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Volume 9, Issue 1
CONTENTS JAOS WINTER 2009
Features
16 Impacted Incisors in Mixed Dentition
By Juan Carlos Echeverri, DDS
22 The Changing Face of Growth Modification

By Leonard J. Carapezza, DDS
16
26 The Benefits of Early Treatment

By Jeffrey H. Ahlin, DDS
32 Early Transitional Dentition Treatment

By Chris Baker, RN, DMD
22
Departments
8 Ortho Industry News
12 Orthobites
Interceptive Orthodontics:
Early Treatment in Orthodontics
26
By David W. Jackson, DDS, FAGD
38 AOS Membership News

42 AGpO Membership News
46 Patients Page
32
Oral Health and Diabetes
This peer-reviewed journal is

published as the official publication
of the American Orthodontic Society
and the Academy of Gp Orthodontics.
On the cover: Dr. James E. McIlwain provides

comprehensive pediatric dental care, specializing in
orthodontics. Dr. McIlwain explains to patient Samantha
Scott the Rapid Palatal Expander appliance and how it will
help her to achieve a beautiful smile. He has been in
practice for more than 20 years and never has lost the
quest for new advancements in early patient treatment.
Individual attention and comprehensive care for each
child are foremost priorities in his routine of treatment.
McIlwain Family Dentistry is located in Tampa, FL.
www.orthodontics.com Winter 2009 5
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EDITORS WELCOME
ASSOCIATION STAFF
Greg Cannizzo, DDS, CDE, JAOS Editor
Cynthia Bordelon
AGpO Executive Director
Academy of Gp Orthodontics
22233 Ridge Road, Suite 101
3617 Municipal Drive, McHenry, IL 60050

Phone: (815) 344-2282 Fax: (815) 344-5815
Email: drgrc@joltmail.com
During this past year, change was more
than just an election slogan. As the first
decade of the new century comes to a
close, change is everywhere. Entire companies have disappeared resulting in thousands losing their jobs and benefits.
Consumer confidence appears to be in a
tail spin. So how can we navigate through
these times of change as storm clouds
have begun to build on the horizon? The
answer to that would be attitude. You get
to decide how this economic soft spot
will affect you. As Helen Keller once said
When one door of happiness closes,
another opens, but often we look so long
at the closed door that we do not see the
one which has been opened for us.
Attitude will be the compass that
guides us through economic storminess
and uncertainty. One of my favorite
stories on attitude begins withOnce
upon a time; there was a monk who ran.
Everyday the monk would lace up his
running shoes and head out along a
popular local path. He always keept to
himself, preferring to train alone. As
other runners passed him or ran by him
they would nod, say hi, or ask how he
was doing. But the monk was rarely
friendly and he scowled whenever
anybody asked him why he ran. He
usually mumbled his answer so that no
one could hear. He never offered to pace
a fellow runner or talk about his training, he kept his work out and knowledge
of running and training to himself.
Everyday, a missionary would lace up
his running shoes and head out along a
neighboring popular path. The missionary was more outgoing and he ran with a
smile on his face. As other runners passed
him or ran by him, he would greet them
by name and ask how their training was
progressing. The missionary was always
enthusiastic and ready to talk about how
Rockwall, TX 75087
(800) 634-2027
fax: (888) 634-2028
great running
was, and he
would gladly
answer anyone
who asked why he ran (sometimes he
would tell people even if they didnt ask!)
He spoke of the mental and physical
health benefits of running and how he
could do it for the rest of his life. He
would educate and help others with their
training showing them how to improve
and be better runners. Soon, he had the
whole village running and enjoying every
step of it.
If you start to feel an economic slow
down, take the opportunity to use that
extra free time to reconnect with your
core patients of record. Dont get stuck
staring at the closed door. Like the
missionary, lace up and take the extra
time to connect with the people around
you. Talk with your patients and reconnect. Be enthusiastic, educate them.
People buy from people they like. Make
sure everyone in your practice and
community knows you offer comprehensive care including orthodontics.
So, in 2009, reconnect not only with
your patients but also with your fellow
members of the AOS and AGpO. This
years joint meeting will be this August 2022, 2009 in Chicago. Make a point to
attend this year and touch base with
colleagues and friends. They are your
village. Being part of the annual meeting
gives you a chance to pick up so many
orthodontic pearls, participate in the best
CE available for Gps and pedodontists
who do orthodontics, and talk to others in
your community.
Ill be looking for you in Chicago
where we will enjoy every step of the
greatest meeting this year.
Advertiser Index
Academy of Gp Orthodontics ....................45
Ortho Arch ................................................11
American Orthodontic Society ..................41
Ortho Organizers ......................................47
ClassOne Orthodontics ................................2
Ortho Technologies....................................19
Dolphin Imaging........................................37
Parkell ........................................................48
Johns Dental Labs ................................30, 35
Rocky Mountain Orthodontics ....................4
Journal of Orthodontics..............................31
Space Maintainers ........................................3
Myofunctional Research ............................21
Vector Dental ............................................29
Ordont Ortho Labs ......................................9
Wild Smiles ................................................10
6 Winter 2009 JAOS
Tom Chapman, CAE

AOS Executive Director
American Orthodontic Society
11884 Greenville Avenue
Suite 112
Dallas, TX 75243
(800) 448-1601
fax: (972) 234-4290
EDITORIAL STAFF
Greg Cannizzo, DDS .................AGpO
Editor
Jordan Balvich, DMD ......................AOS
Co-Editor
Jim Mcllwain, DDS, MSD ..........AOS
Co-Editor
Lisa A. Wright ..................AOS/AGpO
Managing Editor
Email: lisa@wrightgrp.com
EDITORIAL REVIEW BOARD
Azita Anissi, DDS ..............................AOS
Robert Allen, DDS..........................AGpO
Ron Austin, DDS............................AGpO
Chris Baker, RN, DMD......................AOS
Eugene Boone, DDS.......................AGpO
Dan Dandois, DDS ........................AGpO
Fred, Der, DDS ...............................AGpO
Corina Diaz-Bajsel, DDS ................AGpO
Drew Ellenwood, DDS ...................AGpO
Debra Ettle-Resnick, DDS .................AOS
Joe Fallin, DDS...............................AGpO
Robert G. Gerety, DDS......................AOS
Edward Gonzalez, DMD ...................AOS
Sam Gutovitz, DDS........................AGpO
Art Gutierrez, DDS............................AOS
Roy Holexa, DDS ...........................AGpO
David W. Jackson, DDS ....................AOS
Thomas Jacobson, DDS .................AGpO
Kyle McCrea, DDS .........................AGpO
Mitchell S. Parker, DDS.....................AOS
Leslie R. Penley, DDS .....................AGpO
Kurt Raack, DDS ............................AGpO
Jon Romer, DDS ................................AOS
Joseph R. Schmidbauer, DDS............AOS
Robert Shirley, DDS .......................AGpO
Barry Sockel, DDS ..........................AGpO
Juan J. Solano, DDS ..........................AOS
Kurt, Stodola, DDS.........................AGpO
David Thorfinnson, DDS..................AOS
Walter Tippen, DDS.......................AGpO
Helen B. Tran, DDS........................AGpO
Michael Wilkerson, DDS ...............AGpO
William Wyatt, DDS .........................AOS
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PUBLISHED BY
Wright Publishing Group, Inc.
726 Pasadena Avenue South
St. Petersburg, FL 33707
(727) 343-5600
www.wrightgrp.com
ADVERTISING SALES & ANNUAL
MEETING EXHIBIT MANAGER
Kimberly Price
Integrity Media Group
4006 Majesty Palm Court
Tampa, FL 33624
Phone: 813-466-5521
Fax: 813-864-4454
E-mail: kprice@orthodontics.com
CONTRIBUTOR BIOGRAPHIES
Dr. David W. Jackson graduated from Baylor College of
Dentistry in 1978. Dr. Jackson, a member of AOS and AGpO as
well as other professional organizations, operates two highly
successful practices in Farmersville and Rowlett, Texas and
employs over 25 people. He lectures extensively for the American
Orthodontic Society and the International Association for
Orthodontics. His insight to the real world of orthodontics in the
general practice is honest and informative. Find out about upcoming seminars at orthoplusseminars.com.
Dr. Juan Carlos Echeverri is the owner of Echeverri Dental

ADVERTISING & EDITORIAL POLICY
The American Orthodontic Society
welcomes advertising in its publications as
an important means of keeping the
orthodontic practitioner informed of new
and better products and services for the
practice of orthodontics. Such advertising
must be factual, dignified, tasteful and
intended to provide useful product and
service information. These standards apply
to all product-specific promotional material submitted to the American Orthodontic Society. The publication of an advertisement is not to be construed as an endorsement or approval by the American
Orthodontic Society unless the advertisement specifically includes an authorized
statement that such approval or endorsement has been granted. The fact that an
advertisement for a product, service or
company has appeared in an American
Orthodontic Society publication will not
be referred to in collateral advertising. The
American Orthodontic Society reserves the
right to accept or reject advertising at its
sole discretion for any product or service
submitted for publication.
COPYRIGHT
2009. Journal of the American
Orthodontic Society. The material in
each issue of the JAOS is protected by
copyright. None of it may be duplicated,
reprinted or reproduced in any manner
without express written consent from
the publisher. All inquiries and/or
requests should be submitted in writing
to Wright Publishing Group, Inc. or via
email at lisa@wrightgrp.com.
Center in Houston, TX. Fluent in English and Spanish, he has made

presentations in Colombia, Venezuela, Spain and USA in prosthesis,
implants and orthodontics and dental education for patients.
Echeverri is the creator and director of the dental education
outreach program for the schools surrounding his practice. He is a
member of the Greater Houston Dental Society, Texas Dental
Society, American Orthodontic Society, American Dental Association
and Academy of General Dentistry.
Dr. Leonard Carapezza has over 25 years of clinical experience

in pediatric orthodontics and operates a successful private practice in
Wayland, MA. He has degrees from Brandeis University and the
University of Medicine and Dentistry of New Jersey. He served as a
Teaching Fellow at the Harvard School of Dental Medicine and
received a certificate in Pediatric Dentistry from Childrens Hospital.
Dr. Carapezza is currently an Associate Clinical Professor at Tufts
University, School of Dental Medicine and a contributing editor to
the Journal of Clinical Pediatric Dentistry. His lecture experience
includes the Senior Certified Instructor for both the American
Orthodontic Society (AOS) and International Association for
Orthodontics (IAO).
Dr. Jeffrey H. Ahlin has served on the Board of Directors and as

an officer of the American Orthodontic Society and currently
serves on the Board of the AOS Foundation. He is a board certified
diplomate of the AOS and of the American Academy of Pediatric
Dentistry. He has published over 50 papers in professional journals
and two textbooks. He has taught at Harvard Schools of Dental
Medicine and Tufts Dental schools for 20 years and lives in
Gloucester, MA with his wife and two children.
SUBSCRIPTIONS
The Journal of the American Orthodontic
Society is a benefit of membership for
current American Orthodontic Society and
Academy of Gp Orthodontics members.
Annual subscriptions to the quarterly journal (4 issues per year) are available at a rate
of $40/year for US residents, $80 USD/year
for Canada and $100 USD/year internationally. Back issues are available at a rate
of $5 per copy until supplies run out.
To subscribe to the JAOS, please visit
www.orthodontics.com.
Dr. Chris Baker, through her practice in pediatric dentistry

and orthodontics in Lexington, KY, and as a national lecturer
and author, enjoys her passions - connecting with the parents
and child patients, educating professionals and parents in stateof-the-art dental care and management to meet the needs of
todays parents and children. Dr. Bakers greatest opportunities lie
in providing diagnosis and treatment of poor craniofacial growth
patterns and airway obstructions in children as early as possible
to optimize each childs beauty and aesthetics. Dr. Baker is an
AOS Board Examiner and Vice-president of the Society.
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ORTHO INDUSTRY NEWS
Alginate Alternative: Designed for a Variety of

Indications Including Orthodontic Appliances
A new alginate
alternative
impression
material
from
Kettenbach
LP was
introduced
to the U.S.
dental
market late
last year. Silginat is designed for a
variety of indications such
as: anatomical models, opposing
models, fabrication of temporary
crown and bridges, fabricating simple

removable prosthetic restorations,
orthodontic appliances, splints and
case study models, or for most
purposes where an alginate could
be used.
Silginat was designed
with a low-tear resistance to
avoid dislodging restorations
or orthodontic appliance inadvertently. The material also has a high
dimensional stability so model
impressions can be kept for weeks
and poured multiple times. Silginat is also highly thixotropic and
flows properly under pressure.
New Adhesive
Removing Instruments
KOMET USAs adhesive removing instruments were developed

as special instruments for
orthodontists to remove tough
adhesive residue. A study with
Ralf Radlanski, DDS, at the
University of Berlin, shows these
instruments remove adhesive
quickly, and thanks to their
special toothing, without damaging the enamel.
At low contact pressure, the
instruments operate with low vibration and achieve perfectly smooth
8 Winter 2009 JAOS
surfaces while generating minimal

heat. This is due to its innovative
blade geometry. Its twisted blades,
made of durable tungsten carbide,
are suited for precise reduction of
soft materials and assure smooth
operation providing maximum
treatment comfort.
In order to avoid the risk of
damaging the gingiva, all adhesive removers are provided with
smooth, non-cutting tips, and the
safety chamfer at the heads end
eliminates the formation of
grooves. The tapered instrument
is available for contra-angle and
turbine handpieces. The
H22ALGK is designed specifically
for canines and long anterior
teeth, and the egg-shape
(H379AGK) instrument is suited
for the palatinal reduction of
adhesive in the lingual technique.
KOMET is a recognized worldwide leader in the production of
highly specialized and precise
dental rotary instruments. For
more information about adhesive removing instruments,
please call 888-556-3887 or visit
www.komet-usa.com.
Silginat is available in two

delivery systems 362-mL foil bags
for Kettenbachs Plug & Press
automatic dispenser (5:1 ratio); and
38-mL cartridges (1:1 ratio) with an
optimal volume for a single fullarch or two quadrant impressions.
The total set time for Silginat,
when dispensed in cartridges, is 2
minutes, 30 seconds. When Silginat is dispensed in foil bags, it has
a total set time of three minutes.
For more information about
Silginat alginate alternative, please
call 877-KEBA-123 or visit
www.kettenbachusa.com.
Dolphin 3D Offers
Volume Stitching
Offering the ability to stitch

together two separate volumetric
datasets to construct a larger view, this
new feature brings the full view of 3D
technology to a larger demographic of
practitioners. Not all dental specialists have access to large field of view
(FOV) cone beam CT devices, says
Ken Gladstone, manager of Dolphins
imaging software products. But, there
are times these doctors want a larger
view, for example both condyles or
the entire arch. The new Volume
Stitching feature allows the practitioner to import two separate, smaller
scans and stitch them together to
create a single, larger FOV volume
DICOM dataset. Volume stitching is
the perfect tool for smaller field of
view systems to generate larger and
more useful volumes, he adds.
Dolphin products are backed with
round-the-clock, personalized technical support. For more information,
visit www.dolphinimaging.com.
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ORTHO INDUSTRY NEWS
Improve Bonding Experience

Ergonomic
RMOs Indirect Bonding system
(IDB)
provides clinicians a simple and
Headrest
consistent solution for maximizing
practice efficiency while significantly
Receives
improving the patient bonding experience. The system allows for
accurate bracket placement
Design Award extremely
under convenient setup conditions
working on a study model, and most

of the procedures can be conducted
by staff persons with modest training.
RMOs RMbond start-up kit is a
turnkey system that includes all of the
materials necessary to begin Indirect
Bonding for your patients immediately. For more information, please
visit www.rmortho.com.
Sirona introduced the new MultiMotion headrest as an available
option with the Sirona C8+ dental
treatment center. This innovative
headrest comfortably secures the
patients head in a natural position
and allows the practitioner optimal
views of previously inaccessible areas.
Designed in accordance with
Sirona Dental Systems Ergonomics
Program, the MultiMotion headrest
can be tilted and rotated in any
desired direction, enabling both
patient and practitioner to remain
in the optimal ergonomic position
throughout any procedure. With a
single, one-handed motion, the
practitioner can easily adjust the
headrest to gain visual access to all
four quadrants. Switching from the
upper to lower jaw is now quick and
simple. The MultiMotion headrest
improves workflow during basic
treatment scenarios, challenging
endodontic procedures and anytime
a treatment or location specific
instrument is required.
Recently, the MultiMotion headrest
received the 2008 iF Product Design
Award in the Medicine/Health+Care
category. The 26-member jury evaluated the entries on the basis of the
following criteria: design quality,
workmanship, choice of materials,
degree of innovativeness, environmental compatibility, functionality,
ergonomics, visualization of use,
safety, brand value/branding and
universal design.Visit www.sirona.com
for more information about Sirona
and its products.
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ORTHO INDUSTRY NEWS
Appliance Opens Blocked Airways

The Thornton Adjustable Positioner 3 (TAP 3), available from
Accutech Orthodontic Lab, Inc., is a
mandibular advancement device that
improves breathing and eliminates
snoring in 95 percent of all patients.
The TAP 3
Appliance also
helps prevent
conditions
that are
linked to
sleep apnea
such as
chronic
sleepiness,
high-blood
pressure, heart
attack, stroke,
heartburn,
morning
headache and depression. It treats
these conditions without the need for
surgery, continuous positive airway
pressure (CPAP) or medication.
The TAP 3 is a custom-made
adjustable appliance that is worn
while sleeping. The appliance
trays, similar to whitening trays,
snap on over the upper and lower
teeth, and hook together. The
design is based on the same principle as cardiopulmonary resuscitation (CPR). The airway must be
10 Winter 2009 JAOS
opened to allow air to pass

through the throat. The American
Academy of Sleep Medicine recommends oral appliances like the
TAP 3, as a first line of treatment
in cases of mild and moderate
sleep apnea
and in cases of
severe apnea
when CPAP
has not
worked.
The TAP 3
holds the
lower jaw in a
forward position so that it
does not shift
or fall open
during the
night. This
prevents the airway from collapsing. The TAP 3 is the only
mandibular advancement device
that can be adjusted by the patient
or practitioner while in the mouth.
The device provides doctors
numerous options to create the
best, customized treatment solution for their patients.
For more information about
Accutech or the TAP 3 Appliance, please visit
www.accutechortho.com.
Doctors Find A
Way To Make
Early Treatment
Fun For Patients
WildSmiles brackets are creating a
buzz in the world of orthodontics.
Presenting a revolutionary concept to
enhance your practice by offering
patients the opportunity to create
their own orthodontic appliance, the
patented stainless-steel designs,
which are currently available in
flower, heart, star, soccer ball, football
and diamond shapes, were developed
by Dr. Clarke Stevens, a board certified orthodontist in Omaha, NE.
WildSmiles is about helping orthodontists promote their practice in fun
and exciting new ways, while realizing that patient-centered and patientdriven health care is paramount. The
brackets straighten teeth with precision and can be mixed and matched
to give everyone a truly unique smile.
They also can incorporate color elastic ties for added individuality.
WildSmiles appliances were
created from Dr. Stevens desire to
make orthodontics fun - he has
always had a keen interest in serving
patients and creating a positive environment to care for them. I developed WildSmiles brackets because
patients love to make choices.
Patients, parents, grandparents and
friends all enjoy choosing and even
referring, because of WildSmiles,
said Stevens. And price should not be
a concern, as there is virtually no
cost difference to the patient, according to Dr. Stevens. WildSmiles
Brackets are placed cuspid to cuspid
in the maxillary arch only. Their cost
is identical to other esthetic brackets
like porcelain brackets so the patients
need not pay more.
WildSmiles Brackets have been
engineered to provide optimum
aesthetic and functional benefits,
including a patented design, accurate
prescription, straight wire style (their
version of Roth), torque in base, 80
grade mesh bonding base, Axial Placement Technology, compound
contoured surfaces and no sharp
corners that provide easy bonding
clean-up. For more information,
please contact Davin Bickford at 402505-8311 or visit wildsmiles4you.com.
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ORTHOBITES
Interceptive
Orthodontics
E a r l y Tr e a t m e n t i n O r t h o d o n t i c s
By David W. Jackson, DDS, FAGD, IBO
FIG. 1
FIG. 2
Peer pressure and influence has never been so paramount in young

peoples daily lives than it is today. With that said, I would like to show
you a few cases in which I opted to perform interceptive orthodontics
and to explain the reasons why.
s I lecture throughout the United States, I am

constantly asked if Phase I (interceptive
orthodontic treatment) is really necessary or
even indicated at all. Some doctors are very
passionate about the value of early treatment, expanding
the parking lot for the permanent teeth, correcting
transverse and sagittal issues early and holding the space
for the permanent teeth to erupt. Other doctors are just
as opinionated against interceptive orthodontics, stating
that it is just a waste of the parents money and time,
when everything can be accomplished in Phase II or
plain Jane orthodontic care when the child is 11 to 12
years old.
Here are some of my thoughts about this topic. First
and foremost, are you following the golden rule? Do
you feel you are doing the right thing for the patient,
parents and yourself? If the child has a relatively good
smile, borderline Class II which has a 50 percent chance
of becoming a Class I as the lower Es exfoliate, exhibits a
normal overbite/overjet has adequate room for the
12 Winter 2009 JAOS
permanent teeth to erupt, and exhibits little or no maxillary constriction, then interceptive orthodontics would
not be indicated.
My prerequisites in my practices for interceptive
orthodontics are the following:
1. Does the child demonstrate severe sagittal issues
full step class II or III?
2. Does the child have a crossbite?
3. Is there an airway issue?
4. Are there social issues involved are peers making
fun of the childs teeth?
5. Am I doing a service for the child and parents?
It is a fact that grade school age children are
more compliant than middle school children, and
middle school children are more compliant than
high school adolescents. It is also a fact that young
people are more conscious of their appearance and
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ORTHOBITES
FIG. 5
FIG. 3
FIG. 6
FIG. 4
teeth than I was when I was a youth (and yes, I can

recall that far back). In my generation, we wore
blue jeans, white t-shirts, and high top black tennis
shoes in grade school. We began to wear white jeans
and white high top tennis shoes in middle school.
And in high school, white or black worked. Todays
young people face a much more complex school
maze to negotiate. Designer clothes, the right shoes,
the latest of the latest in fashion, and yes, even the
teeth and smile come into everyday interaction at
school. Peer pressure and influence has never been
so paramount in young peoples daily lives. With
that said, I would like to show you a few cases in
which I opted to perform interceptive orthodontics
and to explain why.
Case #1 involves a 7.6 year-old female in which
she and the parents did not like her smile. (Figures
1-6) I had treated her older brother, the family had
been in practice for over 20 years (and still is), the
patient was in cheerleading activities, and her smile
was an integral component of her social activities.
Dentally, she had malposed anterior central incisors,

gapping in the anterior teeth, dental Class II,
normal overbite, slight overjet, slight crowding, her
upper right central incisor overlapping her upper
right lateral incisor, and constriction in the maxilla
and mandible. She exhibited some airway issues:
venous pooling, minor mouth breathing, grade 3
tonsils and allergies. Her cephalometric values were
within normal limits. I opted to treat her inceptively
by placing an upper Nitanium Palatal Expander
(NPE Ortho Organizers) and a lower laboratory
fabricated Williams appliance to gain transverse
width. A referral to an ENT was also advised. Note:
Whether the parents follow through with an ENT
evaluation does not change my approach. I know if
I can widen the palate, I can cause room for the
palatal shelves to fall down and increase the airway
space. I also banded the sixes and anterior teeth and
placed prefabricated utility arch wires (Ortho Organizers) to enhance the smile as that was the parents
major concern to begin with. Treatment time was 15
months. At the end of Phase I, I placed a Fixed
Removable Lingual Arch (Ortho Organizers) and
held the lower arch until I evaluated for Phase II.
After three years, I did treat patient in Phase II
for 18 months. Was Phase I necessary? I could have
surely corrected the issues with only one treatment
phase, bypassing Phase I. However, the patient
would have continued with constriction in the
arches and a smile less than the parents desired.
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ORTHOBITES
FIG. 7
FIG. 10
FIG. 11
FIG. 8
FIG. 12
FIG. 13
FIG. 9
Case #2 is what I hope is a pretty apparent reason

for interceptive orthodontics. (Figures 7 12) I always
14 Winter 2009 JAOS
treat crossbites as soon as possible. This young man

was 9.4-years-old when his parents bought him in for
an orthodontic evaluation. He had an obvious anterior crossbite, maxillary and mandibular crowding,
and minor transverse issues. Dentally, he was a Class I.
This type of anterior crossbite is often created by the
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ORTHOBITES
FIG. 14
FIG. 17
FIG. 18
FIG. 15
FIG. 16
upper anterior teeth erupting on top of the lower

anterior teeth, and the uppers erupting lingually to
the lowers creating a pseudo Class III appearance.
My favorite way to correct this type of malocclusion is
to employ the prefabricated utility arch wires previously
mentioned, advancing the upper utility arch wire by

bending the step down segments of the arch wires from
90 degrees to 45 degrees. This creates additional arch
length and tips the upper anterior teeth forward and over
the lowers. Occasionally, lower composite pads are
required on the lower sixes to open the bite, however,
because we have our mouth open most of the time, often
they are not required. Correcting the underbite usually
takes less than one month to accomplish. As a side
caveat, by increasing the arch length of the arch wire and
tying it into the anterior, a transverse expansion effect is
created. I placed a FRLA for retention. The total treatment
time was 15 months. The patient did not require Phase II.
Case #3 shows a young female, age 8.6, with a full step
Class II dental malocclusion. (Figures 13-18) Again,
cephalometric measurements were within normal limits.
Her dental age was advanced in comparison to her
chronological age. I opted to treat her with utility archwires and a mandibular advancement appliance, the Twin
Force appliance (Ortho Organizers). I kept her in this
appliance for six months, and then continued to keep her
lower jaw forward by employing one medium Class II
elastic per side on the utility archwires for an additional
six months. The elastics were from the lower first molar
hooks to prefabricated posts crimped onto the upper
prefabricated utility archwire. I placed a FRLA for retention. The total treatment time was 12 months. The patient
did not require Phase II. Results were very pleasing.
In summary, one has to ask oneself: Am I helping
the patient with interceptive orthodontics? I always
stress to the parents and the patient that interceptive
orthodontics does not mean that full blown orthodontic care will be avoided. I do tell them that my goal
with interceptive care is to minimize or eliminate
future orthodontics, but I make no guarantees. Am I
always successful with this goal? Of course, I am not.
We, as orthodontic caregivers, should shoot for the
ideal, but accept that reality exists and there are surely
situations beyond our control. Do the right thing with
your patients. What the right thing is depends upon
your orthodontic belief system and clinical experience. I hope this orthobite column provides you
some beneficial insight in your practice and life.
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in
Impacted Incisors
Mixed Dentition:
Surgical & Orthodontic Management
By Dr. Juan Carlos Echeverri, D.D.S.
Using a patient treatment case and images, a clinician presents

guidelines for the diagnosis of impaction of a permanent incisor tooth
with a combination of orthodontics and surgical techniques.
requently pediatric and

general dentists are faced
with a child that has an
incisor that fails to erupt in
the expected manner. The parents
will usually ask when will the tooth
erupt and why is it taking so long.
The doctor will also question why
the eruption of the tooth is delayed
and how they can assist and
manage the situation. This article
will describe the rationale behind
the diagnosis process and how to
manage the situation from a surgical and orthodontic perspective.
Having impacted incisors has
many consequences for the child
patient. Several or all of the below
may affect the patient:
Fig 1, (Initial Exam/

documentation)
Esthetic compromise.
Improper development of
the dentition.
Improper formation of
alveolar bone.
Space loss in the arch formation.

Improper root formation.
Disturbance of the
eruption potential.
Anterior-Posterior discrepancies.
Possible facial asymmetry.
Self-esteem issues.
16 Winter 2009 JAOS
As we evaluate the child who is

between 7 to 12 years of age, it is
important to keep in mind that
the incisor transition should be
complete by 8 years of age. This
allows the establishment of the
mid-mixed dentition of permanent molars and incisors along
with the deciduous segment of
primary teeth (C-D-E) .
What does this mean in our clinical and radiographic exams? If the
patient who is being examined has
almost all of his incisors, except for
one or two, we need to ask

ourselves why? Is the delay normal
due to slow eruption, or is there a
dental, bone or soft tissue interference? Did the tooth or teeth run
out of eruption force? A comprehensive clinical and radiographic
exam will allow the dentist to determine the possible cause. (Fig 1) The
best x-rays for this kind of evaluation in the anterior area is a Periapical x-ray. It will be superior to a
panoramic film in its imaging clarity involving this area.
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If we as the treating or referring

dentist decide to proceed in the
correction of the problem, we must
keep several parameters in mind.
These are as follows:
Remove the mesodens obstruction when no harm will come to

developing permanent teeth
(wait for eruption of first permanent molars)
Fig 3, April 2005 Anterior recall PA X-ray
Prefer to wait until there is 2/3

root development of the adjacent
permanent teeth
Patient age and potential for

Fig 2. (Periapical image of supernumerary teeth)
cooperation also factors in delaying surgical intervention
Some of the causes for these

eruption problems will include
supernumerary teeth, missing teeth,
tooth size/shape anomalies, ankylosis, pathologic lesions, etc. Each and
every one of these will interfere and
be involved in the impaction of
incisors. (Fig 2)
The most common cause for the
impaction of incisors is the presence
of supernumerary teeth. The following reported statistics make them a
factor that we must consider in our
daily diagnosis and treatment planning. Impacted incisors are:
Watchful waiting allows time
Reported in up to 3.6 percent
necessary to make room for

unerupted teeth and to position
them properly.
of children
Occur 10:1 in the maxilla

vs. mandible
Occur 2:1 in boys vs. girls

Usually due to a single Mesiodens 80% of the time and two or
more 20% of the time. Mesodens
usually present with cone-shaped
crowns with a single root
More than 90 percent are

lingually or palatally malpositioned
Approximately 75 percent
remain unerupted and need
surgical removal
Can be responsible for delayed

eruption of permanent teeth,
over-retention of primary teeth,
displaced teeth, diastemas,
abnormal root resorption, follicular or dentigerous cysts, and
resultant malocclusion.
for possible eruption of the

supernumerary, and the avoidance of surgical exposure
When removed, the exposure

of permanent teeth with the
provision of an eruption channel
is recommended
Up to 80 percent of permanent
maxillary teeth will spontaneously erupt after the supernumerary is removed
Orthodontic treatment is often
Taking into account that it is

almost for sure that orthodontic
treatment will be needed with the
patients that have had supernumerary teeth it is important to define
interceptive orthodontics. Interceptive Orthodontics: Recognition of
developing malocclusion factors and
implementation of treatment procedures to eliminate or minimize their
effects on the final occlusion.
To face the problem of retained
teeth, we must: 1) diagnose retention of one or several incisors. 2)
determine the cause of the retention. 3) If it is a supernumerary
tooth or teeth, we must then
proceed to remove the cause, if it is
within the scope of our abilities.
4) re-evaluate the need for
orthodontic treatment.
Fig 4. May 2006, 8 years of age
The orthodontic treatment will

be used to create the space for the
proper eruption of the
tooth/teeth and for the actual
physical guidance of the
tooth/teeth into position.
Case Study
Using all
of the above
information,
lets demonstrate all of
the principles
mentioned
with the
following
case report:
Patient is
a healthy,
female
Fig 5. Periapical X-ray 2007
Hispanic
who is 7 years of age at her first
presentation. Her X-ray of the anterior teeth show a normal presentation of teeth with Stainless Steel
crowns on # E, F and G. (Fig 3)
One year later, the x-ray of her
anterior teeth (PA) shows #8 is in
a delayed eruption pattern,
compared to #9. Teeth #E & F
have been exfoliated. (Fig 4)
In February 2007, the x-ray shows
a deviation of tooth #8 with the root
touching #6 and the crown deviated
from its eruption path. (Fig 5)
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Fig 6. Clinical presentation of # 8 impacted,

patient is 9 years old
At this time, the treating

doctor speaks to the parents
about the need for an orthodontic
consultation and interceptive
treatment. (Fig 6) The patient has
orthodontic records taken in May
2007 and an orthodontic plan is
developed consisting of:
Phase I (orthodontic records)

Correct midline and create
space for tooth #8.
Create the anchorage for the

traction of #8
Localize tooth with x-rays

using the SLOB rule (Same
Lingual Opposite Buccal)
Surgical intervention to locate

the tooth and place an attachment on the coronal portion of
the impacted tooth.
Bring the impacted tooth into
correct the maxillary dental

midline. (Fig 7)
In February 2008, the patient
was intebateded using oral sedation, to expose #8 and place an
attachment on the tooth. An envelope flap was created using the T2
electrode tip with the Sensimatic
Electrosurge 600SE (Parkell, Inc.)
The flap was reflected with a
periostal elevator and the soft tissue
covering the tooth was removed
with a soft tissue curette. The tooth
was located with its incisal edge
pointing toward the opposite direction and the lingual surface was
toward the buccal.
The tooth has an almost 180
degree rotation from its normal
position. Hemostasis is achieved
using Astringent X ( Ultradent)
and pressure on any bleeding
areas. The tooth surface was
cleaned with alcohol impregnated
pellets and air dried. The surface
was etched with 37% ortho phosphoric acid and Single bond
adhesive (3M) was placed on the
etched surface. The pad was
loaded with orthodontic bracket
cement (Unitek) and the pad with
a gold chain attached (OrthoTraction Pads) was attached on
the tooth on its lingual surface as
close as possible to the incisal
edge. (Fig 8)
the arch and occlusion

I retention
Fig 7. Sept
2007 Coil
spring on
0.20SS
Archwire
18 Winter 2009 JAOS
The flap is sutured using Cat Gut

sutures and the patient is placed on
analgesics, antibiotics and clorhexidine mouth wash to prevent pain
and infections. (Fig 9) The patient is
then seen one week later as a surgical
follow-up visit, and then every two
weeks to reactivate the elastic ligature.
The position of the tooth is
monitored by the length of the
chain links remaining. These links
are counted at the initial placement, and are monitored with periapical x-rays as needed. (Fig 10)
Fig 10. Monitoring movement counting links
Place the patient in phase

Bands are placed on maxillary
molars and brackets on all available teeth including primary
teeth, as described by Dr. Robert
Geretty. Arch wire sequence as
described by Dr. David Jackson
was used (.14 NiTi, .18 NiTi, .20
SS) and coil spring force was used
with the .20 Stainless Steel arch
to open the space for # 8 and
Fig 9. Flap closed and sutured
Fig 8. Attached Pad and chain to tooth
The chain portion is pulled

toward the arch wire and cut
short by approximately 2 mm.
The chain is then tied to the arch
wire using .030 elastic thread by
Ortho Organizers Inc., creating
tension on the chain. At this
moment a third incision is made
to allow the flap to be placed
back on the bone for first intension healing.
The tooth was guided into

position until the pad link was
reached. (Fig 11) Due to the
lingual placement of the pad, a
new connection on the tooth
had to be achieved. This new
attachment would allow the
tooth to be guided into the
correct angulation.
Fig 11. Pad level reached
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Fig 12. Chain of 5 directing tooth into position
A soft tissue diode laser (Zap

Laser) was used to remove the soft
tissue covering the buccal surface.
Total hemostasis is achieved by
combining the laser and the
astringent agent. A bracket is
Fig 13. .014 NiTi Archwire
placed on the buccal aspect. The

arch wire with a coil spring maintaining the space between teeth
#7 and #9 is maintained and a
power chain with an uneven
number is used to continue guiding the tooth into position, as per
the technique taught by Dr.
Gerety. (Fig 12)
One month later, the lingual
pad is removed and the power
chain traction is replaced by a
.014 NiTi arch wire to continue
with a constant activation as the
distance is now much reduced.
(Fig 13)
Fig 14. September 08, Panoramic for

radiographic control
This arch wire is used until

tooth #8 has reached the same
level of teeth #7, #9,and #10.
This arch wire is then replaced in
the arch wire sequence with a
.018 NiTi followed by a 16 x 22
NiTi. These last arch wires are
used to correct the position and
the torque of the tooth before the
patient is placed in final retention. A panoramic film (Fig 14)
was taken in the last sequence of
the orthodontic therapy to check
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Fig 15. Pa x-ray showing dilaceration of root
all teeth and structures involved. Normal structures

are observed. An individual periapical film is taken
of #8. (Fig 15)
Root dilaceration is evident and probably caused
by the original mal position of the tooth.
The combined orthodontic therapy allowed for
the correction of the occlusal plane, the anterior
incisor alignment, the anterior open bite, the underdeveloped alveolar bone and the esthetic challenge
for the patient. (Fig 16,17) Once the patient, parents
and doctor are satisfied with the position of the
teeth, including the impacted tooth, the patient will
be placed in a retainer for six months. This is
adequate time to retain the position of the teeth,
and avoid interference with growth, as this treatment was performed in early mixed dentition as a
phase I treatment.
Fig 17. Extra oral view
In conclusion, this article presented guidelines

for the diagnosis of impaction of a permanent
incisor tooth. It elaborated on the role of supernumerary teeth in the impaction of permanent
incisors. It showed using a patient treatment case
and images, how the tooth is diagnosed, located and
treated with a combination of orthodontics and
surgical techniques to bring the impacted tooth into
the oral cavity.
References:
Straight Wire Concepts: Diagnosis and Technique, by
Robert G. Gerety, 8th Edition,
September 2004
The Next Steps, a Three Session Continuum in Orthodontics, by Dr. David W. Jackson, 2006
Comprehensive Advances Series: Concepts and Techniques
for the Orthodontic Practitioner, by Dr. Larry White & Dr.
William E. Wyatt, Sr. 2008
Orthodontic and Orthopedic Treatment in the Mixed
Dentition, by James A. McNamara, Jr., William L Brudon,
Needham Press, Inc 1993
The Handbook of Pediatric Dentistry, Third Edition, The
American Academy of Pediatric Dentistry edited by Arthur
J Nowak & Paul S Casamassimo, Chapters 10 and 11.
Fig 16. intraoral view 17 months of treatment
20 Winter 2009 JAOS
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Class
II
Malocclusion
The Changing
Face of Growth
Modification
An ExperienceBased, Evidence Approach
to Treatment Timing: Mother Helps
Daughter to Achieve A Healthy Smile
S.K. /M.K.
By Dr. Leonard Carapezza
vidence-based clinical dentistry has become the

new paradigm. Randomized clinical trials
(RCT) are considered to be the gold standard to
acquire evidence. The first dental randomized
clinical trials funded by The National Institute of
Dental and Craniofacial Research dealt with early
Class II treatment. The results of these studies claim
effectiveness of the early treatment Class II. The
lingering question posed by these studies was the efficiency of treatment in a conventional specialized
orthodontic practice.
The case report presented in this article is the result
of the continuum of treatment of an early Class II Division I case published in the Spring 2006 (Volume 6 Issue
2) of the Journal of the American Orthodontic Society.
Strategy & Protocol

Do the benefits of early treatment as shown by this
specific treatment strategy and protocol justify the
intervention in the early mixed dentition stage of
development when compared with treatment in the
late mixed or early permanent dentition? The completion of this case report attempts to put into focus the
risk/benefit ratio of early versus late treatment.
Characteristics
An efficacious solution was found to this malocclusion which displayed common Class II characteristics:
Maxilla narrow tapered constricted arch form

One-half to full Class II molar relationship
Mesial lingual rotation of the maxillary molars
Improper over-bite relationship
Improper over-jet relationship
Incompetent lip seal
Retruded position of the mandible
22 Winter 2009 JAOS
Fig. 1a: S.K. 8y 1m

11-11-2004 pre tx.
orthodontic records
facials and intra-orals
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Fig. 1b: S.K.

8y 1m
11-11-04
pretreatment
study
models
Fig. 2: S.K. 9y 11m 9-01-06 Start of finishing phase
Fig 4a: S.K. 11y 6m

4-24-08 post tx facial
and intra-orals
Fig. 4b: S.K. 11y 6m 4-24-08 post tx panelipse film
Review 1st Phase Treatment (Fig.1a,b)

Orthodotic records were taken 11-11-2004 on a
healthy 8.11-year-old Caucasian female, named SK.
Treatment commenced on12-22-2004 with the use of a
Nitanium Palatal Expander (NPE). The NPE accomplished arch development and distal rotation of the
maxillary first permanent molars.
Treatment proceeded two months later with basic
Utility Arch Wire Mechanics. These mechanics established the early treatment objectives of proper overbite, over-jet, molar relationship, lip seal and skeletal
relationship. Serial guidance was started on 7-5-05 with
the utility arch wires remaining as space maintainers.
Fig. 4c: S.K. 11y 6m 4-24-08 post

tx cephalometric film
Finishing Phase
The finishing phase with the continued use of a
fully programmed pre-adjusted straight arch appliance
began on 9-1-06. (Fig .2) The treatment continued with
leveling, aligning and rotation with proper attainment
of molar, cuspid and midline. Inclusion of bracketing
of the permanent second molars was accomplished
during that time period. Final tip, torque and bite
opening were completed on 4/15/08. (Fig.3 ) The case
was debracketed and retention records were then taken
on 4/24/08. (Fig.4 a,b,c,d,e)
Fig. 3: S.K. 11y 6m 4-15-08 F.T.T.B.O.
Fig. 4d: S.K. 11y 6m

4-24-08 post tx
cephalometric tracing
Fig. 4e: S.K. 11y 6m 4-24-08 post tx study models
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Fig. 7a: M.K. 40y 5m 2-23-06 facials and intra-orals
Fig. 5: Levels of evidence
Retention Phase
A maxillary Hawley retainer was placed for the upper
arch to be worn full time six months and then six
months during bed time. A 4x4 lower fixed retainer is
to remain until the summer of the junior or senior year
of high school when an evaluation of third molar
removal would be recommended. This customary retention strategy and protocol has resulted in a close to
zero base problem of lower anterior relapse.
Discussion
There are educators who use the results of the Class
II Randomized Clinical Trials to fortify their beliefs that
there are no benefits to Early Class II Treatment.
The everyday practitioner starts off at a disadvantage
because it is impractical, if not impossible, to conduct
randomized clinical trials in a private practice setting.
These trials with large monetary grants are relegated to
the University under the auspices of a much protected
guild with the temptation of strong bias and early treatment protocols of their choosing. McNarmara stated
when the focus is on early Class II treatment, it is false
to say that all treatment protocols are the same.
The private practitioner has to rely on the integration of the best research evidence available combined
with clinical expertise and patient values. At the
present time, there is a minimum of so called Best
Evidence in the orthodontic literature.
At the base of the hierarchy of evidence is the case
report, but this is the foundation upon which the levels
of the best evidence grows. (Fig.5 ) So, the best the
hands-on practitioner can do at this time is to rely on
the best available evidence to be
found in ones practice.
Fig. 7b: M.K.40y 5m

2-23-06
McNarmara analysis
20 to 30 years ago. The mother (M.K.) of the Early Class

II Treatment Case being presented in this article is one
of those parents. (Fig. 6,7a,b)
Conclusion
In this important paradigm shift, the clinical
judgment of a skilled practitioner and the
patients/parents individual preferences and values
should be given equal weight with the best evaluative scientific evidence in the decision making
process of whether to treat early or late. (Fig.9 )
There are three generally-accepted delivery
systems in orthodontic care: growth modification by
necessity needs early treatment, late Class II treatment which presently is the gold standard of the
orthodontic specialty and spoken of as camouflage
treatment (accepting the skeletal pattern and
making the teeth fit) and orthognathic surgery
when the above can not be accomplished.
Experience-based Evidence
An on-going clinical research
project for the author has been
taking orthodontic records of the
parents of his pediatric orthodontic
patients. Most, if not all, of
these parents had convenFig. 6: M.K. 14y 8m 9th grade:
tional orthodontic treatment
headgear, 4 bicuspid ext.
24 Winter 2009 JAOS
Fig. 9: Evidence based

decision
making process
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A Mothers Point of View Regarding Early Treatment

I am the mother of SK and here is my orthodontic story: I started wearing headgear sometime around age 11 then finishing up with braces at about age 16.
I remember that I had 10 baby teeth and four adult teeth pulled in preparation for,
and during the course of, my braces.When I remember my junior high school and
high school years, I remember that I had braces. I remember that my food at lunch got
stuck in them and that I had to make sure everything was all clear before smiling. I
remember having a night brace and having to sleep with it all the time. I remember it
always popping off at night and worrying that I would have it forever if I could not get
it to stay on when it was supposed to. I also remember worrying that if I had to have it
forever, I would have to take it on sleepovers with me. While I write this, I am certainly
laughing at myself now, but it is funny how the mind of a kid works.
It has come to my attention over the years that many of the constant and daily
headaches that I have had for years could be attributed to the positioning of my jaw
Fig. 8: S.K. 11-year-old (May 08)
because four of my adult bicuspids were removed, possibly unnecessarily due to late
post treatment smile
treatment. Fortunately, the headaches are mostly controlled with daily medicine. I have
been told that I could have surgery to have my jaw realigned, which I will opt not to
do. I remember the exact day that SKs orthodontist looked at my jaw and asked me,
without any prior knowledge, how long I had had daily headaches. When I told him the headaches were for as
long as I could remember, he told me that SK had my original jaw structure but because of early treatment, her jaw
would grow properly and remain properly aligned, resulting in no headaches. Possibly eliminating headaches from
my daughters future is an enormous gift, and we will always be thankful for it.
However, this gift did not come without research. When our dentist advised us in 2004 that SK, age 8,
needed braces we went to two orthodontists, both of whom advised us to wait until SKs permanent bicuspids
came in, which would be at approximately age 11 or 12. After further discussions with our dentist, we were sent
to our current orthodontist for braces. SK is now 11 and her braces are coming off. Her teeth are beautiful and
her smile is infectious. She always lights up a room when she enters it, but now there is even more of a shine
because her teeth are not something you normally see on an 11-year-old. All her friends are starting to get
braces and even though they are all 11 or 12 years old, they are getting teeth pulled to correct the crowding.
SK is done at the time we were told to start her braces. I share our story with as many people as I can
because it is such a positive one. I want as many people to get to take advantage of her experience as possible.
It just does not appear that there is a downside at all. There is a small part of me that would like to bring SK to
the original orthodontists and have SK smile and ask them if they still think we should wait.
Proffit has stated that clinical decisions such as the

optimal time to start treatment are inevitably difficult
because of the variability between patients and the
uncertainty about growth and treatment response.
The proposal from the author is to put fully documented early treatment versus late treatment on the
same playing field and allow the orthodontic practitioner and consumer to judge the risk/benefit ratio
of both of these approaches. The best clinical protocols should be based on the study of short term-long
term treatment outcomes.
References:
Tulloch JF, Phillips C., Proffit WR. Benefit of early Class II treatment:
Progress report of a two-phase randomized clinical trial. Am J
Orthod Dentofacial Orthop 1998; 113: 62-72.
Ghafari J, Shofer FS, Jacobsson-Hunt U, Markowitz DL, Laster LL.
Headgear versus functional regulator in the early treatment Class
II, Division I malocclusion: A randomized clinical trial. AMJ
Orthod Dentofacial Orthop 1998: 113: 51-61.
Keeling SD, Wheeler TT, King GJ. et al. Anteroposterior skeletal and
dental changes after early Class II treatment with bionators and
headgear. Am J Orthod Dentofacial Orthop 1998: 113L 40-50.
University of North Carolina. RCT Class II, NIDCR RO1 type

grant. DE-08708 (UNC owns Data not Federal Gov). Written
request from Tufts Department of Pediatric Dentistry for
specific data denied. September 22, 2005.
McNamara JA. The Dr. Herbert J. Margolis Memorial Lectureship.
Tufts Dent. Cont. Ed. April 12, 2008
Forrest, JL and Miller, S. A.: Evidence-Based Decision Making: A
Translational Guide for Dental Professionals. Lippincott,
Williams and Wilkins, Philadelphia, 2008.
Proffit WR. Tulloch JF. Preadolescent Class II problems: Treat now or

wait? AM J Orthod Dentofacial Orthop 2002: 121: 560-562.
Papadopoulos. MA and G Kiaouris, I.: A Critical evaluation of

meta-analysis in orthodontics, Am. J. Orthod. 131: 589-599,
2007.
Andrews LF. The Straight-wire appliance. J Clin Orthod 10: Feb

Aug 1976.
Carapezza L.J. Objectifying treatment of Malocclusion.

J Pedod 1990; 15: 5-12.
Gianelly, AA., One-phase versus Two-phase Treatment. Am J Orthod

Dentofacial Orthop 1995: 108: 556-9.
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THE
BENEFITS
OF
Open Bite Dental

By Jeffrey H. Ahlin, DDS
The long-term stability of the orthopedic and orthodontic

results in this case demonstrate that early treatment has
a place in a clinicians treatment decisions. With
judicious use, early therapy should not prolong
treatment or be uncomfortable or costly for the patient.
Fig.1: Katie with open bite

at age 7
26 Winter 2009 JAOS
he benefits of early treatment of all types

of malocclusion have been long debated.
Both sides of the argument make salient
points. The detractors of early treatment
argue that waiting until all the permanent teeth
have erupted is less traumatic and less expensive for
the patient than starting in the early mixed dentition. In addition, proponents of one phase treatment emphasize that patient management is easier
for the clinician.
Early treatment proponents claim that correcting a
specific problem early leads to a less complicated Phase
II treatment. Specific claims are made that open bites,
deep bites, cross bites and Class II and III relationships
are more easily treated in the mixed dentition. If a
patient with a deep overbite Class II malocclusion also
suffers from temporalis muscle headaches, then some
authors strongly recommend early treatment to alleviate the patients pain and suffering.1, 2
Perhaps more importantly, investigators have linked
deep bite Class II malocclusion with problems of snoring, sleep apnea, hypertension, and other serious medical conditions.3 The early treatment advocates also
claim that there is a psychosocial benefit to correcting
obvious facial disharmony and oral-facial habits before
schoolmates have a chance to be critical or tease the
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EARLY
TREATMENT
& Facial Deformity
Fig.2: Katies anterior occlusion

at age 7
patient.4 The obvious financial benefit to the patient or

parents is that a more serious surgical procedure could
well be avoided.
The patient presented here, Katie N. (Fig. 1), came
to our office at age 7 with a history of pacifier use for
over three years. There was a very evident deformation of the premaxilla. The patient had no other
medical considerations and was taking no medications. In addition to her malocclusion, the patients
dental history included small occlusal incipient
lesions on her first molars.
Katies anterior open bite was 9mm. with bilateral
posterior cross bite. Her mother stated that Katie used
to love her pacifier and was having some difficulty
eating her food. Some of the patients school friends
were beginning to make derisive comments. Katies
mother was informed of a corrective course of action
and treatment plan.
Mrs. N. was initially reticent about committing to a
two-phase treatment plan. However, after a definitive
two-phase plan of treatment was explained to the
patients mother, including the time period and the
stability of the results, she agreed to go ahead with
Katies treatment. Mrs. N. was assured that with good
patient cooperation, Katie would have a beautiful result
with a full smile. The mother was also informed that
Fig.3: First appliance
her daughter would most

likely need a second
phase of therapy with
full orthodontic brackets
when all of her permanent teeth had erupted.
The Phase I treatment
plan for Katie included
maxillary expansion with
two removable appliances,
(fig. 3) over 10 months
and eight maxillary brackFig.4: Katie at age 10
ets for four months in
order to reduce the open bite
malocclusion and correct the cross bite. This phase of
treatment lasted for 20 months. The second maxillary
expansion appliance had posterior occlusal
coverage. A
Hawley retention
appliance was
placed and the
patient was rephotographed at
Fig.5: Age 10 occlusion
age 10. (Fig. 4 & 5)
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Fig.6: Occlusion at age 20
Fig.7: Katie at age 20 (full face)
28 Winter 2009 JAOS
After the completion of the first phase

of treatment, Katie had a much more
acceptable appearance. Her cross bite and
open bite had been corrected and she was
more comfortable about her facial appearance in school and with her ability to
incise food with her anterior teeth.
However, Katie still had a Class II molar
and canine relationship with a 3.5mm.
overjet. After Phase I correction, a Hawley
appliance was placed. Katie wore the
Hawley retainer during the 15-month resting phase.
Maxillary and mandibular brackets were
placed at age 12, after all the permanent
teeth (except third molars) had erupted. An
arch wire sequence beginning with an .014
NiTi wire with nickel titanium distalizing
springs to the maxillary second molars was
placed in order to lock in a Class I molar
relationship. After the mandibular arch had
an .018X.025 arch placed, interarch Class II
light 1/4 elastics were worn with a
.016X.016 maxillary arch until a Class I
canine relationship was achieved. The
distalizing springs on the maxillary arch
were advanced one tooth per visit until the
space was distal to the canines. Power
chain elastics were used to close in the
canines to a Class I canine relationship.
(Figures 6 & 7).
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Fig.8: Panorex taken at age 7
Fig.9: Panorex taken at age 20
A Class I molar and canine relationship was

achieved in 12 months. Figure 6 shows the anterior
occlusion at age 20, seven years post-treatment from
phase II. The panoramic films, taken at ages 7 and 16
(Figures 8 & 9), show the dental development with
excellent root parallelism and no developing third
molars. The patients mother declined cephalometric
pre- and post-treatment films in order to minimize
radiographic exposure to the patient. Dental retention
included a lower lingual bonded twisted wire and
removable maxillary Hawley retainer. The patient still
wears the maxillary retainer occasionally while sleeping. (Figure 7 is a final full face of Katie at age 20).
The long-term stability of the orthopedic and
orthodontic results (figure 7) demonstrates that early
treatment has a place in our treatment decisions. With
judicious use, early therapy should not prolong treatment, be uncomfortable or costly for the patient. The
use of early treatment regimes could also avert the need
for some surgical procedures for our patients.
References:
1. Ahlin, J. H., Atkins, G., A screening procedure for differentiating temporomandibular joint related headache. J. Headache 1984; 24: 216-221.
2. Ahlin, J. H., The theoretical and practical application of a remoldable craniomandibular appliance. Int. J. Orthod. 1984: 22: 21-23.
3. Roux, F., DAmbrosio, C., Mohsenin, V., Sleep related breathing
disorders and cardiovascular disease. Am J Med 2000; 108: 396-402.
4. Shoroog, A., Locker, D., Streiner, D.L., & Thompson, B., Impact of selfesteem on the oral-health-related quality of life of children with
malocclusion. J Orthod. & Dentofacial Orthoped. 2008. 134: 484-489.
30 Winter 2009 JAOS
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Early Transitional
Dentition Treatment
By Dr. Chris Baker, RN, DMD
It has been estimated that 50,000 patients are born in the U.S. every
year who will develop at least one impacted canine that will require
orthodontic attention by age 10.
oth in skeletal and dental growth and development, and in development of occlusion,
there are times when the extraction of
primary teeth may be an important treatment
consideration. The dramatic possibilities of well-timed
extractions can change your patients lives by:
decreasing risk of and preventing ectopic teeth,
preventing rotated/crowded incisor positions,
improving the natural eruption of permanent
teeth and decreasing the risk of impaction of
permanent teeth,
reducing orthodontic treatment time and sequelae,
improving gingival health and overall dental health.
32 Winter 2009 JAOS
Incisor Crowding & Alignment Instability

Incisor crowding/rotations are a common occurrence
with various negative sequelae and may be preventable
in patients through primary canine extractions. Ectopic
canines or impactions can be a devastating occurrence
in relationship to a normalized occlusion in our
patients, and
although often
treatable, they
can result in
negative sequelae, including
greatly extended
treatment times.
The challenges involved
with crowded
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incisors - instability of anterior tooth alignment and a

high post-orthodontic treatment relapse rate in
mandibular incisors - involve first the shrinking arch
length in our culture. Todays children exhibit frequent
incisor crowding and less arch length than their grandparents did 50 years ago.
Today, the incisors in the transitional dentition
have a high rate of relapse, rotations and crowding;
even bicuspids and canines often exhibit rotations.
[Little] Esthetic concerns are more prevalent, and functional contacts are diminished, resulting in an impact
on occlusal harmony and TMJ health with the growth
of the aging skeleton
The etiologies of mandibular incisor crowding
relapse include:
leaving teeth rotated and allowing interseptal fibers
to develop memory for crowded positions
late forward mandibular growth and aging growth
changes, causing crown uprighting (lingualization)
and tipping of the mandibular incisors
Not holding ideal tooth positions with a lingual
arch until all permanent bicuspids and canines have
erupted.
Not wearing retainers long enough.
How do I reduce the risk of crowding?

You can reduce the risk of rotated and crowded incisors
through the following possible treatment options:
Extract primary teeth if needed. If you make space

for permanent incisors to erupt and become
straight naturally, almost always the natural eruption will be into an aligned position. This requires
extraction of primary teeth as needed before the
eruption of permanent teeth is complete. Once the
DEJ of the erupting tooth passes the alveolar level,
the intra-septal and trans-septal fibers are established and tend to cause relapse of the incisor to
the eruptive position. If the eruptive position was
one of rotation, the incisor will most likely relapse
to that position even after orthodontic correction.
Derotation of teeth just after emergence in the
mouth implies correction before the transseptal
fiber arrangement has been established. In referring to the Dugoni study, Zacchrison says, These
positive results may be related to the stage of
development of the transseptal fibers. Kusters and
colleagues showed the transseptal fibers do not
develop until the CEJ of erupting teeth pass the
bony border of the alveolar process. Foster and
Wiley found that extraction of primary canines
had no detrimental effect on the eventual width of
the permanent canines. Numerous studies have
documented that mandibular incisors tip lingually
as a result of serial extraction, but orthodontic
correction of lingual tip is stable while incisor
derotation is not.
Note mandibular permanent lateral incisors and canines will not fit in the
space of the primary laterals and canines. Extraction of the primary teeth
allows the laterals to erupt and become well-aligned/straight.
Straighten permanent teeth if needed, as

soon as they have erupted and it is feasible. The
sooner the tooth is aligned (straight), the more
likely the developing fibers will help hold the tooth
in the aligned position.
How do you straighten the teeth? First, extract
primary teeth as needed, allow natural eruptive positioning and then evaluate the need for further
orthodontic movements. Then, use a lingual holding
arch if orthodontic treatment is not begun as soon as
all incisors have erupted. Keep the arch in place until
orthodontic treatment is begun.
It is a good option is to provide Phase I treatment as
soon as incisors are erupted: band the six-year molars,
bracket the incisors, apply sectional and/or looped wire
(.014SS or TMA .0175 x .0175) from lateral incisor to
lateral incisor, using utility arch wire (UAW) to correct
arch length and position incisors and molars.
Expand/tip as needed
to an idealized incisor
positions and overbite
and overjet. Create
canine space, correct
molars to Class I and
use elastics as needed
(Class II from kobiashi
hooks on the maxillary
permanent lateral
incisors to mandibular
six-year molars and
Class III from kobiashi
hooks on the mandibular lateral incisors to
maxillary six-year
molars.) After Phase I
treatment is completed
use a lower lingual
holding arch as a
retainer with distal
extensions to hold
incisor positions, and
use an upper Doyle
Hawley design removable retainer. Both of
these retainers should
be worn until all eruption is complete. At that time,
remaining treatment needs (Phase II) can be evaluated.
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Expand and correct arch length as early as feasible.

Utilize holding arches in the transitional dentition
to maintain arch length until all permanent bicuspids and canines have erupted.
Maintain the patients original arch form (evidenced

on mandibular arch). When the dental arch form is
changed with orthodontic tx, there is a post-retention change to its pretreatment shape. In nearly
every case, arch length intercanine width and intermolar width changes prove unstable and return to
pre-tx dimensions. [Shapiro]
Compliance with retainer wear, of course.

Plan extraction of third molars if they are
impacted, in poor position or if space is insufficient
for their eruption.
Extractions as part of treatment for
insufficient arch length : It is important to do a
clinical evaluation and diagnosis to evaluate the timing
recommended for extraction of primary canines to
prevent crowding and rotations of incisors.
Evaluate the space and position of permanent
incisors at the time the primary central incisors are
beginning to exfoliate.
Consider extractions if: 1) the primary incisors
have exfoliated, space appears inadequate and the
permanent incisors are not erupting or are erupting ectopically; 2) the primary incisors have not
exfoliated, space appears inadequate and the
permanent incisors are not erupting; 3) the permanent incisors are erupting lingually to the primary
incisors; 4) the permanent central incisors are
erupted and space appears inadequate for the
permanent lateral incisors.
Timing of extractions should be as soon as the space
shortage and/or malposed incisors have been identified. Remember that most lower incisor teeth will
correct their rotated positions naturally if the space
is adequate and if the eruption is early enough that
the CEJ of the erupting tooth has not passed the
height of the alveolar bone.
Treatment Planning: The parent may be presented
with three options for the child patient:
Do nothing now. Allow natural eruption, allowing rotations/crowding to remain and consider
orthodontic correction later. This option increases
the likelihood of crowded/rotated incisors and
orthodontic relapse in the childs lifetime.
Extract whichever teeth are in the way of the

central incisors (usually the primary laterals
and maybe the primary centrals) and plan to
34 Winter 2009 JAOS
extract primary canines when the permanent

central incisors are ready to erupt. This means
two episodes of local anesthesia, but the edentulous spaces are not as large until permanent
laterals erupt.
Extract (canine to canine) any primary teeth

that are in the space the permanent centrals
and laterals will need. This requires only one
episode of local anesthesia, but does create
larger spaces in esthetic planning until the
permanent laterals erupt.
Children seem to have almost no post-operative
concerns or complaints after the extraction of primary
incisors and canines. And they and their parents are
pleased to see the beautiful smile with beautiful
straight teeth.
Ectopic Unerupted Teeth

We can find references going back to Edward Angle
in his publication in 1907 involving treatment of
ectopic unerupted teeth. Today, Andreasen points out
that eruption fails 1 out of 5 times (20%). This means
that out of 52 eruptions in each patient (20 primary
and 32 permanent teeth), statistically 10+ teeth will
be ectopic.
Ectopic teeth may increase the risk of:
Functional disturbances such as
impactions,
resorption of
adjacent roots
and poor occlusion.
Inadequate
attached
gingivae.
Decreased esthetics such as gingival margin
discrepancies.
Future problems
including insufficient attached
gingivae.
And impacted
teeth and related
sequelae.
The need for
complex and
lengthy
orthodontic
mechanics
with increased
treatment
time of at
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least 1-2 years,

surgically
placed attachments, box
loops and
ballista
springs, molar
distalizing
appliances and
TADs (temporary anchorage
Leite points out that of the population that has
eruption abnormalities of maxillary permanent canines,
85% are palatal, and have adequate arch length while
12.5% resorb incisor roots as they erupt.
12.5% resorb incisors
The literature tells us that resorbed lateral

incisors adjacent to impacted canines typically
have normal crown size. In the majority of cases,
87% of aggressive lateral incisor root resorption,
there is normal mesiodistal crown size of the
lateral incisors. Peg-shaped, small or missing lateral
incisors have been shown to be a predisposing
factor in shorter root length and can result in
palatal canine impactions. It is speculated that the
normal-sized and early developing lateral incisor
roots obstruct the deviated eruption path of
canines and consequently stand a greater chance of
being damaged by resorption.
About Extraction of Primary Canines

Ericson and Kurol found that in cases of extractions of primary canines that 78% of ectopic eruption changed to normal. Two-thirds of those changed
to normal within six months. The remainder
changed to normal within 12 months. After 12
months, there was no further improvement in
permanent canine positions.
The possibilities you offer your patients when you
extract primary canines include:
decreased ectopic eruption
decreased impaction of permanent teeth
reduced risk of impaction sequelae such as intrusion
of adjacent teeth and root resorption/pulpal problems of adjacent teeth
reduced orthodontic treatment time and sequelae
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Fig. 1
Extraction as
Part of Treatment of Ectopic
Unerupted Teeth:
It is important to
do a clinical evaluation and diagnosis to
evaluate the timing
recommended for
extraction of primary
canines to prevent
impaction, failure of
eruption and
other sequelae.
First, evaluate
and diagnose the
Fig. 2
unerupted ectopic
permanent
tooth/teeth. On the radiograph, evaluate the
extended long axis of the permanent canine. At the
time of eruption of lateral incisors, take a panoramic
radiograph. Draw a long axis of the unerupted
canine (figure 1) and extend past the occlusal plane.
If the extended long axis passes more than one adjacent crown width, (figure 2) consider bilateral
extraction of primary teeth. Bilateral extractions
helps maintain midline positions.
At the American Association of Orthodontists (AAO) Early treatment conference, Feb.

2002, researchers reported that.:
An ongoing study shows that the early extraction
of primary canines will prevent the need for surgical
exposure in as many as 80% of these patients if they
are diagnosed [and treated} early enough.
Lesson learned: Diagnose and consider the need for
early treatment due to the severity of complications
that can be caused by unerupted and impacted teeth.
It has been estimated that 50,000 patients are born
in the U.S. every year who will develop at least one
impacted canine that will require orthodontic attention
by age 10. Most are palatal, but this does not even
include a high percentage of canines that do erupt, but
into ectopic/poor positions.
By extracting primary teeth appropriately and judiciously, you can transform lives!
References:
Behrents, Rolf G. Growth in the aging craniofacial skeleton. Monograph
17,Craniofacial Growth Series. Center for human growth and development.U
of Michigan . Ann Arbor . 1985.
Brin I, Becker A, Zilberman Y. Resorbed lateral incisors adjacent to impacted
canines have normal crown size. Am J Orthod Dentofacial Orthop. 1993 Jul;
104(1): 60-6.
Dugoni SA et al. Early mixed dentition treatment: post-retention evaluation of
stability and relapse. Angle Orthodontist 65(5) 1995. 311-320.
Ericson S, Kurol J. Radiographic assessment of maxillary canine eruption in
children with clinical signs of eruption disturbances. Eur J Orthod. 1986
Aug;8(3):133-40.
Ericson S, Kurol J. Early treatment of palatally erupting maxillary canines by
extraction of the primary canines. Eur J Orthod. 1988 Nov;10(4):283-95.
Ericson S, Kurol J. Resorption of maxillary lateral incisors caused by ectopic
eruption of the canines. A clinical and radiographic analysis of predisposing
factors. Am J Orthod Dentofacial Orthop. 1988 Dec;94(6):503-13.
Foster H and Wiley W. Arch length deficiency in the mixed dentition. AJO
1958. 68:61-8.
Before extractions of MX primary canines
Ericson S, Bjerklin K, Falahat B. Does the canine dental follicle cause resorption of permanent incisor roots? A computed tomographic study of erupting
maxillary canines. Angle Orthod. 2002 Apr;72(2):95-104.
Ericson S, Kurol J. Incisor root resorptions due to ectopic maxillary canines
imaged by computerized tomography: a comparative study in extracted teeth.
Angle Orthod. 2000 Aug;70(4):276-83.
Kusters ST , Kuijpers-Jagman AM, Maltha JC. An experimental study in dogs
of transseptal fiber arrangement between teeth which have emerged in
reotated and non-rotated positions. J Dent Res. 1991.70: 192-197.
Leite L. Eruption abnormalities of maxillary permanent canines. JSSPD 6?3) 2000.
Leivesley WD. Minimizing the problem of impacted and ectopic canines.
ASDC J Dent Child. 1984 Sept-Oct;51(5):367-70.
After extractions of MX primary canines
Secondly, recommend extraction if the extended long

axis passes more than one adjacent crown width. (figure 2)
The extended long axis passes not only the lateral incisor
at one crown width, but also into the central incisor
crown. Extended long axis evaluation may give us the ability to predict the majority of unfavorable eruptive paths of
permanent canines earlier than previous analyses. This
analysis is done in the early rather than the late transitional dentition and includes mid-alveolar paths that may
predispose laterals to root resorption. Treatment planning
note: Always extract bilaterally to prevent midline shift!
36 Winter 2009 JAOS
Little, RM. Stability and relapse of mandibular anterior alignment: University

of Wash Studies . Seminars in Orthodontics. 5(3) September, 1999. 191-204.
Little, RM. Stability and relapse: Early treatment of arch length deficiency.
AJODO 121(6) 578-581. June 2002.
Shapiro P. Long term observation of orthodontically treated patients.
Mandibular dental arch form and dimension treatment and post-treatment
changes. AJODO 1974: 66:411-430.
Turpin DL. Early treatment conference alters clinical focus. Am J Orthod
Dentofacial Orthop. 2002
Turpin DL. Where has all the arch length gone? Editorial, AJODO March, 2001. 201.
Warren JJ, Bishara SE. Comparison of dental arch measurements in the
primary dentition between contemporary and historic samples. Am J Orthod
Dentofacial Orthop. 2001 Mar;119(3):211
Zachrisson BU. Important aspects of long-term stability. 1997 JCO
Sept;31(9): 562-583.
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AOS MEMBERSHIP NEWS
JAOS Editor Earns Top Honor
The American
Orthodontic Society
2008-09 Officers
& Directors
President
Arturo R. Gutierrez, DDS
President-Elect
& JAOS Co-Editor
Jordan J. Balvich, DMD
Vice President
Chris Baker, RN, DMD
Secretary-Treasurer
John N. Hanchon, DDS
Immediate Past President
Jon P. Romer, DDS
Board of Directors
Azita Anissi, DDS
Debra Ettle-Resnick, DDS
Robert G. Gerety, DDS
Mitchell S. Parker, DDS
Juan J. Solano, DDS
David M. Thorfinnson, DDS
William E. Wyatt, Sr., DDS
Board of Examiners
Chris Baker, RN, DMD
Robert G. Gerety, DDS
W. Edward Gonzalez, Jr., DMD, PA
David W. Jackson, DDS
Joseph R. Schmidbauer, DDS
Executive Director
Thomas N. Chapman, CAE
JAOS Editor
Greg Cannizzo, DDS
38 Winter 2009 JAOS
became the fourth

In a ceremony
person to be certified.
during the recent
Dr. Cannizzo has a
American Association of Dental
successful general
Editors Annual
dental practice in
McHenry, IL. He and
Meeting in San
wife Linda are the
Antonio, Dr. Greg
parents of two boys
Cannizzo of
McHenry, Illinois,
and two girls. He has
received designabeen the Editor of the
Dr. Greg (at left) Cannizzo earns
Journal since January
tion as a Certified
CDE designation.
2005 and was the CoDental Editor(CDE).
Editor prior to that, as well as
To receive this award, you must
complete 30 hours of continuing
past-president of the AGpO. All
of us affiliated with the Amerieducation in approved subject areas
can Orthodontic Society are
related to writing, editing and
communications. Dr. Cannizzo
proud of Dr. Cannizzo for this
accomplishment and his
became only the 26th person to earn
this distinction and the second Editor
commitment to make The Journal
of the American Orthodontic Sociof the JAOS to be so recognized.
ety the finest GP orthodontic
In 2004, the late Dr. Roger
Rupp, the Journals initial Editor, publication available today.
AOS Course Corner
Tier Advancement Orthodontic Review Course AND the

Financial Strategies Course will
be taught in Dallas on April 3-4,
2009. To help you advance from
Achievement to Fellowship to Diplomate, we offer a two-day educational
course designed to increase your
orthodontic skills. We have also
added the highly popular one-day
Financial Strategies course.
Dr. David Jacksons Missing
Piece of Your Practice Comprehensive Orthodontic Education
Program is set to begin in Kansas
City and San Diego during March.
This four-session course for general
and pediatric dentists will focus on
learning and implementing a proven
system for orthodontic diagnosis and
treatment.
Train your staff with Kay Geretys

Straight Wire for Assistants to
be conducted in Dallas and Atlanta
in February and March as well as the
Advanced Straight Wire for

Assistants conducted in Dallas in
March. This course is a perfect
complement to Dr. Geretys comprehensive courses. However, Kays
knowledge of GP orthodontics and
experience as a clinician makes her
courses valuable whether or not you
are a present or former student of
Dr. Gerety.
Learn intermediate concepts and
techniques from two outstanding
practitioners and teachers, Dr. Bill
Wyatt and Dr. Larry White, beginning in Dallas in January. Expand your
orthodontic skills with a combination
of lecture, case review, wire-bending,
and hands-on typodont workshops.
Learn the orthodontic basics with
Dr. Leonard Carapezza beginning
in March in Wayland (Boston), MA.
Both the beginning and advanced
courses provide a systematic orthodontic approach to treating patients using
the Straight Wire philosophy.
Details on all of our AOS courses can be found at

www.orthodontics.com or by calling 800-448-1601.
ATTENTION
According to Society bylaws, any active member of the AOS may bring new business or old
business before the Board for consideration. The next meeting of the Board of Directors is scheduled for April 2, 2009 at the Addison Crowne Plaza Hotel in Dallas. If you have items for Board
consideration, please fax to the AOS office 972-234-4290 no later than Friday, March 6, 2009.
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AOS MEMBERSHIP NEWS
Valuable Membership Benefits

Retention of membership
is both the most important,
and yet, the most challenging job for a professional
association. In tough
economic times, when every
practice expense must be
Arturo Gutierrez, DDS AOS
scrutinized, we know the
President
cost of AOS membership is
questioned and renewed based on the perceived
value that membership adds to your practice. I have
been a member of AOS for 16 years and my
orthodontic practice has grown each year as a direct
result of the support and education this organization has provided. The AOS is my go to organization for orthodontics and I want it to be yours.
Heres what we offer that deserves your continued
and committed membership in the American
Orthodontic Society:
We are... The largest member-based orthodontic educational organization in America. Course
content is always determined by the Society and not
by special interest groups. This allows our members
to attend high-value education-FIRST programs, all
recognized by the ADA Continuing Education
Recognition Program.
We are The voice for GP orthodontics. Wherever we see discriminatory practices that threaten to
limit your right to practice, were there for YOU and
ALL Society members.
We are The top publisher in GP orthodontics.
The Journal of the American Orthodontic Society is
stuffed with take-away orthodontic pearls AND information on the latest in technology and industry trends.
We do Provide an achievable, but rigorous,
path for tier advancement. Want to increase your
patient base, while improving your orthodontic
skills? Follow our Society credentialing program
from Achievement to Fellowship to Diplomate.
We do Have the best patient information materials for your practice. Krames Communications
publications, the leader in the patient information
industry, are available to you AT OUR COST.
Most importantly The AOS is large enough to
be a voice in the industry, but small enough to value
your membership on an individual basis. In todays
world, that alone is worth the cost of membership.
If youve not done so...RENEW NOW. Even better,
renew and bring a colleague along. You will experience the AOS Advantage! Have a happy and prosperous 2009.
R. Gutierrez, DDS
RENEW YOUR DUES TODAY AND ENSURE YOU ARE INCLUDED IN OUR 2009 MEMBERSHIP AND REFERAL
DIRECTORY. RENEW ONLINE AT WWW.ORTHODONTICS.COM or CALL THE AOS OFFICE AT 800-448-1601.
New Vice-President and Directors Elected

During the recent Annual Meeting in New Orleans, the
general membership elected two new directors and a new
vice-president in accordance with the bylaws of the Society.
The new Vice-President who will
become the Society President in 2010
is Dr. Chris Baker. Dr. Chris is a
Diplomate, Board Examiner, Senior
Instructor and Board Member. She is a
registered nurse who received her
DMD from the University of Kentucky,
then both her certificate in pediatric
Dr. Chris Baker
dentistry and her fellowship in the
Department of Orthodontics from the University of
Connecticut. She served on the University of Connecticut faculty in the department of pediatrics for eight
years and currently serves on the faculty of the University of Kentucky while also practicing in Lexington, KY.
Dr. Baker teaches comprehensive courses in both basic
and advanced orthodontics.
Elected for a term of four years as a Director is Dr.
Azita Anissi. Dr. Anissi is a general dentist practicing in
Rochester, NY. She graduated from the State University
of New York at Buffalo Dental School in

1990 and is currently teaching the residency advancement program at
Rochester General Hospital. More than
30 percent of her practice is dedicated
to orthodontic treatment. Dr. Anissi
received her Diplomate from the AOS at
the New Orleans Annual Meeting this
Dr. Azita Anissi
past October.
Elected for a term of four years as
a Director is Dr. Dave Thorfinnson.
Dr. Thorfinnson graduated from the
University of Minnesota in 1988 and
practices in East Grand Forks, MN.
He has been a member of the AOS
since 1992 and received his Fellowship in 2007. He is a member of the
Dr. David M. Thorfinnson
American Dental Association,
Minnesota Dental Association and past president of
the NW Minnesota District Dental Society, where he
has been involved with the district Ethics and
Bylaws committee and peer review.
JAOSWin09
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AOS MEMBERSHIP NEWS
40 Winter 2009 JAOS
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AGpO MEMBERSHIP NEWS
Board Examination
Fellowship Award Recipient
www.academygportho.com
Academy of
Gp Orthodontics
2009 Officers
President
Drew Ellenwood, DDS
President Elect
Marc Dandois, DDS
Vice President
Thomas Jacobsen, DDS
Secretary - Treasurer
Sam Gutovitz, DDS
Immediate Past-President
Keith Wilkerson, DDS
Board of Directors
Eugene Boone, DDS
Greg Cannizzo, DDS
Corina Diaz- Bajsel, DDS
This year, the Academy recognized Dr. Fred Der of Keswick, Ontario,
Canada who achieved Fellowship status by passing the Fellowship Board
Examination. Dr. Der is the host dentist of the comprehensive two-year,
hands-on orthodontic course taught in his office by Dr. Roy Holexa.
Fred Der, DDS

Kyle McCrea, DDS
Kurt Raack, DDS
Kurt Stodola, DDS
Helen Tran, DDS
Advisory Board
Ron Austin, DDS
Joe Fallin, DDS
Roy Holexa, DDS
Leslie R. Penley, DDS
Bob Shirley, DDS
Barry Sockel, DDS
Walter L. Tippin, DDS
Executive Director
Cynthia Bordelon
42 Winter 2009 JAOS
The Acacdemy of
Gp Orthodontics
2009 Spring Referesher
The Academy of Gp Orthodontics is pleased to present the 2009
Spring Refresher Course featuring speakers on Tip-Edge Plus and
Orthodontic Appliances. This two day event will take place March 27th
and March 28th at the Crowne Plaza Hotel in Addison Texas. Featured
speakers and topics will include Dr. Richard Parkhouse on the Tip
Edge Plus Bracket. Dr. Edward Joneson will speak on The Tip Edge
Experience It makes more sense, and Paul Ruzicka of Ordent Laboratories speaking on Orthodontic Appliance Designs and Adjustments. To
register call the Academy headquarters at 800-634-2027. Dont miss this
opportunity to improve and refresh your orthodontic skills and network
with other dentist and Pedodontists who practice orthodontics.
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Your Practice:
A Safe Investment in Tumultuous Times
Recently, my parents were talking about the current sour times and their incredible, shrinking
retirement. I gave my mother a fright by telling her I was heavily invested in a small company
and that if it went bust, so would I. She anxiously said I needed to immediately diversify. Too late,
I told her, I was too entangled in this group. However, I knew the CEO, and I thought Id still just
make it. My father had to tell her the small company was my dental practice.
Dr. Drew Ellenwood
This is our investment: Ourselves, our practices. Right now, that is probably the best place for
AGpO President
money. I have to remind myself to take time to sit quietly and think on my goals, to look from afar
and evaluate and then come close to organize and refine. During spring cleaning, I jettison the trash; in my practice, I
work to keep the fat trimmed and the weeds out. Though, its not all about building that better mousetrap. Investing in
becoming a better dentist means pressing to become a better me all around. I have to keep connected to my patients as
humans, to my staff as partners in service, and to my family as my touchstone. And remember, the one next to you. That
is, dont take your spouse for granted as your spouse is the most valuable asset in your human portfolio.
My daughter, a sophomore in college, asked me recently about the economy and what to do. I told her the best
place to be during an economic bad time is in school. So it is with you and me. Now is not the time for panic
and believe me Im one to panic but to invest in our education. I advise you, and its just as good as youll get
from any financial guru, to plan and save now to attend the joint annual meeting of the AGpO and the AOS in
Chicago, August 20-23, 2009. This will be a fantastic investment in honing your skills and becoming more effective in your orthodontic practice.
Even earlier in 2009 is the Academys Spring Refresher. It will be held in Dallas on March 27 and 28. On the
first day, the agenda includes Dr. Edward Jones who will lecture on Diagnosing the Maxilla and Paul Ruzicka, President of Ordont, who will lecture on Appliance Designs and Adjustments. On Saturday, Dr. Richard Parkhouse, our
Tip-Edge friend from Wales, will lecture on Tip-Edge Plus.
Hopefully, this can be an ongoing tradition to keep us connected to each other and the best in orthodontic
continuing education. Meanwhile, strap yourself in the roller coaster. Soon the ride will be over.
Drew Ellenwood, DDS
12 Complete Tier Advancement Program

Recently, 12 doctors finished their comprehensive two-year, hands-on course in Kreswick, Ontario, Canada. All
doctors qualified for the Associate Fellowship level of the Academy of Gp Orthodontics Tier Advancement
Program. All recipients completed the Academys 12session comprehensive handson course and earned a minimum 155 CDE hours in Orthodontics and related topics. Also completed was a minimum of three cases during the
handson course, followed by passing a written and oral examination administered by course instructor Dr. Roy
Holexa and host dentist, Dr. Fred Der.
Back row, left to right:
Dr. Younes, Trenton, ON
Dr. Holexa, Fountain Hills, AZ
Dr. Parhar, Edmonton, AB
Dr. Bencak, Lasalle, ON
Dr. Yu, Keswick, ON
Dr. Der, Keswick, ON
Front row, left to right:
Dr. Hartwig-Villa,
Cambridge, ON
Dr. Hildago, London, ON
Dr. Yu, Keswick, ON
Dr. Young, South
Porcupine, ON
Graduates not shown:
Dr. Arrieta, Toronto, ON
Dr. Jeong, Toronto, ON
Dr. Leung, Burlington, ON
Dr. WanChowWah,
Richmond Hill, ON
www.academygportho.com Winter 2009 43
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AGpO Presents Awards at 20th Annual Meeting
The Academy of Gp Orthodontics 20th Annual Meeting was

recently held in Dallas, TX. It was
a successful celebration of education and connection with friends,
colleagues and industry partners.
Dr. Lori Trost, Dr. Keith Wilkerson, Dr. Ralph Garcia, Dr. Larry
Kotlow, Dr. Leslie Penley, Dr. Ron
Austin, Dr. Roy Holexa, and Dr.
Robert Allen spoke on topics that
challenged and inspired the meeting attendees. This years topics of
Airways, Minor Tooth Movement,
TMD, Lasers and Tip Edge Pearls
provided for three full days of
some of the best continuing
education available.
The Saturday night dinner and
Awards Banquet with dancing at
the Copper Bottom Grille, gave
everyone a chance for remembering, recreation and reunion. Next
years annual meeting will be held
as a combined event in Chicago IL
on August 20 23, 2009 with the
American Orthodontic Society.
MEMBERSHIP RECIPIENTS
Mark Dandois, DDS
Hector Garza, DDS
Roy Holexa, DDS
Tom Jacobsen, DDS
Leslie Penley, DDS
Bob Shirley, DDS
Barry Sockel, DDS
FELLOWSHIP RECIPIENT
Fred Der
AGpO AWARD FOR
JOURNALISTIC
CONTRIBUTIONS
Jeffrey Gerhardt, DDS
44 Winter 2009 JAOS
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JAOS PATIENTS PAGE
Oral Health
&
Diabetes
D
iabetes is a great concern for both the medical

and dental professions. Millions of Americans
are affected each year by this disease. Over
the last two decades there has been a thirty to
forty percent increase in diagnosed cases of diabetes,
especially among overweight children and adolescents,
since obesity is a major risk factor. But how can
diabetes affect your oral health?
The Centers for Disease Control defines diabetes as a
disease in which blood glucose levels are above normal.
Most of the food we eat is turned into glucose-or sugarfor our bodies to use for energy. The pancreas produces
a hormone called insulin to help glucose absorb into
the cells of our bodies. When you have diabetes, your
body either doesnt make enough insulin or cant use
its own insulin as well as it should. This causes sugar to
build up in your blood.
Diabetes can cause serious health complications,
including heart disease, blindness, kidney failure, and
lower extremity amputations, and it is the sixth leading cause of death in the United States. Some classic
signs of diabetes are excessive appetite, excessive
thirst, and excessive urination, but the condition may
also cause weight loss, irritability, drowsiness, and
fatigue. Diabetes, as well as any other medical condition, should be reported to your dentist so that
proper care can be delivered.
When diabetes is not controlled it can lead to a
number of dental complications because the high
glucose levels in saliva may help bacteria thrive in the
mouth. Diabetes also reduces the bodys resistance to
infection, and the bodys tissues, including the gums,
are likely to be affected. The most common and
potentially harmful oral health problems associated
with diabetes are gingivitis, periodontitis and rapid
loss of the bone that supports the teeth. According to
the American Dental Association periodontitis is often
linked to the control of diabetes. Patients who have
inadequate blood sugar control appear to develop
periodontitis more often and with greater severity.
These patients also lose more teeth than patients who

have good control of their diabetes.
Diabetes can also affect the amount of saliva in the
mouth, leading to dry mouth and resulting in an
increased risk for cavities. Recurrent canker sores, white
patches on the cheeks, and fungal infections can be an
indication of poor glycemic control in a diabetic
patient. Taste may also be altered in diabetic patients,
making it difficult to maintain a proper diet.
Patients with poorly controlled diabetes are at an
increased risk of other complications, such as infections
and reduced healing. This may make it necessary for
them to take antibiotics prior to certain dental procedures
including oral surgery. For patients taking insulin, it may
be necessary to consult with their physician in order to
increase the dosage in the case of an oral infection. It is
also important for your dentist to know if you take
insulin because the use of local anesthetic can influence
the effects of insulin and can result in hyperglycemia.
So, if you have diabetes, make sure you take care of
your teeth and gums. You may require more frequent
visits to the dentist and more rigorous follow-up treatment to ensure optimum dental health. To offset the
greater risk of gingival and periodontal problems, it is
vital to control your blood glucose levels and to brush
and floss daily. Finally, seek regular dental care to help
keep your mouth healthy and to obtain advice on how
to manage your diabetes.
This message is brought to you by your dentist, a proud member of the American Orthodontic Society and the AGpO.
46 Winter 2009 JAOS
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CONTENTS JAOS WINTER 2009

22 The Changing Face of Growth Modification

26 The Benefits of Early Treatment

32 Early Transitional Dentition Treatment

By David W. Jackson, DDS, FAGD

38 AOS Membership News

Oral Health and Diabetes

This peer-reviewed journal is

On the cover: Dr. James E. McIlwain provides

www.orthodontics.com Winter 2009 5

Greg Cannizzo, DDS, CDE, JAOS Editor

3617 Municipal Drive, McHenry, IL 60050

Ortho Arch ................................................11

American Orthodontic Society ..................41

Ortho Organizers ......................................47

ClassOne Orthodontics ................................2

Johns Dental Labs ................................30, 35

Rocky Mountain Orthodontics ....................4

Space Maintainers ........................................3

Myofunctional Research ............................21

Vector Dental ............................................29

Ordont Ortho Labs ......................................9

Wild Smiles ................................................10

6 Winter 2009 JAOS

Tom Chapman, CAE

Dr. Juan Carlos Echeverri is the owner of Echeverri Dental

Center in Houston, TX. Fluent in English and Spanish, he has made

Dr. Leonard Carapezza has over 25 years of clinical experience

Dr. Jeffrey H. Ahlin has served on the Board of Directors and as

Dr. Chris Baker, through her practice in pediatric dentistry

www.orthodontics.com Winter 2009 7

ORTHO INDUSTRY NEWS

Alginate Alternative: Designed for a Variety of

crown and bridges, fabricating simple

KOMET USAs adhesive removing instruments were developed

surfaces while generating minimal

Silginat is available in two

Offering the ability to stitch

ORTHO INDUSTRY NEWS

Improve Bonding Experience

working on a study model, and most

ORTHO INDUSTRY NEWS

Appliance Opens Blocked Airways

10 Winter 2009 JAOS

opened to allow air to pass

By David W. Jackson, DDS, FAGD, IBO

Peer pressure and influence has never been so paramount in young

s I lecture throughout the United States, I am

teeth than I was when I was a youth (and yes, I can

Dentally, she had malposed anterior central incisors,

Case #2 is what I hope is a pretty apparent reason

treat crossbites as soon as possible. This young man

upper anterior teeth erupting on top of the lower

mentioned, advancing the upper utility arch wire by

Using a patient treatment case and images, a clinician presents

requently pediatric and

Fig 1, (Initial Exam/

Space loss in the arch formation.

As we evaluate the child who is

one or two, we need to ask

If we as the treating or referring

Remove the mesodens obstruction when no harm will come to