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The Journal of Indian Orthodontic Society Official publication of Indian Orthodontic Society (Reg. No.

16920/68 Published quarterly : March, June, September, December Editor Dr. Lodd Mahendra Associate Editor Dr. P Janardhanam Consultant Editors Dr. M.R. Balasubramaniam Dr. Ashima Valiathan Dr. K. Jyothindra Kumar Dr. M.K. Prakash Dr. K. Sadashiva Shetty Dr. N.R. Krishnaswamy Assistant Editors Dr. Ashwin M. George Dr. S. Venkateswarn Dr. G. Shivaprakash Committee for reviews and abstracts Dr. Chetan V. Jayade Dr. Santha Sundari Dr. Sridevi Padmanabhan Dr. A. Nandakumar Dr. P. Navaneetha Krishnan Dr. M.S. Rani Journal Committee Dr. R.B. Sable Dr. Sanjay Ganeshkar Dr. Jayesh Rahalkar Dr. Jayaram Mailankody Dr. K. Ketan Vakil Dr. Rabindra S. Nayak Dr. P. Ganesh Dr. Sarojini Joseph Dr. M.S. Ravi Dr. Sandhya Jain Dr. Divakar Karanth Dr. Nikhil S. Vashi Dr. Vinod Krishnan Dr. K. Ravi Dr. Krishnaraj Dr. Girish Karandikar Dr. Joseph Varghese Dr. Rittu Dugai Dr. K. Uma Shankar Journal Consultative Board Dr. V.P. Jayade Dr. S. Rangachari Dr. V. Surendra Shetty Dr. A.S. Kalha Dr. Akhter Hussain Dr. O.P. Kharbanda

Office Bearers (2009-10) President Dr. Girish Karandikar Hon. Secretary Dr. E.T. Roy President - Elect Dr. N. Kumar Ahuja Immediate Past President Dr. O. P. Kharbanda Vice President Dr. Gurkeerat Singh Hon. Joint Secretary Dr. G. Sivaprakash Hon. Treasurer Dr. Kishore M.S.V. Exofficio (Chairman IBO) Dr. Mani K. Prakash Executive Committee Members Dr. Amish Mehta Dr. Nikhilesh R. Vaid Dr. Anand K. Patil Dr. Pradeep C. Shetty Dr. Anil Singla Dr. Pradeep Jain Dr. Anup B. Kanase Dr. Rajiv Ahluwalia Dr. Ashish Gupta Dr. Rani M.S. Dr. Balvinder S. Thakkar Dr. Ravi Bhutani Dr. Chandra Sekhar G. Dr. Rohan Mascarenhas Dr. Joseph Varghese Dr. Sridevi Padmanabhan Dr. Keluskar M. Dr. Vinay S. Dua Dr. Kohli Virinder S. INDIAN BOARD OF ORTHODONTICS

The Journal of Indian Orthodontic Society (JIOS) Welcomes, contributions both from India and abroad. Its aim is to publish clinical, research and review articles of interest to Orthodontists in India and throughout the world. The Journal is published by the Indian Orthodontic Society. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical photocopying, recording or otherwise, without the prior permission of the Editor. Statements and opinions expressed in the articles and communications herein are those of the authors and not necessarily those of the Editor, Publisher or Association. The Editor, Publisher or Association do not endorse any product or service advertised in this publication, also they do not guarantee any claim made by the manufacturer of such product or service. Applications for advertising space / position should be addressed to the Editor JIOS.

Founded in 1999 by The Indian Orthodontic Society

Board of Directors
Dr. M.K. Prakash Chairman Dr. K. Sadashiva Shetty Vice Chairman Dr. R.B. Sable Secretary - Directors Dr. Vinod Verma Director Dr. C.S. Ramachandra Director

Editorial Office : 48, 4th Street, Padmanabha Nagar, Adyar Chennai - 600 020. E-mail : editorjios@gmail. com 1

Volume 44

Number 2

April - June 2010

CONTENTS
Assessment of acceptability of smile esthetics with different level of gingival display by Orthodontists and general public A comparative study An Avant-garde Indirect Bonding Technique for Lingual Orthodontics using the First Complete Digital Tad (Torque Angulation Device), & Bpd (Bracket Positioning Device) Evaluation of True Incisor Intrusion Attained with Mini-implant Anchorage System for the Correction of Deep Overbite IGF-1 : A Legitimete skeletal maturity indicator Laser Etching of Enamel for Direct Bonding An in Vitro Study Comparison of Dental and Alveolar Arch Width in Patients with Normal Occlusion, Class II Division 1 and Class II Division 2 Malocclusion Rectangular Wires as substitutes for the MAA and Torquing Auxiliary in the Begg treatment A Clinical study Modified Pendulum Appliance for easy insertion and removal Comparison of Frictional Resistance between Conventional Stainless Steel, Metal Insert Ceramic, Self Ligating Stainless Steel and Self Ligating Ceramic Brackets with Stainless Steel Wire: In Vitro Study A Comparative Study of Soft Tissue Changes in Skeletal and Dental Class 11 Division 1 Cases Treated with Removable Functional Appliance as against those Treated with Fixed Functional Appliance Management of Class II Division 2 Malocclusion An Insight A New Equation for Predicting the Width of Unerupted Permanent Canines and Premolars for cosmopolitan Indian Population Orthodontic Conclusions of Systematic Review and Meta Analysis

18 25 29

42

48 54

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63 76

83 89

ASSESSMENT OF ACCEPTABILITY OF SMILE ESTHETICS WITH DIFFERENT LEVEL OF GINGIVAL DISPLAY BY ORTHODONTISTS AND GENERAL PUBLIC A COMPARATIVE STUDY
Authors:

Dr. Tapan Shah (Corresponding Authour)


Post graduate student Department of orthodontics and Dentofacial Orthopedics, Darshan Dental College and Hospital, Udaipur. E-mail : tapan.ortho@yahoo.com Phone : +91-99280 37474

Dr. Kalyani Trivedi, M.D.S.


Professor and Head, Department of orthodontics and Dentofacial Orthopedics, Darshan Dental College and Hospital, Udaipur. E-mail : kalyani.trivedi@rediffmail.com Phone : +91-98253 19810

Dr. Tarulatha Shyagali, M.D.S.


Reader, Department of Orthodontics and Dentofacial Orthopedics, Darshan Dental College and Hospital, Udaipur E-mail : deepu_taru20@rediffmail.com Phone : +91-99291 49217 Abstract : Method Purpose- This study was designed to determine the esthetic perception of an orthodontist and a layman to variations in gingival display during smile. Composed photographs of smile with varying amounts of gingival exposure during smile were rated for attractiveness by laypeople and orthodontists. One smiling photograph with good dental alignment, symmetry and normal amount of gingival display( morley ratio) was used in this study and it was digitally altered to obtain Second, third and fourth photograph by varying the amount of gingival display in increasing fashion from 4mm, 6mm and 8mm respectively. These photographs were shown to laypeople and orthodontists to give the scoring of attractiveness based on five point attractiveness scale. There is a significant difference in the scores given by the orthodontists and laypeople. Compared to layperson orthodontists had given less score as the gingival exposure is increased. Comparatively more amount of gingival exposure is acceptable by the female orthodontist than the male orthodontist. Female layperson did not appreciate the increased gingival exposure in comparison to male laypersons. As the amount of gingival display was increased during smile, Images were scored less attractive by orthodontists and laypersons. Laypersons are found to be more tolerant to increased gingival display at smile. development and social interaction. Facial attractiveness and smile attractiveness appear strongly connected to each other. The fact is that in social interaction, ones attention is mainly directed towards the mouth and eyes of the 3

Results

Conclusion

INTRODUCTION
Facial attractiveness plays a key role in social interaction. It influences mating success, kinship opportunities, personality evaluations; performance, and employment prospects. 13 Furthermore, attractiveness is suggested to influence personality

speakers face, as the mouth is the centre of communication in the face; and the smile plays an important role in facial expression and appearance. An esthetically pleasing smile is not only dependent on components such as tooth position, size, shape, and colour, but also on the amount of gingival display and the framing of the lips buccal corridor space . All these components are supposed to form a harmonic and symmetric entity. The lips are the controlling factor in which, portions of the teeth, gingiva, and oral cavity will be seen in an individuals smile.5 Yet the higher the upper lip is elevated while smiling, the more visible the teeth and gingiva are, and the greater their role is in the esthetic value of the smile. The high smile line, defined as gingival smile line (GSL) or gummy smile (GS), commonly provokes strong concern from clinicians. Orthodontists and surgeons are conditioned to see a GS as esthetically undesirable.9-10 The gummy smile is not necessarily unesthetic in the eyes of the public. Many actors, models and beauty contestants, especially women, expose gingival tissue at smile and are still considered beautiful with beautiful smiles. Kokich et al used female smile and gingival exposure was classified as noticeably unattractive only at 4 mm. The dilemma whether to treat the GS or not is further emphasized by the effect of aging on gingival display.11 Therefore, the purpose of this study is to compare the perception of oral esthetics of person, during smile, evaluated by orthodontists and lay evaluators, in different gingival display situations above upper incisors.

Total four photographs were made, one with normal amount of gingival display which follows the morleys ratio of gingival exposure, (fig 1).and the second, third and forth photograph having gingival exposure of 4mm, 6mm and 8mm respectively.(fig 2,3 & 4) All these photographs were converted into one single presentation. This presentation was shown to 60 orthodontists and 60 laypeople, out of which 30 were males and 30 were females. Selected lay persons did not have any dental training. The slide show was presented with a digital projector (Notevision, model PG-C30XU, Sharp, Conshohocken, Pa) on a white screen. Five warm-up slides, starting at 10 seconds per slide and gradually decreasing to 5 seconds per slide, were included at the beginning of the slide show. The judges were instructed to choose the smile they preferred from each slide and mark their opinion as (1) very unattractive (2) unattractive (3) average (4) attractive (5) very attractive.

STATISTICS
Descriptive statistics included mean and standard deviation. Pearson chi-square and t-test were done to compare the scores given by orthodontists and laypersons. Influence of sex on judging the attractiveness score was also tested and compared by using the same tests.

RESULTS
Overall results of this study show that, as the gingival exposure is increased scores given by the orthodontist and lay man are decreased. The Results of both the tests (irrespective of sex) show that when we compare scores given by the orthodontist and layperson, orthodontists have given less score as the gingival exposure is increased. Where as up till slide B lay men have liked the smile(p<0.05) though the gingival exposure in slide B was increased up to 4 mm.(Table-1.1 & 1.2) We have also found out that there is a difference in the score given by the male and female orthodontist. Females have given more score to slide B compare to males. In slide C and slide D there is no significant difference in scores given by the male and female orthodontist. (Table-2) There is significant difference in esthetic perception between male and female laypersons. Females have given less score compared to males for the slide B (p<0.05). Where as for other slides there was no significant difference.(Table-3.1 & 3.2) 4

MATERIALS AND METHODS


The overall plan was to alter the amount of visible gingival display in subjects smiling images and to have these images judged for smile attractiveness by a panel of laypersons and orthodontists. Frontal smiling, 35-mm color slides of 10 randomly selected people were acquired. All subjects were having acceptable smile with all the normal parameters. Out of them, one photograph of the dentition with good dental alignment and symmetry was selected by the panel of 10 orthodontists. (fig. 1). To produce the varying level of gingival display, the selected digital photograph was imported into Adobe Photoshop version 7.0 (Adobe Systems,San Jose, Calif) and altered to produce varying level of gingival display. Then they were projected on a monitor with all images set to the same magnification. To preserve a realistic appearance, it was decided to leave the intercanine width unaltered.

Figure 1

Figure 2

Figure 3

Figure 4

t-test group statistics


PERSON SLIDEA Orthodontist Layperson SLIDEB Orthodontist Layperson SLIDEC Orthodontist Layperson SLIDED Orthodontist Layperson N 60 60 60 60 60 60 60 60 Mean 4.15 4.05 2.75 4.10 2.15 2.40 1.50 2.00 Std. Deviation .36 .67 .54 .71 .66 .59 .68 .84 .000 030 .000 p .313

Table 1.1

SLIDEB
Score SLIDEB 2 Count of Total 3 Count of Total 4 Count of Total 5 Count of Total Total Count of Total 60 50.0 Orthodontist 18 15.0 39 32.5 3 2.5 3 2.5 3 2.5 39 32.5 15 12.5 60 50.0 Layperson

Chi-Square Tests
Pearson Chi-Square Value 87.429(a) df 3 P .000

Table 1.2

SEX SLIDEA Male orthodontist Female orthodontist SLIDEB Male orthodontist Female orthodontist SLIDEC Male orthodontist Female orthodontist SLIDED Male orthodontist Female orthodontist

N 30 30 30 30 30 30 30 30

Mean 4.30 4.00 2.60 2.90 2.20 2.10 1.50 1.50

Std. Deviation .47 .00 .50 .55 .76 .55 .82 .51

Table 2
6

t-test group statistics


SEX SLIDEA Male layperson Female layperson SLIDEB Male layperson Female layperson SLIDEC Male layperson Female layperson SLIDED Male layperson Female layperson N 30 30 30 30 30 30 30 30 Mean 4.00 4.10 4.50 3.70 2.50 2.30 2.20 1.80 Std. Deviation .79 .55 .51 .65 .68 .47 1.00 .61 .066 .190 .000 P .570

Table-3.1 Chi-Square Tests


PERSON 2 Layperson SEX Male Count of Total Female Count of Total Total Count of Total 3 5.0 3 5.0 3 5.0 3 5.0 3 Score 4 15 25.0 24 40.0 39 65.0 15 25.0 5 15 25.0

PERSON Layperson

Pearson Chi-Square

Value 23.077(b)

Df 3

P .000

Table-3.2
that is not technically perfect when seen from a dental perspective; however, when the smile fits in the face, the imperfections are not always regarded as disturbing.14 This study focused on specific aspect of smile esthetics; the amount of upper gingival exposure in dynamic state of smile. The uniqueness of this study is the differentiation by the sex of the evaluator and by the occupation of the evaluator. 7

DISCUSSION
The design of this study was relatively new in the orthodontic-psychological field. As in literature, a clear discrepancy between self-perception of facial attractiveness and judgment of others was found. Further study of self-perception of facial and oral attractiveness was clearly needed to gain more insight into the oral self-image and esthetic satisfaction. 12, 13 For example, many movie stars have an attractive smile

Laypersons and orthodontists viewed acceptability of gingival display in this study. Earlier study made by Kokich et al,15 where lay people considered smile-line heights in strangers with a general gingival display exceeding 4 mm, as unattractive. In the study of Geron and Atalia,14 laypeople considered 1 mm gingival display as unattractive. However, this study does not support the conclusion made by the author, as our result suggests more than 4 mm gingival display as unattractive. According to this study Esthetic perception for smile by the male and female orthodontist is quite different. This is because scores given to the slide B by the male and female orthodontist is different. The increased gingival exposure is less appreciated by males than females. This suggests that increased gingival exposure is acceptable by the female orthodontists. The results indicate that excessive gingival display is not accepted by female layperson compared to a male lay person, as an esthetic feature for images. It means that female lay persons are not tolerant to gingival exposure, which is a more predominant feature in women. Same way when a comparison is made between a layperson and an orthodontist, a score given by a layperson is more. So, one can conclude that increased gingival exposure is acceptable by the lay people as compared to orthodontists.

2. Bull R, Rumsey N. The Social Psychology of Facial Appearance. New York, NY: Springer Verlag; 1988. 3. Flanary C. The psychology of appearance and psychological impact of surgical alteration of the face. In: Bell WH, ed. Modern Practice in Orthognathic and Reconstructive Surgery. Philadelphia, Pa: Saunders; 1992: 321. 4. Thompson L, Malmberg J, Goodell N, Boring R. The distribution of attention across a talkers face. Discourse Process. 2004;38:145168. 5. Moskowitz M, Nayyar A. Determinants of dental esthetics: a rationale for smile analysis and treatment. Compend Contin Educ Dent. 1995;16:11641166. 6. Frush JP, Fisher RD. The dynesthetic interpretation of the dentogenic concept. J Prosthet Dent 1958;8:558. 7. McNamara JA. Maxillary transverse deficiency. Am J Orthod Dentofacial Orthop 2000;117:56770. 8. Tjan AH, Miller GD, The JG. Some esthetic factors in a smile. J Prosthet Dent. 1984;51:2428. 9. Janzen EK. A balanced smilea most important treatment objective. Am J Orthod. 1977;72: 359372. 10. Peck S, Peck L, Kataja M. The gingival smile line. Angle Orthod. 1992;62:91100. 11. Kokich VO Jr, Kiyak HA, Shapiro PA. Comparing the perception of dentists and lay people to altered dental esthetics. J Esthet Dent. 1999;11:311324. 12. Feingold A. Good-looking people are not what we think. Psychol Bull. 1992;111:304341. 13. Greitemeyer T, Brodbeck F. Wer schon ist, wird auch gut. Z Sozialpsychol. 2000;31:7386. 14. Kokich V, Kiyak H, Shapiro P. Comparing the perception of dentists and lay people to altered dental esthetics. J Esthet Dent. 1999;11:311324. 15. Geron S, Atalia W. Influence of sex on the perception of oral and smile esthetics with different gingival display and incisal plane inclination. Angle Orthod. 2005;75:778784.

CONCLUSION
1. Images were scored less attractive as the amount of gingival display was increased during smile. 2. Compared to orthodontists increased amount of gingival exposure is acceptable by the laypersons. 3. Up till 4mm of gingival exposure is acceptable by the female orthodontists where as it is not so with male orthodontists. 4. Esthetic perception of male and female layperson is different. Females are more concerned about increased gingival display.

BIBLIOGRAPHY
1. Dion K, Berscheid E, Walster E. What is beautiful is good. J Pers Soc Psychol. 1972;24:285290.

AN AVANT-GARDE INDIRECT BONDING TECHNIQUE FOR LINGUAL ORTHODONTICS USING THE FIRST COMPLETE DIGITAL TAD (TORQUE ANGULATION DEVICE), & BPD (BRACKET POSITIONING DEVICE)
Authors:

Dr. Thushar Hegde

Dr. TUSHAR HEGDE, MDS Private Practitioner, Director - Welcare Dental Center & LoCUS Lingual Orthodontic Training Institute, Andheri (W), Mumbai - 66 E-mail: drtusharhegde@rediffmail.com Dr. HARISH DATTADA, MDS (Corresponding Author) Associate Proffessor, Department of Orthodontics, Sardar Patel Institute of Dental and Medical Sciences, Lucknow. India Telephone : +919935567972 Fax : +91-0522-22440335 E-mail : harishdattada@yahoo.co.in Dr. RAJ KUMAR JAISWAL, MDS Assistant Proffessor, Department of Orthodontics, Sardar Patel Institute of Dental and Medical Sciences, Lucknow. India Telephone: +919415023934 Fax: +91-0522-22440335 E-mail: drrajkumarjaiswal@yahoo.co.in

Dr. Harish Dattada

Dr. Raj Kumar Jaiswal

Abstract :

The advantages of Lingual Orthodontics over Labial Orthodontics are many. While better esthetics during treatment is the most obvious, some advantages are purely mechanical, like more efficient distal movement, much easier intrusion, increased expansion, and the built-in capability in the bracket design (7 th generation ORMCO brackets) to reposition the mandible and tempoeromandibular jaw when needed. One of the primary hurdles which needs to be overcome is the irregularity and variability of lingual tooth morphology, and the difficulty of access, making accuracy of Direct Bonding dubious. The scientific practice of Lingual Orthodontics necessitates an Indirect Bonding Technique which allows us to control bracket placement in the laboratory, followed by a reliable and precise transfer procedure of the brackets in order to clinically bond them in the exact position which has been set at the laboratory stage. This article covers an Indirect Bonding Technique using the Torque Angulation Device (TAD) and the Bracket Positioning Device (BPD) which ensure great accuracy while minimizing the potential for error as compared to most methods available to the orthodontist today. This technique has been developed by taking into account the advantages and pitfalls of indirect bonding.

Key words :

Indirect Bonding, Torque Angulation Device, Bracket Positioning Device

INTRODUCTION:
Lingual Orthodontics, as the name suggests involves Orthodontic brackets placed on the lingual surfaces of the teeth and connected by special arch-wires. The key advantage of this approach over traditional procedures is the esthetic enhancement during the treatment. The distress of having visible braces not only during routine daily activities but also during social events and gatherings for all the classes of people who seek esthetics has been greatly overcome. The fact that they can look better without the process significantly interfering with their way of life provides a viable option to an entire segment of individuals who were otherwise indifferent to orthodontic treatment. Also, continuance of the integrity of labial enamel1, 2 which is not etched bonded or scarred during debonding, cannot be overlooked. Disadvantages include speech interference3, 4 and tongue irritation4, 5 during the initial adaptation period, the duration of which is not always predictable. The technique is, clinically more time consuming and patients tend to be more demanding. Smaller inter-bracket distances 6 and smaller arch radius on the lingual aspect demand improvisation of traditionally accepted concepts used in Labial Mechanics. An intricate analysis into the merits/demerits and comparisons with the conventional is beyond the scope of the article. Two crucial aspects play a key role in establishing the success of Lingual Orthodontics: 1. Design of the Bracket (which apart from satisfying several important criteria has to confirm with the varying anatomy of the lingual aspect of the teeth). Since the inception of the technique, great strides have been taken in this direction pioneered by the ORMCO Company, and today we have an array of bracket systems to choose from. 2. Accurate method of indirect bonding The positioning of the brackets in relation to the teeth is the critical factor which is crucial to all available systems. So the trick to get lingual orthodontics to work was to devise a method so the brackets could be placed with proper torque and angulation in relation to the tooth already determined. In 1984, the Ormco Company devised the TARG7 (Torque Angulation Reference Guide) device for more precise bracket positioning, especially for the lingual technique. Over the years, various improvements like thickness compensation and height determination in a digital measuring environment were supplemented to enhance TARGs precision. In 1997, Dr. Weichmann from Germany introduced the Professional TARG and 10

Transfer Optimized Positioning System (TOPS), which still used the Torque blades of the TARG. He also invented the first CAD/CAM Incognito system, which uses customized gold brackets. Various other inventions were introduced over the years but their accuracy remains questionable. In 2004 Mr. Peter Sheffield of Precise Indirect Bonding Systems in cooperation with Polydee Instruments, an engineering company with no previous experience in the dental sector, conceptualized and introduced the Orthodontic Bracket Positioning Device and the Torque Angulation Device (TAD) prototype (Fig 1). After two years of intensive labor focused on making the device user friendly, the production model was finalized, which was precise to 0.10! (Fig 2) This first truly digital Torque angulation contrivance had a unique ability of surveying and measuring the torque and angulation of individual teeth with superior accuracy in comparison to any of its predecessors. With the prepared study model and its base parallel to the Horizontal Occlusal Line in position, the non adjustable surveyor base is used and then the TAD is adjusted to give the best fit for angulation and torque. The operator thereby receives precise digital measurement data for the maloccluded teeth in the mouth so that a suitable prescription for treatment can be made. After this the measurements are used in reverse by changing the survey base to an adjustable one which is then oriented to the preset position of the TAD blade, thus creating an individualized treatment plan for each tooth. This can then be transferred on to the Bracket Positioning device (BPD), which accurately places the brackets on the model from which a custom tray is fabricated. The BPDs induction as a part of the set up makes the entire system reliable, reproducible and most importantly, easy to use (Fig 3).

MATERIALS AND METHOD:


This article aims to demonstrate convincingly, a stepwise technique of indirect bonding using the TAD (Torque Angulation Device) and the BPD (Bracket Positioning Device). 1. The Cast and model are trimmed properly on an Orthodontic model trimmer or preferably referenced using a jig which will set the base parallel to the HOL as explained by Andrews. If the integrity of the lingual surface is in doubt, under trimming the area is recommended for easy placement of the bracket in the mouth. 2. The following reference lines are marked: (Fig 4) Long Axis of the Clinical Crown (LACC).

Midline on the Occlusal and Incisal Edges Mid points on the clinical crown (LA point).

3. The models are surveyed and the height and thickness are recorded using the BPD and brackets on a worksheet (Fig 5a). The shortest teeth are surveyed (Laterals and premolars) with a bracket to mark the slot line. The height is checked on the thickest anterior. Often the bonding height of the posteriors needs to be more to avoid contact with the antagonist necessitating a vertical bend between the canines and pre-molars. A first order bend may sometimes be required mesial to the canine if its thickness is substantially greater than the other anteriors. Increasing the resin pad thickness as a compensation to avoid this bend will result in an excessively thick resin pad and is not recommended. 4. The Set up is performed beginning with the anterior teeth by using the TAD to set the torque and angulation (Fig 5b). The survey base on which the model rests is adjusted to confirm the facial/buccal surface of the tooth to the blade of the TAD by using the tilt of the base in conjunction with the fine height adjustment of the TAD (If the LA point is being used, it can be matched to the scribe line in the centre of the TAD blade). 5. The model and survey base (with its programmed torque and angulation setting) are transferred to the BPD for bracket placement in accordance with the previously conducted height and thickness survey. 6. The outer jaw of the caliper is positioned almost at the incisal or occlusal edge by using the BPD column height adjustment (Fig 6). After this the fine height adjustment is manipulated to allow the caliper to touch the incisal edge lightly. The digital value on the Mitutoyo digimatic DTI is zeroed. 7. The bracket is engaged to the bracket holder with the calipers open. The outer jaws are supported along the buccal aspect of the tooth and the desired height is adjusted to by turning the fine height adjustment to the required setting (Fig 6). 8. After cleaning the bracket base (acetone is recommended to remove grease and contaminants), the bonding material is applied to the bracket base (Fig 6). 9. The outer jaw of the BPD is approximated to the vestibular surface and the and slowly close the thickness calipers by referring to the scale for the required thickness (Fig 7). It is recommended not 11

to pull out and in during this procedure to avoid creating any air space in the pad (Stop just short of the required thickness and then gently tap the last adjustment to the final reading). Ensure removal of excessive bonding material around the bracket base before curing (Fig 7). 10. Light cure for 30 seconds (Fig 7). 11. Check for the following; Bracket position. Angulation and torque of each tooth. Height and thickness for each tooth.

12. Next, the molars tubes are positioned. A special jig is used for this purpose (Since the jigs inclusion increases the width between the jaws of the BPD, it becomes necessary to reset the reading to zero before placing the brackets). During the procedure it must be ensured that the open part of the jig faces mesially (for easier removal, which is done by sliding it out from the distal after bonding) (Fig 8) 13. A resin separator is painted to the vestibular and occlusal surfaces of the model before the transfer tray can be constructed (Fig 9). 14. A hard Light Cure Blockout blue key is prepared covering most of the occlusal and vestibular surfaces, stopping short of the gingival margin by 1.5 to 2mm (Fig 10). A pre-prepared tooth number is stuck to the key (Fig 11). It is recommended not to place it too close to the bracket or the silicone will not be thick enough. 15. The set-up is Light Cured. Notches can be made on the silicone keys to enhance mechanical retention for the forthcoming steps. 16. The indirect bonding tray is made with Memosil (Heraeus Kulzer) which is dispensed in an applicator (Fig 12). The Memosil is applied with steady pressure on the syringe. It is advised to start from the lingual (covering the brackets entirely Fig 13), move on to the occlusal (Fig 13) and finally the labial/ buccal surfaces (Fig 13). 17. The transfer tray is smoothened using the finger (which can be dipped in a viscous liquid like the dishwashing liquid which acts as a separator (Fig 14). Ensure adequate thickness of material over the brackets. 18. After 15 min the tray is rinsed under cold running water. A low pressure compressed air spray is used to break the seal at the distal edge.

Fir. 2 : Torque Angulation Device (TAD) with key elements Fig. 1 : The prototype Torque Angulation Device (TAD)

Fig. 3 : Bracket Placement Device (BPD) with key elements

Fig. 4 : Mark all the reference lines needed to do the set-up, (not too heavily though). These include the Long Axis of the Clinical Crown (LACC), Mid-line on the occlusal, the incisal edge, and the Midpoint of the clinical crowns (LA point)

Fig. 5a : Survey the models and record height and thickness using the BPD and brackets on a worksheet Fig. 5b : Set Torque and Angulation using the TAD 12

Fig. 6 : Transfer the model plus the survey base with its programmed torque and angulation setting to the BPD for bracket placement

Fig. 9 : A resin separator is painted on the vestibular and occlusal surfaces

Fig. 7 : Bonding and Curing

Fig. 10 : Light-cure block out blue keys

Fig. 8 : Special Jig for molar bonding 13

Fig. 11 : Numbering the keys

Fig. 12 : Memosil (Heraeus Kulzer) applicator Fig. 15 : Trimming of the tray

Fig. 13 : Memosil (Heraeus Kulzer) application

Fig. 16 : Removal of the tray

Fig. 14 : Finishing the tray 14

Fig. 17 : Sandblasting and trimming the resin pads

Fig. 18 : Removal of undercuts

Fig. 21 : Spring loaded jaws with horizontal and vertical jigs which allow it to adapt well to any slot 19. A scalpel can be used to trim the margins all the surfaces till the gingival margin (Fig 15). 20. A blunt instrument is wegded under the tray from the lingual with direct pressure under the brackets to ensure their removal along with the tray (Fig 16). 21. The tray is light-cured from the inside to ensure maximum curing of the bracket pads. 22. The resin pads are sandblasted with a micro-blaster using 50 micron alumina (Fig 17). 23. Each bracket is then removed from the tray, and the excess resin around the pad is trimmed with a hand piece and smoothened (Fig 17).

Fig. 19 : Cleaning and finishing of bracket bases

24. Any extensions which may hinder insertion including inter-dental spaces are trimmed (Fig 18). Additional care should be taken to remove Memosil from under large brackets and brackets with hooks to facilitate easy removal of tray and minimize stress. (Fig 18) 25. The tray is cleaned under gentle steam \pressure, followed by water and then dried with compressed air. Individual brackets are then cleaned with a brush followed by acetone or isopropyl alcohol on a cotton micro-brush (Fig 19). 26. The brackets are replaced into the tray with tweezers. The tray is ready after mild steam cleaning followed by wiping with acetone (Fig 20).

DISCUSSION:
Lingual Orthodontics is a precision sensitive technique. The proper positioning of, and value incorporation in the brackets are the most critical aspects in ensuring a smooth, efficient and uncomplicated treatment 15

Fig. 20 : Finished trays

procedure. The laboratory procedures which are mandatory for this to be achieved require sensitive armamentarium designed to achieve exactitude. Several systems like the TARG system 7, the Slot Machine8, the CLASS system9, the KIS system10, the BAS 11 , Lingual Bracket Jig 12 , etc which aim to accomplish this are available commercially. The TAD and BPD device system greatly enhances the accuracy of value incorporation and bracket positioning in comparison to any of the previously available systems. Intensive testing and cross referencing revealed inaccuracies of up to +/-30 in the TARG. The TAD on the other hand is accurate to 0.10. In a previous article / study in the WJO (Crown Inclination of Northern Thai with good Occlusion: A Measurement by Orthodontic Torque Angulation Device (TAD), the Pearson correlation coefficient of the TAD using different operators on intra-calibration (336 data) was 0.978. The other significant advantages over other systems are: Complete digital readings thereby increasing precision. Flattest base among available systems (2 Micro mm). The vertical rod is free of the horizontal sliding calipers (Mitutoyo Digimatic) unlike the TARG where the jaws hang from the vertical rod which may result in erroneous readings. The torque blades which are different for each tooth in the TARG have play of 30.The TAD exhibits an accuracy of up to 0.1o. Up to 350 of positive or negative values can be incorporated depending on requirements to suit labial or lingual prescriptions. Traditional cephalometry calculates proclination values by measurements on the central incisor. The TAD individually measures each tooth to derive true values. The BPD has spring loaded jaws which allow it to adapt well to any slot. It has horizontal and vertical jigs for both slots (Fig 21). Molar tubes have a different jig for ease in placement. The readings can be conveniently stored in a computer by push of a button.

which is imperative for lingual orthodontics. It allows the operator to measure the torque and angulation values of the initial malocclusion and to formulate custom prescriptions and compensations in lieu with the clinicians requirements. It can prove to be a useful tool in research as well as to establish normative values for different populations. The armamentarium is economical and all the steps are fast, easy, clear, precise and most importantly, reproducible.

REFERENCES:
1. Gwinnett, A., Gorelick, L.: Microscopic evaluation of enamel after debonding: Clinical application. Am. J. Orthod., 73:651-655, 1977. Zachrisson, B.U., Arthun, J.: Enamel surface appearance after various debonding techniques. Am. J. Orthod., 75:121-137, 1979. Volume 1986 Apr(252 - 261): Keys to Success in Lingual Therapy- Part 1 - JOHN R. SMITH, DDS, MSD; JOHN C. GORMAN, DMD, MS; CRAVEN KURZ, DDS; RICHARD M. D, Sinclair, P.M.; Cannito, M.F.; Goates, L.J.; Solomos, L.F.; and Alexander, C.M.: Patient responses to lingual appliances, J. Clin. Orthod. 20:396-404, 1986. Volume 1997 Oct(689 - 694): Improving Patient Comfort with Lingual Brackets DIDIER FILLION, D Alexander, R.G.: The Alexander Discipline: Contemporary Concepts and Philosophies, Ormco, Glendora, CA, 1986, pp.371-394. Fillion, D.: The resurgence of lingual orthodontics, Clinical Impressions, 7:2-9, 1998. Creekmore, T.D.: Lingual orthodontics-its renaissance. Am. J. Orthod. 96:120-137,1989. Huge, S.A.: The Customized Lingual Appliance Set-Up Service (CLASS) System, in Lingual Orthodontics, ed. R.Romano, B.C. Decker, Hamilton, Ont., 1998, pp.163-173.

2.

3.

4.

5. 6.

7. 8. 9.

10. Kim Taeweon, BaeGi-Sun, Cho Jaehyung.: New Indirect Bonding method for lingual orthodontics. J. Clin. Orthod. 34;6:348-350,2000. 11. Weichmann, D.: Modulus-Driven Lingual Orthodontics. Clinical Impressions, 10(1)27,2001. 12. Geron S.: The lingual bracket jig. J. Clin. Orthod. 33:457-63, 1999. 16

CONCLUSION:
The TAD and BPD system, by overcoming several key drawbacks of previously available techniques, greatly enhances the accuracy in indirect bonding procedures

CHHATTISGARH DENTAL COLLEGE & RESEARCH INSTITUTE


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Salient Features :
The First & Foremost Dental College in Chhattisgarh. Only Private College in Chhattisgarh Recognised by Ministry of Health & Family Welfare & Dental Council of India, New Delhi. Post Graduate Courses in Oral Medicine and Radiology & Conservative Dentistry and Endodontics with 2 Seats each from the Academic Session 2009-10. An ISO 9001:2000 Certified Institute. Affiliated to Pt. Ravishankar Shukla University, Raipur Built up Area above 2 Lac. Sq. Ft. Highly Experienced & dedicated Teaching Faculty for UG & PG Courses. Large & Well attended Dental OPD. Well Equipped Laboratories with Ultra Modern and Sophisticated Instruments. Large Library with National & International Publications/Journals.

EVALUATION OF TRUE INCISOR INTRUSION ATTAINED WITH MINI-IMPLANT ANCHORAGE SYSTEM FOR THE CORRECTION OF DEEP OVERBITE
Authors:

Dr. U.S. Krishna Nayak (Professor and Head) MDS, F.I.C.D, F.P.F.A, F.A.D.I, F.W.F.O. Department of Orthodontics and Dentofacial Orthopedics, A.B. Shetty Memorial Institute of Dental Sciences, Deralakatte, Mangalore, Karnataka, India. Dr. M.N. Kuttappa (Professor)
Department of Orthodontics and Dentofacial Orthopedics, A.B. Shetty Memorial Institute of Dental Sciences,

Dr. Ashutosh Shetty (Associate Professor)


Department of Orthodontics and Dentofacial Orthopedics, A.B. Shetty Memorial Institute of Dental Sciences.

Dr. Farhat Godhrawala (Post-graduate student)


Department of Orthodontics and Dentofacial Orthopedics, A.B. Shetty Memorial Institute of Dental Sciences, Tel. No : 09886532137 E-mail : farhat.godhrawala@gmail.com Abstract The aim of this study was to investigate the amount of true incisor intrusion achieved using mini-implants. Seven patients with deep overbite and with increased upper incisor/anterior gingival displaywere the sample for our study. After leveling of the maxillary central and lateral incisors with a segmented arch, an intrusive force of 50 gms using Niti closed coil springs was applied from a mini-implant placed between the roots of the two central incisors. The amount of intrusion was evaluated on lateral cephalograms taken at the end of leveling (T1) and 4 months later (T2). The mean incisor intrusion achieved with mini-implants was 3.29mm with standard deviation of 1.11. The mean molar extrusion seen with mini-implants was 0.29 mm with standard deviation of 0.49. The mean of the change in incisor inclination is 0.14degrees with standard deviation of 2.04. The results of this study revealed that true incisor intrusion can be achieved with the use of mini-implants.

INTRODUCTION
Deep overbite is a common component of malocclusion in adults and children. Non surgical treatment alternatives include molar extrusion, incisor intrusion or a combination of both.1 In patients with vertical growth tendencies and patients with increased incisal show, opening the bite by extruding the posterior occlusion would not be recommended. For these patients, true incisor intrusion is the treatment of choice.2 Incisor intrusion can be achieved with various treatment modalities.The most commonly used is the utility arch technique given by Dr Ricketts. But according to 18

Newtons third law of motion, every action has an equal and an opposite reaction, making it virtually impossible to achieve absolute anchorage in which the reaction force does not bring about extrusion of molars. Traditionally, extraoral anchorage has been used to reinforce intraoral anchorage. The use of extraoral anchorage ideally demands full cooperation of the patient for continuous appliance wear, an objective that is difficult to achieve. In mini-implant anchorage system, forces can be applied to produce tooth movement in any direction without detrimental reciprocal forces. This study was to analyze the incisor intrusion achieved skeletal anchorage system.

MATERIALS AND METHODS


The sample of this study consistedof 7 patients with deep overbite and with increased upper incisor/anterior gingival display. An informed consent was taken. Patients were treated with mini-implants in the interradicular bone in maxillary arch. The inclusion criteria was: 1. Patients with deep overbite and increased incisor / anterior gingival display. 2. No active growth left according to cervical 3 vertebrae analysis. The exclusion criteria was 1. Patients with active periodontal disease. 2. Severe craniofacial disorders, such as cleft palate or extensive prosthetic appliances. 3. Medically compromised cases. The sample patients were treated using PEA appliance with 0.022 slot Roth prescription. After the initial alignment of the incisors with 0.016 Niti wire; miniimplants were placed.

The mini-implants used were of the self tapping variety (Leone mini-implants 8mm in length and 2mm in diameter). The surgical procedure is as follows4. A surgical guide was made from a rectangular wire segment to help identify the mini-implant location on the IOPA. (FIG 1, FIG 2) Under local anesthesia, a punch cut was given in the region of the labial frenum in between the maxillary central incisors to denude the alveolar bone. The bone corresponding to the guide wire was drilled with a 1.5 mm. pilot drill using saline irrigation, as far as the length of the mini-implant. The implant was inserted using a miniature screw driver. The position of the mini-implant was documented with an IOPA. (Fig. 3).

Fig. 3 : IOPA after placement of the Mini-Implant after placement of the Mini-Implant Fig. 1 : Intraoral Guide Wire Placement Post-operative antibiotics and analgesics were given to the patient. After an healing period of two weeks , the implant was loaded with a Niti closed coil spring. A force of approximately 50gms was applied from the spring to an 0.018 A J Wilcock base archwire connecting the four incisors and the first molars. The wire was cinched back on the molars to prevent flaring of the incisors. Standardized lateral cephalograms were taken before the mini-implant placement at the end of leveling (T1) and at the end of intrusion 4 months later (T2). Each cephalogram was traced on acetate paper with 0.3mm lead pencil. Two linear and one angular measurements were selected for cephalometric analysis. (FIG 4) 1. Vertical position of the maxillary incisors: perpendicular distance from the midpoint between 19

Fig. 2 : IOPA to Assess the position of the Guide Wire

B. MAXILLARY MOLAR EXTRUSION The mean molar extrusion seen with mini-implants was 0.29 mm with standard deviation of 0.49. C. CHANGE IN INCISOR INCLINATION The mean of the change in incisor inclination is 0.14 degrees with standard deviation of 2.04.

DISCUSSION
The purpose of this study was to quantify overbite correction achieved by mini-implants. Before treating a deep-bite case, it is necessary to determine its cause. The problem may be due to a reduced lower face height and lack of eruption of the posterior teeth or due to the over eruption of the anterior teeth. It is widely accepted that correction of deep bite by extrusion of posterior teeth is both more difficult to accomplish and less stable when it is performed on non growing patients than when it is attempted on those with appreciable growth remaining. Therefore in nongrowing individuals, intrusion of incisors is preferred since it is more stable and along with the correction of deep bite, it helps in the correction of unaesthetic gummy smiles. The sample of our study consisted of 7 patients with deep bite and gummy smiles. In our study the mean true incisor intrusion achieved with mini-implants was 3.29mm. According to the meta-analysis conducted by Julia NG et al 2 incisor intrusion attained during orthodontic treatment in non growing patients by the segmented arch technique was 1.5mm of incisor intrusion in maxillary arch and 1.9mm in the mandibular arch. Also the results of our study are similar to the ones using mini-implants done by Creekmore 5who intruded the maxillary incisors by 6mm in one year, by Kanomi 4 in which the mandibular incisors were intruded by 4mm in six months, by Ohnishi et al 6who intruded maxillary incisors by 3.5mm, by Kim et al7 who reported 4mm of maxillary incisor intrusion in 7 months and Omur PolatOzsoy8 who reported 1.92mm of upper incisor intrusion 4.5 months. Utility arches used for incisor intrusion creates a force system that tends to elongate the molars. In actively growing patients with a good facial pattern this is not a major problem. However, in non-growing patients or those with a poor facial pattern (vertical growers), molar extrusion should be avoided. As a result, the lack of posterior anchorage compromises the ability to intrude the incisors. In our study the mean molar extrusion seen with mini-implants was 0.29 mm. Since the implants were used as a source of anchorage for the 20

Fig. 4 :1. Perpendicular distance from the midpoint between the incisal edge and the apex of the tooth along the long axis (C) to the palatal plane (PP) was measured. 2. Perpendicular distance from the mesio buccal cusp tip of the molar to the palatal plane was measured. 3. Angle between the long axis of the maxillary incisor and the sella-nasion plane (SN plane) was measured. the incisal edge and the apex of the toothalong the long axis (C) to the palatal plane (PP) was 1 measured. 2. Vertical position of the maxillary first molar: perpendicular distance from the mesio buccal cusp tip of the molar to the palatal plane was measured. 3. Change in the inclination of the maxillary incisors: angle between the long axis of the maxillary incisor and the sella-nasion plane (SN plane) was measured.

RESULTS
A. MAXILLARY INCISOR INTRUSION The mean incisor intrusion achieved with mini-implants was 3.29mm with standard deviation of 1.1.

incisor intrusion, the reciprocal forces were not produced at the molars and therefore the side effects like molar extrusion was not seen. The mean of the change in incisor inclination is 0.14degrees with mini-implants. The base archwire was cinched back to prevent flaring of the teeth since the point of force application was buccal to the centre of resistance. Change in the inclination of incisors can bring about relative intrusion of the teeth. If true incisor intrusion is to be calculated, incisal edge cannot be used as a reference since change in the inclination of the crown will change the position of the incisal edge also. Therefore, incisal edge and the root apex are not good reference points. The incisor centroid, defined as a point on the longitudinal axis of the tooth that is independent of any change in inclination, is the reference point of choice.9 fferent approaches to localize the centroid have been reported9,10,11. our study we used the midpoint between the incisal edge and the apex of the upper incisor 1,9the palatal plane was used as the reference plane9,11. Fig. 5 : Case 1

None of the implants showed mobility during the course of the treatment. This could be due the fact that the patients were asked to maintain excellent oral hygiene and clean the region of the implants with chlorhexidine mouthwash to reduce plaque accumulation and thereby control inflammation which is a crucial factor for the clinical success of the miniimplant.12 Mild external root resorption was seen in both groups of patients. Park and Harris13 that incisor intrusion and apical displacement with lingual tipping are highly correlated with external root resorption compared to other types of tooth movement. Nanda and Costopoulos 14 that low forces can cause dental intrusion sufficient to correct a deep bite with minimal apical resorption. Therefore in our study we used light continuous forces to bring about the desired tooth movement. From the results of our study we can say that, in order to reduce deep bite and gummy smiles by intruding the incisors, followed by surgical crown lengthening later, implants are very effective as compared to other non-surgical treatment modalities. Molar extrusion is

PRE-TREATMENT

POST-INTRUSION

SUPER IMPOSITION 21

Fig. 6 : Case 2

PRE-TREATMENT

POST-INTRUSION

SUPER IMPOSITION Fig. 7 : Case 3

PRE-TREATMENT

POST-INTRUSION

SUPER IMPOSITION 22

Fig. 8 : Case 4

PRE-TREATMENT

POST-INTRUSION

SUPER IMPOSITION

not seen with implants. There is no significant change in the inclination of incisors with mini-implants provided the base arch wire is cinched back at the molars.

Table I : VERTICAL POSITION OF THE INCISORS


Serial No. 1. 2. 3. 4. 5. 6. 7. Vertical Position of Incisors-Pre 36 mm 29 mm 29 mm 31 mm 27 mm 30 mm 35 mm Vertical Position of Incisors-Post 32 mm 25 mm 28 mm 27 mm 24 mm 27 mm 31 mm Difference 4 4 1 4 3 3 4

CONCLUSION
From our present study, with an aim to quantify the amount of true incisor intrusion achieved with skeletal anchorage system we can conclude that the miniimplant technique for true incisor intrusion can be considered superior to other treatment modalities. Also considerable amount of true intrusion is achieved in a relatively short period of time. Vertical height of molars does not change with implants. Change in inclination of incisors does not change with implants provided the wire is cinched back at the molar. 23

Table II : VERTICAL POSITION OF THE MOLARS


Serial No. 1. 2. 3. 4. 5. 6. 7. Vertical Position of Molar-Pre 27 mm 25 mm 22 mm 30 mm 26 mm 28 mm 29 mm Vertical Position of Molar-Post 27 mm 25 mm 22 mm 31 mm 27 mm 28 mm 29 mm Difference 0 0 0 1 1 0 0

Table III : INCISOR ANGULATION


Serial No. 1. 2. 3. 4. 5. 6. 7. Incisor Angulation Pre (Degrees) 104 113 107 120 130 128 115 Incisor Angulation -Post4 102 113 109 117 132 130 115 Difference -2 0 2 -3 2 2 0

REFRENCES
1. Weiland FJ, Bantleon HP, Droschl H. Evaluation of continuous arch and segmented arch leveling techniques in adult patients-a clinical study. Am J Orthod Dentofacial Orthop 1996;110: 647-52. 2. Julia NG, Major PW, Heo G, Flores-Mir C. True incisor intrusion attained during orthodontic treatment:A systematic review and meta-analysis. Am J Orthod Dentofacial Orthop 2005; 128:212-19. 3. Hassel B, Farman AG. Skeletal maturation evaluation using cervical vertebrae. Am J Orthod Dentofacial Orthop 1995;107:58-66. 4. Kanomi R. Mini-implant for orthodontic anchorage. J Clin Orthod 1997;31:763-67. 5. Creekmore TD, Eklund MK. The possibility of skeletal anchorage. J Clin Orthod 1983;17:266-69. 6. Onishi H, Yagi T, Takada K. A mini-implant for orthodontic anchorage. Angle Orthod 2005;75:444-52. 7. Kim TW, Kim H, Lee SJ. Correction of deep overbite and gummy smile by using a mini-implant with a segmented wire in a growing Class II Division 2 patient. Am J Orthod Dentofacial Orthop 2006;130:676-85. 8. Omur Polat-Ozsoy, Ayca Arman-Ozcirpici, Firdevs Veziroglu. Miniscrews for upper incisor intrusion. Eur J Orthod 2009

9. Kinzel J, Aberschek P, Mischak I, Droschl H. Study of the extent of torque, protrusion and intrusion of the incisors in the context of Class II, div 2 treatment in adults. J Orofac Orthop 2002;63:283-99 10. Hong RK, Hong HP, Koh HS. Effect of reverse curve mushroom archwire on lower incisors in adult patients: a prospective study. Angle Orthod 2001;71:425-32. 11. Mark G. Hans, Craig Kishiyama, Stephan H. Parker, Regine Noachtar. Cephalometric evaluation of two treatment stratergies for deep overbite correction. Angle Orthod 1994;64: 265-276. 12. Hyo-Sang Park, Seong-Hwa Jeong, Oh-Won Kwon. Factors affecting the clinical success of screw implants used as orthodontic anchorage. Am J Orthod Dentofacial Orthop 2006; 130:18-25 13. Parker RJ, Harris ER. Directions of orthodontic tooth movement associated with external apical root resorption of the maxillary central incisor. Am J Orthod Dentofacial Orthop 1998;114: 677-83. 14. Costopoulos G, Nanda R. An evaluation of root resorption incident to orthodontic intrusion. Am J Orthod Dentofacial Orthop 1996; 109:543-8

24

IGF - I : A LEGITIMETE SKELETAL MATURITY INDICATOR


(Prize Category : 1st Prize, Research Category 13th IOS PG Convention 2009, Davangere)
Author Name :

Dr. Nameeta Kaur


P.G. Student, D.J. College of Dental Sciences & Research, Modinagar. E-mail : nameetakaur@yahoo.com
Dr. Nameeta Kaur

Dr. Reena R. Kumar


Principal, Professor & Head, Dept. of Orthodontics & Dentofacial Orthopedics, D.J. College of Dental Sciences & Research, Modinagar. E-mail : drreena1296@rediff.com

Dr. Reena R. Kumar

Dr. Anil Miglani


Professor, Dept. of Orthodontics & Dentofacial Orthodontics, Modinagar. E-mail : anilmiglani@yahoo.com
Dr. Anil Miglani

ABSTRACT :

Assessment of skeletal maturity is critical to the modality and timing of treatment of various skeletal abnormalities. Since lateral cephalometric radiographs are routinely taken for orhtodontic patients, using the cervical vertebrae from these radiographs to assess skeletal maturity has been especially appealing to orthodontists. Apart from additional radiographic exposure and subjectivity of staging the x-rays, an inherent disadvantage of cervical vertebral stages and hand wrist radiographs is that the final stage of development does not necessarily indicate the completion of growth. In addition lateral tipping of a vertebrae by about 30* may lead to disappearance of curvature on an x-ray which accounts for the absence of curvature on the inferior borders of otherwise mature looking vertebrae. Keeping in view the radiographic artefacts associated with the lateral cepholograms which may mislead the practitioners, it was decided to conduct a study on 13 female and 10 male subjects to assess the skeletal maturity by testing serum insulin-like growth factor 1 (IGF-I) levels. Results from this study indicate that the IGF-I levels are low in the pre-pubertal cervical skeletal stages, rise sharply to their peak in puberty, and decline to approach pre-pubertal levels after puberty. Skeletal maturity, IGF-I, residual growth

KeyWords :

INTRODUCTION
In 1957, Salmon and Daughaday discovered IGF-I, or insulin - like growth factor I as a mediator of the growth hormone (GH) functions. IGF-I was first detected in serum and is a circulating growth hormone-dependent factor, the level of which correlates with sexual maturity. It is used to diagnose growth hormone 25

deficiencies and excess. Precise assessment of IGF-I is useful diagnostic tool for determining GH stastus as its levels do not fluctuate throughout the day unlike the GH levels. IGF-I is measurable is serum, urine and saliva. The levels of IGF-I in saliva are considerably low, nearly less that 1% of serum levels. Additionally, measurements taken from Salivary IGF-I are likely to be inaccurate because of contamination with gingival

fluid or blood. Serum IGF-I measurement is a relatively new, minimally invasive technique and the samples are stable at room temperature for up to two weeks. Accurate determination of skeletal maturity is crucial to the timing fo various orthodontic, orthognathic, and dental implant decisions. The current use of cervical vertebral stages and hadn-wrist radiographs are subjective techniques that involve additional radiographic exposure and lack the ability to determine the intensity of the growth spurt. The use of the radiographs may bias the results as curvatures of about 300 disappear on an x-ray due to lateral tipping of visibly mature vertebrae1. Moreover, studies have shown that chronologic age and dental age are both poor predictors of the pubertal growth spurt2,3. Hence serum IGF-I levels could play a role in the determination of the pubertal status of the patient and as an indicator of residual growth.

who staged the cephalograms were blinded about each patients age, pubertal status and IGF-I levels. The cervical staging technique as described by Baccetti4 was used to stage the vertebrae. Curvatures were defined when the depth of the curvature was 1 mm or greater, and a millimetric rules was used to measure the posterior and inferior borders to determine vertebral shape (Fig.V). IGF-I levels were then subsequently correlated to cervical vertebrae stages.

C. Statistical Analysis :
Analysis of variance (ANOVA) and Spearmans RANK correlation coefficient were used to compare mean IGF - I levels corresponding to the cervical skeletal maturation stages. Correlations were performed to determine the IGF-I levels relating to the various cervical skeletal maturation stages. (Graph I).

AIM AND OBJECTIVES


1. To correlate IGF-I levels to the cervical vertebral stages for assessing skeletal maturity in males and females. 2. To compare the mean IGF-I levels with Cervical vertebrae maturation Index (CVMI)

MATERIAL AND METHODS A. Sample :


The present study consisted of twenty three subjects 13 females and 10 males - from the regular OPD of the Department of Orthodontics, D J College of Dental Sciences & Research, Modinagar. The inclusion criteria were patients between the ages of 9 and 23 years, who were either to begin orthodontic treatment, were in treatment, or were in post treatment follow-up. Exclusion criteria were systemic illness, growth abnormality, and bleeding disorders. The Study was cleared by the Institutional Ethical Commitee.

Figure I : Blood samples stored in an ice box

Figure II : The Centrifuge

B. Procedure :
Blood samples were collected by using kits supplied by Super Diagnostics. The samples were stored in an ice box (Fig I) and sent to the laboratory, where they were centrifuged (Fig II & III) to separate the serum (Fig IV) The samples were subsequently enzyme immunoassayed for IGF - I levels at Super Religare Diagnostics, NewDelhi. Lateral cephalograms were obtained as part of the standard treatment diagnostic protocol. The operators 26 Figure III : Samples being centrifuged

Figure IV : Separation of serum

positive correlation between IGF-I levels and cervical vertebral staging from CS1 to CS4 by showing a gradual increase from CS1 to CS2 (164.96 to 181.52 ng/ml) a sharp increase from CS2 to CS3 (295.12 ng/ml) a gradual increase in CS4 (304.94 ng/ml). A negative correlation was seen thereafter in CS5 222.20 and CS6 (and 135.32 ng/ml) to approach the pre-pubertal levels (Graph I ). The Pearson linear correlation coefficient of +0.68(p>.01), whereas the correlation from CS1 to CS4 showed a correlation coefficient from CS4 to CS6 was -0.676 (p>.01). In CS6, IGF-I levels correlated negatively with chronologic age and the number of months reported to have passed since the onset of puberty with correlation coefficients of -0.531 and -0.522, respectively. Table I : IGF - I levels correlated to the CVS in males C.S 1 2 3. 4. 5. 6. n (%) 20 20 20 20 20 Mean IGF (ngm/mL) 160.30 177.10 289.60 299.20 135.36

Figure V : Cervical staging technique by Baccetti used to stage the vertebrae

Table II : IGF - I levels correlated to the CVS in females C.S 1 2 3. 4. 5. 6. n (%) 15.38 15.38 15.38 15.38 15.38 15.38 Mean IGF (ngm/mL) 169.62 185.94 300.64 310.69 222.20 144.3

Graph I : Correlation of IGF-I levels to the cervical vertebral stages

RESULTS
The IGF - I levels in females were higher than in males at all ages. Table I & II Show the correlation of cervical staging with IGF-I levels in males and females respectively. The male subjects exhibited the highest (299.20 ng/ml) and the lowest values (135.36 ng/ml) of IGF-I with a mean of 212.31 ng/ml at the cervical vertebrae stages CS4 and CS6 respectively. Female subjects exhibited the highest (310.69 ng/ml) and the lowest (126.3 ng/ml) values at CS4 and CS6 with a mean value of 208.52 ng/ml. The mean value of IGF-I from the pooled data of the total sample was highest at CS4 with levels of 304.94 ng/ml and lowest at CS6 with 135.32 ng/ml (Table III). The results showed a 27

Table III : Average pooled data to correlate cervical staging to mean IGF - I levels C.S 1 2 3. 4. 5. 6. n (%) 16.66 16.66 16.66 16.66 8.33 25 Mean IGF (ngm/mL) 164.96 181.52 295.12 304.94 222.20 135.32

DISCUSSION
Cervical vertebrae stages and hand-wrist radiographs currently used to identify peak mandibular bone growth lack the ability to determine the intensity of the growth spurt and its cessation. Additionally, the radiographic artefacts associated with lateral cepholagrams justifies the need to look at serum IGF-I levels as a skeletal maturity indicator. Both GH and IGF-I are important factors for pubertal growth spurt as demonstrated by Mohan.etal5. IGF-I levels do not fluctuate and it has an added benefit of being directly stimulated by androgens in the pre-pubertal stages. It has also been found to play a principal role in local and systemic regulation of longitudinal bone growth. The results of the present study are similar to that of the study conducted by Juul A6 which reported mean serum IGF-I concentration increased slowly in pre-pubertal children from 80 to 200 g per litre with a further steep increase during puberty to approximately 500 g per litre. Post-pubertal circulating IGF-I levels continued to fall to approximately 250 g per litre at 25 years of age. The study conducted by Mohamed Masoud1 on Saudi Arabian population reported a sharp increase in IGF-I levels from CS3 to peak levels at CS5 (208.68 ug/L to 406.82 ug/L) whereas there was a decline between CS5 and CS6 (199.75 ug/L at CS6).In contrast the present study indicated maximum levels of IGF-I in CS4. In the present study, two female subjects, both at CS6 stage of their skeletal maturity presented contrasting IGF-I levels of 126.3 and 143.3 ng/ml. This variance was essentially due to the differences in the number of years post-pubertal which was five and three years respectively. This indicated the negative correlation of IGF-I to cervical skeletal maturity with increasing chronologic age. One of the male subjects at CS6 stage exhibited high levels of IGF-I (222.2 ng/ml). This increased level of serum IGF-I is indicative of residual growth in this male subject.

A multi-centered longitudinal study, with a larger sample size in the future could help to tabulate more authentic data.

BIBLIOGRAPHY
1. Masoud M., Masoud I, Kent R.L : Assessing skeletal maturity by using blood spot insulin-like growth factor I (IGF-I) testing : Am J Orthod Dentofacial Orthop 2008;134:209-16

2. Fishman L.S : Radiographic evaluation of Skelekal Maturation : A clinically oriented method based on hand wrist films. : Angle Orhod,1982:52, 88-112. 3. Fishman LS. Maturation patterns and prediction during adolescence Angle Orthod, 1987;57: 178-93. 4. Baccetti T, Franchi L, McNamara JA Jr. The cervical vertebral maturation (CVM) method for the assessment of optimal treatment timing in dentofacial orthopedics. Sem in Orthod 2005;11:119-29. 5. Mohan S, Richman C, Guo R, Amaar Y, Donahue LR, Wergedal J, et al. Insulin-like growth factor regulates peak bone mineral density in mice by both growth hormone dependent and independent mechanisms. Endocrinology 2003;144:929-36. 6. Juul A, Bang P, Hertel NT, Main K, Dalgaar P, Jorgensen K : Serum insulin-like growth factor-I in 1030 healthy children, adolescents, and adults : relation to age, sex, stage of puberty, testicular size, and body mass index. J Clin Endocrinol Metab 1994;78:744-52. 7. Hassel B, Farman AG. Skeletal maturation evaluation using cervical vertebrae. Am J Othod Dentofacial Orthop 1995;107:58-66. 8. Mitani H, Sato K, Sugawara J, Growth of mandibular prognathism after pubertal growth peak. Am J Orthod Dentofacial Orthop 1993;104: 330-6. 9. Enlow D, Hans M. Essentials of facial growth. Philadelphia:W.B. Saunders ;1996 p.65-72. 10. Ten Cate R. Oral histology. 5th ed. St Louis : Mosby-Year Book, 1998. p.389-94.

CONCLUSION
1. IGF-I levels have a positive correlation with cervical skeletal maturity from the pre pubertal to the late pubertal stages and a negative correlation from the late pubertal to the post pubertal stages. 2. IGF-I may be used as a feasible skeletal maturity indicator and finds applicability as a virtual indicator of residual growth.

28

LASER ETCHING OF ENAMEL FOR DIRECT BONDING AN INVITRO STUDY


Authors:

Dr. Rajesh Reddy K., MDS, Morth RC SEd.


Associate Professor

Dr. Kishore M.S.V., MDS, Morth RC SEd.


Associate Professor
Dr. Rajesh Reddy K.

Dr. K. Sadashiva Shetty, MDS


Professor and Head Department of Orthodontics, Bapuji Dental College and Hospital, Davangere - 577 004, Address for Correspondence :

Dr. Rajesh Reddy K.


Sowbhagya Dental Center, 8-2-502/1/A/B, Sowbhagya Abode, Road No. 7, Banjara Hills, Hyderabad - 500 034, Andra Pradesh, Mob. : +91 94405 63555. E-mail : kuchkullar@yahoo.com Abstract : The aim of theDr. Kishore determine the shear bondSEd. study was to M.S.V, MDS, Morth RC strength of mesh shaped stainless steel Associate Professor orthodontic brackets, bonded to acid etched enamel and laser etched enamel and to compare the shear bond strength following acid etching and laser etching. 50 non carious extracted premolar teeth divided in to 5 groups of 10 each were employed in the study. The buccal surfaces of group - I were subjected to conventional etching using 37% phosphoric acid for 30 seconds, while the other four groups were subjected to Nd:YAG laser etching at different power settings of 80mj, 100mj, 150mj and 200mj respectively for 15 seconds. Brackets were later bonded on to these teeth using Ultimate- light curing primer and adhesive. The shear bond strength of each sample was determined using a universal testing machine and the results were evaluated. Acid Etching, Laser Etching, Bond strength.

Key words :

INTRODUCTION
Orthodontic clinicians have long been interested in the development of methods by which orthodontic brackets could be attached directly to the teeth. This bandless system which eliminates the placing of metal bands with attached brackets as a means for spatial control of teeth during orthodontic tooth movement has several advantages over the full band system. 29

The classical micromechanical method of bonding resins to enamel consists of cleaning the enamel, etching it with phosphoric acid, rinsing and drying it. This acid etching method has been used to promote adhesion since Buonocore (1955), first described the technique to increase the bond strength of resins to enamel, following which Neumann in 1965 applied it to direct bonding of orthodontic brackets. However, the acid etch technique had several undesirable sequelae, which include loss of enamel, enamel cracks

and scratches, enamel decalcification, caries and retention of resin tags with indelible staining. Attempts were made to overcome these problems by crystal growth solutions and sand blasting, but, all these methods resulted in poor bond strength. Recent advances in laser technology and research into its potential have set the stage for a revolution in dental practice. Orthodontic applications of laser treatment were based on the outcome of the earlier studies on laser effects of enamel. There have been conflicting reports by researcher's regarding the viability of using laser etching as an alternative to acid etching. Laser etching produces microscopic cracks, fissures and craters in the enamel surface than conventional demineralization of enamel. It was also noted that lasers induce caries resistance, which would be of interest in orthodontic bonding. The present study is aimed at evaluating the viability of using laser etching as an alternative to routine acid etching.

Group - III: Laser etched group irradiated at 100 milli joules. Group - IV: Laser etched group irradiated at 150 milli joules. Group - V: Laser etched group irradiated at 200 milli joules. Teeth in each group were mounted vertically on different color coded acrylic blocks for subsequent identification. The buccal surfaces of group - I were subjected to conventional etching using 37% phosphoric acid for 30 seconds, while the other four groups were subjected to Nd:YAG laser etching at different power settings of 80mj, 100mj, 150mj and 200mj respectively for 15 seconds. Since there is little surface absorption of the laser beam by enamel, it was coated with a light absorbing material as an initiator (black Indian ink), with the nylon brush over an area slightly greater than that of the bracket base. Brackets were later bonded on to these teeth using Ultimate light curing primer and adhesive. The primer was applied on each etched surface of the teeth in their respective groups and cured. The adhesive paste was applied on to the bracket base and brackets were placed on the long axis of the tooth. Excess adhesive was removed with a sickle scaler and cured with visible light at 450 nm for a 20 second burst to each of the mesial, distal, incisal and gingival margin. The bonded specimens were stored in distilled water for one week before determining the shear bond strength. The shear bond strength of each sample was determined with a Hounsfield universal testing instrument. The cross head speed was 1mm/min and the force values at the point of bond failure of the bracket were recorded. The ultimate shear bond strength was recorded in kilograms and converted to megapascals. Shear bond strength of each sample was calculated using the formula: Bond strength = Breaking Load / Nominal area of bonding. The collected data was subjected to statistical analysis by using one way analysis of variance and the Newman-Keul's multiple range tests at 95% levels of confidence.

AIMS AND OBJECTIVES:


The following objectives are accomplished by this study. 1. To determine the shear bond strength of mesh shaped stainless steel orthodontic brackets when bonded to acid etched enamel and laser etched enamel. 2. To compare the shear bond strength values of acid etched and laser etched enamel and thereby to determine if laser etching can be used as an alternative method.

MATERIALS AND METHODS:


Fifty sound non-carious premolar teeth extracted for orthodontic purpose were selected for this study. The extracted teeth had to meet certain criteria before use. They had to be grossly perfect on buccal surface, devoid of cracks from extraction forceps, be free of caries and have had no pretreatment with a chemical agent such as alcohol, formalin or hydrogen peroxide. These teeth were thoroughly cleaned of any soft tissue, blood and were stored immediately in distilled water to prevent dehydration. The samples were randomly divided into five groups consisting of 10 teeth in each group. They are grouped as: Group - I: Acid etched group conditioned with 37% phosphoric acid for 30 seconds. Group - II: Laser etched group irradiated at 80 milli joules. 30

RESULTS:
One way ANOVA test revealed that different groups exhibited different bond strengths with Group - I showing the highest bond strength followed by Group-V, Group-IV, Group-III and least with Group-II.

Group-I showed significant difference in bond strength with other groups except for Group-V which is statically not significant. On the other hand there was a significant correlation between laser etching and shear bond strength. As the laser etching power increased from 80 mj to 200 mj, the bond strength also increased. On an average, for every 10 mj increase in power, the bond strength increased by 0.5 Mpa. Tables I to VIII shows the values measured and comparisons of all the groups.

DISCUSSION:
Acid etch technique for bonding composite resins to enamel has revolutionized the practice of esthetic dentistry. Buonocore4 was the first to demonstrate that, the bonding of acrylic filling materials to enamel could be substantially increased by conditioning the enamel surface with 37% phosphoric acid. However, following acid etching some amount of enamel is lost making the surface more susceptible to demineralization and initiation of caries around the brackets, which is the major drawback in acid etching. The advantage of laser etching is that, laser itself induces caries resistance producing microscopic cracks, fissures and craters on the enamel that enhance mechanical inter locking with the composite.(Dai.P.Robert Harry 9 ). Various comparative studies between acid etching and laser etching on surface roughness and morphology of enamel have concluded that laser irradiation has caused surface changes similar to that of acid etching. (Arcoria et al3, Shahabi et al40, Ralph. H. Stern et al32, John A. Hess14, Keller & Hibst44 and Osnat Feurstein et al30). The present study evaluates the effectiveness of Nd:YAG laser in conditioning dental enamel for direct bonding of orthodontic brackets and comparing it with conventional acid etch technique. The results of the study show that, the mean shear bond strength value of the acid etched group is 9.24 Mpa, which is the highest comparable value to the laser etched groups. The mean shear bond strength values of laser etching are 2.8 Mpa, 5.51 Mpa, 7.01Mpa and 8.88 Mpa when etched at 80mj, 100mj, 150mj and 200 mj respectively. The shear bond strength of laser etched enamel increased with the power and energy output from the laser unit, a finding consistent with previously reported works. (White.J et al46 and Vonfraunhofer J.A. et al45). Surfaces etched at higher power setting achieved the bond strength which is equal to or above the minimum 31

bond strength needed for the bracket to withstand masticatory forces. (7 mpa By Lopez. J.I.21 and 0.6 kg/ mm2 Vonfraunhofer J.A.36). It was observed that there is an increase in the shear bond strength with an increase in the laser power. Considering this, a statistical prediction was done by taking all the laser etching values and it was found that with increase of laser power by 10 mj there was an increase of 0.5 Mpa in shear bond strength. From these findings it is seen that laser etching can be used as a viable method in preparation of enamel for direct bonding. The effect of laser irradiation on the substrate tooth, notably, the effects on enamel morphology and physiological changes within the deeper structures, await clarification.

SUMMARY & CONCLUSION:


In this study, an attempt was made to use lasers as an alternative method for etching enamel, which may prove a more convenient and time saving procedure in the near technological future. This in-vitro study compared the shear bond strength of brackets adhered to Nd-YAG laser etched enamel with that of brackets adhered to acid etched enamel. The summary of mean shear bond strength of the enamel surfaces etched by laser irradiation and by phosphoric acid was compared. Statistical analysis of the data indicates that, there are significant differences between shear bond strength obtained with laser irradiation and with acid etching of enamel. The bond strengths obtained at the lower power settings (80 mj, 100 mj and 150 mj) showed statistical differences while the bond strength obtained with highest laser power setting (200 mj) was less than that of acid etching but statistically insignificant. However, before concluding that, laser can be used as a substitute to acid etch technique it is necessary to know, the capability of ideal laser system performing hard tissue procedures consistently and effectively, without causing pulpal damage. More research is needed before a potential application of lasers is justified in a clinical setting. Safety and efficacy must be clearly established.

ACKNOWLEDGEMENTS:
The author would like to acknowledge Dr. K. Sadashiva Shetty; my esteemed mentor and tutor through out my life and my colleague Dr. Kishore M.S.V. for their help in compilation of this manuscript.

Fig. 2 : Orthophosphoric Acid Gel (37%) Fig. 1 : Specimens used in the study

Fig. 3 : Nd : YAG Laser Unit

Fig. 4 : Universal Strength Testing Machine (Hounsfield)


32

TABLE -I ENAMEL BOND STRENGTH EVALUATION OF GROUP -1 (Acid etched) Machine Parameters of Test

a) Crosshead Speed b) Grip Distance Specimen No. 1 2 3 4 5 6 7 8 9 10 Mean S.D.

= =

1 mm / min 12 mm KgF 10.37 7.46 8.81 9.14 7.95 10.65 9.94 10.43 7.73 9.94 9.24 1.20 Mpa 10.26 7.38 8.72 9.05 7.87 10.54 9.84 10.32 7.65 9.84 9.15 1.19

33

TABLE - II ENAMEL BOND STRENGTH EVALUATION OF GROUP -2 (Laser etched at 80mj) Machine Parameters of Test

a) b)

Crosshead Speed Grip Distance

= =

1 mm / min 12 mm Sample

Specimen No. 1 2 3 4 5 6 7 8 9 10 Mean S.D.

KgF 4.25 2.86 3.24 2.51 1.74 2.38 1.99 2.85 3.25 3.21 2.83 0.73

Mpa 4.21 2.83 3.21 2.48 1.72 2.36 1.96 2.82 3.22 3.18 2.80 0.72

34

TABLE - III ENAMEL BOND STRENGTH EVALUATION OF GROUP -3 (Laser etched at 100mj) Machine Parameters of Test a) b) Crosshead Speed = Grip Distance = 1 mm / min 12 mm Sample

Specimen No. ` 1 2 3 4 5 6 7 8 9 10 Mean S.D.

KgF 7.35 4.25 3.66 3.53 8.32 5.27 7.94 7.30 3.87 4.22 5.57 1.93

Mpa 7.27 4.21 3.62 3.49 8.23 5.22 7.86 7.22 3.83 4.18 5.51 1.91

35

TABLE - IV ENAMEL BOND STRENGTH EVALUATION OF GROUP -4 (Laser etched at 150mj) Machine Parameters of Test

a) b)

Crosshead Speed Grip Distance

= =

1 mm / min 12 mm Sample

Specimen No. 1 2 3 4 5 6 7 8 9 10 Mean S.D.

KgF 7.71 8.50 8.41 6.55 6.27 5.03 6.89 7.32 6.89 7.28 7.08 1.03

Mpa 7.63 8.41 8.32 6.48 6.21 4.98 6.82 7.24 6.82 7.21 7.01 1.01

36

TABLE - V ENAMEL BOND STRENGTH EVALUATION OF GROUP -5 (Laser etched at 200mj) Machine Parameters of Test

a) b)

Crosshead Speed Grip Distance

= =

1 mm / min 12 mm

Specimen No. 1 2 3 4 5 6 7 8 9 10 Mean S.D.

KgF 7.92 9.33 9.57 7.90 9.96 10.53 7.34 9.02 9.82 8.35 8 8.97 1.05

Mpa 7.84 9.23 9.47 7.82 9.86 10.42 7.26 8.93 9.72 .26 8.88 1.04

37

TABLE - VI SHEAR BOND STRENGTH FOR ACID ETCHING AND DIFFERENT LASER POWER SETTINGS

Shear Bond strength (Mpa) Groups Range Mean SD II

Difference between groups

III

IV

I. Acid Etching
II. LE 80 mj

7.38-10.54

9.15

1.19

P<0.01

PO.01

P<0.01

NS

1.72-4.21

2.80

0.72

PO.01

PO.01

PO.01

III. LE lOOmj

3.49-8.23

5.51

1.91

PO.05

PO.01

IV. LE 150 mj

4.98-9.04

7.01

1.01

PO.05

V. LE200mj

7.26-10.42

8.88

1.04

One way ANOVA

(F = 44.55, PO.01)

New man - Keul's Range test (Pair wise comparisons): Minimum significant Range = 1.5 P 0.05 = 1.9 P< 0.01 I > V > IV > III > II NS Other comparisons are statistically significant *NS: Not Significant

38

TABLE - VII ANOVA TABLE

Source of variation

Sum of squares

Degree of freedom

Mean sum of squares

Variance of ratio, F-value

P-value

Between groups

274.64

04

68.66

Within Groups

44.58 69.30 45 1.54

<0.001

Total

343.94

49

TABLE - VIII CORRELATION BETWEEN LASER ETCHING POWER AND SHEAR BOND STRENGTH

Relationship between

MeanSD

Correlation coefficient V

Regression coefficient 'b'

Prediction equation (prediction of Shear Bond Strength for given Laser Etching

Laser Etching

132.5 + 47.16 + 0.84 0.046 Shear bond strength = 0.046 (Laser Etching Power) - 0.04

Shear Bond strength (Mpa)

6.05 2.55

39

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14. John A.Hess. "Scanning electron mciroscopic study of laser-Induced morphologic changes of a coated enamel surface" Lasers Surg. Med., 1990; 10: 458-462. 15. Jon Artun and Sven Bergland. "Clinical trials with crystal growth conditioning as an alternative to acid etch enamel pretreatment" Am. J. Orthod, 1984;85:333-340. 16. Kenneth L. Zakariasen. "Shedding new light on lasers" J ADA., 1993;124:30-31. 17. Kim Kutsch.V. "Lasers in dentistry: Comparing wavelengths" J AD A, 1993; 124:49-54. 18. Launay Y, Mordon S, Cornil A, Brunetaud J.M. and Moschetto Y. "Thermal effects of lasers on dental tissues". Lasers. Surg.Med., 1987 ; 7:473-477. 19. Legler L.R, Reteif D.H, Bradley E.L. "Effects of Phosphoric acid concentration and etch duration on enamel depth of etch: An in vitro study" Am.J. Orthod. Dentofac. Orthop., 1990; 98: 154-160. 20. Liberman R., Segal T.H., Nordenberg D. and Serebro L.T. "Adhesion of composite materials to enamel: Comparison between the use of aid and lasing as pretreatment". Lasers Surg. Med., 1984; 4:323-477. 21 Lopez J.I. "Retentive shear bond strength of various bonding attachment bases" Am.J.Orthod. Dentofac.Orthop; 1980;77:669-678. 22. Luis Carpos Pastor, Moreno J.V, De Dios LopezGonzalez Gauido, Muriel V.P., Keith moore and Augusto elias. "Comparing the tensile strength of Brackets, Adhered to Laser etched enamel Vs acid etched enamel" J.Am. Dent. Assc. 1997; 128: 732-737. 23. Marilyn Miller and Thomas Truhe. "Lasers in dentistry : An Overview" JADA., 1993; 124: 37-47. 24. Mitchell D.L. "Bandless orthodontic bracket." J.A.D.A., 1967; 74: 103-110. 25. Miura F. "The direct bonding of orthodontic attachment to teeth by means of an epoxy resin adhesive" Am.J. Orthod. Dentofac. Orthop. 1971; 58: 21-40. 26. Mortiz A., Schoop U. Goharkhay K, Szakacs S., Sperr W., Schweidler, E., Wernisch J. and Gutknecht N. "Procedures for enamel and dentin conditioning : A comparison of conventional and innovative methods". J. Esth.Dent, 1998; 10: 84-93.

27. Myers T.D. and McDaniel J.D. "The pulsed Nd:YAG laser: Review of clinical applications" J. Calif.Dent. Assoc, 1991; 19:25-30. 28. Newman and John M.F. "The effects of adhesive systems on tooth surfaces." Am.J.Orthod., 1971; 59:67-75. 29. Newman G.V. "Epoxy adhesives for orthodontic attachments. A progress report." Am.J. Orthod. Dentofac. Orthop., 1965 ;51:901-912. 30. Osnat Feurstein, Daniel Palanker, Fux brunner.A, Asron Lewis and Dan Deutsh "Effect of the ArF Laser on human enamel" Lasers Surg. Med., 1992; 12:471-477. 31. Osorio R. and Toledano "Bracket bounding with 15 and 60 second etching and adhesive remaining on enamel after debonding". Br.J.Orthod., 1999;23:45-48. 32. Ralph H.Stern, Johanna Vahl and Reidar F. Sognnaes "Lased Enamel : Ultra structural observations of pulsed Carbon Dioxide laser effects" J.Dent.Res., 1970; 51:455-460. 33. Retief D.H, Dreyer C.J. and Gavron.G. "The direct bonding of orthodontic attachments to teeth by means of an epoxy resin." Am.J. Orthod., 1970;58:21-40. 34. Retief D.H. and Sandowsky P.L. "Clinical experience with the acid etch technique in Orthodontics". Am.J.Orthod., 1975; 68:645-655. 35. Reynolds I.R. " A review of direct orthodontic bonding." Br.Dent.J; 1975; 2:171-180. 36. Reynolds I.R. and Von Fraunhofer J.A. " Direct bonding of orthodontic brackets - A comparative study of adhesives" Br. J. Orthod 1976; 3: 143-146. 37. Robert M. Pick "Using lasers in clinical dental practice" JADA., 1993 ;124:37-47. 38. Sadowsky P.L., Retief D.H., Cox P.R., Hernandez O.R., Rape W.G., and Bradley E.L. "Effects of etchant concentration and duration on the retention of orthodontic brackets: An in Vivo study". Am.J. Orthod. Dentofac. Orthop., 1990; 98: 417-421. 39. Sargison A.E., McCabe J.F. and Millet D.T. "A laboratory investigation to enamel preparation by

sand blasting or acid etching prior to bracket bonding." Br. J. Orthod, 1999;26:141-146. 40. Shahabi S, Brockhurst P.J. and Walsh L.J. "Effect of tooth-related factors on the shear bond strength obtained with Co2 laser conditioning of enamel" Aust.Dent. J. 1997; 42: 81-84. 41. Silverstone L.M. "The acid etch technique: In vitro studies with special reference to the enamel surface and the enamel surface and the enamel resin interface" An international symposium on the acid etch technique. St.Paul, Minn: North Central publishing . 1975: 13-39. 42. Smith D.C. and Maijer R. "Tensile and shear bond strengths of orthodontic direct bonding adhesives." J.Dent.Mater, 1988; 4:243-250 43. Smith N.R. and Reynolds I.R. "A comparison of three bracket bases : An invitro study". Br.J. Orthod., 1991; 18: 29-35. 44. Ulrich Keller and Raimund Hibst. "Experimental studies of the application of the Er:YAG Laser on dental Hard substances: Light microscopic and SEM investigations". Lasers Surg. Med., 1989; 9:345-351. 45. Von Fraunhofer J.A., Allen, D.J. and Orbell G.M. "Laser etching of enamel for direct bonding" Angle orthod., 1993 ; 63: 73-76. 46. White J., Goodis H, Asbill S. and Watanabe L. "Orthodontic bracket bond strength to Nd: YAG laser etched enamel" J. Dent.Res, 1991;70:297 (Abs - 252) 47. White J., Goodis H, Rose C, Khosrovi P and Hornberger B. "Shear bond strength of Nd:YAG laser treated dentin". J.Dent.Res, 1991; 70:379. (Abs-1048). 48. Wigdor H. Elliot A.B.T, Shahid Ashrafi, Joseph T. and Walsh J.R. "The effect of lasers on dental hard tissues" JADA, 1993; 124:65-70. 49. Wheeler J.J. and Ackerman J.R. "Bond strength of thermally recycled brackets." Am.J. Orthod, 1983; 83: 181-186. 50. Yamamoto E, Ooya.K, Matsuda K. and Okabe H. "Yag Laser effect for acid resistance on tooth enamel" J.Dent.Res., 1974 ;53; 1093. (Abs-7).

41

COMPARISON OF DENTAL AND ALVEOLAR ARCH WIDTH IN PATIENTS WITH NORMAL OCCLUSION, CLASS II DIVISION 1 AND CLASS II DIVISION 2 MALOCCLUSION
Authors:

Dr. Sudhir Munjal, M.D.S.


Professor and Head, Department of Orthodontics and Dentofacial Orthopedics, Dasmesh Institute of Research and Dental Sciences, Faridkot (Pb.)

Dr. Rohit Duggal, M.D.S.


Professor, Department of Orthodontics and Dentofacial Orthopedics, Dasmesh Institute of Research and Dental Sciences, Faridkot (Pb.)

Dr. Sukhdeep Singh Kahlon, M.D.S.


Associate Professor, Department of Orthodontics and Dentofacial Orthopedics, Dasmesh Institute of Research and Dental Sciences, Faridkot (Pb.)

Dr. Sumit Bansal, M.D.S.


Senior Lecturer, Department of Orthodontics and Dentofacial Orthopedics, Dasmesh Institute of Research and Dental Sciences, Faridkot (Pb.) Abstract The aim of this study was to compare the transverse dimensions of the dental arches and alveolar arches in the canine, premolar, and molar regions of Class II division 1 and Class II division 2 malocclusion groups with normal occlusion subjects. This study was performed using measurement on dental casts of 60 normal occlusion (mean age: 20.2 years), 60 Class II division 1 (mean age: 20.3 years), and 30 Class II division 2 (mean age: 20.5 years) malocclusion subjects. Students t-test was performed for statistical analysis.

INTRODUCTION
Arch size and shape affect stability of the dentition and plays an important role in diagnosis and treatment planning. It has been seen that transverse component in Class II patients is of great importance as compared to sagittal and vertical components. In previous studies1-5, Maxillary arch has been found to be narrower in patients with Class II division 1 malocclusion, and expansion was needed during or before treatment. Frhlich6 compared intercanine and intermolar widths of both arches from 51 children with Class II malocclusion with normal occlusion. He did not find much difference in the absolute arch widths of the Class II children in comparison with normal occlusion. Sayin and Turkkahraman7 compared the arch and alveolar widths of patients with Class II division 1 malocclusion and subjects with Class I ideal occlusion 42

in the permanent dentition and found that mandibular intercanine widths were significantly larger in the Class II division 1 group, although maxillary intermolar widths were larger in the normal occlusion sample. Staley et al8 stated that patients with Class II division 1 malocclusion had narrower maxillary intercanine, intermolar, and alveolar widths. A posterior crossbite tendency in the Class II group was also found. Enlow and Hans9 reported that Class II patients have long, narrow anterior cranial bases that affect the nasomaxillary complex and result in long, narrow palates and maxillary arches. Buschang et al10 found that Class II division 2 patients had greater maxillary intercanine and intermolar distances than Class II division 1 patients. Where as Class II division 2 patients showed less mandibular intercanine and intermolar width than the Class I and Class II division 1 patients.

The Objective of this study was to compare the transverse dimensions of the dental arches and alveolar widths of Class II division 1 and Class II division 2 malocclusion groups with the transverse measurements of untreated normal occlusion subjects. Students t-test was used to find the difference in the mean maxillary and mandibular dental arch and alveolar width dimensions among Class II division 1, Class II division 2, and normal occlusion sample.

third molars, and no significant medical history; and (4) no history of trauma, and no previous orthodontic, prosthodontic treatment, maxillofacial or plastic surgery. Digital calipers were used to measure dental and alveolar arch width to the nearest 0.01 mm. All the measurements were done by one investigator. A single investigator measured each arch twice. If the second measurement differed by more than 0.2 mm from the first measurement, the measurement was redone. Independent-samples t-test was applied for comparison of the groups.

MATERIALS AND METHODS


This study was performed using the dental casts of 60 normal occlusion, 60 Class II division 1, and 30 Class II division 2 malocclusion subjects of Dasmesh Institute of Research and Dental Sciences, Faridkot.

RESULTS
Descriptive statistics (mean, standard deviation) and statistical comparison of dental and alveolar width measurements for dental casts in the three groups is shown in Table 2,3,4 and 5. According to the independent samples t-test, statistically significant differences were found in maxillary and mandibular dental arch and alveolar width dimensions among Class II division 1, Class II division 2, and normal occlusion samples.
UAM-M UAP-P UAC-C CANINE PREMOLAR UC-C UP-P MOLAR UM-M

Normal occlusion sample


Dental casts of 60 adult subjects (30 male and 30 female) with normal occlusion were selected that met the following criteria (1) Class I canine and molar relationship with minor or no crowding; (2) normal growth and development, (3) well-aligned upper and lower dental arches; (4) all teeth present except third molars; (5) good facial symmetry determined clinically; (6) no significant medical history; and (7) no history of trauma, and no previous orthodontic, prosthodontic treatment, maxillofacial or plastic surgery.

Malocclusion sample
A sample of 60 subjects (30 male and 30 female) with Class II division 1 malocclusion and a sample of 30 subjects (15 male and 15 female) with Class II division 2 malocclusion were selected. The inclusion criteria used to select Class II division 1 samples was 1. bilateral Class II molar relationship in centric occlusion with the distobuccal cusp tip of the maxillary first molar within one mm (anterior or posterior) from the buccal groove of the mandibular first molar and protrusive maxillary incisors; (2) all teeth present except third molars; (3) no significant medical history; and (4) no history of trauma, and no previous orthodontic, prosthodontic treatment, maxillofacial or plastic surgery. The criteria used to select Class II division 2 samples was (1) Class II molar relationship on at least one side in centric occlusion; (2) Class II permanent canine relationship and retroclination of two or more maxillary incisors; (3) all teeth present except 43

Fig. 1 : Maxillary dental cast measurements

LM-M MOLAR LP-P PREMOLAR CANINE LAC-C LAP-P LAM-M

Fig. 2 : Mandibular dental cast measurements

TABLES : TABLE 1. Maxillary and Mandibular Dental and Alveolar Width measurements used in the study.
1. Maxillary intercanine width (UC-C): the distance between the cusp tips of the right and left canines or the center of the wear facets in cases of attrition. Maxillary interpremolar width (UP-P): the distance between the buccal cusp tips of the right and left first premolars. Maxillary intermolar width (UM-M): the distance between the mesiobuccal cusp tips of the right and left first molars. Mandibular intercanine width (LC-C): the distance between the cusp tips of the right and left mandibular canines. Mandibular intermolar width (LM-M): the distance between the mesiobuccal cusp tips of the right and left first molars.

6.

Maxillary canine alveolar width (UAC-C): the distance between two points at the mucogingival junctions above the cusp tips of the maxillary right and left canines. Maxillary premolar alveolar width (UAP-P): the distance between two points at the mucogingival junctions above the interdental contact point of the maxillary first and second premolars. Maxillary molar alveolar width (UAM-M): the distance between two points at the mucogingival junctions above the mesiobuccal cusp tips of the maxillary first molars. Mandibular canine alveolar width (LAC-C): the projection of UAC-C point in the lower jaw.

7.

2.

8.

3.

9.

4.

5.

10. Mandibular premolar alveolar width (LAP-P): the projection of UAP-P point in the lower jaw. 11. Mandibular molar alveolar width (LAM-M): the projection of UAM-M point in the lower jaw.

Table 2 : The mean arch widths, standard deviation of different teeth in different malocclusion groups in Male.Measurements are in mm. SD indicates standard deviation; NS- not significant. * P < 0.05, ** P < 0.01, *** P < 0.001
MALE MALOCCLUSION ARCH ARCH WIDTH CLASS I CLASS II DIVISION 1 CLASS II DIVISION 2 Normal Occlusion vs Class II Division 1 TEST Normal Occlusion vs Class II Division 2 Class II Division 1 vs Class II Division 2

MEAN

SD

MEAN

SD

MEAN

SD

C-C AC
UPPER

35.60 38.44 41.46 47.12 51.57 59.16 26.17 30.12 33.67 39.23 45.32 56.06

2.92 2.90 2.74 2.33 3.45 3.04 2.44 2.54 2.82 2.70 2.68 2.04

34.80 38.24 41.14 46.38 51.86 59.35 25.87 30.34 35.16 40.13 46.30 56.19

3.01 3.90 3.48 4.65 4.26 4.31 3.36 2.21 2.82 2.62 2.68 2.91

33.07 38.21 40.12 46.88 52.48 62.42 27.90 31.41 35.65 41.96 46.80 57.75 44

3.09 3.53 1.51 3.76 4.01 3.46 1.86 3.80 1.34 1.68 2.80 4.08

NS ** ** * NS NS NS NS ** NS NS NS

** * ** ** NS *** ** NS *** *** NS NS

* * *** * NS ** ** NS NS *** NS NS

P-P AP M-M AM C-C AC

LOWER

P-P AP M-M AM

Table 3 : The mean arch widths, standard deviation at different teeth in the different malocclusion groups in Female. Measurements are in mm.SD indicates standard deviation; NS-not significant.* P < 0.05, ** P < 0.01, *** P < 0.001
MALE MALOCCLUSION ARCH ARCH WIDTH CLASS I CLASS II DIVISION 1 CLASS II DIVISION 2 Normal Occlusion vs Class II Division 1 TEST Normal Occlusion vs Class II Division 2 Class II Division 1 vs Class II Division 2

MEAN

SD

MEAN

SD

MEAN

SD

C-C AC
UPPER

33.58 35.90 40.37 44.61 49.94 56.67 24.95 28.03 32.89 37.52 42.54 52.76

2.94 3.12 2.58 2.88 3.06 4 3.86 2.90 2.90 3.89 3.43 3.20 4.00

33.34 35.75 38.82 44.05 8.86 56.70 25.72 29.34 34.41 37.78 43.80 53.54

3.16 2.04 3.29 2.18 3.96 3.25 3.17 2.15 3.82 3.38 3.15 2.37

32.66 35.42 40.19 45.54 49.83 56.64 25.34 29.68 34.37 38.63 44.28 53.86

1.92 4.49 2.37 2.23 2.94 3.44 1.87 1.12 2.57 1.61 4.24 3.71

NS NS ** NS NS NS NS ** NS NS NS NS

NS ** NS NS NS NS NS ** NS NS NS NS

NS ** NS NS NS NS NS NS NS NS NS NS

P-P AP M-M AM C-C AC

LOWER

P-P AP M-M AM

Table 4 : P-value Upper Arch (Male vs Female)


S.NO. 1 2 3 4 5 6 ARCH WIDTH C-C AC P-P AP M-M AM CLASS I *** *** * *** ** ***
45

CLASS II DIVISION 1 NS *** NS *** *** **

CLASS II DIVISION 2 NS NS NS *** * ***

Table 5 : P-value Lower Arch (Male vs Female)


S.NO. 1 2 3 4 5 6 ARCH WIDTH C-C AC P-P AP M-M AM CLASS I * *** NS ** *** *** CLASS II DIVISION 1 NS * NS *** *** *** CLASS II DIVISION 2 *** NS NS NS * **

DISCUSSION
This study was carried out to compare the dental arch and alveolar base widths of Class II division 1 and Class II division 2 malocclusion groups with untreated normal occlusion groups . Knott VB11,12, DeKock WH13 , Sillman JH14 , Moorrees CFA15 studied growth changes in the transverse arch width found that molar and canine arch widths did not change after age 13 in female subjects and age 16 in male subjects. The minimum ages of the subjects measured in this study were chosen on the basis of these previous studies. Therefore, we assumed that the arch widths of the subjects studied were fully developed. In the normal occlusion sample only subjects with minor or no crowding were included, whereas the absence of crowding was not a criterion in the Class II groups. Several reasons have been put forward for narrower maxillary arch widths in Class II division 1 malocclusions in comparison with a normal occlusion sample i.e. nasal obstruction, finger habits, tongue thrusting, low tongue position, and abnormal swallowing and sucking behaviors. Staley et al8 stated that the maxillary dental arch as a whole is narrower in adults with Class II division 1 malocclusion than it is in adults with normal occlusion and that the subjects with normal occlusion had larger maxillary canine widths than the malocclusion subjects, but no difference was found in mandibular canine widths. In a cross-sectional study, Buschang et al10 found that Class II division 2 patients showed smaller mandibular intercanine and intermolar widths than the Class I and II division 1 patients. 46

Walkow and Peck16 indicated that mandibular canine width was significantly less in Class II division 2 deepbite patients and suggested that the extreme deep bite may inhibit anterior development of the mandibular dentoalveolar segment. In this study, Maxillary intercanine and interpremolar dental and alveolar width was significantly narrower in the Class II division 1 and Class II Division 2 groups when compared with the normal occlusion sample in males.

CONCLUSION
Maxillary intercanine width, premolar width was significantly narrower in the Class II division 1 group when compared with the normal occlusion sample (male). Maxillary canine and premolar alveolar widths was narrower in the Class II division 1 and Class II division 2 groups when compared with the normal occlusion sample (male). There was statistically no difference in the mandibular dental and alveolar width in different malocclusion groups in males and females , except interpremolar dental and alveolar width in male was statistically significant in the Class II division 1 and Class II division 2 groups when compared with the normal occlusion group . There was significant difference in dental and alveolar width among different malocclusions between male and female group.

REFERENCES
1. Bishara SE, Bayati P, Jakobsen JR. Longitudinal comparisons of dental arch changes in normal and untreated Class II, division 1 subjects and their clinical implications. Am J Orthod Dentofacial Orthop. 1996;110:483-489. Tollaro I, Baccetti T, Franchi L, Tanesescu CD. Role of posterior transverse interarch discrepancy in Class II, division 1 malocclusion during the mixed dentition phase. Am J Orthod Dentofacial Orthop. 1996;110:417-422. Baccetti T, Franchi L, McNamara JA Jr, Tollaro I. Early dentofacial features of Class II malocclusion: a longitudinal study from the deciduous through the mixed dentition. Am J Orthod Dentofacial Orthop. 1997;11:502-509. McNamara JA Jr, Brudon WL, Kokich VG. Orthodontics and Dentofacial Orthopedics. Ann Arbor, Mich: Needham Press; 2001: 63-84. McNamara JA Jr. Early intervention in the transverse dimension: is it worth the effort? Am J Orthod Dentofacial Orthop. 2002; 121: 572-574. Frohlich FJ. A longitudinal study of untreated Class II type malocclusion. Trans Eur Orthod Soc. 1961;37:137-159. Sayin MO, Turkkahraman H. Comparison of dental arch and alveolar widths of patients with Class II division 1 malocclusion and subjects with Class I ideal occlusion. Angle Orthod. 2004;74:356-360.

8.

Staley RN, Stuntz WR, Peterson LC. A comparison of arch widths in adults with normal occlusion and adults with Class II division 1 malocclusion. Am J Orthod. 1985;88:163-169 Enlow DH, Hass MG. Essentials of Facial Growth. Philadelphia, Pa: WB Saunders; 1996:1-280

9.

2.

10. Buschang PH, Stroud J, Alexander RG. Differences in dental arch morphology among adult females with untreated Class I and Class II malocclusion. Eur J Orthod. 1994;16: 47-52. 11. Knott VB. Size and form of the dental arches in children with good occlusion studied longitudinally from age 9 years to late adolescence. Am J Phys Anthropol. 1961;19: 263- 284. 12. Knott VB. Longitudinal study of dental arch widths at four stages of dentition. Angle Orthod. 1972;42:387-394. 13. DeKock WH. Dental arch depth and width studied longitudinally from 12 years of age to adulthood. Am J Orthod.1972;62:56-66. 14. Sillman JH. Dimensional changes of the dental arches: longitudinal study from birth to 25 years. Am J Orthod. 1964; 50:824-842. 15. Moorrees CFA. The Dentition of the Growing Child. Cambridge, Mass: Harvard University Press; 1959:87-110. 16. Walkow TM, Peck S. Dental arch width in Class II division 2 deep-bite malocclusion. Am J Orthod Dentofacial Orthop. 2002;122:608-613.

3.

4.

5.

6.

7.

47

RECTANGULAR WIRES AS SUBSTITUTES FOR THE MAA AND TORQUING AUXILIARY IN THE BEGG TREATMENT A CLINICAL STUDY
Authors:

Dr. Tejashri Pradhan

Tejashri Pradhan, MDS Professor, Department of Orthodontics and Dentofacial Orthopedics, Tatyasaheb Kore Dental College and Research Centre, New Pargaon- 416 137, Maharashtra, India. E-mail : tejashripradhan@hotmail.com Phone : 99605 11444 Vijay Jayade, MDS Former Professor and HOD, Department of Orthodontics and Dentofacial Orthopedics, S.D.M. College of Dental Sciences, Dharwad, Presently Professor Emeritus, Sibar Institute of Dental Sciences, Guntur, Andhra Pradesh, India.

Dr. Vijay Jayade

ABSTRACT :

Objective: To evaluate clinically the efficacy of 0.025" x 0.017" braided NiTi (Turbo) ribbon sectional as a substitute for the MAA, and 0.025" x 0.017" braided stainless steel or 0.025" x 0.017" super elastic NiTi ribbon sectional wires as substitutes for the Begg torquing auxiliary, in the root control or active torquing of root apices respectively. The study was conducted on 10 patients. The patients were divided into 2 groups of 5 patients each. The first group consisted of those who were in the Stage I or stage II, and were fitted with 0.025" x 0.017" braided NiTi (Turbo) sectionals, instead of the MAA, during retraction of maxillary anterior teeth. The second group included 5 patients who were ready for the stage III, and were treated with braided stainless steel or super elastic NiTi sectionals in 0.025" x 0.017" size, instead of a torquing auxiliary. Photographs and lateral cephalograms were obtained before the placement of rectangular sectionals and at the end of 6 months. 1 In the first group, retraction of upper incisors ranged from 2 to 4.5mm in the form of controlled tipping, with the root apices practically maintained at the same place. 2. In the second group, two patients attained ideal inclinations, two more showed good improvement in the root inclinations, while the 5th patient insisted on premature appliance removal for personal reasons. A braided NiTi (Turbo) wire sectional in 0.025" x 0.017" size is efficient in bringing about controlled tipping, and 0.025" x 0.017" braided stainless steel or super elastic NiTi sectional is a useful substitute for the four spur torquing auxiliary in the third stage of Begg mechanics. Sectional ribbon rectangular wires, controlled tipping, torque, MAA and Four spur Auxiliary substitutes.

Materials and Methods:

Results:

Conclusion :

KEY WORDS:

48

INTRODUCTION
Correct inclinations of teeth is one of the important objectives of orthodontic treatment. This has also been emphasized by Andrew in his six key features to ideal dental occlusion. Traditional Begg practice led to excessive uncontrolled tipping during the first two stages resulting in excessive retroclination of incisors. This made the third stage involving root corrections unduly prolonged. The relative heavy torquing and uprighting forces employed during the third stage created many mechanical problems, besides enhancing the root resorption possibility. The refined Begg approach attempts to overcome these problems by applying labio-lingual root control from the first stage using Mollenhauer's aligning auxiliary (MAA) for controlled tipping. Further, the torquing auxiliary used in the third stage provides optimum force to torque the maxillary anterior teeth from their lingual inclination to the desired labio-axial inclination. Previously, we reported the findings of our experiment in which the rectangular sectional wires in ribbon mode were tested to compare their force values against those of the MAA and torquing auxiliaries. A braided NiTi ("Turbo" from Ormco Company) sectional wire in 0.025" x 0.017" size was found to have similar force values to those of the MAA, while a braided stainless steel or super elastic NiTi wire sectional in 0.025" x 0.017" size was comparable to a four spur torquing auxiliary in its force generation. Hence the present study was aimed at clinically evaluating these wires as substitutes for the MAA and the Begg torquing auxiliary respectively.

after premolar extractions. Out of these, 5 were in the stage I or stage II, and the remaining 5 had completed the pre-stage III. All the patients were treated by the first author.

Methodology
The first group of 5 patients needing further retraction of upper anteriors by controlled root movement in the stage I and II of Begg therapy were given 0.025" x 0.017" braided NiTi sectionals. These were engaged in the brackets and the 0.018" premium plus base wires were engaged piggy-back over the sectional wires using hook pins and medium elastic force was used. The III stage mechanics of the remaining 5 patients was attempted in two slightly different manners. Out of the 5 patients, 4 received 0.025" x 0.017" braided stainless steel sectionals and the remaining one patient was given the 0.025" x 0.017" super elastic NiTi sectional in the place of a torquing auxiliary. In all these 5 patients, the sectionals were engaged before the 0.020" premium base wire and secured with the hook pins (or the ligature wires when the tooth also had to receive an uprighting spring) and light elastic force was used. The observation period for all the patients was 6 months. Lateral cephalograms and photographs were taken for all the 10 patients at the time the sectional wires were engaged and after 6 months of treatment. The cephalograms were traced and analyzed to study the changes in the positions of the upper incisors. Pre and post changes in the cephalometric values, superimpositions and photographs, of two patients one from each group are presented below

MATERIALS AND METHODS


The study was conducted at the Department of Orthodontics and Dentofacial Orthopedics, S.D.M. College of Dental Sciences and Hospital, Dharwad.

Patient needing Controlled Tipping


Patient's name : Miss. Archana Chougle, Stage of treatment : II, Torquing element for controlled tipping : 0.025" x 0.017 Braided NiTi, Observation period : 6 months.

Materials
The sample consisted of 10 patients (2 male and 8 female) undergoing treatment with the Begg appliance

49

Table No. I : Cephalometric changes and superimposition Upper incisor inclinations 1. 2. 3. 4. 5. 6. UI - SN UI - N perpendicular UI - NF UI - NA UI - A Pog UI - Npog Pre 85 4.5mm 92.5 2.5/0mm 10.5/3.5mm 6mm Post 82.5 1mm 90 1/-2.5mm 9/1.5mm 3.5mm effect -2.5 - 3.5 mm -2.5 -1.5/2.5 -1.5/-2 -2.5 mm

Torquing element : 0.025" x 0.017" Braided NiTi (equivalent to MAA)

Fig. 1 : Before starting the use of a rectangular Sectional substitute for MAA

Fig. 2 : At the end of the use of a rectangular Sectional substitute for MAA

50

Patient needing Root Torquing Patients name : Miss Vani Patil, Stage of treatment : III, Torquing element for active torque : 0.025" x 0.017 Braided Stainless Steel, Observation period: 6 months.

Table No. II : Cephalometric changes and superimposition Upper incisor inclinations 1. 2. 3. 4. 5. 6. UI - SN UI - N perpendicular UI - NF UI - NA UI - A Pog UI - Npog Pre 79 -4.5mm 85 1/ -1.5 mm 10.5/1.5mm 4mm Post 92.5 1mm 101 15 / 0mm 25/4mm 6 mm effect 13.5 3.5 mm 16 15/2 14.5/2.5 2 mm

Torquing element: 0.025" x 0.017" Braided Stainless Steel (equivalent to a four spur auxiliary)

Fig. 3 : Before starting the use of rectangular Sectional 51

Fig. 4 : At the end of the use of rectangular Sectional

RESULTS

Table No. III : Summary of effects of 0.025"x 0.017" Braided NiTi (equivalent to the MAA)

Upper incisor inclinations

Effect on Inclinations Mean Range -1 to -6 -1 to -3.5 mm -2.5 to -6 -1.5to -6/-1 to - 2.5mm -1.5 to -6/-1.5 to - 2.5mm -2 to - 3.5mm S.D. 2.3076 1.0840 1.4318 2.0/0.6 2.2/0.4 0.5477

1. UI - SN 2. UI - N 3. UI - NF 4. UI - NA 5. UI - A Pog 6. UI - Npog

-3.3 -1.9mm -4.1 3.6/-1.5mm -3.6/-1.8mm -2.6mm

Table No. IV : Summary of effects of 0.025"x 0.017" Braided Stainless Steel and Super elastic NiTi (equivalent to four spur auxiliary) Upper incisor inclinations Effect on Inclinations Mean 1. UI - SN 2. UI - N 3. UI - NF 4. UI - NA 5. UI - A Pog 6. UI - Npog 11.3 2.4 mm 12.4 9.8 / 1.5mm 10.7/1.6mm 1.8mm Range 9 to 13.5 0.5 to 3.5 mm 8.5 to 16 3to 15/ 1 to - 2mm 7 to14.5 / 0.5 to 2.5mm 1 to 2.5mm S.D. 1.8235 1.2450 3.4169 4.6 /0.5 3.1/0.7 0.7583

+ve - increase in linear and angular measurement -ve - decrease in linear and angular measurement

52

DISCUSSION
No study can be considered complete till the experimental laboratory findings are validated by a corresponding clinical study. In the 5 patients who were in the first and second stage of Begg treatment, a combination of 0.025" x 0.017" braided NiTi ribbon sectional and the 0.018" base wire brought about retraction of upper incisors to the extent of 2 to 4.5 mm, (Table No. III) over a period of six months. The root apices were practically maintained at the same place. This demonstrated the efficacy of the braided NiTi sectionals in achieving controlled tipping similar to the MAA. In the next group also, encouraging results were seen in the 5 patients who underwent the third stage mechanics wherein the 0.025" x 0.017" braided stainless steel or the 0.025" x 0.017" super elastic NiTi sectional were substituted for the conventional 4 spur auxiliary. The changes noted after 6 months were as follows: a. The increase in inclination of UI to Sn was by 80 130 (Table No .IV) b. The rate of change of inclination was approximately 20 per month. c. The increase in overjet and overbite was 1-2.5mm and 1.5 to 2.5mm respectively which resulted in favorable dental relations. d. The end result was that two patients had attained the ideal inclinations, two others showed good improvement but needed some more torquing with continued IIIrd stage mechanics, while the 5th patient insisted on premature appliance removal due to personal reasons.

higher force such as 0.025" x 0.017" braided stainless steel can be substituted for the MAA, and 0.025" x 0.019" CuNiTi can be substituted for the torquing auxiliary by placing these rectangular sectionals piggyback over the round base wire. (As we stated in our previous article, a small part of the rectangular sectional projects outside the slot in this mode of application; therefore the force generation reduces slightly). 3. However, when lingual root torque is needed on some of the anterior teeth and labial root torque on the remaining (for instance instanding lateral incisors), bending the conventional auxiliaries for suitable reciprocal effect will still be necessary. Whether the brackets with built-in-torque (as developed by Kameda) in combination with the rectangular sectional torquing wire, would solve this difficulty is worth investigating. The present study will help in overcoming one major hurdle in the proper practice of the Begg treatment namely, the time and the efforts involved in bending the MAA or a torquing auxiliary. It is hoped that all the Begg practitioners will make use of the above findings to elevate the standards of their treatment.

CONCLUSION
A clinical study substituting rectangular sectional wires equivalent to the MAA and four spur auxiliary, for applying root control in the I & II stages and lingual root torque in the III stage respectively, was conducted over a period of 6 months in 10 patients. It was observed that the 0.025" X 0.017" braided NiTi (Turbo) sectional wire is efficient in bringing about controlled tipping. Similarly, a 0.025" X 0.017" braided stainless steel or 0.025" x 0.017" super elastic NiTi sectional is an effective substitute for the four spur torquing auxiliary in the third stage of Begg mechanics.

CLINICAL IMPLICATIONS
1. Specific rectangular wires bent in an edgewise mode but engaged in the ribbon mode can be successfully substituted for the MAA or a torquing auxiliary as under. a. A 0.025" x 0.017" braided NiTi sectional wire substitutes nicely for the MAA. b. A 0.025"x 0.017" braided stainless steel or 0.025" x 0.017" super elastic NiTi sectional can be substituted for the III stage torquing auxiliary. In both the above situations, the rectangular wire is inserted first and the round base wire is inserted piggyback. 2. In case the above mentioned wires are not available, rectangular wires producing slightly 53

REFERENCES
1. Andrews L.F .Six keys of normal occlusion. Am J Orthod 1972;62:296-309 2. Begg P R, Kesling P C. Begg orthodontic theory and technique, 2nd ed.Philadelphia: W.B. Saunders Company 1971.p130-139. 3. Mollenhauer B. An aligning auxiliary for ribbon arch brackets: rectangular boxes from ultra fine high tensile wires. Aust Orthod J 1990; 11:219-226. 4. Pradhan.Tejashri, Jayade.V.P. Rectangular Wires as substitutes for the MAA and Torquing Auxiliary in the Begg treatment - An Experimental study. J Ind Orthod Soc 2008; 42:7-15

MODIFIED PENDULUM APPLIANCE FOR EASY INSERTION AND REMOVAL


Authors:

Dr. Manjunath Hegde (Corresponding Author)


Associate Professor Department of orthodontics and dentofacial orthopedics, K. D Dental College and hospital, Chhatikara, Mathura - 281 001. Mobile No : 0091-99975 07042 E-mail : hegde21@yahoo.com

Dr. Manjunath Hegde

Dr. Ankur Gupta


Dr. Ankur Gupta

P.G student Department of orthodontics and dentofacial orthopedics, K. D Dental College and hospital. Mathura, India.

Dr. Neelima Anand

Dr. Neelima Anand, MDS (ORTHODONTICS AND DENTOFACIAL ORTHOPEDICS) Professor and Head of Department Department of orthodontics and dentofacial orthopedics, K. D Dental College and hospital, Mathura, India.

INTRODUCTION
The Pendulum Appliance given by James Hilgers1 is perhaps the most easy and widely used intra oral appliance for molar distilization. Since then many modifications of this appliance have been proposed 1-5 However most of these appliances hamper maintenance of oral hygiene and since they are fixed, they need to be activated intra orally which cannot be done with precision. For extra oral activation the bands have to be removed and recemented which in turn increases the chair side time. A removable version of the Pendulum Appliance was proposed by Scuzzo et al 4 in which the Pendulum springs could be removed for extra oral activation. However, the remaining part of the appliance was still fixed, where the accumulation of food debris over the tissue surface of the palatal button could be a source of tissue irritation. With these shortcomings in mind we propose a new modification, which allows for easy removal and insertion of the 54

appliance so that extra oral activation can be done with ease and precision. The easy removal of the appliance will also aid in cleaning of the tissue surface of the palatal button.

APPLIANCE DESIGN:
The conventional Pendulum Appliance consisted of bands on the first molars and premolars with the retaining wire soldered to the lingual side of the first premolar bands,which created a fixed soldered joint.The spring of the pendulum was then inserted into the lingual sheath of the molar bands. [Fig. 01 and Fig. 02]. Our modification of the Pendulum Appliance consists of round 0.036" tubes, which are soldered on the lingual surface of the first premolar bands so that the retaining wires will slide into these tubes [Fig. 03A and Fig. 03B]. This creates a removable sliding retaining joint. [Figure. 04A and Fig. 04B]. The completed appliance [Fig. 05] has a removable sliding retaining wire on the first premolars and removable

Pendulum springs which slide into the lingual sheaths of the first molar bands. This allows for easy removal and insertion of the appliance, which in turn has the following advantages: 1. It allows precise extra oral activation. (Fig. 06A and Fig. 06B) 2. Permits easy cleaning of the appliance on the palatal surface of the Nance holding button, which is a site for food accumulation. The springs of the pendulum can alternatively be made in stainless steel as compared to the conventionally used TMA wires with this type of modification, as the appliance can be removed easily and smaller and more frequent activations can be given to compensate for the high force decay of stainless steel wires. [Fig. 07A and Fig. 07B] Shows the appliance insertion and the molar distilization after 3 months of treatment using the modified Pendulum Appliance.

allows easy insertion and removal, which permits precise extra oral activation and aids in cleaning the tissue surface of the Nance palatal button where the accumulation of food for long duration can lead to tissue irritation.

REFERENCES:
1. Hilgers J.J.: The Pendulum Appliance for class II non -compliance therapy, J.Clin.Orthod.1992;26: 706-714. 2. Scuzzo, G.and Takemoto, K.: Maxilary molar distilization with a modified Pendulum Appliance, J.Clin.Orthod.1999 ;33: 645-650. 3. Scuzzo, G.Takemoto, K. Pisani, F.: Modified Pendulum Appliance with removable arms, J.Clin.Orthod.2000;34: 244-246. 4. Ecchari, P.Scuzzo, G.Cirelli, N.A modified Pendulum Appliance for anterior anchorage control, J.Clin.Orthod.2003;37: 352-359. 5. Beyza, H.K.;Zafer,O.P.;Kircelli,C.:Maxillary molar distilization with a bone anchored Pendulum Appliances,Angle Orthod.2006;76:650-659.

CONCLUSION:
The Pendulum Appliance is one of the most versatile appliances for molar distilization. This modification

Fig. 1 and Fig. 2 :

Hilgers conventional Pendulum Appliance having fixed soldered retaining wire on the first premolar bands

55

Fig. 3A : 0.036" round tubes soldered on the premolar bands

Fig. 3B : Retaining wires and Pendulum springs made to slide into the lingual attachments

Fig. 4A and Fig. 4B : The modified Pendulum Appliance showing the removable sliding retaining joint

Fig. 5 : The completed modified removable Pendulum Appliance for easy insertion and removal 56

Fig. 6A : Appliance can be easily removed and activated extra orally without the need to remove bands. The tissue surface of the palatal button can be cleaned off the food debris at the same time

Fig. 6B : Extra oral activation allows spring force to be measured before insertion

Fig. 7A : Appliance being fitted intra orally

Fig. 7B : Molar distilization 3 months after treatment

57

COMPARISON OF FRICTIONAL RESISTANCE BETWEEN CONVENTIONAL STAINLESS STEEL, METAL INSERT CERAMIC, SELF LIGATING STAINLESS STEEL AND SELF LIGATING CERAMIC BRACKETS WITH STAINLESS STEEL WIRE : INVITRO STUDY
Authors :

Dr. Sivaram Subbiah


PG Student, SRM Dental College Harmony Flats, No. 11/5-B, Parameswari Nagar, 2ndStreet, Adyar, Chennai - 600 020. Phone No. : 044 24466156, +91984054230

Dr. Balasubramanian, MDS


Dean, SRM Dental College

Dr. K.Ravi, MDS


Vice Principal, SRM Dental College

Dr. P. Krishna Raj, MDS


Professor, SRM Dental College

Dr. S. Dilip, MDS


Professor, SRM Dental College Abstract : Friction is an integral part of fixed orthodontic treatment. Several innovations have been made to reduce friction and thereby get predictable and faster tooth movements. Self ligating brackets are one such innovation which is said to offer the possibility of a significant reduction in average treatment times and also in anchorage requirements. Ceramic Self ligating brackets introduce recently have the added advantage of aesthetics. This study was conducted to compare the frictional resistance of conventional stainless steel, metal insert ceramic, Self ligating stainless steel and Self ligating ceramic brackets against a common stainless steel wire. Fifteen premolar in each group (0.022 Roth prescription) were tested against 0.019x0.025 stainless steel wire using Lloyd universal testing machine. The conventional stainless steel brackets showed a frictional resistance of 66.477.86g metal insert ceramic brackets showed a frictional resistance of 77.52 8.59g . the Self ligating stainless steel brackets had a frictional resistance of 40.217.76g Self ligating ceramic brackets had a frictional resistance of 72.675.76 g Self ligating ceramic brackets do have slightly lesser friction than metal insert ceramic brackets but significantly more than metal brackets . self ligating brackets ,friction, sliding, frictional resistance, metal insert ceramic, Self ligating ceramic.... appropriate force to obtain optimal biologic tissue response and adequate tooth movement during sliding mechanics. The earliest recorded experiments on friction were carried out by the versatile genius Leonardo da Vinci approximately 450 years ago. In 1960, Stoner 2 58

Key words :

INTRODUCTION
Most fixed appliance techniques involve some degree of sliding between bracket and arch wire. Whenever sliding occurs, frictional resistance is encountered. In orthodontics, one needs to understand the impact of friction between brackets and arch wires to apply the

recognized the fact that sometimes applied force is dissipated by friction or improper application and it is important to control and to determine the amount of force that is being received by the individual tooth. Several variables have been found to affect the levels of friction between bracket and wire. These variables may be either mechanical or biologic. Mechanical variables include bracket material, slot size, bracket width and angulation, wire shape, wire size and wire material as well as ligature material and force of ligation. Saliva, plaque, acquired pellicle, and corrosion have been implicated as some of the biologic factors that affect bracket- wire friction3. As early as 1935, the idea of self-ligating brackets began to take shape. Self ligating brackets have an inbuilt metal labial face, which can be opened and closed. Brackets of this type have existed for a surprisingly long time in orthodontics - The Russel Lock edgewise attachment being described by Stolzenberg in 1935. Currently available self-ligating brackets offer the very valuable combination of extremely low friction and secure full bracket engagement and at last, they deliver most of the potential advantages of this type of bracket. These developments offer the possibility of a significant reduction in average treatment times and also in anchorage requirements, particularly in cases requiring large tooth movements. During the last decade, ceramic brackets have become the esthetic alternative to polycarbonate brackets. The monocrystalline and polycrystalline ceramic brackets provide excellent color fidelity and stain resistance. Ceramic brackets are especially popular among adult patients who have expressed a desire for more esthetic appliance. However, ceramic brackets are associated with several problems, increased frictional resistance in sliding mechanics being one of them. To overcome this drawback, metal insert ceramic brackets were introduced recently to have lesser frictional resistance. Since friction plays a major role during alignment and leveling, and also during continuous arch mechanics, more information is required about the magnitude and clinical significance of frictional resistance. Therefore a comparative was undertaken to measure the frictional resistance of conventional stainless steel, metal insert ceramic, Self-ligating stainless steel and Self ligating ceramic brackets with stainless steel arch wire. The purpose of this study was to compare the frictional resistances of conventional stainless steel, and Selfligating stainless steel and Self ligating ceramic brackets against a common stainless steel wire. 59

MATERIALS AND METHODS


In this study, four different types of brackets 15 each were used: conventional stainless steel(Gemini,3M), metal insert ceramic(Clarity,3M), self ligating stainless steel(Claritysl,3M) and self ligating ceramic brackets (Smartclip,3M). All brackets were maxillary first premolar with 0.022 x 0.028 slot size. Sixty arch wire segments, with a .019 x .025 inch stainless steel were used. Arch wire was ligated to the bracket slot with 0.010 inch stainless steel ligature.

METHODOLOGY
A prefabricated commercial 4 inch x 2 inch acrylic plate is used. At one end of the plate a horizontal and vertical line was drawn, the point of intersection of these two lines was taken as a point of bracket placement. The brackets were placed in this point and then stabilized by means of an industrial adhesive. LLOYD Universal testing machine was used with 500 kg load cell to determine the frictional force levels. A wire of about 30 mm length is taken and placed in the bracket and ligated with stainless steel ligatures twisted until taut and then untwisted a quarter turn4. The other end of the acrylic plate was mounted on to the lower grip of universal LLOYD testing machine. The free end of the arch wire was fixed to the upper grip of universal LLOYD testing machine which was connected to the load cell. Before testing each bracket, wire and ligature was cleaned with 95% alcohol and air dried5. Each wire was pulled through the bracket slot by a distance of 7 mm at a speed of 5mm per min, the force levels were recorded from the digital marker. The arch wire and the bracket were tested such that a new bracket and wire is used for every test and then discarded; a fresh ligation is used for each combination. This was done in order to eliminate the influence of dimensional changes. All the tests were done in dry conditions.

RESULTS
The present study was conducted to compare the frictional resistance between four different types of brackets namely conventional stainless steel, metal insert ceramic, self ligating stainless steel and self ligating ceramic brackets against 0.019 x 0.025 stainless steel wire. Totally sixty samples of brackets comprising fifteen of each type were tested to evaluate frictional resistance.

LLOYLD UNIVERSAL testing machine was used to test the frictional resistance. The recorded values which were obtained in Newtons represented the clinical force of retraction that would be applied to the tooth frictional resistance obtained in Newton was converted to grams by multiplying by 101.9. The statistical tests done are One-way Anova analysis and Bonferroni post HOC multiple comparison analysis. The tests showed that the results were statistically significant. The conventional stainless steel brackets showed a frictional resistance of 66.477.86g metal insert ceramic brackets showed a frictional resistance of 77.52 8.59g . the Self ligating stainless steel brackets had a frictional resistance of 40.217.76g Self ligating ceramic brackets had a frictional resistance of 72.675.76 g Self ligating ceramic brackets do have slightly lesser friction than metal insert ceramic brackets but significantly more than metal brackets .

The need for introduction of newer materials which have higher aesthetic values in orthodontics has been triggered by the rise in demands from the patient, community and the practitioners. Ceramic brackets were introduced in orthodontics to meet the increasing esthetic demands. They were first made available commercially in the late 1980s, largely to overcome the esthetic limitations of plastic brackets as they are quite durable and resist staining. (3) (9) In 1996 a new ceramic bracket was introduced to the market in an attempt to minimize some of the problems that were encountered by the clinician. The new bracket had metal insert slot. The ceramic bracket with metal reinforced slot seems to be a promising option to lessen the clinical complication of ceramic brackets. The advantage of a stainless steel slot are to minimize the superficial friction and to help strengthen the bracket to minimize routine orthodontic torque force11. The success of Self ligating brackets led to the development of ceramic Self ligating brackets which have the advantage of both esthetics and less friction. Though there are many studies comparing stainless steel and self ligating stainless steel brackets, very few studies have actually been carried out to evaluate the frictional resistance of the ceramic self ligating brackets. The self ligating stainless steel brackets used in this study is Smartclip. The smartclip brackets self- ligating mechanism consist of two nickel titanium (Nitinol) clips that opens and closes through elastic deformation of the material when the arch wire exerts a force on the clip. The bracket contains no moving door. The feature of no moving doors can eliminate problems such as sticking, spontaneous opening, or plaque build-up that are associated with other types of self ligating brackets. The ceramic self ligating bracket used in this study is clarity SL. Clarity SL is truly a self ligating bracket. They have a pair of Nitinol clip as its primary ligating mechanism. Ceramic rotation arm extends from the mesial-distal side of the bracket body to hold the clips. The cap at the end of the rotation arm retains the clip in mesial direction12. The wire used in this study is rectangular .019 x .025 stainless steel wire. This size of wire gives good overbite control while allowing free sliding through buccal segments. Thinner wires tend to give less overbite and torque control. Thicker wire sometimes restricts free sliding of molars and premolars7 .019x .025 have been found to perform well as these wires are less flexible and hence shows less deflection and binding during 60

DISCUSSION
Friction is a factor in orthodontic anchorage control, particularly with space closure in fixed appliance. Controlling the position of anchor teeth is accomplished best by minimizing the reaction force that reaches them. Unfortunately, anchor teeth usually feel the reaction of anchorage loss by frictional resistance and tooth movement forces, so controlling and minimizing friction is an important aspect of anchorage control7. The friction forces acting at the bracket arch wire interface are due to the complex interaction of various factors. Several variables exist that can directly or indirectly contribute to the frictional force levels between the bracket and the wire. The factors are such as 11) Arch wires: active torque, thickness, cross sectional shape and size 2) Ligation of arch wire to bracket: ligature type, force 3) Brackets: material, width 4) Orthodontic appliances: inter bracket distance, level of bracket slots between adjacent teeth, forces applied for retraction, bracket wire angulations, and point of force application contribute to the frictional forces. One factor which can be controlled by the orthodontist is the choice of the bracket. Previous studies have indicated that stainless steel brackets have an advantage of having the least friction. They are widely used as it is economical and corrosion resistant. But their drawback lies in that they offer little in terms of aesthetics7 and they can cause nickel hypersensitivity in some patients.

space closure. Upper premolar brackets (3M Orthodontics) were chosen to eliminate the effect of 2nd order friction. The results clearly indicate that the bracket material providing the least to highest frictional resistance is Self ligating stainless steel (40.21gms) followed by conventional stainless steel brackets (66.47gms), Self ligating ceramic (72.67gms) and metal insert ceramic (77.52gms) brackets. The statistically significant results obtained clarify the view that metal insert ceramic brackets and Self ligating ceramic brackets have more frictional resistance when compared to conventional and Self ligating stainless steel brackets. The outcome of this study correlates well with previous study did by Omana et al12 who compared the frictional forces of ceramic brackets with stainless steel brackets and found that ceramic brackets again demonstrated significantly higher frictional forces compared to the stainless steel brackets. In 1997 Karamousoz et al 13 reviewed extensively about the properties of ceramic brackets and friction. They stated that the stainless steel brackets in general produce lesser friction than ceramic brackets and friction. They stated that the stainless steel brackets in general produce lesser friction than ceramic brackets. This was attributed to the lower surfaces roughness of stainless steel. They also reported that injection molded ceramic brackets created less friction than other ceramic brackets. They suggested the development of ceramic brackets with smoother slot surfaces and metal inserts to overcome friction. This later was confirmed by Nishio et al in 200414. From this study, we conclude that Self ligating ceramic brackets have the advantage of aesthetics as well as less friction compared to other ceramic brackets.

frictional forces between orthodontic brackets and arch wire. British J Orthod (1995); 22: 41-46. 2. Garner, Allai, and Moore. Comparison of frictional forces. Am J Orthod Dentofac Orthop 1986: 90: sep: 99-2003 3. Kapila, Angolkar, Duncanson, and Nanda. Evaluation of friction between stainless steel brackets and wires. Am. J Orthod Dentofac Orthop 1990; 98: Aug: 117-26. 4. Nathawut Sirisaowaluk, Olenakravchuk, Christopher T C. The influence of ligation on frictional resistance to sliding during repeated displacement. Aust Orthod J 2006;22:141-146. 5. Kusy RP, O Grady PW. Evaluation of titanium brackets for orthodontic treatment; part II the active configuration. Am J Orthod Dentofac Orthop 2000; 118; 675-684. 6. Tidy. Frictional forces in fixed appliances. Am J Orthod Dentofac Orthop 1989; sep: 96:249-54. 7. William R Proffit. Contemporary orthodontics. Mosby inc. 2000. 8. Brantley William. Orthodontic materials. Mosby; 2007. 9. Mc Laughlin RP, Benett J C, Trevisi M J. systematic orthodontic treatment mechanics. St. Louis; Mosby; 2001. 10. Nishio c, da Motta AF, Elias Cn, Mucha. Friction force between ceramic brackets, ceramic with metal-insert slot and stainless steel brackets. Am J Orthod dentofacial Orthop. 2004 Jan; 125 (1): 56-64. 11. www.3morthdontics.com 12. Hamid M Omana, Robert N Moore, Micheal D Bagb. Frictional properties of metal and ceramic brackets. J clin Orthod 1992; 26; 425-432. 13. Karamousoz A, Athanasiou A E, Papadopoulous N A. Clinical characteristics and properties of ceramic brackets. A comprehensive review. Am J Ortho Dentof Orthop 1997: 112: July: 34-40.

SUMMARY AND CONCLUSION


The mean value of the four brackets with the least to highest frictional resistance is Self ligating stainless steel followed by conventional stainless steel brackets; Self ligating ceramic and metal insert ceramic brackets. The Self ligating stainless steel have the least frictional resistance because the two nickel titanium (Nitinol) clips that open and close through elastic deformation of the material when the archwire exerts a force on the clip.

BIBLIOGRAPHY
1. Alison Downing, John F. Mccabe & Peter. H. Gordon- The effect of artificial saliva on the

61

Table 1 : Comparison of mean value between different groups Group Group A Group B Group C Group D Mean S.D 66.47 7.86 77.52 8.59 72.67 5.76 40.21 7.76 P value * <0.001) sig. Significant groups at 5 % level # Group A v/s Group B Group D vs Group A,B & C0

Fig.1 : Self ligating stainless steel bracket

Fig.2 : Self ligating ceramic bracket

Fig.3 : Metal insert ceramic bracket

Fig.4 : Stainless steel bracket

Fig.5 : Smartclip wire disengagement appliance

Fig.6 : Smartclip wire engagement appliance

Fig.7 : Distribution Of Mean Values Between Different Brackets 62

A COMPARITIVE STUDY OF SOFT TISSUE CHANGES IN SKELETAL AND DENTAL CLASS 11 DIVISION 1 CASES TREATED WITH REMOVABLE FUNCTIONAL APPLIANCE AS AGAINST THOSE TREATED WITH FIXED FUNCTIONAL APPLIANCE
Authors:

Dr. Dhiren Gaitonde

Associate Professor MGM Dental College and Hospital Kamothe, Navi Mumbai.

Dr. V. Venkaiah

Professor K.L.Es Institute of Dental Sciences Belgaum.

Dr. Vivek Patni

Reader MGM Dental College and Hospital Kamothe, Navi Mumbai

Dr. Vijay Dikshit

Professor MGM Dental College and Hospital Kamothe, Navi Mumbai Abstract : This study was carried out to determine and compare the changes in the soft tissue profile brought about by a removable functional appliance to those brought about by a fixed functional appliance. Sample size consisted ideal Angles Class 11 Division 1 patients, 10 of which were treated with a Standard Bionator, 10 treated with Jasper Jumper and 10 Untreated Control. Serial lateral cephalometric radiographs were taken before treatment and after 10 months in all the 3 groups. The changes observed were documented in tabular form and comparative statistical analysis was carried out. Results showed that both, the Bionator and the Jasper Jumper were equally effective in bringing about correction of convex soft tissue profile as against the untreated Control sample. However the Jasper Jumper showed a slightly more effectiveness in achieving adequate lip competency without undue increase in lower anterior facial height as compared to the Bionotor. Angles Class 11 Division 1, Standard Bionator, Jasper, Jumper, Soft tissue profil, Lower anterior facial height.

Keywords :

INTRODUCTION
Facial esthetics is a subject of immense interest which embraces all people everywhere. In the modern orthodontic era. the importance of soft tissues in Orthodontics was emphasized by Dr. Edward H Angle, Dr. Charles Tweed, Dr. William Downs, etc in their literature. Orthodontics entered a new era with the advent of Cephalometrics. Various Cephalometric analyses were introduced by various authors : but these were restricted to dental and skeletal tissues. After 1950s soft tissue measurements were quickly recognized as an important factor in treatment planning. 63 Among the various types of malocclusion found in the human population, Class II Division 1 is the most common. Dr. James McNamara 13 has started that mandibular skeletal retrusion was the single most common characteristic of Class II Division 1 malocclusion in children between 8 to 10 years of age. Thus to bring about mandibular advancement various functional appliances have been routinely used as it is a proven fact that functional appliances take advantage of inherent growth potential and cause skeletal changes. One of the most commonly used Removable Functional appliance is the Bionator and the most common Fixed

Functional appliance is the Jasper Jumper. While these appliances affect the hard tissues, they also have an effect on the soft tissues. The Present study was planned to evaluate, compare and document the results in soft tissue facial esthetics brought about by the above two appliances, during a specific treatment period of 10 months.

7. No significant medical or dental histories 8. Positive VTO Serial lateral cephalometric radiographs were taken before initiation of treatment and again repeated after successful treatement in cases of treated group. Successful treatment was defined as achievement of a Class I molar relationship and acceptable soft tissue profile at the time when the lateral cephalograms were repeated. The average treatment time taken to achieve this objective was 10 months. Lateral cephalograms were also taken of the Untreated Control group before and at the end of the observation period.

AIMS AND OBJECTIVES


1. To determine the treatment effects of Removable Functional appliance i.e. Bionator on the soft tissues. 2. To determine the treatment effects of Fixed functional appliance i.e. Jasper Jumper on the soft tissues. 3. To compare the treatment effects caused by Removable functional appliance on the soft tissues to those causes by Fixed functional appliance on the soft tissues. This study is limited to the soft tissue changes as seen in the facial profile of a standard Lateral Cephalometric radiograph.

Cephalometric analysis
The following points were traced on the soft tissue profile as seen on the lateral cephalogram

Soft tissue Landmarks


1. Glabella (G) The most prominent point in the mid-sagittal plane on the forehead. 2. Soft tissue Nasion (N) The soft tissue counterpart of the hard tissue Nation (N) 3. Point P The most prominent point on the tip of the nose. 4. Subnasale (Sn) The point at which the nasal septum merges with the upper cutaneous lip in the mid - sagittal plane. 5. Columella (Cm) The most anterior point on the columella of the nose 6. Labrale Superius (Ls) A point indicating the mucocutaneous border of the upper lip 7. Labrale Inferius (Li) A point indicating the mucocutaneous border of the lower lip 8. Stomion Superius (Stms) The lowermost point on the vermilion of the upper lip 9. Stomion Inferius (Stmi) The uppermost point on the Vermillion of the lower lip. 10. Mentolabial sulcus The point of greatest concavity in the midline between the lower lip and the chin 11. Soft tissue Pogonion (Pog) The most anterior point on the soft tissue chin 12. Soft tissue Menton (Me) The most inferior point on the soft tissue chin 64

MATERIALS AND METHODS


Removable Functional appliance used Standard Bionator. Fixed Funtional appliance used Jasper Jumper. Sample Size : Bionator group : 10 patients Jasper Jumper group : 10 patients Control group : 10 patients Control group consisted of those individuals or children who had not undergone any kind of orthodontic treatment in the past. Age Group : 8 12 years with a mean age of 10 years 5 months Sex : No Criteria

Case Selection criteria :


1. Skelekal and Dental Class II Division 1 malocclusion 2. Angle ANB > 50 3. Angle FMA < 250 4. Overjet = 6 to 10mm 5. Positive overbite 6. Complete records available including Lateral Cephalogram, OPG and Hand wrist radiographs

The three groups were compared in the following manner : 1. Bionator Group To Control Group 2. Jasper Jumper Group To Control Group 3. Bionator Group To Jasper Jumper Group

STATISTICAL ANALISIS
The mean value and the standard deviation were calculated for each difference in the pre and post treatment measurements. Paired t test was performed to determine the significance of difference between the pre and post treatment values of each of the study groups. Students t tests were used to compare the difference between the Treatment groups and the Control group and between the two treatment groups. p value < 0.05 denoted a significant difference.

Cephalometric Measurements
Skeletal Measurements Angle ANB Lower anterior facial height (ANSMe)

ERROR ANALYSIS
Five cephalograms from each group were randomly selected in order to determine the combined degree of tracing and measurement error. Differences with a p value < 0.05 were considered statistically significant.

Soft Tissue Measurement


Facial Facial Convexity (Angle GSnPog) Inter labial gap (Stms Stmi) mm Lower anterior facial height (Soft tissue SnMe)

RESULTS
This study was conducted to compare the soft tissue changes in the facial profile brought about by the Bionator to those brought about by Jasper jumper in Angles Class II Division 1 cases. Pre and Post treatment lateral cephalometric radiographs of 3 groups of 10 patients each were studied. These 3 groups were named T1, T2, and C. T1 Bionmator Group T2 Jasper Jumper Group T3 Control Group Paired t test was carried out to study the significance of the changes between the pre and post treatment values. Student t test was carried out to determine the statistical significance of the average difference between the treatment groups and the control group and also between the two treatment groups. The Significance was documented in the following manner : If t Value < 2.10 Non-significant If t Value = 2.10 2.88 Significant at p<0.05 If t Value = 2.88 3.42 Very significant at p<0.01 If t Value > 3.42 Highly significant at p<0.001 The 3 study groups were compared in the following manner : Group T1 to Group C, Group T2 to Group C Group T1 to Group T2 The following tables show the results which are obtained after comparison between the 3 groups : 65

Maxilla
Maxillary prognathism (mm)

Upper Lip
Upper lip length (mm) Upper lip thickness (mm) Upper lip S line (mm) Upper lip E line (mm) Nasolabial Angle H Angle First described by Reed Holdaway 11. H line joins Pog to tip of the upper lip. H Angle is formed by H line to N- Pog line

Lower Lip
Lower lip length (mm) Lower lip thickness (mm) B thickness Lower lip S line (mm) Lower lip E line (mm) Mentolobial sulcus (mm)

Nose Prominence Chin


Pog thickness (mm) Z Angle The difference in the Pre and Post treatment values for each parameter was calculated. The difference for each parameter was compared for the three study groups.

TABLE 1 COMPARISION OF PRE AND POST TREATMENT VALUES IN THE BIONATOR (T1) GROUP
PRE-TREATMENT Mean A. 1. 2. B. I. 1. 2. 3. II III IV 1. 2. 3. a. b c d V 1. 2. 3. 4. a. b. c. d. VI VII 1. 2. SKELETAL Angle ANB LAFH (ANS-Me) SOFT TISSUE FACIAL Facial convexity Interlabial Gap LAFH (Sn-Me) MAXILLA Max. Prognathism MANDIBLE Mand. Prognathism UPPER LIP Length Thickness Procumbency U.Lip - S line U.Lip - E line Nasolabial Angle H.Anlge LOWER LIP Length Thickness Bthickness Procumbency 1 lip to S line 1 lip to E line Mento labial sulcus Mentolabial Angle NOSE Prominence CHIN Pog thickness Z -Angle +19.50 +6mm 65.15mm +2.75mm -10.65mm +18.4mm +10mm +4.55mm +3.25mm 80.50 21.50 +11.5mm 13.55mm +9.45mm +1.15mm +1.50mm +7.35mm 80.250 +11.5mm +8.35mm 60.25
0

MEASUREMENT

POST-TREATMENT Mean S.D.

S.D.

MEAN DIFF.

t VALUE

p VALUE

+7.80 59.4mm

1.56 1.8324

+4.50 62.55mm

1.33 0.9907

-3.30

3.5604

0.001 0.001

+3.15mm 5.6134

1.7329 0.8540 1.5554 1.5703 1.0409 2.0087 1.0916 0.4138 0.7534 4.2960 2.2010

+15.550 +3.8mm 68.4mm +4.35mm -5.45mm +20.6mm +10.25 +2.35mm +1.95mm 87.350 17.80

1.0916 1.1136 1.1005 1.7524 0.7071 1.5537 1.7329 1.3344 1.2030 5.7737 2.0877

-4.150 -2.2mm

4.8005 2.3229

0.001 0.05 0.001 NS 0.001 NS NS NS NS NS NS NS NS NS NS NS 0.001

+3.25mm 4.8524 +1.6mm -5.2mm 1.5507 4.3125

+2.2mm 1.4420 +0.25mm 1.1999 -2.2mm -1.3mm +6.850 -3.70 1.8449 1.1607 1.9407 2.0103

1.8679 +13.75mm 2.0409 0.7071 12.2mm 1.0014 1.19999 +9.55mm 1.4072 1.1426 1.0071 0.0495 1.8020 1.1329 1.0216 1.1714 66 +3.35mm +3.15mm +5.25mm 103.10 +13.2mm +9.35mm 66.35
0

+2.25mm 1.3677 -1.35mm 0.8450 +0.1mm 0.1541 +2.2mm 1.1765 +1.65mm 1.8449 -2.1mm +22.850 +1.7mm +1mm +6.1
0

1.0495 1.5537 0.6559 1.9524 1.0514 1.0877 1.1240

3.5135

13.6065 0.001 0.7534 0.0495 4.4140 NS NS 0.001

TABLE 2 COMPARISION OF PRE AND POST TREATMENT VALUES IN THE JASPER JUMPER (T2) GROUP
PRE-TREATMENT Mean A. 1. 2. B. I. 1. 2. 3. II III IV 1. 2. 3. a. b. c. d. V 1. 2. 3. 4. a. b. c. d. VI VII 1. 2. SKELETAL Angle ANB LAFH (ANS-Me) SOFT TISSUE FACIAL Facial convexity Interlabial Gap LAFH (Sn-Me) MAXILLA Max. Prognathism MANDIBLE Mand. Prognathism UPPER LIP Length Thickness Procumbency U.Lip - S line U.Lip - E line Nasolabial Angle H.Anlge LOWER LIP Length Thickness Bthickness Procumbency 1 lip to S line 1 lip to E line Mento labial sulcus Mentolabial Angle NOSE Prominence CHIN Pog thickness Z -Angle +20.150 +6.23mm 64.35mm +2.55mm -12.55mm +17.7mm 11.05mm +4.7mm +4.05mm 82.10 22.30 +13.4mm +15.5mm +9.35mm +1.35mm +2.05mm +8.25mm 79.20 1.2217 0.7071 1.6503 1.3933 1.2163 2.8801 2.2201 1.8920 1.5532 5.0410 2.0320 1.4407 1.9310 2.2612 0.9820 1.4701 0.6742 1.7210 +15.60 +1.43mm 66.4mm +2.8mm -5.3mm +19.6mm 12.3mm +2.55mm +2.15mm 87.450 17.70 1.26 0.4995 2.61 1.61 0.8670 2.5601 2.6905 1.2550 1.5910 4.63 1.5324 -4.550 -4.8mm 5.0913 4.1643 0.001 0.001 0.01 NS 0.001 NS NS NS NS NS NS 0.05 NS NS NS NS 0.001 0.001 NS NS 0.001 +8.20 61.25mm 0.947 1.8809 +4.750 63.2mm 0.5516 1.4013 -3.450 3.9724 0.001 0.01 +1.95mm 3.2225 S.D. POST-TREATMENT Mean S.D. MEAN DIFF. t VALUE p VALUE

MEASUREMENT

+2.05mm 3.199 +0.25mm 0.4361 -6.95mm 5.805

+1.9mm 1.380 +1.25mm 0.3821 -2.15mm -1.9mm +5.350 -4.60 1.8360 0.9610 1.8679 2.0964

+16.75mm 0.9514 +13.8mm +10.9mm +2.9mm +3.5mm +5.55mm 106.450 11.65mm 10.2mm 68.2
0

+3.35mm 2.2024 -1.7mm 1.1607 +1.55mm 0.9420 +1.55mm +1.45mm -2.7mm +27.250 +0.9mm +0.5mm +5.1
0

0.8809 1.9762 1.0572 1.2610 0.4702 2.0534 0.4095 1.1136 1.0877

1.9326 0.5320 3.6670 17.4940 0.2050 0.1498 3.0367

+10.75mm 0.9575 10.15mm 63.1


0

1.1053 1.7329 67

TABLE 3 COMPARISON OF FIRST AND SECOND OBSERVATION VALUES IN THE CONTROL (C) GROUP
PRE-TREATMENT Mean A. 1 2. B. I. 1 2. 3. II III IV 1. 2. 3. a. b. c. d. V 1. 2. 3. 4. a. b. c. d. VI VII 1. 2. SKELETAL Angle ANB LAFH (ANS-Me) SOFT TISSUE FACIAL Facial convexity Interlabial Gap LAFH (Sn-Me) MAXILLA Max. Prognathism MANDIBLE Mand. Prognathism UPPER LIP Length Thickness Procumbency U.Lip - S line U.Lip - E line Nasolabial Angle H.Anlge LOWER LIP Length Thickness Bthickness Procumbency 1 lip to S line 1 lip to E line Mento labial sulcus Mentolabial Angle NOSE Prominence CHIN Pog thickness Z -Angle +8.30 58.55mm 1.6320 1.4420 +8.750 57.75mm 1.22 1.72 +0.450 -0.8mm 0.212 1.32 NS NS S.D. POST-TREATMENT Mean S.D. MEAN DIFF. t VALUE p VALUE

MEASUREMENT

+210 +5.95mm 64.1mm +2.70mm -10.45mm +16.2mm +10.85mm +4.3mm +4.35mm 820 21.950 11.75mm 14.3mm 8.95mm +1.55mm +2mm +7.1mm 77.30 +10.5mm 11.45mm 62.150

1.4740 1.5904 2.56 1.7956 2.0320 1.2620 0.9910 0.8910 0.6916 5.04 1.88 1.1714 0.6740 1.4740 1.6950 2.0540 2.3524 1.9435 1.7534 1.5904 2.0314

+21.40 +5.90mm 63.3mm -3.45mm -13.5mm +15.55mm 9.90mm +4.05mm +4.50mm 81.30 21.850 11.60mm 14.4mm +9.05mm +2.05mm +2.05mm +8mm +74.850 +10.75mm 11.1mm 58.350

1.1820 0.9906 1.9320 1.5519 2.5640 0.8819 1.0546 1.5516 0.9321 4.69 0.6559 1.5560 0.4755 1.6324 0.9960 1.9540 2.0504 2.0305 1.0935 1.9321 1.9924

+0.40 1.25 +0.05mm 1.41 +0.8mm 1.0912 +0.75mm 0.333 +3.05mm 1.9720 -0.65mm -0.95mm -0.25mm -0.15mm -0.70 -0.10 -0.15mm -0.1mm +0.1mm +0.5mm +0.05mm -0.9mm +2.450 0.5350 1.2740 1.76 1.65 1.274 1.7880 1.90 0.61 0.1541 0.7564 0.6504 1.48 2.0160

NS NS NS NS NS NS NS NS NS NS NS NS NS NS NS NS NS NS NS NS NS

+0.25mm 0.4340 -0.35mm -3.80 1.74 2.0310

68

TABLE - I COMPARISON OF SOFT TISSUE CHANGES BETWEEN BIONATOR & CONTROL GROUPS
TREATMENT GRP. (T1) Mean A. 1 2. B. I. 1 2. 3. II III IV 1. 2. 3. a. b. c. d. V 1. 2. 3. 4. a. b. c. d. VI VII 1. 2. SKELETAL Angle ANB LAFH (ANS-Me) SOFT TISSUE FACIAL Facial convexity Interlabial Gap LAFH (Sn-Me) MAXILLA Max. Prognathism MANDIBLE Mand. Prognathism UPPER LIP Length Thickness Procumbency U.Lip - S line U.Lip - E line Nasolabial Angle H.Anlge LOWER LIP Length Thickness Bthickness Procumbency 1 lip to S line 1 lip to E line Mento labial sulcus Mentolabial Angle NOSE Prominence CHIN Pog thickness Z -Angle -4.150 -2.2mm +3.25mm +1.6mm -5.2mm +2.2mm +0.25mm -2.2mm -1.3mm +6.850 3.70 +2.25mm -1.35mm +0.1mm +2.2mm +1.65mm -2.1mm +22.850 +1.7mm +1mm +6.1
0

MEASUREMENT

CONTROL GRP. (C) Mean +0.450 -0.8mm S.D. 0.6852 0.5375

S.D. 0.4216 0.4743

MEAN DIFF.

t VALUE

p VALUE

-3.30 +3.15mm

-3.750 +3.95mm

4.0372 0.001 17.4246 0.001

0.5297 0.8882 0.6687 0.8433 1.1832 1.6865 0.9910 1.8135 2.0028 4.8256 4.2960 1.1365 1.0554 1.8529 0.7528 0.4743 0.6146 1.4347 0.6749 1.4337 1.005 69

-0.40 -0.05mm -0.8mm +0.75mm +3.05mm -0.65mm -9.95mm -0.25mm +0.15mm -0.70 -0.10 -0.15mm +0.1mm +0.1mm +0.5mm +0.05mm +0.9mm -2.450 +0.25mm -0.35mm -3.8
0

0.7379 0.6433 0.5869 2.0446 0.8760 1.4916 1.3834 1.3176 1.4916 2.3823 1.8679 0.7472 1.005 1.7748 0.8819 0.9846 0.5676 0.7246 1.3591 0.7835 1.2065

-4.550 -2.15mm +4.05mm +0.85mm -8.25mm +2.85mm +1.20mm -1.95mm -1.45mm +7.550 -3.60 +2.40mm -1.45mm 0 +1.70mm +1.60mm -3.0mm +25.350 +1.45mm +1.35mm +9.9
0

4.5318 2.3687

0.001 0.05

14.0390 0.001 0.3084 6.5530 1.3761 0.6308 1.0493 0.6908 0.4138 1.2629 1.554 0.9579 0 1.4085 1.2035 NS 0.001 NS NS NS NS NS NS NS NS NS NS NS

11.3389 0.001 23.5838 0.001 0.7898 1.1793 5.9796 NS NS 0.001

TABLE - II COMPARISON OF SOFT TISSUE CHANGES BETWEEN JASPER JUMPER & CONTROL GROUPS
TREATMENT GRP. (T1) Mean A. 1 2. B. I. 1 2. 3. II III IV 1. 2. 3. a. b. c. d. V 1. 2. 3. 4. a. b. c. d. VI VII 1. 2. SKELETAL Angle ANB LAFH (ANS-Me) SOFT TISSUE FACIAL Facial convexity Interlabial Gap LAFH (Sn-Me) MAXILLA Max. Prognathism MANDIBLE Mand. Prognathism UPPER LIP Length Thickness Procumbency U.Lip - S line U.Lip - E line Nasolabial Angle H.Anlge LOWER LIP Length Thickness Bthickness Procumbency 1 lip to S line 1 lip to E line Mento labial sulcus Mentolabial Angle NOSE Prominence CHIN Pog thickness Z -Angle -6.95mm +1.9mm +1.25mm -2.15mm -1.9mm +5.350 -4.60 +3.25mm -1.7mm +1.55mm +1.55mm +1.45mm -2.7mm +27.250 +0.9mm +0.5mm +5.10 1.0659 1.5055 2.3244 1.1068 1.1738 3.9934 2.9796 0.9763 0.9775 2.2167 1.1891 0.7976 0.5869 1.0069 1.1005 1.1547 0.9944 +3.05mm -0.65mm -0.95mm -0.25mm +0.15mm -0.70 -0.10 -0.15mm +0.1mm +0.1mm +0.5mm +0.05mm +0.9mm +2.450 +0.25mm -0.35mm -3.80 0.8960 1.4916 1.3834 1.3176 1.4916 2.3823 1.8679 0.7472 1.1005 1.7748 0.8819 0.9846 0.5676 0.7246 1.3591 0.7835 1.2065 -4mm +2.55mm +2.20mm -1.80mm -2.05mm +6.050 -4.50 6.8595 0.001 -4.550 -4.8mm +2.05mm +0.25mm 0.5986 0.9189 0.4972 1.7834 +0.40 -0.05mm -0.8mm +0.75mm 0.7379 0.6433 0.5869 2.0446 -4.950 -4.75mm +2.85mm -0.50mm 5.9187 0.001 3.8014 0.01 11.7167 0.001 0.2017 NS S.D. CONTROL GRP. (C) Mean S.D. MEAN DIFF. t VALUE p VALUE

MEASUREMENT

-3.450 +1.95mm

0.4216 0.5503

+0.450 -0.8mm

0.6852 0.5375

-3.900 +2.75mm

6.2295 0.001 11.3056 0.001

+1.2294 NS 0.4794 NS 1.2319 1.2470 0.7534 1.1136 NS NS NS NS 0.01 NS NS NS NS 0.001 0.001 NS NS 0.001

+3.50mm 3.3375 -1.8mm 1.3266 +1.145mm 0.4794 +1.05mm +1.40mm -3.6mm +29.700 +0.65mm +0.85mm +8.90 0.6483 1.2563 13.9427 21.6754 0.4227 1.1547 6.4137

70

TABLE - III COMPARISON OF SOFT TISSUE CHANGES BETWEEN BIONATOR AND JASPER JUMPER GROUPS
BIONATOR GROUP (T1) Mean A. 1 2. B. I. 1 2. 3. II III IV 1. 2. 3. a. b. c. d. V 1. 2. 3. 4. a. b. c. d. VI VII 1. 2. SKELETAL Angle ANB LAFH (ANS-Me) SOFT TISSUE FACIAL Facial convexity Interlabial Gap LAFH (Sn-Me) MAXILLA Max. Prognathism MANDIBLE Mand. Prognathism UPPER LIP Length Thickness Procumbency U.Lip - S line U.Lip - E line Nasolabial Angle H.Anlge LOWER LIP Length Thickness Bthickness Procumbency 1 lip to S line 1 lip to E line Mento labial sulcus Mentolabial Angle NOSE Prominence CHIN Pog thickness Z -Angle -3.30 +3.15mm S.D. 0.4216 0.4743 JASPER JUMPER GROUP (T2) Mean -3.450 +1.95mm S.D. 0.4216 0.5503 MEAN DIFF. t VALUE p VALUE

MEASUREMENT

-0.150 +1.10mm

0.2576 5.2234

NS 0.001

-4.150 -2.2mm +3.25mm +1.6mm -5.2mm +2.2mm +0.25mm -2.2mm -1.3mm +6.850 -3.70 +2.25mm -1.35mm +0.1mm +2.2mm +1.65mm -2.1mm +22.850 +1.7mm +1mm +6.10

0.5297 0.8882 0.6687 0.8433 1.1832 1.6865 1.3176 1.8135 2.0028 4.8256 4.2960 1.1365 1.0554 1.8529 0.7528 0.4743 0.6146 1.4347 0.6749 1.4337 1.005

-4.550 -4.8mm +2.05mm +0.25mm -6.95mm +1.9mm +1.25mm -2.15mm -1.9mm +5.350 -4.60 +3.35mm -1.7mm +1.55mm +1.55mm +1.45mm -2.7mm +27.250 +0.9mm -0.5mm +5.10

0.5986 0.9189 0.4972 1.7834 1.0659 1.5055 2.3244 1.1068 1.1738 3.9934 2.9796 0.9733 0.9775 2.2167 1.1891 0.7976 0.5869 1.0069 1.1005 1.1547 0.9944

-0.400 -2.6mm +1.20mm +1.35mm -1.75mm +0.3m -1mm -0.05mm +0.6mm +1.500 -0.90 +1.10mm -0.35mm +1.45mm +0.65mm +0.20mm -0.6mm +4.40 +0.8mm +0.5mm +10

0.5439 2.1198 4.1742 1.0679 1.0784 1.6865 0.5223 0.0203 0.2212 1.3344 0.1541 0.8122 0.2415 0.5614 0.6031 0.2922 2.2326 2.2553 0.8246 2.254 0.6624

NS 0.05 0.001 NS NS NS NS NS NS NS NS NS NS NS NS NS 0.05 0.05 NS NS NS

71

TABLE - IV COMPARISON OF THE TREATMENT EFFECTS BETWEEN THE THREE STUDY ROUPS
BIONATOR GROUP JASOER JUMPER GROUP

MEASUREMENT

CONTROL GROUP

SIGNIFICANCE

Mean
Skeletal 1. Anlge ANB 2. LAFH (ANS - Me) Soft Tissue 1. Facial Convexity 2. Inter Labial Gap -4.150 -2.2mm -3.30 +3.15mm

S.D

Mean

S.D
0.4216

Mean
+0.450 -0.80mm

S.D
0.6852 0.5375
Bionator from Control Jasper Jumper from Control Bionator from Control Jasper Jumper from Control Bionator from Jasper Jumper Bionator from Control Jasper Jumper from Control Bionator from Control Jasper Jumper from Control Bionator from Jasper Jumper Bionator from Control Jasper Jumper from Control Bionator from Jasper Jumper None Bionator from Control Jasper Jumper from Control None None None None None None Jasper Jumper from Control None None None None Bionator from Control Jasper Jumper from Control Bionator from Jasper Jumper Bionator from Control Jasper Jumper from Control Bionator from Jasper Jumper None None Bionator from Control Jasper Jumper from Control

0.4216 -3.450 0.4743

+1.95mm 0.5503

0.5297 0.882

-4.550 -4.8mm

0.5986 0.9189

+0.40 -0.05mm

0.7379 0.6433

3. LAFH (Sn-Me)

+3.25mm

0.6687

+2.05mm 0.4972

-0.80mm

0.5869

4. Max Prognathism 5. Mand Prognathism 6. U. Lip length 7.U. Lip thickness 8.U. Lip - S line 9.U. Lip - E line 10. Nasolabial Angle 11. H - Anlge 12. L. Lip Length 13. L. Lip Thickness 14. B Thickness 15. L. Lip - S line 16. L. Lip - E line 17. Mentolabial Sulcus 18. Mentolabial Angle

+1.6mm -5.2mm +2.2mm +0.25mm +2.2mm -1.3mm +6.850 -3.7 +2.25mm -1.35mm +0.1mm +2.2mm +1.65mm -2.1mm +22.850

0.8433 1.1832 1.6865 1.3176 1.8135 2.0028 4.8256 4.2960 1.1365 1.0554 1.8529 0.7528 0.4743 0.6146 1.4347

+0.25mm 1.7834 -6.95mm +1.9mm 1.0659 1.5055

+0.75mm 2.0446 +3.05mm 0.8760 -0.65mm -0.95mm -0.25mm 1.4916 1.3834 .3176

+1.25mm 2.3244 -2.15mm -1.9mm +5.350 -4.60 1.1068 1.1738 3.9934 2.9796

+0.15mm 1.4916 -0.700 -0.10 -0.15mm +0.1mm +0.1mm +0.5mm 2.3823 2.3823 0.7472 1.1005 1.7448 0.8819

+3.35mm 0.9733 -1.7mm 0.9775

+1.55mm 2.2167 +1.55mm 1.1891 +1.45mm 0.7976 -2.7mm +27.250 0.5869 1.0069

+0.05mm 0.9846 +0.9mm -2.450 0.5676 0.7246

19. Nose Prominence 20. Pog Thickness 21.Z - Angle

+1.7mm +1mm +6.10

0.6749 1.4337 1.005

+0.9mm +0.5mm +5.10

1.1005 1.1547 0.9944

+0.25mm 1.3591 -0.35mm -3.80 -0.7835 1.2065

72

DISCUSSION
In the present study, 3 groups of Angles Class II Division 1 malocclusion, each comprising of 10 patients each were compared. The difference between the pre and post treatment values were obtained and subjected to statistical analysis. Results showed that the Bionator

about a marked improvement in the skeletal jaw relationship from Class II to Class 1 by virtue of a significant increase in the forward growth of the mandible rather than by restriction of maxillary growth

B. SOFT TISSUES
1. Facial: Angle of Convexity (G-Sn-Pog) showed a significant post-treatment decrease in both, the Bionator as well as the Jasper Jumper groups as compared to an increase in the Control group. This decrease in the facial convexity was mainly due to the soft tissue Pogonion coming forward and to a lesser extent, due to the Subnasale being restricted in its forward movement. These findings corretate well with those of Forsberg and Odenrick8 and also with those of D. William Lange12 who reported a significant increase in the advancement of Soft tissue Pogonion by Activator and Bionator therapy respectively. Comparison between the two treatment groups showed that both, Bionator as well as Jasper Jumper were equally effective in bringing about an improvement in the facial profile convexity by significant forward movement of the mandible but without any restricting effect on the maxilla 2. Lips: Dr Charles Burstone5 concluded that lips show very significant changes in the soft tissue profile after orthodontic treatment.

Before Bionator treatment

After Bionator treatment

Upper Lip
Before Jasper Jumper treatment After Jasper Jumper treatent There were no significant changes in the length and thickness of the upper lip in the Bionator as well as the Jasper Jumper group when compared to the Control group. The nasolabial angle did not show any statistically significant increase in both, the Bionator and the Jasper Jumper groups as compared to the Control group. Statistically insignificant retrusive effect on the upper lip was observed when measured from the S line and E line. Anderson J. Paul et al1 had stressed the importance of H line in evaluating facial profile. The H Angle, although it as compared to a minimal effect seen in the Control group, this decrease was not the forward movement of the Pogpoint

and the Jasper Jumper groups showed significant changes in the soft tissue facial complex as compared to the untreated Control group

A. SKELETAL
Angle ANB decreased by 3.3 (0.001) in the Bionator group and by 3.45 (0.001) in the Jasper Jumper group as compared to an increase of 0.45 in the Control group. This decrease in Angle ANB was more because of the forward movement of the mandible rather than restriction of the maxillary growth. However, no statistically significant difference was observed in the decrease in Angle ANB when the Bionator group was compared to the Jasper Jumper group; thus indicating that both these appliances bring 73

Lower Lip
There was a significant increase in the length of the lower lip after treatment with the Bionator and with the Jasper Jumper as compared to a slight decrease as

observed in the Control sample. The increase in lip length by the Jasper Jumper was considered statistically significant when compared to the Control group (p0.01) whereas that caused by the Bionator was not statistically significant. This is due to the fact that functional appliance treatment leads to uprighting of Similar findings were reported by D. William Lange et.al12 There was a reduction in the Interlabial gap by 2.2mm (p0.05) after treatment with the bionator and by 4.8mm (0.001) after treatment with the Jasper Jumper. The Control group showed minimal changes in the pre and post treatment values. This shows that these appliances help achieve lip competency which is showed more effectiveness in achieving lip closure than the Bionator. The depth of the Mentolabial sulcus decrease by 2.1mm in Bionator group and by 2.7mm in Jasper Jumper group as compared to an increase of 0.9mm in the Control group. This is due to the fact that the functional appliance treatment by the forward movement of Pog; thus leading to an increase in lip consistency and a decrease in depth of the Mentolabial sulcus. This effect was more pronounced after Jasper Jumper treatment than after Bionator treatment. The Mentolabial Angle showed most significant change after treatment with functional appliances. One of the major effects seen with the Bionator and the Jasper Jumper treatment was the uncurling of the lower lip, thus increasing the Mentolabial Angle. This angle showed a dramatic increase by 22.85 (0.001) in Bionator group and by 27.25 (0.001) in Jasper Jumper group as compared to a decrease of 2.45 in the Control group. Comparison of Bionator and Jasper Jumper group showed an increased efficiency of Jasper Jumper in having an uncurling effect on the lower lip (0.05)

LOWER ANTERIOR FACIAL HEIGHT (LAFH)


There was a significant post-treatment increase in the skeletal lower anterior facial ehight in both the treatment groups as compared to a minimal change observed in the Control group. This increase in LAFH was observed more in the Bionator group (3.25mm) than in the Jasper Jumper group. This was due to the fact that during functional appliance treatment, the posterior teeth were allowed to erupt, resulting in downward rotation of the mandible, thus increasing the lower facial height. There lesser increase in LAFH in Jasper Jumper group was due to the fact that this appliance works on the expansion principle due to which the resultant force vector is along the Y axis, leading to minimal molar extrusion, thus causing very little downward rotation of the mandible. Whereas the resultant force vector of the Bionator has a strong vertical component which leads to significant molar extrusion thus causing significant increase in LAFH

CONCLUSION
The purpose of this study was to compare the changes in the soft tissue profile brought about by Removable Functional appliance (Bionator) as against those brought about by a Fixed functional appliance (Jasper Jumper) Thus, based on the sample of this study, the following conclusions can be drawn: Treatment with Bionator as well as Jasper Jumper leads to an appreciable decrease in the soft tissue facial convexity. This was more due to forward positioning of the mandible in both the treatment groups No restraining effect on the maxilla was observed in both the treatment groups There was an appreciable increase in lower anterior facial height after Bionator and Jasper Jumper treatment. This increase was observed more after Bionator treatment than after Jasper Jumper treatment. Treatment with Bionator as well as Jasper Jumper leads to an increased lip competency due to the uncurling effect and increase in length of the lower lip. This achievement of lip competency was appreciated more after Jasper Jumper therapy than after Bionator therapy

ZAngle
As described by Merrifield15 this angle gives an accurate description of the lower face relationship and eliminates the vagueness of eye judgement. The uncurling effect on the lower lip leading to a mor vertical positioning of the profile line is shown by an increase in the Z angle by 6.1(0.001) in the Bionator group and by 5.1(0.01) in the Jasper Jumper group as compared to a decrease of 3.8 observed in the Control group. Comparison of treatment results in Bionator to the Jasper Jumper group showed no significant difference. 74

Ultimately one can conclude that both, Bionator as well as Jasper Jumper are more or less equally effective in bringing about an improvement in facial balance and harmony in Class 11 Division 1 malocclusion cases if treatment is brought about in the growth phase.

REFERENCES
1. Andreson Paul J. Donald R. Joondeph; David L. Turpin; 1973 A Cephalometric study of profile changes in Orthodontically treated cases ten years out of retention Am. J. Orthod;43;324-336 2. Bishara Samir; et al.; 1995 A Computer-assisted photogrammetric analysis of soft tissue changes after Orthodontic treatment. Part 1: Methodology and Reliability Am. J. Orthod. Dentofac. Orthop;107;633-639 3. Bloom Leonard A; 1961 Perioral profile changes in Orthodontic treatment 4. Burstone Charles J : 1958 The Integumental Profile Am. J. Orthod; 44;1;1-25 5. Burstone Charles J : 1967 Lip posture and its significance in treatment planning Am. J. Orthod; 52; 4; 262-284 6. Cummins David M; et al.; 1995 A Computerassisted photogrammetric analysis of soft tissue changes after Orthodontic treatment. Part 11: Results Am. J. Orthod. Dentofac. Orthop; 108; 3847 7. Forsberg Carl-Magnus; Lars Odenrick; 1979 Changes in the relationship between the lips and

the esthetic line from eight years of age to adulthood Eur; J; Orthod; 1;265-270 8. Forsberg Carl-Magnus; Las Odenrick; 1981 Skeletal and soft tissue response to Activator treatment Eur; J; Orthod; 3;247-253 9. Graber T. M; Bedrich Neumann; 1984 Removable Orthodontic Appliances W.B. Saunders Company; 357-375 10. Jacobson Alexander; 1995 Radiographic Cephalometry- From Basics to Videoimaging Ouintessence Publishing Co, Inc.; 11. Holdway Reed A; 1983 A soft tissue cephalometric analysis and its use in orthodontic treatment planning Am. J. Orthod; 84; 1; 1-20 12. Koch. R; A. Gonzales; E. Witt; 1979 Profile and soft tissue changes during and after Orthodontic treatment Eur. J. Orthod; 1; 193-199 13. Lange William D; et al; 1995 Changes in soft tissue profile following treatment with the Bionator The Angle Orthodontist; 65; 6; 423-430 14. McNamara James Jr; 1981 Components of Class 11 malocclusion in children 15. Merrifield Levern. L; 1966 The profile line as an aid in critically evaluating facial esthetics Am. J. Orthod. Dentofac. Orthop; 52; 11; 804-822 16. Morris David. O; Heather M. llling; Robert T Lee; 1988 The prospective evaluation of Bass, Bionator and Twin Block appliances. Part 11- Soft tissues Eur. J. Orthod; 20; 633-684 17. Roos Nills; 1977 Soft tissue changes in Class 11 treatment Am. J. Orthod.;72;2;165-175

75

MANAGEMENT OF CLASS II DIVISION 2 MALOCCLUSION AN INSIGHT


Author:

Prof. Dr. C.S. Ramachandra


Diplomat Indian Board of Orthodontics Professor & Head Dept. of Orthodontics, Principal, AECS Maaruti Dental College & Research Center, Bangalore.

Dr. C.S. Ramachandra

Abstract :

Class II Div 2 malocclusion has been a challenging clinical entity in terms of treatment and more so in terms of stability of the result. When one browses through the literature, a lot is documented on the etiology and treatment approach. This article tries to compile such information and present cases treated by infusing them in to the treatment regime. Intrusion and Torqueing of incisors, reduction of inter incisal angle and non extraction approach to improve lip support could be some of the factors leading to successful outcome.

Key Words :

Inter incisal angle, Deep bite, Lip line, Centroid and class II division 2. It is possible to believe that unlike in other forms of malocclusions the incisors in class II div 2 malocclusion occupy a predetermined position which could make one think to be by a divine guidance. On the contrary the local environmental factors influence the erupting incisors, which make their behavior more predictable. Infraocclusion of buccal segment and counter clockwise rotation of the mandible leads to an excess of soft tissue in the lower face and results in an upward shift of the lip line and this influences the maxillary incisors to get retroclined which is demonstrated as in the figures 1 to 4.

INTRODUCTION
Class II div2 malocclusion is characterized by the manifestation of a group of features which make it qualified to be termed as a syndrome. The following are the characteristics to reckon with: Increased lower lip pressure on the upper incisors and increased masticatory muscle forces 2 Deep bite, retroclined maxillary centrals, proclined laterals and even morphologically different upper incisors such as thinner crowns labiolingually 3 and high collum angle 4 Class II skeletal discrepancy with counter clock wise rotation which adds to the problem of deep bite, chin prominence and reduced lower facial height. Familial occurrence of Class IIdiv2 has been documented in great deal and there is strong evidence of genetics as the main etiological factor in the development of this type of malocclusion. After evaluating 114 class II div 2 cases Markovic observed that the monozygotic twins showed 100% concordance and 90% of the dizygotic twins showed discordance5. Certain studies point to an incontestable genetic influence probably autosomal dominant with incomplete penetration and variable expressivity. It could also possibly be explained by a polygenic model with a simultaneous expression of a number of genetically determined morphological traits rather than controlled by a single gene1. 76

fig :1

fig: 2

fig:3

fig:4

Fletcher has convincingly established that the upper incisors retroclined in Class II div 2 after their emergence in to the oral cavity. The project involved a serial study of early development and tooth eruption between the ages of 4.5 to12.5 years6 . In this type of malocclusion upper central incisors could have large collum angle, which can pose problems in intrusion

and torqueing movements. Torqueing of these teeth with pronounced collum angle are likely to have their roots positioned closer to the palatal cortical plate than expected and could be a factor responsible for relapse.4 Many clinicians hypothesize that retroclination of the maxillary central incisors in class II Div 2 malocclusion is caused by increased resting lip pressure. Lapatki et al revealed that the retroclination of maxillary central incisors are primarily due to high lip line and not due to hypertonic peri oral musculature. Higher the lip line, the lower lip exerts more pressure on the incisal half resulting in the retroclination of the maxillary incisors as demonstrated in figure 5.7

College, Bangalore it is only 3% amongst the patients seeking treatment. Figures rang form 3% to6.4% world wide. It could be argued that people with class II division 2 malocclusion look smart and it could be one reason for their not seeking treatment. Inadequately trained doctors and poor choice of appliance could result in unstable results creating an impression among general public that this type of malocclusion is untreatable. It is challenging to treat such syndrome like entity which demands the clinician to target/treat all the features responsible so as to achieve pleasing and stable outcome.

Treatment rationale:
Following could be the list of our objectives, and achieving this will ensure a stable outcome. 1. De crowding and Aligning: This would be the priority to every one and the main force behind patient motivation. Fig: 5 Lapatki et al have concluded that Orthodontic treatment of class II Div2 cases should include: Intrusion and torqueing of maxillary incisors, Eliminate the high pressure exerted by the lower lip on maxillary incisors and consequently reduce the post orthodontic relapse. 2. Overbite reduction: Deep over bite results in breakdown of both hard and soft tissues. It is necessary to establish correct incisal relation to preserve the health of the oral structures.

Limitations imposed by the soft tissues enveloping the dentition were thought to be inviolable. This has inhibited the clinicians in treating class II div 2 malocclusions. Selwyn and Barnett while highlighting the significance of pressure exerted by soft tissue, have stressed on its role in evaluating the situation, determining the possibilities and limitations of the treatment. The best therapeutic approach is certainly the intrusion and torqueing of the maxillary incisors, which is the only means of eliminating the high pressure exerted by the lower lip on them.8 Crowding associated with this type of malocclusion appears to be on the higher side and very often clinicians are tempted to advice premolar extractions. But Salzmann has categorically stated that extraction should be considered rarely.9 Mills in a study of sixty treated cases found that over bite commonly relapses and showed that the best treatment results are obtained where there is a combined reduction in inter incisal angle and over bite(10). Incidence of class II div2 malocclusion is lowest amongst all. In our department at Maaruti Dental 77

3. Reduction in inter incisal angle to 125-130 degrees : This would mutually prevent the incisors from supra erupting and there by preventing the relapse of division 2 pattern.

same which can be aided by forwardly directed forces. One should even contemplate surgical advancement of mandible in adult cases so as to achieve class 1 situation, with out which achieving correct incisal relation would be a dream.

4. Bring the centroid of the maxillary incisor lingual to the mandibular incisal tip : The maxillary centrals tend to revert back to their previous position which is typical to this malocclusion after treatment. This type of relapse could be prevented bya) Getting the mandibular anteriors bodily forward and not merely tipping. b) Torqueing the maxillary centrals enough, so as to direct the occlusal forces generated by the mandibular incisors labial to the centroid of the maxillary central incisors. 7.Retention Protocol : Preferably bonded lingual retainer for the mandibular anteriors and for the upper arch Hawleys or molded clear retainers would be advisable.

CASE REPORT:
The clinician can be influenced by factors such as the training availed, philosophy followed, and facility available in selecting the appliance. Three cases treated by me are presented where an effort is made to satisfy the listed objectives which are crucial in the stability of the results achieved. .022 slot pre adjusted system was used for their effectiveness in establishing required torque to the maxillary incisors and induce bodily movement of mandibular anterior teeth. These patients had all the classical features of class II div2 malocclusion. The first two cases are treated with out any extractions, but the third case had an impacted mandibular canine which was removed. (Since there was Boltons excess in the mandibular anteriors, this did not matter). Self ligating brackets were used in the maxillary arch for this case. Maxillary teeth are addressed initially and once enough clearance is achieved brackets are bonded to mandibular teeth. The arch wire sequence was similar in all these cases-started with .016 Niti. for first two months followed by 16*22 RCS Niti and progressively filling the slot up to 21*25 SS wires. Class II elastic forces are used to achieve inter arch correction. For the maxillary teeth, vacuum molded retainer and for mandibular teeth bonded lingual retainers were given. 78

5. Support the facial profile : Positioning of incisors as directed in rationale no 3 & 4 would help in straightening the profile and eliminate the sunken face appearance and aged look.

6. Correct the buccal segment to Class I : Many a time opening the bite eliminates the restrictive effect on the mandible allowing forward shift of the

CASE 1: Pre treatment:

Progress :

Finish:

ANALYSIS: Steiner Measurement Norm SNA Angle SNB Angle ANB Angle U 1 to NA dist U 1 to NA angle L 1 to NB distance 4 L 1 to NB angle Pog to NB distance Interincisal angle Occlusal to SN angle Go-Gn to SN angle Mechanotherapy :

Measured 82 76.5 80 72.7 2 3.9 4 -3.4 22 1.6 -4.3 25 1.3 5.4 131 -1.0 14 20.3 32 20.0

ANALYSIS: Steiner Norm SNA Angle SNB Angle ANB Angle U 1 to NA dist U 1 to NA angle L 1 to NB distance L 1 to NB angle Pog to NB distance Interincisal angle Occlusal to SN angle Go-Gn to SN angle 79

82 80 2 4 22 4 25

Measured 74.9 72.6 2.3 14.6 30.4 10.4 23.9 10.0 131 123.5 14 15.5 32 21.2

CASE 2: Pre treatment:

Progress :

Finish:

ANALYSIS: Steiner Norm SNA Angle SNB Angle ANB Angle U 1 to NA dist U 1 to NA angle L 1 to NB dist L 1 to NB angle Pog to NB dist Interincisal angle Occl to SN angle Go-Gn to SN angle Mechanotherapy : ANALYSIS: Steiner Norm Measured SNA Angle 82 86.1 SNB Angle 80 83.3 ANB Angle 2 2.8 U 1 to NA dist 4 6.1 U 1 to NA angle 22 28.6 L 1 to NB dist 4 6.5 L 1 to NB angle 25 20.0 Pog to NB dist 8.0 Interincisal angle 131 128.6 Occl to SN angle 14 10.4 Go-Gn to SN angle 32 17.3 80 82 80 2 4 22 4 25 Measured 9.2 84.2 5.1 -5.3 1.1 1.7 13.1 10.5 131 160.6 14 6.0 32 15.9

CASE 3: Pre treatment:

Finish:

ANALYSIS: Steiner Measured SNA Angle 82 79.8 SNB Angle 80 74.1 ANB Angle 2 5.7 U 1 to NA dist 4 -7.3 U 1 to NA angle 22 0.3 L 1 to NB dist 4 -0.5 L 1 to NB angle 25 12.5 Pog to NB dist 3.1 Interincisal angle 131 173 Occl to SN angle 14 19.4 Go-Gn to SN angle 32 32.6 Mechanotherapy : Norm

ANALYSIS: Steiner Norm Measured SNA Angle 82 78.8 SNB Angle 80 72.8 ANB Angle 2 6.0 U 1 to NA dist 4 3.5 U 1 to NA angle 22 23.2 L 1 to NB dist 4 11.7 L 1 to NB angle 25 29.1 Pog to NB dist 5.6 Interincisal angle 131 121.7 Occl to SN angle 14 22.6 Go-Gn to SN angle 32 33.6

81

DISCUSSION:
Orthodontic treatment mechanics has evolved over the time enabling operators to provide better results while treating malocclusions. It is important to ensure stability of what is achieved to claim long term success. If we attain the former and fail in the later, it mandates us to investigate in to the structural flaws which caused the relapse. Most of the clinicians would achieve the best form of finish by de crowding and aligning and partially opening the bite but may not go to the extent of looking into the reduction of inter incisal angle and bringing the centroid of maxillary incisor behind the mandibular incisal edge. Most of the time the class 2 situation gets corrected with the unlocking of the mandible aided by class 2 elastic forces, as shown in the cases presented if the treatment is undertaken during the early permanent dentition. In sever cases of inter arch discrepancy, surgical options can be considered. It is advisable to practice bonded lingual retainer in the mandibular arch and vacuum molded retainers for the maxillary teeth which can precisely hold the teeth in their corrected position.

2.

Grant. T. Mclntyre, Declan. T. Millett- Lip Shape and Position in class II div 2 malocclusion- 2006 Angle Orthodontist, 76, 5. 737- 742. N.R.E. Robertson, Roy Hilton- Feature of the upper central incisor in class II div 2- 1965. Angle orthodontist 35, 51-53,. Helen P. Delivanis et al- Variation in morphology of the maxillary central incisors found in class II div2 malocclusion. 1980 AJO-DO, 438-443. Milan D. Markovic- At the crossroads of oral facial genetics.1992 European Journal of Orthodontics 14. 469-481. Fletcher. GGT- The retroclined upper incisor. 1975, BJO. 2. 207-216. Lapatki. B.G. et al, - The importance of the level of the lip line and resting lip pressure in class II div 2 malocclusion - 2002. J Dent Res 81.5.323328, B.J.Selwyn-Barnett- Rationale of treatment for class II Div 2 malocclusion- 1991,BJO.18. 173- 181. Salzmann.J- Practice of Orthodontics. 1966. 661.

3.

4.

5.

6. 7.

8. 9.

REFERENCE:
1. Mossey.P.A- The heritability of malocclusion, 1999 BJO.26, 195-203.

10. Mills J. R. E - The problem of overbite in Class II Division 2 malocclusions, 1973. BJO, 1, 34-48

82

A NEW EQUATION FOR PREDICTING THE WIDTH OF UNERUPTED PERMANENT CANINES AND PREMOLARS FOR COSMOPOLITAN INDIAN POPULATION
Authors:

Dr. Krishnakumar R. Jaju (Corresponding Author)


Dr. Krishnakumar R. Jaju

Post Graduate student Dept. Orthodontics and Dentofacial Orthopaedics M.G.Vs K.B.H. Dental College and Hospital Nashik, Maharashtra - 422003, India. E-mail : drkjaju@gmail.com Mobile No. : 09665863863

Dr.Nitin D. Gulve
Dr.Nitin D. Gulve

Professor & Guide Dept. Orthodontics and Dentofacial Orthopaedics M.G.Vs K.B.H. Dental College and Hospital Nashik, Maharashtra - 422003, India.

Dr. Shrikant S. Chitko

Dr. Shrikant S. Chitko

Professor & Head of the Department Dept. Orthodontics and Dentofacial Orthopaedics M.G.Vs K.B.H. Dental College and Hospital Nashik, Maharashtra - 422003, India.

Abstract :

Predicting the size of unerupted teeth during the mixed dentition period is a critical factor in managing the developing occlusion of a growing child. The most commonly used prediction method of Tanaka and Johnston is based on data from a sample of children of Northern European descent. The accuracy of this method when applied to a different ethnic population is questionable. This study aimed to determine a linear regression equation that would predict the sum of the mesiodistal widths of unerupted mandibular and maxillary permanent canines and premolars based on the sum of the widths of the four mandibular permanent incisors and first permanent molars. Tanaka and Johnston's equations were modified in order to improve the accuracy of the prediction for the cosmopolitan Indian population. Dental casts of I00 subjects were used to formulate the linear regression equation. A paired Student t test was used to compare the actual and predicted sums of the permanent canines and premolars. The difference found between the actual and predicted values of the canine and premolars was not found to be significant. The method showed good prediction accuracy and was easy to use. Mixed dentition space analysis, Tanaka and Johnston equation.

Keywords :

INTRODUCTION:
Predicting the size of unerupted teeth during the mixed dentition period is a critical factor in managing the developing occlusion of a growing child. The ability to predict the sizes of unerupted canine and premolars in the mixed dentition is of prime importance.1 Many methods of predicting the mesiodistal width of unerupted canines and premolars in the mixed dentition 83

have been reported. These methods use three distinct ways to achieve their purposes. The first employs direct measurements of the teeth from radiographs with or without the use of a prediction formula as reported by Nance 2, Moorrees et al 3, and Staley et al 4. The second uses prediction tables based on measurements of other erupted permanent teeth, as reported by Ballard and Wylie 5, Carey 6, Moyers 7 , Huckaba 8, Tanaka and Johnston 9, Ferguson et al 10. The third method involves

a combination of the previous two methods, i.e., the use of prediction tables associated with measurements of erupted and unerupted teeth, as recommended by Hixon and Oldfather 11, Staley and Kerber 12, Bishara and Staley 13, Ingerval and Lennartsson 14, Staley et al 15 . Paula et al 16. Tanaka and Johnston 9 Space Analysis is a simple and widely used method to predict the sizes of unerupted canines and premolars in mixed dentition for both jaws and for both the genders. Al-Khadra et al in 1993 showed that the Tanaka and Johnston analysis overestimates the sizes of unerupted canines and premolars in the majority of cases 17. Later, Nourallah et al included maxillary first permanent molar in addition to mandibular incisors. They found correlation between the sum of width of mandibular incisors and maxillary permanent first molar with sum of width of mandibular canine and premolars was higher 1. Camilo et al found the correlation between sum of width of mandibular canine and premolar with sum of width of permanent mandibular incisors and mandibular first molars with maximum correlation coefficient among non- radiographic methods. Also found the regression equation to predict the width of unerupted canines and premolars. Our aim in this study was to determine the group of teeth which represent the maximum correlation with the width of permanent canines and premolars in the cosmopolitan Indian population and also to formulate the regression correlation equation for the same. A separate equation to be formulated for male and female for both the jaws, as the literature shows significant difference in the width of the teeth in males and females18.

mandibular teeth from the right first permanent molar to the left first permanent molar. The measurements were made as carefully as possible to avoid any damage to the casts. The data was collected, the correlation values were calculated using below mentioned groups with sum of width of maxillary and mandibular permanent canine and premolars 1. Sum of width of mandibular incisors. 2. Sum of width of mandibular incisors and mandibular first molar. 3. Sum of width of mandibular incisors and maxillary first molar. Further regression correlation equation was formulated separately for male and female, maxillary and mandibular permanent canine and premolars. The equations were subjected to statistical analysis to check the accuracy. The actual values and predicted values were compared using paired t test.

RESULTS:
The correlation values for three groups with sum of width of permanent mandibular and maxillary canine and premolars determine (Table I) and the results showed the positive correlation with all the three groups. 1. Sum of width of mandibular canine and premolars showed higher correlation with sum of mandibular incisors and mandibular molar. 2. Sum of width of maxillary canine and premolars showed higher correlation with sum of mandibular incisors and maxillary molar. Correlation coefficient for male and female (Table II) was calculated separately between sum of width of mandibular incisors and mandibular first molar with sum of width of permanent mandibular canine and premolars and between sum of width of mandibular incisors and maxillary first molar with sum of width of permanent maxillary canine and premolars. The regression correlation equation was derived to predict sum of width of permanent mandibular and maxillary canine and premolars for both the jaws for Male and Female. The regression equation is: Y = a + bX In which Y (dependent variable, Y1 sum of width of maxillary canine and premolars, Y2 - sum of width of mandibular canine and premolars ) equals the predicted 84

Material and Methods:


Pre-treatment plaster models of 100, 16- to 25-yearold patients (50 men and boys, 50 women and girls) were selected from the records of the Orthodontic Department at M.G.Vs K.B.H Dental College & Hospital, Nashik. All the casts had all relevant teeth (ones used for comparison) fully erupted and presented with no proximal caries or fillings, morphological anomalies, missing teeth, proximal or occlusal abrasion, or attrition. A Digital Vernier Caliper (0.01 mm accuracy) with modified pointed beaks was used to measure the mesiodistal widths of all the teeth (Fig:1). The caliper beaks were inserted from the buccal (labial), and held occlusally parallel. The beaks were then closed until gentle contact with the contact points of the tooth was made. The measurements included the mesiodistal width of all the twelve maxillary and

sum of the mesiodistal widths in the millimeter of the mandibular/maxillary permanent canines and premolar on both sides, X ( independent variable ) equals the sum of the mesiodistal width of the 4 mandibular permanent incisors plus the mesiodistal width of the 4 mandibular permanent incisors plus the mesiodistsal width of permanent maxillary/mandibular first molars (X1 sum of width of mandibular incisors and maxillary first molars, X2 - sum of mandibular incisors and mandibular first molars). The constant a is the y intercept, and the constant b is the slope of the regression. The values of constant a and b are as follows. Estimated equations for males: 1. Upper canine and premolar: Y = 11.65 + 0.725X
1 2

maxilla r = 0.641, mandible r = 0.6821). The literature shows difference between the right and left side were small and not statistically significant. So, both the sides were considered together for individual arch. The ideal prediction method should determine no difference between predicted and actual widths of permanent canine and premolar and the standard deviation of the difference should be as small as possible. The formulated equation though overestimates the width of canine and premolar but the value predicted is very close to the actual values. The difference in means of the actual and predicted values showed no statistically significant difference and also the standard error was small (Table III). Thus, the above method provides a good non radiographic prediction method. It is simple, practical, and specific for the population from which it is developed. However no method is 100% precise. Similarly this method can overestimate or underestimate. Overestimating seems to be better to prevent lack of space, but this approach could suggest tooth extraction for some patients. Overestimation of only 1mm beyond the actual width of the permanent canine and premolar on each side of the arch would not affect the extraction or non- extraction decision7, 20.

2. Lower canine and premolar: Y = 12.22 + 0.663X Estimated equations for the females; 1. Upper canine and premolar: Y = 19.44 0.553X
1

2. Lower canine and premolar: Y = 16.13 + 0.678X

Using the formulae sum of width permanent canine and premolar for mandibular and maxillary arch. The calculated or predicted values were compared with actual measured values. The difference was not found to be statistically significant (Table III).

DISCUSSION:
For the Indian population it was found that when the maxillary and mandbular 1st molars were included along with the sum of incisors there was more correlation seen with the respective sum of width of permanent maxillary and mandibular canine and premolars( maxilla r = 0.6751; mandible r = 0.6651). These values were greater than the Tanaka and Johnston values obtained by Sable et al for Indian population (maxilla r = 0.619; mandible r = 0.663)19 and also by the original Tanaka and Johnston study (maxilla r = 0.63; mandible r = 0.65) 9. The difference between male and female tooth widths is been shown in several studies18. So, the correlation coefficient of sum of width of mandibular incisors and mandibular first molar with sum of width of permanent mandibular canine and premolars; and sum of width of mandibular incisors and maxillary first molar with sum of width of permanent maxillary canine and premolars were calculated for each sex separately. More closer correlation was obtained for each sex ( male- maxilla r = 0.716, mandible r = 0.656; female 85

CONCLUSION:
1. The correlation coefficient obtained fora. Sum of width of Mandibular incisors and mandibular first molar with sum of width of permanent mandibular canine and premolars. b. Sum of width of Mandibular incisors and maxillary first molar with sum of width of permanent maxillary canine and premolars. is higher than using only mandibular incisors to predict the mesiodistal width of canines and premolars. 2. The simplified regression equation predicts the sum of width of the permanent canine and premolar very close to the actual measurements. Thus, providing an easy and simple way for prediction of width of canine and premolars. 3. Further research for individual ethnic population groups for better predictability needs to be done with increased sample size to increase the accuracy of the equation.

REFERENCES:
1. Nourallah WA, Gesch D, Khordaji MN, Splieth C. New Regression Equations for Predicting the Size of Unerupted Canines and Premolars in a Contemporary Population. Angle Orthod 2002;72:216221. 2. Nance HN. The limitations of orthodontic treatment, I: mixed dentition diagnosis and treatment. Am J Orthod 1947;33:177-223. 3. Moorrees CFA, Thomsem SO, Jensen S, et al. Mesiodistal crown diameters of the deciduous and permanent teeth in individuals. J Dent Res 1957;36:39-47. 4. Staley RN, OGorman TW, Hoag JF, et al. Prediction of the widths of unerupted canines and premolars. J Am Dent Assoc 1984;108:185-90. 5. Ballard ML, Wylie WL. Mixed dentition case analysis. Estimating size of unerupted permanent teeth. Am J Orthod 1947;33:754-9. 6. Carey CW. Linear arch dimension and tooth size. Am J Orthod 1949;35:762-75. 7. Moyers RE. Handbook of orthodontics. 4th ed. Chicago: Year Book Medical Publishers, 1988:577. 8. Huckaba GW. Arch size analysis and tooth size prediction. Dent Clin North Am 1964;11:431-40. 9. Tanaka MM, Johnston LE. The prediction of the size of unerupted canines and premolars in a contemporary orthodontic population. J Am Dent Assoc 1974;88:798-80i. 10. Ferguson FS, Macko D J, Sonnenberg EM, et al. The use of regression constants in estimating tooth size in a Negro population. Am J Orthod 1978;73:68-72. 11. Hixon EH, Oldfather RE. Estimation of the sizes of unerupted cuspid and bicuspid teeth. Angle Orthod 1958; 28:236-40. 86

12. Staley RN, Kerber PE. A revision of the Hixon and Oldfather mixed-dentition prediction method. Am J Orthod 1980;78:296-302. 13. Bishara SE, Staley RN. Mixed dentition mandibular arch length analysis: A step-by-step approach using the revised Hixon-Oldfather prediction method. Am J Orthod 1984; 86:130-5. 14. Ingervall B, Lennartsson B. Prediction of breadth of permanent canines and premolars in the mixed dentition. Angle Orthod 1978;48:62-9, 15. Staley RN, Shelly TH, Martin JF. Prediction of lower canine and premolar widths in the mixed dentition. Am J Orthod 1979;76:300-9. 16. Paula S, Almeida MAO, Lee PCF. Prediction of mesiodistal diameter of unerupted lower canines and premolars using 45 cephalometric radiography. Am J Orthod Dentofacial Orthop 1995;107:309-14. 17. Al-Khadra BH. Prediction of the size of unerupted canines and premolars in contemporary Arab population. Am J Orthod Dentofacial Orthop. 1993;104:369372. 18. Melgco CA, Tirre de Sousa MA, and Carlos de Oliveira AR. Mandibular permanent first molar and incisor width as prediction of mandibular canine and premolar width. Am J Orthod Dentofacial Orthop. 2007;132:3405. 19. Sable R.B, Dabir P A, Jacob M. Indian norms for the prediction of unerupted permanent canines and premolars segment using statistical prediction techniques. J Indian Orthod Society.1996:27;155161. 20. Bishara SE, Jakobsen JR, Abdallah EM, Garcia AF. Comparisons of mesiodistal and buccolingual crown dimensions of the permanent teeth in three populations from Egypt, Mexico, and the United States. Am J Orthod Dentofacial Orthop. 1989;96:416-22.

Fig. 1 : Digital Vernier Caliper with modified pointed beaks, used to measure the mesiodistal widths of all the teeth

Table I : Correlation coefficient values for the three groups of teeth with sune of width of maxillary and manibular canine and premolar
Sum of width permanent Mandibular canine and premolars Sum of width of Mandibular incisors Sum width of Mandibular incisors and mandibular first molar Sun of width of Mandibular incisors and maxillary first molar 0.6247 Sum of width of permanent Maxillary canine and premolars 0.5927

0.6551

0.6514

0.648

0.6751

87

Table II : Correlation coefficient for male and female


Male Sum of width of Mandibular incisors and mandibular first molar with sum of width of permanent mandibular canine and premolars 0.656 0.6821 Female

Sum width of Mandibular incisors and maxillary first molar with sum of width of permanent maxillary canine and premolars 0.716 0.6417

Table II : Showing mean values of actual and predicted canines and premolars and their significance values.
Actual value of canine + premolar (Mean) Predicted value of canine + premolar (Mean) Mean Male 50 Upper Lower Female 50 Upper Lower 42.5432 mm 2.12 41.665 mm 2.171 42.5478 mm 2.002 41.5974 mm 2.24 42.8343 mm 1.52 41.692 mm 1.417 43.1375 mm 1.281 42.1567 mm 1.525 -0.29 mm -0.02 mm -0.58 mm -0.55 mm SD 1.46 1.62 1.52 1.62 1.49 1.62 1.67 1.12 0.438* 0.946* 0.084* 0.148* Difference (actual predicted) Standard Significance error (P value)

88

ORTHODONTIC CONCLUSIONS OF SYSTEMATIC REVIEW AND META ANALYSES


Authors:

Dr. Nidhi Kedia (BDS),


Postgraduate Student Department of Orthodontics, Manipal College of Dental Sciences, Manipal
Dr. Nidhi Kedia

Dr. Ashima Valiathan (BDS (Pb); DDS; MS (USA)


Professor and Head, Director of Post Graduate Studies, Department of Orthodontics and Dentofacial Orthopedics, Manipal College of Dental Sciences, Manipal Adjunct Professor Case Western Reserve University Cleveland, Ohio, USA. Address for correspondence:

Dr. (Mrs.) Ashima Valiathan


BDS (Pb); DDS; MS (USA) Professor and Head of Department Director of Post Graduate Studies Department of Orthodontics and Dentofacial Orthopedics, Manipal College of Dental Sciences, Manipal Manipal: 576104 Karnataka, India. Ph. no: 0820-2922184. Email id: avaliathan@yahoo.com

Abstract :

Evidence-based health care depends on application of the best knowledge a discipline can offer about the clinical course of a disease or condition and the effectiveness of alternative treatments. Systematic reviews and Meta analyses are considered the preferred method for identifying all of the available knowledge, determining which information is best and summarizing it in a clinically useful manner. The evidence produced by such Meta-analytic and systematic review procedures can be considered the strongest possible. Although systematic reviews are the best available source of evidence, a critical appraisal and a cautious interpretation of the results are essential. Extrapolation of findings from systematic reviews into clinical practice must consider the methodological quality and external validity of the studies used in such reviews.

INTRODUCTION
The principles and philosophy of evidence-based practice rapidly are becoming established in all areas of health care. Evidence-based Dentistry is defined by American Dental Association as an approach to oral health care that requires the judicious integration of systematic assessments of clinically relevant scientific evidence, relating to the patients oral and medical 89

condition and history, with the dentists clinical expertise and the patients treatment needs and preferences. Clinical practice guidelines are defined as systematically developed statements to assist practitioners and patients in arriving at decisions on appropriate health care for specific clinical circumstances.To produce well-developed guidelines,

one should use the methods of the evidence-based process to assemble, organize and synthesize the best available evidence from clinical research and integrate this with clinical expertise in the formation of clinical recommendations. Evidence-based health care depends on application of the best knowledge a discipline can offer about the clinical course of a disease or condition and the effectiveness of alternative treatments. It is difficult for clinicians to read and assimilate into their practice the information from the many articles published each year. During the 1990s, expert panels of clinical research methodologists and other specialists developed protocols to reduce bias in collecting and synthesizing findings from clinical scientific studies. The product of this process of reviewing the knowledge base related to a specific clinical question is known as a systematic review of the evidence. Today, systematic reviews and Meta analyses are considered the preferred method for identifying all of the available knowledge, determining which information is best and summarizing it in a clinically useful manner. Systematic review (SR) has been defined as a review that has been prepared using a systematic approach to minimizing biases and random errors which is documented in a materials and methods section (Egger et al 2003). Meta Analysis is defined as a review that uses quantitative methods to combine the statistical measures from two or more studies and generates a weighted average of the effect of an intervention, degree of association between a risk factor and a disease or accuracy of a diagnostic test. The primary advantage of the systematic reviews and Meta-analyses are that it not only tells us what we do know, but also what we do not. The strengths of systematic reviews and Meta-analyses include a clearly defined question, a comprehensive search strategy, explicit inclusion criteria, assessment of the methodological quality of the included studies, synthesis of the data and a summary of the results. Their tremendous value lies in the rigorous methods that are used to minimize bias and in their ability to combine smaller studies and thus increase statistical power to detect a treatment effect. They increase the overall sample size by combining data from individual studies, thus increasing the statistical power of the analysis and the precision to assess the treatment effects. On the other hand, systematic reviews often do not produce final, definitive answers for health care; 90

instead, they often show where high-quality primary studies are lacking and help to define future agendas. Meta-analysis has been used to give helpful insight into: allow a more objective evaluation of the evidence, present a more precise estimate of treatment effects & the overall effectiveness of interventions (e.g., psychotherapy, outdoor education), the relative impact of independent variables (e.g., the effect of different types of therapy), and the strength of relationship between variables and Might explain the heterogeneity between studies.

There are few systematic reviews that address a small number of questions. These questions address only a small proportion of the clinical decisions. These problems may explain in part why there are relatively few systematic reviews of topics relevant to orthodonticsnamely, that the number of studies addressing a given clinical question, the design of these studies and their power often are inadequate. The principles and philosophy of evidence-based practice rapidly are becoming established in all areas of health care. Evidence-based Dentistry is defined by American Dental Association as an approach to oral health care that requires the judicious integration of systematic assessments of clinically relevant scientific evidence, relating to the patients oral and medical condition and history, with the dentists clinical expertise and the patients treatment needs and preferences. Clinical practice guidelines are defined as systematically developed statements to assist practitioners and patients in arriving at decisions on appropriate health care for specific clinical circumstances.To produce well-developed guidelines, one should use the methods of the evidence-based process to assemble, organize and synthesize the best available evidence from clinical research and integrate this with clinical expertise in the formation of clinical recommendations. Evidence-based health care depends on application of the best knowledge a discipline can offer about the clinical course of a disease or condition and the effectiveness of alternative treatments. It is difficult for clinicians to read and assimilate into their practice the information from the many articles published each year. During the 1990s, expert panels of clinical research methodologists and other specialists developed protocols to reduce bias in collecting and synthesizing findings from clinical scientific studies.

The product of this process of reviewing the knowledge base related to a specific clinical question is known as a systematic review of the evidence. Today, systematic reviews and Meta analyses are considered the preferred method for identifying all of the available knowledge, determining which information is best and summarizing it in a clinically useful manner. Systematic review (SR) has been defined as a review that has been prepared using a systematic approach to minimizing biases and random errors which is documented in a materials and methods section (Egger et al 2003). Meta Analysis is defined as a review that uses quantitative methods to combine the statistical measures from two or more studies and generates a weighted average of the effect of an intervention, degree of association between a risk factor and a disease or accuracy of a diagnostic test. The primary advantage of the systematic reviews and Meta-analyses are that it not only tells us what we do know, but also what we do not. The strengths of systematic reviews and Meta-analyses include a clearly defined question, a comprehensive search strategy, explicit inclusion criteria, assessment of the methodological quality of the included studies, synthesis of the data and a summary of the results. Their tremendous value lies in the rigorous methods that are used to minimize bias and in their ability to combine smaller studies and thus increase statistical power to detect a treatment effect. They increase the overall sample size by combining data from individual studies, thus increasing the statistical power of the analysis and the precision to assess the treatment effects. On the other hand, systematic reviews often do not produce final, definitive answers for health care; instead, they often show where high-quality primary studies are lacking and help to define future agendas. Meta-analysis has been used to give helpful insight into: allow a more objective evaluation of the evidence, present a more precise estimate of treatment effects & the overall effectiveness of interventions (e.g., psychotherapy, outdoor education), the relative impact of independent variables (e.g., the effect of different types of therapy), and the strength of relationship between variables and Might explain the heterogeneity between studies.

small proportion of the clinical decisions. These problems may explain in part why there are relatively few systematic reviews of topics relevant to orthodonticsnamely, that the number of studies addressing a given clinical question, the design of these studies and their power often are inadequate.

SUMMARY OF VARIOUS SYSTEMATIC REVIEWS AND META ANALYSES: 1. Diagnosis and treatment planning:
Skeletal maturity determined by hand-wrist radiographic analysis correlates with overall facial growth velocity, although the association of maxillary and mandibular growth velocities to skeletal maturity is less clear-cut. (Carlos Flores-Mir et al 2004) Prevalence of hypodontia differs by continent and gender; being higher in Europe and Australia than for North American Caucasians. In addition, the prevalence of dental agenesis in females is 1.37 times higher than in males. The mandibular second premolar is the most affected tooth (Mattheeuws et al 2004), followed by the maxillary lateral incisor and the maxillary second premolar. Generally unilateral occurrence of dental agenesis is more common than bilateral occurrence. However bilateral agenesis of maxillary lateral incisors is more common than unilateral, with the overall prevalence of agenesis in the maxilla being similar to that in the mandible (Polder et al 2004). Occlusal grinding in the primary dentition, with/ without the addition of an upper removable expansion plate may be effective in preventing a posterior crossbite from being perpetuated to the mixed and permanent dentitions(Petren S et al 2003) Moyers method of mixed dentition analysis can show population variations, and development of prediction tables for specific populations is needed (Buwembo et al 2003). Lateral cephalograms have acceptable reliability for evaluation of adenoid size. However, cephalograms are less reliable for evaluation of the size of the posterior nasopharyngeal airway (Major et al 2006). Evidence for a direct causal relationship between craniofacial structure and obstructive sleep apnoea (OSAS) is unsupported by the literature, both qualitatively and quantitatively. The two most consistent, strong effect sizes with the highest

There are few systematic reviews that address a small number of questions. These questions address only a 91

diagnostic accuracies had variables related to mandibular structures (Sn/MPA, Go-Gn). Although mandibular body length (Go-Gn) appears to be an associated factor, this does not support causality (Miles et al 1996). Tooth transposition seems to occur more often unilaterally than bilaterally, with maxillary prevalence and no sex preference, and it is significantly unrelated to dental anomalies, such as congenitally missing teeth, peg-shaped or hypoplastic teeth, or impacted teeth. There might be an association with over-retained deciduous teeth (Papadopoulos et al 2009). Orthodontic patients without cutaneous piercing had no statically significant difference in Ni hypersensitivity prevalence; this was also true for patients who had orthodontic treatment before piercing. Patients who had cutaneous piercing before orthodontic treatment had a statistically significant increase in the prevalence of Ni hypersensitivity. Scientific evidence suggests that orthodontic treatment is not associated with an increase of Ni hypersensitivity, unless patients have a history of previous cutaneous piercing exposure to Ni (Kolokitha et al 2008). No evidence about the relationships between temporomandibular disorders (TMDs) and orthodontic treatment exists (Kim et al 2002). Children with overjets larger than 3 mm are approximately twice as much at risk of traumatic dental injuries on anterior teeth than children with overjets less than 3 mm.The effect of overjet on the risk of dental injury is less in boys than in girls of the same overjet group and the risk of anterior tooth injuries tends to increase with increasing overjet size (Nguyen et al 1999).

were found after puberty compared with before puberty. The difference may not be clinically significant (0.8 mm). No anteroposterior or vertical dental changes were associated with RME. Long-term transverse skeletal maxillary increase with rapid maxillary expansion (RME) is approximately 25% of the total dental expansion achieved in prepubertal adolescents, with more favourable long-term outcomes expected in less skeletally mature patients. RME appears not to produce clinically significant anteroposterior or vertical skeletal changes(Lagravere et al 2005) Subjects who had undergone Slow Maxillary Expansion had less relapse compared with subjects who had undergone RME(Lagravre et al 2005) Based on a secondary level of evidence, surgically assisted rapid palatal expansion (SARPE) produces greatest expansion at the molars diminishing progressively to the anterior part of the dental arch. Nasal patency is improved by the procedure, with minimal sagittal and vertical skeletal changes arising. (Lagravere et al 2006) Maxillary protraction has a significant treatment effect, with an ANB increase of 1.73 (Jager et al2001). Limited true incisor intrusion is achievable in both arches. In non-growing patients, the segmented arch technique can produce 1.5mm of incisor intrusion in the maxillary arch and 1.9mm in the mandibular arch (Julia Ng et al 2005). True maxillary molar intrusion (with high-pull headgear is achievable) of 0.96mm during orthodontic treatment has been shown to occur, although clinical evidence with appropriate quantification is deficient. The magnitude of reported change suggests molar intrusion in isolation (with high-pull headgear) is unlikely to address significant anterior open-bite malocclusions (Ng et al 2006). There is actually little autonomous improvement in overbite from age 8 up to age 50. There is an average 76% mean stability for anterior open bite correction in adolescents. There is an 84% level of stability for surgical open bite correction in adults. The long-term difference in stability between a maxillary or mandibular correction was not large, although maxillary surgery may increase stability slightly and have a greater esthetic impact. Rigid fixation is found to be better than non-rigid fixation for stability in the mandible.

2. Treatment Mechanics:
Immediate changes resulting from rapid maxillary expansion (RME) are both dental and skeletal in nature, although dental changes predominate in transverse dental dimension. No statistically significant mandibular expansion with the exception of the intercondyle width was identified (Lagravere et al2005). Long-term dental arch changes after rapid maxillary expansion (RME): Similar maxillary molar and cuspid expansion could be found in adolescents and young adults. Significantly less indirect mandibular molar and cuspid expansion was attained in young adults compared with adolescents. More transverse dental arch changes 92

Effect of lip bumpers on mandibular arch dimensions: An increase in arch length was attributed to incisor proclination, distalization, and distal tipping of the molars. There were also increases in arch width and intercanine and deciduous intermolar or premolar distances (Hashish et al 2009) Most studies that reported a reduction in temporomandibular dysfunction ( TMD) signs and symptoms after orthognathic treatment reported this association in skeletal Class II patients. A decrease in the prevalence of signs and symptoms by more than 50% postsurgery compared with the presurgery state was reported in some studies whereas fewer subjects with skeletal Class III or a o high mandibular plane angle (>32 ) seemed to benefit from surgery. Thus, the participants skeletal deformity could have had a direct impact on TMD, especially after surgery. Patients having orthognathic treatment for correcting dentofacial deformities and also suffering from TMD are more likely to see improvements in their signs and symptoms than deterioration. Clicking is more likely to improve than deteriorate after surgery. In contrast, crepitus does not seem to be affected by surgery. Most patients experience restriction in mouth opening and lateral excursions after surgery. This, however, continues to improve, and most patients regain the full range of movement 2 years after surgery (Riyami et al 2009). Bimaxillary surgical therapy could be considered an effective procedure in skeletal Class III malocclusion correction. Surgical correction of skeletal Class III malocclusion after combined maxillary and mandibular procedures appears to be stable for maxillary advancements up to 5 mm and for the correction of presurgical sagittal intermaxillary discrepancies smaller than 7 mm (Mucedero et al 2008). The engagement angle depends on archwire dimension and edge shape, as well as on bracket slot dimension, and is variable and larger than published theoretical values. Clinically effective torque can be achieved in a 0.022 inch bracket slot with archwire torsion of 15 to 31 degrees for active self-ligating brackets and of 23 to 35 degrees for passive self-ligating brackets with a 0.019 x 0.025 inch stainless steel wire (Archambault et al 2010). There are indications that extraction treatment lasts longer than the non-extraction therapy; age does not seem to play a role provided the patients are in the permanent dentition; when Class II division 1 93

malocclusions are considered, there is evidence that the earlier the orthodontic treatment begins the longer its duration; combined orthodontic surgical treatment duration is variable and appears to be operator sensitive; various factors, such as the technique employed, the skill and number of operators involved, the compliance of the patients, and the severity of the initial malocclusion and impacted maxillary canines prolong treatment(Athanasiou et al 2008).

3. Functional appliances/ orthopedic appliances:


Orthopedic appliances in Class III treatment. Data derived from medium/high quality research described over 75% of success of orthopedic treatment of Class III malocclusion (RME and facial mask therapy) at a follow-up observation 5 years after the end of orthopedic treatment. Thus, aggressive overcorrection at a skeletal level appears to be advisable and essential to the stability of the treatment outcome (De Toffol et al 2008). Protraction face mask therapy is effective in Class III patients who are growing, but to a lesser degree in patients who are older than 10 years of age. Protraction in combination with an initial period of expansion may provide more significant skeletal effects (Kim et al 1999) Functional appliances in Class II treatment No appreciable restraining effect on the forward growth of the maxilla in either group (Andresen and Frankel appliances) is seen. A slight mean increase in mandibular growth could be observed, mainly in a vertical direction but there is no change in the position of the glenoid fossa (Mills et al 1991). The amount of supplementary mandibular growth achieved with functional appliances appears to be significantly larger if the functional treatment is performed at the pubertal peak in skeletal maturation. The Herbst appliance shows greatest efficiency, with an additional mandibular growth increment of 0.28mm per month followed by the Twin-block with 0.23mm per month (Cozza et al 2006). In contrast, evidence of enhanced mandibular growth related to functional appliance treatment is limited and only seen when Articulare is used as a reference point for calculation of mandibular unit length (Chen et al 2002). Extra oral appliances improve the sagittal intermaxillary relationship, demonstrating a large effect

on the maxillary skeleton. They appear to achieve this growth modification by means of a sutural response. These appliances show very little clinical improvement in overjet. Combination appliances (with both functional and extra oral appliance components) seem to affect the sagittal intermaxillary relationship by acting mainly on the mandibular skeleton as well as having a dentoalveolar effect on overjet. No significant change in the maxilla was seen. Functional appliances (activators and twin block) improve mainly by their effect on the mandible and show an important dental effect by overjet reduction. Twin block appliances also show a significant effect on the maxilla. Functional appliances and combination appliances reveal a large decrease in overjet, which is not the case in the singular use of extraoral traction (Antonarakis et al 2007). Fixed functional appliances, Activators and Bionators produce statistically significant but clinically insignificant changes in soft tissue profile (Flores Mir et al 2006). Removable Twin-block appliances also produce little change in the soft tissue profile, with no change in the anteroposterior position of the lower lip and the soft tissue menton or improvement of the facial convexity being found (Flores Mir et al 2006). Crown / Banded Herbst appliance did not produce statistically significant changes in the sagittal length or position of the skeletal maxilla. Dental changes have more impact than skeletal changes in the correction of Class II division 1 malocclusions (Barnett et al 2008).

timing for palatal closure requires further investigation (Nollet et al 2005). Distraction osteogenesis is preferred to conventional osteotomy for younger CLP patients with more severe deformities. Distraction osteogenesis can correct moderate to large discrepancies by either complete or incomplete Le Fort I osteotomy, with concurrent mandibular osteotomy less frequently required. There is no conclusive data on differences in surgical relapse, velopharyngeal function and speech between the two approaches, with both alternatives delivering marked improvements in facial aesthetics (Cheung et al 2006).

5. Oral appliances in obstructive sleep apnoea (OSA)


Oral appliances improve subjective sleepiness and obstructive sleep apnoea (OSA) compared with a control. While Continuous Positive Airway Pressure (CPAP) is more effective than oral appliances, the difference in symptomatic response between these two treatments is not significant. Oral appliances may be recommended for treatment of mild symptomatic OSA, and those patients who are unwilling or unable to tolerate CPAP therapy (Lim 2006). However, oral appliance therapy may have adverse effects on the craniomandibular and craniofacial complex (Hoekema et al 2004).

6.Iatrogenic effects and preventive measures


The treatment-related causes of root resorption include the total distance the apex moves and the time such movement takes (Segal et al 2004). Valiathan A et al (1999)reported higher incidence of root resorption with Begg treatment in a review paper. Fluoride-releasing bonding materials have a cariesinhibitory effect of 20% of total caries experience likely to develop during orthodontic treatment with fixed appliances. Daily use of 0.05% sodium fluoride mouth rinses may reduce the severity of enamel demineralization during fixed appliance therapy. Use of Glass Ionomer cement for bracket bonding reduces the prevalence and severity of white spots compared with composite resins (Benson et al 2005). The use of topical fluorides in addition to fluoride toothpaste during fixed appliance therapy reduces the incidence of decalcification in populations with both fluoridated

4. Cleft lip and palate (CLP): aetiology, impact and management


CL/P and CP occurrence is correlated with increasing birth order (Vieira et al 2002) and maternal smoking (Zeiger et al 2005). However increased maternal age is not associated with the development of isolated oral clefts. The parental craniofacial complex in orofacial clefting is distinctive in comparison to the non-cleft and isolated cleft palate population. However, these differences are subtle and their characterization difficult (Weinberg et al 2006). Patients undergoing both soft and hard palate closure before 3 yrs have significantly poorer occlusal outcomes, measured with the GOSLON yardstick. Delayed palatal closure generally results in better dental arch relationships, although the optimal 94

and non-fluoridated water supplies (Chadwick et al2005). Valiathan. A et al (1997) reported a prevalence of white spot lesions to vary from 4.9% to 84% of tooth surfaces. Valiathan. A et al (1992) reviewed the efficacy of four fluoride releasing bonding agents Flour- Ever Oba, Time line, Ultra bond and Orthodontic cement VP 862. It was found that all the four bonding agents were efficacious in caries inhibition and showed initial burst effect but the Time line and Ultra bond were not suitable as orthodontic adhesive due to poor shear bond strength. The controlled evidence suggests that orthodontic therapy is associated with small amounts of alveolar bone loss, gingival recession and increased pocket depth. This suggests a small mean worsening of periodontal status after orthodontic therapy. Claims that orthodontic therapy result in overall improved periodontal health cannot be supported with the existing controlled evidence(Anne-Marie Bollen et al 2008): Therapeutic administration of eicosanoids resulted in increased tooth movement, whereas their blocking led to a decrease. Non-steroidal antiinflammatory drugs (NSAIDs) decreased tooth movement, but non-NSAID analgesics, such as paracetamol (acetaminophen), had no effect. Corticosteroid hormones, parathyroid hormone, and thyroxin have all been shown to increase tooth movement. Estrogens probably reduce tooth movement, although no direct evidence is available. Vitamin D3 stimulates tooth movement, and dietary calcium seemed to reduce it. Bisphosphonates had a strong inhibitory effect (Bartzela et al 2009).

postretention between 0.5 and 0.6 mm. Although statistically significant differences were noted, it was not considered clinically important. The net change in mandibular intercanine width of approx. zero supports the concept of maintenance of the initial inter-canine width in orthodontic treatment (Burke et al 1998). The mean expansion was 6 mm (1.3 mm). Of the 6-mm average, 4.9 mm was retained while wearing retainers, which subsequently was reduced to 3.9 mm during the short-term postretention period. In the long-term postretention period, only 2.4 mm of the residual expansion remained; this was no greater than what is documented as normal growth. There was inadequate evidence that the expansion achieved beyond what is expected from normal development of the maxilla could be retained (Schiffman et al 2001).

LIMITATIONS OF META ANALYSIS AND SYSTEMATIC REVIEWS:


First, there is the possibility that the data used in meta-analyses are not homogeneous. Homogeneity 19 is an important requisite of meta-analyses. Altman believed that the meta-analyses and systematic reviews of prognostic studies are difficult- set of studies being too diverse and/or too weak. No statistical test can overcome and rectify the methodological shortcomings of poorly designed primary studies. Part of the problem is that some systematic reviews, or the research studies they are based upon, have not accounted for confounders that may preclude appropriate interpretations. There is no doubt that the Meta analysis and systematic reviews has its place in the evidencebased dentistry paradigm: however the validity of its findings is greatly dependent on the quality of the individual studies incorporated into the analysis.

5. Stability/retention
There is weak evidence of enhanced stability in both the mandibular and maxillary labial segments associated with circumferential supracrestal fibrotomy combined with Hawley retainers, versus Hawley retainers in isolation. More occlusal settling arises with a Hawley retainer than with a clear overlay retainer after a retention phase of three months. (Littlewoods et al 2006). Regardless whether treatment was extraction or nonextraction, mandibular intercanine width tends to increase during treatment by about 1 to 2 mm, to decrease at postretention to approx. the original dimension, and to show a net change after 95

CONCLUSION
Ackerman20 appropriately stated, The challenge facing orthodontists in the 21st century is the need to integrate the accrued scientific evidence into clinical orthodontic practice, because systematic review and Meta Analyses investigating orthodontic subjects are few, hence only a few orthodontic questions have been answered with well-supported evidence so far, at least as confirmed by Meta Analyses. Although systematic reviews are the best available source of evidence, a critical appraisal and a cautious interpretation of the results are essential.

REFERENCES
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Class II Malocclusion. A Meta-analysis. Angle Orthod. 2007; 77(5):907-14. 12. P S Fleming and A T DiBiase. Systematic reviews in orthodontics: what have we learned? International Dent J. 2008; 58: 10-14. 13. Anne-Marie Bollen, Joana Cunha-Cruz, Daniel W. Bakko, Greg J. Huang and Philippe P. Hujoel. The Effects of Orthodontic Therapy on Controlled Evidence Periodontal Health: A Systematic Review. J Am Dent Assoc 2008; 139; 413-422. 14. Theodosia Bartzela, Jens C. Trp, Edith Motschall, and Jaap C. Maltha. Medication effects on the rate of orthodontic tooth movement: A systematic literature review. Am J Orthod Dentofacial Orthop. 2009;135: 16-26. 15. Salma Al-Riyami, Susan J. Cunningham,band David R. Moles. Orthognathic treatment and temporomandibular disorders: A systematic review. Part 2. Signs and symptoms and meta-analyses. Am J Orthod Dentofacial Orthop. 2009; 136:626. 16. Amy Archambault; Ryan Lacoursiere; Hisham Badawi; Paul W. Major; Jason Carey, Carlos FloresMir. Torque Expression in Stainless Steel Orthodontic Brackets. A Systematic Review. Angle Orthod. 2010; 80:201210. 17. Manuel O. Lagravere; Paul W. Major; Carlos Flores-Mir. Long-term Skeletal Changes with Rapid Maxillary Expansion: A Systematic Review. Angle Orthod 2005; 75: 10461052. 18. Manuela Mucedero; Antonella Coviello; Tiziano Baccetti; Lorenzo Franchi; Paola Cozza. Stability Factors after Double-Jaw Surgery in Class III Malocclusion: A Systematic Review. Angle Orthod. 2008; 78 (6):1141-5. 19. Altman DG. Systematic reviews in health care: systematic reviews of evaluation of prognostic variable. Br Med J. 200; 323: 224-228. 20. Ackerman M. Evidence-based orthodontics for the 21st century. J Am Dent Assoc 2004; 135: 162-7.

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