthe experiment had been completed, and werehandled with bonding tweezers to avoid anycontamination that might affect the results. Theresin was applied to the basis of the tubes andthen the set was placed in position. The tubeswere positioned in the center of the buccal surfaceand then pressed firmly to obtain a thinlayer of bonding material. All excess was carefullyremoved with the aid of an explorer probebefore light curing, which was performed witha curing light (Ultraled - Dabi Atlante, RibeirãoPreto, Brazil, 10 VA power), with light intensitybeing measured by a 450 mW/cm 2 radiometer(Demetron Research Corp.) for 20 seconds, accordingto manufacturer’s instructions.Initially, direct bonding procedure was thesame for both groups.Immediately after conventional direct bonding,an additional layer of resin was applied to thetube/tooth interface in Group 1. A metal spatulawas used to standardize the amount of resin applied.A mark was made 2 mm from the tip ofthe spatula and enough Transbond XT paste wasapplied to fill the space as far as the mark (Fig1). The resin was then applied to the tube/toothinterface with the aid of a brush dipped in theadhesive, followed by curing for 10 seconds (Figs2, 3 and 4). Ten seconds of light curing were appliedto the reinforcement since the light wasshone directly onto the additional resin, and accordingto the manufacturer’s instruction this isthe recommended curing time when using aestheticbrackets that allow the light directly ontothe bonding material.In Group 2 (Fig 5), after conventional directbonding, 40 seconds were allowed to elapsebefore placing the curing light occlusally foranother 10 seconds since total curing time inthe experimental group was 30 seconds. This40-second time was determined based on theFigurE 1 - Standardization of additional amount of resin applied to occlusalsurfaces of tube/tooth interface in Group 1.Dental Press J Orthod 60.e32011 May-June;16(3):60.e1-8

In vitro study of shear bond strength in direct bonding of orthodontic molar tubesFigurE 2 - Resin application to occlusal surfaceof tube/tooth interface in Group 1.FigurE 3 - Applying resin to occlusal surfacesof tube/tooth interface with aid of brushdipped in adhesive.FigurE 4 - Test specimens in Group 1: Conventionaldirect bonding followed by applicationof additional layer of resin to occlusalsurfaces of the tube/tooth interface.average time required for reinforcement applicationin Group 1.After bonding, the specimens were storedin distilled water for 24 hours at a temperatureof 37ºC. After this period, the groups had theirshear bond strength tested in a universal machine(EMIC, DL line, series 385, São José dosPinhais, PR, Brazil) operating at a speed of 0.5mm/min (Fig 6). The results were obtained in kilogram-force(kgf), converted into Newtons anddivided by the tube base area, yielding results inMPa. The results obtained in MPa were recordedby the computer connected to the test machineupon bracket debonding.Descriptive statistics was then performed:Means, standard deviations (SD), medians andminimum and maximum values.The results were analyzed using Student’sindependent t-test. A 5% significance level wasadopted.RESULTSTable 1 presents the mean values, standard deviations(SD), medians and minimum and maximumvalues, and kilogram-force MPa (kgf) at thetime the tubes were debonded.Group 1 showed a higher statistically significantshear bond strength than Group 2 (Table 2).FigurE 5 - Test specimens in Group 2: Conventional direct bonding, followedby additional 10-second light-curing.DISCUSSIONAs a science, orthodontics has undoubtedlymade enormous strides in recent decades. Advancesin materials for direct bonding and cementation,in metal alloys used in orthodontic wires,orthodontic accessories, techniques, mechanicsand anchorage devices have proven extremely relevantfor treatment implementation.Dental Press J Orthod 60.e4 2011 May-June;16(3):60.e1-8

Vercelino CRMP, Pinzan A, Gurgel JA, Bramante FS, Pinzan LMtablE 1 - Means, standard deviations (SD), medians and minimum andmaximum values in MPa, and kilogram-force (kgf).Group 1 Group 2MPa Kgf MPa KgfMean 17.08 23.69 12.60 17.48SD 3.28 4.55 1.97 2.74Median 16.35 22.66 13.1 18.16Minimum 11.68 16.2 8.38 11.63Maximum 24.54 34.03 15.68 21.75TABLE 2 - Comparison between groups (independent t-test).Group 1 Group 2 pMean (MPa) 17.08 12.60 0.00** Statistically significant (p< 0.05).FigurE 6 - Position of the shear bond strength testing device.However, despite all these improvements,most orthodontists have for decades banded molarteeth instead of directly bonding orthodontictubes. 7 There is evidence in the literature thatbonded molar tubes show a higher incidence ofclinical failures than accessories that are bondedin more anterior regions of the dental arch. 10,18However, it is essential to note that posteriorteeth are subjected to greater masticatory efforts 15and the occurrence of a higher percentage of clinicalfailures in this region is therefore perfectly justifiable.It should also be emphasized that thereare no clinical studies showing that the banding ofmolars is more effective than directly bonding tothese teeth. In conducting a longitudinal study toclinically evaluate the periodontium of banded vs.bonded molars, Boyd and Baumrind 2 found thatbanded maxillary molars had a higher incidenceof clinical failures than bonded maxillary molarswhereas the reverse was true to lower molars.Today, with the development of orthodonticdirect bonding materials, it seems more importantto focus on clinical procedures that increasethe bond strength of available materials. Therefore,the purpose of this study was to determinewhether application of an additional layer of resinto the occlusal surface of the buccal tube/toothinterface increases the bonding quality of orthodontictubes to molar teeth.To this end, laboratory tests were performed intwo groups: In Group 1, the experimental group,an additional layer of resin was applied to the occlusalsurface of the tube/tooth interface, and inGroup 2, the control group, after conventional directbonding, the tube/tooth interface was lightcured for an additional 10 seconds. Additionalcuring was applied to Group 2 in order to eliminateany variables related to curing time since thetotal time in Group 1, after applying the reinforcement,was 30 seconds.According to resistance theory, when a forceis applied to a body (tube), which is attached toanother element (tooth) using a bonding material(resin), tension (T) is calculated by means of appliedforce (F) divided by contact area (A) (T = F/ A). Considering that the resin — of all the elementsinvolved in the tests — is the material withthe lowest breakage stress, in order to increasethe shear bond strength of the tube/resin/toothDental Press J Orthod 60.e52011 May-June;16(3):60.e1-8

In vitro study of shear bond strength in direct bonding of orthodontic molar tubescomplex we should increase the surface area. Itwas therefore with this purpose that the resin reinforcementwas applied (Fig 7).From these results it was possible to observegreater bond strength in Group 1, with a statisticallysignificant difference compared to Group2 (Tables 1 and 2). The additional layer of resincreated an additional area of contact betweentooth and tube and thus the applied force wasdivided by a more extensive area, yielding betterresults for this group.The mean value found for Group 2 (control)is similar to results obtained by Knoll, Gwinnettand Wolf, 8 who noted a bond strength of 11±4MPa, and Bishara et al, 1 who found a mean valueof 11.8±4.1 MPa.Upon completion of this study, a third groupwas outlined whose teeth had only received conventionaldirect bonding of tubes with a totalcuring time of 20 seconds. The results showed astatistically significant difference compared to thegroup that received reinforcement during bondingbut were similar to the group that received theadditional 10-second light-curing. 14Proffit, Fields and Nixon 15 showed that inbalanced faces, posterior teeth are subjectedto greater masticatory forces, with forces ofaround 30 kg being exerted. In this study, themean force in kilogram-force at the time ofdebonding the tubes in Group 1 was 23.69 kgf(Table 1), a value closer to what Proffit, Fieldsand Nixon 15 found than to the value obtained inGroup 2 (17.48 kgf, Table 1).Since most of the factors involved in the procedureof directly bonding molar tubes cannotbe changed by the orthodontist (salivation, difficultaccess to the bonding procedure, absenceof uniform buccal surfaces and resin thickness,initial patient age and the occurrence of occlusalinterference), 9 this alternative method proposedfor performing this procedure seems toincrease the clinical quality of the direct bondingof orthodontic tubes.FigurE 7 - A) Conventional direct bonding; B) Enlargement of resin areato increase bond strength of whole tube/resin/tooth set.Moreover, in assessing in vivo tubes bondedby means of the conventional method ofbonding to molars using self-etching primerand Transbond XT resin, Pandis et al 10 observedthat the first failure occurred after 23months on average (20 to 26 months). Sincein this study the group with reinforced resinshowed better bond strength than the groupwith conventional bonding, probably the timefor observation of clinical failure with the aidof the resin reinforcement will be longer thanthis period, when the most orthodontic casesare already finished.Despite the fact that adhesive productshave a rough surface that favors the accumulationof plaque, 18 the region where the additionallayer of resin is applied can be easily cleanedby the patient and controlled by professionalsduring consultations. Besides, it is located farfrom the gingival margin, causing no damageto periodontal tissues.Before deciding between banding or bondingmolars several factors should be evaluatedsuch as the quality of the adhesive materialused for direct bonding, the substrate (amalgam,resin, porcelain, enamel, metal alloys) andthe clinical needs (type of movement, clinicalcrown height, need for installation of anchoragedevices). 2,17,18 After careful considerationDental Press J Orthod 60.e6 2011 May-June;16(3):60.e1-8

Vercelino CRMP, Pinzan A, Gurgel JA, Bramante FS, Pinzan LMof these factors, if the choice falls on directbonding, the method proposed in this studyappeared to increase effectiveness.The adhesive remnant index was not calculatedbecause the aim of this study was to evaluatea new approach to bonding orthodontic molartubes and not to evaluate the bonding system.Despite the high values obtained in thisstudy, only one specimen sustained enamel fracturewhile the tubes were being debonded. Thefracture occurred in the tooth that exhibitedthe highest value during shear testing (34.03kgf, 24.54 MPa, Table 1). However, it is importantto emphasize that recent studies comparingin vivo with in vitro bond strength have shownthat the values obtained in vivo proved to be significantlylower than those obtained in vitro. 5,13Based on the results, Penido et al 13 stressed theimportance of evaluating the acceptable valuesof bond strength of orthodontic accessories obtainedthrough mechanical testing.The amount of additional layer of resin usedin this in vitro study represents a fixed valuefor comparison between groups. Based on theseresults, one can infer that the amount of resinwas effective in increasing shear bond strength.However, for clinical use of this method, theauthors recommend to quantify the bondingmaterial so as not to interfere with the occlusalrelationship between upper and lower molars.A clinical investigation is currently underway to ascertain the findings of this laboratorystudy since during bonding no saliva contaminationoccurred and neither were there anydifficulties placing the tubes in the posteriorregion. Therefore, laboratory test results maybe better than those achieved in clinical research.However, it is important to emphasizethat, although none of the groups was affectedby the above mentioned problems, group 1showed the best results.CONCLUSIONSBased on the results of this study, applicationof an additional layer of resin to the occlusalsurfaces of the tube/tooth interface enhancedbond strength of orthodontic buccal tubesbonded directly to molar teeth.Dental Press J Orthod 60.e72011 May-June;16(3):60.e1-8

In vitro study of shear bond strength in direct bonding of orthodontic molar tubesReferEncEs1. Bishara SE, Gordan VV, VonWald L, Olson ME.Effect of an acidic primer on shear bond strength oforthodontic brackets. Am J Orthod Dentofacial Orthop.1998;114(3):234-7.2. Boyd RL, Baumrind S. Periodontal considerations in the useof bonds or bands on molars in adolescents and adults.Angle Orthod. 1992;62(2):117-26.3. Geiger A, Gorelick L, Gwinnett AJ. Bond failure ratesof facial and lingual attachments. J Clin Orthod.1983;17(3):165-9.4. Giannini C, Francisconi PAS. Resistência à remoção debraquetes ortodônticos sob ação de diferentes cargascontínuas. Rev Dental Press Ortodon Ortop Facial.2008;13(3):50-9.5. Hajrassie MKA, Khier SE. In-vivo and in-vitro comparison ofbond strengths of orthodontic brackets bonded to enameland debonded at various times. Am J Orthod DentofacialOrthop. 2007;131(3):384-90.6. Johnston CD, McSherry PF. The effects of sanblasting on thebond strength of molar attachments - an in vitro study. Eur JOrthod. 1999;21(3):311-7.7. Keim RG, Gottlieb EL, Nelson AH, Vogels DS 3rd. JCO studyof orthodontic diagnosis and treatment procedures. Part 1:results and trends. J Clin Orthod. 2002;36(10):553-68.8. Knoll M, Gwinnett AJ, Wolff MS. Shear strength of bracketsbonded to anterior and posterior teeth. Am J OrthodDentofacial Orthop. 1986;89(6):476-9.9. Millett DT, Hallgren A, Fornell AC. Bonded molar tubes:A retrospective evaluation of clinical performance. Am JOrthod Dentofacial Orthop. 1999;115(6):667-74.10. Pandis N, Christensen L, Eliades T. Long-term clinical failurerate of molar tubes bonded with a self-etching primer. AngleOrthod. 2005;75(6):1000-2.11. Park DM, Romano FL, Santos-Pinto A, Martins LP, NouerDF. Análise da qualidade de adesão de diferentes basesde braquetes metálicos. Rev Dental Press Ortodon OrtopFacial. 2005;10(1):88-93.12. Pasquale A, Weinstein M, Borislow AJ, Braitman LE. In-vivoprospective comparison of bond failure rates of 2 selfetchingprimer/adhesive systems. Am J Orthod DentofacialOrthop. 2007;132(5):671-4.13. Penido SMMO, Penido CVSR, Santos-Pinto A, SakimaT, Fontana CR. Estudo in vivo e in vitro com e semtermocliclagem, da resistência ao cisalhamento debraquetes colados com fonte de luz halógena. Rev DentalPress Ortodon Ortop Facial. 2008;13(3):66-76.14. Pinzan-Vercelino CRM, Pinzan A, Gurgel JA, Bramante FS,Pinzan LM. In vitro evaluation of an alternative method tobond molar tubes. J Appl Oral Sci. 2011;19(1):41-6.15. Proffit WR, Fields HW, Nixon WL. Occlusal forces in normaland long-face adults. J Dent Res. 1983;62(5):566-71.16. Rosa CB, Pinto RA, Habib FAL. Colagem ortodôntica emesmalte com presença ou ausência de contaminação salivar:é necessário o uso de adesivo auto-condicionante ou deadesivo hidrofílico? Rev Dental Press Ortodon Ortop Facial.2008;13(3):34-42.17. Trevisi H. Sistema individualizado de posicionamento debraquetes. In: Trevisi H. SmartClip: tratamento ortodônticocom sistema de aparelho autoligado: conceito ebiomecânica. Rio de Janeiro: Elsevier; 2007. p. 71-123.18. Zachrisson BU. A posttreatment evaluation of direct bondingin orthodontics. Am J Orthod. 1977;71(2):173-89.Submitted: September 2009Revised and accepted: April 2010Contact addressCélia Regina Maio Pinzan VercelinoAlameda dos Sabiás, 58CEP: 18.550-000 - Boituva / SP, BrazilE-mail: cepinzan@hotmail.comDental Press J Orthod 60.e8 2011 May-June;16(3):60.e1-8