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Whats New in Dentistry

Vincent Kokich, DDS, MSD


Implant surfaces accelerate bone deposition. It
has been well established in previous studies that
bone forms around endosseous root form implants
that are used to replace missing teeth. In addition, it
is also known that simply creating a hole in the alveolar bone will also heal and fill in with bone. Is there
any difference in the rate at which bone repair occurs
in an empty hole compared with the rate of bone deposition around a titanium implant? This interesting
question was addressed in a study that was published
in the Journal of Dental Research (2007;86:862867).
The experimental research project was conducted in
mice. Holes were created in the alveolar bone, the soft
tissue was replaced over the site, and the hole was
allowed to fill in with bone. Histologic sections were
made of the healing bony margin at various times during the healing process. A similar hole was then made
in the alveolar bone of adult mice, and a titanium implant was placed in the hole. A similar histologic assessment of the healing at the bone-implant interface
was matched with the same time observations of the
animals with the empty holes. The results of this study
showed that when the implant was present, the sites
showed accelerated differentiation of peri-implant cells
into osteoblasts and accelerated remodeling of new
bone matrix compared with the sites with the empty
holes. In addition, these researchers found that although the cortical edges of the bone did not always
come uniformly into contact with the implant surface,
the time course of repair was equivalent whether or
not a small gap existed. In conclusion, this study
showed that osteoblast differentiation and new bone
deposition begins sooner around implants, which suggests that the implant surface and the microenvironment around implants favors osteogenesis.

local application of platelet-rich plasma should induce


bone regeneration and increase the healing of the
graft site. This hypothesis was tested in an experimental study in rabbits published in the International
Journal of Oral and Maxillofacial Implants (2007;22:
563568). The sample for this study consisted of 12
New Zealand rabbits. Two identical cranial defects, 10
mm in diameter, were created in each rabbit. One of
the defects was grafted with platelet-rich plasma, but
the contralateral defect was left unfilled and served as
a negative control. The healing of the defects was
evaluated histologically at two, four, six, and eight
weeks after surgery. At two weeks, histologic samples
showed poor bone formation in both experimental and
control defects. At week 4, new bone was slightly
formed in the control defects, whereas in the defects
grafted with platelet-rich plasma, a complete bone
bridge linking both sides of the defect could be seen.
At eight weeks, the amount of newly formed bone was
similar in both defects. In conclusion, local administration of platelet-rich plasma in cranial defects in rabbit
calvaria stimulates the first phases of bone regeneration. However, over the long term, there are no differences in the quality or quantity of bone in the experimental or control sites.
Altering the risk-benefit ratio of fluoride among
young children. The use of fluoride for promoting oral
health has always involved a balance between the
protective benefit against caries and the risk of developing fluorosis. Monitoring fluoride exposure in childhood continues to be important in preserving the effectiveness of fluorides in caries prevention, while limiting the risk of fluorosis. Early fluoride exposure protects newly erupting deciduous teeth, creating a
healthier oral environment. However, the current generation of children is exposed to numerous fluoride
sources, each of which has an unknown balance of
benefit and risk. A study published in the Journal of
Dental Research (2007;86:723728) evaluated the
balance of benefit and risk of several fluoride exposures among a large group of children. More than 650
children participated in the study. Fluoride exposure
history for these randomly selected children was collected to calculate exposure to fluoridated water, fluoridated toothpaste, and other fluoride sources. Caries

Platelet-rich plasma accelerates early bone regeneration. Bone grafting is a common surgical procedure in patients who will receive implants to replace
missing teeth. The grafting materials can be autogenous (native bone) or alloplastic (human cadaver bone
or bovine bone). After adequate healing, an implant
can be placed into the remodeled bone-graft site. In
an attempt to accelerate the healing of the graft site,
clinicians have proposed adding platelet-rich plasma
(from the patient) to the bone graft material. In theory,
3

Angle Orthodontist, Vol 78, No 1, 2008

4
experience, recorded when a child was six years old,
and fluorosis prevalence, recorded at examination
were compared between and among groups with different levels of fluoride exposure. Fluorosis prevalence
was found to be 11.3%, whereas caries prevalence
was 32.3%. Exposure to fluoridated water was positively associated with fluorosis but negatively associated with caries. Using 1000-ppm-fluoride toothpaste
or eating, licking, or swallowing toothpaste was associated with a higher risk of fluorosis without additional
benefit in caries protection. The authors suggest beginning toothpaste use at 19 to 30 months old, using
toothpaste fluoridated at 400 to 550 ppm (rather than
1000 ppm), encouraging spitting after brushing, and
discouraging eating/licking toothpaste habits in young
children.
Immediate loading of splinted implants has high
success rates. Immediate implant placement (placed
into the socket at the time of tooth extraction) offers
several advantages: shorter healing time, reduced resorption of the alveolar process, and fewer surgical
visits. However, over the long term what happens to
the bone level around implants that are placed into
extraction sockets. That question was answered in a
study published in the International Journal of Maxillofacial Implants (2007;22:187194). The sample for
this study consisted of 17 patients between the ages
of 57 and 82 years. All patients had a hopeless maxillary and/or mandibular dentition. As a result, their remaining teeth were extracted and six to eight implants
were placed at the time of extraction and restored
within 72 hours. Some of the implants were placed in
native bone (n 97) and some were placed into the
extraction sockets (n 42), for a total of 139 implants.
Radiographs were taken of these implants at the time
of placement, then at three months, six months, and
annually for five years. The radiographs were digitized,
and the bone level changes were measured using a
computer-assisted method. The overall results indicated that for all implants, about 0.6 mm of bone was
lost after the first six months. When stratifying for native bone implants versus extraction socket implants,
it was found that less bone was lost around those implants placed in extraction sockets after six months.
However after the first year, native bone implants and

Angle Orthodontist, Vol 78, No 1, 2008

KOKICH

extraction socket implants underwent similar rates of


adjacent bone loss with no statistically significant differences between the two groups. The authors conclude that a combination of immediate implants placed
in extraction sockets and implants placed in native
bone can be immediately loaded with a fixed full-arch
prosthesis and remain stable for longer than five
years. The bone loss adjacent to these implants is
similar to that seen surrounding those implants placed
and restored using traditional protocols.
Chlorhexidine provides antibacterial protection
to specific implant surfaces. Chlorhexidine has been
shown to be an effective antibacterial agent for patients who are susceptible to periodontal pathogens.
The bactericidal effect of chlorhexidine can enhance
the healing of periodontal defects around teeth when
used in conjunction with other therapeutic methods of
combating periodontal disease. Does chlorhexidine
have a similar beneficial antibacterial effect around implants? This important clinical question was addressed
in a study that was published in the Journal of Periodontology (2006;77:11941200). This laboratory
study used titanium disks that could be immersed in
chlorhexidine and then subjected to bacteria. Half of
the titanium disks had a smooth surface, and the other
half were sand-blasted/acid-etched to produce a rough
surface. The disks were soaked in 0.1% or 0.2% chlorhexidine digluconate for 24 hours. After that time, the
authors determined how much chlorhexidine had been
adsorbed by the two titanium surfaces and determined
the antibacterial potential of the disks after exposure
to Streptococcus mutans. The results of this study
showed that chlorhexidine adsorption rates were significantly higher when using the 0.2% concentration of
chlorhexidine. In addition, the adsorption was twofold
higher on the rough titanium disks compared with the
smooth surface. Finally, larger bacterial inhibition was
obtained with the 0.2% chlorhexidine concentration
and the rough surface titanium disks. In conclusion,
the authors have shown that chlorhexidine is adsorbed
by titanium, a higher concentration is more effective,
and a rough titanium surface produces higher adsorption. Based on this research, it is suggested that chlorhexidine can provide an antibacterial effect around
dental implants.

Original Article

Which Hard and Soft Tissue Factors Relate with the Amount of Buccal
Corridor Space during Smiling?
Il-Hyung Yanga; Dong-Seok Nahmb; Seung-Hak Baekc
ABSTRACT
Objective: To investigate which hard and soft tissue factors relate with the amount of buccal
corridor area (BCA) during posed smiling.
Materials and Methods: The samples consisted of 92 adult patients (19 men and 73 women; 56
four first bicuspids extraction and 36 nonextraction treatment cases; mean age 23.5 years),
who were treated only with a fixed appliance and finished with Angle Class I canine and molar
relationships. To eliminate the crowding effect on the buccal corridor area, lateral cephalograms,
dental casts, and standardized frontal posed smile photographs were obtained at debonding stage
and 28 variables were measured. Pearson correlation analysis, multiple linear regression analysis,
and independent t-test were used to find variables that were related with buccal corridor area ratio
(BCAR).
Results: Among the lateral cephalometric and dental cast variables, FMA, lower anterior facial
height, upper incisor (U1) exposure, U1 to facial plane, lower incisor (L1) to mandibular plane, L1
to N-B, Sn (subnasale) to soft tissue menton (Me), Sn to stomodium superius (stms), stms to
Me, and interpremolar width were significantly negatively correlated with BCAR. Occlusal plane
inclination and buccal corridor linear ratio did not show any significant correlation with BCAR.
Multiple linear regression analysis generated a three-variable model: Sn to Me, U1 exposure,
and sum of tooth material (STM) (R 2 0.324). There was no significant difference in BCAR
between extraction and nonextraction groups.
Conclusions: To control the amount of BCA for achieving a better esthetic smile, it is necessary
to observe the vertical pattern of the face, amount of upper incisor exposure, and sum of the tooth
material.
KEY WORDS: Posed smiling; Buccal corridor area; Buccal corridor area ratio

INTRODUCTION

Bergman,7 Arnett et al,8 and Proffit9 emphasized the


importance of the esthetics in the frontal view. Therefore, it is necessary for orthodontists to shift the focus
from the sagittal plane to the frontal plane during evaluation of their patients when planning and assessing
orthodontic treatment.10
In addition, orthodontic patients are concerned with
not only their static appearances, but also with their
dynamic appearances during conversation and
smile.1115 The smile designing in orthodontic treatment is the social posed smile, which is known to be
repeatable and reproducible.12,1619
The buccal corridor is one of the evaluation points
in smile esthetics.2022 It is a space between the maxillary lateral teeth and the corner of the mouth during
smile, which appears as a black or dark space.16,23 The
narrow maxillary arch13,14,2425 and extraction in the upper dentition26 were thought to be causes of the buccal
corridor. Others suggested that the anterior-posterior

Although there have been numerous soft tissue


analyses of the face,18 those mostly dealt with the soft
tissue profile in the sagittal plane. However, Arnett and
a
Graduate student (PhD), Department of Orthodontics,
School of Dentistry, Seoul National University, Seoul, South Korea.
b
Professor Emeritus, Department of Orthodontics, School of
Dentistry, Seoul National University, Seoul Bareum Dental Clinic, Seoul, South Korea.
c
Associate Professor, Department of Orthodontics, School of
Dentistry, Seoul National University, Seoul, South Korea.
Corresponding author: Seung-Hak Baek, DDS, MSD, PhD,
Associate Professor, Department of Orthodontics, Dental Research Institute, School of Dentistry, Seoul National University,
#28 Yeonkun-dong, Jongro-Ku, Seoul, 110-768, South Korea
(e-mail: drwhite@unitel.co.kr)

Accepted: February 2007. Submitted: December 2006.


 2007 by The EH Angle Education and Research Foundation,
Inc.
DOI: 10.2319/120906-502.1

Angle Orthodontist, Vol 78, No 1, 2008

YANG, NAHM, BAEK

position of the maxilla and the rotation of the upper


molars could be influencing factors on the buccal corridor.11,12,15,19,20
Since the buccal corridor is actually two-dimensional
on frontal view and can be seen differently according
to light condition, quantification of the smile from the
frontal photographs can be done using linear measurements, propoprtions,12,15,16,1921,27 and a mesh diagram with the extrapolation method.15,19,28 Therefore, it
is necessary to quantify color and density of the pixel
unit of the buccal corridor in a histogram and to measure two-dimensionally the buccal corridor area (BCA).
The purpose of this study was to quantify two-dimensionally the BCA and to determine which hard and soft
tissue factors are related with the amount of BCA during posed smiling.
MATERIALS AND METHODS
The samples consisted of 92 adult patients (19 men
and 73 women; 56 four first bicuspids extraction and
36 nonextraction treatment cases; mean age: 23.5
years) to eliminate growth changes of the hard and
soft tissues. The patients had been treated only with
a fixed appliance and finished with Angle Class I canine and molar relationships. The patients with facial
asymmetry (chin point deviation 4 mm), temporomandibular joint disorder, cleft lip and palate, or any
other syndromes, orthognathic surgery experience,
and more than two missing teeth were excluded because these might result in abnormal neuromuscular
activities during smile. Also, to get rid of any crowding
effect on BCA, lateral cephalograms, dental casts, and
standardized frontal posed smile photographs were
obtained at the debonding stage.
Lateral cephalograms were taken with the patients
Frankfort horizontal (FH) plane parallel to the floor and
with centric occlusion and unstrained lips. The tracings
were digitized with a digitizer (Intuos2 graphic tablet,
Wacom Technology Co, Vancouver, Canada) and analyzed by V-Ceph (Cybermed, Seoul, Korea). Reference lines and cephalometric landmarks are listed in
Figures 1 and 2. For lateral cephalometric measurements, seventeen variables of the anteroposterior position of the maxilla, skeletal vertical pattern, denture
pattern, and soft tissue vertical lengths were used and
are listed in Figure 3. The values were measured up
to 0.05 and 0.05 mm.
For measurements of the dental casts, the mesiodistal width of each tooth from the upper right to left
first molar was measured with a digital vernier caliper
(Mitutoyo, Aurora, Ill) in 0.01 mm units and their sum
calculated. The intercanine, interpremolar, and basal
arch widths were recorded. The angulation and inclination of the upper incisors and canines were meaAngle Orthodontist, Vol 78, No 1, 2008

Figure 1. Reference lines. (1) Frankfort horizontal plane (porion to


orbitale). (2) Nasion perpendicular line (N-perp, line perpendicular to
FH plane through nasion). (3) Subnasale perpendicular line (Snperp, line perpendicular to FH plane through subnasale).

Figure 2. Cephalometric landmarks. (A) Skeletal and dental landmarks: 1. S (sella); 2. N (nasion); 3. Or (orbitale); 4. Po (porion); 5.
Ar (articulare); 6. Go (gonion); 7. Me (menton); 8. Pog (pogonion);
9. ANS (anterior nasal spine); 10. PNS (posterior nasal spine); 11.
Point A (subspinale); 12. Point B (supramentale); 13. Occlusal plane
point; 14. U1E (incisor superius); 15. L1E (incisor inferius); 16. U1A
(root apex of the upper central incisor); 17. L1A (root apex of the
lower central incisor). (B) Soft tissue landmarks: 18. Gl (glabella);
19. N (soft tissue nasion); 20. Sn (subnasale); 21. stms (stomion
superius); 22. Me (soft tissue menton).

QUANTIFICATION OF THE BUCCAL CORRIDOR SPACE

Figure 3. (A) Variables of anteroposterior position of maxilla: 1. A to N-perpendicular (mm); 2. A to Sn-perpendicular (mm). (B) Variables of
the skeletal vertical pattern measurements: 1. Facial height ratio [(S-Go/N-Me) 100, %]; 2. Frankfurt mandibular plane angle (FMA, degrees);
3. Lower anterior facial height (LAFH, ANS-Me, mm); 4. Overbite depth indicator (ODI, degrees). (C) Variables of denture pattern: 1. Upper
incisor (U1) to facial plane (mm); 2. Occlusal plane to S-N (degrees); 3. U1 to Sn-perp (mm).; 4. U1 exposure (mm); 5. Lower incisor (L1) to
A-Pog (mm); 6. L1 to N-B (mm). (D) Variables of the soft tissue vertical length: 1. N to Me (mm); 2. N to Sn (mm); 3. Sn to Me (mm); 4.
Sn to stms (mm); 5. stms to Me (mm).

sured with an angulation- and inclination-measuring


gauge (InvisiTech Co, Seoul, Korea) in 0.1 units. Variables of dental casts are listed in Figure 4. The cephalometric and cast measurements were reliable according to the results of Dahlbergs formula.

Posed smile photographs were taken with a Nikon


FM2 analog film camera (Nikon, Tokyo, Japan) and
KODAK Elite Chrome 35mm slide film (Eastman Kodak Co, Rochester, NY). The patients were positioned
with the FH plane and the interpupillary line parallel to
Angle Orthodontist, Vol 78, No 1, 2008

YANG, NAHM, BAEK

Figure 4. Variables of dental casts. (A) Measurement of the inclination and angulation of the teeth with an angulation- and inclination-measuring
gauge (Invisitech Co, Seoul, Korea) in the units of 0.1. Variables are as follows: IA (average angulation of the upper central and lateral incisors
of both sides), CA (average angulation of upper canines of both sides), CI (average inclination of upper canines of both sides), PI (average
inclination of upper first and second premolars of both sides), occlusal plane was used as a reference plane. (B) Measurement of the arch
widths and mesiodistal width of each tooth on the dental cast with a digital vernier caliper (Mitutoyo, Aurora, Ill). Variables are as follows: ICW
(intercanine width between cusp tips of upper canines), IPW (average interpremolar width at contact point between first and second premolar
in nonextraction case and interpremolar width at second premolars in extraction case), ICBAW (intercanine basal arch width between the upper
canines), IPBAW (interpremolar basal arch width at centroid between the upper first and second premolars), Sum of tooth material (sum of
the mesiodistal widths of the teeth from the upper right to left first molars, STM).

the floor and were asked to touch their teeth slightly


and to smile. When we took a picture of the posed
smile, we created a standardized repeatable and reproducible method. The imaginary center line of the
patients face was aligned to the center vertical line on
the grid of the viewfinder and both sides of the patients ears showed the same amount to prevent transverse rotation.
Since the buccal corridor can be seen differently according to different light conditions, all procedures
were carried out in a studio under standardized light
conditions to get the actual BCA. The photographs
were developed and fixed by a professional. They
were then scanned with Epson Expression 1680/pro
scanner (Epson, Long Beach, Calif) under 24-bit color
mode and 600 dpi. The scanned images were saved
as JPEG files (standard baseline format) at the maximum quality as set at level 12. The mouth area in each
photograph was magnified to fill the screen of a 14.1
inch TFT SXGA monitor (1400 1050 pixels, Flatron L1720B, LG, Seoul, Korea), using Adobe Photoshop 7.0 software (Adobe Systems Inc, San Jose,
Calif).
Variables of posed smile photographs are listed in
Figure 5. For calculation of the buccal corridor linear
ratio (BCLR), intercanine and intercommissural widths
were measured in 0.01 mm units with the linear measuring tool in Adobe Photoshop 7.0 software. For precise area measurements, a polygonal lasso to select
the smile areas and magic wand (options: tolerance
Angle Orthodontist, Vol 78, No 1, 2008

[1525], anti-aliased [on], and contiguous [on]) were


used to decide the buccal corridors. The pixel number
in both areas was attained in the pixel histogram menu
and the buccal corridor area ratio (BCAR) was calculated. These were verified with the reliability test; r
.999 for the smile area, r .989 for the buccal corridor
area. To analyze the test-retest reliability of the BCAR
measurement techniques, the smile area and BCA of
30 randomly selected smile photographs were measured 4 weeks after initial measurement. Intraclass
correlation coefficient was computed for assessment
of the test-retest data, which was 0.989 (P .01) for
BCA using the magic wand tool and 0.999 (P .01)
for the smile area using the polygonal lasso tool. The
result substantiated the reliability of these computeraided area measurement techniques.
To find variables that were related with the BCAR,
Pearson correlation analysis was performed. Independent t-test was performed to compare the means of
BCAR between extraction and nonextraction groups.
With the variables showing the statistically significant
correlation, a multiple linear regression analysis was
used to remove its intercorrelation among these independent variables as well as to discover the more
important variables which could predict the amount of
BCA.
RESULTS
According to Pearson correlation analysis, FMA (P
.05), LAFH (P .01), U1 exposure (P .01), U1

QUANTIFICATION OF THE BUCCAL CORRIDOR SPACE

Figure 5. Variables of posed smile photographs. (A) Buccal corridor


linear ratio ([C to C / Ch to Ch] 100 [%]), C means distal surface
of the upper canine; Ch, corner of the mouth. (B) Buccal corridor
area ratio ([buccal corridor area / smile area] 100 [%]). Smile area
means area between upper and lower lip; Buccal corridor area, Total
area of right and left buccal corridors.

to facial plane (P .01), L1 to mandibular plane (P


.01), L1 to N-B (P .05), Sn to Me (P .01), Sn to
stms (P .05), and stms to Me (P .01) were significantly correlated with the BCAR (Table 1). Among
the dental cast measurements, the sum of tooth material (P .05) and interpremolar width (P .05) were
significantly correlated. Occlusal plane inclination and
buccal corridor linear ratio did not show any significant
correlation with BCAR.
There was no statistically significant difference in
BCAR between the extraction and nonextraction
groups (Table 2).
Multiple regression analysis produced a three-variable model, which consisted of Sn to Me, U1 exposure, and sum of tooth material with the adjusted R 2
0.324 (Table 3).
DISCUSSION
To measure the actual area instead of the linear ratio of the buccal corridor space, the BCAR was used
as a dependent variable for correlation analysis in this
study (Table 1). In Pearson correlation analysis for determining the correlation between BCAR and the other
variables (Table 1), the variables for the anteroposterior position of the maxilla (A to N perp and A to Sn
perp) and the inclination of the occlusal plane did not

9
show statistically significant correlations, which conflicted with results of former studies.1215,20
Among the variables for the skeletal vertical pattern,
FMA (P .05, Table 1) and LAFH (P .01, Table 1)
showed statistically significant negative correlations.
There were also significant negative correlations in the
variables of the soft tissue vertical length; Sn to Me
(P .01, Table 1), Sn to stms (P .05, Table 1), and
stms to Me (P .01, Table 1). However, there was
no significant correlation in N to Sn. Therefore, vertical
length in the lower half of the soft tissue profile was
significantly negatively correlated with the amount of
BCAR. A possible reason why stms-Me showed the
strongest correlation was the possible relationship with
the activities of the lips. During smiling the lower lip
showed a larger extent of motion than the upper lip.
Together with these results the long face can be said
to have a tendency for less buccal corridor.
Among the denture pattern measurements, there
were statistically significant negative correlations in U1
exposure (P .01, Table 1), U1 to facial plane (P
.01, Table 1), L1 to mandibular plane (P .01, Table
1), and L1 to N-B (P .05, Table 1). These suggest
that the more anteriorly and downwardly positioned
the upper incisors and anteriorly and upwardly positioned the lower incisors were, the less the BCAR was.
These incisor positions could be a part of the dental
compensation effect of the hyperdivergent tendency in
a skeletal vertical pattern.
In dental cast measurements, interpremolar width (P
.05, Table 1) showed a statistically significant negative correlation with BCAR. The narrower the interpremolar width was, the larger the BCAR. This was in
accord with the results of former studies.13,14,24,25
Although sum of tooth material (P .05, Table 1)
showed a negative correlation coefficient, which suggested the extraction group had a high possibility of
having a large buccal corridor, there was no statistically significant difference of the BCAR between the
extraction and nonextraction groups (Table 2). This
was in discord with the results of former studies.26
Those findings mean that the amount of buccal corridor space did not correlate with whether extractions
were done or not, but with the sum of tooth material.
If the size of each tooth was slightly larger than normal
in extraction cases, eventually the sum of tooth material could be larger than normal and vice versa for
the nonextraction group.
These discords1215,20,26 and accords13,14,24,25 to former studies were mainly due to the newly-introduced
method of measuring the buccal corridor space in this
study. Former methodology was horizontal linear measurement, but the method used in this study dealt with
two dimensions. This is the reason the vertical comAngle Orthodontist, Vol 78, No 1, 2008

10

YANG, NAHM, BAEK

Table 1. Correlation Between Buccal Corridor Area Ratio and Other Variablesa

Variables
Anteroposterior position of the maxilla

A to N-perpendicular, mm
A to Sn-perpendicular, mm
Facial height ratio (FHR)
Frankfurt mandibular plane angle (FMA), degrees
Lower facial height ratio (LAFH), degrees
Overbite depth indicator (ODI), degrees
Occlusal plane to S-N, degrees
U1 Exposure, mm
U1 to Facial plane, degrees
U1 to Sn-perpendicular, mm
L1 to A-Pog, mm
L1 to Mandibular plane, mm
L1 to N-B, mm
N to Sn, mm
Sn to Me, mm
Sn to stms, mm
stms to Me, mm
Sum of tooth material (STM), mm
Incisor angulation (IA), degrees
Canine angulation (CA), degrees
Canine inclination (CI), degrees
Premolar inclination (PI), degrees
ICW, mm
IPW, mm
ICBAW, mm
IPBAW, mm
BCLR, %
BCAR, %

Skeletal vertical pattern

Occlusal plane inclination


Denture pattern

Soft tissue vertical length

Dental cast

Smile photographs

Mean

SD

Pearson
Correlation
Coefficientb

0.94
14.35
0.63
28.41
46.78
68.38
20.62
3.16
8.74
9.43
1.82
46.03
6.03
55.62
79.13
25.16
53.96
43.83
3.93
5.43
1.70
5.23
36.90
46.82
34.23
47.46
71.80
5.27

2.41
2.23
0.05
6.17
4.22
5.83
4.86
1.62
3.36
2.49
3.09
3.41
2.34
3.88
5.46
2.20
4.19
2.88
2.44
4.74
6.63
6.14
1.85
1.90
2.97
3.17
5.12
1.75

0.075
0.156
0.082
0.219*
0.428**
0.001
0.054
0.421**
0.370**
0.186
0.044
0.410**
0.260*
0.196
0.438**
0.256*
0.437**
0.221*
0.076
0.083
0.011
0.175
0.181
0.229*
0.084
0.091
0.962

* P .05.
** P .01.
a
SD indicates standard deviation; U1, upper central incisor; L1, lower central incisor; STM, sum of tooth material which is sum of the
mesiodistal widths of the teeth from the upper right to left first molars; IA, average angulation of the upper central and lateral incisors of both
sides; CA, average angulation of upper canines of both sides; CI, average inclination of upper canines of both sides; PI, average inclination
of upper first and second premolars of both sides; ICW, intercanine width between cusp tips of upper canines; IPW, average interpremolar
width at contact point between first and second premolar in nonextraction case and interpremolar width at second premolars in extraction case;
ICBAW, intercanine basal arch width between the upper canines; IPBAW, interpremolar basal arch width at centroid between the upper first
and second premolars; BCLR, buccal corridor linear ratio; BCAR, buccal corridor area ratio.
b
Pearson correlation analysis. In this study the correlation coefficients greater than 0.20 and less than 0.20 had statistical significance
(r .26, r .26, P .01; r .20, r .20, P .05, 2-tailed).

ponents of the cephalometric and cast measurements


had an important effect on the BCA.
In multiple linear regression analysis of BCAR (Table 3), the hard and soft tissue factors affecting the
amount of BCAR were the soft tissue vertical length
(Sn to Me), the amount of upper incisor exposure, and
Table 2. Comparison of Buccal Corridor Area Ratio Between the
Nonextraction and Extraction Groupsa

Variable
BCAR

Nonextraction
Group (N 36)

Extraction Group
(N 56)

Mean

SD

Mean

SD

5.15

1.61

5.34

1.84

Angle Orthodontist, Vol 78, No 1, 2008

Table 3. Multiple Linear Regression Analysis of Buccal Corridor


Area Ratioa
Significant Variables

Significance
P Value (2-Tailed)
.62

NS

Independent t-test, BCAR indicates buccal corridor area ratio;


SD, standard deviation; NS, nonspecific.
a

sum of tooth material. The reason why these three variables were selected follows: The variables in the skeletal vertical pattern (FMA and LAFH) were excluded
because of the collinearity with Sn to Me. That is, Sn
to Me can explain the vertical pattern of the underlying skeletal structures. Because most of the persons

Sn-Me, mm
U1 exposure, mm
Sum of tooth material, mm

Coefficient Adjusted R2
0.117
0.357
0.124

0.183
0.289
0.324

P value
.001
.001
.02

a
Multiple linear regression analysis. N 92, P .05, adjusted
R2 .324. U1 indicates upper central incisor.

11

QUANTIFICATION OF THE BUCCAL CORRIDOR SPACE

with large Sn to Me tend to have large Sn to stms


and stms to Me, these two soft tissue vertical length
variables were also excluded in the multiple linear regression analysis. The variables on the position of the
lower incisors (L1 to mandibular plane and L1 to N-B)
were excluded because the lower incisors were well
located in a given small range of position according to
the position of the upper incisors after orthodontic
treatment. Because sum of tooth material had a strong
correlation (r 0.720, P .001) from the correlation
matrix, the interpremolar width was excluded from the
regression model.

10.

11.

12.
13.

14.

CONCLUSIONS
With the newly-introduced method for BCA, the buccal corridor is a multifactorial phenomenon. To control the amount of BCA for achieving a better esthetic
smile, it is necessary to observe the vertical pattern
of the face, amount of upper incisor exposure, and
sum of the tooth material.
Extraction or nonextraction treatment did not affect
the amount of BCA.

15.

16.
17.

18.
19.

REFERENCES
1. Burstone CJ. The integumental profile. Am J Orthod. 1958;
44:125.
2. Ricketts RM. Cephalometric synthesis. Am J Orthod. 1960;
46:647673.
3. Merrifield LL. The profile line as an aid in critically evaluating
facial esthetics. Am J Orthod. 1966;52:804822.
4. Scheideman GB, Bell WH, Legan HL, Finn RA, Reisch JS.
Cephalometric analysis of dentofacial normals. Am J Orthod. 1980;78:404420.
5. Holdaway RA. A soft-tissue cephalometric analysis and its
use in orthodontic treatment planning. Part I. Am J Orthod.
1983;84:128.
6. Powell N, Humphreys B. Proportions of the Aesthetic Face.
New York, NY: Thieme-Stratton Inc; 1984:1550.
7. Arnett GW, Bergman RT. Facial keys to orthodontic diagnosis and treatment planning. Part I. Am J Orthod Dentofacial Orthop. 1993;103:299312.
8. Arnett GW, Jelic JS, Kim J, Cummings DR, Beress A, Worley CM Jr, Chung B, Bergman R. Soft tissue cephalometric
analysis: diagnosis and treatment planning of dentofacial
deformity. Am J Orthod Dentofacial Orthop. 1999;116:239
253.
9. Proffit WR. The soft tissue paradigm in orthodontic diag-

20.
21.

22.

23.

24.

25.
26.
27.

28.

nosis and treatment planning: a new view for a new century.


J Esthet Dent. 2000;12:4649.
Kerns LL, Silveira AM, Kerns DG, Regennitter FJ. Esthetic
preference of the frontal and profile views of the same smile.
J Esthet Dent. 1997;9:7685.
Ackerman JL, Proffit WR, Sarver DM. The emerging soft
tissue paradigm in orthodontic diagnosis and treatment
planning. Clin Orthod Res. 1999;2:4952.
Ackerman MB, Ackerman JL. Smile analysis and design in
the digital era. J Clin Orthod. 2002;36:221236.
Sarver DM, Ackerman MB. Dynamic smile visualization and
quantification: part 1. Evolution of the concept and dynamic
records for smile capture. Am J Orthod Dentofacial Orthop.
2003;124:412.
Sarver DM, Ackerman MB. Dynamic smile visualization and
quantification: part 2. Smile analysis and treatment strategies. Am J Orthod Dentofacial Orthop. 2003;124:116127.
Ackerman MB, Brensinger C, Landis JR. An evaluation of
dynamic lip-tooth characteristics during speech and smile in
adolescents. Angle Orthod. 2004;74:4350.
Hulsey CM. An esthetic evaluation of lip-teeth relationships
present in the smile. Am J Orthod. 1970;57:132144.
Rigsbee OH 3rd, Sperry TP, BeGole EA. The influence of
facial animation in smile characteristics. Int J Adult Orthodon Orthognath Surg. 1988;3:233239.
Morley J. Smile design terminology. Dent Today. 1996;15:
70.
Ackerman JL, Ackerman MB, Brensinger CM, Landis JR. A
morphometric analysis of the posed smile. Clin Orthod Res.
1998;1:211.
Ackerman MB. Buccal smile corridors. Am J Orthod Dentofacial Orthop. 2005;74:528529.
Ritter DE, Gandini LG, Pinto Ados S, Locks A. Esthetic influence of negative space in the buccal corridor during smiling. Angle Orthod. 2006;76:198203.
Parekh SM, Fields HW, Beck M, Rosenstiel S. Attractiveness of variations in the smile arc and buccal corridor space
as judged by orthodontists and laymen. Angle Orthod. 2006;
76:557563.
Lombardi RE. The principles of visual perception and their
clinical application to denture esthetics. J Prosthet Dent.
1973;29:358382.
Snyder RJ. Class II malocclusion correction: an American
board of orthodontics case. Am J Orthod Dentofacial Orthop. 1999;116:424429.
McNamara JA. Maxillary transverse deficiency. Am J Orthod Dentofacial Orthop. 2000;117:567570.
Ghafari JG. Emerging paradigms in orthodonticsan essay. Am J Orthod Dentofacial Orthop. 1997;111:573580.
Snow SR. Esthetic smile analysis of maxillary anterior tooth
width: the golden percentage. J Esthet Dent. 1999;11:177
184.
Naylor CK. Esthetic treatment planning: the grid analysis
system. J Esthet Restor Dent. 2002;14:7684.

Angle Orthodontist, Vol 78, No 1, 2008

Original Article

Autotransplantation of 28 Premolar Donor Teeth in


24 Orthodontic Patients
Tadasu Tanakaa; Toshio Deguchib; Toru Kageyamac; Ryuzo Kanomid;
Masahiro Inouee; Kelvin W.C. Foongf
ABSTRACT
Objective: To test the null hypothesis that premolar autotransplantation is not successful for
orthodontic patients.
Materials and Methods: In the present study, 28 premolar transplants from 24 orthodontic patients were associated with orthodontic treatment. At a routine 3-month appointment, patients
underwent a dental radiograph and a chair-side observation for periodontal problems. Three sets
of dental radiographs were taken by one dental assistant using a custom holder at: preoperation
(T0), 2 year postoperation (T1), and retention (T2) (4- to 14-year follow-up observation) stages.
All transplants were conducted in a one-phase operation by one operator (Dr Inoue). Recipient
sites were: ten for missing maxillary canines, nine for maxillary centrals and laterals, eight for
lower second premolar, and five for other missing premolar sites. All recipients maintained the
retained primary tooth with a socket.
Results: The success ratio of all 28 transplants was 100%, although four transplants shorter than
a 4-year period of observation were omitted. Two transplant patients, one with a medical history
of histiocytosis and the other with a history of osteomyelitis of the maxilla without a recipient
socket, were also excluded from this study. Eleven of 22 premolar transplants had a root canal
treatment (RCT), four of which had RCT within 2 years after the operation.
Conclusions: The null hypothesis was rejected. The success ratio of premolar transplants was 100%.
KEY WORDS: Autotransplantation; Donor premolar; Hypodontia; Long-term follow-up; Orthodontics; Tooth movement

INTRODUCTION

been applied in orthodontics and oral surgery.2,3 Although both allotransplantation and cryotransplantation need a tooth bank, allotransplantation might result
in an immune reaction for donors and recipients
teeth. Experimental and clinical studies on tooth transplantation continue.47
Recently, a few papers on premolar donor autotransplantation have been published.810 Although autotransplantation has historically been popular in
northern European countries,2,3,811 this could be related to the dentists training background that was based
on a closer relationship between dental surgery and
medicine. On the other hand, there is lack of information on tooth autotransplantation from American

Since the 1960s and 1970s, allotransplantation,


cryotransplantation,1 and autotransplantation have
a
Graduate PhD student, Graduate School (Unit of Orthodontics) and Institute for Oral Science, Matsumoto Dental University
School of Dentistry, Nagano, Japan.
b
Professor and Head, Graduate School (Unit of Orthodontics)
and Institute for Oral Science, Matsumoto Dental University School
of Dentistry, Nagano, Japan. Professor, Orthodontic Postgraduate
Program, Department of Preventive Dentistry, National University
of Singapore and Hospital, Faculty of Dentistry, Singapore.
c
Associate Professor, Graduate School (Unit of Orthodontics)
and Institute for Oral Science, Matsumoto Dental University
School of Dentistry, Nagano, Japan.
d
Private practice, Hyogo-ken, Japan.
e
Associate Professor, Department of Oral Implantology, Osaka Dental University, Osaka, Japan.
f
Associate Professor, Orthodontic Postgraduate Program,
Department of Preventive Dentistry, National University of Singapore and Hospital, Faculty of Dentistry, Singapore.
Corresponding author: Dr Toshio Deguchi, Graduate School
(Unit of Orthodontics) and Institute for Oral Science, Matsumoto

Angle Orthodontist, Vol 78, No 1, 2008

Dental University, 1780. Gohbara-Hirooka, Shiojiri, Nagano 3990781 Japan


(e-mail: pndtd@nus.edu.sg)
Accepted: February 2007. Submitted: December 2006.
 2007 by The EH Angle Education and Research Foundation,
Inc.
12

DOI: 10.2319/120706-495.1

13

AUTOTRANSPLANTATION IN ORTHODONTIC TREATMENT


Table 1. Characteristics of Donor Samples and Three Different
Stages of Root Development
Variation of Root
Development
Root length complete (Rc)
Root length 3/4 (3/4R)
Root length 1/2 (1/2R)
Total

Donors, Patients, Patient Age,


N
N
Years
SD
9
17
2
28

9
13
2
24

14.45
12.34
11.82
12.55

2.10
0.57
1.35
1.82

and Asian orthodontists. In Japanese or Asian populations with a higher rate of extraction cases, there are
numerous opportunities for autotransplantation of donor premolars to the sites of missing permanent teeth,
eg, mandibular second premolar, maxillary incisors,
and canines.
Most patients with partial anodontia (hypodontia) will
benefit from autotransplantation, which could be successful over a long-term observation. There is only
one original paper of tooth transplantation in a Japanese sample,12 so there is still a lack of information for
donor premolar autotransplantation related to orthodontic treatment.
MATERIALS AND METHODS
Thirty-three orthodontically treated patients from a
private orthodontic clinic were treated with the autotransplantation of 38 donor premolars from 1988 to
2004. Five out of 33 patients, who were transferred
from other orthodontists for autotransplantation, did
not return for progress records. Four transplants with
less than a 4-year period of observation were omitted.
In addition to these, two transplant patients, one of
which had a medical history of histiocytosis and the
other a history of osteomyelitis of the maxilla without
a recipient socket, were excluded. The present study
consists of 24 donor patients associated with 28 donor
premolars. All recipient sites had maintained the retained primary teeth.
Success was categorized as: (1) the crown:root ratio
was 1:1; (2) longer than 4-year survival in the mouth;
(3) nonankylosis; (4) nonsevere periodontal problems;
and (5) physiological mobility. If one of these criteria
was not met, the case was recorded as a failure.
A total of 24 donor patients consisted of 14 female
and 10 male patients, ranging in age from 9 years and
8 months to 16 years. The majority (90%) of the donor
patients were between 12 and 14 years old (Table 1).
The period of follow-up observation for 28 premolar
transplants is described in Table 2.
Twenty-eight premolar donors were autotransplanted to the recipient sites of missing teeth as follows:
Ten donor premolars were autotransplanted to the
sites of deciduous canines; seven were autotransplanted to the deciduous second premolar; and six

Table 2. Period of Follow-Up Observation for 28 Premolar Transplants


Case Number 110 Case Number 1120
Patient
Number
1
2
3
4
5
6
7
8
9
10

Case Number 2128

Period,
Years

Patient
Number

Period,
Years

Patient
Number

Period,
Years

12
12
14
14
14
13
13
4
13
12

11
12
13
14
15
16
17
18
19
20

10
11
10
10
8
10
9
7
6
8

21
22
23
24
25
26
27
28

6
5
5
4
4
4
10
4

were autotransplanted to maxillary central and lateral


incisor sites. Five premolar donors were autotransplanted to the sites of other premolars (Figure 1).
Clinical and radiographic observations of all premolar donors were obtained. Root length measurements were done by radiographs taken prior to the
operation (T0), 2 years postoperatively (T1), and 4
years thereafter (T2). Clinical checks (gingival condition, tooth mobility) were done semiannually, concurrently with the patients visit.
Although Moorrees13 classification is popular for the
evaluation of the eight stages of root development, our
study simply classified root development into three different stages; half root (1/2R), quarter root (3/4R) and
complete root (Rc) stages because the small sample
size of transplants would not justify the classification
into eight stages. The 1/2R stage is similar to stage 3
of Moorrees classification; the 3/4R stage is stage 4,
and root complete (Rc) is stage 57.The progress of
each donors root growth was studied at T0, T1, and
T2 stages (Table 3). The length of the tooth crowns
and roots were calculated (NIH Image, version 1.62,
National Institutes of Health) on a computer incorporating a radiograph at T0, T1, and T2. The increase in
root length at T0T1, T1T2, and T0T2 was classified into a growth group and a decrease in length into
a nongrowth or resorption group. The means of root
progress were obtained (Table 3). The dental radiograph in this study was taken by a single dental operator using a Cone Indicator (Hanshin Technical Lab
Ltd, Hyogo, Japan).
Surgical Procedures
There are a few papers discussing different surgical
procedures in a one-stage or two-stage operation.14,15
In the present surgical procedure, one oral surgeon
(Dr Inoue), with a clinical periodontic background, performed all transplantations of the donor premolars in
a one-stage operation. Operation procedures in the
Angle Orthodontist, Vol 78, No 1, 2008

14

TANAKA, DEGUCHI, KAGEYAMA, KANOMI, INOUE, FOONG

Figure 1. Donor and recipient sites of 28 premolar transplants.

Table 3. The Root Complete Progress of Premolar Donors at T0, T1, and T2 Stages
Root Length, mm

Stage of Root
Growtha
Rc

3/4R

1/2R

n
Growth

Nongrowth or resorption

Growth

Nongrowth or resorption

11

Growth

Nongrowth or resorption

Mean
(SD)
Mean
(SD)
Mean
(SD)
Mean
(SD)
Mean
(SD)
Mean
(SD)

Difference, mm

T0

T1

T2

T0T1

T1T2

T0T2

12.59
(1.96)
14.74
(4.39)
10.83
(1.28)
11.05
(1.99)
5.02
()
13.53
()

13.94
(2.45)
14.03
(4.05)
13.12
(1.40)
10.46
(2.44)
7.85
()
10.85
()

14.42
(2.41)
13.29
(3.98)
11.86
(1.99)
11.08
(2.90)
6.94
()
11.61
()

1.52
(0.57)
0.42
(1.44)
1.67
(0.60)
1.58
(1.67)
2.83
()
2.45
()

0.32
(0.47)
1.10
(1.47)
1.26
(1.53)
0.53
(1.15)
0.91
()
0.53
()

1.14
(0.12)
1.74
(0.57)
0.87
(1.80)
0.83
(1.91)
1.92
()
1.92
()

Rc indicates complete root; 3/4R, quarter root; 1/2R, half root.

present transplants were focused on: (1) the pilot drill,


which is used in dental implants, was applied for socket enlargement; (2) the epithelial attachment of the recipient was retained without damage; (3) teeth from
donors were extracted in about 10 minutes after jiggling to maintain the periodontal membrane and Hertwigs epithelial root sheath; and (4) the socket was
carefully managed at recipient sites with two roots.
The orthodontic treatment progress and surgical
procedures of the first patient are shown in Figures 2
through 4. The female patient was our first autotransplanted orthodontic case, and information on this patient was published previously.16 The patients records
at pretreatment are shown in Figure 2AE. The surgical procedures are described in Figure 3AE, and
the posttreatment records are shown in Figure 4AE.
Figures 5 and 6 are the panoramic radiographs at T0
Angle Orthodontist, Vol 78, No 1, 2008

and T1 and dental radiographs at the T0, T1, and T2


stages of premolar donors and transplants.
In this patient, the maxillary lateral incisors and canines were congenitally missing. The mandibular first
premolar donors were transplanted to the sites of the
remaining maxillary deciduous lateral incisors and canines. The premolar donor teeth were diagnosed for
extraction to solve the orthodontic problems in the patient. There was no sacrifice of premolars in the patients. A few weeks following surgery, the donor premolars were transplanted to the sites of the maxillary
anterior teeth. The maxillary anterior teeth were initially
moved to correct their rotated position in order to minimize the risk of ankylosis. A few months after initial
movement, the transplanted premolars were shaped
to the morphology of lateral incisors or canines. Endodontic therapy was applied, if needed. Edgewise ap-

15

AUTOTRANSPLANTATION IN ORTHODONTIC TREATMENT

Figure 2. The first autotransplanted patient. (AE) Oral photos at pretreatment records.

pliance therapy with a 0.018 pretorqued bracket was


initiated, involving a sequence of Niti leveling arch
wires and completed with a 0.017 0.025 finishing
ideal arch wire. Treatment time was 45 months.
RESULTS
All 28 premolar donors were classified into three
stages of root development. Another five premolar donors were autotransplanted in patients who had been
referred from other orthodontists to our clinics. Unfortunately, all referred autotransplanted patients did not
return for follow-up observations.
All autotransplanted premolars were checked at a
chair-side observation during the latest appointment.
All donors were well-maintained in occlusion and presented a normal periodontal condition for an extensive
follow-up (Table 2). However, there is a lack of history
or records of detailed periodontal observation, eg,
depth of pockets. Four pairs of twin sisters are included in these 28 cases, three of which showed a bilateral
missing upper canine, while one was bilaterally missing the lower second premolars.
Sixteen premolars out of 28 premolar donors (57%)
were autotransplanted to the sites of upper incisors
and canines. Most premolar donors needed to be reshaped to the morphology of the upper incisors and
canines (Figures 1 and 4D).
Root development of the autotransplanted premolars was studied. The amount of root development and
nongrowth or resorption at T0T1, T1T2, and T0T2
was studied in all premolar donors (Table 3).

At T0, there were nine premolar donors with Rc, 17


with 3/4R and two with 1/2R. At T1T2 stages, root
growth transplants of Rc subjects showed root resorption (mean 0.32 mm). Nongrowth transplants of
3/4R subjects showed root growth (mean 0.53 mm).
At T0T2 stages, three out of 9 Rc premolars
showed root growth (mean of 1.14 mm) and six premolars showed nonroot growth (mean of 1.74 mm).
Six out of 17 premolars of 3/4R showed root growth
(mean 0.87 mm), and 11 premolar transplants showed
nongrowth (mean 0.83 mm). One of the 1/2R subjects showed growth (1.92 mm), while the other
showed nongrowth (1.92 mm). The overall progress
of premolar transplants through T0T2 stages is summarized in Table 4.
In the present study, the ratio of pulp survival in the
transplants was 60.7%. Eleven out of 24 premolar
transplants had root canal treatment (RCT), four of
which had a RCT within 2 years after surgery. One out
of 1/2R and 3/4R subjects showed root bending.
DISCUSSION
Recently, two excellent papers for autotransplantation were published.8,9 Autotransplantation is a traditional method in the field of dentistry. This clinical trial
focused on patients with missing teeth who needed
orthodontic treatment. All donor premolars were extracted for orthodontic treatment and transplanted to
the sites of the missing teeth without sacrificing any of
the patients teeth. Tsukiboshi12 described 250 conventional autotransplantations in fully developed teeth
Angle Orthodontist, Vol 78, No 1, 2008

16

TANAKA, DEGUCHI, KAGEYAMA, KANOMI, INOUE, FOONG

Figure 3. The procedures of autotransplant operation. (A) Removal of maxillary deciduous canine. (B) Transplantation of mandibular first
premolar to the site of recipient. (C) Extraction of mandibular first premolar. (D, E) A plate was cemented.

that took place over a period of 15 years. The success


rate was 82%, while that of artificially formed sockets
was 60%.
Recently, Jonsson and Sigurdsson9 reported the autotransplantation of 40 premolars to premolar sites
with a long-term follow-up. The success rate of long
follow-ups was 92.5%. In 35 out of 40 cases, the premolar transplants were utilized to substitute the miss-

Figure 4. (AE) Oral photos at posttreatment.


Angle Orthodontist, Vol 78, No 1, 2008

ing mandibular second molar while the remaining five


were used to replace maxillary premolars.
In the present clinical trial, 7 out of 24 premolar donors were applied to the sites of the missing mandibular second premolar. Interestingly, 16 donor premolars (57%) were placed at the sites of the missing maxillary central, lateral, and canine. In this study the success rate of premolar transplants was 100%, which is

AUTOTRANSPLANTATION IN ORTHODONTIC TREATMENT

17

Figure 5. Panoramic radiographs at pretreatment and posttreatment.

a higher ratio than that reported in Jonsson and Sigurdssons9 data. Five premolar transplants with less
than 4 years of observation were excluded from this
study, but were well-maintained. The transplant in the
patient with histiocytosis was maintained 4 years after
the operation, and the transplant in the other patient
with osteomyelitis of the maxilla fell out 7 years after
the operation, resulting in severe bone loss.
However, one of the markers for the success of
transplants is a 1:1 ratio of crown and root,1719 which

clinically shows a shorter root than the usual root


shape. Although the dental radiographs were taken by
a Cone Indicator and a single operator to minimize the
error of root measurement, measurement accuracy
may be critical to evaluate the actual changes in root
development in traditional radiographs. In the present
study, the range of transplant root length was 11 mm
to 14 mm, except for one 1/2R patient. The average
root length for a normal first premolar and second premolar was 12 mm and 13 mm, respectively in Japa-

Figure 6. Dental radiographs of donors of mandibular left and right first premolars and the transplants at the sites of missing maxillary lateral
incisors and canines at T1 and T2.
Angle Orthodontist, Vol 78, No 1, 2008

18

TANAKA, DEGUCHI, KAGEYAMA, KANOMI, INOUE, FOONG


Table 4. The root complete progress of premolar donors from T0 to T2 stages

nese samples.20 The premolar transplants maintained


an almost normal root length in orthodontic patients.
Three-dimensional evaluative methods for root development associated with root bending can result in
more accurate data.
Premolar transplants, which are conventionally
placed at the sites of maxillary incisors and canines,
were placed at the rotated position because of a lack
of bone width, and the rotated position was orthodontically corrected a month later. Crown reshaping of
premolar transplants to the shape of recipient teeth
was done 4 or 5 months later. An endodontic treatment was performed, if needed.
Jonsson and Sigurdsson9 showed a 76% pulp survival in transplants with partly formed roots. Czochrowska et al8 reported 30 transplants in 25 patients
of which 22 had an orthodontic treatment without performing the endodontic treatment in the long-term follow-up. The ratio of pulp survival in the present transplants was 60.7%. This low ratio of pulp survival could
be related to the recipient sites of upper incisors and
canines, whose crown needed to be reshaped for the
premolar transplants.
In the present autotransplantation cases with missing teeth, premolar extraction for the purpose of orthodontic treatment was needed in all cases. Except for
surgical procedures, patients did not sacrifice teeth
during autotransplantation. Although all donor teeth in
the present study were the first or second premolar,
the lower third molars could also be useful for autotransplantation without a risk to the patient.2123 The
clinical application of a recently developed miniscrew2426 or miniplate27 anchorage system could be
another choice to close the space in missing teeth
sites without causing side effects.
Slagsvold and Bjercke11 report that half of root transplants might attain normal or almost normal lengths if
autotransplantation could be ideally performed. They
commented that genetics may control root growth, and
Angle Orthodontist, Vol 78, No 1, 2008

the formation of adequate roots seems to be secured,


provided epithelial sheath integrity is maintained.
Advanced biological research on bone-periodontal
membrane biomaterials,28,29 cultured membrane,30 and
pulpal reaction histobiology31,32 can also improve the
quality of tooth autotransplantation with more roots
and bone development. Tooth regeneration is a future
dream.33
CONCLUSIONS
The null hypothesis was rejected. The success ratio
of premolar transplants in orthodontic patients in this
study was 100% after excluding two transplant patients, one with a medical history of histiocytosis and
the other with a history of osteomyelitis of the maxilla
without a recipient socket. The follow-up period of
five transplants was shorter than the 4-year criteria,
but they maintained good functionality in the mouth.
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1. Bartlett P, Reade P. Cryopreservation of developing teeth.
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2. Andreasen J, Schwarz O. Atlas of Replantation and Transplantation of Teeth. Freiburg, Switzerland: Mediglobe SA;
1992:111221, 257276.
3. Schwarz O, Frederiksen K, Klausen B. Allotransplantation
of human teeth. A retrospective study of 73 transplantations
over a period of 28 years. Int J Oral Maxillofac Surg. 1987;
16:285301.
4. Temmerman L, De Pauw GA, Beele H, Dermaut LR. Tooth
transplantation and cryopreservation: state of the art. Am J
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6. Schwarz O. Autotransplantation of cryo-preserved tooth in
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AUTOTRANSPLANTATION IN ORTHODONTIC TREATMENT

8.

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larization after cryopreservation and autotransplantation of


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rates 1741 years posttreatment. Am J Orthod Dentofacial
Orthop. 2002;121:110119.
Jonsson T, Sigurdsson TJ. Autotransplantation of premolars
to premolar sites. A long-term follow-up. Am J Orthod Dentofacial Orthop. 2004;125:668675.
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Slagsvold O, Bjercke B. Autotransplantation of premolars
with partly formed roots: a radiographic study of root growth.
Am J Orthod. 1974;66:355366.
Tsukiboshi M. Autotransplantation of teeth: predictable success. Dent Traumatol. 2002;18:157180.
Moorrees JFA, Fanning EA, Hunt EE Jr. Age variation of
formation stages for 10 permanent teeth. J Dent Res. 1963;
42:14901502.
Nethander G. Autogenous free tooth transplantation with a
two-stage operation technique. Swed Dent J Suppl. 2003;
161:151.
Nethander G, Skoglind A, Kahnberg KE. Experimental autogenous tooth transplantation in the dog: a comparison between one- and two-stage surgical techniques. Acta Odontol Scand. 2003;61:223229.
Kanomi R, Inoue M. Application of autotransplantation to
clinical orthodontics. J Ortho Practice. 1997;13:1126.
Schwarz O, Bergmann P, Klausen B. Resorption of autotransplanted human teeth: a retrospective study of 291
transplantations over a period of 25 years. Int Endod J.
1985;18:119131.
Kristerson L, Lagerstrom L. Autotransplantation of teeth in
cases with agenesis or traumatic loss of maxillary incisors.
Eur J Orthod. 1991;13:486492.
Kugelberg R, Tegsjo U, Malmgren O. Autotransplantation of
45 teeth to the upper incisor region in adolescents. Swed
Dent J. 1994;18:165172.
Fujita T, Kirino T, Yamashita Y. Text Book of Dental Anatomy. 22nd ed. Tokyo: Kanehara Publishing Co, Ltd; 1995:
5978.
Sobhi MB, Rana MJ, Manzoor MA, Ibrahim M, Tasleem-ulHudda. Autotransplantation of endodontically treated third
molars. J Coll Physicians Surg Pak. 2003;13:372374.

19
22. Bauss O, Schwestka-Polly R, Killaridis S. Influence of orthodontic derotation and extrusion on pulpal and periodontal
condition of autotransplanted immature third molars. Am J
Orthod Dentofacial Orthop. 2004;125:488496.
23. Mejare B, Wannfors K, Jansson L. Transplantation of their
molars with complete root formation. Oral Surg Oral Med
Oral Pathol. 2004;97:231238.
24. Deguchi T, Takano-Yamamoto T, Kanomi R, Hartsfield JK
Jr, Roberts WE, Garetto LP. The use of small titanium
screws for orthodontic anchorage. J Dent Res. 2003;82:
377381.
25. Miyawaki S, Koyama I, Inoue M, Mishima K, Sugawara T,
Takano-Yamamoto T. Factors associated with the stability
of titanium screws placed in the posterior region for orthodontic anchorage. Am J Orthod Dentofacial Orthop. 2003;
124:373378.
26. Sugawara J, Daimaruya T, Umemori M, Nagasaka H, Takahashi I, Kawamura H, Mitani H. Distal movement of mandibular molars in adult patients with the skeletal anchorage
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16.

Angle Orthodontist, Vol 78, No 1, 2008

Original Article

Complications during Mandibular Midline Distraction


The First 100 Patients

Julia von Bremena; Dominik Schaferb; Wolfgang Katerb; Sabine Rufc


ABSTRACT
Objective: To analyze the number and type of complications during mandibular midline distraction.
Materials and Methods: The records of 100 consecutive patients who underwent mandibular
midline distraction were evaluated, and complications which occurred up to 2 weeks after surgery
were recorded.
Results: Fourteen patients had complications during the distraction period. In four cases the
screw of the appliance rotated back between the activations. In three cases the osteotomy had
to be repeated because the symphysis did not open; two cases developed scar strictures, in
another two a lower incisor fractured. One case developed an abscess, one a mandibular swelling,
and one a large gingival recession.
Conclusions: Complications during or shortly after mandibular midline distraction surgery are
relatively rare and mostly mild or transient. Only 3% of the patients presented irreversible damage.
Thus, mandibular midline distraction appears to be a relatively safe method of expanding the
mandible.
KEY WORDS: Mandibular midline distraction; Complications

INTRODUCTION

1973, when Snyder et al6 in an animal experiment


lengthened a canine mandible after initially having created a segmental defect, which they successfully reconstructed. It was, however, not until 1992 that
lengthening of the mandible through distraction osteogenesis was performed in humans.7
The first report of an expansion of the mandible in
the transverse dimension after surgically splitting the
symphysis was published by Guerrero8 in 1990. Mandibular arch expansion had previously been attempted
with a variety of orthodontic appliances, but always resulted in major relapse9 since the symphysis ossifies
at the age of one year, and thus cannot be expanded
transversally, at least not in the conventional manner.
Mandibular midline distraction could therefore be a
treatment option in cases with severe mandibular
crowding combined with a well-aligned upper arch, a
V-shaped mandible, unilateral or bilateral scissor bites,
and maxillomandibular transverse deficiencies with
narrow arches.1012
The concept of mandibular midline distraction is basically the same as that of a surgically assisted rapid
maxillary expansion (RME). However, in contrast to
the maxilla, no lateral surgical disjunction has to be
performed since the mandible has no rigid connection
to the skull. A distraction of the mandible, thus, will not
be parallel, but always rotate around the condyles.

Distraction osteogenesis nowadays is a common


method of generating new tissue between two bone
segments through traction. The origin of this technique
goes back to 1905, when Codivilla1 lengthened a
shortened femur. Due to a high complication rate this
method was initially not accepted and was more or
less forgotten over the years. In 1954, however, Ilizarov rediscovered distraction osteogenesis and applied it on the lower extremities to heal fractured long
bones with segmental defects.25
During the following years, distraction osteogenesis
was a treatment option for long bones only, until in
Assistant Professor, Department of Orthodontics, University
of Giessen, Giesen, Germany.
b
Private practice, Department of Oral and Maxillofacial Surgery, Bad Homburg, Germany.
c
Professor and Head, Department of Orthodontics, University
of Giessen, Giesen, Germany.
Corresponding author: Dr Julia von Bremen, Department of
Orthodontics, University of Giessen, Schlangenzahl 14, 35392
Giessen, Germany
(e-mail: Julia.v.Bremen@dentist.med.uni-giessen.de)
a

Accepted: February 2007. Submitted: January 2007.


 2007 by The EH Angle Education and Research Foundation,
Inc.
Angle Orthodontist, Vol 78, No 1, 2008

20

DOI: 10.2319/011507-17.1

COMPLICATIONS DURING MANDIBULAR DISTRACTION

21

Figure 1. Age distribution (in increasing order) of 100 subjects treated with mandibular midline distraction with and without simultaneous
surgically-assisted rapid maxillary expansion (RME).

Although from a surgical point of view mandibular


midline distraction is a simple and fast procedure,
complications do occur.1315 To our knowledge no
study exists, which evaluates possible surgical complications in a large patient sample. It was therefore
the aim of this study to analyze the number and type
of complications during mandibular midline distraction.
MATERIALS AND METHODS
The records of the first 100 consecutive patients (55
female, 45 male) treated in the surgical practice of Dr
Kater, Bad Homburg, Germany were evaluated and
the complications recorded. Only those complications
which arose during or up to 2 weeks after the distraction period were included.

Figure 2. Maxillary, mandibular, and maximum/minimum measurements: Tooth-borne mandibular distraction appliance used for all 100
subjects.

The patients ages varied between 11 and 62 years


(mean age: 27.6 years). In 83 of the 100 subjects a
surgically assisted RME was performed simultaneously with the mandibular midline distraction. The remaining 17 patients got a mandibular midline distraction exclusivelybecause of their younger age the maxilla
could be expanded in a nonsurgical manner or no
maxillary expansion was required (Figure 1). All patients had tooth-borne distraction devices, and they
were referred to the surgical practice by 31 different
orthodontists.
All operations were performed by Dr Kater or under
his direct supervision by one of his two residents. The
following standardized surgical procedure was used in
all patients. The tooth-borne distraction appliance had
been set in place by the orthodontist (Figure 2). Starting at the bottom of the chin, the symphysis was vertically sectioned with an oscillating saw blade up to
two-thirds of mandibular height where the incisor roots
start (Figure 3). The last one-third of mandibular height
was split open with a spatula placed between the roots
under light tapping pressure (Figure 4). After reassuring that the two mandibular halves were mobile, the
tissues were readapted and a latency period of 1 week
was maintained to allow for callus formation. The activation of the appliance started after 7 days, normally
with 0.250.5 mm per day, until the desired amount of
distraction had been reached.
RESULTS
Of all 100 patients, 86% had no complications,
whereas 14% did (Figure 5). Patients with complicaAngle Orthodontist, Vol 78, No 1, 2008

22

VON BREMEN, SCHAFER, KATER, RUF

Figure 5. Frequency of complications in 100 mandibular midline distraction patients.

Figure 3. Vertical sectioning of the lower two-thirds of the symphysis


with an oscillating blade.

tions included the following: one patient developed


mandibular swelling, and four patients had an instable
screw in the distraction device which rotated back between the activations. Another two patients developed
scar strictures (Figure 6). In three cases the osteotomy
had to be repeated because the symphysis did not
open; one patient developed a mandibular abscess;
and one patient had a gingival recession (Figure 7). In
two cases the root of a lower incisor fractured (Figure
8).
DISCUSSION
In the available literature concerning complications
during mandibular midline distraction in humans, the

Figure 4. Splitting of the mandible with spatula placed between the


incisor roots.
Angle Orthodontist, Vol 78, No 1, 2008

number of subjects was never greater than 24 patients.13 To our knowledge, the present study is the
first to describe 100 consecutively treated patients,
thus providing representative subject material.
The distractors used for all patients of the present
study were tooth-borne, which has the advantage in
that no second surgical approach is necessary to remove the appliance; this at the same time increases
patient acceptance. Furthermore, the risk of tissue inflammation or irritation13 is lower when using toothborne distractors, and they are much less expensive
than the bone-borne titanium appliances.
Of the complications in the present subjects, the
mandibular swelling observed in one patient was most
likely a hematoma, since no signs of inflammation,
such as pain, redness, or fever were present. This can
occur if the muscles of the mouth floor are accidentally
injured when splitting the symphysis.
In 4% of the patients the distraction device screw
was instable and rotated back between activations.

Figure 6. Scar strictures after mandibular midline distraction.

COMPLICATIONS DURING MANDIBULAR DISTRACTION

23

Figure 7. Recession development after mandibular midline distraction

Weil et al14 also reported a failure of the distraction


screw in four out of nine patients. If the failure of the
screw is not recognized early enough, this might lead
to a premature osteosynthesis. In the present subject
material, this was avoided by inserting a little pin to prevent the screw from rotating back anteriorly (Figure 9).
The development of scar strictures (2%) is not a serious complication from the surgical point of view, but
can be annoying for the patient. If the patients find
these strictures disturbing, they can easily be removed, otherwise they can be left in place like an additional frenulum.
In 3% of the total subjects, the osteotomy had to be
repeated due to a premature osteosynthesis. Weil et
al14 also observed this in four of nine patients, although
in these cases this was due to a failure of the distraction screw. For the present subjects, it appears as if
the latency period of 1 week was too long, thus causing the early reossification. Other authors report latency periods of 5 days,13 and it might be speculated that
a shorter latency period might have prevented these
reosteotomies.
An explanation for the mandibular abscess, observed in one of the present subjects, is difficult. Of
course, an infection of some kind is always a possible
complication after any surgical intervention, but normally this should not happen.
In 1% of the cases a gingival recession developed.
Uckan et al13 also observed recessions in four out of
24 patients (16.7%) after the distraction. Other authors
have analyzed the periodontal condition of the lower
anterior teeth after mandibular midline distraction.
Kewitt and Van Sickels15 reported one patient who developed a periodontal pocket of 4 mm with a widened
periodontal ligament, but no crestal bone loss. Furthermore, two of their 15 patients had a Class II mobility of their central incisors following distraction. They
remarked, however, that at the time of evaluation the

Figure 8. Fracture of lower incisor root during mandibular midline


distraction. (A) Fracture line immediately after osteotomy. (B) Separating lower incisor root halves during the distraction period. The
split-off part of the root was removed after the distraction phase.

patients were still in full arch orthodontic appliances.


This on its own, even without previous surgery, can
cause transient widened periodontal ligaments, increased pocket depths, or tooth mobility. The same
phenomenon was also observed by Mommaerts et al16
who found a transient phase of enlarged pocket
depths during the consolidation phase, which had returned to normal values 1 year postoperatively.
In two cases the root of a lower incisor fractured.
Dorfman and Turvey17 suggested having a 35 mm
space between the apices to safely make an osteotAngle Orthodontist, Vol 78, No 1, 2008

VON BREMEN, SCHAFER, KATER, RUF

24

Only 3% of the patients presented irreversible damage.


Mandibular midline distraction appears to be a relatively safe method of expanding the mandible.
REFERENCES

Figure 9. Instable screw: pin inserted in distraction screw to prevent


anterior rotation.

omy. This, of course, is rarely the case in patients with


anterior crowding, which make up the majority of mandibular midline distraction patients. The osteotomy for
the present subjects was performed with an oscillating
saw only in the lower two-thirds of the mandible to
minimize the risk for the roots of the lower incisors.
The possibility that the blade itself traumatized the
roots thus seems unlikely. The roots have to have fractured when the last part of the symphysis was split
open with the spatula. Mommaerts et al16 also observed root damage of one central incisor out of 14
patients undergoing bimaxillary transverse osteodistraction. Due to this complication, the patients described by Mommaerts et al16 needed root canal treatment. In the present subjects, in one case a small lateral part of the root was split off, which was removed
after the distraction phase. Since the damaged tooth
showed no clinical signs of injury (vitality remained,
normal mobility), it was left in situ. In the other case,
the injured incisor had to be extracted, since the root
damage was too severe to perform endodontic treatment.
Of the 14 patients with complications, which was
14% of the total subjects, the two cases with instable
screws and the two with scar strictures can be considered mild complications. Patients who developed an
abscess or swelling of for whom the osteotomy had to
be repeated were catergorized as having serious, but
transient complications. These complications do impair, but they also pass. Therefore, three patients remained with serious and at least somewhat lasting
complications. The recession had already spontaneously improved after new bone had formed, but two
patients had irreversible damage due to a fractured
tooth.
CONCLUSIONS
Complications during or shortly after mandibular
midline distraction surgery are relatively seldom and
mostly mild or transient.
Angle Orthodontist, Vol 78, No 1, 2008

1. Codivilla A. On the means of lengthening, in the lower limbs,


the muscles and tissues which are shortened through deformity. Am J Orthop Surg. 1905;2:353369.
2. Ilizarov GA. The principles of the Ilizarov method. Bull Hosp
Jt Dis Orthop Inst. 1988;48:111.
3. Ilizarov GA. The tension-stress effect on the genesis and
growth of tissues. Part I. The influence of stability of fixation
and soft-tissue preservation. Clin Orthop Relat Res. 1989;
238:249281.
4. Ilizarov GA. The tension-stress effect on the genesis and
growth of tissues. Part II. The influence of the rate and frequency of distraction. Clin Orthop Relat Res. 1989;239:
263285.
5. Ilizarov GA. The possibilities offered by our method for
lengthening various segments in upper and lower limbs. Basic Life Sci. 1988;48:323324.
6. Snyder CC, Levine GA, Swanson HM, Browne EZ Jr. Mandibular lengthening by gradual distraction. Preliminary report. Plast Reconstr Surg. 1973;51:506508.
7. McCarthy JG, Schreiber J, Karp N, Thorne CH, Grayson
BH. Lengthening the human mandible by gradual distraction. Plast Reconstr Surg. 1992;89:18.
8. Guerrero CA. Rapid mandibular expansion. Rev Venez Ortod. 1990;48:12.
9. Little RM, Riedel RA, Stein A. Mandibular arch length increase during the mixed dentition: post retention evaluation
of stability and relapse. Am J Orthod Dentofacial Orthop.
1990;97(5):393404.
10. Contasti G, Guerrero CA, Rodriguez AM, Legan HL. Mandibular widening by distraction osteogenesis. J Clin Orthod.
2001;35(3):165173.
11. Conley R, Legan H. Mandibular symphyseal distraction osteogenesis: diagnosis and treatment planning considerations. Angle Orthod. 2003;73:311.
12. Duran I, Malkoc S, Iseri H, Tunali M, Tosun M, Kucukkolbasi
H. Microscopic evaluation of mandibular symphyseal distraction osteogenesis. Angle Orthod. 2005;76:369374.
13. Uckan S, Guler N, Arman A, Mutlu N. Mandibular midline
distraction using a simple device. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod. 2005;100:E85E91.
14. Weil TS, van Sickels JE, Payne CJ. Distraction osteogenesis for correction of transverse mandibular deficiency: a
preliminary report. J Oral Maxillofac Surg. 1997;55:953
960.
15. Kewitt GF, Van Sickels JE. Long-term effect of mandibular
midline distraction osteogenesis on the status of the temporomandibular joint, teeth, periodontal structures, and neurosensory function. J Oral Maxillofac Surg. 1999;57:1419
1425.
16. Mommaerts MY, Polsbroek R, Santler G, Correia PEGS,
Abeloos JVS, Ali N. Anterior transmandibular osteodistraction: clinical and model observations. J Craniomaxillofac
Surg. 2005;33:318325.
17. Dorfman HS, Turvey TA. Alterations in osseous crestal
height following interdental osteotomies. J Oral Surg. 1979;
48:120125.

Original Article

Occlusal Morphology 1 Year after


Orthodontic and Surgical-Orthodontic Therapy
A Quantitative Analysis of Clinically Successful Patients

Claudia Dellaviaa; Luis Tomas Huanca Ghislanzonib; Redento Perettac


ABSTRACT
Objective: To evaluate morphologic characteristics of occlusion (contact points, contact areas,
and frequency of contact) in clinically successful patients 1 year after orthodontic and surgicalorthodontic therapy followed by passive retention.
Materials and Methods: Twenty-two orthodontic and 18 surgical-orthodontic patients were analyzed. All patients were treated with standard edgewise technique by the same orthodontist. Contact points and areas were evaluated using a new method of digital image analysis of occlusal
impressions. Polivinylsyloxan impressions were taken, scanned, and turned into gray-scale images. The physic relationship of light absorbance through the polivinylsyloxan for known thickness
was calculated to determine contact areas (less than 50 m of thickness) and near contact areas
(less than 350 m of thickness).
Results: The contact area was significantly larger in the orthodontic than in the surgical-orthodontic patients (Students t-test, P .05). The surgical-orthodontic group had significantly fewer
contact points than the orthodontic group only at 150 m of thickness. In both groups of patients,
the first molar had the largest contact surface. Occlusal support was distributed mainly in the
posterior regions with an important role involving the first molars.
Conclusion: Surgical-orthodontic patients appear to have smaller contact surfaces and fewer
contact points than orthodontic patients do. However, there were no differences in the number of
teeth in contact with opposing teeth.
KEY WORDS: Occlusion; Retention; Orthognathic surgery

INTRODUCTION

These objectives can be assessed using Andrewss4


six keys to define the best occlusion when finishing a
case. It is clinically accepted that occlusion control is
transferred from appliances to a patients neuromuscular system at the end of treatment. Unfortunately,
the modality of occlusal assessment is still unknown.
It can be supposed that there is a good integration
between new occlusal morphology and muscular function when occlusion shows stability along time and the
follow-up is negative for TMJ pain. It is of clinical interest to define anatomic parameters to assess the
evolution of each case during the period of occlusal
recovery (1 to 3 years after treatment).
Sullivan et al5 found fewer contact points in postorthodontic patients than in control subjects, with the
number of contacts increasing with time. Further along
in retention, occlusion is a dynamic condition influenced by the natural tendency to relapse, occlusal
forces, the neuromuscular system, and the retention
appliances themselves. Occlusal recovery involves
many factors, and a variation in contact points is re-

Clinical success after orthognathic therapy can be


defined as a combination of six factors: (1) patient
(and patients family) satisfaction, (2) correct occlusal
relationship (one tooth against two), (3) stability 1 year
after treatment, (4) incisal/canine guide with posterior
disclusion in protrusive and lateral movements, (5) patient comfort when chewing, and (6) no pain in the
temporomandibular joint (TMJ).13
a
Research Assistant, Department of Human Morphology,
University of Milan, Milan, Italy.
b
Postgraduate Student (DDS), Department of Human Morphology, University of Milan, Milan, Italy.
c
Postgraduate student (MD, PhD), Department of Human
Morphology, University of Milan, Milan, Italy.
Corresponding author: Dr Claudia Dellavia, Department of
Human Morphology, University of Milan, Via Mangiagalli 31, Milano, Italy 20133 (e-mail: claudia.dellavia@unimi.it)

Accepted: January 2007. Submitted: October 2006.


 2007 by The EH Angle Education and Research Foundation,
Inc.
DOI: 10.2319/103106-448.1

25

Angle Orthodontist, Vol 78, No 1, 2008

26

DELLAVIA, GHISLANZONI, PERETTA

lated to overbite/overjet modifications.6 In conventional


orthodontic treatment, there is a 14% augment in the
number of contact points at 3 months,7 which becomes
56% at 1 year.8
Several methods have been proposed to measure
contact areas. Unfortunately, most of these systems
are operator dependent.9 The polyvinyl-siloxane impression method is virtually operator independent with
great repeatability.10 The material is fluid before setting, thus having nil resistance to mandibular closure
force without modifying the proprioceptive sensation
during clenching. Contact points and surfaces have
been studied by digital image analysis of silicon impression thickness in control subjects and compared
to subjects with malocclusion11 and to postorthodontic
patients.12 In addition, the interpretation of digital data
obtained with the scanning of the impressions, where
described, appears imprecise.11
To date, few data about occlusal morphology in
postsurgical-orthodontic patients are available.13
The objective of the current study is to describe the
characteristics of occlusion in surgical-orthodontic patients compared to conventionally treated orthodontic
patients 1 year after the end of the orthodontic therapy, applying a new method of computing areas and
points of contact and near contact from polyvinyl-siloxane occlusal impressions.

occlusion (mean ANB of ORTHOs 2.2 1.6;


SURGs 2.2 1.3), except for four surgical patients with Class II tendencies.
After treatment, the patients occlusion was stabilized with a Begg plaque in the upper arch and a
spring retainer in the lower arch.
At the first-year recall, patients completed a self-administered questionnaire specifically designed to measure their satisfaction (esthetic appearance, comfort
when chewing, absence of pain in the TMJ). All patients were satisfied. In addition, the orthodontist assessed a correct occlusal relationship (one tooth
against two), incisal/canine guide with back disclusion
in protrusive and lateral movements, and stability 1
year after treatment.
The current measurements were performed at the
first year after the beginning of retention (12 months
after orthodontic treatment completion for both groups,
18 months after surgery for the surgical patients).
All subjects gave their informed consent to the experiment. All procedures were noninvasive and performed with minimal discomfort to the subjects. All occlusal impressions were performed by a single operator. The study protocol was approved by the local
ethics committee.

MATERIALS AND METHODS

Occlufast Rock (Zhermack Inc, Trieste, Italy) silicone-based registrations of occlusion were obtained in
maximum intercuspation. This polyvinyl-siloxane was
chosen because of the ease of dispensing and application, good viscosity, fast setting time (1 minute), detail of impression, and hardness and rigidity once set.
The impression material was injected on the occlusal
plate of all the teeth of the lower arch with a disposable
syringe. Each subject was seated upright in a dental
chair, maintaining the natural head position. Patients
were asked to bite down firmly into maximum intercuspation for 20 seconds and to keep this position with
a light force until the material had set.
An image of each occlusal registration was obtained
with a Hewlett Packard ScanJet 6100C/T scanner
(Palo Alto, Calif). A standard record at known thickness was used to check the same light power for each
scanning. The software program Adobe Photoshop
was used to convert the image into a luminance (grayscale) image and to manually insulate the platform
area of each tooth (Figure 1).
Since the opacity of the material increases proportionally to thickness, calibration step wedges of polyvinyl-siloxane of known thickness were used to establish the relationship between each level of the 256
gray scale and the thickness of the occlusal registration (Table 1; Figure 2). Thickness was measured us-

Forty patients aged 14 to 32 years were analyzed:


22 patients (6 men, 16 women; mean age 20.0
years, SD 6.3, range 1428) were treated with
orthodontic therapy (ORTHOs) and 18 patients (6
men, 12 women; mean age 24.8 years, SD 4.4,
range 1832) were treated with surgical and orthodontic therapy (SURGs).
Before the therapy, the orthodontic group was composed of 4 skeletal Class I malocclusion patients (0
ANB 4), 15 patients with a Class II tendency,
and 3 patients with a Class III tendency. The surgical
group was composed of 3 patients with a Class II tendency and 15 patients with a skeletal Class III malocclusion. In both groups, most of the subjects had a
normal vertical dimension (facial index 60%70%);
only a few cases of open and deep bite were observed.
Surgical patients were treated with combined maxillary Le Fort I and sagittal mandibular osteotomies. All
subjects were treated with a standard edgewise technique by the same orthodontist. The orthodontic therapy ended about 6 months after surgery.
After the completion of the orthodontic treatment,
the vertical dimension showed only a minimal variation, while all patients finished with a skeletal Class I
Angle Orthodontist, Vol 78, No 1, 2008

Estimation of Occlusal Contact Areas and Points

27

MORPHOLOGICAL OCCLUSION IN POSTORTHODONTIC PATIENTS

Figure 1. Scanned image of the occlusal registration (mandibular


surface facing downward) in one orthodontic patient. On the left side
is an example of manual insulation of each single tooth.

ing a diabase control plane with comparator. The


mean error was 20 m. The calibration step wedges
were scanned and analyzed with Image Pro Plus software (Media Cybernetics Inc, Silver Spring, Md). A
gray-scale value according to the pixel density was
obtained (ie, the thickness of the sample). Using a
physical theoretical approach to the phenomenon of
light absorbance through a material, we defined an
equation that fit with our data as
y 455,614e (0,000993x) x0,19099
where x is the value of thickness in micrometers and
y the luminosity in gray-scale values.
According to previous studies with silicone impressions,10,14 actual contacts were defined as areas of
contact with a thickness at or below 50 m, and near
contacts were defined as those with a thickness at or
below 350 m. Contact areas and points were considered at 50, 150, 250, and 350 m after calculating the
gray-scale equivalent of the threshold thickness.
In addition, the frequency of contact was computed
evaluating the presence of at least one contact point
on each tooth.
An asymmetry index for contact areas and points
was calculated according to the following formula:
Table 1. Thickness and Luminosity With Error Measures (Range
and SD) for Each Calibration Step Wedge
Step
Wedge,
n

Thickness,
m

Range

Luminosity,
GSa

SD

1
2
3
4
5
6
7
8

50
90
120
170
250
270
320
600

2070
70110
100140
160200
210300
240300
290360
570630

208.2
174.8
156.7
141.2
125.2
120.5
110.3
73.0

11.9
13.6
11.7
9.3
4.3
9.0
3.9
5.9

GS indicates gray-scale value.

Figure 2. Relation between thickness in m (x) and luminosity in


gray scale (y).

Asymmetry Index

right side left side


100
right side left side

The absolute values of the asymmetry index were also


used to avoid right- or left-side prevalence. For each
patient, the relative weight of every tooth/group of
teeth contact area was balanced on the total area. The
same procedure was performed for the number of contact points.
The repeatability of the procedure (impression,
scanning, and manual insulation of single teeth) was
tested, repeating the examination 4 times in 6 control
subjects. A good repeatability was assessed, as the
mean coefficient of variation was 2.3% (range, 0.6%
5.1%) for contact areas and 4.8% for contact points,
(range, 1.2%8.4%).
Statistical Analyses
For each subject, the area and number of contacts
for each tooth were computed. The skewness and kurtosis showed that the total area and the number of
contacts were normally distributed within each group.
Descriptive statistics (mean, standard deviation, and
coefficient of variation) were calculated for each variable (age, contact area, and points).
The mean values of each variable were compared
in the two groups of patients using a Students t-test
for independent samples. Comparisons between
groups were computed by a two-way factorial analysis
of variance (ANOVA) test to evaluate the effect of therapy (factor 1) and the location of the teeth in the arch
(eg, anterior/posterior; factor 2). The interaction beAngle Orthodontist, Vol 78, No 1, 2008

28

DELLAVIA, GHISLANZONI, PERETTA

Table 2. Contact Area and Points in the Orthodontic and Surgical-Orthodontic Patients
Orthodontic (n 22)

Surgical-Orthodontic (n 18)

SD

CV, %

SD

CV, %

Students
t-Test

Area, mm2
50 m
150 m
250 m
350 m

15.3
42.6
74.7
99.4

9.2
19.8
28.1
33.4

60
45
38
33

6.9
28.3
54.2
75.0

3.1
13.7
24.6
31.9

49
47
45
42

***
*
*
*

Points (n)
50 m
150 m
250 m
350 m

21.3
26.8
27.3
26.0

9.1
6.0
5.1
4.3

43
23
19
16

17.2
22.2
24.6
24.3

6.3
6.3
6.0
5.7

36
27
25
21

nsa
*
ns
ns

Measurement

a
ns indicates not significant.
* P .05; ** P .01; *** P .001.

tween the two factors was also computed. A 2 test


was used to compare the gender distribution and the
frequency of contact of each tooth and group of teeth
between the two groups of patients.
A correlation coefficient was computed to assess
the influence of age on contact areas and points. For
all analyses, the level of significance was set at 5% (P
.05).
RESULTS
Significant age differences were found between the
two groups of patients. The ORTHOs were younger
than the SURGs (Students t-test, P .05). No difference in gender distribution was found between the two
groups (2 test). Within each group, no significant effect of age was found on contact areas and points
(correlation coefficient, P .05).
Table 2 reports the mean area and points of contact
(50 m) and near contact at 350 m and at intermediate thickness. There was a great intragroup variability, with the coefficient of variation ranging from
33% to 60% for the areas and 16% to 43% for the
number of points. The ORTHOs contact area was significantly larger than the SURGs area at all levels
(Students t-test, P .05; Figure 3). The contact points
were significantly different only at 150-m thickness
(P .05).
The mean values of area and contact points separately for each tooth are reported in Table 3. The mandibular first molar had the largest contact area in both
groups and the highest number of contact points in the
ORTHOs.
Differences between the contact area and points on
the right and left sides were not statistically significant
for the overall patients nor for the two groups (Students t-test). For the overall patients, the mean index
of asymmetry was 3% for areas (SD 29%) and
1% for points (SD 22%). The mean absolute valAngle Orthodontist, Vol 78, No 1, 2008

ues of the index were 24% for areas (SD 17%) and
16% for points (SD 15%).
In the observed patients, 390 of the 556 (70%) analyzed mandibular teeth (two patients had their first
premolars extracted) were in contact with their maxillary opponents: a mean of 9.8 mandibular teeth were
in contact with their opponents (SD 2.6). There were
no differences between the two groups. Of the 390
teeth in contact, 196 contacts occurred on the right
side and 194 on the left side. The anterior teeth (incisors and canines) were in contact in 45% of the ORTHOs (60 of 132) and in 52% of the SURGs (56 of
114). The posterior teeth (premolars and molars) were
in contact in 88% of the ORTHOs (152 of 172) and in
85% of the SURGs (122 of 152). On average, the teeth
with the highest frequency of contact were the first molar (95% ORTHOs; 100% SURGs) and the second
molar (98% ORTHOs; 89% SURGs). There were no
significant differences between the two groups in the
frequency of contact of single (Table 3) or grouped
(anterior, posterior) teeth (2 test).
The contact area and points relative weight per
group of teeth in the ORTHOs and in the SURGs are
listed in Table 4. Between the two groups of patients,
no differences were found in the distribution of contact

Figure 3. Mean contact area of each single tooth in orthodontic (ORTHOs) and surgical-orthodontic patients (SURGs). On the x-axis are
the mandibular teeth; on the y-axis is the contact area (thickness
50 m) in mm2.

29

MORPHOLOGICAL OCCLUSION IN POSTORTHODONTIC PATIENTS


Table 3. Mean Area, Points, and Frequency of Contact for Each Mandibular Tooth in the Two Groups of Patients
Orthodontic (n 22)

Surgical-Orthodontic (n 18)

Tooth

Area, mm2

Points

Frequency, %a

Area, mm2

Points

Frequency, %a

Central incisor
Lateral incisor
Canine
First premolar
Second premolar
First molar
Second molar

0.3
0.2
0.4
0.6
0.8
3.6
2.7

1.0
1.2
1.3
1.3
2.1
3.8
2.8

25
43
68
75
84
95
98

0.2
0.2
0.2
0.3
0.4
1.4
1.4

1.1
1.5
1.0
1.2
1.5
2.5
2.7

44
39
72
72
78
100
89

Frequency, % indicates the frequency of presence in contact.

area and number of contact points relative weights; in


addition, the interaction between the two factors was
not significant (ANOVA two-way test). No effect of the
location of the teeth in the arch (anterior and posterior
teeth) was found, and the interaction of the location
factor with the therapy factor was not significant.
DISCUSSION
The photo-occlusion technique is operator independent. It is a computerized, semiautomatic image analysis system that recognizes the occlusal contacts and
near contacts according to a threshold thickness/luminosity previously identified. In the present investigation, the silicon was preferred to other materials
since it appeared to be the most precise, repeatable,
and operator-independent material to examine occlusal morphology.9,11 A pilot study was conducted so that
the operator could become familiar with the experimental procedure. The current protocol was similar to
the one defined by Owens et al,11 but the calibration
curve describing the intensity of light expressed in gray
scale was more accurate for thicknesses greater than
50 m. The present curve represents an optimal approximation of light behavior through the impression
material for values of thickness (larger than 50 m)
concerning contact and near-contact points. These
concerns minimized bias.
Table 4. Contact Area and Points Relative Weight (in Percentages) per Group of Teeth (Balanced on Total Area/Points) in the Two
Groups of Patients
Orthodontic
(n 22)

Surgical-Orthodontic
(n 18)

Teeth
Group

Area %

Points %

Area %

Points %

Incisors
Canines
Premolars
Molars
Anteriorsa
Posteriorsb

6
5
17
72
12
88

16
9
25
50
25
75

9
5
17
68
15
85

22
9
23
46
32
68

a
b

Incisors and canines.


Premolars and molars.

In the present study, the orthodontic patients were


significantly younger than the surgical ones. All of the
ORTHOs underwent therapy after the pubertal growth
peak, in the last phase of growth, while the SURGs
can be definitely considered an adult sample. The age
difference is due to the necessity of growth ending before performing surgical treatment. The influence of
age cannot be excluded in occlusal recovery independent from the therapy. Most investigations refer to adolescent subjects, which allows us to compare our orthodontic group with results of previous studies.12,15
Nevertheless, contact and near-contact surfaces at 50
and 350 m were independent from gender and age
in accordance with Gurdsapsri et al.10
Previous studies16,17 found 7 to 12 contact points for
hemimandibles in healthy subjects. Similarly, 9.7
4.1 contact points for hemimandibles were found in the
present work. Dincer et al12 compared 20 untreated
subjects with 20 orthodontic patients after 9 months of
retention. They found no differences in the number of
contact points between patients and controls. The current data in the orthodontic group were comparable
with these findings12 and led us to investigate weather
the occlusion in surgical-orthodontic patients at the
end of treatment is comparable with occlusion of pure
orthodontic patients.
The mean contact area appears to be related to the
therapy. The ORTHOs contact area and near-contact
area are significantly larger than the SURGs values.
A possible explanation of these results could be the
change of chewing habits of all patients undergoing
surgical treatment. After surgery, patients report a certain difficulty when grinding food and a discomfort
when biting hard foods, such as bread and carrots.
This sensation improves with time, until disappearing
1 to 2 years after surgery. Masticatory efficiency measured with standard sieve techniques in surgical patients was found to be lower than in control subjects.18
The postsurgical functional situation was generally
better than the presurgical one. The masticatory cycles were less variable, showing a higher stability of
occlusion.19,20 Other investigations found a relation beAngle Orthodontist, Vol 78, No 1, 2008

30
tween chewing efficiency/number of teeth in contact
and area of near contact.21 The smaller area and the
fewer contact points observed in the SURGs than in
the ORTHOs could be explained by the lower dynamic
stimulus to mastication of surgical patients during the
occlusal recovery period. Since considerable change
in bite force, which is not primarily related to jaw movement, occurs after orthognathic surgery, 22 these
changes may explain a significant proportion of the
differences between the groups in the number and
size of contact areas. This factor in conjunction with
the inherent compressibility of the periodontal ligament
may explain the differences observed when the teeth
were held in occlusion. Furthermore, the lack of any
way of standardizing the occlusal force may also have
influenced the findings.
Nevertheless, an increased number of contacts in
postsurgical-orthodontic patients 6 months after surgery was reported by Athanasiou.13 In the current
work, patients were evaluated 18 months after surgery, and at this time, their recovery period may be
not concluded yet.
The absolute values of the asymmetry index found
for the area and the number of contact points indicate
a certain degree of individual asymmetry, in accordance with the work of McDevitt and Warreth.6
The absence of contact between the upper and lower anterior teeth occurred in 53% of the analyzed patients. Similar findings in young control subjects were
reported by McNamara and Henry (40%).15 A 15% lack
of contact was observed among the posterior teeth of
the analyzed subjects. Possible explanations could be
the straightening of the curve of Spee, the augment of
the upper curve, and the overtreatment of overbite/
overjet.
The higher frequency of contact of the central incisor
in SURGs than in ORTHOs may be accounted for by
the total horizontal anterior relapse and postoperative
counterclockwise rotation of the mandible observed in
surgical Class III patients (most SURGs) after bilateral
sagittal split osteotomy.23
The number of contacts on first molars in the ORTHOs is comparable to the findings of Dincer et al12 in
normal subjects. Molars are the teeth more frequently
in contact with their opponents, which underlines their
role in keeping occlusal stability. Further studies in
larger samples are needed to define the morphologic
occlusal changes in orthodontic and surgical-orthodontic patients after 1 year of retention.
Although there were differences between the groups
in terms of the size and number of contacts, there
were no differences in the number of teeth in contact
with opposing teeth. Furthermore, there were no differences in the frequency of contacting teeth when this
was further analyzed by grouped teeth (anterior or
Angle Orthodontist, Vol 78, No 1, 2008

DELLAVIA, GHISLANZONI, PERETTA

posterior). The way the orthodontists finish cases, in


accordance to the literature,24 is probably what determines the number of teeth in contact with their opponents. In contrast, the size and number of contacts
could be related to the neuromuscular system recovery peculiar of each patient.
CONCLUSIONS
The analyzed surgical-orthodontic patients had
smaller contact surfaces and fewer contact points
than orthodontic patients did.
There were no differences in the number of teeth in
contact with opposing teeth.
REFERENCES
1. Mascarenhas AK, Vig K, Joo BH. Parents satisfaction with
their childs orthodontic care: a comparison of orthodontists
and pediatric dentists. Pediatr Dent. 2005;27:451456.
2. Mahony D. Refining occlusion with muscle balance to enhance long-term orthodontic stability. Gen Dent. 2005;53:
111115.
3. Clark JR, Evans RD. Functional occlusion: I. A review. J
Orthod. 2001;28:7681.
4. Andrews LF. The six keys to normal occlusion. Am J Orthod. 1972;62:296309.
5. Sullivan B, Freer TJ, Vautin D, Basford KE. Occlusal contacts: comparison of orthodontic patients, post-treatment
patients, and untreated controls. J Prosthet Dent. 1991;65:
232237.
6. McDevitt WE, Warreth AA. Occlusal contacts in maximum
intercuspation in normal dentitions. J Oral Rehabil. 1997;24:
725734.
7. Durbin DS, Sadowsky C. Changes in tooth contacts following orthodontic treatment. Am J Orthod Dentofacial Orthop.
1986;90:375382.
8. Gazit E, Lieberman MA. Occlusal contacts following orthodontic treatment: measured by a photocclusion technique.
Angle Orthod. 1985;55:316320.
9. Millstein P, Maya A. An evaluation of occlusal contact marking indicators: a descriptive quantitative method. J Am Dent
Assoc. 2001;132:12801286.
10. Gurdsapsri W, Ai M, Baba K, Fueki K. Influence of clenching
level on intercuspal contact area in various regions of the
dental arch. J Oral Rehabil. 2000;27:239244.
11. Owens S, Buschang PH, Throckmorton GS, Palmer L, English J. Masticatory performance and areas of occlusal contact and near contact in subjects with normal occlusion and
malocclusion. Am J Orthod Dentofacial Orthop. 2002;121:
602609.
12. Dincer M, Meral O, Tumer N. The investigation of occlusal
contacts during the retention period. Angle Orthod. 2003;
73:640646.
13. Athanasiou AE. Number and intensity of occlusal contacts
following surgical correction of mandibular prognathism. J
Oral Rehabil. 1992;19:145150.
14. Sakaguchi RL, Anderson GC, DeLong R. Digital imaging of
occlusal contacts in the intercuspal position. J Prosthodont.
1994;3:193197.
15. McNamara DC, Henry PJ. Terminal hinge contact in dentitions. J Prosthet Dent. 1974;32:405411.
16. Korioth TW. Number and location of occlusal contacts in
intercuspal position. J Prosthet Dent. 1990;64:206210.

MORPHOLOGICAL OCCLUSION IN POSTORTHODONTIC PATIENTS

17. Athanasiou AE, Melsen B, Kimmel P. Occlusal tooth contacts in natural normal adult dentition in centric occlusion
studied by photocclusion technique. Scand J Dent Res.
1989;97:439445.
18. Iwase M, Sugimori M, Kurachi Y, Nagumo M. Changes in
bite force and occlusal contacts in patients treated for mandibular prognathism by orthognathic surgery. J Oral Maxillofac Surg. 1998;56:850856.
19. Kobayashi T, Honma K, Shingaki S, Nakajima T. Changes
in masticatory function after orthognathic treatment in patients with mandibular prognathism. Br J Oral Maxillofac
Surg. 2001;39:260265.
20. Youssef RE, Throckmorton GS, Ellis E III, Sinn DP. Com-

31
parison of habitual masticatory cycles and muscle activity
before and after orthognathic surgery. J Oral Maxillofac
Surg. 1997;55:699708.
21. Julien KC, Buschang PH, Throckmorton GS, Dechow PC.
Normal masticatory performance in young adults and children. Arch Oral Biol. 1996;41:6975.
22. Proffit WR, Turvey TA, Fields HW, Phillips C. The effect of
orthognathic surgery on occlusal force. J Oral Maxillofac
Surg. 1989;47:457463.
23. Politi M, Costa F, Cian R, Polini F, Robiony M. Stability of
skeletal Class III malocclusion after combined maxillary and
mandibular procedures: rigid internal fixation versus wire
osteosynthesis of the mandible. J Oral Maxillofac Surg.
2004;62:169181.

Angle Orthodontist, Vol 78, No 1, 2008

Original Article

Mandibular Asymmetry in Class II Subdivision Malocclusion


Gokmen Kurta; Tancan Uysalb; Yildiray Sismanc; Sabri Ilhan Ramoglud
ABSTRACT
Objective: To evaluate the condylar and ramal mandibular asymmetry in a group of patients with
Class II subdivision malocclusion to identify possible gender differences between male and female
subjects.
Materials and Methods: Mandibular asymmetry measurements (condylar, ramal, and condylarplus-ramal asymmetry values) were performed on the panoramic radiographs of 80 subjects (34
male and 46 female). The study group consisted of 40 Class II subdivision patients (18 male and
22 female; mean age 14.53 3.14 years). The control group consisted of 40 subjects with normal
occlusion (16 male and 24 female; mean age 14.43 3.05 years). The Kruskal-Wallis test was
used to determine the possible statistically significant differences between the groups for condylar,
ramal, and condylar-plus-ramal asymmetry index measurements. Identified differences between
groups were further analyzed using the Mann-Whitney U-test at the 95% confidence interval (P
.05).
Results: No gender-related difference was found for any of the asymmetry indices. Comparison
of condylar, ramal, and condylar-plus-ramal asymmetry index values and gonial angle measurements for Class I and Class II sides in the Class II subdivision group and for right and left sides
in the Class I group showed no statistically significant differences. However, the Class II subdivision group has longer values for condylar, ramal, and condylar-plus-ramal height measurements
and only these differences were statistically significant (P .001).
Conclusions: Except for condylar ramal and condylar-plus-ramal height measurements, Class II
subdivision patients have symmetrical condyles when compared to normal occlusion samples
according to Habbets mandibular asymmetry indices.
KEY WORDS: Condylar asymmetry; Class II subdivison; Mandibular asymmetry; Orthopantomograph

INTRODUCTION

eruption of the mandibular first molars in relation to


normally positioned maxillary first molars.2
Asymmetry in the face and dentition is a naturally
occurring phenomenon. Before planning orthodontic
treatment to correct subdivision problems, the origin of
the asymmetry must be identified. The treatment of
Class II malocclusions characterized by dentoalveolar
asymmetries presents difficulties for clinicians because of the determination of the source of the malocclusion. A question arises as to whether subdivision
malocclusions caused by dentoalveolar or skeletal deviations or any compromise treatment plans lead to
additional complications, such as tipping of the occlusal plane, dental instability, or temporomandibular disharmonies.3
Alavi et al4 showed that the unilateral distal positioning of the mandibular first molars was the primary contributor to an anteroposterior discrepancy in this type
of malocclusion, but they did not define that the mandibular molar position was due to a skeletal asymmetry

Unilateral Class II cases were classified as subdivision cases by Angle.1 He reported that a Class II
molar relationship developed because of the distal
a
Assistant Professor, Department of Orthodontics, Faculty of
Dentistry, Erciyes University, Kayseri, Turkey.
b
Associate Professor and Chair, Department of Orthodontics,
Faculty of Dentistry, Erciyes University, Kayseri, Turkey.
c
Assistant Professor and Chair, Department of Oral Diagnosis and Radiology, Faculty of Dentistry, Erciyes University, Kayseri, Turkey.
d
Research Assistant, Department of Orthodontics, Faculty of
Dentistry, Selcuk University, Konya, Turkey.
niversitesi
Corresponding author: Dr Tancan Uysal, Erciyes U
Dishekimligi Fakultesi, Ortodonti A.D. Melikgazi, Kampus Kayseri, 38039 Turkey
(e-mail: tancanuysal@yahoo.com)

Accepted: March 2007. Submitted: February 2007.


 2007 by The EH Angle Education and Research Foundation,
Inc.
Angle Orthodontist, Vol 78, No 1, 2008

32

DOI: 10.2319/021507-73R

33

CONDYLAR ASYMMETRY IN CLASS II SUBDIVISION


Table 1. Mean and Standard Deviation of Chronogical Ages and ANB for Each Groupa
Age, Years
Groups
Normal occlusion

Class II subdivision

ANB, Degree

Gender

Mean

SD

Mean

SD

Male
Female
Total
Male
Female
Total

16
24
40
18
22
40

13.38
15.13
14.43
14.67
14.41
14.53

2.31
3.33
3.05
3.24
3.13
3.14

2.42
2.20
2.29
3.77
3.95
3.87

1.14
1.03
1.06
2.95
2.46
2.66

N indicates sample size; SD, standard deviation.

or a dentoalveolar asymmetry. Rose et al5 concluded


that the mandible in Class II subdivision malocclusions
did not exhibit unusual skeletal positioning or skeletal
asymmetry. Only the mandibular dentition was found
to be asymmetric, resulting in a relative distal positioning of the lower first molar on the Class II side. Janson
et al6 found similar findings with Rose et al5 indicating
that mandibles showed no unusual skeletal or positional asymmetries. In a recent study, Azevedo et al7
found results similar to those of Janson et al.6 However, in another study, Janson et al8 found that there
was a tendency for mandibular asymmetry in subgroups of Class II subdivision subjects compared with
the control group.
Habets et al9 described a method for evaluating condylar and ramal asymmetry. This method has been
used to calculate the condylar and ramal heights for
comparing the right and left sides of the mandible for
asymmetries in temporomandibular disorder (TMD)
patients, Class I, Class II, and Class III malocclusions,
bilateral posterior crossbites, and different skeletal patterns.918
A review of the literature revealed no studies that
measured the condylar and ramal asymmetry of Class
II subdivision patients and compared it with that of normal subjects using the method described by Habets et
al.9
Therefore, the objectives of this study were to determine the condylar and ramal mandibular asymmetry
in a group of patients with Class II subdivision malocclusion and compare these data with similar measurements from a sample with normal occlusion. The
intent is to identify possible gender differences between male and female subjects.
MATERIALS AND METHODS
Two groups were selected from the archives of the
Erciyes University, Faculty of Dentistry and Department of Orthodontics. The present study was performed on orthopantomograms (OPG) of 40 normal
occlusion and 40 Class II subdivision malocclusion
subjects. The distributions of age and ANB in different
groups for all subjects are shown in Table 1.

Normal Occlusion Sample


The OPGs of the 40 adolescent control subjects (16
male and 24 female) with normal occlusion met the
following criteria19:
Class I canine and molar relationship with minor or
no crowding; normal growth and development; wellaligned upper and lower dental arches;
All teeth present except third molars;
Good facial symmetry determined clinically;
No significant medical history;
No history of trauma, or any previous orthodontic,
prosthodontic treatment, maxillofacial or plastic surgery.
Class II Subdivision Sample
The OPGs of the 40 subjects (18 male and 22 female) with Class II subdivision malocclusion were selected from patient records and met the following criteria7:
A complete Class I molar relationship on one side
of the dental arch with a full Class II relationship on
the other side;
No previous orthodontic treatment;
No lateral mandibular shift during closure, as determined by clinical examination;
No history of facial trauma or medical conditions that
could have altered the growth of the apical bases;
The absence of any severely malaligned or blocked
out teeth.
Intraoral photographs and plaster models were used
to classify the patients according to their malocclusion.
These subjects were also evaluated with clinical histories and examinations. These were selected in clinical evaluations by three examiners.
Since OPGs are routinely used as a screening procedure in this clinic, all subjects had films available for
review. These radiographs were exposed with Orthopantomography OP100 (Tuusula, Finland) which had
been standardized previously. All were taken in standard manner by the same operator. The subjects were
Angle Orthodontist, Vol 78, No 1, 2008

34

KURT, UYSAL, SISMAN, RAMOGLU

Figure 1. Measuring method according to Habets et al.9

positioned with the lips in rest position and the head


oriented to the Frankfort horizontal plane.7
All the films were traced and measured by the same
author (YS). The outline of the condyle, the ascending
ramus, and corpus of both sides were traced on acetate paper. On the tracing paper, A-line was drawn
between the most lateral points of the condylar image
(O1) and of the ascending ramus image (O2) (Figure
1). To the A-line (the ramus tangent) from the most
superior point of the condylar image, a perpendicular
B-line was drawn. The vertical distance from B-line on
the ramus tangent to the O1 projected on the ramus
tangent was measured. This distance was called the
condylar height (CH). The distance between the O1
and O2 was called the ramus height (RH). A C-line was
constructed as a tangent on corpus mandible of each
side, and the angle between A-line and C-line was
measured as the gonial angle (Figure 1). To measure
the condylar, ramal, and condylar-plus-ramal asymmetry, the following formula was used:
Asymmetry index

CHright CHleft
100
CHright CHleft

Angle Orthodontist, Vol 78, No 1, 2008

Statistical Analysis
Four weeks after the first measurements, 20 randomly selected OPGs were remeasured. A pairedsamples t-test was applied to the measurements. The
difference between the first and second measurements of the 20 radiograms was insignificant. Correlation analysis yielded the highest r value, 0.995, for
right gonial angle measurement and the lowest r value,
0.878, for left condylar height measurements. The
method error was calculated by using Dahlbergs formula. Values ranged from 0.399 to 0.974 and were
within acceptable limits.
All statistical analyses were performed using the
SPSS software package (Statistical Package for Social Sciences for Windows, version 10.1, SPSS Inc,
Chicago, Ill). Descriptive statistics were computed.
The Kruskal-Wallis test was used to determine the
possible statistically significant differences between
the groups for condylar, ramal, and condylar-plus-ramal asymmetry index measurements. Identified differences between groups were further analyzed using

35

CONDYLAR ASYMMETRY IN CLASS II SUBDIVISION


Table 2. Statistical Side Comparisons of Normal Occlusion Sample and Class II Subdivision Patientsa
Class I Group
Right Side

Subdivision Group
Left Side

Class I Side

Class II Side

Variable

Mean

SD

Mean

SD

Test

Mean

SD

Mean

SD

Test

CH
RH
CH RH
Gonial angle

5.16
34.28
39.44
125.80

1.27
3.65
3.83
7.78

4.99
33.61
38.60
126.18

1.21
3.94
3.91
7.23

NS
NS
NS
NS

5.83
41.55
47.36
124.84

1.62
7.66
7.93
6.55

6.24
41.04
47.29
125.04

1.68
7.72
8.31
6.26

NS
NS
NS
NS

SD indicates standard deviation; NS, not significant.

Table 3. Statistical Comparisons of All Asymmetry Measurements Between Class II Subdivision Patients and Normal Occlusion Samplea
Class I Group

Class II Subdivision Group

Variable

Mean

SD

Min

Max

Mean

SD

Min

Max

Test

CH
RH
CH RH
Gonial angle
CH index
RH index
CH RH index

7.66
51.09
58.74
188.89
7.57
2.52
2.06

1.74
5.43
5.65
11.01
8.39
2.29
1.50

5.25
37.50
45.00
166.75
0.00
0.00
0.00

12.50
64.50
72.00
212.00
38.46
8.11
5.41

9.16
61.91
71.07
187.55
11.56
2.67
2.63

1.98
11.33
11.81
9.13
10.75
2.41
2.17

5.25
42.75
53.75
170.75
0.00
0.00
0.00

13.00
85.25
95.50
207.75
41.67
11.90
10.56

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

SD indicates standard deviation; Min, minimum; Max, maximum; NS, not significant.
*** P .001.

the Mann-Whitney U-test at the 95% confidence interval (P .05).


RESULTS
According to the Mann-Whitney U-test, no genderrelated difference was found for any vertical height, for
the gonial angle, and for any of the asymmetry indices
in intragroup comparisons. Therefore, data for both
genders were pooled.
Comparison of condylar, ramal, and condylar-plusramal measurements and gonial angle for Class I and
Class II sides in the Class II subdivision group and for
right and left sides in the Class I group did not show
any statistically significant differences (Table 2).
Descriptive statistics (mean, standard deviation,
minimum, and maximum) and statistical comparisons
of variables between normal occlusion and Class II
subdivision groups are shown in Table 3. The statistical analysis showed that asymmetry measurements
were affected by the investigated occlusion type. Condylar, ramal, and condylar-plus-ramal height measurements showed statistically significant differences (P
.001) between groups. However, gonial angle and index measurements did not show any statistically significant differences.
DISCUSSION
OPG has been used for the assessment of side-toside height differences and the measurement of con-

dylar, ramal, and total heights to define side-to-side


asymmetries.918 Bilateral views of the mandible can
be obtained with OPG, and vertical measurements can
be achieved.20 The use of panoramic radiographs to
evaluate side-to-side differences is questionable, but
a number of studies have been made that supported
the use of the panoramic technique.9,10,21 These reports suggested that acceptable results can be
achieved with panoramic radiographs which are noninvasive, have a favorable cost-benefit relationship,
and expose subjects to relatively low doses of radiation.22
Studies2324 have shown the posteroanterior cephalometric (PA) film to have some limitations of methodology and reliability. The submental vertex (SMV)
view has been suggested2526 as a better alternative
for the cephalometric assessment of asymmetry. However, the SMV is capable of significant distortion,23,27
especially in the analysis of mandibular asymmetry,
since the mandible is positioned farthest from the film
plane. While still useful in comparative research studies of asymmetry, both PA and SMV roentgenograms
may have limited value in orthodontic diagnosis and
treatment planning for the individual.28 In a recent
study, Kambylafkas et al22 showed that OPGs could
be used to assess vertical posterior mandibular asymmetries.
The reproducibility of vertical and angular measurements on OPG is acceptable if the patients head is
positioned properly in the equipment.17,29,30 Habets et
Angle Orthodontist, Vol 78, No 1, 2008

36
al10 concluded that the headholder must be fixed well
to the orthopantomograph, and the head has to be well
centered in the headholder of the orthopantomograph
when a clinical orthopantomograph is to be evaluated.
In this study, all the films were taken in ideal conditions
and inadequate or poor quality films were excluded.
Studies of the etiology of condylar asymmetries in
which gender differences have been investigated also
revealed no statistically significant differences.9,15 In
this study, no gender related statistically significant differences were found between compared sides and investigated groups. These findings support the studies
of Habets et al,9 Kiki et al17 and Sezgin et al18 that used
the same method described in the present study.
Condylar, ramal, and condylar-plus-ramal height
values were higher in the Class II subdivision group
than the normal occlusion group, and the differences
were statistically significant (P .001). In the literature,9,17,18 all investigations were carried out on only
condylar, ramal, and condylar-plus-ramal asymmetry
index, and there is no study that evaluated the posterior vertical heights with the method used in this
study, so that our findings could not be compared.
However, the measurements done in different studies
regarding the ramus length showed that vertical measurements in ramus have higher values in Class II
subdivision patients compared with normal occlusion
patients.6,7
The method described by Habets et al9 has been
used for evaluating condylar and ramal asymmetries
in TMD patients and in different malocclusions.918 Habets et al10 found that asymmetry index values greater
than 3% must be taken into consideration as vertical
asymmetries because of technical errors during film
exposure. In this study, in Class II subdivision and
control groups, condylar asymmetry indexes were
found above 3% (11.56 10.75% and 7.57 8.39%,
respectively) indicating asymmetry, but the difference
was statistically insignificant.
Other studies evaluating condylar asymmetry with
this method in different malocclusions and in TMD patients also found asymmetry values greater than 3%
both in study and control groups.1216 These high values indicating asymmetry both in experimental and
control groups can be attributed to shape, angular and
positional differences between right and left condyles
without any pathology or without any related malocclusion.31 Cohlmia et al32 found that left condyle was positioned more anteriorly than the right condyle and
Yale31 showed the shape and angular differences of
condyles. On the other hand, Kambylafkas et al22 stated in a recent study that condylar height was unreliable when determining asymmetry from the panoramic
radiograph because of the small dimension of the
Angle Orthodontist, Vol 78, No 1, 2008

KURT, UYSAL, SISMAN, RAMOGLU

measurement and operator error in tracing and identifying landmarks.


Gonial angle, ramal index, and condylar-plus-ramal
index measurements used for evaluating posterior vertical dimensions of the mandible were found similar
between the two groups and any differences were statistically insignificant. The findings of our study support
the other studies that concluded the mandible in Class
II subdivision malocclusions does not exhibit unusual
skeletal positioning or skeletal asymmetry.47 In the
present study, no dentoalveolar measurements were
done, but the absence of any vertical asymmetry in
the vertical posterior heights of the mandible supports
the idea that the contributing factor of asymmetrical
anteroposterior molar relationship on the Class II side
is mainly dentoalveolar. Azevedo et al7 compared the
degree of skeletal asymmetry between subjects with
Class II subdivision malocclusion and subjects with
normal occlusion. They reported that the main component of the Class II subdivision is dentoalveolar, primarily distal positioning of the first mandibular molar
on the Class II side and secondarily mesial positioning
of the maxillary molar on the same side even though
the patients had apparent facial asymmetry.
In the absence of moderate to severe skeletal asymmetries in Class II subdivision patients, dentoalvoelar
treatment approaches must be taken into consideration. Janson et al33 suggested three premolar asymmetric extraction treatments in Class II subdivision patients. This treatment protocol can yield to shorter
treatment time than four premolar extractions and
tends to correct midline deviations due to asymmetric
molar relationship with minimum incisor retraction
more successfully.3 In the existence of moderate to
severe skeletal asymmetries, ie, hemifacial microsomia patients, more diagnosis is needed for understanding the source of the problem. Dental compensation treatment options can be evaluated in the correction of Class II subdivision patients if no skeletal
asymmetry exists.
CONCLUSIONS
Ramal index, condylar-plus-ramal index, and gonial
angle measurements representing posterior vertical
mandibular heights were similar between the two
groups.
Condylar asymmetry index values in the Class II
subdivision group and the normal occlusion group
were not statistically significantly different. This indicates that the mandibles in Class II subdivision
malocclusions do not exhibit unusual skeletal positioning or skeletal asymmetry.
REFERENCES
1. Angle EH. Classification of malocclusion. Dental Cosmos.
1899;41:248264.

CONDYLAR ASYMMETRY IN CLASS II SUBDIVISION

2. Wertz RA. Diagnosis and treatment planning of unilateral


Class II malocclusions. Angle Orthod. 1975;45:8594.
3. Turpin DL. Correcting the Class II subdivision malocclusion,
Commentary. Am J Orthod Dentofacial Orthop. 2005;128:
555556.
4. Alavi DG, BeGole EA, Schneider BJ. Facial and dental arch
asymmetries in Class II subdivision malocclusion. Am J Orthod Dentofacial Orthop. 1988;93:3846.
5. Rose JM, Sadowsky C, BeGole EA, Moles R. Mandibular
skeletal and dental asymmetry in Class II subdivision malocclusions. Am J Orthod Dentofacial Orthop. 1994;105:
489495.
6. Janson GR, Metaxas A, Woodside DG, de Freitas MR, Pinzan A. Three-dimensional evaluation of skeletal and dental
asymmetries in Class II subdivision malocclusions. Am J
Orthod Dentofacial Orthop. 2001;119:406418.
7. Azevedo AR, Janson G, Henriques JF, Freitas MR. Evaluation of asymmetries between subjects with Class II subdivision and apparent facial asymmetry and those with normal occlusion. Am J Orthod Dentofacial Orthop. 2006;129:
376383.
8. Janson G, de Lima KJ, Woodside DG, Metaxas A, de Freitas MR, Henriques JF. Class II subdivision malocclusion
types and evaluation of their asymmetries. Am J Orthod
Dentofacial Orthop. 2007;131:5766.
9. Habets LL, Bezuur JN, Naeiji M, Hansson TL. The Orthopantomogram, an aid in diagnosis of temporomandibular
joint problems. II. The vertical symmetry. J Oral Rehabil.
1988;15:465471.
10. Habets LLMH, Bezuur JN, VanOoij CP, Hansson TL. The
orthopantomogram, an aid in diagnosis of temporomandibular joint problems. I. The factor of vertical magnification. J
Oral Rehabil. 1987;14:475480.
11. Miller VJ. Condylar asymmetry and handedness in patients
with temporomandibular disorders. J Oral Rehabil. 1997;24:
549551.
12. Miller VJ, Zeltser R, Zeltser CH, Yoeli Z. The condylar
asymmetry-age relationship in determining myogenous or
arthrogenous origin of pain in patients with temporomandibular disorders. J Oral Rehabil. 1996;23:392394.
13. Miller VJ, Smidt A. Condylar asymmetry and age in patients
with an Angles Class II division 2 malocclusion. J Oral Rehabil. 1996;23:712715.
14. Miller VJ, Bodner L. Condylar asymmetry measurements in
patients with an Angles Class III malocclusion. J Oral Rehabil. 1997;24:247249.
15. Saglam AM. The condylar asymmetry measurements in different skeletal patterns. J Oral Rehabil. 2003;30:738742.
16. Saglam AA, Sanli G. Condylar asymmetry measurements
in temporomandibular disorders. J Contemp Dent Pract.
2004;5:5965.

37
17. Kiki A, Kilic N, Oktay H. Condylar asymmetry in bilateral
posterior crossbite patients. Angle Orthod. 2007;77:7781.
18. Sezgin OS, Celenk P, Arici S. Mandibular asymmetry in different occlusion patterns. Angle Orthod. 2007;77:803807.
19. Uysal T. Eriskin Turk Toplumunda Dentofacial Yapilarin Ideal Transversal Boyutlarinin Model ve Posteroanterior Sefalometrik Filmler Araciligiyla Degerlendirilmesi [PhD thesis].
Konya, Turkey: Selcuk University, Health Science Institute;
2003.
20. Wabeke KB, Spruijt RJ, Habets LL. Spatial and morphologic
aspects of temporomandibular joints with sounds. J Oral
Rehabil. 1995;22:2127.
21. Bezuur JN, Habets LL, Hansson TL. The recognition of
craniomandibular disorders; condylar symmetry in relation
to myogenous and arthrogenous origin of pain. J Oral Rehabil. 1989;16:257260.
22. Kambylafkas P, Murdock E, Gilda E, Tallents RH, Kyrkanides S. Validity of panoramic radiographs for measuring
mandibular asymmetry. Angle Orthod. 2006;76:388393.
23. Cook JT. Asymmetry of the craniofacial skeleton. Br J Orthod. 1980;7:3338.
24. Richardson ME. The reproducibility of measurements on
depressed posteroanterior cephalometric radiographs. Angle Orthod. 1967;37:4851.
25. Berger H. Problems and promises of basilar view cephalograms. Angle Orthod. 1961;31:237245.
26. Forsberg CT, Burstone CJ, Hanley KJ. Diagnosis and treatment planning of skeletal asymmetry with the submentalvertical radiograph. Am J Orthod. 1984;85:224237.
27. Williamson, EH, Simmons MD. Mandibular asymmetry and
its relation to pain dysfunction. Am J Orthod. 1979;76:612
617.
28. Peck S, Peck L, Kataja M. Skeletal asymmetry in esthetically pleasing faces. Angle Orthod. 1991;61:4348.
29. Larheim TA, Svanaes DB. Reproducibility of rotational panoramic radiography: mandibular linear dimensions and angles. Am J Orthod Dentofacial Orthop. 1986;90:4551.
30. Larheim TA, Svanaes DB, Johannessen S. Reproducibility
of radiographs with the orthopantomograph 5: tooth length
assessment. Oral Surg Oral Med Oral Pathol. 1984;58:736
741.
31. Yale SH. Radiographic evaluation of the temporomandibular
joint. J Am Dent Assoc. 1969;79:102107.
32. Cohlmia JT, Ghosh J, Sinha PK, Nanda RS, Currier GF.
Tomographic assessment of temporomandibular joints in
patients with malocclusion. Angle Orthod. 1996;66:2735.
33. Janson G, Cruz KS, Woodside DG, Metaxas A, de Freitas
MR, Henriques JFC. Dentoskeletal treatment changes in
Class II subdivision malocclusions in submentovertex and
posteroanterior radiographs. Am J Orthod Dentofacial Orthop. 2004;126:451463.

Angle Orthodontist, Vol 78, No 1, 2008

Original Article

Morphological Characteristics of the Symphyseal Region in


Adult Skeletal Class III Crossbite and Openbite Malocclusions
Chooryung Judi Chunga; Sinae Jungb; Hyoung-Seon Baikc
ABSTRACT
Objective: To evaluate the relationship of the morphological characteristics of the symphyseal
region of adult Class III malocclusion to the differences in overjet and overbite.
Materials and Methods: The basal and symphyseal widths along with the alveolar and symphyseal heights were evaluated using data from the lateral cephalograms of Korean adult male skeletal Class III, divided into crossbite (n 28) and openbite (n 41) groups. Korean male normal
occlusion samples (n 32) were used as controls.
Results: The width of the symphyseal region including the basal width, point B width, Id width,
symphyseal thickness, and pogonion width were similar in adult Class III crossbite and normal
occlusion groups, but significantly less in the adult Class III openbite group (P .001). The
alveolar height was similar in the adult Class III crossbite and control groups, but significantly less
in the adult Class III openbite group (P .05). However, the symphyseal height was similar in
all three groups.
Conclusions: An openbite, rather than a negative overjet, is the major factor influencing the
symphyseal morphology in an adult Class III malocclusion.
KEY WORDS: Symphysis; Overjet; Overbite; Morphology; Skeletal Class III; Adult

INTRODUCTION

sential for achieving better results, stability, and periodontal health, as well as for avoiding root resorption.11,12 In particular, in the case of a severe adult skeletal Class III malocclusion, the proper amount of
decompensation including the labial inclination of the
lower incisors is necessary before orthognathic surgery.12 On the other hand, lingual inclination of the lower incisors is needed for camouflage treatment. Either
way, incisor movement confined within the bone is recommended.13
The difference in overbite, such as an openbite and
normal overbite, is associated with the dimensions of
the symphysis.3,6 However, the morphological characteristics of the symphysis combined with the different force vectors loaded to the lower incisors, such as
in crossbite and Class III openbite have not been fully
evaluated. Therefore, this study focused on the morphological characteristics of the symphyseal region in
adult skeletal Class III malocclusion with crossbite or
openbite and compared them with normal occlusion.

The morphology of mandibular symphysis is important because it serves as the primary reference for the
esthetics of the facial profile and is a determinant in
planning the lower incisor position during orthodontic
and orthognathic surgery.1,2 The factors associated
with the symphyseal growth and morphology include
the functional neuroskeletal balance,3 masseter muscle thickness,4 mandibular plane angle,2,5 overbite,3,6,7
lower incisor angle,8 occlusal hypofunction and its recovery,9 inheritance,10 and more.
During orthodontic treatment, limiting incisor movement within the bone structure is believed to be esInstructor, Department of Orthodontics, College of Dentistry,
Yonsei University, Seoul, South Korea.
b
Graduate PhD student, Department of Orthodontics, College
of Dentistry, Yonsei University, Seoul, South Korea.
c
Professor, Department of Orthodontics, College of Dentistry,
Yonsei University, Seoul, South Korea.
Corresponding author: Dr Hyoung-Seon Baik, Department of
Orthodontics, College of Dentistry, Yonsei University, 134 Shinchon-Dong, Seodaemun-gu, Seoul, 120-752 South Korea
(e-mail: crchung@yumc.yonsei.ac.kr)
a

MATERIALS AND METHODS


The pretreatment digital lateral cephalograms of Korean adult male patients (over the age of 18 years)
who visited the Orthodontic Clinic of Yonsei University
between 2005 and 2006 were classified into either the

Accepted: December 2006. Submitted: October 2006.


 2007 by The EH Angle Education and Research Foundation,
Inc.
Angle Orthodontist, Vol 78, No 1, 2008

38

DOI: 10.2319/10.2139/101606-427.1

39

SYMPHYSIS OF ADULT CLASS III MALOCCLUSION

Class III crossbite group (mean age 23.2 4.7 years)


or the Class III openbite group (mean age 21.3 3.4
years) according to the molar and incisor relationship.
The inclusion criteria of the crossbite group were: Angle Class III molar relationship, negative overjet and
overbite, but with incisor contact at maximum intercuspation including the edge-to-edge bite. The inclusion
criteria of the Class III openbite group were: Angle
Class III molar relationship, negative overjet, but without any incisor contact between the central and lateral
incisors. The Class III openbite also included samples
with deep vertical incisor overlap, but without incisor
contact due to the large reverse overjet (4 mm). After
the primary screening process, the incisor relationship
was reconfirmed using the orthodontic casts. Any patient with prior orthodontic treatment, tooth loss, abnormal tooth morphology, congenital disorders, or diseases such as rheumatoid arthritis was excluded.
A total of 28 Class III crossbite and 41 Class III
openbite cases were collected for the study. In addition, the lateral cephalograms of Korean adult male
with normal occlusion (mean age 20.1 3.2, n 32)
collected at the Craniofacial Deformity Center, Yonsei
University, were used as the control. The normal occlusion criteria were: Class I molar and canine relationships, a normal range of overjet (24 mm) and
overbite (24 mm) with incisor contact, good alignment
without any missing teeth (total of 28 or more) and no
prior orthodontic treatment. The cephalograms of the
normal occlusion group were obtained from healthy
adult volunteers with informed consent according to
the World Medical Associations Declaration of Helsinki.
Digital cephalograms were taken at the dental hospital, College of Dentistry, Yonsei University, using
Cranex3 (Soredex, Helsinki, Finland) and converted
as a 12-bit DICOM (Digital Imaging and Communications in Medicine) file. The detection of the cephalometric landmarks was conducted directly on the
screen-displayed digital image with a mouse-controlled cursor in connection with the computerized program using V-Ceph software (CyberMed Inc, Seoul,
Korea) for cephalometric analysis by two experienced
orthodontists.
Additional landmarks and measurements were
based on previous reports in order to allow a more
comprehensive study of the mandibular structure.8,14
The symphyseal landmarks are described in Figure 1.
The cephalometric data of the control, Class III
crossbite, and Class III openbite groups were examined by analysis of variance (ANOVA) using statistical
software (Statview, Cary, NC). The results are presented as a mean SD. P .05 was considered
significant.
Duplicate tracings of all 32 landmarks on 15 ran-

domly chosen cephalograms were done at a 2-month


interval by the same examiner. The systemic error was
evaluated with a paired t test at P .05. No significance was noted in the measurements of the first and
the second evaluation.
RESULTS
Cephalometric Characteristics of the
Three Groups
Table 1 provides a summary of the skeletal and dental characteristics of the control, Class III crossbite,
and Class III openbite groups. The skeletal features of
the Class III crossbite group in the anterior-posterior
dimension were similar to those of the skeletal Class
III openbite group, with a larger SNB, gonial angle, and
mandibular body length compared with the control
group (P .05). The skeletal Class III openbite group
showed higher values for vertical dimension measurements such as the gonial angle, mandibular plane angle, and facial height ratio than the control and Class
III crossbite groups (P .05).
The Width of the Symphysis Is Narrower in
Class III Openbite
The basal width, point B width, and Id width were
similar in the control and Class III crossbite groups.
However, the basal width, pogonion width, and Id
widths were all significantly lower in the Class III openbite group than in the control and Class III crossbite
groups (P .05; Figure 2A; Table 2).
The width parameters distant from the teeth also indicated a similar pattern. While the symphyseal thickness and pogonion width were similar in the control
and the Class III crossbite groups, they were significantly lower in the Class III openbite group (P .01;
Figure 2B; Table 2).
The Height of the Alveolar Bone Was Lower in
the Class III Openbite
The alveolar height was similar in the control and
the Class III crossbite groups. However, it was significantly lower in the Class III openbite group (P
.0001; Figure 2B; Table 2). The symphyseal height
was similar in all three groups. The total height of the
symphyseal region was similar in the control and Class
III crossbite groups, but was significantly lower in the
Class III openbite group (P .05; Figure 3; Table 2).
DISCUSSION
The mandibular bone is strongly influenced by the
masticatory function.1518 In particular, the maxillofacial
region contains essentially membranous bone and is
Angle Orthodontist, Vol 78, No 1, 2008

40

CHUNG, JUNG, BAIK

Figure 1. Landmarks and measurements of the symphyseal region. Conventional mandibular landmarks: Me, menton; Pg, pogonion; B,
supramentale; Id, infradentale; Idl, lingual point infradentale. Landmarks based on Suri et al14: PAP, posterior alveolar point, most posteroinferior
midplaned point on the anterior border of the ascending ramus; Inf Go, inferior gonion, midplaned point on the lower border of the mandible
where the convexity at Go merges with the concavity of the antegonial notch; RBS, ramus body syncline, the point of intersection of a line
drawn from Inf Go to PAP with the cortical outline of the midplaned mandibular nerve; Bl, lingual point B, the point of intersection of a line
drawn from RBS to B, with the lingual contour of symphysis; saj, symphysis-alveolar junction, the midpoint of a line drawn from Bl to B; Pgl,
lingual point pogonion, the highest point on the lingual contour of the symphysis, located by the greatest perpendicular distance from a line
drawn from the saj to Me; malv, (midpoint of anterior alveolus), midpoint of a line drawn from Idl to Id. Landmark base on Nojima et al8: B,
point on the lingual outline of the symphysis drawn from B perpendicular to a line connecting malv to Me. Mandibular measurements: alveolar
height, length of a line drawn from malv to saj; symphyseal height, length of a line drawn from saj to Me; symphyseal thickness, the sum of
the lengths of the perpendiculars dropped from Pg and Pgl to a line drawn from saj to Me; basal width, length of a line drawn from Bl to B.

Table 1. Dental and Skeletal Characteristics of the Control, Class III Crossbite, and Class III Openbite Groups (Mean SD)a
Control (n 32)

Crossbite (n 28)

Measurements

Mean

SD

Mean

SD

Age
SNA
SNB
ANB difference
Saddle angle
Articular angle
Gonial angle
Anterior cranial base length, mm
Posterior cranial base length, mm
Ramal height (mm)
Mandibular body length, mm
FH to Mn.plane angle
Posterior facial height (PFH), mm
Anterior facial height (AFH), mm
Facial height ratio
U1 to SN
IMPA
Interincisal angle

20.1
82.6
80.0
2.5
125.4
147.8
118.1
74.3
40.2
59.7
83.6
22.4
96.1
138.6
0.7
108.2
97.2
123.3

3.2
2.7
3.0
2.1
3.7
6.3
7.1
3.1
3.1
6.4
5.3
5.2
7.5
6.0
0.0
5.9
7.3
8.5

23.2
81.3
84.3
3.0
122.8
146.6
121.5
73.1
40.0
60.7
87.1
22.6
96.3
139.9
0.7
111.1
87.5
130.4

4.7
3.8
3.6
1.9
7.0
8.9
6.5
3.4
3.7
5.4
4.2
5.4
6.8
6.9
0.0
6.8
7.0
7.9

Openbite (n 41)
P

a
a

a
a

Mean

SD

21.3
80.1
83.8
3.7
122.4
145.1
128.8
73.1
39.2
59.2
87.9
27.8
94.1
145.5
0.6
109.6
81.8
132.3

3.4
3.6
4.8
3.0
4.9
5.1
6.1
3.8
2.9
5.9
5.3
5.3
6.1
6.0
0.0
6.3
7.3
8.9

P
a
a
a
a
a,b

a
a,b
a,b
a,b
a,b
a

a indicates statistical significance from the control; b indicates statistical significance between the crossbite and openbite with P .05.

Angle Orthodontist, Vol 78, No 1, 2008

41

SYMPHYSIS OF ADULT CLASS III MALOCCLUSION

Figure 3. The alveolar height is lower in the Class III openbite. Although the alveolar height and total height was significantly lower in
the Class III openbite than in the control and crossbite groups, the
symphyseal height was similar in all three groups. The data are expressed as mean SD. Statistical significance compared to the
control with *P .05.

mandibular incisors, the morphological characteristics


of the mandibular symphysis can vary between the
normal overjet/overbite and crossbite, and a negative
overjet but with a positive overbite. The difference in
the Class III openbite was also evaluated because the
overbite is reported to be one of the major factors influencing the symphyseal dimension. The width and
height of the mandibular symphysis was only significantly lower in the Class III openbite group indicating
that overbite rather than the overjet was the major influencing factor.
Earlier studies on the morphology of the symphyseal
region in adult Japanese samples based on the divergence of the mandibular plane angle reported that the
alveolar bone thickness negatively correlated with the
mandibular plane angle, while the symphyseal thickness distant from the incisors near the base of the
mandible was rather stable.2,8 However, our results
clearly indicate a decrease in thickness not only in the
alveolar bone region, but also in the symphyseal thickness in the case of the Class III openbite. This suggests that the basal bone of the symphyseal region
can also show an adaptive alteration to achieve a

Figure 2. The symphyseal thickness is thinner in Class III openbite.


Basal width, point B width, and Id width (A) along with the symphyseal thickness and pogonion width (B) were similar in the control
and crossbite groups, while all the measured parameters were significantly lower in the Class III openbite. The data are expressed as
mean SD. Statistical significance compared to the control with *P
.05 and **P .0001.

more susceptible to environmental factors such as the


stimulating influence of muscles and extrafunctional
forces.4,19 During the power stroke of mastication, the
middle and lower third of the labial aspect of the symphysis is predominantly sheared dorsoventrally, twisted and bent16 according to the magnitude and position
of the bite force.15,17 Therefore, it was hypothesized
that, due to the difference in bite force direction of the

Table 2. Symphyseal Dimension of the Control, Class III Crossbite, and Class III Openbite Groups (Mean SD)a
Control (n 32)

Crossbite (n 28)

Openbite (n 41)

Measurements

Mean

SD

Mean

SD

Mean

SD

Basal width (B-Bl)


Point B width (B-B)
Id width (Id-Idl)
Symphyseal thickness (sum)
Pogonion width (Pog-Pgl)
Alveolar height (malv-Saj)
Symphyseal height (Saj-Me)
Total height (malv-Me)

9.58
9.76
6.98
16.35
16.29
12.45
25.48
36.93

1.85
1.77
0.76
1.32
1.47
2.08
1.83
2.78

8.88
9.08
6.71
15.82
15.79
10.88
25.39
35.52

1.84
1.94
0.94
1.48
1.58
2.87
1.93
2.52

.21
.25
.47
.29
.71
.06
.68
.22

6.74
6.98
5.83
14.22
14.38
10.12
25.06
34.78

1.64
1.93
1.20
1.45
1.49
4.01
2.49
3.49

P
.0001
.0001
.0001
.0001
.0001
.05
.42
* .05

**
**
**
**
**
*

* P .05; ** P .0001.
Angle Orthodontist, Vol 78, No 1, 2008

42
functional neuroskeletal balance in the craniofacial
complex due to the absence of an incisor contact.3,4,6,9
Patients with a vertical growth pattern, openbite, and
high mandibular plane angle were reported to have a
similar8 or larger vertical dimension of the symphysis.2,6 However, these results were rather conflicting.
The alveolar height and total height of the symphyseal
region were lower in the Class III openbite in our study.
The bone actively responds to loading or mechanical
stimulation and undergoes remodeling.2024 In the case
of a long bone, the amount of bone formation is lower
during unloading while the amount of bone resorption
is higher resulting in a decrease in the total bone
mass.2426 In the maxillofacial region, the absence of
incisor contact can induce compensatory tooth eruption along with the elongation of the alveolar bone,
which causes an increase in the alveolar height, particularly in growing adolescents as previously reported.9,2730
In contrast, in the cases of tooth loss, infraocclusion
due to ankylosis or denture wear, vertical height and
bone volume of the alveolar bone may also decrease
in the long term.3135 Therefore, the net result of the
bone dimension in response to a prolonged openbite
is quite difficult to define. Compared with many studies
on the morphological characteristics of openbite malocclusion in adolescents, this study mainly focused on
adult samples. The compensatory lengthening of the
lower anterior alveolar height was reported to be limited.30 Therefore, it is possible that the persistence of
the openbite and the loss of incisor contact/function in
the long term, as our adult samples might have caused
a decrease in the vertical dimension of the alveolar
bone region.
Differing from the symphyseal width, the symphyseal height was similar in the Class III openbite group
and control. The attachment of the geniohyoid and genioglossus muscle at the basal level of the symphyseal area with muscle activation during oral function
might have influenced this result. Parafunctional habits
including the tongue, have also been reported to be
associated with the compensatory mechanism of a
high angle malocclusion.28 However, this limited study
did not include evaluation parameters for the tongue
or the soft tissue.
Recently, occlusal hypofunction was shown to suppress alveolar and jaw bone formation while its recovery induced an enhancement in bone formation. This
suggests the positive influence of occlusal function on
alveolar and jaw bone formation during the growth period.9 Clinically, early treatment for a skeletal Class III
malocclusion is quite controversial due to the unpredictable growth of the mandible. It would be interesting
to determine if early intervention during the growth period to recover or to maintain the overbite would at
Angle Orthodontist, Vol 78, No 1, 2008

CHUNG, JUNG, BAIK

least enhance the thickness of the symphysis in the


long term, even though it may not be sufficient to fully
compensate for the anterior-posterior discrepancy.
CONCLUSIONS
The width of the symphyseal region is similar in adult
Class III crossbite and normal occlusion groups, but
significantly lower in the adult Class III openbite
group.
The alveolar height is similar in the adult Class III
crossbite and control groups, but significantly lower
in the adult Class III openbite group. However, the
symphyseal height was similar in all three groups.
This suggests that unloading due to the openbite,
rather than a negative overjet, is the major factor
influencing the symphyseal morphology in an adult
Class III malocclusion.
ACKNOWLEDGMENT
This study was supported by the Craniofacial Deformity Center of Yonsei University Dental Hospital

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2. Tanaka R, Suzuki H, Maeda H, Kobayashi K. Relationship
between an inclination of mandibular plane and a morphology of symphysis [in Japanese]. Nippon Kyosei Shika Gakkai Zasshi. 1989;48:720.
3. Haskell BS. The human chin and its relationship to mandibular morphology. Angle Orthod. 1979;49:153166.
4. Kubota M, Nakano H, Sanjo I, Satoh K, Sanjo T, Kamegai
T, Ishikawa F. Maxillofacial morphology and masseter muscle thickness in adults. Eur J Orthod. 1998;20:535542.
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6. Ceylan I, Eroz UB. The effects of overbite on the maxillary
and mandibular morphology. Angle Orthod. 2001;71:110
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7. Beckmann SH, Kuitert RB, Prahl-Andersen B, Segner D,
The RP, Tuinzing DB. Alveolar and skeletal dimensions associated with overbite. Am J Orthod Dentofacial Orthop.
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8. Nojima K, Nakakawaji K, Sakamoto T, Isshiki Y. Relationships between mandibular symphysis morphology and lower incisor inclination in skeletal class III malocclusion requiring orthognathic surgery. Bull Tokyo Dent Coll. 1998;39:
175181.
9. Shimomoto Y, Iwasaki Y, Chung CY, Muramoto T, Soma K.
Effects of occlusal stimuli on alveolar/jaw bone formation. J
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10. Garn SM, Lewis B, Vicinus JH. The inheritance of symphyseal size during growth. Angle Orthod. 1963;33:222231.
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12. Proffit WR, Whilte RPJ, Sarver DM. Contemporary Treat-

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Suri S, Ross RB, Tompson BD. Mandibular morphology and
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Hylander WL. In vivo bone strain in the mandible of Galago
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Hylander WL. Stress and strain in the mandibular symphysis of primates: a test of competing hypotheses. Am J Phys
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Korioth TW, Hannam AG. Deformation of the human mandible during simulated tooth clenching. J Dent Res. 1994;
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Korioth TW, Hannam AG. Mandibular forces during simulated tooth clenching. J Orofac Pain. 1994;8:178189.
Dulkin J. Secondary cartilage: a misnomer? Am J Orthod.
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Currey JD. The many adaptations of bone. J Biomech.
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Burger EH, Klein-Nulend J. Microgravity and bone cell mechanosensitivity. Bone. 1998;22:127S130S.
Vico L, Lafage-Proust MH, Alexandre C. Effects of gravitational changes on the bone system in vitro and in vivo.
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Frost HM. Wolffs Law and bones structural adaptations to
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Rodan GA. Mechanical loading, estrogen deficiency, and
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25. Bikle DD, Halloran BP. The response of bone to unloading.
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26. Ishijima M, Rittling SR, Yamashita T, Tsuji K, Kurosawa H,
Nifuji A, Denhardt DT, Noda M. Enhancement of osteoclastic bone resorption and suppression of osteoblastic bone
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occur in the absence of osteopontin. J Exp Med. 2001;193:
399404.
27. Beckmann SH, Segner D. Changes in alveolar morphology
during open bite treatment and prediction of treatment result. Eur J Orthod. 2002;24:391406.
28. Betzenberger D, Ruf S, Pancherz H. The compensatory
mechanism in high-angle malocclusions: a comparison of
subjects in the mixed and permanent dentition. Angle Orthod. 1999;69:2732.
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A. Dentoalveolar compensation in subjects with vertical
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32. Carlsson GE. Responses of jawbone to pressure. Gerodontology. 2004;21:6570.
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105.

Angle Orthodontist, Vol 78, No 1, 2008

Original Article

Early Treatment to Correct Class III Relations with or without Face Masks
Arnim Godta; Claudia Zeyhera; Dorothee Schatz-Maiera; Gernot Gozb
ABSTRACT
Objective: To determine what therapeutic effects can be expected in the case of early treatment
of Class III relations with removable appliances with or without face masks.
Materials and Methods: Records available at the university clinic of Tubingen for 41 patients
who had undergone early treatment because of prognathic abnormalities were retrospectively
evaluated. Lateral cephalograms taken and casts obtained at baseline and at the end of early
treatment were included in the analysis. Two treatment strategies were compared. The first group
included removable functional orthopedic appliances only (FOA group), while the second group
was treated with removable appliances and with face masks mounted on a cemented maxillary
expansion appliance (face mask group).
Results: Positive changes were achieved in both groups for overjet (FOA group: 1.3 mm; face
mask group: 2.2 mm) and Wits values (FOA group: 0.4 mm; face mask group: 1.7 mm).
Moreover, a change in mean ANB values was achieved in the face mask group (0.9). The FOA
group exhibited a reduction in mandibular angles. Changes in maxillary inclination with reduced
inclination angles led to increases in overjet and overbite. The face mask group showed dorsal
rotation of the mandible with reduced SNB values (0.8).
Conclusion: Early treatment of prognathism is a meaningful option, as demonstrated by the
dentoskeletal (and hence functional) improvements observed in the present study.
KEY WORDS: Prognathism; Class III; Early treatment; Face mask; Prognathism activator

INTRODUCTION

er effect on maxillary growth and more pronounced


enlargement of the SNA angles than the postpubertal
group. Baccetti et al2 and Kim et al3 reported that treatment with face masks to ventralize maxillary growth
was more effective in early than in late mixed dentitions. Similarly, Suda et al4 observed that face masks
combined with maxillary expansion appliances were
more effective in early than in late phases of skeletal
maturation.
Similar results were obtained with functional orthopedic appliances (FOAs). Baccetti and Tollaro5 reported that treatment with a mandibular retractor influenced mandibular rotation and condylar development
more effectively in children with deciduous than mixed
dentition. Wilhelm-Nold and Droschl6 achieved better
treatment outcomes in deciduous than in permanent
dentitions using chin caps with or without simultaneous application of Frankels function regulator type
III.
Essential requirements for early treatment of Class
III relations include optimal timing but also selecting
the most appropriate orthodontic appliance. Removable plates, functional orthopedic appliances, and face
masks (frequently mounted on a cemented maxillary
expansion appliance) are known to be clinically effec-

Considering the protracted treatment schedules in


prognathism, any information that would shed light on
the effectiveness of early treatment in the deciduous
dentition or in the early phase of the mixed dentition
is relevant. One important question is whether the
changes induced to skeletal or dental relations by early treatment will be permanent.
The success of early treatment has been confirmed
by investigations of maxillary protraction using Delaire
face masks with various modifications. Takada et al1
reported on treatment with maxillary protraction headgears in three different age groups. The prepubertal
and midpubertal groups revealed a significantly greatAssistant Professor, Department of Orthodontics, University
of Tubingen, Tubingen, Germany.
b
Professor and Department Chair, Department of Orthodontics, University of Tubingen, Tubingen, Germany.
Corresponding author: Dr Arnim Godt, Department of Orthodontics, University of Tubingen, Osianderstrasse 2-8, 72076 Tubingen, Germany
(e-mail: arnim.godt@med.uni-Tubingen.de)
a

Accepted: January 2007. Submitted: November 2006.


 2007 by The EH Angle Education and Research Foundation,
Inc.
Angle Orthodontist, Vol 78, No 1, 2008

44

DOI: 10.2319/110606-455.1

45

EARLY TREATMENT OF CLASS III RELATIONS


Table 1. Treatment Groups Including Number of Patients, Treatment Duration, and Gender Distribution

Maxillary expansion appliance face mask


Functional orthopedic appliances only plate

No. of
Patients

Female

Male

Mean Age at
Baseline, y

Mean Duration of
Treatment, mo

17
24

11
13

6
11

6.98
7.12

29.47
31.29

tive in this connection. Frequently, the therapy does


not remain confined to a specific type of appliance but
may instead include various appliances in combination, depending on the treatment progress.
The objective of the present study was to investigate
the effects of treatment with strictly removable appliances compared to treatment with removable appliances in combination with face masks.
MATERIALS AND METHODS
The records of 41 patients who had undergone early
treatment because of prognathic abnormalities were
used for retrospective analysis. Only patients with negative Wits values7 or negative differences between individual and measured ANB values8 were included.
None of the patients had reached the late phase of
mixed dentition. Patients with syndromes were excluded from the study.
Patients who had been treated exclusively with removable appliances (plates, functional orthopedic appliances) were assigned to the FOA group. Patients
who alternated between removable appliances and a
face mask mounted on a maxillary expansion appliance were assigned to the face mask group. The orientation of tensile forces was ventrocaudal, starting at
palatally mounted hooks. Table 1 shows number of
patients, gender distributions, mean ages at baseline,
and treatment periods.
Treatment was carried out for a mean of 31.3
months in the FOA group and for a mean of 29.5
months in the face mask group. Casts were fabricated,
and standardized lateral cephalograms were taken
and analyzed both at baseline and after early treatment was completed. The casts were used to evaluate
overjet and overbite; the cephalometric parameters
are illustrated in Figure 1.
Lateral cephalograms were analyzed by a single investigator using fr-win software (Computer Konkret
AG, Falkenstein, Germany). Another 10 cephalograms
obtained at least 2 months later were arbitrarily picked
for analysis. In accordance with Dahlberg,9 the combined systematic error was calculated as d 2/2n ,
where d is the difference between two measurements
and n is the number of measurements performed in
duplicate. The systematic error in this study was found
to be 0.76 (range, 0.46 to 1.23) for angular measurements and 0.80 mm (range, 0.41 to 1.16 mm) for
linear measurements.

As a normal distribution could not be assumed given


the small number of cases, the t-test could not be applied reliably, and the statistical comparison of the result for the two groups was done using the two-sided
Wilcoxon test with JMP10 statistic software.
Table 2 shows the average baseline values for the
situations in both groups. Larger differences were
seen only for the sagittal values for SNB, ANB, Wits,
and overjet, although only the ANB and overjet values
were statistically significant.
The treatment provider used his or her own discretion in determining which appliances were to be used
during the course of treatment. The values demonstrate, however, thatin addition to removable therapyface masks mounted on a cemented maxillary expansion appliance (face mask group) were used in the
more pronounced skeletal Class III cases. A removable treatment only (FOA group) was performed for
the less pronounced Class III cases.
RESULTS
An overview of the results is provided in Table 3.
The effect of early treatment on maxillary position was

Figure 1. Illustration of angles and distances measured in cephalograms. 1: SNA; 2: SNB; 3: ANB (not shown); 4: Wits value; 5:
SNPog; 6: SN-MeGo; 7: y-axis (SNGn); 8: Go2 angle (NGoMe); 9:
SN-SpP (maxillary inclination); 10: mandibular angle (ArGoMe); 11:
length of maxilla; 12: length of mandible; 13: angulation of upper first
incisor; and 14: angulation of lower first incisor.
Angle Orthodontist, Vol 78, No 1, 2008

Z
GODT, ZEYHER, SCHATZ-MAIER, GO

46
Table 2. Baseline Values for Both Groupsa
Variable
SNA,
SNB,
ANB,
Wits, mm
SN-Pog,
SN-MeGo,
y-axis,
Go2 (NGoMe),
NS-SpP,
Mandibular angle (ArGoMe),
Length of maxilla, mm
Length of mandible, mm
Angulation of upper first incisors,
Angulation of lower first incisors,
Overjet, mm
Overbite, mm

FOA Group
80.72
77.83
2.90
2.43
78.03
36.42
66.93
74.99
6.30
129.77
43.87
66.56
98.11
88.55
0.58
0.30

Face Mask Group

(79.56, 81.90)
(76.40, 79.25)
(2.01, 3.79)
(3.28, 1.57)
(76.53, 79.52)
(34.20, 38.63)
(65.45, 68.42)
(73.44, 76.54)
(5.08, 7.52)
(127.18, 132.35)
(42.75, 44.98)
(64.94, 68.18)
(94.05, 102.17)
(84.83, 92.28)
(0.12, 1.29)
(0.48, 1.08)

80.84
79.68
1.36
3.74
79.23
36.42
66.95
75.48
6.34
130.08
42.79
66.89
97.83
86.84
0.82
0.12

(79.45, 82.23)
(77.98, 81.37)
(0.30, 2.42)
(4.76, 2.72)
(77.46, 81.00)
(33.78, 39.05)
(65.19, 68.72)
(73.64, 77.33)
(4.89, 7.78)
(127.01, 133.16)
(41.47, 44.11)
(64.97, 68.82)
(92.97, 102.70)
(82.37, 91.31)
(1.66, 0.01)
(0.82, 1.07)

P Value
.989
.149
.027
.086
.466
.781
.905
.516
.791
.822
.216
.791
.842
.797
.026
.895

a
FOA indicates that patients were exclusively treated with plates and functional orthopedic appliances; face mask, that a face mask was
used in addition. Data include 95% confidence intervals and P values derived from intergroup comparisons of mean values using the Wilcoxon
test.

small in both groups. SNA values increased by 0.40


in the FOA group treated exclusively with removable
appliances, as compared to 0.29 in the face mask
group treated additionally with a maxillary expansion
appliance and face mask (Figure 1). The SNB values
increased by 1.08 in the FOA group but decreased
by 0.81 in the face mask group. The difference between both groups was statistically significant.
Changes in chin position were 1.38 in the FOA
group and 0.01 in the face mask group. This intergroup difference was not statistically significant. ANB
and Wits values changed in accordance with SNA and
SNB values. The ANB values decreased by 0.47 in
the FOA group but increased by 0.88 in the face mask
group. Wits values increased in both groups (FOA
group: 0.38 mm; face mask group: 1.67 mm). The

skeletal effect in reducing Class III relations was more


pronounced in the face mask group than in the FOA
group, and it was more pronounced in the mandible
than in the maxilla.
Intergroup differences in SN-MeGo values were
highly significant (P .001), as those angles decreased by 1 in the FOA group while they increased
by 1.12 in the face mask group. Statistical significance was also reached for intergroup changes in yaxis values over the course of treatment, although the
significance level was only P .05. These angles increased by 0.15 in the FOA group and by 1.4 in the
face mask group. Go2 angles (NGoMe) decreased by
0.37 in the FOA group and increased by 1.49 in the
face mask group. This difference was again significant
at the .01 level.

Table 3. Differences Between Findings in Cephalograms and on Casts at the Beginning and End of Treatmenta
Variable
SNA,
SNB,
ANB,
Wits, mm
SN-Pog,
SN-MeGo,
y-axis,
Go2 (NGoMe),
NS-SpP,
Mandibular angle (ArGoMe),
Length of maxilla, mm
Length of mandible, mm
Angulation of upper first incisors,
Angulation of lower first incisors,
Overjet, mm
Overbite, mm
a

FOA Group
0.40
1.08
0.47
0.38
1.38
1.00
0.15
0.37
0.85
2.97
1.51
3.56
6.18
3.84
1.33
1.50

(0.73, 1.53)
(0.29, 1.87)
(1.29, 0.35)
(0.55, 1.31)
(0.47, 2.28)
(1.80, 0.20)
(0.55, 0.85)
(1.10, 0.36)
(0.68, 2.37)
(4.37, 1.21)
(0.28, 2.74)
(2.23, 4.90)
(2.70, 9.66)
(1.17, 6.52)
(0.76, 1.91)
(0.77, 2.23)

Face Mask Group


0.29
0.81
0.88
1.67
0.01
1.12
1.40
1.49
0.15
0.32
1.94
3.63
4.27
0.59
2.15
0.50

(1.05, 1.64)
(1.74, 0.13)
(0.10, 1.85)
(0.57, 2.78)
(1.08, 1.07)
(0.17, 2.07)
(0.57, 2.23)
(0.62, 2.37)
(1.96, 1.66)
(2.42, 1.78)
(0.48, 3.41)
(2.04, 5.12)
(0.10, 8.44)
(2.62, 3.80)
(1.46, 2.84)
(0.38, 1.38)

FOA indicates that patients were exclusively treated with plates and functional orthopedic appliances.

Angle Orthodontist, Vol 78, No 1, 2008

P Value
.958
.006
.121
.276
.092
.001
.043
.004
.779
.04
.623
.811
.648
.13
.075
.11

EARLY TREATMENT OF CLASS III RELATIONS

Maxillary inclinations toward the cranial base (NSSpP) increased by 0.85 in the FOA group, whereas
they decreased by 0.15 in the face mask group. The
mandibular angles (ArGoMe) decreased by 2.97 in
the FOA group and by 0.32 in the face mask group.
The difference in the decrease was statistically significant (P .05).
Maxillary elongation was 1.51 mm in the FOA group
and 1.94 mm in the face mask group over the course
of treatment. This intergroup difference was not statistically significant. Mandibular elongation was minor in
both groups (FOA group: 3.56 mm; face mask group:
3.62 mm).
Angulations of the upper first incisors increased by
6.18 in the FOA group and by 4.27 in the face mask
group relative to the cranial base. Angulations of the
lower incisors changed by 3.84 in the FOA group and
by 0.59 in the face mask group relative to the mandibular plane. Overjet increased by 1.33 mm in the
FOA group and by 2.15 mm in the face mask group.
At the same time, bite deepening occurred. Overbite
increased by 1.5 mm in the FOA group, compared to
only 0.5 mm in the face mask group.
DISCUSSION
The present study was designed to investigate the
effects of early treatment to correct Class III abnormalities. The devices used for treatment included removable appliances such as prognathism activators
and maxillary plates alone or in combination with a
face mask mounted on a maxillary expansion appliance. The effects that were achieved over the course
of early treatment are illustrated by the findings of the
study.
As no separate control group was available, the results were compared with groups of untreated Class
III cases in the literature. The group described by
Chong et al12 spanned an age range of 6.36 to 8.02
years, while the group described by Macdonald et al11
spanned an age range of 8.7 to 11.3 years. The basis
for age comparison is better with Chong et al,12 while
the basis for observation time comparison is better
with Macdonald et al.11
SNA angles decreased by 0.3 in the FOA group
and 0.4 in the face mask group over 2.5 years, which
indicates that skeletal Class III relations were reduced,
although these reductions fell short of the changes reported in the literature. Macdonald et al11 and Takada
et al1 achieved mean changes ranging between 1.5
and 2.3 with the use of protraction headgears within
1 to 1.1 years. Chong et al12 reported changes of 0.9
over an observation period of 2 years. Jager et al13
and Kim et al3 published results of meta-analyses
comprising 12 and 14 publications dealing with max-

47
illary protraction. Covering observation periods between 6 and 24 months, the SNA values in these studies increased by 1.4 and 1.7, respectively.
SNA angles in untreated control groups changed by
values ranging from 0.3 to 0.2 within a given observation period.11,12 Similar values have been reported for other sagittal parameters (SNB, ANB, and Wits).
Treatment with protraction headgears has shown a
greater effect than in the present study concerning the
reduction of skeletal Class III relations in terms of enlarged ANB angles. Macdonald et al11 and Takada et
al1 achieved increases of 3.4 and 3.6 within 1 year,
respectively; Chong et al12 observed a mean enlargement of 2 within 2 years. The corresponding value in
the present study was 0.8 (face mask group). Wits
values in the face mask group increased by 1.7 mm,
which is similar to the finding of 1.9 mm reported by
Chong et al.12 However, Macdonald et al11 found that
some of the sagittal effects achieved with face masks
were lost in the follow-up period when no treatment
was performed. While the effects achieved are smaller
with exclusively removable appliances, findings obtained in control groups11,12 have clearly demonstrated
that they are able to induce minor improvements and
to counteract the progression of Class III abnormalities.
Similarly, the overjet changes recorded in the present study (1.3 and 2.1 mm) were smaller than
those reported by Macdonald et al11 and Chong et al12
after continuous treatment with protraction headgears
(5.0 and 4.8 mm) but larger than those observed
in a control group (0.4 mm).11 The increases in overjet we recorded during additional treatment with face
masks compared to treatment with removable appliances only fell short of statistical significance but were
nevertheless relevant from a clinical viewpoint.
The results for maxillary elongation in both groups
were in keeping with values ranging from 1.8 to 2.2
mm reported by Chong et al12 and Takada et al.1 The
results for mandibular elongation, by contrast, were
clearly more pronounced than those given by the
above study groups (3.6 mm vs 1.9 mm12 or 2.6 mm1).
In fact, they were close to the 4.4 mm on record for
an untreated control group.12 Possible reasons include
the longer observation period (30 months vs 24 or 12
months) and the switching of appliances. Sagittal relations (ANB, Wits, and overjet) could be improved despite the fact that mandibles were distinctly elongated
during treatment compared to the length of maxillae,
the mean difference being roughly 2 mm. The changes
observed in vertical parameters might explain this phenomenon: SN-MeGo, Go2, and mandibular angle were
reduced in the FOA group. The mandible shifts to a
more distal position in the alveolar region. The chin
region, by contrast, will move slightly in a ventral diAngle Orthodontist, Vol 78, No 1, 2008

Z
GODT, ZEYHER, SCHATZ-MAIER, GO

48
rection (SN-Pog: 1.4). The anterior maxilla swivels
in a caudal direction, resulting in bite deepening (overbite: 1.5 mm).
In the literature, face masks with buccally mounted
hooks used to secure the rubber elastics have been
described to cause anterior rotation of the maxilla, with
changes in NL-NSL values ranging between 0.25
and 1.4.1,1216 The patient sample analyzed in the
present study revealed only a small degree of maxillary rotation. Possible reasons may be found in the
specific configuration we used, including a ventrocaudally oriented force vector, palatally mounted hooks to
hang in the rubber elastics, and intermittent treatment
with FOA appliances.
Our finding of posterior rotation of the mandible is
in keeping with similar results obtained in numerous
previous studies investigating various modified versions of the facemask.1419 The results of a meta-analysis by Jager et al13 and Kim et al3 revealed that SNMeGo angles became enlarged by 0.9 and 1.8 during treatment with face masks. Jager et al13 believed
that the main reason for the documented reductions of
SNB values by 0.9 was posterior rotation of the mandible.
The present study also confirmed that chin positions
were more dorsal after treatment with an additional
face mask than with FOA appliances only (SN-Pog: 0
vs 1.4). Posterior rotation of the mandible will counteract bite deepening. Yuksel et al20 observed a 1.9mm reduction in overbite during exclusive treatment
with face masks over 7 months in the early phase of
mixed dentition. This is in contrast to Chong et al,12
who reported increases in overbite of 0.8 mm following
exclusive treatment with face masks. In our patient
sample, face masks in combination with removable
appliances would also be associated with overbite increases of 0.5 mm. As a possible explanation for this
discrepancy, Naumann et al21 indicated that the degree of overbite is not directly related to any vertical
parameters in the lateral cephalograms.
Different effects of face masks and functional orthopedic appliances on vertical parameters were also reported by Cozza et al17 in a study dealing with patients
who wore a face mask in the first treatment phase,
followed by a functional orthopedic appliance in the
second phase. SN-MeGo and base angles increased
in the first phase, and one again decreased in the second phase. Macdonald et al11 also observed an enlargement of the FMA angle during 8 months of treatment with face masks, which again was followed by a
reduction over the next 2 years, during which no treatment was performed.
The proclination of maxillary anterior segments (angulation of the central incisors) in our group treated
exclusively with removable appliances can be asAngle Orthodontist, Vol 78, No 1, 2008

cribed to the impact of sagittally acting elements such


as Bertoni screws or Y plates. The skeletal effects observed in the face mask group gave rise to greater
increases of ANB values than in the FOA group. This
difference was statistically significant.
Surprisingly, some proclination of the mandibular
anterior segment (angulation of the central incisors)
was present both in the FOA group and in the face
mask group. A plausible explanation for this phenomenon would be that the observation period coincided
with the transition phase to permanent dentition in
about 30% of patients. The permanent anterior teeth
will erupt at a lingual position to the deciduous teeth
and will be prompted by lingual pressure to move in a
labial direction, thereby resulting in proclination of the
mandibular anterior segment.22
CONCLUSIONS
While improvements in sagittal relations (ANB, Wits,
and overjet) can be achieved with both therapeutic
approaches, the effect is more pronounced when the
face mask is used.
Exclusive treatment with plates and functional orthopedic appliances induces a reduction of the mandibular angle, causing the mandible to shift dorsally.
The anterior maxilla will move in a caudal direction
as the overbite stabilizes, thereby causing bite deepening.
Treatment with a face mask will increase the degree
of overjet, notably by dorsal rotation of the mandible.
However, the effect of the mask is mitigated by additional treatment with FOA appliances.
The changes revealed by the present study in overjet and cephalometric sagittal parameters demonstrate that early treatment is clinically indicated.
REFERENCES
1. Takada K, Petdachai S, Sakuda M. Changes in dentofacial
morphology in skelettal Class III children treated by a modified maxillary protraction headgear and a chin cup: a longitudinal cephalometric appraisal. Eur J Orthod. 1993;15:
211221.
2. Baccetti T, McGill JS, Franchi L, McNamara JA, Tollaro I.
Skelettal effects of early treatment of Class III malocclusion
with maxillary expansion and face-mask therapy. Am J Orthod Dentofac Orthop. 1998;113:333343.
3. Kim JH, Viana MAG, Graber TM, Omerza FF, BeGole EA.
The effectiveness of protaction face mask therapy: a metaanalysis. Am J Orthod Dentofacial Orthop. 1999;115:675
685.
4. Suda N, Ishii-Suzuki M, Hirose K, Hiyama S, Suzuki S, Kuroda T. Effective treatment plan for maxillary protraction: is
the bone age useful to determine the treatment plan? Am J
Orthod Dentofacial Orthop. 2000;118:5562.
5. Baccetti T, Tollaro I. A retrospective comparison of functional appliance treatment of Class III malocclusion in the

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EARLY TREATMENT OF CLASS III RELATIONS

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15.

deciduous and mixed dentitions. Eur J Orthod. 1998;20:


309317.
Wilhelm-Nold I, Droschl H. Die Fruhbehandlung der Progenie im Milchgebi im Vergleich zur Behandlung im Wechselgebi. Fortschr Kieferorthop. 1990;51:165179.
Jacobson A. The witsappraisal of jaw disharmony. Am
J Orthod. 1975;67:125138.
Panagiotidis G, Witt E. Der individualisierte ANBWinkel.
Fortschr Kieferorthop. 1977;38:408416.
Dahlberg G. Statistical Methods for Medical and Biological
Students. New York, NY: Interscience Publications; 1940.
SAS Institute Inc. JMP Version 4.0.0 [computer program].
Cary, NC: SAS Institute Inc; 2000.
Macdonald KE, Kapust AJ, Turley PK. Cephalometric
changes after the correction of Class III malocclusion with
maxillary expansion/facemask therapy. Am J Orthod Dentofacial Orthop. 1999;116:1324.
Chong YH, Ive JC, Artun J. Changes following the use of
protraction headgear for early correction of Class III malocclusion. Angle Orthod. 1996;66:351362.
Jager A, Braumann B, Kim C, Wahner S. Therapieeffekte
der maxillaren Protraktion bei Patienten mit einer AngleKlasse III. J Orofac Orthop. 2001;62:275284.
Ishii H, Morita S, Takeuchi Y, Nakamura S. Treatment effect
of combined maxillary protraction and chincap appliance in
severe skeletal Class III cases. Am J Orthod Dentofacial
Orthop. 1987;92:304312.
Kapust AJ, Sinclair PM, Turley PK. Cephalometric effects

16.

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of face mask/expansion therapy in Class III children: a comparison of three age groups. Am J Orthod Dentofacial Orthop. 1998;113:204212.
Ngan P, Hagg U, Yiu C, Merwin D, Wei SHY. Soft tissue
and dentoskeletal profile changes associated with maxillary
expansion and protraction headgear treatment. Am J Orthod Dentofacial Orthop. 1996;109:3849.
Cozza P, Marino A, Mucedero M. An orthopaedic approach
to the treatment of Class III malocclusions in the early mixed
dentition. Eur J Orthod. 2004;26:191199.
Kajiyama K, Murakami T, Suzuki A. Evaluation of the modified maxillary protractor applied to Class III malocclusion
with retruded maxilla in early mixed dentition. Am J Orthod
Dentofacial Orthop. 2000;118:549559.
Silva Filho OG, Magro AC, Capelozza Filho L. Early treatment of Class III malocclusion with rapid maxillary expansion and maxillary protraction. Am J Orthod Dentofacial Orthop. 1998;113:196203.
cem TT, Keykubat A. Early and late facemask
Yuksel S, U
therapy. Eur J Orthod. 2000;23:559568.
Naumann SA, Behrents RG, Buschang PH. Vertical components of overbite change: a mathematical model. Am J
Orthod Dentofacial Orthop. 2000;117:486495.
Bakker PJMR, Wassenberg HJW, Van der Linden FPGM.
Wechsel der unteren Schneidezahne. In: van der Linden
FPGM, ed. Der Verlauf des Zahnwechsels, Verlag zahnarztlich-medizinisches Schrifttum. Munchen, Germany: Verlag
zahnarztlich-medizinisches Schrifttum; 1980:35.

Angle Orthodontist, Vol 78, No 1, 2008

Original Article

Facial Soft Tissue Profile Following Bimaxillary Orthognathic Surgery


Ayse Tuba Altug-Ataca; Halise Bolatoglub; Ufuk Toygar Memikogluc
ABSTRACT
Objective: To determine the changes in the position and area of nasal and labial soft tissues in
adult skeletal Class III patients who underwent bimaxillary orthognathic surgery.
Materials and Methods: Pretreatment (T1), preoperative (T2), and posttreatment (T3) cephalometric variables and upper-lower lip areas were measured on lateral cephalometric radiographs
for 20 individuals (9 male, 11 female; mean age 21.3 years at T1, 22.4 years at T2, and 23.4
years at T3) who had maxillary advancement and mandibular setback. Analysis of variance (ANOVA) and Duncan tests were used to compare the cephalometric and area measurements at the
beginning of treatment, and at presurgery and postsurgery, respectively. Paired t-tests were also
performed to analyze changes within the periods.
Results: The tip of the nose was affected less with the movement of the underlying skeletal
structure (0.25%), while the soft tissue B point (B) moved equally with the skeletal B point. As
the maxilla related variables increased due to the forward movement, the upper labial areas
decreased. With the backward movement of the mandible, the middle and inferior lower labial
areas increased, while the superior lower labial area decreased.
Conclusions: The results of our study suggest that the dramatic improvement in the facial profiles
of the bimaxillary surgery patients is primarily related to the backward movement of the mandible
and the significant reduction in the superior lower lip area.
KEY WORDS: Class III malocclusion; Orthognathic surgery; Cephalometrics; Digital planimeter

INTRODUCTION

skeletal Class III discrepancies. Although several studies have been published on soft tissue changes following maxillary or mandibular surgery alone, few studies
have been reported on soft tissue changes with bimaxillary surgery. Moreover, the possibility that lip volume may be one of the most important contributing
factors in facial improvement makes including area
measurements in the prediction of postoperative soft
tissue changes imperative.2,3
Therefore, the aims of this study were (1) to evaluate the skeletal changes and soft tissue responses of
skeletal Class III patients treated by bimaxillary orthognathic surgery, and (2) to establish a relationship
between cephalometric linear measurements and
cephalometric area measurements.

Successful surgical planning and accurate prediction of orthognathic surgery outcomes include not only
occlusal correction and a well-balanced skeletal relationship, but the improvement of esthetics and function
as well. For this reason, the prediction of postsurgical
soft tissue changes is a crucial part of the presurgical
treatment planning process.1
A combination of mandibular setback plus maxillary
advancement is one of the most common bimaxillary
orthognathic surgical procedures for correcting severe

Assistant Professor, Department of Orthodontics, School of


Dentistry, University of Ankara, Ankara, Turkey.
b
Research Assistant, Department of Orthodontics, School of
Dentistry, University of Ankara, Ankara, Turkey.
c
Professor, Department of Orthodontics, School of Dentistry,
University of Ankara, Ankara, Turkey.
Corresponding author: Dr Ayse Tuba Altug-Atac, Ankara
Universitesi, Dis Hekimligi Fakultesi, Ortodonti Anabilim Dali,
06500, Besevler, Ankara, Turkey
(e-mail: aysealtug@yahoo.com)
a

MATERIALS AND METHODS


Twenty consecutive skeletal Class III patients (9
male, 11 female; mean age: 21.3 years; range: 17.08
30.08 years) were selected for this retrospective study.
All patients were treated at the Ankara University Departments of Orthodontics and Oral and Maxillofacial
Surgery.

Accepted: February 2007. Submitted: December 2006.


 2007 by The EH Angle Education and Research Foundation,
Inc.
Angle Orthodontist, Vol 78, No 1, 2008

50

DOI: 10.2319/122206-525.1

51

SOFT TISSUE PROFILE FOLLOWING BIMAXILLARY SURGERY


Table 1. The Distribution of the Patients According to Gender and
Mean Chronological Age for Stages T1 (Pretreatment), T2 (Presurgery), and T3 (Posttreatment)
Mean Chronological Age, Year

Female
Male
Total

T1

T2

T3

11
9
20

21.1
21.5
21.3

22.3
22.5
22.4

23.0
23.8
23.4

All patients:
Were nonsyndromic;
Received presurgical orthodontics by different residents but with the same protocol;
Underwent maxillary advancement by Le Fort 1 osteotomy (no maxillary impaction) and mandibular
setback by bilateral sagittal split osteotomy, without
any additional surgical procedures by the same surgical team.
The lateral cephalometric radiographs were taken
by the same operator on the same machine at three
time points (Table 1):

Figure 1. Skeletal measurements: 1: SNA; 2: SNB; 3: ANB; 4: SN/


GoGn; 5: A-VR; 6: A-HR; 7: B-VR; 8: Pg-VR. Dental measurements:
9: U1i-VR; 10: L1i-VR; 11: Overjet; 12: Overbite; 13: U1/ANS-PNS;
14: L1/Me-Go.

T1: Pretreatment;
T2: Immediate preoperative (24 days before surgery
for surgical planning);
T3: Posttreatment (following the removal of fixed orthodontic appliances, at least 10 months after surgery).
Cephalometric Analysis
Cephalograms were obtained under standardized
conditions. Patients were in centric occlusion, and a
relaxed lip position was obtained by requesting the patients to gently stroke their lips and relax.4 This was
repeated several times to ensure a relaxed position
without any muscular contraction.
Lateral cephalograms were traced, and cephalometric reference points were determined using acetate
tracing paper. The SN plane was taken as the horizontal reference plane (HR), and the perpendicular to
the SN plane through the S point was taken as the
vertical reference plane (VR). These reference planes
were used as guides in measuring the projected distances of the reference landmarks. Twenty-two landmarks were digitized and 32 variables analyzed using
the PorDios (Purpose on Request Digitizer Input Output System, trademark of the Institute of Orthodontic
Computer Science, Aarhus, Denmark) cephalometric
analysis program (Figures 1 and 2).
The upper and lower lip areas were measured in
mm2 on the lateral cephalograms using a digital planimeter (Ushikata X-Plan380dIII/460dIII, Tokyo, Japan) (Figure 3a, b). The upper lip was divided into two

Figure 2. Upper lip-related soft tissue measurements: 15: Pn-VR;


16: Sn-VR; 17: ULA-VR. Lower lip-related soft tissue and skeletal
measurements: 20: LLA-VR; 21: B-VR; 22: Pg-VR.

parts (Area 1 and 2) and the lower lip was divided into
three parts (Area 3, 4, and 5) (Figure 4).
Statistical Analysis
Statistical analysis was performed using the Minitab
statistical software package (Minitab Statistical Software Release 13 for Windows). Analysis of variance
(ANOVA) and Duncan tests were used to compare the
cephalometric and planimetric measurements of biAngle Orthodontist, Vol 78, No 1, 2008

52

ALTUG-ATAC, BOLATOGLU, MEMIKOGLU

Figure 4. Area measurements: The upper lip was divided into two
parts (Area 1 and 2). 18: Area 1: superior upper labial area; the area
between point A, subnasal, upper lip anterior and supradental point.
19: Area 2: inferior upper labial area; the area below supradental
and upper lip anterior line. The lower lip was divided into three parts
(Area 3, 4, and 5) from the incisal edge of the mandibular central
incisor (L1i), infradentale (Id), B point, and pogonion point. Lines
dividing the lower lip area were constructed parallel to the mandibular occlusal plane. 23: Area 3: superior lower labial area; 24: Area
4: middle lower labial area; 25: Area 5: inferior lower labial area.

maxillary orthognathic surgery patients at the beginning of treatment, and before and after surgery (Tables
2 and 3). Paired t-tests were also performed to analyze changes within the observation periods (Table 3).
The relationship of linear sagittal changes in soft-tissue variables to the repositioning of skeletal landmarks
was expressed using the following formula (Table 4):
T3-T2 mean of soft tissue changes
Ratio
T3-T2 mean of skeletal changes
Error Study
Cephalometric landmarks of a radiograph are digitized twice and the program (PorDios) automatically
rejects the digitizing procedure if the two digitized
points do not match. Area measurements were repeated three times by the same investigator, and the
average values of the three measurements were calculated to eliminate errors in measurement.
RESULTS
The comparison of the mean values and standard error of means of the soft tissue and skeletal variables
between three different observation periods of the treatment are presented in Table 2. The most significant differences in skeletal variables were observed in SNA (P
.001), subsequently in ANB (P .001), and A-VR (P
.05). The differences in dental measurements were
seen in U1i-VR (P .05), L1/Me-Go (P .01), and
overjet (P .001). The soft tissue variables differed from

Figure 3. (a) Digital planimeter. (b) Measurement of the areas using


the digital planimeter.
Angle Orthodontist, Vol 78, No 1, 2008

53

SOFT TISSUE PROFILE FOLLOWING BIMAXILLARY SURGERY

Table 2. Comparison of the Mean Values of the Soft and Skeletal Tissue Variables at the Beginning of Treatment (T1), End of Presurgical
Orthodontics (T2), and at the End of Treatment (T3) by Analysis of Variance (ANOVA) and Duncan Testa
T1 Pretreatment
Parameters

Sx

T2 Presurgery
X

T3 Posttreatment

Sx

Sx

Test

Skeletal Measurements
1. SNA, degrees
2. SNB, degrees
3. ANB, degrees
4. SN/GoGn, degrees
5. A-VR
6. A-HR
7. B-VR
8. Pg-VR

78.16
83.27
5.11
38.05
57.03
63.86
56.91
57.03

0.71
0.81
0.56
1.03
1.07
0.75
1.71
1.93

78.08
82.98
4.90
38.42
57.28
64.59
57.02
57.03

0.72
0.89
0.66
0.93
1.19
0.80
1.86
2.09

81.39
81.23
0.15
37.2
60.83
65.14
53.81
54.69

0.63
0.74
0.39
0.93
1.00
0.97
1.49
1.78

Dental Measurements
9. U1i-VR
10. L1i-VR
11. Overjet
12. Overbite
13. U1/ANS-PNS, degrees
14. L1/Me-Go, degrees

58.34
62.81
5.65
0.22
27.86
18.51

1.32
1.51
0.63
0.68
1.29
1.71

58.54
64.85
7.28
1.05
28.47
25.48

1.38
1.77
0.63
0.62
1.51
1.83

62.91
60.18
3.42
0.19
24.92
17.12

1.37
1.32
0.18
0.17
1.36
1.61

Upper Lip Measurements


15. Pn-VR
16. Sn-VR
17. ULA-VR
18. Area 1
19. Area 2

95.12
76.42
75.50
231.78
116.04

1.21
1.20
1.45
8.91
6.82

95.54
76.63
76.09
240.99
118.01

1.24
1.27
1.64
9.75
6.99

96.44
78.05
78.26
220.04
95.70

1.14
1.06
1.41
9.96
6.10

Lower Lip Measurements


20. LLA-VR
21. B-VR
22. Pg-VR
23. Area 3
24. Area 4
25. Area 5

76.54
69.41
68.75
190.80
129.38
166.35

1.69
1.80
1.95
10.6
6.39
7.94

78.22
69.31
68.70
184.7
129.85
184.85

2.01
2.01
2.10
13.1
7.45
9.98

74.88
65.97
66.79
142.85
142.23
203.7

1.56
1.55
1.65
9.97
5.38
10.7

23

13

***

***

***

***

***

***

***

***

***

**

12

**

**

**

**

**

* P .05; **P .01; ***P .001.


a
X indicates mean; Sx, the error of mean.

each other at Area 2 (P .05), Area 3 (P .01), and


Area 5 (P .05) between the three observation periods.
In Table 3, the changes between observation periods as couples (paired t-test; T2-T1, T3-T1 and T3T2) are presented, but the comparison between those
couples are evaluated (ANOVA and Duncan test).
There were significant differences between presurgery
(T1 and T2) and posttreatment (T3) stages for almost
all variables. As the mean values of the variables were
more or less similar in T1 and T2, almost no difference
in comparison of those time-points with posttreatment
was observed (BC). The only variable which was different in the comparison of BC was Area 5.
The ratios of the changes between the skeletal and
corresponding soft tissue variables are presented in
Table 4. This table shows the changes between T2
(presurgery) and T3 (posttreatment). Pronasale was
affected less with the movement of the underlying
skeletal structure (0.25%), while soft tissue B point (B)
moved equally with skeletal B point as a result of the
mandibular setback (1.04%). When the ratios in Table

4 are evaluated as a whole, the soft tissues are affected less in the nasal area and the soft tissue improvement increases gradually as we move to the labiomental and chin areas.
Table 5 gives us the comparison between the area
measurements and the corresponding linear soft and
skeletal tissue variables. As the maxilla and maxillary
dentoalveolar structures moved forward, the upper labial areas (Area 1 and 2) decreased. The middle and
inferior lower labial areas (Areas 4 and 5) increased
with the backward movement of the mandible. Area 3
(superior lower labial area) decreased, however, and
the lower incisors (L1i-VR) and lower lip (LLA-VR)
moved backward at the end of the treatment.
DISCUSSION
The relatively small sample size of the present study
(20 individuals: 9 male and 11 female) is a result of
the strict selection criteria applied so as to eliminate
some of the drawbacks of the retrospective study design.
Angle Orthodontist, Vol 78, No 1, 2008

54

ALTUG-ATAC, BOLATOGLU, MEMIKOGLU

Table 3. Comparison of the Cephalometric and Planimetric Changes Occurred During Presurgical Orthodontics (A; T2-T1), Between Pretreatment and Posttreatment Periods (B; T3-T1), and Presurgery and Posttreatment Periods (C; T3-T2), by Analysis of Variance (ANOVA) and
Duncan tests. Paired t-Tests Were Also Performed to Analyze Changes Within the Groupsa
A

T2-T1

T3-T1

T3-T2

Sd

Sd

Sd

Test

A-B

Skeletal Measurements
1. SNA, degrees
2. SNB, degrees
3. ANB, degrees
4. SN/GoGn, degrees
5. A-VR
6. A-HR
7. B-VR
8. Pg-VR

0.08
0.28
0.20
0.37
0.25
0.72
0.11
0.01

0.32
0.30
0.38
0.32
0.36
0.36
0.62
0.77

3.23***
2.03***
5.25***
0.85
3.80***
1.28*
3.10***
2.34*

0.44
0.39
0.38
0.70
0.49
0.57
0.80
0.99

3.30***
1.75***
5.05***
1.23
3.55***
0.56
3.21***
2.35*

0.44
0.28
0.46
0.68
0.46
0.50
0.72
0.86

***
***
***

***
***
***

***
***
***

***

***

***

**

**

**

Dental Measurements
9. U1i-VR
10. L1i-VR
11. Overjet
12. Overbite
13. U1/ANS-PNS, degrees
14. L1/Me-Go, degrees

0.21
2.04**
1.63**
1.27**
0.61
6.97***

0.51
0.68
0.54
0.38
1.28
1.52

4.58***
2.63**
9.07***
0.41
2.94*
1.39

0.63
0.79
0.63
0.71
1.30
1.24

4.37***
4.67***
10.70***
0.86
3.55***
8.36***

0.40
0.83
0.68
0.64
0.76
1.25

***
***
***
*
*
***

***
***
***
*
***

***
***
***
*
*
***

Upper Lip Measurements


15. Pn-VR
16. Sn-VR
17. ULA-VR
18. Area 1
19. Area 2

0.42
0.21
0.59
9.21
1.96

0.35
0.30
0.53
5.34
4.78

1.32**
1.63***
2.77***
11.74
20.35***

0.36
0.41
0.48
6.72
3.50

0.90**
1.42***
2.18***
20.95*
22.31***

0.30
0.35
0.50
8.06
4.68

*
*
**
***

*
*
**
***

*
*
**
***

Lower Lip Measurements


20. LLA-VR
21. B-VR
22. Pg-VR
23. Area 3
24. Area 4
25. Area 5

1.68*
0.10
0.05
6.10
0.47
18.50***

0.65
0.59
0.82
8.15
6.86
4.60

1.66*
3.43***
1.96
47.90***
12.86
37.32

0.67
0.86
0.96
10.2
6.24
5.10

3.34***
3.33***
1.91*
41.80*
12.39*
18.82***

0.62
0.79
0.75
15.7
5.49
3.99

***
**

***
**

**

**

**

**

Parameters

**

B-C

**

A-C

**

* P .05; **P 01; ***P .001.


a
D indicates mean of differences; Sd, standard error of the differences.

Table 4. The Ratios of the Movements of the Skeletal and Soft


Tissue Variables Following Bimaxillary Orthognathic Surgery (T2-T3)
Soft Tissue (S)

Hard Tissue (H)

D
Maxillary variables
Pn-VR
Sn-VR
ULA-VR
ULA-VR

Ratio
(S:H), %

0.90**
1.42***
2.18***
2.18***

A-VR
A-VR
A-VR
U1i-VR

3.55***
3.55***
3.55***
4.37***

0.25
0.40
0.61
0.50

Mandibular variables
LLA-VR
3.34***
B-VR
3.33***
Pg-VR
1.91*

L1i-VR
B-VR
Pg-VR

4.67***
3.21***
2.35*

0.72
1.04
0.81

* P .05; **P 01; ***P .001.


a
D indicates mean of differences.
Angle Orthodontist, Vol 78, No 1, 2008

Improvements in skeletal and soft tissue variables


following bimaxillary orthognathic surgery were
achieved in all patients included in this study. Postsurgical evaluation was assessed using lateral cephalometric radiographs taken at the end of treatment
(1014 months post surgery), and no edema was recorded clinically in any of the patients.5,6
In the present study, the use of any variable related
to the anterior nasal spine was avoided as maxillary
surgery will often alter that landmark. Alteration of
point A was also a possibility5; however, no clinical or
radiographic damage was observed in that area, thus
providing some reassurance for the use of point A as
a landmark.
Treatment outcomes were evaluated by comparing
immediate presurgery (T2) cephalograms, in which the
dentoalveolar structures were decompensated, with
posttreatment (T3) cephalograms. Pretreatment (T1)
radiographs were also used in order to overcome mis-

55

SOFT TISSUE PROFILE FOLLOWING BIMAXILLARY SURGERY

Table 5. The Relationship Between Linear Soft Tissue and Skeletal Tissue Movements of Maxillary-Mandibular Components and UpperLower Lip Areas Following Bimaxillary Orthognathic Surgery (T3-T2)
Soft Tissue

Hard Tissue
D

Soft Tissue
D

Maxillary variables
Area 1

Area 2

20.95*
22.31***

A-VR
U1i-VR

3.55***
4.37***

Sn-VR
ULA-VR

1.42***
2.18***

Mandibular variables
Area 3

Area 4

Area 5

41.80*
12.39*
18.82***

L1i-VR
B-VR
Pg-VR

4.67***
3.21***
2.35*

LLA-VR
B-VR
Pg-VR

3.34***
3.33***
1.91*

* P .05; **P 01; ***P .001.


a
D indicates means of differences; Sd, standard error of the differences.

interpretations resulting from the presence of brackets,


which may present a problem in any study evaluating
soft tissue changes, especially in the lips.
Recent cephalometric investigations have found that
movements of hard and soft tissue after orthognathic
operations were strongly correlated horizontally, but
not vertically,7 and that the position of the lips could
not be predicted accurately.8 In the present study, in
order to provide a better assessment of lip response
to hard tissue changes, the areas were examined and
linear horizontal changes used to establish a better
relationship between area measurements. The vertical
position of point A (A-HR) is included in Tables 2 and
3 to indicate that no maxillary superior repositioning
was planned or performed in any of the patients.
Several ratios have been presented over the years
by a number of workers, but most of these were related to maxillary or mandibular surgery alone.912 It is
commonly believed that changes following bimaxillary
surgery are similar to changes following the separate
performance of the two procedures.1 However, more
significant differences have been reported in soft tissue changes among bimaxillary patients than singlejaw surgery patients,13 and prediction errors have been
found to be more common among bimaxillary osteotomy patients than single-jaw osteotomy patients.14
Posposil14 explained the disparity as due to the dramatic soft tissue changes following bimaxillary surgeries, especially in skeletal Class III dysgnathia cases.
We also felt it necessary to separately evaluate bimaxillary surgeries and support our proportional findings with the results of changes in area.
The results of this study support the findings of previous studies showing the ratio of maxillary soft tissue
improvement to be lower than that of mandibular soft
tissue improvement following bimaxillary surgery (Table 4).8,7,15,16 Previous studies on single-jaw and bimaxillary surgery have explained the weaker soft tissue response following maxillary hard tissue advancement to be related to the resection of the anterior nasal

spine area during the Le Fort I osteotomy and the variability in surgical closure of the soft tissue incision in
maxillary surgery.6,7,1518
In agreement with the present study, the forward
movement of the tip of the nose (Pn-VR) and subnasal
area (Sn-VR) was previously reported to be less than
that of the upper lip (Table 4).10,11 Epker et al19 reported
that less advancement will produce less effect on the
nasal tip, whereas more advancement will not produce
more effect. The authors also reported that nasal tip
projection is affected only by the management of the
nasal septum at surgery.19 It has also been reported
that the nose tip change following maxillary advancement surgery is usually temporary.20
We recorded significant reductions in the upper lip
areas (Table 5; Area 1 and 2), despite significant forward movement in both the maxillary base and the
upper lip.6,10,21 Bays et al21 reported upper lip compression and thinning as a result of anterior repositioning
of the maxilla. It has also been suggested that thin lips
tend to follow the hard tissue more closely than thick
lips.22,23
The variability of soft tissue changes after maxillary
surgery is related to the differential response of various parts of the soft tissues, wide individual variation
in surgical wound healing, and surgical technique.
Since the surgical site is much closer to the upper lip
in maxillary surgery than in mandibular surgery, it is
not surprising that scarring of the upper incision during
wound healing would have a much greater affect on
the upper lip area than on the lower lip and chin area.
Additionally, firm attachment to the base of the nose
prevents the proportional horizontal and vertical movement of the upper lip in correspondence with hard tissue movement.11,16
It should also be remembered that the upper lip may
be supported by the lower incisors in presurgical patients exhibiting sagittal maxillary deficiency. In such
cases, advancement of the maxilla will not displace the
upper lip in proportion to the anterior maxillary moveAngle Orthodontist, Vol 78, No 1, 2008

56
ment.21 Stella et al23 mentioned a dead space, which
is most noticeable in more severely maxillary retrognathic patients, where an actual air pocket exists between the maxillary dentoalveolar structures and the
upper lip mucosa. The authors suggested that a maxilla advanced into this dead space would show no
change in soft tissue contours.23
The ratios of the anteroposterior movements of the
soft to hard tissue variables of the mandible are in general agreement with previous studies (for the ratio of
lower lip to mandibular incisal tip [0.72%]7,11,24; for soft
tissue to hard tissue B points [1.04%]7,24,25; and for soft
and hard tissue pogonion [0.81%]7) (Table 4). The relationship between the soft to hard tissue B point has
been observed to be the most creditable, but the relationship between soft and hard tissues gradually decreases at the level of the lower incisor and pogonion.
Although the Area 5 increases significantly at the pogonion level, the ratio is smaller compared to point
B.25,26 Stella et al23 and Gjrup and Athanasiou25 suggested that soft tissues at the chin are significantly
influenced by preoperative thickness of the area. The
adaptation of mental and superhyoid muscles to the
new position of the mandible may offer an additional
explanation for that finding.
The most significant relationship between soft-tohard tissues was observed at the lower incisor level.
In contrast to the increases in Areas 4 and 5, the area
related to the lower incisors (Area 3) decreased significantly at the end of treatment (Table 5). The lower
lip is morphologically different from other soft tissue
landmarks. It is pliable, directly influenced by the
movements of maxillary and mandibular incisors, perioral muscles and underlying muscle attachments, and
its thickness-tonicity differs among individuals.27 The
significant decrease found in the superior lower lip
area is likely attributable to overjet changes in correction of severe malocclusion.28 It is most likely that the
retruded position of the maxillary and mandibular incisors prior to surgery created an increase and anterior
curve in the pliable part of the lower lip (Area 3) that
was relatively decreased by surgery. The initial increase in the lower lip area could also be explained
by the effort to assure mouth closure in severe Class
III malocclusions.3 The stretching of the upper lip following maxillary advancement might have affected the
reduction in Area 3. Regardless of the cause, it is likely
that the decrease in lower lip area holds the key to the
improvement of facial esthetics in severe Class III patients.
CONCLUSIONS
The dramatic improvement in facial profiles of bimaxillary surgery patients is primarily related to
Angle Orthodontist, Vol 78, No 1, 2008

ALTUG-ATAC, BOLATOGLU, MEMIKOGLU

backward movement of the mandible and significant


reduction in the lower lip area.
Decreases in the superior lower lip area should be
considered during surgical planning for Class III patients so as not to worsen the soft tissue profile.
Because maxillary advancement does not significantly improve nose/upper lip tissues, it should be
avoided in borderline Class III patients, who would
benefit from a mandibular setback alone.
REFERENCES
1. Proffit WR. Treatment planning: the search for wisdom. In:
Proffit WR, White RP Jr, eds. Surgical Orthodontic Treatment. St Louis, Mo: Mosby-Year Book; 1991:142191.
2. Verdonck A, Jorissen E, Carels C, Van Thillo J. The interaction between soft tissues and the sagittal development of
the dentition and the face. Am J Orthod Dentofacial Orthop.
1993;104:342349.
3. Toygar UT, Akcam MO, Arman A. A cephalometric evaluation of lower lip in patients with unilateral cleft and palate.
Cleft Palate Craniofac J. 2004;41:485489.
4. Burstone CJ. Lip posture and its significance in treatment
planning. Am J Orthod. 1967;53:262284.
5. Bailey LTJ, Collie FM, White RP Jr. Long-term soft tissue
changes after orthognathic surgery. Int J Adult Orthodon
Orthognath Surg. 1996;11:718.
6. Enacar A, Ugur Taner T, Toroglu S. Analysis of soft tissue
profile changes associated with mandibular setback and
double-jaw surgeries. Int J Adult Orthodon Orthognath Surg.
1999;14:2735.
7. Chew MT. Soft and hard tissue changes after bimaxillary
surgery in Chinese Class III patients. Angle Orthod. 2005;
75:959963.
8. Koh CH, Chew MT. Predictability of soft tissue profile
changes following bimaxillary surgery in skeletal Class III
Chinese patients. J Oral Maxillofac Surg. 2004;62:1505
1509.
9. Hershey HC, Smith LH. Soft tissue profile change associated with surgical correction of the prognathic mandible. Am
J Orthod. 1974;65:483502.
10. Dann JJ 3rd, Fonseca RJ, Bell WH. Soft tissue changes
associated with total maxillary advancement: a preliminary
study. J Oral Surg. 1976;34:1923.
11. Lines PA, Steinhauser WW. Soft tissue changes in relationship to movement of hard structures in orthognathic surgery:
preliminary report. J Oral Surg. 1974;32:891896.
12. Turvey TA, White RP Jr. Maxillary surgery. In: Proffit WR,
White RP Jr, eds. Surgical Orthodontic Treatment. St Louis,
Mo: Mosby-Year Book; 1991:248263.
13. Eckhardt CE, Cunningham SJ. How predictable is orthognathic surgery? Eur J Orthod. 2004;26:303309.
14. Posposil OA. Reliability and feasibility of prediction tracing in
orthognathic surgery. J Craniomaxillofac Surg. 1987;15:79.
15. Jensen AC, Sinclair PM, Wolford LM. Soft tissue changes
associated with double jaw surgery. Am J Orthod Dentofacial Orthop. 1992;101:266275.
16. Lin SS, Kerr WJS. Soft and hard tissue changes in Class
III patients treated by bimaxillary surgery. Eur J Orthod.
1998;20:2533.
17. Mansour S, Burstone C, Legan H. An evaluation of soft tissue changes resulting from Le Fort I maxillary surgery. Am
J Orthod. 1983;84:3747.
18. Rosen HM. Lip-nasal aesthetics following Le Fort I osteotomy. Plast Reconstr Surg. 1988;81:171179.

SOFT TISSUE PROFILE FOLLOWING BIMAXILLARY SURGERY

19. Epker BN, Stella JP, Fish LC, eds. Maxillary deficiency.
Chapter 11, In: Dentofacial Deformities. Integrated Orthodontic and Surgical Correction. Vol 1. St Louis, MO: Mosby
Year Book; 1986:492538.
20. Turvey TA, White RP. Maxillary surgery. In: Proffit WR,
White RP, eds. Surgical Orthodontic Treatment. St Louis,
Mo: Mosby-Year Book; 1991:248263.
21. Bays RA, Hegtvedt AK, Timmis DP. Maxillary Orthognathic
surgery. In: Peterson LJ, ed. Principles of Oral and Maxillofacial Surgery. Philadelphia, Pa: Lippincott-Raven Publishers; 1997:13731376.
22. Oliver BM. The influence of lip thickness and strain on upper
lip response to incisor retraction. Am J Orthod. 1982;82:141.
23. Stella JP, Streater MR, Epker BN, Sinn DP. Predictability of
upper lip soft tissue changes with maxillary advancement.
J Oral Maxillofac Surg. 1989;47:697703.

57
24. Suckiel JM, Kohn MW. Soft tissue changes related to the
surgical management of mandibular prognathism. Am J Orthod. 1978;73:676680.
25. Gjrup H, Athanasiou AE. Soft-tissue and dentoskeletal
profile changes associated with mandibular setback osteotomy. Am J Orthod Dentofacial Orthop. 1991;100:312
323.
26. Gaggl A, Schultes G, Karber H. Changes in soft tissue profile after sagittal split ramus osteotomy and retropositioning
of the mandible. J Oral Maxillofac Surg. 1999;57:542.
27. Lu CH, Ko EWC, Huang CS. The accuracy of video imaging
prediction in soft tissue outcome after bimaxillary orthognathic surgery. J Oral Maxillofac Surg. 2003;61:333342.
28. Sarver DM, Weissman SM. Long-term soft tissue response
to Le Fort I maxillary superior repositioning. Angle Orthod.
1991;61:267276.

Angle Orthodontist, Vol 78, No 1, 2008

Original Article

Soft Tissue Profile in White Brazilian Adults with


Normal Occlusions and Well-Balanced Faces
Helio Scavone Jra; Wesley Zahn-Silvab; Karyna Martins do Valle-Corottia;
Ana Carla Raphaelli Nahasa
ABSTRACT
Objective: To analyze anteroposterior soft tissue facial parameters for a sample of white Brazilian
adults and to compare these measurements with the values proposed for white North American
adults.
Materials and Methods: Facial profile photographs were taken of 59 white Brazilians (30 men
and 29 women) with normal occlusions and balanced faces with ages ranging from 18 to 30
years. The independent Students t-test (P .05) was used to compare the soft tissue parameters
of the Brazilians with those of the North Americans.
Results: White Brazilian women presented a less protruded face compared with white American
women except for the glabella region. White Brazilian women showed a smaller nasal projection,
less protruded upper and lower lips, a more obtuse nasolabial angle, and a smaller projection of
the B point and chin than white American women. Conversely, the two male groups demonstrated
less evident soft tissue profile differences, with the exception of the nose projection, which was
smaller in white Brazilian men than in white American men.
Conclusions: A universal standard of facial esthetic is not applicable to diverse white populations.
Differences regarding the soft tissue profile features were found between white Brazilians and
white Americans. These differences should be considered in the orthodontic/orthognathic surgery
diagnosis and treatment plan for white Brazilians together with the patients individual opinion and
perception of beauty.
KEY WORDS: Photographs; Facial profile; Normal occlusion

INTRODUCTION

tures and soft tissue profile between white Americans/


Europeans and African-Americans,13 Koreans,4 Japanese,512 and Chinese.13 Facial differences between
white populations of distinct continents or countries
have been reported previously also.1421
Among the several numeric facial analyses currently
employed, the analysis proposed by Arnett et al22 has
been used broadly by orthodontists and maxillofacial
surgeons. However, the measurements proposed for
these analyses were achieved based on a white American sample and may not be applicable as a reference
for diagnosis and treatment of other ethnic groups.
White Americans descend mostly from English, Polish,
Dutch, and French populations. Scottish, Spanish, and
Scandinavian populations are also part of the immigration history of North America. On the other hand,
white Brazilians come from the Mediterranean countries, primarily Portugal, Italy, and Spain. Considering
these background differences, the facial standards for
white Brazilians might be distinct from the norms of
white Americans. Scavone et al23 also demonstrated

Although numerous previous attempts were made to


identify an esthetic facial ideal, contemporary orthodontics recognizes the ethnic and personal diversity of
human facial contours. A large number of studies demonstrated the presence of specific dentofacial characteristics in each ethnic group, leading professionals
to consider these differences in orthodontic and surgical diagnosis and treatment planning. Remarkable
differences have been identified in both skeletal feaAssociate Professor, Department of Orthodontics, University
of Sao Paulo City, Sao Paulo, Brazil.
b
Graduate student (MS), Department of Orthodontics, University of Sao Paulo City, Sao Paulo, Brazil.
Corresponding author: Dr Helio Scavone Jr, Department of
Orthodontics, University of Sao Paulo City, R Cesario Galero,
432/448, Sao Paulo, SP, 03071-000, Brazil
(e-mail: helioorto@uol.com.br)
a

Accepted: February 2007. Submitted: October 2006.


 2007 by The EH Angle Education and Research Foundation,
Inc.
Angle Orthodontist, Vol 78, No 1, 2008

58

DOI: 10.2319/103006-447.1

EVALUATION OF SOFT TISSUE PROFILE

59

significant differences between Japanese Brazilians


and white Americans, as measured by the seven soft
tissue facial profile normative values proposed by Arnett el al.22 The results of this recent study emphasize
the importance of determining reference values specific for each ethnic group.
Therefore, the goals of this study were to establish,
on the basis of facial profile photographs, some reference values for seven anteroposterior soft tissue
variables in a sample of white Brazilian adults with normal occlusions and well-balanced faces, and also to
compare these values with those proposed by Arnett
et al.22
MATERIALS AND METHODS
The sample included 59 white Brazilian adults (30
men and 29 women) prospectively selected by two
Brazilian orthodontists on the basis of the following criteria: age from 18 to 30 years; presenting clinically
normal occlusions24 (accepting minor crowding); showing orthognathic profiles, closed lip posture (lip sealing), and facial symmetry; no previous orthodontic
treatment; no history of trauma or plastic or orthognathic surgery.
Standardized facial profile photographs were taken
with the patient in the natural head position (NHP),2529
centric relation, and relaxed lip posture.29 All photographs were taken with a Yashica Dental Eye III camera mounted on a tripod, leveled with the optical axis
of the lens horizontal and the film plane vertical. The
subjects were positioned standing at 1.7 meters from
the camera in a mechanical device used to provide
both a vertical reference line perpendicular to the floor
plane (true vertical line) and a real metric scale during
image measurement.
Photographs were digitized with a Microsoft computer (Microsoft Corporation) that used Deskscan II
version 2.9 software and a Hewlett Packard Scanjet
4C image scanner (Hewlett-Packard Development
Company) with 300 DPI resolution. Images were
transferred to the Radiocef 2000 software (Radio
Memory, Belo Horizonte, Brazil) where landmark identification (Figure 1) was performed by a single calibrated investigator, and soft tissue profile variables
(Figure 2) were measured. The true vertical line (TVL)
was originally represented by the metric scale perpendicular to the floor. Later, it was transferred directly
over the computerized image of the soft tissue facial
profile, passing through subnasale (Sn). The image/
actual size ratio was calculated by means of the same
software, having the metric scale image as a reference
parameter.
The mean and standard deviation of each variable
were determined for male and female subgroups. In-

Figure 1. Soft tissue points used in the facial profile evaluation: glabella (G), nasal tip (NT), columnella (C), subnasale (Sn), upper lip
anterior (ULA), lower lip anterior (LLA), soft tissue B point (B), and
soft tissue pogonion (Pog).

Figure 2. Linear measurements (true vertical line [TVL] projections).


TVLG: horizontal distance from TVL to glabella point; TVLNT:
horizontal distance from TVL to nasal tip point; TVLULA: horizontal
distance from TVL to upper lip anterior point; TVLLLA: horizontal
distance from TVL to lower lip anterior point; TVLB: horizontal distance from TVL to soft tissue B point; TVLPog: horizontal distance
from TVL to soft tissue pogonion point. The TVL is perpendicular to
the floor plane and passes through the subnasale point (Sn).
Angle Orthodontist, Vol 78, No 1, 2008

SCAVONE JR, ZAHN-SILVA, DO VALLE-COROTTI, NAHAS

60
dependent t-tests were used to compare male-female
differences and to compare the white Brazilian sample
values with those originally proposed by Arnett et al22
for a white American sample. Results were regarded
as significant for P .05.
In order to assess the method error, 20 photographs
of the sample were randomly selected and measured
again 45 days after the first evaluation. Casual and
systematic errors were calculated comparing the first
and second measurements with Dahlbergs formula30
and dependent t-test, respectively, at a significance
level of 0.05.
A method was also developed to assess eventual
distortions in the photographic images and the corresponding measurements. With this purpose, millimetric scales were fixed horizontally and vertically in the
mechanical device utilized to provide the reference
vertical line (true vertical line). Subsequently, 10 photographs were taken of these millimetric scales, their
images transferred to Radiocef 2000 software and 12
segments of 100 mm were measured with this software. The measurements obtained by the computerized method, based on the photographic images of the
millimetric scales, were compared to the real known
size of the segments, ie, 100 mm. The differences between the computerized measurements and the actual
size measured defined the distortions of the photographic images in the 12 regions evaluated in the photographic area, horizontally and vertically.

Table 1. Comparison of White-Brazilian Facial Profile Variables


Between Female and Male Subjects (t-Test)a

RESULTS

White Brazilian/White American Comparisons

None of the variables had statistically significant


systematic errors. The causal errors ranged from 0.52
(TVLLLA) to 0.58 (TLVB), with the exception of
NLA, which showed a more considerable error of 4.04.
The image/actual size ratio of the photographs corresponded to 1:2.8. Linear measurements were converted and are presented as the actual dimensions.
The distortions of the photographic measurements
were extremely reduced and never exceeded 0.76%
in any of the directions evaluated.

All evaluated soft tissue variables showed statistical


significant differences between white Brazilian and
white American female subjects (Table 2). White Brazilian women presented with the glabella more anteriorly positioned, smaller nasal projection, less protruded upper and lower lips, and a more obtuse nasolabial
angle compared with white American women. Additionally, a smaller projection of the B point and chin,
in relation to the true vertical line, was noted in the
white Brazilian women.
Among the seven soft tissue variables analyzed,
only one demonstrated a significant difference between white Brazilian and white American male subjects (Table 3). The nasal projection (TLV-NT) was
smaller in the white Brazilian men compared with the
white American men with a mean difference of 2.1
mm. Although no statistically significant differences
had been recorded between the two male groups regarding the other variables, white Brazilian men
showed a tendency toward a less protruded face in all
facial levels analyzed, except for the mentolabial sulcus (Table 3).

Sexual Dimorphism
Table 1 presents the mean and standard deviation
of measurements for the male and female white Brazilian samples. The soft tissue profile variables that
showed significant sexual dimorphism were TLV-NT
and TLV-ULA. The male subjects had a slightly greater
nasal projection (mean difference: 1.4 mm) and larger
upper lip protrusion (mean difference: 1 mm) compared with the female subjects.
Angle Orthodontist, Vol 78, No 1, 2008

Female (n 29)

Male (n 30)

Variables

Mean

SD

Mean

SD

Significance

TVL-G
TVL-NT
TVL-ULA
TVL-LLA
TVL-B
TVL-Pog
NLA

5.5
13.9
1.3
1.0
7.8
6.4
113.9

4.3
1.6
1.8
2.8
4.1
5.2
10.8

7.4
15.3
2.3
0.0
7.1
4.5
108.9

3.8
2.1
1.8
2.2
3.4
5.1
11.6

NS
**
*
NS
NS
NS
NS

a
n indicates number of patients; SD, standard deviation; NS, not
significant.
* P .05; ** P .01; *** P .001.

Table 2. Female Comparisons Between White-Brazilian (n 29)


and White-American (n 26) Samples (t-Test)a
White-Brazilian

White-American
(Arnett et al)

Variables

Mean

SD

Mean

SD

Significance

TVL-G
TVL-NT
TVL-ULA
TVL-LLA
TVL-B
TVL-Pog
NLA

5.5
13.9
1.3
1.0
7.8
6.4
113.9

4.3
1.6
1.8
2.8
4.1
5.2
10.8

8.5
16.0
3.7
1.9
5.3
2.6
103.5

2.4
1.4
1.2
1.4
1.5
1.9
6.8

**
***
***
***
**
***
**

n indicates number of patients; SD, standard deviation.


* P .05 ** P .01 *** P .001.

61

EVALUATION OF SOFT TISSUE PROFILE


Table 3. Male Comparisons Between White-Brazilian (n 30) and
White-American (n 20) Samples (t-Test)a
White-Brazilian

White-American
(Arnett et al)

Variables

Mean

SD

Mean

SD

Significance

TVL-G
TVL-NT
TVL-ULA
TVL-LLA
TVL-B
TVL-Pog
NLA

7.4
15.3
2.3
0.0
7.1
4.5
108.9

3.8
2.1
1.8
2.2
3.4
5.1
11.6

8.0
17.4
3.3
1.0
7.1
3.5
106.4

2.5
1.7
1.7
2.2
1.6
1.8
7.7

NS
***
NS
NS
NS
NS
NS

a
n indicates number of patients; SD, standard deviation; NS, not
significant.
* P .05; ** P .01; *** P .001.

DISCUSSION
The present study was designed to establish reference values in a sample of white Brazilian adults for
some soft tissue facial profile variables, and also to
compare the results with normative values that were
proposed by Arnett et al22 for white Americans. It is
important to emphasize that the main inclusion criteria
were normal occlusion and facial balance, which are
not always related to beauty, and perception of which
is subjective and depends on cultural trends.
Even though this study conducted a numeric analysis of the facial profile, standardized facial photographs were used instead of cephalometrics, since the
Brazilian Ethical Committee does not allow radiographic exposure of patients for the exclusive purpose
of investigation. Therefore, in order to compare the
values achieved from the white Brazilian sample with
those proposed by Arnett et al22 for white Americans,
the reduction factor of the photographic image was
calculated and the linear measurements were corrected for their actual values.
All photographs were digitized and measured by the
same examiner, to eliminate the interexaminer error.
Systematic errors of the evaluated variables were not
statistically significant. Casual errors for most measurements were reduced and will not be addressed
except for the nasolabial angle (mean 4.04), for
which results should be interpreted with care. The
magnitude of the NLA significant error may be assigned to the difficulty in identifying the points involved
in this measurement, especially subnasale and columnella. Additionally, the proximity between the three
points used in the construction of NLA might also contribute to this error. Despite the distortion of the photographic images and the corresponding measurement methods, the method adopted in this research
was reliable since the maximum distortion verified never exceeded 0.76%.
Only two soft tissue variables presented statistically

significant sexual dimorphism in the white Brazilian sample. White Brazilian male subjects showed a more prominent nose and a more protruded upper lip. In white
American patients, Arnett et al,22 using the true vertical
line as a reference, observed that male patients presented a more protruded nose and a less projected B
point than female patients. Considering a different reference line (vertical line passing through porion) in the
evaluation of the soft tissue profile, Lundstrom et al31
showed that white male patients had a greater projection
of nasion, nose tip, upper and lower lips, point B, and
chin compared with white female patents.
The soft tissue profile features of white Brazilian
women were quite distinct compared with white American women. All linear variables analyzed were smaller
in the white Brazilian women showing that they have
a smaller nose and a more retruded lower face than
white American women (Table 2). Although a previous
study on cephalometric standards for white Brazilians
had shown more protruded incisors compared to white
Americans,16 the results of this study pointed to more
posteriorly positioned lips in the former. The upper and
lower lips of white Brazilian women were respectively
2.4 and 2.9 mm less protruded than the white American women. The nasolabial angle was also more
opened in the white Brazilian women confirming the
retrusive profile pattern.
White Brazilian women also exhibited a smaller projection of B point and chin, with a mean difference of
2.5 and 3.8 mm, respectively, in relation to white
American women. Differently from the women, white
Brazilian men had just a few differences from white
American men regarding the soft tissue profile characteristics. White Brazilian men showed a smaller
nose and a less protruded upper lip than white American men, with a mean difference of 1.4 and 1.0 mm,
respectively (Table 3).
These results are in accordance with other studies
that also showed facial profile differences between different white groups. Erbay et al18 reported that Anatolian Turkish adults had more retrusive upper and
lower lips compared with white American norms. Borman et al21 found a more convex facial profile and
more closed nasolabial angle in Turkish adults than in
other populations. Comparing Saudis and white Americans, Hashim and AlBarakati20 showed significant differences in most of the soft tissue variables evaluated.
In addition, differences in dentoskeletal cephalometric
norms were also found between white Americans and
Greeks,14 white Brazilians,16 and white Europeans.19
On the other hand, analyzing some soft tissue profile
variables, Lundstrom et al30 did not find differences between Swedish subjects and white Americans.
It must be stressed that many of the soft tissue profile differences found between the Brazilian and the
Angle Orthodontist, Vol 78, No 1, 2008

SCAVONE JR, ZAHN-SILVA, DO VALLE-COROTTI, NAHAS

62
American samples may not be attributable only to ethnic differences, but also to examiners individual perceptions of facial balance. Although the Brazilian sample comprised adults with normal occlusions and balanced faces, this does not necessarily mean a high
standard of facial beauty. In fact, probably it would be
better to say that this sample included men and women with satisfactory facial balance. Similarly, the American sample22 was selected according to the personal
judgment of just one of the authors. Of course, the
American sample does not represent the average soft
tissue facial profile of white Americans. In the same
way, the selection of the Brazilian sample was also
influenced by individual perceptions of the examiners.
However, the purpose of this investigation was not to
establish standards of beauty, but instead to provide
some reference values that can be helpful for soft tissue facial profile evaluation.
In general, Brazilians exhibited a large variability of
the soft tissue profile features, as shown by the high
values of the standard deviation of the variables analyzed (Tables 2 and 3). This means that there is considerable diversity of the facial profile in patients with
normal occlusions and well-balanced faces, and this
point should be taken into account. In addition, it is
also important to highlight that the results could have
been different, especially regarding lip protrusion, if
the sample had been selected on the basis of facial
beauty by the public. Peck and Peck32 showed that the
general public admires a more protrusive dentofacial
pattern in relation to the cephalometric standards dictated. Auger and Turley33 and Nguyen and Turley34
concluded that there was a linear trend toward fuller
and more anteriorly positioned lips in fashion magazines during the last century.
CONCLUSIONS
Differences regarding the soft tissue profile features
exist between white Brazilians and white Americans.
A universal standard of facial profile esthetic is not
applicable to diverse white populations.
REFERENCES
1. Huang WJ, Taylor RW, Dasanayake AP. Determining cephalometric norms for Caucasians and African Americans in
Birmingham. Angle Orthod. 1998;68(6):503512.
2. Sushner NI. A photographic study of the soft-tissue profile
of the Negro population. Am J Orthod. 1977;72(4):373385.
3. Sutter RE Jr, Turley PK. Soft tissue evaluation of contemporary Caucasian and African American female facial profiles. Angle Orthod. 1998;68(6):487496.
4. Hwang HS, Kim WS, McNamara JA Jr. Ethnic differences
in the soft tissue profile of Korean and European-American
adults with normal occlusions and well-balanced faces. Angle Orthod. 2002;72(1):7280.
5. Alcalde RE, Jinno T, Pogrel MA, Matsumura T. CephaloAngle Orthodontist, Vol 78, No 1, 2008

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9.
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11.

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metric norms in Japanese adults. J Oral Maxillofac Surg.


1998;56(2):129134.
Miyajima K, McNamara JA Jr, Kimura T, Murata S, Iizuka
T. Craniofacial structure of Japanese and European-American adults with normal occlusions and well-balanced faces.
Am J Orthod Dentofacial Orthop. 1996;110(4):431438.
Miura F, Inoue N, Suzuki K. Cephalometric standards for
Japanese according to the Steiner analysis. Am J Orthod.
1965;51:288295.
Takahashi R, Pinzan A, Henriques JF, Freitas MR, Almeida
RR, Janson G. FOB-USP Cephalometric standards for Japanese-Brazilian youths with normal occlusion. R Dental
Press Orthodon Orthop Facial. 2001;6(2):1324.
Engel G, Spolter BM. Cephalometric and visual norms for
a Japanese population. Am J Orthod. 1981;80(1):4860.
Cotton WN, Takano WS, Wong WM. The Downs analysis
applied to three other ethnic groups. Angle Orthod. 1951;
21(4):213220.
Iwasawa T, Moro T, Nakamura K. Tweed triangle and softtissue consideration of Japanese with normal occlusion and
good facial profile. Am J Orthod. 1977;72(2):119127.
Reitz PV, Aoki H, Yoshioka M, Uehara J, Kubota Y. A cephalometric study of tooth position as related to facial structure
in profiles of human beings: a comparison of Japanese (Oriental) and American (Caucasian) adults. J Prosthet Dent.
1973;29(21):157166.
Cooke MS, Wei SH. A comparative study of southern Chinese and British Caucasian cephalometric standards. Angle
Orthod. 1989;59(2):131138.
Argyropoulos E, Sassouni V. Comparison of the dentofacial
patterns for native Greek and American-Caucasian adolescents. Am J Orthod Dentofacial Orthop. 1989;95(3):238
249.
Basciftci FA, Uysal T, Buyukerkmen A. Craniofacial structure of Anatolian Turkish adults with normal occlusions and
well-balanced faces. Am J Orthod Dentofacial Orthop. 2004;
125(3):366372.
Cerci V, Martins JE, Oliveira MA. Cephalometric standards
for white Brazilians. Int J Adult Orthodon Orthognath Surg.
1993;8(4):287292.
Erbay EF, Caniklioglu CM. Soft tissue profile in Anatolian
Turkish adults: Part II. Comparison of different soft tissue
analyses in the evaluation of beauty. Am J Orthod Dentofacial Orthop. 2002;121(1):6572.
Erbay EF, Caniklioglu CM, Erbay SK. Soft tissue profile in
Anatolian Turkish adults: part I. Evaluation of horizontal lip
position using different soft tissue analyses. Am J Orthod
Dentofacial Orthop. 2002;121(1):5764.
Franchi L, Bacetti T, McNamara JA Jr. Cephalometric floating norms for North American adults. Angle Orthod. 1998;
68(6):497502.
Hashim HA, AlBarakati SF. Cephalometric soft tissue profile
analysis between two different ethnic groups: a comparative
study. J Contemp Dent Pract. 2003;4(2):6073.
zgur F, Gursu G. Evaluation of soft-tissue morBorman H, O
phology of the face in 1,050 young adults. Ann Plast Surg.
1999;42(3):280288.
Arnett GW, Jelic JS, Kim J, Cummings DR, Beress A, Worley CM Jr, Chung B, Bergman R. Soft tissue cephalometric
analysis: diagnosis and treatment planning of dentofacial
deformity. Am J Orthod Dentofacial Orthop. 1999;116(3):
239253.
Scavone H Jr, Trevisan H Jr, Garib DG, Ferreira VF. Facial
profile evaluation in Japanese-Brazilian adults with normal
occlusions and well-balanced faces. Am J Orthod Dentofacial Orthop. 2006;129:721. e1e5.

EVALUATION OF SOFT TISSUE PROFILE

24. Angle EH. Malocclusion. In: Angle EH, ed. Treatment of


Malocclusion of the Teeth. 7th ed. Philadelphia, Pa: SS
White Dental Manufacturing Company; 1907:2859.
25. Lundstrom F, Lundstrom A. Natural head position as a basis
for cephalometric analysis. Am J Orthod Dentofacial Orthop.
1992;101(3):244247.
26. Moorrees CFA, Kean MR. Natural head position, a basic
consideration in the interpretation of cephalometric radiographs. Am J Phys Anthropol. 1958;16:213234.
27. Moorrees CF. Natural head positiona revival. Am J Orthod Dentofacial Orthop. 1994;105(5):512513.
28. Viazis AD. A cephalometric analysis based on natural head
position. J Clin Orthod. 1991;3:172181.
29. Arnett GW, Bergman RT. Facial keys to orthodontic diagnosis and treatment planning. Part I. Am J Orthod Dentofacial Orthop. 1993;103(4):299312.

63
30. Dahlberg G. Statistical Methods for Medical and Biological
Students. New York, NY: Interscience; 1940:122132.
31. Lundstrom A, Forsberg CM, Peck S, McWilliam J. A proportional analysis of the soft tissue facial profile in young
adults with normal occlusion. Angle Orthod. 1992;62(2):
127133.
32. Peck H, Peck S. A concept of facial esthetics. Angle Orthod.
1970;40(4):284318.
33. Auger T, Turley P. The female soft tissue profile as presented in fashion magazines during the 1900s: a photographic analysis. Int J Adult Orthodon Orthognath Surg.
1999;14(1):718.
34. Nguyen D, Turley P. Changes in the Caucasian male facial
profile as depicted in fashion magazines during the twentieth century. Am J Orthod Dentofacial Orthop. 1998;114(2):
208217.

Angle Orthodontist, Vol 78, No 1, 2008

Original Article

Occlusal Changes from Primary to Mixed Dentitions in Nigerian Children


Chukwudi Ochi Onyeasoa; Michael Chukwudi Isiekweb
ABSTRACT
Objective: To evaluate longitudinally the occlusal changes between the deciduous and early
mixed dentition stages in Nigerian children.
Materials and Methods: The occlusion of 145 3- to 5-year-old children was initially assessed at
a popular pre-primary school center in Ibadan, Nigeria in October 2002, using the Foster and
Hamilton criteria. The same group of children was followed up for reexamination in October 2006
in the primary school section of the center. Of 61 students who were located and reexamined, 54
(26 male and 28 female) qualified for the study. The molar relationship was assessed using Angle
classification, and other occlusal features such as spacing, crowding, overbite, and overjet were
also assessed. Descriptive statistics, chi-square test, as well as Pearson correlation coefficient,
were applied as appropriate in the analysis of the data.
Results: Of 32 subjects initially having a flush terminal relationship (Class 1), 22 (68.7%) resulted
in a Class I molar relationship, seven (21.9%) had Class II, and three (9.4%) had asymmetric
relationships. Mesial step (Class III) was formed initially in 18 and 11 (61.1%) resulted in Class
I. A Class III developed in five (27.8%). Significant positive correlations were found for molar
relationship, crowding, overbite, and overjet variables (P .01) between the two periods of assessments, but all were below 0.7 value.
Conclusions: Angle Class I molar relationship was favored by initial flush terminal plane and
mesial step relationships in the deciduous dentition.
KEY WORDS: Occlusion; Growth; Development; Nigerian children

INTRODUCTION

sion are often reflected or worsened in the permanent


dentition.1,79 Therefore, the primary dentition is believed to provide the basis for studying occlusion and
for predicting the occlusion of the permanent dentition.
Relatively recently there were some reports on the
occlusion of the pre-primary Nigerian school children,
aged 35 years, which have provided some information on the pattern of occlusion in the primary dentition
in the country.1015 Nigeria being a large multi-ethnic
nation, the last reports attempted to assess any possible ethnic variations in the occlusion of the preschool
children.14,15
Just like in other countries, the philosophy of early
orthodontic treatment and preventive and interceptive
orthodontics is advocated in Nigeria.13,1621 This treatment philosophy is more needful considering the high
poverty level in a developing economy like Nigeria and
the high cost of comprehensive orthodontic treatment.
According to Bishara et al,1 an understanding of the
anteroposterior changes that occur in the occlusion
between the deciduous and permanent dentition is
crucial for the clinician involved in early orthodontic
treatment. While there are studies from other parts of
the globe in relation to growth and development of the

The establishment and maintenance of normal occlusion constitute one of the important objectives of
orthodontic treatment whether it is preventive, interceptive, or corrective.1 Understandably, earlier reports
on occlusal characteristics or patterns in Nigerian population involved only the permanent dentition.26 However, the status of the primary dentition affects the development of the permanent occlusion to the extent
that certain traits and anomalies of the primary occlu-

a
Senior Lecturer/Consultant Orthodontist, Department of
Child Oral Health, Faculty of Dentistry, College of Medicine, University College Hospital, University of Ibadan, Ibadan, Nigeria.
b
Professor, Department of Child Dental Health, School of
Dentistry, College of Medicine, Lagos, University Teaching Hospital (LUTH), University of Lagos, Lagos, Nigeria.
Corresponding author: Dr CO Onyeaso, Department of Child
Oral Health, College of Medicine, University of Ibadan, Ibadan,
Nigeria (e-mail: coonyeaso@yahoo.com)

Accepted: February 2007. Submitted: February 2007.


 2007 by The EH Angle Education and Research Foundation,
Inc.
Angle Orthodontist, Vol 78, No 1, 2008

64

DOI: 10.2319/021207-66.1

65

OCCLUSAL CHANGES IN NIGERIAN CHILDREN

occlusion,2229 there is no such report so far from Nigeria.


Therefore, the purpose of this longitudinal pilot study
was to evaluate the changes in occlusion of a group
of Nigerian children from the deciduous to the early
mixed dentition stages of occlusal development.
MATERIALS AND METHODS
The material for this follow-up investigation was obtained from a pre-primary school center of a popular
nursery and primary school near the Dental Center/
Faculty of Dentistry, College of Medicine, University of
Ibadan, Ibadan, Nigeria. The center is attended by preprimary and primary school children from various parts
of Ibadan City. Ibadan is a city in the southwest part
of Nigeria and the largest city in the whole of the
southern Sahara. Outside the Yoruba ethnic group,
the city plays host to other Nigerians from virtually all
parts of the country.
After obtaining permission from the Oyo State Ministry of Education and the management of the center
to carry out the study in October 2002, initially 145 preprimary school Nigerian children comprising 62 boys
and 83 girls aged 35 years were examined. They
were all examined in their school premises under natural illumination, using the criteria of Foster and Hamilton30 to assess the anteroposterior relationship of the
second deciduous molars and other occlusal features.
Other occlusal variables assessed were spacing in the
arches, crowding, overjet, overbite, and oral habits.
The presence of other anomalies recorded included
scissors bite, crossbite, anterior open bite, trauma to
teeth, double teeth, and carious teeth. The names,
ages, and gender of the children were recorded during
the examination.
Of the 145 subjects initially evaluated during the primary dentition stage (Time 1), only 61 subjects were
located and reexamined 4 years later (October 2006)
in the primary school classes of the same center (Time
2). Seven of the 61 subjects were excluded in the final
study sample because their first permanent molars
were not yet fully erupted. The rest of the initial 145
subjects could not be located as some of the families
had relocated to other parts of the country or outside
the country. Some of the children had gone to other
primary schools in the city and other parts of the country, and the school authority could not identify the
schools.
In the final study sample none of the 54 subjects (26
male and 28 female) had any congenitally missing
teeth at both examination times; none of them had any
history of early loss of second deciduous molar and
none experienced any form of dental treatment including orthodontic care.

The anteroposterior relationship of the arches was


recorded at the second examination (Time 2) based
on the Angle criteria.31 Other occlusal variables examined included spacing, crowding, overbite, overjet,
oral habits, and other anomalies as recorded during
the first examination (Time 1). More details about the
criteria for the occlusal parameters assessed at Time
1 and Time 2 in this study are available in other reports.12,30,32
In this paper, only the initial anteroposterior relationships of the second deciduous molars of the final study
sample, occlusal changes between the first time (Time
1) and the second time (Time 2) including molar relationships, overjet, crowding, and spacing variables
are reported.
Intra-examiner Reliability Test
Very good intra-examiner reliabilities of the same
examiner (Dr Onyeaso) on the assessments of these
occlusal features have been reported earlier.13,32
Statistical Analyses
Descriptive statistics including frequency and percentage distribution of variables were calculated at the
two examinations. Then chi-square test was used to
determine whether significant gender differences were
present, and significance was predetermined at the
0.05 level of confidence. Pearson correlation coefficients (r) were calculated to determine associations
between changes in molar relationships, overjet, overbite, crowding, and spacing features of the initial and
final occlusions of the subjects.
RESULTS
The second deciduous molar relationships of the final study sample at the time of initial examination
(Time 1) are shown in Table 1. Changes in molar relationship from the deciduous to the early mixed dentitions in the final study sample are shown in Table 2.
Twenty-two (68.7%) of 32 subjects initially having a
flush terminal plane relationship resulted in a Class I
molar relationship. Eleven (61.1%) of 18 subjects who
initially had a Class III (mesial step) relationship of the
second deciduous molars became a Class I molar relationship while five (27.8%) resulted in a Class III relationship.
Table 3 shows the age and gender distribution of
the Angle classification of the final study sample. Significantly more male subjects had a Class I molar relationship at age 8, but female subjects at the age of
9 (P .05).
The overbite pattern of the subjects at Time 1 and
Time 2 is shown in Table 4 with a majority of subjects
Angle Orthodontist, Vol 78, No 1, 2008

66

ONYEASO, ISIEKWE

Table 1. Occlusal (Anteroposterior) Relationships of the Second Deciduous Molars of the Subjects at the Time of First Examination (Time
1)a
Gender
Male

Female

Total

Molar Relationship

(%)

(%)

(%)

Class 1 (Flush terminal plane relationship)


Class 2 (Distal step)
Class 3 (Mesial step)
Asymmetric relationships (Right and left sides of the arches)
Total

15

10
1
26

(46.9)

(55.6)
(33.3)
(48.1)

17
1
8
2
28

(53.1)
(100)
(44.4)
(66.7)
(51.9)

32
1
18
3
54

(59.3)
(1.8)
(33.3)
(5.6)
(100)

X 2 1.609; df 3; P .657.

Table 2. Occlusal (Anteroposterior) Changes From the Initial Deciduous Molar Relationships (Time 1) to the Present Permanent Molar
Relationships (Time 2)
Present Permanent Molar Relationships (Angle Classification)

Initial Deciduous Molar Relationships


(According to Foster and Hamilton30)
Class 1 (Flush terminal plane, n 32)
Class 2 (Distal step, n 1)
Class 3 (Mesial step, n 18)
**Asymmetric (left and right sides, n 3)
Total

Class I

Class II

Class III

Asymmetric Relationship
(Right and Left)

(%)

(%)

(%)

(%)

22
1
11
3
37

(68.7)
(100)
(61.1)
(100)
(68.5)

(21.9)

(5.6)

(14.8)

(27.8)

(9.3)

(9.4)*

(5.6)***

(7.4)

* All three subjects with asymmetric Angle classification resulting from initial Class 1 (flush terminal plane) had Class II on one side and
Class I on the other.
** All three subjects with initial asymmetric relationships in the deciduous dentition that resulted in Angle Class I relationship had Class III
(mesial step) on one side and Class I (flush terminal plane) on the other.
*** The only subject with initial symmetric Class II (mesial step) relationship which did not result into symmetric Angle classification had
Angle Class I on the left side and scissors bite on the right side.

maintaining normal overbite at both stages of occlusal


development. Table 5 gives the overjet pattern of the
same subjects at the different stages of occlusal development with normal overjet having the highest proportions43 (79.6%) and 36 (66.7%) at Times 1 and
2, respectively.
Table 6 shows the correlations of the occlusal traits
at the two stages of occlusal development, according
to Pearson correlation coefficient with three of them
(overjet, overbite, and crowding) giving positively significant correlations (r .357, P .008; r .428, P
.001; and r .601, P .000), respectively, while generalized spacing of the anterior segments in the deciduous dentition (Time 1) and corresponding spacing in
the same regions in the early permanent set (Time 2)
did not (r .245, P .074). All the correlations for
the occlusal variables were lower than 0.7.
DISCUSSION
According to Bishara et al,1 the final molar occlusion
is dependent on a number of dental and facial skeletal
changes, both genetic and environmental, that interact
to achieve, or not achieve normal occlusion.
Angle Orthodontist, Vol 78, No 1, 2008

The distribution of Angle molar classification and


other occlusal variables in this study that resulted from
the time of initial examination (Time 1) is consistent
with earlier reports in epidemiological and clinical studies among Nigerians.2,3,4,32,33 The findings in this present investigation indicated that if the initial occlusion in
the primary dentition is a flush terminal plane (Class I)
or mesial step (Class II), a majority of the subjects will
develop into Angle Class I in the permanent dentition.
This is consistent with the findings of Bishara et al.1
Meanwhile, the only subject in this study initially having distal step relationship of the second deciduous
molars resulted in a normal Angle Class I molar relationship. This observation deserves a good follow-up
of the subject to complete the permanent dentition so
as to ascertain any possible change of this molar relationship into a Class II relationship. It is generally
accepted the distal step relationship of the second deciduous molars usually results in a distocclusion
(Class II) molar relationship in the permanent dentition.1,79
There was no consistent gender difference observed in the permanent molar relationship in this

67

OCCLUSAL CHANGES IN NIGERIAN CHILDREN


Table 3. Age and Gender Distribution of the Angle Classification of the Childrena
Age (Year) and Gender
7a
M

Anteroposterior Molar Relationship


(Angle Classification)
Class I
Class II
Class III
Asymmetric relationships (right
and left)
Total

8b

F
%

9c

M
%

F
%

Total

M
%

F
%

M
%

F
%

12

(32.4) 10

2
(40)
2

(27.0)
(25)
(40)

(24.3)

3
5
1

(8.1)
(62.5)
(20)

3
(12.5)

(8.1)

21
1
2

(56.8) 16
(12.5) 7
(40)
3

(43.2)
(87.5)
(60)

14

1
(48.3) 15

(25)
(51.7)

1
10

(25)
2
(47.6) 11

(50)
(52.4)

(25)

(75)

1
25

(25)
3
(46.3) 29

(75)
(53.7)

At age 7: X 2 3.151; df 3; P 0.369.


At age 8: X 2 9.000; df 3; P 0.029 (significantly more male patients had class I molar relationship at age 8).
c
At age 9: X 2 4.000; df 1; P 0.046 (significantly more female patients had class I at age 9).
a
b

Table 4. Overbite Pattern of the Subjects at Time 1 and Time 2 of


the Occlusal Developmenta
Time 1
Overbite

Frequency
(%)

Normal
Increased
Reversed
Reduced
AOB
E-to-E bite
a

Time 2

42
1
6

3
2

77.8
1.8
11.1

5.6
3.7

Overbite

Frequen- (%)
cy

Normal
Increased
Reversed
Reduced
AOB
E-to-E bite
Incomplete

34
2
1
3
10
2
2

63
3.7
1.8
5.6
18.5
3.7
3.7

AOB indicates anterior openbite; E-to-E bite, edge to edge bite.

Table 5. Overjet Pattern of the Subjects at Time 1 and Time 2 of


the Occlusal Development a
Time 1
Overbite
Normal
Increased
Reversed
AOB
E to E bite
a

Time 2

Frequency, %
43

6
3
2

79.6

11.1
5.6
3.7

Overbite
Normal
Increased
Reversed
AOB
E to E bite

Frequency, %
36
5
1
10
2

66.7
9.3
1.8
18.5
3.7

AOB indicates anterior openbite; E-to-E bite, edge to edge bite.

study. Again, this is consistent with previous studies in


Nigerian children showing no defined gender bias for
the molar occlusions.2,3,3234
Overbite and overjet patterns of the subjects at the
two periods of examination are consistent with Nigerian literature on occlusions in the deciduous and permanent dentitions.4,12,14,15 In the present study, only
one of the occlusal variables (spacing of the arches)
did not correlate positively between the primary and
early mixed dentition stages. This could be due to the
fact that the generalized spaces recorded in the deciduous (primary) dentitions were utilized for the eruption of the larger permanent incisors in the early mixed
dentition.
While it should be noted that the changes in the
other four occlusal features were significantly positively correlated, it is worth noting also that all the positively significant correlations (r) were below 0.7. One
of the main purposes of correlating the variables between the deciduous and early mixed dentition stages
is to possibly predict the occlusion in the permanent
dentition. Correlations below 0.7 or r 0.8 do not give
an accurate prediction for individuals.24 Therefore, although these correlations in this Nigerian study are
significant and could be a guide, they do not guarantee
an accurate prediction of the occlusal features in the

Table 6. Correlation Coefficient (r) Between the Occlusal Traits at Time 1 and Time 2 of Examinations of the Subjects
Time 2
Time 1

Overjet

Overjet
Overbite
Crowding
Spacing
Second deciduous molar relationship

.357**

Overbite

Crowding

Spacing

First Permanent
Molar

.428**
.601**
.245
.492**

** Correlation is significant at the 0.01 level (2-tailed).


Angle Orthodontist, Vol 78, No 1, 2008

68
permanent dentition. The current finding is in agreement with the findings of Bishara et al.1,24
A follow-up of these subjects is being planned to
ascertain their definitive occlusal status in the full permanent dentition stage when the children would have
been in secondary school. The idea of having at least
one Growth and Development Study Center in Nigeria
is to be advocated as this will help in having more
longitudinal studies that can also guarantee larger
sample sizes.
CONCLUSIONS
The establishment of a Class I molar relationship is
favored more by a flush terminal plane (Class I) and
mesial step (Class III) relationships of the second
deciduous molars.
All occlusal features studied had significant positive
correlations between the primary and the early
mixed dentition stages with crowding having the
highest value, except generalized spacing in the anterior segments in the primary dentition and corresponding spacing in the same regions in the early
mixed dentition.
Although significant correlations were found for most
of the occlusal features between the two stages of
occlusal development, all were below 0.7 values.
This could be suggestive of a poor predictive power
of these variables from the occlusal features in the
primary (deciduous) dentition.
REFERENCES
1. Bishara SE, Hoppens BJ, Jakobsen JR, Kohout FJ. Changes in the molar relationship between the deciduous and permanent dentitions: a longitudinal study. Am J Orthod Dentofacial Orthop. 1988;93:1928.
2. Richardson A, Ana JR. Occlusion and malocclusion in Lagos. J Dent. 1973;1:134139.
3. Isiekwe MC. Malocclusion in Lagos, Nigeria. Community
Dent Oral Epidemiol. 1983;11:5962.
4. Isiekwe MC. Distribution of overjet values in a Negro population in Nigeria. Community Dent Health. 1986;3:6164.
5. Isiekwe MC. Classified occlusal problem in young Nigeriana clinical study. Odontostomatol Trop. 1987;12:6771.
6. Aggarwal SP, Odusanya SA. Orthodontic status of school
children in Ile-Ife, Nigeria. Acta Odontol Pediatr. 1985;6:9
12.
7. Bougue EA. Some results from orthodontia in deciduous
teeth. J Am Med Assoc. 1908;1:267269.
8. Infante PF. Malocclusion in the deciduous dentition in white,
black and Apache Indian children. Angle Orthod. 1975;45:
213218.
9. Richardson A. Interceptive orthodontics in General Dental
Practice. Br Dent J. 1982;3:8588,123127,166170.
10. Otuyemi OD, Sote EO, Isiekwe MC, Jones SP. Occlusal
relationships and spacing or crowding of teeth in the dentitions of 34-year-old Nigerian children. Int J Paediatr Dent.
1997;7:155160.
11. Onyeaso CO, Sote EO. Prevalence of ideal occlusion in
Nigerian pre-school children. J Med Sci. 2001;3(1):2831.
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ONYEASO, ISIEKWE

12. Onyeaso CO, Sote EO. A study of malocclusion in the primary dentition in a population of Nigerian Children. Niger J
Clin Pract. 2002;5:5256.
13. Onyeaso CO, Sote EO, Arowojolu MO. Need for preventive
and interceptive orthodontic treatment in 35-year-old Nigerian children in two major cities. Afr J Med Med Sci. 2002;
31(2):115118.
14. Onyeaso CO. Occlusion in the primary dentition. Part 1: a
preliminary report on comparison of antero-posterior relationships and spacing among children of the major Nigerian
ethnic groups. Odontostomatol Trop. 2006;29(114):914.
15. Onyeaso CO. Occlusion in the primary dentition. Part 2: A
comparison of some occlusal traits among pre-school children of the 3 major ethnic groups in Nigeria. Odontostomatol Trop. 2006;29(115):2329.
16. Onyeaso CO. An epidemiological survey of occlusal anomalies among secondary school children in Ibadan, Nigeria.
Odontostomatol Trop. 2003;26(102):2529.
17. Onyeaso CO, Denloye OO, Taiwo TO. Preventive and interceptive orthodontic demand for malocclusion. Afr J Med
Med Sci. 2003;32(1):15.
18. Onyeaso CO. Oral habits among 710-year-old school children in Ibadan, Nigeria. East Afr Med J. 2004;81(1):1621.
19. Onyeaso CO. Need for preventive/interceptive orthodontic
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an epidemiological survey. Odontostomatol Trop. 2004;
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Nigerian population: an indication of poor dental awareness/
attitude. Odontostomatol Trop. 2005;28(111):59.
21. Onyeaso CO, Onyeaso AO. Occlusal/dental anomalies
found in a random sample of Nigerian school children. Oral
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23. Foster TD, Grundy MC. Occlusal changes from primary to
permanent dentitions. Br J Orthod. 1986;13(4):187193.
24. Bishara SE, Khadivi P, Jakobsen JR. Changes in tooth sizearch length relationships from the deciduous to the permanent dentition: a longitudinal study. Am J Orthod Dentofacial
Orthop. 1995;108(6):607613.
25. Bishara SE, Jakobsen JR, Vorhies B, Bayati P. Changes in
dentofacial structures in untreated class II division I and normal subjects: a longitudinal study. Angle Orthod. 1997;
67(1):5566.
26. Varrela J. Development of distal occlusion: a follow-up study
in the early mixed dentition. J Dent Res. 1997;76:18.
27. Tsujino K, Machida Y. A longitudinal study of the growth
and development of the dental arch width from childhood to
adolescence in Japanese. Bull Tokyo Dent Coll. 1998;39(2):
7589.
28. Warren JJ, Bishara SE, Yonezu T. Tooth size-arch length
relationships in the deciduous dentition: a comparison between contemporary and historical samples. Am J Orthod
Dentofacial Orthop. 2003;123(6):614619.
29. Bishara SE, Jakobsen JR. Individual variation in tooth-size/
arch length changes from the primary to permanent dentitions. World J Orthod. 2006;7(2):145153.
30. Foster TD, Hamilton MC. Occlusion in the primary dentition.
Br Dent J. 1969;126:7679.
31. Angle EH. Classification of malocclusion. Dent Cosmos.
1899;41:24864,350357.
32. Onyeaso CO. Prevalence of malocclusion among adolescents in Ibadan, Nigeria. Am J Orthod Dentofacial Orthop.
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OCCLUSAL CHANGES IN NIGERIAN CHILDREN

33. Onyeaso CO, Aderinokun GA, Arowojolu MO. The pattern


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69
34. Otuyemi OD, Ogunyinka A, Dosumu O, Cons NC, Jenny J.
Malocclusion and orthodontic treatment need of secondary
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index (DAI). Int Dent J. 1999;49:203210.

Angle Orthodontist, Vol 78, No 1, 2008

Original Article

Maxillary and Mandibular Dentoalveolar Heights of French-Canadians


10 to 15 Years of Age
Peter H. Buschanga; Roberto Carrillob; Sean S. Liuc; Arto Demirjiand
ABSTRACT
Objective: To establish reference data for anterior and posterior dentoalveolar heights of growing
French-Canadians with untreated normal occlusions and malocclusions.
Materials and Methods: The mixed longitudinal sample includes 227 French-Canadians, 119
male and 108 female, with cephalograms taken annually between 1015 years of age. Maxillary
and mandibular dentoalveolar heights were measured as the perpendicular distances of the incisor
tips and first molar mesial cusp tips to the palatal (ANS-PNS) and mandibular (Go-Me) planes.
Results: Male dentoalveolar heights were significantly (P .05) greater than female heights at
all ages. Dentoalveolar heights at 15 years of age were significantly larger (P .05) than at 10
years of age, with differences ranging from 2.14.2 mm in male subjects and from 2.13.8 mm
in female subjects. The greatest difference in dentoalveolar heights between the 10- and 15-yearold age groups was for the maxillary first molar; the maxillary central incisor height showed the
smallest age effects. The coefficients of variation were greater for the maxillary than the mandibular dentoalveolar heights. Correlations of dentoalveolar heights within jaws ranged from 0.53 to
0.82; correlations between jaws ranged from 0.30 to 0.44. The mandibular heights showed the
strongest associations.
Conclusions: French-Canadian adolescents require age- and sex-specific reference data for dentoalveolar heights.
KEY WORDS: Dentoalveolar height; Cephalometrics; French-Canadians; Reference data; Adolescents; Eruption

INTRODUCTION

cally treated by inhibiting or stimulating dentoalveolar


growth. Determining how much dentoalveolar modification might be necessary during treatment requires
reference data (ie, growth standards) and an understanding of how the heights are interrelated. To be
clinically applicable, reference data must be population-specific, unbiased, and, perhaps most importantly,
precise enough to estimate extreme percentiles.
Existing reference data for dentoalveolar heights of
White adolescents are limited. The majority of studies
pertaining to dentoalveolar heights do not provide reference data for clinical application. They were designed to compare superimposition methods,2 describe longitudinal changes,3 illustrate dentofacial maturation,4,5 and evaluate different facial patterns.6 For
Whites, only two sets of reference data are currently
available. The Michigan survey describes the dentoalveolar heights of untreated male (n 47) and female
(n 36) subjects followed from 10 to 15 years of age.7
The Kings College School of Medicine and Dentistry
study, conducted in UK, describes dentoalveolar
heights of 58 male and 63 female Whites.8 Due to lim-

Adolescents undergo dramatic changes in maxillary


and mandibular dentoalveolar heights that hold important clinical implications. 1 Due to greater vertical
growth potential, dentoalveolar heights of adolescents
can be easily manipulated and corrected. For instance, open and deep bite malocclusions, as well as
hyperdivergent or hypodivergent facial types are typiProfessor, Department of Orthodontics, Baylor College of
Dentistry, Dallas, Tex.
b
Research Fellow, Department of Orthodontics, Baylor College of Dentistry, Dallas, Tex.
c
Graduate Student (PhD), Department of Orthodontics, Baylor College of Dentistry, Dallas, Tex.
d
Professor, Department of Stomatology, Faculty of Dental
Medicine, Univeristy of Montreal, Montreal, Canada.
Corresponding author: Dr PH Buschang, Department of Orthodontics, Baylor College of Dentistry, 3302 Gaston Avenue,
Dallas, Tex 75124
(e-mail: phbuschang@tambcd.edu)
a

Accepted: March 2007. Submitted: January 2007.


 2007 by The EH Angle Education and Research Foundation,
Inc.
Angle Orthodontist, Vol 78, No 1, 2008

70

DOI: 10.2319/092006-381.1

71

DENTOALVEOLAR HEIGHTS OF FRENCH-CANADIAN ADOLESCENTS


Table 1. Sample Sizes (N) by Sex, Age, and Dentoalveolar
Heightsa
Age, Years
Tooth

Sex

10

11

12

13

14

15

U1

M
F
M
F
M
F
M
F

111
102
106
97
111
101
99
83

115
107
105
97
116
107
98
77

114
106
104
91
116
106
94
67

115
107
97
88
118
107
93
65

111
104
90
82
113
100
87
51

109
79
87
68
113
81
78
40

U6
L1
L6

a
U1 indicates upper incisor tip; U6, upper first molar mesial cusp
tip; L1, lower incisor tip; and L6, lower first molar mesial cusp tip.

ited sample sizes and sample differences in dentoalveolar heights, additional reference data are needed
to determine population parameters, especially for other population groups.
The purpose of this study was to describe the anterior and posterior dentoalveolar heights of growing
French-Canadian adolescents between 10 and 15
years of age and to evaluate their interrelationships.
This study is uniquely based on a large number of
subjects who are representative of the larger population.
MATERIALS AND METHODS
The sample included untreated growing adolescents
between 10 and 15 years of age with four FrenchCanadian grandparents. The records were collected
by the Human Growth and Research Center, University of Montreal, Montreal, Canada. The sample was
drawn from three randomly selected school districts
representing the socioeconomic background of the
larger population.9 Within each district, the individuals
were chosen at random from 107 randomly selected
schools. This mixed-longitudinal sample includes 227
individuals (119 male and 108 female) with untreated
normal occlusions and malocclusions (Table 1). The
number of subjects decreased over time due to dropouts, loss of teeth during the course of the study, and
elimination of teeth with major restorations.
Calculation of Dentoalveolar Height
The cephalograms were traced and eight landmarks
were identified and digitized (Figure 1). All lateral
cephalograms were traced by the same technician,
with an overall reliability ranging between 0.947 and
0.996. PNS and the lower molar mesial cusp tip
showed the lowest and highest reliabilities, respectively. Maxillary dentoalveolar heights were defined as the
perpendicular distances of the incisor tip and first molar mesial cusp tip to the palatal plane (ANS-PNS).

The mandibular dentoalveolar heights were calculated


based on the perpendicular distances of the lower incisor tip and lower first molar mesial cusp tip to the
mandibular plane (Go-Me). The four dentoalveolar
heights were corrected for radiographic enlargement.
Based on skewness and kurtosis, all of the dentoalveolar height measures were normally distributed.
The mean, standard deviation, and coefficient of variation were calculated using SPSS (Version 12.0.1,
SPSS Inc, Chicago, Ill). Students t-tests were used to
compare the growth changes between male and female subjects at each age based on a significance
level of P .05. Associations between dentoalveolar
heights were quantified using Pearson product-moment correlations.
RESULTS
Statistical comparisons (t-test) showed that all but
three of the dentoalveolar heights were significantly (P
.05) greater in male than female subjects (Table 2).
The exceptions included maxillary first molar heights
at the age of 13 years and mandibular first molar
heights at the ages of 12 and 13 years. Mandibular
incisor heights at age 15 years showed the largest sex
difference.
All four dentoalveolar heights increased significantly
with age (Table 2; Figures 2 and 3). Dentoalveolar
heights at 15 years of age were 2.14.2 mm (7.6%
23.0%) greater than the heights at 10 years of age.
Maxillary incisor dentoalveolar height showed, on average, the smallest changes between 10 and 15 years
of age (8.4% for male; 8.8% for female subjects), followed by mandibular incisor (11.0% for male; 7.6% for
female subjects), mandibular molar (13.6% for male;
12.1% for female subjects), and maxillary molar height
(23.0% for male; 21.5% for female subjects), respectively.
Within each jaw the absolute variation, as represented by the standard deviation, was consistently
greater for incisor dentoalveolar heights than for the
molar heights. The coefficients of variation, representing relative variation, were approximately 2%3%
greater for the maxillary than for the mandibular dentoalveolar heights. The coefficients of variation
showed no clear pattern of differences within the jaws
(Table 2).
The correlations between the dentoalveolar heights
(Table 3) within the mandible were larger (0.700.82)
than the correlations within the maxilla (0.550.69). Incisor dentoalveolar heights show higher associations
between arches (0.530.58) than molar heights (0.08
0.34). The correlations between dentoalveolar heights
at the incisors of one arch and the dentoalveolar
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72

BUSCHANG, CARRILLO, LIU, DEMIRJIAN

Table 2. Maxillary and Mandibular Dentoalveolar Heights of Untreated French-Canadians 10 to 15 Years of Age (mm), Measured as the
Perpendicular Distance of the Upper Dentition to the Palatal Plane (ANS-PNS) and for Lower Dentition to the Mandibular Plane (Go-Me)a
10
Tooth

Sex

U1

M
F
M
F
M
F
M
F

U6
L1
L6

11

Mean SD

CV

8.8%
10.0%
9.8%
10.2%
6.2%
6.2%
6.8%
6.3%

25.0
23.9
18.3
17.7
35.4
34.1
26.4
25.6

2.2*
2.4
1.8*
1.8
2.2*
2.1
1.8*
1.6

12

Mean SD

CV

9.1%
9.8%
8.9%
11.4%
6.4%
6.3%
7.1%
6.9%

25.2
24.4
19.2
18.5
35.8
34.7
26.7
26.1

2.3*
2.4
1.7*
2.1
2.3*
2.2
1.9*
1.8

Mean SD

CV

9.4%
10.1%
8.6%
10.5%
6.9%
6.5%
7.7%
7.5%

25.6
24.7
19.7
19.1
36.3
35.3
27.2
26.7

2.4*
2.5
1.7*
2.0
2.5*
2.3
2.1
2.0

a
SD indicates standard deviation; CV, coefficient of variation; Change, mean changes from 10 to 15 years of age (mm); U1, upper incisor
tip; U6, upper first molar mesial cusp tip; L1, lower incisor tip; and L6, lower first molar mesial cusp tip.
* Indicates significant sex difference (P .05).

Figure 1. Digitized landmarks and dentoalveolar height measurements used in the maxilla and mandible. PNS indicates posterior nasal spine;
ANS, anterior nasal spine; U1, upper incisor tip; U6, upper first molar mesial cusp tip; Go, gonion; Me, menton; L1, lower incisor tip; and L6,
lower first molar mesial cusp tip.
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73

DENTOALVEOLAR HEIGHTS OF FRENCH-CANADIAN ADOLESCENTS


Table 2. Extended
13

14

Mean SD

CV

9.2%
9.9%
8.9%
10.5%
7.0%
6.4%
7.9%
7.3%

26.0
25.3
20.3
20.1
37.3
35.9
28.0
27.6

2.4*
2.5
1.8
2.1
2.6*
2.3
2.2
2.0

15

Mean SD

CV

9.8%
10.5%
8.3%
10.1%
7.3%
6.0%
7.9%
7.4%

26.6
25.8
21.6
20.8
38.3
36.4
29.2
28.3

2.6*
2.7
1.8*
2.1
2.8*
2.2
2.3*
2.1

1015

Mean SD

CV

9.6%
10.3%
8.0%
10.8%
6.8%
6.6%
8.2%
7.7%

27.1
26.2
22.5
21.4
39.5
36.7
30.5
28.7

2.6*
2.7
1.8*
2.3
2.7*
2.4
2.5*
2.2

Change SD
2.1
2.1
4.2
3.8
3.9
2.6
3.6
3.1

1.4
1.0
1.2
1.2
1.2
1.0
1.3
1.6

Figure 2. Maxillary and mandibular dentoalveolar heights (mm) for untreated male French-Canadian children 10 to 15 years of age. , 25th
to 75th percentile band. , 25th to 50th and 75th to 95th percentile bands.
Angle Orthodontist, Vol 78, No 1, 2008

74

BUSCHANG, CARRILLO, LIU, DEMIRJIAN

Figure 3. Maxillary and mandibular dentoalveolar heights (mm) for untreated female French-Canadian children 10 to 15 years of age. , 25th
to 75th percentile band. , 25th to 50th and 75th to 95th percentile bands.

Table 3. Correlation Coefficients Relating the Dentoalveolar Heights Within and Between Archesa
Dentoalveolar Heights
Within Arches

Between Arches

Age, Years

U1 & U6

L1 & L6

U1 & L1

U6 & L6

U1 & L6

U6 & L1

10
11
12
13
14
15

0.60
0.55
0.56
0.62
0.68
0.69

0.70
0.74
0.71
0.79
0.78
0.82

0.58
0.53
0.57
0.54
0.54
0.53

0.17*
0.08*
0.09*
0.22*
0.34
0.31

0.39
0.35
0.39
0.41
0.42
0.44

0.36
0.30
0.30
0.35
0.42
0.41

a
U1 indicates upper incisor tip; U6, upper first molar mesial cusp tip; L1, lower incisor tip; and L6, lower first molar mesial cusp tip.
* Indicates nonsignificant (P .05).

Angle Orthodontist, Vol 78, No 1, 2008

DENTOALVEOLAR HEIGHTS OF FRENCH-CANADIAN ADOLESCENTS

heights at the molars of the opposite arch ranged between 0.30 and 0.44.
DISCUSSION
Dentoalveolar heights increased an average of
7.6%23.0% between 10 and 15 years of age, depending more on tooth position than arch. The increases (2.14.2 mm) were similar to those reported
by Bhatia and Leighton8 (1.84.1 mm) and Riolo and
coworkers7 (1.84.6 mm). With the exception of the
maxillary incisor dentoalveolar height, the mean values observed at the various ages compare closely
with those of Bhatia and Leighton.8 The difference in
anterior maxillary dentoalveolar development implies
an enhanced susceptibility to extrinsic factors. In general, dentoalveolar heights (after correcting for enlargement) reported by Riolo and coworkers7 were
slightly larger than ours, as well as those reported by
Bhatia and Leighton.8 Because similar landmarks and
measurements were used in all three studies, the
small differences that exist were probably due to sample bias, population differences in body size, facial
morphology, or tooth size.10 Nevertheless, the marked
similarity of means across samples indicates that the
data herein reported may be applicable beyond the
French-Canadian population.
Dentoalveolar heights of male subjects were larger
than the corresponding heights of female subjects.
Sex differences, which ranged from 3.1%4.4% at 10
years and from 3.5%7.6% at 15 years, compare well
with those reported by Bhatia and Leighton8 and are
somewhat smaller than those reported by Riolo and
coworkers. 7 Dentoalveolar heights were probably
greater in male adolescents because they undergo
more vertical growth and have larger teeth than female
adolescents.9,11,12 Interestingly, there was a reduction
or lack of a sex difference around 12 and 13 years of
age, as previously reported.8,13 The reduction in sex
differences at these ages may be due to the females
initiating their adolescent growth spurt earlier than
males.14,15
Variability of dentoalveolar height increased with
age, depending upon the jaw and tooth position. The
coefficients of variation for maxillary dentoalveolar
heights were between 2%3% larger than those of the
mandibular arch. Bhatia and Leighton,8 as well as Riolo and coworkers,7 also showed greater relative variation for maxillary than for mandibular dentoalveolar
heights. Correlations between dentoalveolar heights
within the maxilla were also weaker than associations
within the mandible. Weaker maxillary correlations
might be associated with the greater angular changes
that have been reported for the maxillary molars.16 The
increased variability observed suggests that the max-

75
illary dentoalveolar region has greater adaptive capacity than the mandibular dentoalveolar region, perhaps
due to differences in the amounts of eruption that occur or to differences in bone quality.17
The utility of reference data depends largely on how
precise and representative they are. Because our
sample sizes were usually two or three times larger
than existing reference data,7,8 the estimates might be
expected to be more precise. Precision is important
because it allows orthodontists to make a better assessment at the extreme percentiles, where patients
with serious problems are often found. The results are
also representative of the larger population because
the subjects were randomly selected; they comprise a
nonorthodontic sample with normal occlusions and
malocclusions. Moreover, the mean values compared
well with other Whites, particularly with those reported
by Bhatia and Leighton.8 For all of these reasons, the
present results provide some of the best reference
data available for making clinical decisions about dentoalveolar height.
Importantly, the results of this study do not represent the actual longitudinal changes of dentoalveolar
heights that occur during adolescence. As shown by
the classic implant studies of Bjork and Skieller,16 the
actual changes are often camouflaged by the bone
remodeling that occurs on the surfaces of the maxilla
and mandible. For example, maxillary dentoalveolar
heights are likely to be underestimated during growth
because the nasal floor is resorptive. Similarly, the
anterior aspect of the lower mandibular border tends
to be appositional, which causes longitudinal estimates of dentoalveolar based on the mandibular
plane to be overestimated. These reference data
were developed to evaluate dentoalveolar heights
cross-sectionally. The charts and tables serve as diagnostic tools used to determine the extent of problems based on a single observation.
Since orthodontists regularly alter dentoalveolar
heights, it is important to be able to assess the individuals needs during diagnosis and treatment planning. After determining the appropriate vertical position
of the maxillary incisor relative to the upper lip, the
dentoalveolar height of the maxillary incisor should be
measured (Figure 1) and compared to the age and sex
specific norms provided (Table 2; Figures 2 and 3).
This roughly estimates the patients appropriate percentile ranking, particularly if it corresponds to the patients body size percentiles. Based on the observed
relationships between the dentoalveolar heights (Table 3), the upper incisor percentile provides the basis
for estimating the appropriate percentiles of the upper
molar, the lower incisor, and the lower molar. Due to
the limited strength of the associations, the percentile
rankings should be used as adjustable guidelines rathAngle Orthodontist, Vol 78, No 1, 2008

76
er than as rigid goals. The forgoing approach makes
it possible to identify areas of discrepancy for the patient and to determine the best treatment approach.
By using these standards in conjunction with facial esthetics and proportions, treatment mechanics can be
better planned and controlled to produce more efficient
treatments and better outcomes.
CONCLUSIONS
French-Canadian adolescents require age- and sexspecific reference data for dentoalveolar heights because
Dentoalveolar heights increase from 1015 years
of age, with the anterior and posterior heights
showing the smallest and greatest changes, respectively.
Male adolescents have larger dentoalveolar
heights than female adolescents.
Relative variability is 2% to 3% greater in the maxillary dentition than in the mandibular dentition; absolute variability was consistently greater for the incisors than the molar heights in both jaws.
Correlations between dentoalveolar heights ranged
from moderate to low, with mandibular heights showing the strongest associations.
ACKNOWLEDGMENTS
This research was partially supported by Medical Research
Council (MRC) grant MA-8917 and by Fonds des Rescherche
en Sante du Quebec (FRSQ) grant 850043.

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15. Buschang PH, Tanguay R, Demirjian A, LaPalme L, Turkewicz J. Mathematical models of longitudinal mandibular
growth for children with normal and untreated Class II, division 1 malocclusion. Eur J Orthod. 1988;10:227234.
16. Bjork A, Skieller V. Facial development and tooth eruption.
An implant study at the age of puberty. Am J Orthod. 1972;
64:339383.
17. Peterson J, Wang Q, Dechow PC. Material properties of the
dentate maxilla. Anat Rec A Discov Mol Cell Evol Biol. 2006;
288:962972.

Original Article

Oral Breathing and Head Posture


Antonino Marco Cucciaa; Maurizio Lottib Domenico Caradonnac
ABSTRACT
Objective: To determine the head posture and cephalometric characteristics in oral breathing
children.
Materials and Methods: Lateral cephalograms taken in natural head posture of 35 oral breathing
patients (OB) (mean age 8.8 2.2 years SD; range 513 years) and of 35 patients with varied
malocclusions and physiological breathing (PB) (mean age 9.7 1.6 years SD; range 713 years)
were examined.
Results: A Students t-test showed that an increase in angles NSL/OPT (P .000), NSL/CVT (P
.001), FH/OPT (P .000), FH/CVT (P .005), and NSL/VER (P .000); a decrease in the
distance MGP-CV1p (P .0001); and a decrease in the angles MGP/OP (P .000) and OPT/
CVT (P .036) were found in the OB group. A low position of the hyoid bone (H-MP, P .009),
a major skeletal divergence (ANS-PNS/Go-Me, P .000), and an increased value of the ANB
angle (P .023) were present in OB patients. To ascertain if the changes in posture were connected with posterior obstruction of the upper respiratory airways, the OB group was divided into
two subgroups based on the distance Ad2-PNS being greater than or less than 15 mm. No
significant differences were found between these two groups.
Conclusions: Our data suggest that OB children show greater extension of the head related to
the cervical spine, reduced cervical lordosis, and more skeletal divergence, compared with PB
subjects.
KEY WORDS: Oral breathing; Head posture

INTRODUCTION

tions.13 Ricketts4 maintained that head extension represents a functional answer to facilitate oral breathing
(OB) in order to compensate nasal obstruction. Tecco
et al5 studied the changes in head posture in mouth
breathing girls after treatment with rapid maxillary expansion (RME). They reported that RME is able to increase the capacity of the nasopharyngeal airways
and leads to significant changes in the craniocervical
angles.
In a study undertaken on healthy young adults, OB
was artificially induced by nasal obstruction. The authors evaluated the relationship between the true vertical and the nasion-tragus line as well the C7-tragus
line, and found significant differences in extension of
the neck as measured by the C7-tragus/vertical line
angle, with the other (nasion-tragus/vertical line angle)
showing greater variability.6
Another study evaluated the influence of total nasal
obstruction and the absence of vision on head posture
(singly and combined). The results indicate that total
nasal obstruction, by the use of a nose clip, induces a
change in head posture (head elevation).7
It has been noted that there are changes in the association between the nasopharyngeal resistance and

Oral breathing has been reported to cause changes


in human head posture. The head position relative to
the cervical spine is the result of integration at the central nervous system level of different external and internal inputs, including visual, cutaneous, musculotendinous, and vestibular receptors.
Breathing is one of the prime functions fulfilled by
man, and it can have considerable effects on the morphology and on the craniofacial and cervical funca
Staff Scientist, Department of Dental Sciences and Department of Orthodontics and Gnathology, University of Palermo,
Palermo, Italy.
b
Research Assistant, Department of Dental Sciences, University of Palermo, Palermo, Italy.
c
Professor, Department of Orthodontics and Gnathology,
University of Palermo, Palermo, Italy.
Corresponding author: Dr Antonino Marco Cuccia, Department of Dental Sciences, University of Palermo, Via del Vespro
129 Palermo, 90127 Italy
(e-mail: cucciaam@odonto.unipa.it)

Accepted: February 2007. Submitted: November 2006.


 2007 by The EH Angle Education and Research Foundation,
Inc.
DOI: 10.2319/011507-18.1

77

Angle Orthodontist, Vol 78, No 1, 2008

78
the variations of the craniocervical parameters (with
reduction in craniocervical angulation through head
flexion) following a tonsillectomy or adenoidectomy,810
rapid maxillary expansion (RME),5 and after cortisone
therapy in children with asthma and chronic rhinitis. In
one study on children suffering from allergies, the use
of a cortisone nasal spray (budesonide) reduced nasal
resistance, thus causing an increased flexing of the
head.11 To approach the problem from another direction, no significant variation in airway resistance was
seen after cranial extension obtained by manipulation.12
The existing correlations among OB, craniocervical
posture, and craniofacial development indicate that
further confirmation is needed in the morphogenetic
consequences of bronchial asthma and of chronic allergic rhinitis.13,14
The aim of this research was to analyze the influence of OB, not necessarily connected to an upper
airway obstruction, on head posture in children in order to establish possible postural alterations associated with OB, before the same might condition their
development.
MATERIALS AND METHODS

CUCCIA, LOTTI, CARADONNA

rium problems, visual, hearing or swallowing disorders, and facial or spinal abnormalities (ie, torticollis,
scoliosis, or kyphosis). A teleradiograph was taken of
each subject (70 in total) in the natural head position
(NHP), and all teleradiographs were evaluated cephalometrically. The parents of all patients gave informed consent for participation in the study.
Craniofacial Measurements
Fourteen angular and three linear measurements
that formed the basis of the postural and craniofacial
analysis and airways dimension1517 were measured by
hand for each subject. A ruler and a protractor accurate to 0.5 mm and 0.5 were used. The Ad2-PNS value was measured in all subjects in the OB group. On
the basis of the obtained data the group was divided
into two subgroups of 12 and 23 patients: subjects with
values 15.5 mm and subjects with values 15 mm.
The association between the increases in the nasopharyngeal resistance, using an active anterior rhinomanometer, and Ad2-PNS values 15 mm, encouraged the choice of this measurement in order to differentiate between the patients.18 The cephalometric
points, lines, and angles used in the study are shown
in Figures 1 and 2.

Subjects
The sample included 35 oral breathing (OB) children
and 35 physiological breathing (PB) children, consecutively admitted in the Department of Orthodontics,
University of Palermo, who needed orthodontic treatment. The first group of OB subjects comprised 14
(40%) boys and 21 (60%) girls (age 513 years, average 8.8 years, SD 2.2 years). All patients had a
history of OB, confirmed by their parents and the medical history. On clinical examination these patients
showed lip inefficiency at rest, dental crowding in the
upper arch, adenoidal facies, and reduced maxillary
transverse dimension with unilateral or bilateral crossbite.
Evaluation of the breathing pattern for most of this
group showed a diaphragmatic mode of inhalation with
underexpansion of the thorax and a reduced mobility
of the nostrils suggesting a reduced patency of the
upper airway. OB was shown by water vapor condensed on the surface of a mirror placed outside the
mouth. The cause of OB was not established.
The second group of PB subjects comprised 16
(46%) boys and 19 (54%) girls (age 713 years, average 9.7 years, SD 1.6 years). These children were
chosen at random from a group of children who had
varied orthodontic problems, but who did not have a
past history or any clinical signs of OB.
Exclusion criteria for both groups included previous
or ongoing orthodontic treatment, vestibular or equilibAngle Orthodontist, Vol 78, No 1, 2008

Method Errors
In the postural recording method, the radiographs
were taken with the subject standing in NHP as described by Sahin Saglam and Uydas.19 Duplicate determinations were also carried out for all the linear and
angular variables measured on the lateral cephalometric radiographs by two orthodontists. The measurements were undertaken 2 weeks apart and no significant differences were found for any of the craniofacial and airway variables in the two data sets (paired
t-test).
The measurement error was calculated using 20 radiographs (10 randomly chosen from OB and 10 from
PB) and Dahlbergs formula. For linear distances the
error varied from 0.4 mm (H-MP) to 0.75 mm
(H-CV3ia-RGN) with a mean of 0.52 mm, while for angles the error varied from 0.40 (CVT/HOR) to 0.80
(OPT/NSL) with a mean of 0.65.
Statistical Method
Cephalometric variables are presented as mean,
standard deviation (SD), and the lowest and highest
values. The Students t-test was used to determine if
significant cephalometric differences existed between
the OB and the PB children.
Three subgroups representing those with normal
values, increased values, and reduced values com-

CEPHALOMETRIC ANALYSIS

Figure 1. Diagrammatic representation of the anatomic points used


to identify craniofacial parameters on lateral cephalometric radiographs. Point A: most posterior point on the anterior contour of the
upper alveolar process; Point ANS: anterior nasal spine, the tip of
the bony anterior nasal spine of the maxilla; Point B: deepest point
on the anterior contour of the lower alveolar process; Point Ba: Basion, the median point of the anterior margin of the foramen magnum; Point Go: Gonion, the constructed point of the intersection of
the ramus plane and the mandibular plane; Point RGN: Retrognation, most posterior point of the mandibular symphysis; Point N: Nasion, the most anterior point of the frontonasal suture in the median
plane; Point PNS: Posterior nasal spine, the tip of the bony posterior
nasal spine; Point S: Sella, the midpoint of the pituitary fossa; Point
O: Orbitale, the most inferior point on the inferior margin of the orbit;
Point Me: Menton, the most inferior point on the symphysis of the
mandible. Point Po: Porion, the most superior point of the external
auditory meatus; Point Oph: Ophisthion, the most anterior point on
the posterior border of the foramen magnum in the sagittal plane;
Point Ad2: Superior adenoidal point, on perpendicular from point
PNS to S-Ba line; Point CV1p: the most posterior and superior point
of the spinous process of atlas (the first cervical vertebra); Point
CV2ap: the most superior point of the odontoid process; Point CV2tg
the tangent point at the superior, posterior extremity of the odontoid
process of the second cervical vertebra; Point CV2ip: most inferior
and posterior point on the second cervical vertebra corpus; Point
CV2ia: most anterior and inferior point of body of the second cervical
vertebra; Point CV3ia: most anterior and inferior point of body of third
cervical vertebra; Point CV4ip: most inferior and posterior point on
the fourth cervical vertebra corpus; Point H: most superior and anterior point on the body of the hyoid bone.

79

Figure 2. Linear and angular measurements of cephalometric analysis. MGP (McGregor plane): line connecting point PNS to Oph; OP
(odontoid plane): line connecting points CV2ap to CV2ia; OPT: line
connecting the tangent point at the superior, posterior extremity of the
odontoid process of the second cervical vertebra (CV2tg) and the
most inferior/posterior point on the second cervical vertebra corpus
(CV2ip); CVT (posterior tangent cervical): an extended line from
CV2tg to CV4ip; FH (the Frankfurt horizontal plane): line connecting
Porion (Po) and Orbitale (O); NL (palatal plane): extended line from
ANS to PNS; MP: (mandibular plane) extended line from Me to Go;
NSL (anterior cranial base): extended line from nasion to sella; VER:
the gravity determined vertical; HOR the perpendicular to VER; Ad2PNS (the rhinopharyngeal airway dimension): distance in millimeters
between PNS and the nearest adenoidal part on the perpendicular to
the line S-Ba; H-MP: distance to the hyoid bone measured perpendicular to the mandibular plane; H-CV3ia: distance to the hyoid bone
measured perpendicular from the line RGN-CV3ia; MGP-CV1p: distance in millimeters between MGP and CV1p; NSL/VER: the angle
between NSL and VER; NSL/Ba: inner angle formed by the connection of N, S, and Ba in that order; MGP/OP (craniovertebral angle):
posterior inferior angle comprised of the intersection of McGregor
plane and the odontoid plane; NSL/OPT: head position in relation to
the second cervical vertebra, intersection of NSL with OPT; NSL/CVT
(head position in relation to the second and the fourth cervical vertebrae): angle between NSL and CVT; FH/OPT: angle created by extension of the Frankfurt horizontal plane and OPT; FH/CVT: angle
created by extension of the Frankfurt horizontal plane and CVT; OPT/
HOR (the cervical inclination): the angle between OPT and HOR;
CVT/HOR (the cervical inclination): the angle between CVT and HOR;
OPT/CVT (the cervical curvature): the angle between CVT and OPT;
NL/MP: angle between NL and MP; SNA: angle formed by the connection of the sella, nasion, and A point; SNB: inner angle formed by
the connection of the sella, nasion, and B point; ANB: difference between angles SNA and SNB.

Angle Orthodontist, Vol 78, No 1, 2008

80

CUCCIA, LOTTI, CARADONNA

Table 1. Variables Studieda


Oral Breathing (n 35)

NSBa, degrees
MGP/OP, degrees
NSL/VER, degrees
NSL/OPT, degrees
NSL/CVT, degrees
FH/OPT, degrees
FH/CVT, degrees
OPT/HOR, degrees
CVT/HOR, degrees
OPT/CVT, degrees
MGP-CV1p, mm
H-MP, mm
H-CV3ia-RGN, mm
SNA, degrees
SNB, degrees
ANB, degrees
ANS-PNS/Go-Me, degrees
a

Physiological Breathing (n 35)

Mean

SD

Max

Min

Mean

SD

Max

Min

133.8
93.45
102.4
108
111.79
97.61
100.71
83.00
79.21
3.79
6.84
14.78
3.8
81.74
77.1
4.65
30.64

6.66
10.9
6.68
9.96
9.60
10.80
10.54
9.24
8.24
3.79
3.99
6.30
5.05
4.45
3.90
2.17
5.41

154
115
125
133
134
123.5
124.5
62
67
14
20
31
13
90
84
10
40

119
66
81
92
91
84
80
101
00
4
1
4
10
75
70
1.5
20

132.79
103.77
93.25
98.14
103.64
88.15
93.65
84.42
78.92
5.5
9.84
10.07
7.15
80.92
77.55
3.37
23.97

5.00
9.05
5.63
8.64
9.41
8.84
9.59
8.79
8.08
2.83
2.54
8.14
8.73
4.29
3.94
2.43
5.83

144.7
120.5
105
116.5
126.5
106.5
116.5
101
101
12
14.5
31
31
90
87
7.5
39.5

122.5
82
81
80
86
75
78
71
61
3
3.5
7
7
73
67.5
3
14

Students t-test
t

0.717
4.309
6.196
4.424
3.332
4.010
2.931
0.470
0.364
2.139
3.752
2.707
1.965
0.785
0.480
2.324
4.961

NS
0.000
0.000
0.000
0.000
0.000
0.005
NS
NS
0.036
0.000
0.009
NS
NS
NS
0.023
0.000

Max indicates maximum; Min, minimum; NS, not significant.

Table 2. Ratio for Each Variable of Altered Valuesa With Regard to Normal Values in Oral and Physiological Breathing
Oral Breathing
Variables
NSBa, degrees
MGP/OP, degrees
NSL/OPT, degrees
NSL/CVT, degrees
OPT/CVT, degrees
MGP-CV1p, mm
SNA, degrees
SNB, degrees
ANB, degrees
ANS-PNS/Go-Me, degrees
a

Physiological Breathing

Normal
Values (SD)

Value Altered,
%

a.e.,
%

a.d.,
%

Value Altered,
%

a.e.,
%

a.d.,
%

42.85
57.10
85.70
80.00
54.28
51.42
62.80
65.71
62.85
48.57

73.34
0.05
100.00
100.00
0.26
0.38
68.18
30.43
100.00
100.00

26.66
0.95
0.00
0.00
0.74
0.62
31.82
69.57
0.00
0.00

40.00
57.10
62.85
60.00
34.28
77.14
48.57
45.71
40.00
31.42

71.42
65.00
90.90
85.71
66.66
92.59
52.94
43.75
85.71
36.36

28.58
35.00
0.90
14.29
33.34
7.41
47.06
56.25
14.29
63.64

131
102
91
97
5
7
80
78
2
25

4.5
5
6
6
2
2
2
2
2
6

a.e. indicates altered on excess; a.d., values altered on defect.

pared with the standard values,20 were created within


each group (OB and PB). A chi-square test was used
to analyze the data. The purpose was to see if the
different value of a craniocervical parameter, in both
groups, was due to an excessive flexion on PB or an
exaggerated extension on OB. Within the OB group,
two further subgroups were created with Ad2-PNS values less than 15 mm and greater than 15.5 mm. A
Students t-test was used to compare the values between these two subgroups.
Statistical significance was set at the value P .05.
Data were analyzed using the Primer of Biostatistics
for Windows (version 4.02).21
RESULTS
When OB children were compared with PB children,
the following craniocervical angles were significantly
greater: NSL/OPT (P .0001), NSL/CVT (P .0001),
Angle Orthodontist, Vol 78, No 1, 2008

FH/OPT (P .0001), FH/CVT (P .005), and NSL/


VER (P .0001). The distance MGP-CV1p was significantly smaller (P .0001) as was angle MGP/OP
(P .0001) and angle OPT/CVT (P .036).
A lower position of the hyoid bone, as measured by
a greater distance H-MP (P .009) was present in
OB children. An increase in the maxillomandibular
plane angle (ANS-PNS/Go-Me, P .0001) and an increase in angle ANB (P .023) were seen in the OB
group (Table 1).
Tables 2 and 3 show the ratio and number distribution for each variable as well as the normal, increased, and decreased values for the OB and PB
groups. In particular, PB patients present a greater
proportion of children with an increased value for
MGP/OP (P .012) and MGP-CV1p (P .001), and
a smaller proportion of children with decreased value
for OPT/CVT (P .022) and increased values for an-

81

CEPHALOMETRIC ANALYSIS

Table 3. Number of Patients With Normal, Increased, And Reduced Values of Cephalometric Variables Oral Breathing (OB) and Physiological
Breathing (PB) Compared Using a Chi-Square Test
Normal Values

MGP/OP
NSL/OPT
NSL/CVT
OPT/CVT
MGP/CV1p
SNA
SNB
ANB
ANS-PNS/Go-Me
NSBa

Reduced Value

Normal vs Increased

PB

OB

PB

OB

PB

15
5
7
16
17
13
12
13
18
20

15
13
14
23
8
18
19
21
24
21

19
0
0
14
11
7
16
0
0
4

7
2
3
4
2
8
9
2
7
4

1
30
28
5
7
15
7
22
17
11

13
20
18
8
25
9
7
12
4
10

2.580
0
0.260
5.280
0.512
0
2.601
0.113
3.077
0.105

0.108
1
0.611
0.022
0.474
0.989
0.107
0.736
0.079
0.746

6.313
4.287
3.348
0.027
10.43
1.540
0.147
3.768
6.758
0

0.012
0.038
0.067
0.870
0.001
0.122
0.701
0.052
0.009
1

Ad2-PNS
15.5 mm
(n 12)

Ad2-PNS
15 mm
(n 23)

n 12

n 23

1.78
0.56
0.05
0.41
0.013
0.46
0.55
0.41
0.24
1.21
1.04
1.51
0.56
0.01

130.79
94.87
107.87
112.16
97.58
101.87
4.29
6.45
14.41
2.37
82.83
78.45
4.37
30.62

Normal vs Reduced

OB

Table 4. Comparison of Cephalometric Variables Between the Two


Subgroups of Oral Breathing (Mean SD)a

NSBa
MGP/OP
NSL/OPT
NSL/CVT
FH/OPT
FH/CVT
OPT/CVT
MGP-CV1p, mm
H-MP, mm
H-CV3ia-RGN, mm
SNA
SNB
ANB
ANS-PNS/Go-Me

Increased Value

6.5
10.30
9.76
9.41
10.15
9.76
3.25
2.70
3.87
5.00
5.03
4.60
2.29
5.47

134.89
92.71
108.06
110.71
97.63
100.10
3.53
7.04
14.97
4.54
81.17
76.39
4.80
30.65

6.42
11.05
10.28
9.87
11.34
11.09
4.09
4.57
7.53
5.02
4.13
3.37
2.07
5.50

P value is not significant.

gle ANS-PNS/Go-Me (P .009). In OB patients an


increased number of children with an increased value
of NSL/OPT (P .038) was always evident.
Table 4 shows the measurements of all craniocervical variables in the two subgroups: Ad2-PNS 15.5
mm and Ad2-PNS 15 mm. No statistical differences
were found for any of the cephalometric parameters
between the two subgroups.
DISCUSSION
Oral respiration alters the muscle forces exerted by
the tongue, cheeks, and lips upon the maxillary arch.
Intraorally, the dentist might expect to find a narrow
maxillary arch with a high palatal vault, a posterior
crossbite, a Class II or III dental malocclusion, and an
anterior open bite.22
The purpose of this study was to assess whether
there was a relationship between OB and variables of
head posture in children before these same variables

might influence their development. An abnormal posture of the head changes the load in several joints of
the craniovertebral region, resulting in unfavorable
dentofacial and craniofacial growth.23
Our main finding is that in OB patients a well-defined
postural picture is often evident: reduction of cervical
lordosis and increased extension of the atlanto-occipital joint to maintain the Frankfurt plane horizontal. Further analysis of the data with the chi-square test confirms this result. Only MGP/OP and MGP-CV1p suggest an excessive craniocervical flexion in the PB subjects.
Several studies have shown that OB is connected
with a variation in the head posture and with a increased craniocervical extension1 in order to increase
the dimension of the airway24,12 and the oropharyngeal
permeability4 with mandibular and lingual postural
modifications, and of the soft palate as well.25
Some authors have evaluated the patency of the
upper airways using cephalometric techniques and established a connection between the reduction of the
nasopharyngeal space and the increase of the craniocervical angle.26,27
Even if no association emerges between obstruction
of nasopharyngeal space and craniocervical extension, we cannot conclude that craniocervical extension
does not depend on the superior airway obstruction,
owing to the absence of information about the nasal
resistances in this study. In fact, the OB subdivision in
Ad2-PNS 15.5 mm and 15 mm only underlines the
different adenorhinopharyngeal conditions of these patients, without revealing any details about nasal resistance.
However, there are studies which have demonstrated, by rhinomanometric tests, a significant relationship
between a smaller distance Ad2-PNS or impaired nasal breathing and a wide craniocervical angulation and
forward inclination of the cervical spine.1,28
In our analysis, the ANB angle and the intermaxillary
divergence (ANS-PNS/Go-Me) are present and preAngle Orthodontist, Vol 78, No 1, 2008

82

CUCCIA, LOTTI, CARADONNA

vailing in OB patients, which agrees with other studies.29 These skeletal measurements indicate a tendency for OB children to present a dolichofacial Class II
skeletal pattern.
The hyoid bone is located in a lower position in OB
patients. Other studies found a correlation between a
lower hyoid bone position in relation to the mandibular
plane and increase in craniocervical extension.30,31
However, Bibby32 supported the stability of the hyoid
position which should not be influenced by the postural
anomalies of oral breathers.

13.

CONCLUSIONS

16.

OB causes an increase in head elevation and a


greater extension of the head related to the cervical
spine and influences hyoid bone position and intermaxillary divergence.
OB during growth may alter NHP, as well as craniofacial morphology.
Changing the mode of breathing from oral to nasal
early in adolescence may promote a tendency towards normalization of the craniofacial dimensions
with growth.

12.

14.

15.

17.

18.

19.

20.

REFERENCES

21.

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Morphologic response to changes in neuromuscular patterns experimentally induced by altered modes of respiration. Am J Orthod. 1984;85:115124.
3. McNamara JA. Influence of respiratory pattern on craniofacial growth. Angle Orthod. 1981;51:269300.
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tance and head posture: effect of intranasal corticosteroid


(Budesonide) in children with asthma and perennial rhinitis.
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Weber ZJ, Preston CB, Wright PG. Resistance to nasal airflow related to changes in head posture. Am J Orthod. 1981;
80:536545.
Trask MG, Shapiro GG, Shapiro PA. The effect of perennial
allergic rhinitis on dental and skeletal development. A comparison of sibling pairs. Am J Orthod Dentofacial Orthop.
1987;92:286293.
Wenzel A, Hojensgaard E, Henriksen JM. Craniofacial morphology and head posture in children with asthma and perennial rhinitis. Eur J Orthod. 1985;7:8392.
Solow B, Tallgren A. Head posture and craniofacial morphology. Am J Phys Anthrop. 1976;44:417435.
Rocabado M. Biomechanical relationship of the craniocervical analysis of lateral teleradiograph. Revista Chilena de
Ortodoncia. 1984;1:4252.
Solow B, Sandham A. Cranio-cervical posture: a factor in
the development and function of the dentofacial structures.
Eur J Orthod. 2002;24:447456.
Sfondrini G, Caprioglio A, Mira E, Gandini P. Il Bambino
Adenoideo. Quaderni di Odontoiatria Infantile, 4th ed. Milano, Italy: Masson; 1989;5066.
Sahin Saglam AM, Uydas NE. Relationship between head
posture and hyoid position in adult females and males. J
Craniomaxillofac Surg. 2006;34:8592.
Capurso U, Garino GB. Ortognatodonzia e Funzione Masticatoria. Clinica Delle Disfunzioni Cranio-Cervico-Mandibolari. Milano, Italy: Masson; 1992;2027.
Glantz SA. Primer of Biostatistics, 5th ed. New York, NY:
McGraw-Hill; 2002;6780.
Cazzolla AP, Campisi G, Lacaita GM, Cuccia AM, Ripa A,
Testa NF, Ciavarella D, Lo Muzio L. Changes in pharyngeal
aerobic microflora in oral breathers after palatal rapid expansion. BMC Oral Health. 2006;6:2.
Darnell MW. A proposed chronology of events for forward
head posture. J Craniomandibular Pract. 1983;1:4954.
Warren DW, Lehman MD, Hinton VA. Analysis of simulated
upper airway breathing. Am J Orthod. 1984;86:197206.
Vig PS, Spalding PM, Lints RR. Sensitivity and specificity
of diagnostic tests for impaired nasal respiration. Am J Orthod Dentofacial Orthop. 1991;99:354360.
Capurso U, Garino GB. Nuovi orientamenti nella cefalometria cranio-cervico-mandibolare. Mondo Ortod. 1990;15:
419427.
Solow B, Siersbaek-Nielsen S, Greve E. Airway adequacy,
head posture, and craniofacial morphology. Am J Orthod.
1984;86:214223.
Solow B, Skov S, Ovesen J, Norup PW, Wildschiotdz G.
Airway dimensions and head posture in obstructive sleep
apnoea. Eur J Orthod. 1996;18:571579.
Hellsing E, McWilliam J, Reigo T, Spangfort E. The relationship between craniofacial morphology, head posture
and spinal curvature in 8, 11 and 15-year-old children. Eur
J Orthod. 1987;9:254264.
Ozbek MM, Miyamoto K, Lowe AA, Fleetham JA. Natural
head posture, upper airway morphology and obstructive
sleep apnoea severity in adults. Eur J Orthod. 1998;20:133
143.
Hoekema A, Hovinga B, Stegenga B, De Bont LG. Craniofacial morphology and obstructive sleep apnoea: a cephalometric analysis. J Oral Rehabil. 2003;30:690696.
Bibby RE. The hyoid bone position in mouth breathers and
tongue-thrusters. Am J Orthod. 1984;85:431433.

Original Article

Temporal Expression of SOX9 and Type II Collagen in Spheno-Occipital


Synchondrosis of Mice after Mechanical Tension Stimuli
Teddy Cendekiawana; Ricky W.K. Wongb; A. Bakr M. Rabiec
ABSTRACT
Objective: To associate the expressions of SOX9 and type II collagen during growth in the synchondrosis with and without tensile stress in order to understand the role of these factors in the
growth of cartilage in spheno-occipital synchondrosis.
Materials and Methods: Sixty 1-day-old male BALB/c mice were randomly divided into experimental and control groups. Each group was subdivided again into five different time points which
were 6, 24, 48, 72, and 168 hours. Each subgroup consisted of five mice. Each mouse was
sacrificed using an overdose of pentobarbitone sodium. The synchondroses were aseptically removed and incubated in a 24-well plate with or without tensile stress in tissue culture. Tissue
sections were stained immunohistochemically to quantitatively analyze the expression of SOX9
and type II collagen.
Results: There was a statistically significant increase of 57% (P .001) in the expression of
SOX9 between the experimental and control groups at 24 hours, followed by a significant increase
of 44.4% (P .001) in the expression of type II collagen at 72 hours.
Conclusions: SOX9 may play an important role for early differentiation of chondrocytes and
increase the expression of type II collagen, a major component of the extracellular matrix, during
the growth of cartilage in the spheno-occipital synchondrosis.
KEY WORDS: Spheno-occipital synchondrosis; SOX9; Type II collagen; Tensile stress; Cartilage

INTRODUCTION

Turner syndrome, craniosynostosis syndromes, cleidocranial dysplasia, and cleft palate.3


The synchondrosis develops from a cartilaginous
template known as the chondrocranium which eventually is replaced by bone through endochondral ossification. The role of cartilage in endochondral ossification is obviousit provides the anlagen for bone
formation. Rabie and co-workers59 showed that cartilage formation is closely related to bone formation in
the mandibular condyle of growing rats. As the cartilage formation increases it will offer more opportunity
for more bone to form because cartilage serves as a
template onto which bone will form.5 Corresponding to
these results, the growth of the synchondroses must
be modulated harmoniously by a cascade of events
from various growth factors and regulatory factors that
originate internally in the synchondroses. Unlike the
long bones, where many regulatory factors have already been identified, only a few studies were performed to investigate the factors regulating the growth
of the spheno-occipital synchondrosis.10,11
This led us to look for SOX9 expression during
growth of the spheno-occipital synchondrosis due to
its critical role in governing chondrocyte differentiation.

Cranial base synchondroses are important growth


centers of the craniofacial skeleton. This is especially
true of the spheno-occipital synchondrosis because of
its late ossification and major contribution to post natal
cranial base growth. This serves as an important link
between the development of the cranial vault and the
facial skeleton.14 Disturbance in their development
causes abnormalities in the craniofacial region such as
Apert syndrome, Crouzon syndrome, Down syndrome,

Resident, Department of Orthodontics, The University of


Hong Kong, Hong Kong.
b
Associate Professor, Department of Orthodontics, The University of Hong Kong, Hong Kong.
c
Professor, Department of Orthodontics, The University of
Hong Kong, Hong Kong.
Corresponding author: Dr Ricky WK Wong, Department of
Orthodontics, The University of Hong Kong, 34 Hospital Road,
Prince Phillip Dental Hospital, Hong Kong SAR, China
(e-mail: fyoung@hkusua.hku.hk)
a

Accepted: March 2007. Submitted: January 2007.


 2007 by The EH Angle Education and Research Foundation,
Inc.
DOI: 10.2319/012507-36.1

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84

CENDEKIAWAN, WONG, RABIE

Figure 1. (A) Mechanical spring before activation. (B) Mechanical spring after activation.

SOX9 has essential, nonredundant roles in specifying


the commitment and differentiation of mesenchymal
cells toward the chondrogenic lineage in all developing
skeletal elements.12 Furthermore, SOX9 directly activates gene expression of type II collagen, a major
component of cartilaginous extracellular matrix that
acts as an early and abundant main marker of the
chondrocytes and forms the framework of cartilage
matrix.13,14 Therefore, we hypothesized that SOX9 and
type II collagen expression could be induced by mechanical stimulation (tensile stress). Thus, SOX9 may
play a role in the early differentiation of chondrocytes
and increase the expression of type II collagen,12,13 a
major component of extracellular matrix, during cartilage growth in the spheno-occipital synchondrosis.
The objectives of this study were to:

Surgical Explants of Cranial Base

Identify and quantify the temporal expression of


SOX9 transcription factor in the spheno-occipital
synchondrosis with and without mechanical stimulation (tensile stress).
Identify and quantify the temporal expression of type
II collagen in the spheno-occipital synchondrosis with
and without mechanical stimulation (tensile stress).
Associate the expression of SOX9 and type II collagen events occurring during growth of the synchondrosis in order to understand the role these factors play in the growth of the cartilage in the sphenooccipital synchondrosis.

The serum free protocol was modified from Shum et


al,14 but modified using BGJb medium (GIBCO, Invitrogen) supplemented with 2 mg/mL bovine serum albumin (BSA; Sigma A-9647), 100 g/mL sodium
ascorbate (Sigma A-4034), 1 mM beta-glycerophosphate (Fluka 50020), antibiotics and antimycotics
(GIBCO, Invitrogen). The medium culture was
changed every 24 hours.

MATERIALS AND METHODS


This experiment was approved by the committee on
the Use of Live Animals in Teaching and Research of
The University of Hong Kong (CULATR 1106-05). Sixty 1-day-old male BALB/c mice were randomly divided
into experimental and control groups. Each group was
subdivided again into five different time points which
were 6, 24, 48, 72, and 168 hours. Each subgroup
consisted of five mice.
Angle Orthodontist, Vol 78, No 1, 2008

Each mouse was sacrificed by injecting intra peritoneal (i/p) an overdose of pentobarbitone sodium
(150200 mg/kg) according to the euthanasia guidelines of Rodent Feti and Neonates from the Laboratory
Animal Unit, The University of Hong Kong. An incision
was made across the cranium to remove the brain
from the cranial base, then the mandible was dissected and removed. An excision was started from the
baso-occiptal synchondrosis and ran to the posterior
part of the hard palate. The spheno-occipital synchondrosis was aseptically removed and incubated in a 24well plate with or without mechanical stimulation (tensile stress) in medium culture at 37C and 5% CO2.
Medium Culture

Mechanical Spring
The mechanical spring was made according to the
model of Ikegame et al15 and was adjusted to deliver
0.2 gram tensile stress when the distance at the top
of each arm (length 4 cm) was set at 5 mm and decreased at a rate of 0.01 g/mm (Figure 1). For the
control, the springs were maintained at 5 mm by
means of adhesive tape, hence giving 0 gram of tensile stress (Figure 1).
Immunohistochemistry
The methods of tissue preparation, sectioning and
techniques of immunohistochemistry of SOX9 and

85

SOX9 AND TYPE II COLLAGEN EXPRESSION IN SYNCHONDROSIS

type II collagen were the same as those described by


Rabie et al.7 Immunohistochemistry of the transcription
factor SOX9 and type II collagen was performed in
order to localize their expression in the spheno-occipital synchondrosis after incubation in medium culture
with different time intervals. The specificity of the antibody was ascertained against an epitope corresponding to amino acids 407496 of SOX9 of human
origin and epitope mapping near the C-terminus of collagen 1 type II of human origin. For negative controls,
nonimmune serum was applied instead of the primary
antibodies. Specimens from the tibia served as positive controls.
After the sections were dewaxed and rehydrated,
antigenic sites were exposed by digestion with 0.1 M
citric acid (pH 3) for 30 minutes at 37C and nonspecific binding was reduced by treating in 3% H2O2 for
10 minutes followed by incubation 3% BSA (Sigma
A-9085) blocking serum. The sections were then incubated with polyclonal rabbit-anti-human SOX9 (Santa Cruz Bio Inc, Santa Cruz, Calif; sc-20095), dilution
1:100, and secondary biotin-conjugated goat anti-rabbit for SOX9 (Dako E0432), dilution 1:200, preadsorbed with ABC reagent (Strept ABComplex/HRP,
Dako K0377) successively each for 1 hour at 37C.
The sections were washed with tris buffered saline
(TBS) between each step.
After the sections in the type II collagen groups were
dewaxed, rehydrated, and treated in 3% H2O2 and protease digestion (Proteinase K, Sigma P-6556, 10 g/
mL), they were incubated 3% BSA (Sigma A-9085)
blocking serum with goat polyclonal antibody type II
collagen (Santa Cruz Bio; sc-7763), dilution 1:200 and
secondary biotin-conjugated rabbit anti-goat for type II
collagen (Dako 0466) dilution 1:200, preadsorbed with
ABC reagent successively each for 1 hour at 37C.
The sections of both SOX9 and type II collagen were
developed in 0.05% 3,3-diaminobenzidine (Sigma
D-5637) for 2 minutes and counterstained with Mayer
hematoxylin for 3 minutes, cleaned, and mounted with
coverslips.
Quantitative and Statistical Analysis
Brown staining (at least 100 pixel) that localizes the
expression of SOX9 and type II collagen in the
spheno-occipital synchondrosis was measured with a
true-color RGB (red-green-blue) computer-assisted
image analyzing system with a digital camera (Leica
DC 300 V2.0, Wetzlar, Germany) and with software
(Leica Qwin Pro, version 2.6; Leica Microsystems Imaging Solutions) following the method of Rabie et al.7
This system acquires high-definition digital images of
the specimen, and features from the acquired images
are selected by the operator. The amount of positive

staining (Figure 2) is recognized and quantified by the


computer software according to the color, shade, and
contrast of the feature selected. The sections were
quantified under a fixed measurement frame 165 m2
at 40 magnification (Leitz Orthoplan, Wetzler, Germany). Each section was examined and confirmed to
be located in the midsagittal plane consistently by
comparing the width of the spheno-occipital synchondrosis. For each subject, three sections were measured and a total of 240 sections were quantified. The
amount of staining for all sections was quantified and
evaluated by one examiner. The difference between
the experimental and control groups was tested by unpaired t-test with SPSS for Windows (version 13.0,
SPSS Inc, Chicago, Ill).
Method Error
Ten randomly drawn SOX9 and type II collagen
specimens were quantified on two separate occasions
about 1 month apart to calculate the method error.
Method error in measuring the areas of the staining
was calculated by the formula:
ME

2n

where d is the difference between two registrations,


and n is the number of double registrations. The method error (mm2) for the measurements of SOX9 and
type II collagen was found to be 0.002 and 0.005, respectively. A P value larger than .05 was used to indicate that there were no statistically significant differences between two measurements.
RESULTS
SOX9
Histologically, SOX9 was expressed by the cells in
the proliferative and prehypertrophic zones of the
spheno-occipital synchondrosis as shown in Figure
2A. Mechanical tension stimuli led to earlier higher expression of SOX9 starting at 6 hours in the experimental groups in all regions when compared to the
expression at 6 hours in the control groups (P .001).
The maximum expression peaked at 24 hours, while
at 24 hours in the control groups the expression declined (Figure 3). When the expression was followed
until 168 hours, the experimental group SOX9 maintained a higher level of expression during mechanical
tension stimuli than it did in the control groups. There
was a statistically significant increase (P .001) of
57% in the expression of SOX9 between control and
experimental groups at 24 hours.
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86

CENDEKIAWAN, WONG, RABIE

Figure 2. (A) Immunostaining of SOX9 at 24 hours of experimental groups with different zones (marked with arrows): proliferative zone (PZ),
prehypertrophic zone (PH), and hypertrophic zone (HZ). (B) Photomicrograph in high magnification (100) showing a positive immunostaining
of SOX9 indicated by brown stains (marked with arrows). (C) Immunostaining of type II collagen. (D) Negative control.

Type II Collagen
Histologically, type II collagen was expressed by the
cells in the proliferative, prehypertrophic, and hypertrophic zones of the spheno-occipital synchondrosis as
shown in Figure 2. There was a statistically significant
increase (P .01) in the expression of type II collagen
between the control groups and experimental groups
at 48 hours, and maximum expression peaked at 72
hours compared to the control groups at the same
time. Regarding the 72-hour experimental group, the
expression of type II collagen had a significant increase of 44.4% (P .001) compared to the control
groups (Figure 3).
DISCUSSION
In the present study we applied a tensile stress
across the spheno-occipital synchondrosis and examined the temporal pattern of SOX9 and type II colAngle Orthodontist, Vol 78, No 1, 2008

lagen expression. This thus demonstrated that SOX9


is an important factor for early cell differentiation and
cartilage formation in the spheno-occipital synchondrosis. Tensile stress produced by a mechanical
spring led to an increase of SOX9 expression in the
experimental groups compared to the control groups.
Increases in SOX9 expression indicated more mesenchymal cells differentiate into the chondrogenic
pathway and that will produce more cartilage formation. This will lead to an increase in bone formation
and hence growth.7
The important role of SOX9 as a regulatory factor
was demonstrated in patients who had campomelic
dysplasia as described by Foster et al16 and Wagner
et al.17 They described campomelic dysplasia as a rare
genetic disease or severe human dwarfism syndrome
due to the lack expression of SOX9. This clearly
showed the importance of SOX9 in skeletal development. A study of SOX9 inactivation in limb bud using

87

SOX9 AND TYPE II COLLAGEN EXPRESSION IN SYNCHONDROSIS

Figure 3. (A) The temporal pattern of SOX9 expression during mechanical tension stimuli. (B) The temporal pattern of type II collagen
expression during mechanical tension stimuli. Mean and SD (n
20). Significant differences between control and experimental groups
are marked with asterisks (* P .05; ** P .01; *** P .001).

the Cre recombinase/loxP recombination system before chondrogenic mesenchymal condensation resulted in the complete absence of mesenchymal condensation and of subsequent cartilage and bone formation.18 So far no other transcription factors have been
identified that might control early chondrogenic cell
fate and differentiation upstream or in the same steps
as SOX9 in all developing cartilage elements.10 An increase in SOX9 expression will increase the number
of mesenchymal cells differentiating into chondrocytes.6 Since chondrocytes will synthesize cartilage,
and cartilage is the structural template for bone
growth, identifying the temporal pattern of expression
of SOX9 transcription factor will be an excellent marker for monitoring acceleration of growth.
In control groups, the SOX9 reached a maximum
level of expression at 6 hours and showed a decrease
thereafter as shown in Figure 3. During mechanical
tension stimuli, however, SOX9 reached a level of expression at 6 hours that was higher than that of the

control group, and reached a maximum level of expression at 24 hours. This indicated an increase in the
differentiation of mesenchymal cells into chondrocytes, thus possibly increasing the population of chondrocytes potentially available for chondrogenesis. The
maximum expression of SOX9 achieved was 57%
higher compared to the control groups. Throughout the
experiment, SOX9 still maintained a higher level of expression compared to the control groups.
To further investigate the role of SOX9 in chondrogenesis of the synchondrosis, we also monitored the
level of type II collagen expression since SOX9 expression regulates type II collagen by directly binding
to 48-bp Col2a1 enhancer segments. Transcription of
type II collagen gene starts to be expressed following
mesenchymal cell condensation that precedes cartilage formation, thus it represents an early marker of
chondrocyte differentiation.19 Its essential structural
role in cartilage is most clearly demonstrated by the
abnormal skeletal phenotypes displayed by humans
and mice carrying mutant pro1(II) collagen chains.20
The important role of type II collagen mutation in craniofacial development and growth has been confirmed
using transgenic Del 1 mice, in which the mutation is
characterized by overall retardation of chondrogenesis
and osteogenesis such as a reduced anteroposterior
length, a smaller size of the mandible, a palatal cleft,
and a downward bending snout.21
In the control groups, the maximum level of type II
collagen expression was reached at 168 hours, but in
experimental groups the maximum expression was
reached at 72 hours and still maintained a higher level
of expression until 168 hours (Figure 3B). This indicated an earlier differentiation of chondrocytes and enhanced level of matrix synthesis resulting in earlier and
more cartilage formation. The maximum expression of
type II collagen was 44% higher compared to control
groups.
The increased expression of SOX9 clearly preceded
the deposition of cartilage in the spheno-occipital synchondrosis, indicating that SOX9 is a determinant factor for chondrocyte differentiation rather than a consequence. Proliferating mesenchymal cells subjected
to the SOX9 expression will differentiate into chondrocytes, thus increasing the synchondrosis growth potential. Furthermore, SOX9 acts upon these cells to
enhance type II collagen synthesis, hence increasing
the cartilage matrix formation. The increase in cartilage matrix offers a bigger template to accommodate
more bone at a later stage.
CONCLUSIONS
Mechanical tension stimuli (tensile stress) increases
SOX9 and type II collagen expression in the sphenooccipital synchondrosis.
Angle Orthodontist, Vol 78, No 1, 2008

88
SOX9 may play a role for early differentiation of
chondrocytes and increase the expression of type II
collagen, a major component of extracellular matrix,
during the growth of cartilage in the spheno-occipital
synchondrosis.

CENDEKIAWAN, WONG, RABIE

12.

13.

ACKNOWLEDGMENTS
This research was supported by The Committee on Research
and Conference Grants, The University of Hong Kong (CRCG
10206657.36170.08003.301). We thank Dr Dai Juan and Mr
Chui Ying Yip of the Hard Tissue Laboratory for their technical
assistance in the histological preparation, and also Mr Shadow
Yeung for his kind assistance with the statistical analyses.

14.

15.

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3. Nie X. Cranial base in craniofacial development: developmental features, influence on facial growth, anomaly, and
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in the glenoid fossa. J Dent Res. 2003;82(9):725730.
7. Rabie ABM, She TT, Hagg U. Functional appliance therapy
accelerates and enhances condylar growth. Am J Orthod
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8. Xiong H, Rabie ABM, Hagg U. Mechanical strain leads to
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10. Tang M, Mao JJ. Matrix and gene expression in the rat cranial base. Cell Tissue Res. 2006;324(3):467474.
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Lefebvre V, Huang W, Harley VR, Goodfellow PN, de Crombrugghe B. SOX9 is a potent activator of the chondrocytespecific enhancer of the pro alpha1(II) collagen gene. Mol
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Zhou G, Lefebvre V, Zhang Z, Eberspaecher H, de Crombrugghe B. Three high mobility group-like sequences within
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Ikegame M, Ishibashi O, Yoshizawa T, Shimomura J, Komori T, Ozawa H, Kawashima H. Tensile stress induces
bone morphogenetic protein 4 in preosteoblastic and fibroblastic cells, which later differentiate into osteoblasts leading to osteogenesis in the mouse calvariae in organ culture.
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Foster JW, Dominguez-Steglich MA, Guioli S, et al. Campomelic dysplasia and autosomal sex reversal caused by
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Wagner T, Wirth J, Meyer J, et al. Autosomal sex reversal
and campomelic dysplasia are caused by mutations in and
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Akiyama H, Chaboissier MC, Martin JF, Schedl A, de Crombrugghe B. The transcription factor Sox9 has essential roles
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Original Article

Gene Therapy to Enhance Condylar Growth Using rAAV-VEGF


Juan Daia; A. Bakr M. Rabieb
ABSTRACT
Objective: To test the hypothesis that the introduction of specific vascular growth inducting genes
would favorably affect mandibular condylar growth in Sprague-Dawley (SD) rats over a limited
experimental period. Therefore, the aim of this study is to examine the effect of gene therapy on
condylar growth by means of a morphological assessment.
Materials and Methods: Ninety 35-day-old female SD rats were randomly divided into three
groups, which received any of the injections of recombinant adeno-associated virus mediated
vascular endothelial growth factor (rAAV-VEGF), rAAV mediated enhanced green fluorescence
protein (rAAV-eGFP), or phosphate-buffered saline (PBS) into both mandibular condyles. Each
group of rats was sacrificed on the following experimental days: 7, 14, 21, 30, and 60. Left halves
of the mandibles were isolated and digital pictures were obtained in a standardized manner.
Results: The length of condylar process (B-F) as well as mandibular length (A-F) significantly
increased on day 30 and continued to increase until the end of the experiment. Moreover, the
width of condyle (Q-R) had increased significantly from day 30 and lasted to day 60. Condylar
length (C-D) was found to be significantly longer on day 60.
Conclusions: Gene therapy with VEGF stimulates condylar growth at will. The rAAV-VEGF is an
excellent candidate for future gene therapy to induce mandibular growth.
KEY WORDS: Gene therapy; rAAV; VEGF; Mandibular condylar growth

INTRODUCTION

tigenicity, and disease transmission. Most would agree


that the current patient care regimen is inefficient, expensive, and painful, and therefore needs to be improved.25
The rapid development of recombinant DNA technology has led to the development of growth factorbased approaches. Using the specific gene encoding
the proteins, we are now able to synthesize large
quantities of the therapeutic proteins for treatment purposes.6,7 Local administration of insulin-like growth factor (IGF-I) in the mandibular condyle of rats has been
shown to induce actual bone formation.8,9
Although these findings are promising, the possible
applications of these growth factors are limited by their
short biological half-life which requires repeated administrations and expensive dosages.10 Recent advances in molecular biology have led to fast progress
in the development of gene therapy and the most
promising novel approaches to maximally stimulate
bone formation in animals as well as in humans.11
Since Baum and OConnell12 first described the potential impact of gene therapy on dentistry, gene therapy
has forged its own position as a novel strategy to induce bone formation. Earlier, we reviewed advances
of gene therapy for the repair of craniofacial bone
defects.3 By means of this technique, genes can be

Scientific advances in the 21st century have helped


us to understand molecular factors that regulate condylar growth.1 Genetic disorders in the craniofacial region lead to a number of craniofacial anomalies. For
example, micrognathia and hemifacial microsomia are
such conditions where impaired condylar growth requires comprehensive surgical intervention. Currently,
the available approaches include distraction osteogenesis, orthognathic surgery, bone grafting using autogenous bone, allogenic bone grafts, and others. Osteoinductive matrices are limited by their disadvantages such as bone graft resorption, their association with
lack of volume, donor site morbidity, potential for ana
Graduate PhD student, Department of Orthodontics, University of Hong Kong, Hong Kong, SAR, China.
b
Professor, Department of Orthodontics, University of Hong
Kong, Hong Kong, SAR, China.
Corresponding author: Dr A. Bakr M. Rabie, Orthodontics and
The Biomedical and Tissue Engineering Group, Faculty of Dentistry, The University of Hong Kong, 34 Hospital Road, Hong
Kong SAR, China
(e-mail: rabie@hkusua.hku.hk)

Accepted: March 2007. Submitted: October 2006.


 2007 by The EH Angle Education and Research Foundation,
Inc.
DOI: 10.2319/102606-441.1

89

Angle Orthodontist, Vol 78, No 1, 2008

90
therapeutically used to produce osteoinductive growth
factors in the local environment to heal experimental
craniofacial defects.1315 This has direct and profound
implications for the treatment of craniofacial deformities. Most recently, we were able to construct a delivery vehicle where potential therapeutic genes could be
delivered to the condyle.16
Vascular endothelial growth factor (VEGF) has been
shown to play an important role in mandibular condylar
growth.1,1719 VEGF is a potent regulator of neovascularization expressed during endochondral ossification
of the condyle.1,17 Chondrocytes of the mandibular
condyle express VEGF which stimulates neovascularization and marks the onset of endochondral ossification.
Some successful gain of function studies with recombinant VEGF proteins or gene therapy has yielded
significant increases in vascularization and bone regeneration in a defects model.20,21 Local administration
of recombinant human vascular endothelial growth
factor (rhVEGF) was found to enhance the amount of
tooth movement.22,23 Moreover, rhVEGF administration
leads to enhanced blood vessel formation and ossification in bone defects.20 In vivo gene therapy with adenovirus mediated VEGF proved to modify bone defect healing.21,24 Thus, VEGF has possible clinical applications for inducing bone formation. More recently,
Rabie et al25 successfully established recombinant adeno-associated virus (rAAV) mediated VEGF delivery
system and identified transgene distribution in the condylar cartilage and significant increase in the expression of chondrogenic and osteogenic markers. Therefore, the aim of this study is to further investigate the
morphological changes in the mandibular condyles
treated by VEGF gene therapy.

DAI, RABIE

Figure 1. Schematic illustration of method for condylar measurements.26 A: The most anterior point of the lingual alveolar bone; B:
The midpoint of mandibular foramen; C: The most anterior point of
condyle; D: The most inferior (posterior) point of condyle; E: The
middle of point C and D; F: Intersection point of B-E extension line
and outer contour of condyle; G: Posteriorinferior point of attachment of digastric muscle; H: The most inferior point of lower border
of angular process; Q: The outermost point of ventral contour of
condyle; R: The outermost point of dorsal contour of condyle; BF:
Condylar process axis; GH: Mandibular plane.

MATERIALS AND METHODS

and the ear cartilage, followed by a blunt dissection to


expose the zygomatic arch and the posterior margin
of the articular eminence.16 The 50 L volume of
rAAV-VEGF164 (2 1011, genome copies), rAAV-eGFP
(2 1011, genome copies) or PBS was slowly injected
directly into the posterior attachment of rat condyle
through a 30-gauge needle connected with a microsyringe in a downward and backward direction. The
needle was allowed to remain in place for another 5
minutes before being slowly retracted at the end of
each injection. Care was taken to avoid injecting the
blood vessels around the condyle. One interrupted
4-0 silk suture was used to close the incision. Six rats
from each subgroup were sacrificed at 7, 14, 21, 30,
and 60 days postinjection by an intraperitoneal injection of Dorminal. After death, the heads of those SD
rats were first skinned and then dissected into two
halves. The left halves were immediately delivered to
do the morphological analysis.

Local Injection of rAAV-VEGF and rAAV-eGFP


Into Rat Condyle

Morphological Measurement

The animal experiments were approved by the


Committee on the Use of Live Animals in Teaching
and Research (CULATR 897-04) of the University of
Hong Kong. Ninety 35-day-old female Sprague-Dawley (SD) rats were obtained from the Animal Units of
the University of Hong Kong. These SD rats were randomly allotted into one experimental group with rAAVVEGF injection and two control groups with rAAVeGFP (enhanced green fluorescence protein) or PBS
(phosphate-buffered saline) injection. The body weight
of each rat was measured both at the beginning and
at the end of the experiment.
After anesthetization of the rats, an anterior-posterior sterile incision, 1.5 cm in length, was made in the
skin between the posterior end of the zygomatic arch

Gross morphological analysis was carried out as described in detail previously.26 Digital photos of the lateral view of the left mandibles were taken using a true
color video camera (JVC TK-C1380, Tokyo, Japan) to
allow for the angular and linear measurements.26 The
condylar head in particular was separated from the
mandible and inserted into a homemade columniform
abutment for photo taking.27 The photos were taken
through the digital picture capture system with a ruler
to standardize the amplification. To increase the accuracy of the small morphological measurement
changes, the images were magnified two times the
original size with the known scale and were traced with
selected landmarks and distance (Figure 1, Table 1).
Measurement was blind and evaluated by two inde-

Angle Orthodontist, Vol 78, No 1, 2008

91

INDUCE MANDIBULAR CONDYLAR GROWTH


Table 1. Definition of Linear and Angular Measurements26
Variables
B-F
A-F
A-B
C-D
Q-R
C-GH
F-GH
D-GH
BF/GH

Definition
The length of condylar process
Mandibular length
Length of mandibular base
Length of condyle
Width of condyle
The distance from point C to mandibular plane
The distance from point F to mandibular plane
The distance from point D to mandibular plane
Angle of condylar process axis to mandibular plane

pendent tracings, which were carried out at an interval


of at least 2 weeks. Ten species were randomly selected for the evaluation of method error, which was
calculated with Dahlbergs formula Me d 2/2n ,
where d represents the difference between two registrations and n is the number of duplicate registrations. The method error determined was 0.13 mm for
linear measurement and 1.4 for angular measurement, which were both statistically insignificant (P
.05).
Statistical Analysis
The statistical analysis was processed with SPSS
for Windows (SPSS Inc, Chicago, IL) for one-way
analysis of variance (ANOVA) with a Bonferroni multiple comparisons test to compare the mean difference
among the experimental group and two control groups
at each time point. P values were considered to be
statistically significant when less than .05.
RESULTS
Changes in Body Weight During the Experimental
Period
A gradual increase in body weight was recognized
during the experimental period in both experimental
and control groups (Figure 2). However, no significant
difference in body weight was detected among the one
experimental group and two control groups (P .05).
Morphological Analysis
The length (C-D) and width (Q-R) of the condylar
head increased significantly from day 30 to day 60.
Moreover, the length of the condylar process (B-F) together with the dependent mandibular length (A-F) significantly increased from day 30 to day 60. The distance from the posterior part of the condylar head (D)
to the mandibular plane (GH plane) increased on day
60 followed by the increased distance between the
midpoint of the condylar surface (F) to the GH plane.
However, the change of position of the point F did not
affect the angle of BF/GH. The length of mandibular

Figure 2. Body weight during the study period. There were no significant differences in body weight among the three groups.

base (A-B) and the distance between the reference


point on the most anterior surface of the condyle (C)
and the GH plane remained unchanged in both groups
throughout the whole period (Table 2).
DISCUSSION
In the present study, we injected the mandibular
condyle with rAAV mediated VEGF and demonstrated
significant condylar growth. Such growth lasted for the
duration of the experiment, which was 60 days after
injection. This work should be considered as proof of
principle that a key regulatory growth factor can stimulate mandibular growth at will.
Growth of mandibular condylar cartilage is partly genetically determined, but is also influenced by exogenic factors including mechanical factors and numerous
systemic and local mediators.28 Furthermore, the effects of mechanical and systemic factors is, in part,
mediated by growth factors, which play a central role
in the local regulation of cartilage growth and metabolism.1,29 This gives gene therapy a critical role in the
future for management of anomalies related to growth.
Gene therapy offers new possibilities to either correct
a defective gene in a given tissue or organs or to deliver the lacking growth factors in a given tissue to
stimulate a function.
Osteogenesis (the formation of new bone) and angiogenesis (the invasion of new blood vessels) are
closely correlated.30 VEGF, the best-characterized angiogenic factor, has been shown to play an important
role in long bone and mandibular condylar growth.1,31
When VEGF was inactivated in mice through the systemic administration of a soluble receptor chimeric
protein (sFlt-1), blood vessel invasion was almost
completely suppressed, concomitant with impaired trabecular bone formation and expansion of hypertrophic
chondrocyte zone.31 Some reports demonstrated a
successful effect of recombinant VEGF and in vivo
Angle Orthodontist, Vol 78, No 1, 2008

92

DAI, RABIE

Table 2. Values of Linear and Angular Measurements of Mandibular Morphology in Experimental and Control Groups at Different Time Pointsa
7 days
VEGF

eGFP

B-F
5.25 0.25 5.30
A-F
22.7 0.41 22.55
A-B
18.00 0.26 18.15
C-D
3.26 0.21 3.21
Q-R
1.24 0.15 1.27
C-GH
8.83 0.25 8.64
F-GH
8.54 0.18 8.36
D-GH
7.27 0.13 7.14
BF/GH 42.51 2.60 42.33

14 days
PBS

VEGF

0.26 5.18 0.26 5.78


0.57 22.35 0.76 22.34
0.49 18.23 0.34 18.18
0.42 3.12 0.12 3.32
0.12 1.26 0.15 1.38
0.16 8.73 0.18 9.26
0.15 8.47 0.19 9.17
0.12 7.21 0.17 7.75
1.50 42.17 1.72 42.75

eGFP

21 days
PBS

0.24 5.69 0.28 5.67


0.51 22.61 0.68 22.54
0.52 18.54 0.16 18.46
0.19 3.19 0.17 3.25
0.11 1.35 0.18 1.34
0.17 9.11 0.12 9.27
0.31 8.91 0.21 9.02
0.32 7.77 0.24 7.82
3.44 43.25 1.95 43.17

0.30
0.51
0.51
0.19
0.13
0.16
0.16
0.21
2.92

VEGF
6.02
24.28
18.56
3.38
1.54
10.11
9.67
8.30
41.28

0.34
0.47
0.49
0.27
0.12
0.26
0.35
0.39
2.46

eGFP
5.73
24.10
18.61
3.31
1.41
10.18
9.53
8.15
42.08

0.36
0.58
0.41
0.19
0.13
0.12
0.38
0.22
3.18

PBS
5.83
24.19
18.81
3.27
1.43
10.26
9.87
8.51
43.64

0.43
0.32
0.23
0.28
0.13
0.23
0.39
0.25
2.54

a
VEGF indicates vascular endothelial growth factor; eGFP, enhanced green fluorescence protein; PBS, phosphate-buffered saline.
* P .05; ** P .01.

gene therapy on bone formation.20,21 The advance of


virus research has brought rAAV into the limelight of
viral gene therapy. The major advantages of rAAV include the potential for long-term transgene expression,
less pathogenicity, low immunogenicity, and the ability
to infect a broad range of host tissues including both
dividing and nondividing cells.3 Most recently, we first
reported that transgene can be transferred to the mandibular condyle in vivo by rAAV delivery.16
The reporter gene of eGFP, an exogenous intracellular molecule, was used for in situ identification of delivered gene32 and to eliminate the role of delivery vehicle. The local delivery of rAAV-VEGF in the present
study resulted in elongated mandibular condylar
growth in the posterior part of the condyle. This was
due to the fact that VEGF was locally delivered into
the mandibular condyle through the posterior attachment. The rAAV-VEGF vector (2225 nm in size) was
small enough to diffuse from the injected joint space
to the cell surface layers, and then deeper to infect
chondrocytes and hypertrophic chondrocytes and to
make them secrete the growth factor, VEGF, to regulate the microenvironment in the condyle.25 Moreover,
in the previous study, we extracted RNA from the remote organs of liver, kidney, heart, and spleen of
rAAV-VEGF injected animals for reverse transcription
polymerase chain reaction (RT-PCR) analysis. The exogenous VEGF was not detected, thereby reducing
the prospects of systemic adverse effects.25
Treated by VEGF gene therapy, the growth of the
condyle ultimately resulted in the increase in mandibular length (A-F); no increase was identified in the
length of mandibular base (A-B); and the distances of
point F as well as point D to mandibular plane demonstrated an increase, but the position of point C was
kept stable. Moreover, the changed position of point F
did not affect the angle of condylar process to the
mandibular plane (BF/GH). Thus, it pointed out that
mandibular condylar growth occurred in a backward
and upward direction.
Angle Orthodontist, Vol 78, No 1, 2008

After continuous bite-jumping treatment, the most


prominent cellular response was documented in posterior surface of the condyle, but not in the anterior
surface. The condyle expressed its adaptability in
terms of directional changes in mandibular growth,1
the distance from point F and D to GH was reduced,
together with the reduction of the angle of the condylar
process to the mandibular plane, which displaced the
condylar process backwards but downwards.26 Hence,
the directional remodeling of mandibular condyle by
gene therapy and bite-jumping treatment was different
in the vertical direction, but similar in the sagittal direction. Gene therapy is still in its infancy stage for
experimental growth of the mandibular condyle. We
hope that in the near future we can target cells in the
superior layer of the condyle that could result in a more
upward growth of the condyle and thus help in regulating direction of growth.
One interesting finding in this study was the delayed
effect on morphological change. Five time points, 7,
14, 21, 30, and 60 days, were selected because each
of these time points demonstrate the peak expression
of one of the growth factors expressed during induced
growth of the mandible.1,18 For example, VEGF expression was evident on day 14, while chondrogenesis
peaked on day 21, and osteogenesis on day 30 during
mandibular advancement. Day 60 was added to determine whether the gene expression was still evident
after the injection for a longer time. On day 7, 14, and
21, all the measured morphological parameters of the
rats mandibles showed no significant difference
among the rAAV-VEGF delivery, rAAV-eGFP, and
PBS injected group. From day 30, parameters of condylar width and length demonstrated a significant increase. Up to day 60, more parameters showed significant change. Since it was known that the rAAV vector exists as a single stranded DNA virus, while the
viral genome is transported to the nucleus within minutes after infection,33 in vivo transduction takes days
to weeks as a consequence of lagging second-strand

93

INDUCE MANDIBULAR CONDYLAR GROWTH


Table 2. Extended
30 days
VEGF
6.55
26.21
19.66
3.63
1.64
10.38
9.96
8.35
40.24

0.44
0.42
0.37
0.17
0.12
0.3
0.26
0.33
4.02

eGFP
5.85
25.33
19.83
3.39
1.46
10.40
9.77
8.46
42.31

0.23**
0.23*
0.31
0.20*
0.10*
0.11
0.19
0.33
3.66

60 days
PBS
6.06
25.44
19.74
3.41
1.45
10.31
9.84
8.44
41.83

0.22*
0.60*
0.28
0.15*
0.11*
0.14
0.29
0.21
3.28

synthesis.34 On the other hand, VEGF expressed on


the basis of extractable protein from mandibular condyle was significantly increased from day 14, and the
biochemical analysis showed that osteogenic markers
of alkaline phosphatase activity and osteocalcin content significantly increased from day 30.25 Taken together, it was consistent with the earlier reports that
VEGF expression was closely correlated to mandibular condylar growth, which preceded the peak of bone
formation.1,19,27 In the near future, it is necessary to
know whether these genetically treated rats need reinjection or inhibition to avoid relapse or overgrowth.
Therefore, the long-term effect on mandibular condylar
growth by VEGF gene therapy needs to be investigated further.
CONCLUSIONS
The present study provides further evidence that local rAAV mediated VEGF gene transfer enhances
the size of mandibular condyle leading to mandibular
condylar growth. It provides the basis to regulate
mandibular condylar growth for future clinical practice.
ACKNOWLEDGMENTS
This study was supported, in part, by a grant to The University
Strategic Research Theme: Genomics, Proteomics & Bioinformatics, The University of Hong Kong, grant 10206152.11222.
21700.302.01 and the CERG grant awarded to Professor Rabie,
10206968.22311.08003.324.01.

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Schwarz EM. Light-activated gene transduction of recombinant adeno-associated virus in human mesenchymal stem
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Suzuki S, Itoh K, Ohyama K. Local administration of IGF-I
stimulates the growth of mandibular condyle in mature rats.
J Orthod. 2004;31:138143.
Zhang F, Fischer K, Lineaweaver WC. DNA strand gene
transfer and bone healing. J Long Term Eff Med Implants.
2002;12:113123.
Chen Y, Cheung KM, Kung HF, Leong JC, Lu WW, Luk KD.
In vivo new bone formation by direct transfer of adenoviralmediated bone morphogenetic protein-4 gene. Biochem
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Baum BJ, OConnell BC. The impact of gene therapy on
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Original Article

Duration and Anchorage Management of Canine Retraction with Bodily


Versus Tipping Mechanics
Nir Shpacka; Moshe Davidovitcha; Ofer Sarnea; Narchos Panayib; Alexander D. Vardimonc
ABSTRACT
Objective: To compare tipping mechanics (TM) and bodily mechanics (BM) with respect to duration, angulation, and anchorage loss during canine retraction.
Materials and Methods: TM and BM brackets were bonded to the upper right and left canines,
respectively, of 14 subjects requiring maxillary first premolar extractions. The upper canines were
retracted with variable nickel titanium closed coil springs (F 0.50 or 0.75 N) attached posteriorly
to a Nance anchorage appliance through the first molars. Panoramic radiographs and dental casts
were taken at five time points. Canine angulation was assessed with custom metallic jigs inserted
into the vertical slots of the canine brackets prior to radiographic exposure.
Results: The canine crown contacted the second premolar after 102.2 106 and 99.0 80.0
days, and achieved root uprighting in 72.0 31.3 and 37.2 42.7 additional days with the TM
and BM groups, respectively. Only the uprighting stage differed significantly between the two
mechanics (P .05). During retraction, tooth angulation differed significantly (P .001) between
the TM (6) and BM (0.8) groups. Anchorage loss, as assessed by mesial molar movement,
was 1.2 0.3 mm and 1.4 0.5 mm for the TM and BM groups, respectively.
Conclusions: Bodily canine retraction occurred faster (38 days) than tipping due to a shorter
duration of root uprighting. Anchorage loss (17%20%) was similar for both retraction methods,
ie, maximum anchorage could not be provided by the Nance appliance. Both TM and BM brackets
had inadequate rotational control of the retracted canine.
KEY WORDS: Anchorage; Retraction; Bodily; Tipping; Canine

INTRODUCTION

nearly pure bodily movement of teeth due to creation


of force couples in the bracket resulting from its rectangular arch wire slot. In contrast, the Begg bracket,
a modified version of Angles ribbon arch appliance,
maintains only a point contact with the arch wire, thus
facilitating tipping mechanics (TM) of the dental crown
or root.1
Proponents of TM claim that it has several unique
advantages. These include, reduced (molar) anchorage loss, decreased treatment time, elimination of extraoral appliances, and reduced risk of root resorption.1 However, the BM group of appliances has become the most popular fixed orthodontic appliance to
date due to its simplified method of exerting first, second, and third order control.2
In an effort to combine aspects of both the classic
Begg and edgewise designs, Kesling3 developed the
Tip-Edge bracket (Figure 1) originally intended for canine retraction in premolar extraction cases. The TipEdge bracket is a single wing bracket with a 0.022
0.028 inch arch wire slot with disto-incisal and mesiogingival corners chamfered at a 25 angle. The cham-

Modern orthodontics employs various fixed appliance systems, each with its own advantages and disadvantages. Two of these systems are the edgewise
and Begg appliances. The design of the edgewise
bracket permits bodily mechanics (BM) resulting in
Instructor, Department of Orthodontics, The Maurice and
Gabriela Goldschleger School of Dental Medicine, Tel Aviv University, Tel Aviv, Israel.
b
At present, private practice, Limassol, Cyprus; former Graduate student (MS), Department of Orthodontics, The Maurice
and Gabriela Goldschleger School of Dental Medicine, Tel Aviv
University, Tel Aviv, Israel.
c
Professor and Department Head, Department of Orthodontics, The Maurice and Gabriela Goldschleger School of Dental
Medicine, Tel Aviv University, Tel Aviv, Israel.
Corresponding author: Dr Nir Shpack, School of Dental Medicine, Department of Orthodontics, Tel Aviv University, Tel Aviv,
Israel 69978
(e-mail: nshpack@post.tau.ac.il)
a

Accepted: February 2007. Submitted: January 2007.


 2007 by The EH Angle Education and Research Foundation,
Inc.
DOI: 10.2319/011707-24.1

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Angle Orthodontist, Vol 78, No 1, 2008

96

Figure 1. Tip-Edge bracket. Vertical slot (a) for the insertion of auxiliaries such as hooks, uprighting and rotation springs. Disto-incisal
and mesio-gingival corners chamfered at 25 (b), and wing-like extensions of the arch wire slot (c).

fered corners of the bracket allow for a large amount


of tipping during retraction as is practiced in the Begg
technique. The Tip-Edge bracket also contains a 0.016
0.022 inch vertical slot for the insertion of auxiliaries
such as elastic hooks, and uprighting or rotation
springs. In the Begg technique the latter tools are used
to cause a tendency to rotate in order to affect root
uprighting and tooth rotation.3 Additional rotational
control is provided by the wing-like extensions of the
arch wire slot which serve to increase the mesial-distal
dimension of this single-wing bracket (Figure 1).
The most time-consuming stage of premolar extraction-based orthodontic treatment is canine retraction.
Any procedure which reduces the time required to perform this stage will also serve to shorten overall treatment time. Lotzof et al4 compared rates of canine retraction using Tip-Edge and edgewise brackets utilizing a 2 N force delivered by frequent replacement of
elastic chain. They reported that the rate of canine retraction using the Tip-Edge bracket was slightly faster,
and that the anchorage loss with the edgewise bracket
was greater than that found with the Tip-Edge bracket.
However, they were not able to confirm this claim statistically, nor were differences in root position during
canine retraction reported. Kesling5 claimed that the
conclusions of Lotzof et al4 were invalid because of
improper levels of force application to the Tip-Edge
bracket, reducing its efficiency as a result of an unfavorable biological response (ie, hyalinization).5
Smith and Storey6 and Streed7 reported that during
canine retraction 5%55% of the extraction space can
Angle Orthodontist, Vol 78, No 1, 2008

SHPACK, DAVIDOVITCH, SARNE, PANAYI, VARDIMON

be taken up by mesial movement of the anchorage


unit (ie, the first molar and second premolar). Ziegler
and Ingervall8 compared sliding and nonsliding mechanics during canine retraction and concluded that
the mean anchorage loss was 30% for both methods
without any significant differences between them.
They also found that in both TM and BM approximately
30 of mesiolabial rotation of the canines typically occurred during retraction.
Paulson and Ingervall8 performed a laminographic
investigation of molar anchorage during canine retraction. A force of 0.500.75 N between the molars and
canines was used for retraction against a transpalatal
arch and cervical headgear (worn nightly). They reported that in five out of the six subjects forward movement of the molars was not significant and concluded
that anchorage loss was prevented by the steps taken
to counteract it as well as the application of a light
force. Geron et al10 found that anchorage loss is a multifactorial response that is primarily affected by the
amount of crowding and mechanics (labial vs lingual),
and secondarily by age, location of extraction site, and
overjet, in declining order of importance.
The objective of the present study was to compare
canine retraction undertaken with tipping and bodily
mechanics. Four variables were compared including
duration, angulation, rotation, and anchorage loss. The
null hypothesis of this study is that no differences exist
between TM and BM in the duration of canine retraction at all five time points, nor is there any difference
in angulation, rotation, and anchorage loss.
MATERIALS AND METHODS
This prospective study comprised 14 subjects presenting for orthodontic therapy to the Department of Orthodontics of the University of Tel Aviv, School of Dental
Medicine. Their treatment was determined to include the
extraction of both maxillary first premolars. Inclusion in
the study was pursuant to the receipt of each subjects
consent in accordance with the Helsinki protocol.
Prior to undergoing dental extractions, a Nance (button) appliance soldered to the bands of the maxillary
first permanent molars was inserted. After extraction
of the maxillary first premolars, each subject had 0.022
0.028 inch Victory (3M-Unitek, Monrovia, Calif) orthodontic brackets bonded to the incisors and second
premolars. For the BM, an edgewise bracket with a
vertical slot (Victory #017919 3M Unitek) was bonded
to the maxillary left canine. For the TM, a Tip-Edge
bracket (#296016; TP Orthodontics, LaPorte, Ind) was
bonded to the right (Figure 2).
A polyvinylsiloxane impression of the canines with
their respective brackets was made to act as a matrix
should bracket failure occur in order to facilitate re-

97

CANINE RETRACTION WITH BODILY VERSUS TIPPING MECHANICS

and activated by hooking onto the arch wire, whereas


the BM canine (left) underwent any necessary root
uprighting by the placement of appropriate second order bends in the arch wire.
Retraction Duration
Experimental data were gathered at the following
five time points (comprising three stages):

Figure 2. Canine retraction carried out with a tipping mechanics


(TM, right) and bodily mechanics (BM, left) bracket using nickeltitanium closed coil springs. The left canine has contacted the second premolar and root uprighting is occurring. A Nance appliance is
also present.

bonding in the original bracket position. Active canine


retraction did not commence until a 0.018-inch stainless steel arch wire was engaged. Canine retraction
was accomplished using 0.5 and 0.75 N nickel-titanium closed coil springs (GAC, Central Islip, NY) from
the TM and BM brackets, respectively, to the gingival
hooks of each respective molar band (Figure 2).
Root uprighting of the TM canine (right) was
achieved with a preformed uprighting spring (TP Orthodontics) inserted into the vertical slot of the bracket

T0: prior to canine retraction;


T1a: when one of the canine crowns contacts the
second premolar;
T1b: when the other canine comes into contact with
the second premolar;
T2a: when one of the canine roots was uprighted; and
T2b: when the other canine root was deemed to be
uprighted.
At each time point, dental cast of the maxillary arch,
a panoramic radiograph, and intraoral photographs
were obtained for each patient.
Canine Angulation
The panoramic radiographs were taken with jigs
made of 0.016 0.022 inch stainless steel wire inserted in the vertical slots of the canine brackets. Canine angulation was defined as the angle formed by
the intersection of the infraorbital line and a line extending from the jig placed into the vertical slots of
each canine (Figure 3).11

Figure 3. Panoramic radiograph with jigs inserted in the vertical slots as landmarks for canine angulation in relation to the infra-orbital line.
Angle Orthodontist, Vol 78, No 1, 2008

98

SHPACK, DAVIDOVITCH, SARNE, PANAYI, VARDIMON

Figure 5. The acrylic mold of the palate with two wires projected to
the central fossa of the first molars of the initial dental cast (a T0),
and transferred to the final dental cast (b T2) to determine the
amount of anchorage loss.
Figure 4. Canine rotation, defined as the angle formed by a line
through the distal and mesial contact points of the canine to the midpalatal raphe.

Canine Rotation
Rotational change in canine position was measured
from the dental casts using the method of Ziegler and
Ingervall.8 The angle formed between a line through
the distal and mesial contact points of the canine, and
the midpalatal raphe was measured at T0 and T2 (Figure 4).
Anchorage Loss
Change in sagittal position of the maxillary first molar was also assessed from the dental casts. A transferable reference was fabricated using an acrylic mold
of the palatal raphe, anatomically fitted for each subject, in which were embedded and had extending from
it wires directed to the central fossa of the first permanent molar of the pretreatment dental cast (Figure
5).4 This device was hence placed on the same site
on final dental casts (T2) upon which could be measured differences in the location of the molars from T0
to indicate the extent of anchorage loss.

ferences between the groups. A P value .05 was


considered statistically significant.
RESULTS
Duration of Canine Retraction
The time required to retract the canine crown until
its contact with the second premolar (T0T1), is shown
in Table 1. This took 102.2 106 and 99.0 80.0
days in the TM and BM groups, respectively. Root
uprighting (T1T2) took 72.0 31.3 and 37.2 42.7
days in the TM and BM groups, respectively (Table 1).
Comparison of the mean values between the groups
during T0T1 and T1T2 determined that their differences were statistically significant only during the
uprighting stage (P .05). The mean time required to
achieve crown retraction and root uprighting (T0T2)
was 174.2 98.3 and 136.2 104.5 days for the TM
and BM groups, respectively. However, the difference

Table 1. Duration of Canine Retraction (T0T1), Uprighting (T1


T2), and Total Treatment (T0T2) and Level of Significance for the
Edgewise and Tip-Edge Systems
Duration of Retraction

Statistic Analyses
Descriptive statistics including mean values and
standard deviations were calculated. Multivariate analysis of variance (MANOVA) with repeated measures
and paired t-test were performed to evaluate the difAngle Orthodontist, Vol 78, No 1, 2008

Stage

Tipping Mechanics,
Days

Bodily Mechanics,
Days

P Value

T0T1
T1T2
T0T2

102.2 106.0
72 31.3
174.2 98.3

99.0 80.0
37.2 42.7
136.2 104.5

.93
.02
.33

99

CANINE RETRACTION WITH BODILY VERSUS TIPPING MECHANICS


Table 2. Change in Canine Angulation During Retraction (T0T1),
Uprighting (T1T2), and Total Treatment (T0T2) and Level of Significance for the Tipping Mechanics (TM) and Bodily Mechanics
(BM) Systems
Angulation
Stage

Tipping Mechanics,
Degrees

Bodily Mechanics,
Degrees

T0
T1
T0T1
T2
T1T2
T0T2

91.0 5.7
97.1 8.5
6.1
93.8 5.6
3.3
2.8

93.8 4.9
93.0 6.0
0.8
94.2 6.5
1.2
0.4

P Value

.001
.018
.05

in total time between the two types of mechanics was


not statistically significant (Table 1).
Angulation
Angular changes in canine position were measured
from the panoramic radiographs using the radiopaque
jigs (Figure 3). During retraction (T0T1) the canine
tipped by 6.1 (from 91 5.7 to 97.1 8.5) in the
TM group and by 0.8 (from 93.8 4.9 to 93.0
6.0) in the BM group, demonstrating a significant intergroup difference (P .001). During root uprighting
(T1T2), the canine moved by 3.3 (from 97.1
8.5 to 93.8 5.6) in the TM group and by 1.2 (from
93.0 6.0 to 94.2 6.5) in the BM group, demonstrating a significant intergroup difference (P .05)
(Table 2).
Rotation
During retraction (T0T1), the canine rotated distopalatally by 15.4 (from 151.2 12.3 to 166.6
16.0) in the TM group, and by 18 (from 148.8 12.1
to 166.8 17.9) in the BM group. During root uprighting (T1T2), the canine continued to rotate by 3.1
(from 166.6 16.0 to 169.7 16.0) in the TM group
and by 2.2 (from 166.8 17.9 to 169.0 16.6) in
the BM group (Table 3). No statistically significant difference existed when comparing the amounts of rotation between groups (Table 3). However, within each
group the amount of rotation, as canine retraction progressed, was found to be statistically significant (P
.001).
Anchorage Loss
Anterior movement of the maxillary first permanent
molar (ie, loss of anchorage) as a result of total canine
retraction (T0T2) as measured directly from dental
casts was 1.2 0.3 mm in the TM group and 1.4
0.5 mm in the BM group (Table 4). Differences in the
amount of forward movement of the first molars between the two groups were not statistically significant.

DISCUSSION
The velocity of tooth movement during orthodontic
treatment depends on various factors. For example,
the level of cellularity or density of alveolar bone,12 formation of hyalinized tissue adjacent to the dental root
due to the application of excessive mechanical
force,13 or the discontinuation of force application14
causing an interruption of the initial strain-lag phaseundermining resorption cycle of tooth movement,15 as
well as the magnitude of force applied.16 Differences
in the methodology of force application have been proposed to maximize the speed of orthodontic treatment
while eliciting a biologically sound response.
Using constant force levels (nickel titanium closed
coil springs) together with anchorage enhancement
(Nance button), the responses of canine retraction into
maxillary first premolar extraction sites using Tip-Edge
and edgewise mechanics were compared. Differing
levels of force (lighter on the TM side) were employed
in order to resolve the criticism of previous investigations,4,17 which did not differentiate between the bracket types and the forces applied. Under these conditions, it was found that the crowns of canines in each
group contacted the second premolar within similar
times (99 vs 102 days, ie, a 3-day difference). However, in this study it was found that the need for root
uprighting of canines retracted with tipping mechanics,
resulted in significantly greater time (38 days) for complete canine retraction in comparison to the bodily mechanics, thus rejecting the null hypothesis. It is posTable 3. Change in Canine Rotation During Retraction (T0T1),
Uprighting (T1T2), and Total Treatment (T0T2), and Level of Significance for the Tipping Mechanics (TM) and Body Mechanics (BM)
Systems
Rotation
Stage

Tipping Mechanics,
Degrees

Bodily Mechanics,
Degrees

T0
T1
T0T1
T2
T1T2
T0T2

151.2 12.3
166.6 16
15.4
169.7 16.0
3.1
18.5

148.8 12.1
166.8 17.9
18
169.0 16.6
2.2
20.2

P Value

NS
NS
NS

NS indicates not significant.


Table 4. Anchorage Loss for the Total Treatment Time (T0T2)
and Level of Significance for the Tipping Mechanics (TM) and Bodily
Mechanics (BM) Systems
Anchorage
Stage

Tipping
Mechanics, mm

Bodily
Mechanics, mm

P Value

T0-T2

1.2 0.3

1.4 0.5

NS

NS indicates not significant.


Angle Orthodontist, Vol 78, No 1, 2008

100
sible that the center of rotation using TM bracket lies
inferior to the apex, ie, the apex is displaced mesially.
If the apex is displaced mesially, obviously this will increase the total time involved, as there will be more
uprighting required.
The findings regarding crown retraction are in
agreement with those of Lotzof et al4 and Huffman and
Way.17 However, the time required to accomplish root
uprighting, which was not evaluated by previous studies, but analyzed here, differentiates between the two
groups (P .05). The additional time required to upright the root during the uprighting phase (T1T2) in
the TM group can be explained by the greater distal
crown tip (6.1) observed in this group as compared
to the essentially parallel root movement of the BM
group (0.8) during the retraction phase (T0T1).
These findings reject the null hypothesis and correspond to the effect for which each of these bracket
types was designed to achieve.
Retraction of the canine tooth with a force labial to
its center of resistance will cause a tendency for the
tooth to rotate distopalatally. Rotation control with single wing brackets is thought to be less than that of
twin/Siamese brackets. However, the amount of rotation incurred by the canines during retraction was not
found to differ significantly between the two groups,
corroborating the null hypothesis. Of interest is the fact
that during the uprighting stage (T1T2), the rotation
did not correct. This emphasizes the need to apply
compensating rotation measures subsequent to the
uprighting stage (after T2).
The effect of the strain on the posterior anchorage
teeth used to retract the canines was determined from
initial (T0) and final (T2) dental casts. It was found that
molar anchorage loss occurred to the same extent in
both groups accepting the null hypothesis (Table 4).
Geron et al10 found an anchorage loss of 3.9 2.3
mm by the end of orthodontic treatment in patients
treated with extraction of upper first premolars. This
suggests that the majority of molar anchorage loss
does not occur during canine retraction when the
Nance appliance is in place (33%), rather during incisor retraction when the Nance appliance is removed
(67%). However, in calculating space management,
17%20% of the extraction space is lost due to protraction of the anchorage segment despite the placement of a Nance button appliance. Perhaps an appliance, which rests on the palatal mucosa, should not
be relied upon to provide maximum anchorage.
CONCLUSIONS
Retraction of the maxillary canine into the first premolar extraction site using nickel titanium closed coil

Angle Orthodontist, Vol 78, No 1, 2008

SHPACK, DAVIDOVITCH, SARNE, PANAYI, VARDIMON

springs occurred faster with BM brackets than with


TM brackets.
Significantly greater time was required to fully upright the canines with TM brackets. This greater time
corresponded with the amount of distal crown tipping
expressed by these teeth during retraction.
No differences were found in the amount of molar
anchorage loss between the two groups.
The Nance appliance was not found to provide absolute (maximum) anchorage.
Rotational control of the retracted canines was similar and insufficient within both groups. A derotation
phase should be followed once canine retraction has
been completed.

REFERENCES
1. Begg PR. Light arch wire technique. Am J Orthod. 1961;47:
3048.
2. Proffit W. Contemporary Orthodontics. St Louis, Mo: Mosby;
1992:344346.
3. Kesling PC. Expanding the horizons of the edgewise arch
wire slot. Am J Orthod Dentofacial Orthop. 1986;94:2637.
4. Lotzof L, Fine H, Cisneros G. Canine retraction. A comparison of two preadjusted bracket systems. Am J Orthod Dentofacial Orthop. 1996;110:191196.
5. Kesling PC. Comments on canine retraction and bracket
angulations. Am J Orthod Dentofacial Orthop. 1997;111:
14A16A.
6. Smith R, Storey E. Force in orthodontics and its relation to
tooth movement. Austr J Dent. 1952;56:1118.
7. Streed S. A Method of Measuring Clinical Orthodontic Tooth
Displacement [thesis]. Minneapolis, MN: University of Minnesota; 1964.
8. Ziegler P, Ingervall B. A clinical study of maxillary canine
retraction with a retraction spring and with sliding mechanics. Am J Orthod Dentofacial Orthop. 1989;95:99106.
9. Paulson R, Speidal T, Isaacson R. A laminographic study
of cuspid retraction versus molar anchorage loss. Angle Orthod. 1970;40:110115.
10. Geron S, Shpack N, Kandos S, Davidovitch M, Vardimon
AD. Anchorage lossa multifactorial response. Angle Orthod. 2003;73:730737.
11. Weber J, Almeida R, Tavano O, Fernando H. Assessment
of mesiodistal inclination through panoramic radiography. J
Clin Orthod. 1991;24:304306.
12. Reitan K. Effects on force magnitude and direction of tooth
movement on different alveolar bone types. Angle Orthod.
1964;34:244247.
13. Reitan K. Clinical and histological observation on tooth
movement during and after orthodontic treatment. Am J Orthod. 1967;53:721745.
14. Graber T, Vanarsdall R. Orthodontics, Current Principles
and Techniques. St Louis, Mo: Mosby; 1994:215216.
15. Burstone CJ. The biomechanics of tooth movement. In:
Krauss BS, Riedel RA, eds. Vistas in Orthodontics. Philadelphia, PA: Lea & Febiger; 1962:197213.
16. Reitan K. Some factors determining the evaluation of forces
in orthodontics. Am J Orthod. 1957;43:3245.
17. Huffman JD, Way D. A clinical evaluation of tooth movement along arch wires of two different sizes. Am J Orthod.
1983;83:453459.

Original Article

Factors Associated with the Success Rate of


Orthodontic Miniscrews Placed in the
Upper and Lower Posterior Buccal Region
Cheol-Hyun Moona; Dong-Gun Leeb; Hyun-Sun Leeb; Jeong-Soo Imc; Seung-Hak Baekd
ABSTRACT
Objective: To determine the success rate and the factors related to the success rate of orthodontic miniscrew implants (OMI) placed at the attached gingiva of the posterior buccal region.
Materials and Methods: Four hundred eighty OMI placed in 209 orthodontic patients were examined retroactively. The sample was divided into young patients (range 1018 years, N 108)
and adult patients (range 1964 years, N 109). The placement site was divided into three
interdental areas from the first premolar to the second molar in the maxilla and mandible. According to soft tissue management, the samples were divided into incision and nonincision groups.
Chi-square tests and multiple logistic regression analyses were used.
Results: The overall success rate was 83.8%. Dislodgement of the OMI occurred most frequently
in the first 12 months, and more than 90% of the failures occurred within the first 4 months. Sex,
age, jaw, soft tissue management, and placement side did not show any difference in the success
rate. Placement site, however, showed a significant difference in the mandible of adult patients.
There was no difference in the success rate in the maxilla.
Conclusions: Placement site is one of the important factors for success rate of OMI.
KEY WORDS: Miniscrew; Success rate; Placement site

INTRODUCTION

success rates of OMI have reported a variety of success rate from 37% to 94%.1,611 The success rates
differ because: (1) There are significant differences in
the duration of use, patient age, level, and direction of
the applied force, and placement site between the OMI
and the prosthetic implants. For example, while the
OMI has to be removed after completion of the mission, the prosthetic implants should be maintained
semi-permanently. (2) OMI have been used in younger
patients rather than the prosthetic implants. (3) Although the prosthetic implants sustain multi-directional
and heavy occlusal force, the OMI bear a smaller force
with a more regular direction. (4) Several products
from different manufacturers with various types of
length, diameter, design, and material of the OMI have
been combined in the previous studies.613
To determine objectively the success rate of the
OMI, it is necessary to confine the sample to the same
type of OMI from one manufacturer. Also, in order to
find the factors related to the OMI success rate, the
clinical characteristics including patient sex, age, jaw,
placement site, soft tissue management, and placement side have to be examined.1,1416 Therefore, the
purposes of this study were to determine the success
rate of OMI and to determine which factors were re-

The orthodontic miniscrew implants (OMI) offer several advantages such as sufficient anchorage in noncompliant patients, simplicity of insertion and removal,
and relatively low cost.1,2
Long-term studies report success rates of more than
90% for prosthetic implants.35 However, the long-term
a
Professor and Department Chair, Department of Orthodontics, Gachon Medical School, Gil Medical Center, Incheon,
South Korea.
b
Resident, Department of Orthodontics, Gachon Medical
School, Gil Medical Center, Incheon, South Korea.
c
Associate Professor, Department of Preventive Medicine,
Gachon Medical School, Gil Medical Center, Incheon, South Korea.
d
Associate Professor, Department of Orthodontics, School of
Dentistry, Dental Research Institute, Seoul National University,
Seoul, South Korea.
Corresponding author: Dr Cheol-Hyun Moon, Department of
Orthodontics, Gachon Medical School, Gil Medical Center, 1198
Kuwol-Dong, Namdong-Ku, Incheon, 405-760, South Korea
(e-mail: orthodm@gilhospital.com)

Accepted: March 2007. Submitted: December 2006.


 2008 by The EH Angle Education and Research Foundation,
Inc.
DOI: 10.2319/121706-515.1

101

Angle Orthodontist, Vol 78, No 1, 2008

102

MOON, LEE, LEE, IM, BAEK


Table 2. The Distribution of Patients According to Age
Young Patient
(n 108)
Range
Age, years 1018
Screw, n

Figure 1. The orthodontic miniscrew used in this study. (A) 1.6 mm


in diameter and 8 mm in length. (B) The orthodontic miniscrews were
placed for the purpose of anchorage reinforcement.

lated to the success rate of OMI placed at the attached


gingiva of the posterior buccal region.
MATERIALS AND METHODS
The subjects involved in this study were 209 patients (male 78, female 131) who visited the Department of Orthodontics at G dental hospital for orthodontic treatment and received at least one OMI
(Dual-Top Anchor system, 1.6 mm diameter, 8 mm
length, self-drilling style, Jeil Medical Co, Seoul, Korea) in either the upper or lower buccal posterior regions for the purpose of anchorage reinforcement (Figure 1). The total number of OMI used in this study was
480 (Table 1).
Table 1. Distribution of Patient and Miniscrews

Male
Female
Total

Number of Patients

Number of Miniscrews

78
131
209

157
323
480

Angle Orthodontist, Vol 78, No 1, 2008

Mean

Adult Patient
(n 109)
SD

Range

14.40 2.50

1964

253

Mean

SD

26.21 7.11

P value
.000

227

The OMI were placed at the attached gingiva just


adjacent to the mucogingival junction at a 70 to 80
angle to the long axis of the teeth in both the maxilla
and mandible. Insertions were performed by four clinicians and were checked by the one supervisor in the
Department of Orthodontics at the G dental hospital.
To reduce the error incurred by lack of experience, the
first ten miniscrews inserted by each clinician were not
included in this study.
An orthodontic force less than 200 grams was applied to the OMI from 23 weeks after placement using
elastic chains or nickel-titanium closed-coil springs. If
the OMI did not show any mobility after the first 8
months of orthodontic force application, it was defined
as a success.
To assess the effect of patient age on the success
rate, the patients were divided into two groups according to age: young patients less than 18 years of age
(N 108; mean age 14.4 years; range 1018
years) with 253 OMI, and adult patients who were older than 19 years of age (N 109; mean age 26.2
years; range 1964 years), with 227 OMI (Table 2).
To assess the effect of the placement site on the
success rate, the locations where OMI were placed at
the buccal attached gingival area were divided into six
groups: Mx1 (area between the maxillary first and second premolars); Mx2 (area between the maxillary second premolar and first molar); Mx3 (area between the
maxillary first and second molars); Mn1 (area between
the mandibular first and second premolars); Mn2 (area
between the mandibular second premolar and first molar); and Mn3 (area between the mandibular first and
second molars).
To measure the effect of the soft tissue management on the success rate, the patients were divided
into two groups: incision method (local anesthesia,
shape stab incision [34 mm], reflection of the gingival
flaps, and placement of the OMI [note: the soft tissue
was not sutured]); and nonincision method (insertion
of the OMI was performed without soft tissue incision).
The success rates according to age, sex, jaw (maxilla or mandible), placement side and site, soft tissue
management, and the overall success rate were calculated. Chi-square tests and multiple logistic regression analyses were used to estimate differences in the

103

FACTORS ASSOCIATED WITH THE SUCCESS OF MINISCREWS

Table 3. The Success and Failure of Screws According to Sex, Age, Jaw, Placement Site, Soft Tissue Management, and Placement Sidea
Variables
Sex
Age
Jaw
Placement site

Soft tissue management


Placement side

Success, n

Failure, n

Success Rate, %

P value

132
270
208
194
233
169
126
202
74
195
207
210
192
402

25
53
45
33
46
32
11
57
10
37
41
40
38
78

84.1
83.6
82.2
85.5
83.5
84.1
91.8
78.0
88.1
84.1
83.5
84.0
83.5
83.8

.892

Male
Female
Young patient
Adult patient
Maxilla
Mandible
P1
P2
P3
Nonincision
Incision
Left
Right

Total

.335
.868
.001

.862
.877

Placement site of miniscrew was divided into three subgroups. P1 means miniscrews which were placed between first premolar (P1) and
second premolar (P2), miniscrews which were placed between the second premolar and the first molar; P3, miniscrews which were placed
between the first molar and second molar.
a

success rate and to determine which factors were related with the success rate of the OMI.
In this study, the odds ratio was also calculated. The
odds ratio is defined as the ratio of the probability that
success occurs to the probability that it does not. An
odds ratio of 1 implies that success is equally likely
between the interest group and the reference group.
An odds ratio greater than 1 implies that the success
is more likely in the interest group. An odds ratio less
than 1 implies that the event is less likely in the interest
group.
RESULTS
The overall success rate was 83.8% (402 of 480
OMI) (Table 3). Dislodgement of OMI occurred most
frequently in the first 12 months, and more than 90%
of failures happened within the first 4 months (Table
4).
When compared to the overall success rate, there
was no significant difference in the success rate according to sex, age, jaw, soft tissue management, and
Table 4. The Distribution of Miniscrews According to Used Duration in Failure Case
Duration,
Months
1
12
23
34
45
56
67
7
Total

Number of
Miniscrews
11
32
18
11
3
2
1
0
78

Accumulation Mean and SD


Percentage, Percentage, of Duration,
%
%
Months
14.1
41.0
23.0
14.1
3.9
2.6
1.3
0
100

14.1
55.1
78.1
92.2
96.1
98.7
100
100

1.65 (1.27)

sidedness. However, placement site showed a significant difference in the success rate in adult patients (P
.001) (Table 3). Placement site showed a significant
difference in the success rate in adult patients, but not
in young patients, especially in the area between the
mandibular second premolar and the first molar (Table
5). The area between the second premolar and the
first molar showed a significantly lower success rate
than the area between the first and second premolars
in the mandible (Table 6).
There was no significant difference in the success
rate according to the odds ratio of sex, age, placement
site, soft tissue management, and placement side in
the maxilla (Table 7). Although there was no significant
difference in odds ratio between the maxilla and mandible, the odds ratio in the maxilla and mandible
showed an opposite tendency according to sex, age,
and placement side (Tables 6 and 7).
DISCUSSION
Ever since Kanomi12 and Costa et al13 suggested
titanium miniscrews as intraoral anchorage devices,
various kinds of miniscrews were used for orthodontic
anchorage reinforcement.2,6,17,18 Therefore, it is necessary to compare the success rate among the miniscrews. The total success rate in this study (83.8%,
Table 3) was higher than the 37.0% reported by Kim
and Choi7 and 78.6% by Moon,1 and was similar to the
83.9%85.0% by Miyawaki et al9 and the 81.1%
88.6% reported by Kuroda et al.19 However, it was lower than the 80.0%93.6% reported by Park et al8 for
four types of miniscrews, and the 93.3% reported by
Park.10
Dislodgement of OMI occurred most frequently in
the first 12 months, and more than 90% of the failures
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104

MOON, LEE, LEE, IM, BAEK

Table 5. Success Rate of Screws According to Locationa


Number of Success/Total Cases (Success Rate, %)

YP
AP

Mx1

Mx2

Mx3

Mn1

Mn2

Mn3

P value

37/43 (86.0)
26/28 (92.9)

60/76 (78.9)
64/77 (83.1)

20/26 (76.9)
26/29 (89.7)

31/34 (91.2)
32/32 (100.0)

50/63 (79.4)
28/43 (65.1)

10/11 (90.9)
18/18 (100.0)

0.511
0.000

a
Mx1 means miniscrews which were placed between the maxillary first premolar and second premolar; Mx2, miniscrews which were placed
between the maxillary second premolar and first molar; Mx3, miniscrews which were placed between the maxillary first molar and second
molar; Mn1, miniscrews which were placed between the mandibular first premolar and second premolar; Mn2, miniscrews which were placed
between the mandibular second premolar and first molar; Mn3, miniscrews which were placed between the mandibular first molar and second
molar; YP, young patient; AP, adult patient.

happened within the first 4 months (Table 4). The average duration of the failure cases in this study was
1.65 months, which was shorter than 3.40 months of
Park et al.8 It is likely, therefore, if the OMI withstands
more than a 4-month period of force application, it can
be considered successful and stable.
In this study, patient sex was not related to the success rate (Table 3), which was in accord with the results of Park et al8 and Miyawaki et al.9 Therefore, we
assumed that sex was not related to the clinical success of the OMI.
Regarding the criteria to separate into different age
groups, Park et al20 reported that the under 15-yearold patient group suffered a lower success rate than
the over 15-year-old patient group because they had
thin cortical bone and poor bone quality. Park10 insisted that the success rate for the under 20 age group
was higher than that of the over 20 age group, but
Miyawaki et al9 stated that there was no significant difference in the success rates of the under 20 age
group, 20-to-30 age group, and the over 30 age group.
In this study, the samples were divided into the young
patient group under 18 years of age and the adult patient group older than 19 years of age. This division
was based on the fact that growth has been achieved
in most of the girls and in the majority of boys at 18
years of age.21

Although there was no significant difference between adult and young patient groups, the adult patient group showed a higher success rate in the maxilla, but the young patient group showed a higher success rate in the mandible (Tables 3, 6, and 7).
With regard to the jaw and success rate, Park et al8
reported that the maxilla had a higher success rate
than the mandible. However, Miyawaki et al9 stated
that the placement site of the miniscrews in the maxilla
or mandible was not related to the success rate. This
was in accord with our results (Table 3). It was interesting that, in spite of the statistical insignificance, the
maxilla and mandible showed an opposite tendency
for the success rate according to age. Further studies
are needed in terms of the relationship between age,
jaw, and success rate.
There was no significant difference in the success
rate between the right and left side (Tables 3, 6, and
7). This is in disagreement with the results of Park et
al8 who reported that the left side had a significantly
higher success rate than the right side. In our opinion,
if the miniscrews were properly placed in the attached
gingiva according to the protocol, and if the oral hygiene care was well done, the chance of soft tissue
inflammation around the miniscrew could be decreased. Therefore, there would be no difference in
the success rate between the right and left sides.

Table 6. Odds Ratios of Independent Variables for Success by Multiple Logistic Regression Analysis in the Mandiblea
Variables
Sex
Age
Placement site

Soft tissue management


Placement side

Odds Ratio
Male
Female
Young patient
Adult patient
Mn1
Mn2
Mn3
Nonincision
Incision
Left
Right

Reference
1.085
Reference
0.765
Reference
0.126
1.318
Reference
0.813
Reference
0.547

95% CI
0.4712.503
0.3411.717
0.0360.439
0.12913.424
0.2163.055
0.1452.060

CI indicates confidence interval. Placement site of miniscrew was divided into three subgroups. Mn1 means miniscrews which were placed
between the mandibular first premolar and second premolar; Mn2, miniscrews which were placed between the mandibular second premolar
and first molar; Mn3, miniscrews which were placed between the mandibular first molar and second molar.
a

Angle Orthodontist, Vol 78, No 1, 2008

105

FACTORS ASSOCIATED WITH THE SUCCESS OF MINISCREWS


Table 7. Odds Ratios of Independent Variables for Success by Multiple Logistic Regression Analysis in the Maxillaa
Variables
Sex
Age
Placement site

Soft tissue management


Placement side

Odds Ratio
Male
Female
Young patient
Adult patient
Mx1
Mx2
Mx3
Nonincision
Incision
Left
Right

Reference
0.896
Reference
1.688
Reference
0.515
0.594
Reference
0.706
Reference
1.019

95% CI
0.4371.834
0.8753.258
0.2191.214
0.2081.697
0.2571.942
0.3742.775

CI indicates confidence interval. Placement site of miniscrew was divided into three subgroups. Mx1 means miniscrews which were placed
between the maxillary first premolar and second premolar; Mx2, miniscrews which were placed between the maxillary second premolar and
first molar; Mx3, miniscrews which were placed between the maxillary first molar and second molar.
a

Regarding the placement site of the OMI, the areas


between the first and second premolars in the maxilla
and between the first and second premolars in the
mandible of both young and adult patients had the
highest success rate. The area between the second
premolar and the first molar in adult patients had the
lowest success rate (Table 5). In particular, there was
a significant difference in the success rate according
to the placement site in the mandible (Tables 5 and
6).
In the maxilla, although there was no significant difference, Mx1 had a higher success rate than Mx2 and
Mx3 (Table 6). In the mandible, Mn1 had a significantly
higher success rate than Mn2 (Table 6). However,
Mn1 and Mn3 did not show a significant difference
(Table 6). Therefore, Mx1 could be considered as the
most stable placement site in the maxilla, and Mn2,
the most unstable site in the mandible.
Bone quality is known to be one of the major factors
in the stability of miniscrews.22 Since Mn2 has thinner
cortical bone than Mn3,22 Mn2 could show a lower success rate than Mn3 in this study. However, Mx2
showed a lower success rate than Mx1 even though
Mx2 has thicker cortical bone than Mx1.22,23 The success rates in the maxillary molar region, which had the
lowest success rate for prosthetic implants due to
bone quality,24,25 were not significantly different from
other sites in this study (Table 5). These results suggested that other factors beyond bone quality such as
soft tissue thickness,23 oral hygiene,22 and root proximity23 might affect the success rate of the miniscrews.
Park2 pointed a narrow interradicular space as the
reason for failure. Deguchi et al22 recommended that
miniscrews less than 1.5 mm in diameter could reduce
the failure rate at the upper and lower posterior teeth
in cases where the roots of the adjacent teeth are too
close. Poggio et al26 reported that the amount of mesiodistal bone existing between the first and second

premolars in the maxilla and mandible could guarantee a high success rate at Mx1 and Mn1 (Table 5).
Park et al20 suggested that wider interradicular
space could be obtained in cases of insertion with angulation. To avoid the contact between roots and miniscrew and to increase the amount of cortical bone
thickness, Park2 recommended an angle of 30 to 40
to the long axis of the teeth in the maxilla and 20 to
60 in the mandible. However, severe angulation to the
cortical bone surface during insertion of the miniscrews can create soft tissue irritation2 and slippage
of the miniscrew at its contact with cortical bone.20 In
this study, after check up the root proximity with the
periapical radiograph, we established that the miniscrews were inserted at 70 to 80 angles to the long
axis of the teeth both maxilla and mandible. This more
horizontal insertion technique eliminated the problems
associated with more vertical insertion methods.
Reports indicate that insertion methods of the OMI
are diverse. Costa et al13 inserted miniscrews by the
pilot-drilling method without soft tissue incision; Moon1
by the self-drilling method without soft tissue incision;
and Kanomi,12 Park,6 and Park17 by the pilot-drilling
method after soft tissue incision. Kim et al27 and Kim
and Chang28 reported that after soft tissue incision, the
self-drilling group was more stable than the pilot-drilling group, and Kim and Choi7 reported that the pilotdrilling method had a higher failure rate than the selfdrilling method.
Since the OMI used in this study had self-drilling
capacity, pilot drilling was not performed in both
groups in order to compare exclusively the effect of
soft tissue management between the incision group
and the nonincision group. Park2 indicated that soft tissue impingement during insertion of the miniscrews
could be a cause of failures, but Miyawaki et al9 reported that the flapless (nonincision) group had a higher success rate than the flap surgery (incision) group.
Angle Orthodontist, Vol 78, No 1, 2008

106
In this study, there was no difference between the nonincision and incision groups (Tables 3, 6, and 7).
Miyawaki et al9 reported 0% success with 1.0 mm
diameter miniscrews and, therefore, it was not suitable
for clinical use. However, the 1.2 mm, 1.3 mm, or 1.5
mm diameter miniscrew had similar or higher success
rates than the 1.6 mm miniscrew.8,9,19 Since our study
was confined to 1.6 mm diameter miniscrews, we
could not compare the effect of the diameter of miniscrews to the success rate. Miyawaki et al9 and Lim
et al14 reported that the diameter affected the success
rate, but Park et al8 reported that it did not have any
effect. The miniscrews with a smaller diameter would
decrease the chance of root damage. Direct comparisons of these results are impossible because these
success rates are based on various insertion methods
and sizes of screw.8
CONCLUSIONS
If OMI withstands more than a 4-month period of
force application, it can be considered successful
and stable.
Sex, age, jaw, soft tissue management, and placement side were not related to the success rate of
OMI.
Placement site could be considered one of the important factors to get a better result of OMI when
clinicians decide to use OMI, especially in the mandible of the adult patients.
REFERENCES
1. Moon CH. Clinical Use and Failure of Skeletal Anchorage
System. Seoul: Narae Publishing Inc; 2002:34;1479.
2. Park HS. Orthodontic Treatment Using Micro-implant. 2nd
ed. Seoul: Narae Publishing Inc; 2006:1115;398406.
3. Minsk L, Polson AM, Weisgold A, Rose LF, Sanavi F,
Baumgarten H, Listgaryen MA. Outcome failures of endosseous implants from a clinical training center. Compend
Contin Educ Dent. 1996;17:848859.
4. Lekholm U, Gunne J, Henry P, Higuchi K, Linden U, Bergstrom C, Steenberghe DV. Survival of the Branemark implant in partially edentulous jaws: a 10-year prospective
multicenter study. Int J Oral Maxillofac Implants. 1999;14:
639645.
5. Orenstein IH, Tarnow DP, Morris HF, Ochi S. Factors affecting implant mobility at placement and integration of mobile implants at uncovering. J Periodontol. 1998;69:1404
1412.
6. Park HS. A new protocol of the sliding mechanics with micro-implant anchorage (MIA). Korea J Orthod. 2000;30:
677685.
7. Kim YH, Choi JH. The study about retention of miniscrews
used for intraoral anchorage. J Korean Dent Assoc. 2001;
39:684687.
8. Park HS, Jeong SH, Kwon OW. Factors affecting the clinical
success of screw implants used as orthodontic anchorage.
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MOON, LEE, LEE, IM, BAEK

9. Miyawaki S, Koyama I, Inoue M, Mishima K, Sugahara T,


Takano-Yamamoto T. Factors associated with the stability
of titanium screw placed in the posterior region for orthodontic anchorage. Am J Orthod Dentofacial Orthop. 2003;
124:373378.
10. Park HS. Clinical study on success rate of microscrew implants for orthodontic anchorage. Korea J Orthod. 2003;33:
151156.
11. Moon CH. The clinical use and failure of skeletal anchorage
system. J Korean Dent Assoc. 2002;40(1):6874.
12. Kanomi R. Mini-implant for orthodontic anchorage. J Clin
Orthod. 1997;31:763767.
13. Costa A, Raffaini M, Melsen B. Microscrews as orthodontic
anchorage. A preliminary report. Int J Adult Orthodon Orthognath Surg. 1998;13:201209.
14. Lim JW, Kim WS, Kim IK, Son CY, Byun HI. Three dimensional finite element method for stress distribution on the
length and diameter of orthodontic miniscrew and cortical
bone thickness. Korea J Orthod. 2003;33:1120.
15. Kang ST, Kwon OW, Sung JH, Kyung HM, Park HS. Comparison of histological observation and insertion and removal torque values between titanium grade 2 and 4 microimplants. Korea J Orthod. 2006;36:171177.
16. Byoun NY, Nam EH, Yoon YA, Kim IK. Three-dimensional
finite element analysis for stress distribution on the diameter
of orthodontic mini-implants and insertion angle to the bone
surface. Korea J Orthod. 2006;36:178187.
17. Park HS. The skeletal cortical anchorage using titanium microscrew implants. Korea J Orthod. 1999;29:699706.
18. Oh MY, Chung KR, Kwon YD, Ryu DM, Lee BS. The clinical
use of miniscrew for intraoral anchorage (1). J Korean Dent
Assoc. 2000;38:1821.
19. Kuroda S, Sugawara Y, Deguchi T, Kyung HM, Yamamoto
TT. Clinical use of miniscrew implants as orthodontic anchorage: success rates and postoperative discomfort. Am J
Orthod Dentofacial Orthop. 2007;131:915.
20. Park YC, Kim JK, Lee JS. Atlas of Contemporary Orthodontics. Seoul: Shin Hung International; 2005:01104;145
161.
21. Huertas D, Ghafari J. New posteroanterior cephalometric
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treated with palatal expansion. Angle Orthod. 2001;71:285
292.
22. Deguchi T, Nasu M, Murakami K, Yabuuchi T, Kamioka H.
Quantitative evaluation of cortical bone thickness with computed tomographic scanning for orthodontic implants. Am J
Orthod Dentofacial Orthop. 2006;129:721. e7721.e12.
23. Kim HJ, Yun HS, Park HD, Kim DH, Park YC. Soft-tissue
and cortical-bone thickness at orthodontic implant sites. Am
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24. Misch CE. Dental Implant Prosthetics. St. Louis, MO: Mosby; 2005:130141.
25. Schnitman PA, Rubenstein JE, Whorle PS, DaSilva JD,
Koch GG. Implants for partial edentulism. J Dent Educ.
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26. Poggio PM, Incorvati C, Velo S, Carano A. Safe zones: a
guide for miniscrew positioning in maxillary and mandibular
arch. Angle Orthod. 2006;76:191197.
27. Kim JW, Ahn SJ, Chang YI. Histomorphometric and mechanical analysis of the drill-free screw as orthodontic anchorage. Am J Orthod Dentofacial Orthop. 2005;128:190
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28. Kim JW, Chang YI. Effect of drilling process in stability of
micro-implants used for orthodontic anchorage. Korea J Orthod. 2002;32:107115.

Original Article

Influence of Surface Characteristics on


Survival Rates of Mini-Implants
Karim Chaddada; Andre F.H. Ferreirab; Nico Geursc; Michael S. Reddyd
ABSTRACT
Objective: To compare the clinical performance and the survival rate of two mini-implant systems
with different surface characteristics under immediate orthodontic loading.
Materials and Methods: Seventeen machined titanium (MT) mini-implants and 15 sandblasted,
large grit, acid-etched (SLA) mini-implants were placed in 10 patients. The mini-implants were
immediately loaded and the patients seen at 7, 14, 30, 60, and 150 days. Clinical parameters
such as anatomical location, character of the soft tissue at the screw head emergence, type of
mini-implant system, diameter, and length were analyzed. In addition, the insertion torque recorded at the time of insertion was also assessed. Survival rate and clinical parameters were evaluated
by the chi-square exact tests using the SAS version 9.1.
Results: The overall survival rate was 87.5%. Over the four failing mini-implants, three were MT
and one SLA resulting in an individual survival rate of 82.4% and 93.4%, respectively. In the
failure group, all the fixtures had their screw emergence at the oral mucosa and recorded a torque
range of less than 15 Ncm. The insertion torque statistically influenced the survival rate of the
mini-implants (P .05). Surface treatment, anatomical location, as well as soft tissue emergence
were not statistically significant.
Conclusion: Surface characteristics did not appear to influence survival rates of immediately
loaded mini-implants.
KEY WORDS: Anchorage; Mini-implants; Loading

INTRODUCTION

teeth3,4 supported the migration of implantology into orthodontics. Current interest in utilizing implants as osseous anchors for orthodontics may represent a valuable alternative to conventional methods.5
Pioneering data from Linkow,6 added to that of later
investigators,7,8 have demonstrated the utility of implanted anchors in orthodontics. Moreover, the application of orthodontic forces appears to have a positive
effect on peri-implant osseous tissue.9,10 Initially, large
diameter implants were inserted into the alveolar process, the palate, and the retromolar area.1115 More recently, strategically placed mini-implants, requiring
minimally invasive surgery appear to have overcome
many of the issues associated with the larger devices.
While preliminary data look promising, mini-implants
have not equaled the success of root-form devices
and concerns regarding design, osseointegration,
post-insertion infection, and questions about optimal
preload healing time remain subjects for further investigation.1619
The purpose of the present study was to evaluate
the survival rate and to compare clinical performance
of two mini-implant systems with different surface

Anchorage control is a fundamental aspect of orthodontic biomechanics. Poor anchorage control during
therapy may increase treatment time and lead to an
unfavorable result.1 Concerns with commonly used extraoral apparatus include socially unacceptable esthetics, the potential for injury, and an impractical dependence on patient compliance.2 The historical success of root-form dental implants to replace missing
Private practice of periodontics, Austin, Tex.
Assistant Professor, Department of Orthodontics, School of
Dentistry, University of Alabama at Birmingham, Birmingham,
Ala.
c
Associate Professor, Department of Periodontics, University
of Alabama at Birmingham, Birmingham, Ala.
d
Professor and Department Chair, Department of Periodontics, University of Alabama at Birmingham, Birmingham, Ala.
Corresponding author: Dr Karim Chaddad, Department of
Periodontics, University of Alabama at Birmingham, 1919 7th
Ave South, SDB 412, Birmingham, AL 35294
(e-mail:e-mail: kcchaddad@gmail.com)
a
b

Accepted: February 2007. Submitted: October 2006.


 2008 by The EH Angle Education and Research Foundation,
Inc.
DOI: 10.2319/100206-401.1

107

Angle Orthodontist, Vol 78, No 1, 2008

108

CHADDAD, FERREIRA, GEURS, REDDY

Figure 2. Sandblasted, large grit, acid-etched.

Figure 1. Machined titanium.

characteristics under immediately applied continuous


orthodontic loading.
MATERIALS AND METHODS
The performances of two screw-shaped titanium
mini-implant systems were assessed in the present
study. The Dual-Top (Jeil Medical Corporation, Seoul,
Korea) is a machined pure titanium (MT), self tapping,
threaded mini-implant available in diameters of 1.4,
1.6, and 2.0 mm and in lengths of 6.0, 8.0, and 10.0
mm. The insertion protocol recommends either a hand
or a motorized screw driver (Figure 1). The C-implant
(Implantium Inc, Seoul, Korea) is also a titanium miniimplant with a distinctive characteristic of having a
sandblasted, large grit and acid-etched (SLA) surface
treatment and a 2-mm machined polished collar. Its
1.8 mm diameter is available in lengths of 8.5, 9.5 and
10.5 mm and can only be inserted with a hand screw
driver (Figure 2).
Ten healthy patients, ages 13 to 65 years, whose
treatment plan included the use of temporary anchorage devices (TADs), were included in the study. ClinAngle Orthodontist, Vol 78, No 1, 2008

ical and radiographic data were analyzed to determine


the survival rate of the two mini-implant systems. Data
were captured for 32 TADs.
Prior to beginning treatment, standard orthodontic
records were obtained for each patient. Treatment
plans were then developed through orthodontic and
periodontal collaboration. The two mini-implant systems were alternately placed until a minimum of 15
mini-implants were placed for both systems. Some patients received implants from both systems under
study while other patients were treated with implants
from either the MT or the SLA system.
Immediately prior to the procedure, patients rinsed
with a prophylactic mouthwash (0.12% chlorhexidine).
Mini-implant patients were placed under local anesthesia; no incision or mucoperiosteal flaps were required
for any of the sites. A starter drill, used at 800 rpm
under copious irrigation, was utilized to enter the alveolar cortex. The mini-implants were placed using the
system-specific screw driver. At the final revolutions of
implant placement, a torque ratchet was utilized to
identify implants which required greater than 15 Ncm
of torque for final seating (Figures 3 and 4). Patients
were instructed to continue a twice daily regimen of
chlorhexidine rinses for 1 week. Follow-up data were
captured at 7, 14, 30, 60, and 150 days after loading.
Following surgical placement, the mini-implants

109

SURFACE CHARACTERISTICS OF MINI-IMPLANTS

Figure 4. Close-up view of torque ratchet.

Figure 5. Immediately loaded large grit acid-etched implants.

Figure 3. Torque ratchet.

were immediately loaded with a NiTi coil-spring or an


elastic chain generating an initial force magnitude of
50 to 100 g (Figure 5). After 2 weeks of healing, the
force was increased reaching a level of 250 g. The
orthodontic movements accomplished included molar
intrusion, molar uprighting, retraction of protruded anterior teeth, and protraction of posterior teeth.

Anatomical location (posterior maxilla vs posterior


mandible), the design (machined titanium vs sandblasted, acid-etched) and dimensions of each implant,
the character of soft tissue at the screw head emergence (keratinized vs oral mucosa), and magnitude of
applied orthodontic forces were recorded for each patient. In addition, the torque range at the time of insertion was recorded. A perception of surgical challenge for each type of mini-implant was recorded by
the periodontist on a three-point scale (simple, moderate, and difficult). Postsurgical pain encountered for
the first few days was recorded by each patient; using
a four-point scale (no pain, mild, moderate, severe).
During the course of orthodontic treatment, the implant
sites were examined at every visit for signs of infection
or others complications.
The absence of inflammation or clinically detectable
mobility, and the ability to maintain implant stability unAngle Orthodontist, Vol 78, No 1, 2008

110

CHADDAD, FERREIRA, GEURS, REDDY

Table 1. Distribution of the Implants Based on the Surface Treatment and the Location
Number of
Implants

Percent of
Implants

Anatomical location
Maxilla
Mandible

17
15

53.1
46.9

Soft tissue location


Keratinized
Oral mucosa

11
21

34.4
65.6

Implant surface
Machined titanium
Sandblasted, acid-etched

17
15

53.1
46.9

Assessment

9.1. The influence of the clinical parameters on the


survival rate of the mini-implants was also evaluated
using chi-square exact tests.
RESULTS
The overall survival rate was 87.5%. The MT and
SLA mini-implant systems had survival rates of 82.5%
and 93.5% survival rates, respectively.
Seventeen of the implants placed were MT and 15
were SLA. The distribution of mini-implants based on
surface characteristics and location is shown in Table
1. The distribution of mini-implants based on diameter,
length, and torque is shown in Table 2. The majority
of the mini-implants emerged through the oral mucosa
as opposed to the keratinized tissue, and two-thirds
had a torque value higher than 15 Ncm at the time of
placement.
Surgeon-reported ease of use was significantly different between the two systems favoring the machined
titanium type (Table 3). Due to its insertion technique
and instrumentation design, most clinicians agreed
that MT was easier to use (94.1% rated simple) in
comparison to the SLA system (93.3% rated moderate). None of the surgical procedures were considered
difficult.
Clinical mobility and peri-implant inflammation were
diagnosed on a total of four implants. Two implants
failed 14 days after placement and the other two failed
after being under loading for 85 days. Torque range
appears to be a critical variable for survival. All successful mini-implants had a torque range at insertion
greater than 15 Ncm (Table 4).
Although the failed implants were all placed in areas
of nonkeratinized tissue with three of them in the posterior maxilla (Table 4), correlations between anatomical location, soft tissue type, and the survival rate
were not statistically significant.
Among the MT failure group, two mini-implants had
a diameter of 1.6 mm with a length of 10 mm and the
third had a diameter of 1.4 mm with a length of 6 mm.
Implant dimensions did not influence the survival rate.

Table 2. Distribution of the Implants in Relation to the Diameter,


Length, and Torque Value
Assessment

Number of Implants

Percent of Implants

Implant diameter
1.4 mm
1.6 mm
1.8 mm
2.0 mm

4
9
15
4

12.5
28.1
46.9
12.5

Implant length
6 mm
8 mm
8.5 mm
10 mm

5
7
15
5

15.6
21.9
46.9
15.6

Torque range
15 Ncm
15 Ncm

13
19

40.6
59.4

der orthodontic load, identified a successful implant. If


an implant failed during the orthodontic treatment, the
time from implant insertion to failure diagnosis was
also recorded.
Statistical Analysis
Correlation between the two different implant systems and the clinical parameters gathered were evaluated by chi-square exact tests using the SAS version

Table 3. Correlation Between Surface Characteristic and Clinical Parametersa


Surface Characteristic MT

Surface Characteristic SLA

Assessment

Number

Percent

Number

Percent

P value

Significance

Surgical handling
Simple
Moderate
Difficult

16
1
0

94.1
5.9
0.0

1
14
0

6.7
93.3
0.0

.0001

Torque range
15 Ncm
15 Ncm

6
11

35.3
64.7

7
8

46.7
53.3

.513

NS

a
MT indicates machined titanium; SLA, sandblasted, large grit, acid-etched; NS, not significant.
* P .05.

Angle Orthodontist, Vol 78, No 1, 2008

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SURFACE CHARACTERISTICS OF MINI-IMPLANTS


Table 4. Influence of the Clinical Parameters on the Survival Ratea
Assessment
Anatomical location
Maxilla
Mandible
Soft tissue emergence
Keratinized
Oral mucosa
Implant diameter
1.4 mm
1.6 mm
1.8 mm
2.0 mm
Implant length
6 mm
8 mm
8.5 mm
10 mm
Surface characteristic
Machined titanium
Sandblasted, acid-etched
Torque range
15 Ncm
15 Ncm

Total Number
of Implants

Number of
Implant Failures

Percent Survival

17
15

3
1

82.3
93.3

11
21

0
4

100.0
81.1

4
9
15
4

1
2
1
0

75.0
77.8
93.3
100.0

5
7
15
5

1
0
1
2

80.0
100.0
93.3
60.0

17
15

3
1

82.4
93.4

13
19

4
0

69.2
100.0

P value

Significance

.348

NS

.121

NS

.496

NS

.159

NS

.348

NS

.004

NS indicates not significant.


* P .05.

The only SLA mini-implant failure had a diameter of


1.8 mm and a length of 8.5 mm. Although two-thirds
of the failing mini-implants were MT, the survival rate
was not statistically affected by the implant surface
characteristics.
The majority of the patients (8/10) reported either no
postinsertion pain or mild discomfort; two patients,
who had teeth extracted at the same appointment, reported moderate pain the first few days. Interestingly,
no pain or other symptoms were reported by patients
with failing implants.
DISCUSSION
The overall success rate of 87.5% found in this
study compares favorably to reports by Park et al,20
and Buchter et al,21 who have reported 80% or greater
success rates.
Numerous reports in the periodontal literature imply
a preference for coated or roughened surface treatments,2224 suggesting the increased surface area may
enhance early osseointegration, even in poor quality
bone, and improve survival. Aldikacti,25 examining
peri-implant osseous tissue surrounding SLA implants
loaded with a continuous force of 200 g for 52 weeks
in dogs, found a thicker corticalization of bone trabeculae and an increase in bone opposition.
In other observations, Chung et al26 and Randow et
al27 demonstrated successful distal molar movement
and en masse retraction of maxillary teeth with the aid

of SLA mini-implants. In these studies, however, the


authors recommend a 6- to 8-week preloading healing
period.
Early clinical experiences suggested 6 to 12 weeks
as an optimal osseointegration period before the orthodontic loading.28 In a more recent study, Lee and
Chung29 described the effect of early loading on the
osseointegration of an SLA mini-implant in animals
and found that premature loading after a 4-week healing period did not adversely affect the process. Interestingly, Deguchi et al30 have demonstrated that miniimplants with as little as 5% bone contact at the boneimplant interface successfully resisted orthodontic
force.
Although the survival rate of the SLA mini-implants
in this investigation was higher compared with the MT
group (93.5% to 82.5%), the correlation between the
implant surface characteristics and the rate of success
was not statistically significant. These findings suggest
that altering an implant surface to create more surface
area and increase bone contact may not be the primary consideration when using mini-implants as orthodontic anchors.
In the present study, more than half of the failing
mini-implants occurred in the posterior maxilla, but the
influence of skeletal topology on the survival rate was
not statistically significant. These findings are in agreement with the experiences reported by Huja et al31 who
found that mini-screws with only 5% bone contact
Angle Orthodontist, Vol 78, No 1, 2008

112
could resist a force application of 200300 g. A retrospective examination of 134 titanium screws and 17
plates inserted in 51 patients by Miyawakis group32
found that thin cortical bone significantly lowered success rate. By contrast, Cheng et al33 proposed that the
high bone density in the posterior mandible might induce overheating during the drilling sequence and,
therefore, increase the failure rate.
The anatomical location and inflammation of periimplant tissue has been shown to affect the survival
rate.34 Although statistically insignificant, all failing implants in the present study had a screw emergence in
the oral mucosa rather than keratinized gingiva. It
must be noted that the number of mini-implants placed
through oral mucosa nearly doubled the number of
those placed in keratinized tissue (Table 1). Two miniimplants from the four failing ones were placed on the
same patient and were able to withstand the immediate orthodontic loading for more than 85 days before
they were lost. Poor oral hygiene, resulting in localized
inflammation of the surrounding peri-implant tissue,
might be a better explanation for the failure rather than
immediate function.
Overall dimensions of the devices used in this study
were not demonstrated relevant to the survival rate.
The smallest mini-implant diameter inserted was 1.4
mm and the shortest length was 6 mm. Miyawaki32 reported the successful fixation of 17 mini-plates with
two screws of 2.0 mm diameter and 5 mm length and
noted that monocortical insertion with a limited length
was sufficient to stabilize the fixtures. Moreover, the
same author demonstrated that screws with 1.0 mm
diameter or less had a significantly lower success rate
in comparison to the 1.5 or 2.3 mm diameter screws.
Recent clinical experiences with dental implants
have emphasized the importance of the torque value
related to immediate loading. In a study of immediately
loaded single tooth implants, Ottoni et al34 reported a
20% reduced risk of failure for every 9.08 Ncm added
to the torque range. Degidi et al35 recommended a
torque value of more than 25 Ncm for immediate loading of dental implants.
A significant finding of the present study is the range
of torque values recorded at the time of placement. All
implants placed with a minimum torque value of 15
Ncm survived immediate loading. This finding was statistically significant. Motoyoshi et al36 recommended an
implant placement torque range of 5 to 10 Ncm. Their
recommendation was based on the fact that higher
torque values did not yield higher survival rates. The
latter study did not correlate torque values to other variables to account for implant success. Perhaps, if all
other variables responsible for implant survival are ideal, insertion torque values smaller than 15 Ncm may
be clinically successful.
Angle Orthodontist, Vol 78, No 1, 2008

CHADDAD, FERREIRA, GEURS, REDDY

Although not recorded in this study, the SLA miniimplants presented a higher level of osseointegration
at the time of removal. This clinical observation was
based on the higher torque necessary for removal of
SLA mini-implants when compared with smooth machined titanium implants. Our clinical experience indicates that surface treated (SLA) implants could be advantageous in areas of poor bone quality, and loading
should be delayed for 6 to 8 weeks when initial osseointegration has occurred. Additionally, bone density, assessed by torque required for insertion, and
ability to control inflammation are perceived as essential to increase the survival rates of mini-implants.
CONCLUSIONS
Surface characteristics did not appear to influence
survival rates of immediately loaded mini-implant.
A torque value of more than 15 Ncm recorded at the
time of insertion appears to be one of the critical
variables for mini-implant survival under immediate
loading.
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15. Wehrbein H, Glatzmaier J, Mundwiller U, Diedrich P. The
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16. Kanomi R. Mini-implant for orthodontic anchorage. J Clin
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17. Bae S, Park HS, Kyung HM, Kwon OW, Sung JH. Clinical
application of micro-implant anchorage. J Clin Orthod. 2002;
36:298302.
18. Miyawaki S, Koyama I, Inoue M, Mishima K, Sugahara T,
Takano-Yamamoto T. Factors associated with the stability
of titanium screws placed in the posterior region for orthodontic anchorage. Am J Orthod Dentofacial Orthop. 2003;
124:373378.
19. Costa A, Raffini M, Melsen B. Miniscrews as orthodontic
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20. Park HS, Lee SK, Kwon OW. Group distal movement of
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J, Meyer U. Load-related implant reaction of mini-implants
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Immediate functional loading of Branemark dental implants.
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RS. Osseous adaptation to continuous loading of rigid endosseous implants. Am J Orthod. 1984;86:95111.
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Miyawaki S, Koyama I, Inoue M, Mishima K, Sugahara T,
Takano-Yamamoto T. Factors associated with the stability
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124:373378.
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of the risk factors associated with failure of mini-implants
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Ottoni JM, Oliveria ZF, Mansini R, Cabral AM. Correlation
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Degidi M, Piattelli A. Comparative analysis of 702 dental
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114.

Angle Orthodontist, Vol 78, No 1, 2008

Original Article

Cellular, Humoral, and Histopathologic Analysis in Rats Implanted with


Orthodontic Nickel Brackets
Cassio Vicente Pereiraa; Estela Kaminagakurab; Paulo Rogerio Ferreti Bonanb;
Renata Avelar Bastosc; Luciano Jose Pereirad
ABSTRACT
Objective: To determine the immune response related to nickel and nickel-free orthodontic appliances using cellular (total and differential leukocytes) and humoral (IgA) quantification.
Materials and Methods: Thirty-five Wister rats were randomly distributed into three groups (A,
B, and C). In the A group, the animals were subdivided into three subgroups (A1: control, without
brackets; A2: nickel-free brackets; and A3: nickel brackets) with seven animals in each group; the
animals were sacrificed after 14 days. Groups B and C received only nickel brackets and were
kept for 14 days. After this period, the implants were removed and the rats were sacrificed. In
group B, the animals were sacrificed 2 days after the appliance removal (16 days in total); and
in group C, the animals were sacrificed 7 days after the brackets removal (21 days in total). Total
and differential leukocyte number, IgA quantification and histopathologic analysis were done. Histopathologic analysis of subcutaneous tissue related to the orthodontic brackets was done as well.
Results: There were significant differences between the number of leukocytes for the nickelimplanted animals and the nickel-free and control groups after 14 days of implantation (P .05).
However, there was no significant difference among groups A1, A2, and A3 for the differential
number of leukocytes and for the IgA quantification, except for the number of monocytes, which
was three times higher in the nickel group (A3). The histopathologic findings did not show differences between groups.
Conclusions: Nickel did not promote significant adverse biological effects.
KEY WORDS: Nickel; Immunology; Bracket

INTRODUCTION

tigen becomes specifically sensitized to this antigen,


and this contact can result in pathologic reactions.1
Nickel is the most common cause of contact allergy.
Epidemiologic data indicate that the number of nickelsensitive people has increased, especially among
younger age groups. The frequency of nickel hypersensitivity in young women has recently been reported
to be around 20%, which is almost 10 times higher
than that reported for young men.24
Nickel materials are used in dentistry largely in prosthesis production and orthodontic appliances. However, few studies have been conducted to determine
the real action of this agent in the mouth and the tissue
response when in contact with this substance. There
has been concern about hypersensitivity reactions of
nickel-allergic subjects in association with metallic orthodontic appliances. Adverse responses have been
reported occasionally such as stomatitis, gum hyperplasia, cheilitis, labial desquamation, and erythema

The action of the immune system against an antigen


leading to sensitivity in the human body is called a
hypersensitivity reaction. The body exposed to this ana
Professor, Microbiology and Immunology, Lavras University
Center, Minas Gerais, Brazil.
b
Professor, Oral Pathology, Lavras University Center, Minas
Gerais, Brazil.
c
Undergraduate student, Biology, Lavras University Center,
Minas Gerais, Brazil.
d
Professor, Clinical Dentistry Graduate Program, Vale do Rio
Verde University, Minas Gerais, Brazil.
Corresponding author: Dr Luciano Jose Pereira, Clinical Dentistry Graduate Program, Vale do Rio Verde University-UNINCOR, Av Castelo Branco, 82, Tres Coracoes, Minas Gerais
37200-000, Brazil
(e-mail: lucianojosepereira@yahoo.com.br)

Accepted: February 2007. Submitted: December 2006.


 2007 by The EH Angle Education and Research Foundation,
Inc.
Angle Orthodontist, Vol 78, No 1, 2008

114

DOI: 10.2319/122906-536.1

115

BIOLOGICAL RESPONSE TO NICKEL BRACKETS


Table 1. Animal Distribution According to the Implantation Period
and Group
Group
A1
A2
A3
B
C

Time

Type of Brackets

14
14
14
16
21

7
7
7
7
7

None (control)
Nickel-free
Nickel
Nickel
Nickel

d
d
d
d
d

multiforme. 56 Metal-sensitive patients can present


symptoms ranging from contact allergy to autoimmune
disease.7
Nickel contact dermatitis is common among orthodontic patients. During orthodontic treatment, nickelsensitized patients can present higher risks of discomfort in the mouth, making treatment and hygiene difficult.6 Besides, patients with nickel orthodontic appliances show concentrations of this substance in the
saliva and also in the blood. This fact suggests that
nickel ions are delivered to the organism leading to
allergic responses.8
In clinical practice the professional should be aware
about the possibility of hypersensitivity, especially to
nickel.9 Thus, the aim of the present research was to
determine the immune response related to nickel and
nickel-free orthodontic brackets using humoral (IgA)
and cellular (total and differential leukocytes) quantification and histopathologic analysis in rats after subcutaneous implantation of orthodontic brackets.
MATERIAL AND METHODS
Sample
The sample comprised 35 Wistar rats, weighing approximately 250 g. The rats were randomly distributed
into three groups (A, B, and C) according to the timetable of the experiments (implantation). In the A group,
the animals were subdivided into three groups (A1:
control, without brackets; A2: nickel free brackets; and
A3: nickel brackets) with seven animals in each; they
were sacrificed after 14 days.
The animals in groups B and C received only nickel
brackets and were kept for 14 days. After this period,
the implants were removed and the rats were sacrificed. In group B, the animals were killed 2 days after
appliance removal (16 days in total); and in group C,
the animals were sacrificed 7 days after the brackets
were removed21 days in total (Table 1).
Bracket Implantation
All the animals received intraperitoneal anesthesia
(ketamine, 50 mg/kg, and xylazine, 10 mg/kg) and had
their backs shaved (4 4 cm). The brackets were
implanted in the subcutaneous tissue following a small

incision. The incision was sutured and the animals received an analgesic injection (sodic dipyrone, 0.3 mL/
100 g weight). The animals were sacrificed according
to the predetermined timetable, and the blood samples
were collected using vacutainers in the renal artery.
Total and Differential Leukocyte Number
Samples containing 5 mL of blood and heparin were
used to count the total and differential number of leukocytes.10 The counting was done by one calibrated
examiner, who was blind to the origin of the samples.
After the dilutor liquid was added to the blood sample
and homogenized (glacial acetic acid and methylene
blue), the sample was transferred to a Neubauer
chamber where the number of leukocytes was counted.
After the total number of leukocytes quantification,
the differential analysis was executed using one drop
of blood on a lamina stained with May-Grunwald Giemsa.10 The number of neutrophils, eosinophils, basophils, monocytes, and lymphocytes was determined.
The resulting values were expressed in percent per
mm3. In this phase, duplicates were done.
IgA Quantification
Blood samples of 1 mL were collected in vacutainers without EDTA. The tubes were centrifuged to separate the serum, and the IgA quantification was carried
out (Kit Biotecnica/turbidimetry for IgA).
Biopsies and Histopathologic Analysis
All tissues removed from the bracket implantation
sites were fixed in 4% buffered formalin and embedded in paraffin. Sections of 5 m were cut, mounted
on glass slides and stained with hematoxylin and eosin (H&E). The samples were analyzed independently
by three observers and the results were compared.
Statistical Analysis
The total number and the differential count of leukocytes and the IgA quantification were compared
among groups using analysis of variance (ANOVA)
(SPSS 9.0; SPSS, Chicago, Ill) followed by a Tukey
test for determination of contrasts.
RESULTS
The total (mm3) and differential (%) quantification of
leukocytes and the amount of IgA (mg/dL) in the A1,
A2, and A3 groups after 14 days of bracket implantation are shown in Table 2.
There were significant differences between the
number of leukocytes for the nickel-implanted animals
Angle Orthodontist, Vol 78, No 1, 2008

116

PEREIRA, KAMINAGAKURA, BONAN, BASTOS, PEREIRA

Table 2. Mean Values for the Total and Differential Quantification


of Leukocytes and the Amount of IgA in Groups A1, A2, and A3 after
14 Days of Bracket Implantationa
Leukocytes/
mm3
A1
A2
A3

4200.0a
4470.0a
9170.0b

Neutrophils, Monocytes, Lymphocytes,


%
%
%
63.0a
66.0a
58.0a

3.0a
3.0a
9.0b

34.0a
31.0a
32.0a

Table 3. Mean Values for the Total and Differential Quantification


of Leukocytes and the Amount of IgA (mg/dL) in Groups A3, B, and
Ca

IgA,
mg/dL
60.0a
52.0a
54.0a

Leukocytes/
mm3
A3
B
C

9170.0a
8810.0a
11,940.0a

Neutrophils, Monocytes, Lymphocytes,


%
%
%
58.0a
46.0b
27.0c

9.0a
7.0a
10.0a

33.0a
47.0b
63.0c

IgA,
mg/dL
58.40a
64.70a
59.90a

a
IgA indicates immunoglobulin A; pairs of values having different
superscript letters in the same vertical line are significantly different
(P .05).

a
IgA indicates immunoglobulin A; pairs of values having different
superscript letters in the same vertical line are significantly different
(P .05).

when compared with the nickel-free and control


groups after 14 days of implantation (P .05). However, there was no significant difference among
groups A1, A2, and A3 for the differential number of
leukocytes and for the IgA quantification, except for
the number of monocytes. The monocytes were three
times more prevalent in the nickel group (A3) when
compared with the other two groups. There were no
significant differences in the number of neutrophils and
lymphocytes among the nickel (A3), nickel-free (A2)
and control groups (A1) (P .05).
In Table 3 the values for the total and differential
number of leukocytes and IgA quantification are
shown for the groups after 14, 14 2, and 14 7
days of implantation, ie, groups A3, B, and C respectively. The results showed no significant differences (P
.05) according to the time of implantation and removal of the bracket for the total number of leukocytes, number of monocytes, and IgA quantification.
However, the number of neutrophils was reduced significantly (P .05) in groups A3 (58.0%), B (46.0%),
and C (27.0%); and the number of lymphocytes increased in groups A3 (33.0%), B (47.0%), and C
(63.0%).

cells (Figure 1C). In all cases the presence of fibroblasts and some blood vessels was noticed.
Group C: Occasional inflammatory cells were found
and the wound healing could be observed (Figure
1D).

Histopathologic Findings
The histopathologic findings of the analyzed material showed:
Group A1: All cases showed an inflammation composed of neutrophils, macrophages, and lymphocytes, and many blood vessels.
Group A2: In five cases, chronic inflammation was
found with macrophages, lymphocytes, and some
plasma cells (Figure 1A). In two cases the inflammation response was similar to the control group.
Group A3: All samples exhibited an intense chronic
inflammation with macrophages, lymphocytes, and
some plasma cells, however, without a granulomatous organization (Figure 1B).
Group B: Inflammation was observed in six cases
with the majority showing few chronic inflammatory
Angle Orthodontist, Vol 78, No 1, 2008

DISCUSSION
A large variety of metallic alloys are routinely used
in dentistry.11 The percentage of nickel in the alloy
varies from 8%, as in stainless steel, to more than
50%, as in the nickel-titanium alloys.12 The discharge
of nickel ions, which is a strong immunologic sensitizer, may result in contact hypersensitivity.13
In the present study, the results shown in Table 2
indicated an increase in the total number of leukocytes
in the nickel group (A3) when compared with the nickel-free (A2) and control (A1) groups. An immune response induced by nickel appliances is considered
Type IV hypersensitivity.
In this context, nickel binding to endogenous macromolecules can stimulate macrophages and cytotoxic
cells, up-regulating the expression of adhesion molecules.1416 The differential quantification of leukocytes
in the current research shows that the difference in the
total number of leukocytes was caused by an increase
in the number of monocytes. It has been reported that
low-dose exposure to nickel can alter the metabolism
of human monocytes.17 Additionally, nickel induces T
lymphocytes to produce several cytokines, including
interferon IF- and interleukin IL-2, IL-5, and IL-10,
and stimulates cellular proliferation.18 The A group rats
were killed after only 14 days of implantation. The
monocytes are cells which originate macrophages and
both form the first line of defense in the organism. Circulating monocytes represent cells that have not fully
differentiated. Further evolution occurs at various tissue sites where the monocytes have deposited. These
cells play pivotal roles in both humoral and cell-mediated immune reactions to pathogens.19 It has been
stated that antigens associated with macrophages are
greater sensitizers than free antigens. In addition, it is
necessary that the antigen is linked to macrophages

BIOLOGICAL RESPONSE TO NICKEL BRACKETS

117

Figure 1. (A) Microphotography showing chronic inflammation with macrophages, lymphocytes, and plasma cells (H&E, 200). (B) Microphotography showing macrophages, lymphocytes, and plasma cells (H&E, 200). (C). Microphotography showing few chronic inflammatory cells
(H&E, 100). (D) Microphotography showing fibroblasts, some blood vessels, and few inflammatory cells (H&E, 200).

before the action of the lymphocytes B and T can occur.20


The nickel-free group (A2) did not present significant
differences when compared to the control group (A1)
with respect to the blood components evaluated after
14 days of implantation. This fact suggests that a decrease in the amount of nickel in the orthodontic alloys
may reduce immune reactions.2123
The results obtained for the groups A3, B, and C
showed that the total number of leukocytes did not
differ among the groups after removal of the nickel
bracket. However, in the differential quantification a
decrease was observed in the percentage of neutrophils and an increase in the percentage of lymphocytes as the time following appliance removal increased. It has been reported that dermatitis usually
peaks at about 48 hours. It is caused by small

amounts of antigen, and it is characterized by infiltration with lymphocytes. Typical sensitization can be
caused by nickel present in dental appliances. Once
the antigen is removed, the reaction disappears in approximately 10 days.19 However, in the present study
the rats were killed after only 2 (B) and 7 (C) days.
This fact explains the higher amount of lymphocytes
in the C group, followed by B and A3 groups. The
decrease in the number of neutrophils after the appliance removal can be justified by the fact that the antigen (nickel) was removed. Neutrophils are most commonly present at the initial inflammatory response.
This concerted effort by the wounded cell layers is accompanied by, and might also be partially regulated
by, a robust inflammatory response. This inflammatory
response shows neutrophils first and then macrophages with mast cells emigrating from nearby tissues and
Angle Orthodontist, Vol 78, No 1, 2008

118
from the circulation.24 As time elapses after the surgical removal of the bracket, the inflammatory response
tends to decrease and consequently, so does the
number of neutrophils.
Although human beings have been sensitized, the
induction of contact allergy in experimental animals is
difficult, which implies that nickel is not the potent contact allergen that has been anticipated.4 In this way,
there was no difference in the amount of IgA among
groups, suggesting that the nickel in the orthodontic
appliances was not enough to create a humoral response using the present methodology.
The release of nickel from alloys or devices is,
among other things, related to the surface area, exposure time, and environment; but there seems to be
no exact knowledge of the type and duration of oral
exposure needed to elicit the induction of tolerance or
reaction.4 The continuous exposure to nickel alloys
might lead to oral tolerance mechanisms that modulate nickel sensitivity, as evidenced by the lower cell
proliferation index in patients undergoing orthodontic
treatment over 24 months. However, further studies
are needed to clarify the major cell phenotype associated with the immune response.6
The nickel allergy comprises Type IV hypersensitivity reactions which are cell-mediated by T lymphocytes.25 These cells are an important component of the
immune response to many intracellular pathogens and
some nondegradable antigens.25 These reactions are
initiated by CD4 T lymphocytes with the accumulation of macrophages, and other effector cells in response to T cell cytokines.26 The efficiency of metallic
nickel or nickel compound phagocytosis by the macrophages or giant cells depends on the size and surface changes of the nickel particles.25 These cells are
also of central importance in the induction of antigenspecific T lymphocyte activation.25 Microscopically, in
this study there were no differences between the inflammatory cells found in the groups with brackets that
contained or did not contain nickel. At 14 days after
bracket implantation, the presence of neutrophils,
macrophages, and lymphocytes, and many blood vessels was observed. After this period, the inflammatory
cells were gradually changed by fibroblasts and connective tissue. Probably, the presence of inflammatory
cells in the wound is related to insertion and removal
procedures.
Authors have reported that the concentration of
nickel liberated from orthodontic apparatus does not
reach cytotoxic levels,27 and its concentration in serum
and saliva from patients who wear fixed orthodontic
appliances is similar to those found in healthy individuals.8 It can be suggested that the nickel in the orthodontic appliances was not enough to create a humoral
response using the present methodology. Nickel has
Angle Orthodontist, Vol 78, No 1, 2008

PEREIRA, KAMINAGAKURA, BONAN, BASTOS, PEREIRA

a long-standing history of successful use in dentistry,


and there are no significant reports of biological effects
attributed to nickel-containing dental appliances and
restorations.25
CONCLUSIONS
The total number of leukocytes increased when nickel apparatuses were subcutaneously implanted in
rats.
The difference in the total number of leukocytes was
caused by an increase in the number of monocytes,
which is characterized by hypersensitivity Type IV.
There was no difference in the levels of IgA among
the groups.
The total number of leukocytes did not differ among
the groups after removal of the nickel bracket. In the
differential quantification, an increase was observed
in the percentage of lymphocytes, and a decrease
was observed in the percentage of neutrophils as
the time following appliance removal increased. The
histopathologic findings did not show differences between the groups.
ACKNOWLEDGMENT
We wish to thank Mr Ademir Felcio Alves (UNILAVRAS) for
technical assistance.

REFERENCES
1. Roitt IM. Imunologia. 5th ed. Sao Paulo, SP: Atheneu; 2000:
1294.
2. Schubert H, Berova N, Czernielewski A, et al. Epidemiology
of nickel allergy. Contact Dermatitis. 1987;16(3):122128.
3. Nielsen NH, Menne T. Nickel sensitization and ear piercing
in an unselected Danish population. Glostrup Allergy Study.
Contact Dermatitis. 1993;29(1):1621.
4. Kerosuo H, Kullaa A, Kerosuo E, Kanerva L, Hensten-Pettersen A. Nickel allergy in adolescents in relation to orthodontic treatment and piercing of ears. Am J Orthod Dentofacial Orthop. 1996;109(2):148154.
5. Dunlap CL, Vincent SK, Barker BF. Allergic reaction to orthodontic wire: report of case. J Am Dent Assoc. 1989;
118(4):449450.
6. Marigo M, Nouer DF, Genelhu MC, Malaquias LC, Pizziolo
VR, Costa AS, Martins-Filho OA, Alves-Oliveira LF. Evaluation of immunologic profile in patients with nickel sensitivity
due to use of fixed orthodontic appliances. Am J Orthod
Dentofacial Orthop. 2003;124(1):4652.
7. Stejskal VD, Hudecek R, Stejskal J, Sterzl I. Diagnosis and
treatment of metal-induced side-effects. Neuro Endocrinol
Lett. 2006: Dec 29:27(suppl1).
8. Agaoglu G, Arun T, Izgi B, Yarat A, Izgu B. Nickel and chromium levels in the saliva and serum of patients with fixed
orthodontic appliances. Angle Orthod. 2001;71(5):375379.
9. Athanasiou AE, Pafliotelis J. Allergic reactions to orthodontic materials and a protocol for the management of patients
[in Greek]. Orthod Epitheorese. 1989;1(2):3742.
10. Carvalho MG, Silva MBS. Hematology: Laboratory Techniques and Interpretation [in Portuguese]. Belo Horizonte,
MG: UFMG Editors; 1988:1139.

119

BIOLOGICAL RESPONSE TO NICKEL BRACKETS

11. Janson GR, Dainese EA, Consolaro A, Woodside DG, Freitas MR. Nickel hypersensitivity reaction before, during and
after orthodontic therapy. Am J Orthod Dentofacial Orthop.
1998;113(6):655660.
12. Asgharnia MK, Brantley WA. Comparison of bending and
tension tests for orthodontic wires. Am J Orthod. 1986;
89(3):228236.
13. Janson GR, Dainese EA, Pereira ACJ, Pinzan A. Clinical
evaluation of nickel hypersensitivity reaction in patients under orthodontic treatment. Ortodontia. 1994;27:3137.
14. Wataha JC, Hanks CT, Sun Z. Effect of cell line on in vitro
metal ion cytotoxicity. Dent Mater. 1994;10(3):156161.
15. Wataha IC, Sun ZL, Hanks CT, Fang DN. Effect of Ni ions
on expression of intercellular adhesion molecule 1 by endothelial cells. J Biomed Mater Res. 1997;36(2):145151.
16. Wataha JC, Lockwood PE, Marek M, Ghazi M. Ability of Nicontaining biomedical alloys to activate monocytes and endothelial cells in vitro. J Biomed Mater Res. 1999;45(3):
251257.
17. Wataha JC, Lockwood PE, Schedle A, Noda M, Bouillaguet
S. Ag, Cu, Hg and Ni ions alter the metabolism of human
monocytes during extended low-dose exposures. J Oral
Rehabil. 2002;29(2):133139.
18. Fernandez-Botran R, Sanders VM, Mosmann TR, Vitetta
ES. Lymphokine-mediated regulation of the proliferative re-

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21.
22.

23.
24.
25.
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sponse of clones of T helper 1 and T helper 2 cells. J Exp


Med. 1988;168(2):543558.
Slots J, Taubman MA, Yankell S. Contemporary Oral Microbiology and Immunology. St. Louis, MO: Mosby-Year
Book; 1992.
Silva WD, Mota I. Basic and Applied Immunology. 5th ed.
Rio de Janeiro, RJ: Guanabara Koogan; 2003:1388.
Staerkjaer L, Menne T. Nickel allergy and orthodontic treatment. Eur J Orthod. 1990;12(3):284289.
Kitaura H, Nakao N, Yoshida N, Yamada T. Induced sensitization to nickel in guinea pigs immunized with mycobacteria by injection of purified protein derivative with nickel.
New Microbiol. 2003;26(1):101108.
Rahilly G, Price N. Nickel allergy and orthodontics. J Orthod. 2003;30(2):171174.
Martin P, Leibovich SJ. Inflammatory cells during wound repair: the good, the bad and the ugly. Trends Cell Biol. 2005;
15(11):599607.
Setcos JC, Babaei-Mahani A, Silvio LD, Mjor IA, Wilson NH.
The safety of nickel containing dental alloys. Dent Mater.
2006;22(12):11631168.
Hogan LH, Weinstock JV, Sandor M. TCR specificity in infection induced granulomas. Immunol Lett. 1999;68(1):115
120.
Grimsdottir MR, Hensten-Pettersen A, Kullmann A. Cytotoxic effect of orthodontic appliances. Eur J Orthod. 1992;
14(1):4753.

Angle Orthodontist, Vol 78, No 1, 2008

Original Article

Forces in the Presence of


Ceramic Versus Stainless Steel Brackets with
Unconventional vs Conventional Ligatures
Tiziano Baccettia; Lorenzo Franchia; Matteo Camporesib
ABSTRACT
Objective: To compare the forces resulting from four types of bracket/ligature combinations: ceramic brackets and stainless steel brackets combined with unconventional elastomeric ligatures
(UEL) and conventional elastomeric ligatures (CEL) during the leveling and aligning phases of
orthodontic therapy.
Materials and Methods: The testing model consisted of five 0.022-inch preadjusted brackets
(second premolar, first premolar, canine, lateral incisor, and central incisor) for each of the two
bracket types. The canine bracket was welded to a sliding bar that allowed for different amounts
of offset in the gingival direction. The forces generated by a 0.014-inch superelastic nickel titanium
wire in the presence of either the UEL or CEL bracket/ligature systems at different amounts of
upward canine misalignment (1.5 mm, 3 mm, 4.5 mm, and 6 mm) were recorded.
Results: Significant differences were found between UEL and CEL systems for all tested variables
(P .01) with the exception of the canine misalignment of 1.5 mm. The average amount of
recorded force in the presence of CEL was negligible with 3.0 mm or greater of canine misalignment. On the contrary, during alignment, a force available for tooth movement was recorded in
the presence of both ceramic and stainless steel brackets when associated with UEL.
Conclusions: The type of ligature used influenced the actual amount of force released by the
orthodontic system significantly more than the type of bracket used (stainless steel vs ceramic).
KEY WORDS: Orthodontic ligatures; Esthetic fixed appliances; Friction

INTRODUCTION

treatment, with a continuous effort to overcome several problems of these types of brackets: brittleness
leading to bracket or tie-wing failure, iatrogenic enamel
damage during debonding, enamel wear of opposing
teeth, and high frictional resistance to sliding mechanics.26
Beside esthetics, a second desirable condition in
fixed appliance therapy with preadjusted brackets consists in the reduction of frictional forces between the
bracket and the guiding archwire during both the initial
treatment phases of leveling and aligning and the sliding mechanics for space closure. Friction is the resistance to motion that exists when a solid is moved tangentially with respect to the surface of another contacting solid.7 Friction is, thus, inherent to sliding systems and influences the rate of orthodontic
movement.8 During mechanotherapy involving movement of the bracket along the wire, friction at the
bracket-archwire interface may prevent the attainment
of optimal force levels in the supporting dental tissue.
Therefore, an understanding of the force required to
overcome friction is important so that the appropriate

In modern society the esthetic aspect of the orthodontic therapy is important because the number of
adults that undergo orthodontic therapy is increasing.1
The development of appliances that combine both acceptable esthetics and adequate technical performance is an important goal. Ceramic brackets were
developed to improve esthetics during orthodontic
a
Assistant Professor, Department of Orthodontics, The University of Florence, Florence, Italy; Thomas M. Graber Visiting
Scholar, Department of Orthodontics and Pediatric Dentistry,
School of Dentistry, The University of Michigan, Ann Arbor,
Mich.
b
Research Fellow, Department of Orthodontics, The University of Florence, Florence, Italy.
Corresponding author: Tiziano Baccetti, DDS, PhD, Dipartimento di Odontostomatologia, Universita` degli Studi di Firenze,
Via del Ponte di Mezzo, 46-48 50127, Firenze, Italy
(e-mail: t.baccetti@odonto.unifi.it)

Accepted: February 2007. Submitted: December 2006.


 2008 by The EH Angle Education and Research Foundation,
Inc.
Angle Orthodontist, Vol 78, No 1, 2008

120

DOI: 10.2319/011107-11.1

LOW-FRICTION LIGATURES FOR TWO TYPES OF BRACKETS

magnitude of force can be used to produce appropriate biologic tooth movement.9 To explain the friction
between wire and bracket, several variables such as
bracket material, wire material, and wire section can
be studied.1012 For instance, ceramic brackets show a
high level of frictional resistance because the ceramic
material yields a higher coefficient of friction than
stainless steel due to differences in the plastic and
elastic properties of the materials.7
Previous research1315 stated that friction can be determined also by the nature of the ligation. An innovative system of unconventional ligatures is an actual
alternative to self-ligating brackets. Recently, unconventional elastomeric ligatures (UEL) have been developed to be combined with both ceramic and stainless steel brackets.16 Once the unconventional ligature
is applied on the bracket, the interaction between the
ligature and the slot forms a tube-like structure,
which allows the archwire to slide freely and to produce its effects more readily on the dentoalveolar component. In vitro studies17,18 have compared the frictional forces generated by the UEL and the conventional
elastomeric ligatures (CEL) with 0.014-inch superelastic nickel titanium wire and 0.019 0.025 inch stainless steel wire. The amount of both static and kinetic
friction was minimal (10 g) in the UEL group in the
presence of aligned brackets with both types of wires,
and it was less than half of that shown by CEL in the
presence of a misaligned canine bracket.
The aim of the present in vitro study was to compare
the differences in the forces available for tooth movement during the alignment phase of fixed appliance
therapy when utilizing either ceramic or stainless steel
brackets with either unconventional or conventional
elastomeric ligatures.
MATERIALS AND METHODS
All materials used in this study were supplied by Leone Orthodontic Products (Sesto Fiorentino, Firenze,
Italy). An experimental model18 was used to assess the
forces produced by:

121

Figure 1. Ceramic bracket (AQUA) with unconventional elastomeric


ligature (Slide). (A) Frontal view. (B) Lateral view.

stainless steel brackets) for the second premolar, first


premolar, canine, lateral incisor, and central incisor.
The interbracket distance was set at 8.5 mm. The canine bracket was welded to a sliding bar that allowed
for different vertical positions, while the other brackets
were mounted in a vice-like device. A section of
0.0215 0.028 inch stainless steel wire was used to
align all the brackets.
The forces generated by the testing unit consisting
of wire, brackets, and either CEL and UEL were measured under dry conditions and at room temperature
(20 2 C) by means of an Instron 4301 testing machine (Instron Corp, Canton, Mass) with a load cell of
10 N. The upper end of the sliding bar bearing the
canine bracket was connected to the Instron crosshead. A 0 gram frictional force was recorded by the
testing machine when pulling the sliding bar with the
canine bracket in an upward direction in the absence
of any orthodontic wire.
A round 0.014-inch superelastic nickel titanium wire
(Memoria, Leone Orthodontic Products, Sesto Fiorentino, Firenze, Italy) was tested. This type of wire is
frequently used during the aligning and leveling phase
of the straight-wire technique.9 The wire was secured
into the preadjusted brackets using the two types of

a. Esthetic ceramic brackets (AQUA) with esthetic


UEL (Slide) (Figure 1);
b. Esthetic ceramic brackets (AQUA) with CEL (transparent mini modules, with an inside diameter of 1.3
mm and thickness of 0.9 mm);
c. Stainless steel brackets (STEP) with silver UEL
(Figure 2);
d. Stainless steel brackets (STEP) with CEL.
The buccal segment model (Figure 3) consisted of
either five esthetic ceramic or five stainless steel
0.022-inch preadjusted brackets (Roth prescription for
the ceramic brackets and MBT prescription for the

Figure 2. Stainless steel bracket (STEP) with unconventional elastomeric ligature (Slide). (A) Frontal view. (B) Lateral view.
Angle Orthodontist, Vol 78, No 1, 2008

122

BACCETTI, FRANCHI, CAMPORESI

RESULTS

Figure 3. Experimental in vitro model with misaligned canine bracket.

ligatures: UEL (Slide) and CEL (mini modules). The


elastomeric ligatures were placed immediately before
each test run, to avoid ligature force decay.
The Instron machine recorded the forces released
by the archwire-bracket-ligature system following four
different amounts of upward displacement of the sliding bar bearing the canine bracket: 1.5 mm, 3.0 mm,
4.5 mm, and 6.0 mm of misalignment. The forces generated by the wire with either ceramic or stainless steel
brackets with UEL and CEL were recorded. The forces
produced by each wire/ligature combination were tested 20 times with new wires and ligatures on each occasion. A total of 320 tests were carried out (80 tests
for esthetic ceramic brackets with UEL, and 80 tests
for esthetic ceramic brackets with CEL; 80 tests for
stainless steel brackets with UEL, and 80 tests for
stainless steel brackets with CEL).
Statistical Analyses
Descriptive statistics were calculated for the forces
generated by the wire/ligature combinations at the four
different amounts of canine misalignment. The comparisons between the results for the two types of
brackets with UEL and CEL were carried out by means
of Kruskal-Wallis test with Tukeys post hoc test (P
.05) (SigmaStat 3.1, Systat Software Inc, Point Richmond, Calif).
Angle Orthodontist, Vol 78, No 1, 2008

The descriptive statistics and the analysis of the


comparisons on the forces released by the orthodontic
wire in the presence of ceramic brackets with UEL and
with CEL, and in the presence of stainless steel brackets with UEL and with CEL are shown in Table 1.
At a canine misalignment of 1.5 mm, differences between ceramic brackets with UEL and CEL were not
significant for any of the tested variables. At the same
amount of canine misalignment, the differences between ceramic and stainless steel brackets with UEL
and with CEL were not significant either.
The comparison between the unconventional ligatures and CEL in conjunction with ceramic and stainless steel brackets showed that, in the presence of
UEL, a significantly greater amount of force was generated when canine misalignment was of 3.0 mm, 4.5
mm, and 6.0 mm. When the two types of brackets (ceramic vs stainless steel) with UEL were compared, no
significant differences were found in the presence of
1.5 mm, 3.0 mm, 4.5 mm, and 6.0 mm of misaligned
canine. The same results were found in the comparison between the ceramic and stainless steel brackets
with CEL. The average amount of released force for
both types of brackets in the presence of CEL with 3.0
mm of canine misalignment or greater was approximately zero.
DISCUSSION
The aim of the present study was to compare the
forces released by an orthodontic archwire in the presence of two types of brackets (stainless steel brackets
and esthetic ceramic brackets) by combining them
with either conventional or unconventional elastomeric
ligatures during the leveling and aligning phase of
fixed appliance therapy. A testing device similar to the
one proposed recently by Franchi and Baccetti18 was
conceived to recreate clinical conditions for the leveling and aligning phase of straight-wire technique, ie,
to study the forces released during alignment of a displaced tooth by allowing for different amounts of vertical misalignment of one bracket (canine bracket) with
respect to the four remaining aligned brackets.
In the presence of a 1.5-mm misaligned canine the
forces produced by the two types of brackets with UEL
and with CEL were not statistically different, and they
ranged from 95 to 120 g. Similar results were found in
a previous work on stainless steel brackets.18 Starting
from a 3.0-mm misalignment of the canine bracket, the
difference in behavior between UEL and CEL became
statistically significant. The use of CEL produced a
negligible amount of released force for alignment
when the tooth misalignment was greater than or
equal to 3 mm, whereas the use of low-friction liga-

123

LOW-FRICTION LIGATURES FOR TWO TYPES OF BRACKETS

Table 1. Descriptive Statistics and Statistical Comparisons of the Forces (grams) Released by the Ceramic Brackets (B) With Low-Friction
Ligatures (Slide) and With CEL vs Stainless Steel (SS) Brackets With Low-Friction Ligatures (Slide) and With CEL at Different Amounts of
Canine Misalignment (CM)a
Ceramic B. Slide

0.014
0.014
0.014
0.014

SE1.5
SE3.0
SE4.5
SE6.0

mm
mm
mm
mm

CM
CM
CM
CM

Ceramic B. CEL

SD

Mean

SD

Significance

115.9
124.3
115.4
111.0

3.3
5.7
5.7
6.5

110.6
0.3
0.4
0.2

8.1
0.2
0.5
0.2

NS
*
*
*

Mean

SD

Mean

SD

Significance

97.6
112.4
99.7
116.6

7.6
6.7
8.0
12.9

91.9
0.1
0.1
0.1

2.7
0.1
0.1
0.1

NS
*
*
*

SS B. Slide

0.014
0.014
0.014
0.014

SE1.5
SE3.0
SE4.5
SE6.0

mm
mm
mm
mm

CM
CM
CM
CM

SS B. CEL

Ceramic B. Slide

0.014
0.014
0.014
0.014

SE1.5
SE3.0
SE4.5
SE6.0

mm
mm
mm
mm

CM
CM
CM
CM

SS B. Slide

Mean

SD

Mean

SD

Significance

115.9
124.3
115.4
111.0

3.3
5.7
5.7
6.5

97.6
112.4
99.7
116.6

7.6
6.7
8.0
12.9

NS
NS
NS
NS

Ceramic B. CEL

0.014
0.014
0.014
0.014

SE1.5
SE3.0
SE4.5
SE6.0

mm
mm
mm
mm

CM
CM
CM
CM

Kruskal-Wallis Test

Mean

SS B. CEL

Mean

SD

Mean

SD

Significance

110.6
0.3
0.4
0.2

8.1
0.2
0.5
0.2

91.9
0.1
0.1
0.1

2.7
0.1
0.1
0.1

NS
NS
NS
NS

* P .05. NS indicates not significant.


a
UEL indicates unconventional elastomeric ligatures; CEL, conventional elastomeric ligatures.

tures allowed for the release of an average amount of


force of 110 g and 130 g (for ceramic and stainless
steel brackets, respectively). The statistical comparison between the two bracket types in the presence of
UEL and CEL did not show a significant difference at
any of the amounts of canine misalignment. Therefore,
the type of ligature influenced the actual amount of
force released by the orthodontic system significantly
more than the type of bracket (stainless steel vs ceramic).
The outcomes of the current study indicate that
when a slight amount of tooth alignment is needed (1.5
mm) the differences in the performance of conventional vs unconventional ligatures are minimal (with both
types of brackets), while these differences become
significant when correction of a misalignment greater
than 3.0 mm is attempted. A negligible amount of force
for alignment is actually available in the presence of
conventional ligatures and of a misalignment equal to
or greater than 3.0 mm (with both types of brackets).
On the other hand, the presence of UEL enables
ceramic brackets to release a significant amount of
orthodontic force during the aligning and leveling

phases of treatment, very similarly to stainless steel


brackets. Therefore, the use of recently developed unconventional ligatures allows the orthodontist to join
the advantages of low-friction biomechanics to those
in the use of esthetic ceramic brackets. The clinical
interpretation of these data, however, requires further
consideration. Each individual test with the Instron machine was performed with new elastomeric ligatures.
No attempt was made in the present study to evaluate
the effect of time and oral environment on the amount
of force released in the presence of different types of
elastomeric ligatures.19,20
CONCLUSIONS
The forces released by orthodontic wire in the presence of esthetic ceramic brackets were similar to
those released by stainless steel brackets with both
low-friction and conventional elastomeric ligatures.
For tooth misalignments of 3.0 mm or greater, the
force available for tooth movement was recorded in
the presence of either type of bracket only in the
presence of unconventional ligatures, while in the
Angle Orthodontist, Vol 78, No 1, 2008

124
presence of conventional ligatures the amount of
force generated was negligible.

BACCETTI, FRANCHI, CAMPORESI

11.

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Original Article

Shear Bond Strength of a New High Fluoride Release


Glass Ionomer Adhesive
Samir E. Bisharaa; Manal Solimanb; John F. Laffoonc; John Warrend
ABSTRACT
Objective: To determine the shear bond strength of a new resin glass ionomer adhesive with
higher fluoride release properties when bonding orthodontic brackets.
Materials and Methods: Sixty freshly extracted human molars were collected and stored in a
solution of 0.1% (weight/volume) thymol. The teeth were cleaned and polished. The teeth were
randomly separated into three groups according to the enamel conditioner/etchant and adhesive
used. Group I: 20 teeth conditioned with 10% polyacrylic acid and brackets bonded with the new
glass ionomer adhesive. Group II: 20 teeth conditioned with 37% phosphoric acid and brackets
bonded with the new glass ionomer adhesive. Group III (control): 20 teeth etched with 37% phosphoric acid and brackets bonded with a composite adhesive.
Results: The results of the analysis of variance comparing the three experimental groups (F
10.294) indicated the presence of significant differences between the three groups (P .0001).
The shear bond strengths were significantly lower in the two groups bonded with the new glass
ionomer adhesive whether conditioned with polyacrylic acid (x 3.2 1.8 MPa) or phosphoric
acid (x 2.3 1.1 MPa), while the mean shear bond strength of the composite adhesive was
5.2 2.9 MPa.
Conclusions: Although the increased fluoride release from the new glass ionomer has the potential of decreasing decalcification around orthodontic brackets, the shear bond strength of the
material is relatively low.
KEY WORDS: Glass ionomer; Fluoride; Shear bond strength

INTRODUCTION

need for separation, absence of posttreatment band


spaces, facilitation of application of attachments to
partially erupted teeth, minimization of the danger of
decalcification with loose bands, easier detection and
treatment of caries, and a much more esthetic appearance for the patient.4 In spite of all these advantages, the problem of enamel decalcification around
orthodontic brackets is a serious problem that clinicians are still facing, particularly in patients with less
than optimal oral hygiene.
The surface layer of enamel which is lost during
etching with phosphoric acid was estimated to vary
between 10 and 30 m,5 while the depth of penetration
of the resin tags reached up to 50 m.6 The clean-up
procedure of the adhesive following debonding may
remove up to 55.6 m of surface enamel.7 As a result
of this potential for significant enamel loss, various investigators considered alternative treatments of the
enamel surface in preparation for the bonding procedure including the use of maleic acid8,9 and polyacrylic
acid,10 together with the use of glass ionomer adhesives that are also able to release fluorides.1118

Since Buonocore introduced the acid etch bonding


technique in 1955, the concept of bonding various resins to enamel has developed applications in all fields
of dentistry including the bonding of orthodontic brackets.2,3 This approach has several advantages such as
enhanced ability for plaque removal by the patient,
minimization of soft-tissue irritation, elimination of the
1

Professor of Orthodontics, College of Dentistry, University


of Iowa, Iowa City, Iowa.
b
Instructor, Department of Conservative Dentistry, Menia
University, Menia, Egypt.
c
Research Assistant, College of Dentistry, University of Iowa,
Iowa City, Iowa.
d
Associate Professor, Department of Preventive and Community Dentistry, College of Dentistry, University of Iowa, Iowa
City, Iowa.
Corresponding author: Dr Samir E. Bishara, Orthodontics,
University of Iowa, Iowa City, S219 DSB, Iowa City, Iowa 52242
(e-mail: Samir-bishara@uiowa.edu)
a

Accepted: February 2007. Submitted: October 2006.


 2007 by The EH Angle Education and Research Foundation,
Inc.
DOI: 10.2319/100405-347.1

125

Angle Orthodontist, Vol 78, No 1, 2008

126
In general, glass ionomer products are divided into
three different categories: luting cements, restorative
materials, and liners. Liner glass ionomer materials
are differentiated from other glass ionomer cements by
their extremely small particle size (about 5 m or less).
Because of the favorable characteristics of glass ionomer liners,1114 particularly the long-term release of
fluorides,12,13 attempts were made to improve their
physical properties to make them more useful in areas
where strength is of primary importance.
From an orthodontic perspective one of the disadvantages of glass ionomer products is their relatively
low shear strength.15 As a result, glass ionomer hybrids were introduced that combine the properties of
composites and glass ionomers.16 The use of a 10%
polyacrylic acid solution is recommended for use with
these adhesive systems to minimize enamel loss. This
combination of using polyacrylic acid as an enamel
conditioner together with the glass ionomer adhesives
provided the advantages of minimal loss of the enamel
surface and the availability of fluoride ions around the
brackets during orthodontic treatment.16
Continued attempts have been made to improve the
initial bond strength of the glass ionomers while enhancing its fluoride-releasing characteristics.1618 A
new glass ionomer bonding agent that is suggested to
have an exceptional fluoride release ability was recently introduced and can be used as sealant, surface
protection, and restorative material.19 Such a bonding
material, if it also has adequate shear bond strength,
will have the important advantage of providing added
protection around orthodontic brackets.
The purpose of this study was to evaluate the shear
bond strength of orthodontic brackets bonded with a
new glass ionomer adhesive with significant fluoride
release properties.
MATERIALS AND METHODS
Teeth
Sixty freshly extracted human molars were collected
and stored in a solution of 0.1% (weight/volume) thymol. The criteria for tooth selection included intact buccal enamel, not subjected to any pretreatment chemical agents, eg, hydrogen peroxide, with no cracks due
to the pressure of the extraction forceps, and no caries. The teeth were cleaned and then polished with
nonfluoridated pumice and rubber prophylactic cups
for 10 seconds.
The teeth were embedded in acrylic placed in phenolic rings (Buchler Ltd, Lake Bluff, Ill). A mounting jig
was used to align the facial surface of the tooth to be
perpendicular with the bottom of the mold, ie, each
tooth was oriented so its labial surface would be parallel to the force during the shear strength test.
Angle Orthodontist, Vol 78, No 1, 2008

BISHARA, SOLIMAN, LAFFOON, WARREN

Adhesive
Two orthodontic adhesive systems were used:
GC Fuji Triage (GC America Inc, Alsip, Ill) which is
a light-cured glass ionomer adhesive that chemically bonds to tooth structures. Triage is a new radiopaque glass ionomer and is suggested to have
exceptional fluoride release properties and is used
to seal noncavitated lesions as well as pits and fissures.19 The continuous fluoride release from glass
ionomers over the course of orthodontic treatment
is thought to help protect teeth from decalcification
and prevent caries.18,19 According to the manufacturer, Triage is moisture-friendly and also provides
a strong lasting bond to the tooth structure.19
Transbond XT bonding system (3M Unitek, Monrovia, Calif) is a composite adhesive that contains
Bis GMA, Bis EMA, and quartz/silica fillers.
Brackets
Maxillary central incisor brackets were used to bond
all teeth (Victory Series, 3M Unitek). The average surface area of the bracket base was determined to be
11.7 mm2.
Groups Tested
The teeth were randomly divided according to the
enamel conditioner/etchant and adhesive used.
Group I: In 20 teeth, the enamel was conditioned with
a 10% polyacrylic acid for 20 seconds and washed
for 20 seconds. Excess water was blotted away
with a moist cotton roll. The teeth were bonded
with the Triage glass ionomer following the manufacturers instructions. The GC Triage capsule
was triturated for 10 seconds. The bracket with the
adhesive was placed on the tooth and light cured
for 40 seconds, 10 seconds at a time from the
mesial, distal, occlusal, and gingival.
Group II: In 20 teeth, the enamel was conditioned with
a 37% phosphoric acid gel for 15 seconds. The
teeth were washed, dried, and then bonded with
Triage as in Group I.
Group III (Control): In 20 teeth, the enamel was
etched with a 37% phosphoric acid gel for 15 seconds followed by thorough washing and drying.
The sealant was placed on the tooth and the
brackets were bonded with the Transbond XT adhesive and light cured for 20 seconds.
In all groups, before light curing the adhesive, the
brackets were pressed on the tooth with 300 g of force
using a force gauge (Correx Co, Bern, Switzerland),
and excess adhesive was removed with a sharp scaler.

127

BOND STRENGTH OF FLUORIDE RELEASING ADHESIVE

Debonding Procedure
A steel rod with one flattened end was attached to
the crosshead of a Zwick test machine (Zwick GmbH
& Co, Ulm, Germany). An occlusogingival load was
applied to the bracket, producing a shear force at the
bracket-tooth interface. A computer electronically connected with the Zwick test machine recorded the results of each test. Shear bond strengths were measured at a crosshead speed of 5 mm/minute. Bracket
removal was performed within a half hour from the
time the teeth were bonded to simulate the time at
which the initial archwires are ligated.

Table 1. Descriptive Statisticsa (in MPa) and the Results of the


Analysis of Variance Comparing the Shear Bond Strengths of the
Three Groups Tested
Mean

SD

Range

Duncan Test**

I. Transbond XT

Groups Tested*

5.2

2.9

1.110.4

Triage with:
II. Polyacrylic acid
III. Phosphoric acid

3.2
2.3

1.8
1.1

1.27.1
0.95.1

B
B

F ratio 10.294; P .0001.


* Group I: Composite etched with 37% phosphoric acid; Group II:
Triage Glass ionomer conditioned with 10% polyacrylic acid. Group
III: Triage Glass ionomer etched with 37% phosphoric acid.
** Groups with different letters were significantly different from
each other.
a

Evaluation of the Residual Adhesive


After bond failure, the teeth and brackets were examined under 10 magnification. Any adhesive remaining after bracket removal was assessed using a
modified adhesive remnant index (ARI) and scored
with respect to the amount of resin material adhering
to the enamel surface.20 The modified ARI scale has
a range between 5 and 1, with 5 indicating that no
adhesive remained on the enamel; 4, less than 10%
of adhesive remained on the surface; 3, more than
10% but less than 90% of the adhesive remained; 2,
more than 90% of the adhesive remained; and 1, all
of the adhesive remained on the tooth, along with the
impression of the bracket base. The ARI scores were
also used as a more complex means of defining the
site of bond failure between the enamel, the adhesive,
and the bracket base.

Table 2. Frequency Distribution of the Adhesive Residual Index


(ARI) Scores of the Three Groups Testeda
ARI Scores*
Groups Tested*

I. Transbond XT

14

20

Triage with:
II. Polyacrylic acid etch
III. Phosphoric acid etch

12
9

5
7

3
4

20
20

X2 2.63; P .662; Sample size in each group 20.


* Group I: Composite etched with 37% phosphoric acid; Group II:
Triage Glass ionomer conditioned with 10% polyacrylic acid. Group
III: Triage Glass ionomer etched with 37% phosphoric acid. The ARI
Score has a range between 5 and 1, with 5 indicating that no adhesive remained on the enamel; 4, less than 10% of adhesive remained on the tooth surface; 3, more than 10% but less than 90%
of the adhesive remained on the tooth; 2, more than 90% of the
adhesive remained; and 1, all of the adhesive remained on the tooth,
along with the impression of the bracket base.
a

Statistical Analyses
Descriptive statistics including the mean, standard
deviation, and minimum and maximum values were
calculated for each of the three groups tested. The
analysis of variance was used to determine whether
significant differences existed between the various
groups. If a significant difference was present, a Duncans multiple range test was used to identify which
groups were different. The chi-square test was used
to determine significant differences in the ARI scores
between the different groups. For the purpose of the
statistical analysis, ARI scores 1 and 2 were combined, as were ARI scores 4 and 5. Significance for
all statistical tests was predetermined at P .05.
RESULTS

ferences between the groups (P .0001). The mean


shear bond strength for the composite Transbond XT
group was significantly larger 5.2 2.9 MPa than for
the two glass ionomer groups. The mean shear bond
strength of the glass ionomer adhesive conditioned
with 10% polyacrylic acid was 3.2 1.8 MPa and that
for the group etched with a 37% phosphoric acid was
2.3 1.1 MPa.
Adhesive Residual Index (ARI)
The ARI scores for the three groups tested are presented in Table 2. The 2 test results (2 2.63) indicated that there were no significant differences between the three groups (P .662) regarding the site
of bond failure.

Shear Bond Strength


The descriptive statistics for the shear bond strength
are presented in Table 1. The results of the analysis
of variance comparing the three experimental groups
(F 10.294) indicated the presence of significant dif-

DISCUSSION
Clinicians are interested in learning about the properties of the adhesive systems they use in order to
optimize their ability to handle them properly and effiAngle Orthodontist, Vol 78, No 1, 2008

128
ciently as well as provide patients with better treatment. The ability of some of these adhesives to release significant amounts of fluoride ions provides an
added advantage to the bonding system by minimizing
decalcification around orthodontic brackets. A new
glass ionomer protective sealant/adhesive with exceptional fluoride release properties has been recently introduced.19 The use of such a material can potentially
provide a significant advantage, particularly in orthodontic patients with less than optimal oral hygiene.
The present findings indicated that the shear bond
strength of the brackets bonded with the new high fluoride release glass ionomer adhesive was significantly
lower than that for the group bonded with the composite adhesive. The use of 37% phosphoric acid etch
did not improve the shear bond strength of the glass
ionomer adhesive.
The evaluation of the ARI scores indicated that there
was no significant difference in the frequency of bond
failure between the various groups tested and was
mostly a cohesive failure.
Although the increased fluoride release from the
new glass ionomer adhesive has the potential of decreasing decalcification around orthodontic brackets,
the shear bond strength of the material needs to significantly increase to allow for the reliable bonding of
orthodontic brackets.
CONCLUSIONS
When compared with a composite adhesive, the
shear bond strength of the new glass ionomer adhesive was significantly lower in the initial half hour
after bonding. This was true whether the enamel was
conditioned with a 10% polyacrylic acid or was
etched with a 37% phosphoric acid.
The clinician needs to take into consideration all the
characteristics of each adhesive system, including
working properties, bond strength, and fluoride release.
REFERENCES
1. Buonocore MG. A simple method of increasing the adhesion
of acrylic filling materials to enamel surfaces. J Dent Res.
1955;34:849853.
2. Newman GV, Snyder WH, Wilson CW. Acrylic adhesives
for bonding attachments to tooth surfaces. Angle Orthod.
1968;38:1218.

Angle Orthodontist, Vol 78, No 1, 2008

BISHARA, SOLIMAN, LAFFOON, WARREN

3. Retief DH, Dreyer CJ, Gavron G. The direct bonding of orthodontic attachments to teeth by means of an epoxy resin
adhesive. Am J Orthod. 1970;58:2140.
4. Zachrisson BU. Cause and prevention of injuries to teeth
and supporting structures during orthodontic treatment. Am
J Orthod. 1976;69:285300.
5. Wickwire NA, Rentz D. Enamel pretreatment: a critical variable in direct bonding systems. Am J Orthod. 1973;64:499
512.
6. Buonocore MG, Matsui A, Gwinnett A. Penetration of resin
dental materials into enamel surfaces with reference to
bonding. Arch Oral Biol. 1978;13:6170.
7. Fitzpatrick DA, Way DC. The effects of wear, acid etching,
and bond removal on human enamel. Am J Orthod Dentofacial Orthop. 1997;72:671681.
8. Triolo PT Jr, Swift EJ Jr, Mudgil A, Levine A. Effects of
etching time on enamel bond strengths. Am J Dent. 1993;
6:302304.
9. Olsen ME, Bishara SE, Damon P, Jakobsen JR. Evaluation
of Scotchbond Multipurpose and maleic acid as alternative
methods of bonding orthodontic brackets. Am J Orthod
Dentofacial Orthop. 1997;111:498501.
10. Smith DC. A new dental cement. Br Dent J. 1968;125:381
394.
11. Prosser HJ, Powis DR. The characterization of glass-ionomer cements: the physical properties of current materials. J
Dent Res. 1984;12:231240.
12. Swift EJ Jr. Effects of glass ionomers on recurrent caries.
Oper Dent. 1989;14:4043.
13. McCourt JW, Cooley RL, Huddleston AM. Fluoride release
from fluoride-containing liners/bases. Quintessence Int.
1990;21:4145.
14. Soderholm KJM. Correlation of in vivo and in vitro performance of adhesive restorative materials: a report of the
ASC MD156 Task Group on Test Methods for the Adhesion
of Restorative Materials. Dent Mater. 1991;7:7483.
15. Bishara SE, Gordan VV, VonWald L, Jakobsen JR. Shear
bond strength of composite, glass ionomer and acidic primer adhesive. Am J Orthod Dentofacial Orthop. 1999;115:24
28.
16. Silverman E, Cohen M, Demke RS, Silverman M. A new
light-cured glass ionomer cement that bonds brackets to the
teeth without etching in the presence of saliva. Am J Orthod
Dentofacial Orthop. 1995;108:231236.
17. Bishara SE, VonWald L, Olsen ME, Laffoon JF. Effect of
time on the shear bond strength of glass ionomer and composite orthodontic brackets. Am J Orthod Dentofacial Orthop. 1999;116:616620.
18. Hatibovic-Kofman S, Koch G. Fluoride release from glass
ionomer cement in vivo and in vitro. Swed Dent J. 1991;15:
253258.
19. http://www.gcamerica.com/gctriage.html 7/16/2004.
20. Oliver RG. The effect of different methods of bracket removal on the amount of residual adhesive. Am J Orthod
Dentofacial Orthop. 1988;93:196200.

Original Article

Effect of Acidulated Phosphate Fluoride and


Casein PhosphopeptideAmorphous Calcium
Phosphate Application on Shear Bond Strength
of Orthodontic Brackets
nverd
Defne Kecika; Sevi Burcak C
ehrelib; C
agla Sarc; Bahtiyar U
ABSTRACT
Objective: To evaluate the effect of a recently introduced prophylactic agent, casein phosphopeptideamorphous calcium phosphate (CPP-ACP), on shear bond strength of brackets and compare it with the effect of acidulated phosphate fluoride (APF).
Materials and Methods: Forty-eight freshly extracted mandibular bovine incisors were used.
Teeth were randomly divided into four groups (n 12) as follows: group 1 served as control, and
no pretreatment was performed on the enamel; group 2, enamel was treated with 1.23% APF
and CPP-ACP, respectively; group 3, enamel was treated with CPP-ACP; and group 4, enamel
was treated with 1.23% APF for 4 minutes. In all groups, brackets were bonded using a conventional acid-etch and bond system (Transbond XT, 3M Unitek, Monrovia, Calif). Bonded specimens
were first stored in deionized water at 37C for 24 hours, subjected to thermal cycling for 1000
cycles, and further stored in distilled water for 6 weeks before debonding procedures. After debonding, teeth and brackets were examined under a stereomicroscope at 10 magnification for
any adhesive remaining, in accordance with the modified adhesive remnant index.
Results: The shear bond strengths of all experimental groups were significantly higher than that
of the control group (P .01). There was no significant difference between the shear bond
strengths of the experimental groups (P .05).
Conclusion: The use of CPP-ACP either alone or combined with APF could be considered as
an alternative prophylactic application in orthodontic practice since it did not compromise bracket
bond strength.
KEY WORDS: Shear bond strength; Casein phosphopeptideamorphous calcium phosphate
(CPP-ACP); Topical fluoride

INTRODUCTION

problems of great concern in orthodontics.1 Although


caries and enamel decalcification can be greatly reduced by maintaining good oral hygiene and using a
fluoride-containing dentifrice, use of prophylactic
agents are also recommended. Reports suggest that
topical fluoride application may reduce or eliminate decalcification during fixed orthodontic treatment.2 Several methods of topical fluoride application in orthodontic practice are (1) before etching,3,4 (2) during
etching,5,6 or (3) after etching (before bracket bonding)
the enamel.7,8
The mechanism by which fluoride reduces decalcification and caries has also been shown to increase
the resistance of enamel to acids.9 The fluoride deposits in hydroxyapatite form fluorapatite, which is
claimed to affect the bond strength and/or debonded
interface.10 Some studies11,12 have reported that topical

White spot decalcification and caries formation under and around orthodontic bands or brackets are
a
Research Fellow, Department of Orthodontics, Faculty of
Dentistry, Baskent University, Ankara, Turkey.
b
Research Fellow, Department of Pedodontics, Baskent University, Ankara, Turkey.
c
Postgraduate Student, Department of Orthodontics, Faculty
of Dentistry, Baskent University, Ankara, Turkey.
d
Professor, Department of Mining and Engineering, Hacettepe University Faculty of Engineering, Ankara, Turkey.
Corresponding author: Dr Sevi Burcak Cehreli, Department of
Pedodontics, Baskent University, Ankara, Bahcelievler, Turkey
(e-mail: seviburcak@yahoo.com)

Accepted: January 2007. Submitted: December 2006.


 2008 by The EH Angle Education and Research Foundation,
Inc.
DOI: 10.2319/122506-529.1

129

Angle Orthodontist, Vol 78, No 1, 2008

130
application of fluoride can interfere with the bonding
mechanism, resulting in reduced bond strength of dental resins. In contrary, other studies1315 demonstrated
that the topical application of the fluoride did not adversely affect either the etch pattern on the enamel or
the bond strength of composite resin.
Recently, a milk protein derivative, casein phosphopeptideamorphous calcium phosphate (CPP-ACP)
complex, has been introduced for caries prevention
and enamel remineralization.16 The proposed mechanism of action of CPP-ACP is related to its localization
at the tooth surface, where it buffers free calcium and
phosphate ion activities, maintaining a state of supersaturation with respect to tooth enamel, thereby preventing demineralization and facilitating remineralization.16 Some recommended professional applications
for CPP-ACP complex are white spot prevention/removal in orthodontics, immediately following surgery
bleaching, following professional tooth cleaning, after
application of topical fluoride, and to provide a topical
coating for patients suffering from erosion, caries, and
conditions arising from xerostomia.17
Despite recommendations for its utilization in orthodontics, there are no available data reporting the effects of CPP-ACP on bracket bonding. The aim of this
study, therefore, is to evaluate and compare the effects of topical application of CPP-ACP, acidulated
phosphate fluoride (APF), and both on shear bond
strength of brackets. The null hypothesis is that the
shear bond strength of orthodontic brackets is not affected by tested enamel pretreatment methods.
MATERIALS AND METHODS
Forty-eight extracted bovine permanent mandibular
incisors were collected from a local slaughterhouse.
Immediately after harvesting, the teeth were cleaned
of debris and soft tissue remnants and then polished
with nonfluoridated pumice and rubber prophylactic
cups at low speed for 10 seconds. Tooth selection criteria included absence of any visible irregularity or
crack of the enamel surface under 4 magnification
and the availability of a macroscopically smooth, flat
labial surface suitable for bonding. The teeth were randomly assigned to one of four groups:
Group 1: Served as control, and no pretreatment was
performed on enamel.
Group 2: Enamel was treated with 1.23% APF (Sultan,
Topex, NJ) for 4 minutes and CPP-ACP (Recaldent Tooth Mousse; GC Europe, Leuven, Belgium) for 3 minutes, respectively.
Group 3: Enamel was treated with CPP-ACP for 3 minutes.
Group 4: Enamel was treated with 1.23% APF for 4
minutes.
Angle Orthodontist, Vol 78, No 1, 2008

NVER
KECIK, CEHRELI, SAR, U

Orthodontic metal brackets (Microarch Standard;


GAC International, Bohemia, NY) with a base area of
approximately 11.26 mm2 were used to bond all teeth.
During and after specimen preparation, the teeth
were stored in distilled water at room temperature. To
exclude possible differences in bond strength caused
by the orthodontic adhesive used, all brackets were
bonded with the same material (Transbond XT; 3M
Unitek, Monrovia, Calif). Before bonding, each bracket
was subjected to a 300-g compressive force for 10
seconds, as described previously by Bishara et al.18
The excess resin was removed with a small scaler
before photopolymerization. A halogen lightcuring unit
(Hilux; Benlioglu, Istanbul, Turkey) was used for curing
the resin, 20 seconds from both the mesial and distal
sides. The adequacy of the units irradiance was confirmed with a radiometer before photopolymerization.
Specimens were stored in deionized water at 37C
for 24 hours, and then thermal cycling in deionized
water was performed at 5C 2C to 55C 2C for
1000 cycles. The total period of exposure to both 5C
2C and 55C 2C was 10 seconds, with a dwell
time of 5 seconds in each bath. The teeth were then
kept in distilled water at 37C for 6 weeks before testing procedures. The water was changed every week.
After thermal agitation and water storage, the roots
were removed with a low-speed diamond saw under
coolant water, and the crowns were embedded in
acrylic placed in phenolic rings, with a mounting jig
used to align the labial surface of each tooth so that it
was perpendicular to the bottom of the mold. Samples
were then mounted in the jig attached to the universal
testing device (model 4204; Instron, Canton, Mass).
For shear testing, the specimens were secured in the
lower jaw of the machine so that the bracket base of
the sample paralleled the direction of the shear force.
The specimens were stressed in an occlusogingival
direction with a cross-head speed of 1 mm/min, as in
previous studies.19,20 The force required to dislodge the
bracket was recorded in newtons and converted to
megapascals with the following equation: shear force
(MPa) debonding force (N)/[w l] (mm2), where w
width of the bracket base, l height of the bracket
base, and 1 MPa 1 N/mm2.
After debonding, the teeth and the brackets were
examined under a stereomicroscope at 10 magnification for any adhesive remaining, in accordance with
the modified adhesive remnant index (ARI).21 ARI
scores range from 5 to 1, in which 5 no adherence
of composite on enamel, 4 less than 10% of composite remaining on the enamel, 3 more than 10%
but less than 90% of composite remaining on the
enamel, 2 more than 90% of composite remaining
on the enamel, and 1 all composite remaining on
the enamel, with the impression of the bracket base.

131

EFFECT OF CPP-ACP ON SHEAR BOND STRENGTH


Table 1. Descriptive Statistics in Megapascals and Results of Kruskal-Wallis Test Comparing Shear Bond Strength of Four Groupsa

Table 3. Frequency Distribution of Adhesive Remnant Index (ARI)


Scores of the Groups

Group
1
2
3
4

ARI Score

(control)
FCPP-ACP
CPP-ACP
APF

12
12
12
12

5.37
6.43
5.98
6.46

0.71
0.55
0.69
0.62

5.27
6.57
5.72
6.33

a
b
b
b

Identical lettering in the last column indicates values that are not
significantly different at P .05.
a

The Kruskal-Wallis test at P .05 was used to determine whether significant differences existed between the shear bond strengths of the groups.22 The
2 (P .05) test was used to determine significant
differences in the ARI scores among the different
groups.
RESULTS
The descriptive statistics for the shear bond
strengths of the four groups are presented in Table 1.
There was a significant difference among the shear
bond values of the test groups and the control group
(P .002). The bond strengths of the test groups were
significantly greater than those of the control group (P
.05). There was no statistically significant difference
among the groups pretreated with the APF application,
CPP-ACP application, or combined application of
these agents. All the groups showed a higher percentage of ARI scores of 5, Table 2. The ARI scores
for the four groups are listed in Table 3. The 2 test
results indicated no significant differences among the
groups regarding mode of debonding. Enamel detachment was not found in either group. The most frequent
debonding occurred in the bracket-resin interface
(66% for the control group and 58% for the test group).
DISCUSSION
The question regarding the most appropriate caries
prophylactic method in orthodontic practice still merits
further research. A recent systematic review reports
that the use of topical fluorides in addition to fluoride
toothpaste appears to reduce the incidence of decalcification in patients undergoing orthodontic treatment
with fixed appliances.23
Table 2. Intergroup Comparisons and Significance Value (P )
Intergroup Comparison
Group
Group
Group
Group
Group
Group

12
13
14
23
24
34

P
.000
.037
.000
.084
.932
.070

Group
1
2
3
4

1
1

2
4
3
3

2
1
1
1

8
7
7
7

Gwinnett et al found that topically applied fluorides


could significantly reduce bond strength by disrupting
the formation of enamel tags.24,25 These authors have
demonstrated the formation of a globular reaction
product (possibly CaF) on the etched surface and
have recommended thorough rinsing of the enamel after topical fluoride application. In the present study,
although every effort was made to remove all the
agents from the enamel surface, this was not a great
concern since prophylactic agents were applied prior
to acid etching of the enamel.
Hirce et al7 found that etching enamel for 4 minutes
with 50% phosphoric acid containing 2% sodium fluoride
significantly weakened the bond strength compared to
etching teeth with 50% phosphoric acid alone for 1 minute. The difference in application time is a confounding
variable that limits any conclusions about the effect of
fluoride on bonding. The decrease in bond strength
might be attributed to overetching the enamel and obliterating all enamel tags. Other factors such as variation
in the fluoride concentrations used, improvements in the
properties of the bonding agents, and/or the bracket retention mechanism could also affect the results.
Contrary to the findings of Hirce et al,7 Garcia-Godoy et al11 reported that acid-etching enamel with 60%
phosphoric acid containing 0.5% sodium fluoride produced statistically higher shear bond strengths compared with enamel etched with 38% phosphoric acid
alone. More recently, Garcia-Godoy26 found no difference in shear bond strength between teeth that were
pretreated with APF and teeth that did not receive APF
pretreatment.
When the effect of APF pretreatment is considered,
the findings of the present study are in accordance
with the previous findings of Garcia-Godoy et al.11 Although there was no significant difference among test
groups, the fluoride-pretreated enamel demonstrated
the higher bond strength that is followed by fluoride
CPP-ACP in the pretreated group. The enhanced
bond strength presented herein might be attributed to
differences in the study design. Previously reported
data were obtained by using extracted human premolars as substrate. Intact human premolars vary in
the curvature of their labial surface and represent a
complex three-dimensional convex configuration for
Angle Orthodontist, Vol 78, No 1, 2008

NVER
KECIK, CEHRELI, SAR, U

132
bonding with conventional testing methods. Thus, in
the present study, bovine teeth were used because
bovine enamel has been reported to be a reliable substitute for human enamel in bonding studies, with no
statistically significant difference in enamel-bonding
value.27,28 However, some minor differences among
the human enamel and bovine enamel have been reported.
Because bovine enamel and dentin develop more
rapidly during tooth formation, bovine enamel has larger crystal grains and more lattice defects than human
enamel does.29 This may contribute to a reported lower
critical surface tension in bovine enamel than in human enamel.30 These differences might have contributed to the results of the present study.
Reynolds31 suggested that a minimum bond strength
of 6 to 8 MPa was adequate for most clinical orthodontic needs. These bond strengths are considered
able to withstand masticatory and orthodontic forces.
In this experiment, all bond strength values achieved
were much above this minimal requirement. The results of this study indicated that shear bond strength
is favorably affected when the enamel surfaces have
been treated with 1.23% APF, CPP-ACP, or their combination.
This study provides preliminary data on the effect of
the CPP-ACP on the shear bond strength of brackets.
However, one should consider the limitations of in vitro
tests when interpreting the results.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

CONCLUSIONS
APF application, CPP-ACP application, and a combined application of these agents may safely be
used for caries prophylaxis before bracket bonding
when a three-step bonding procedure is used. Further research is indicated to test the effect of these
prophylactic applications when self-etch adhesive
systems are used.
The effects of three tested applications on shear
bond strength were not significantly different. This
finding necessitates conduction of further studies to
compare the effectiveness of these methods to
choose the best caries prevention method for clinical
use in orthodontics.

16.
17.
18.

19.

20.

21.

REFERENCES
1. Artun J, Brobakken BO. Prevalence of carious white spots
after orthodontic treatment with multibonded appliances.
Eur J Orthod. 1986;8:229234.
2. Shannon IL. Prevention of decalcification in orthodontic patients. J Clin Orthod. 1981;15:694705.
3. Wang WN, Sheen DH. The effect of pretreatment with fluoride on the tensile strength of orthodontic bonding. Angle
Orthod. 1991;61:3134.
4. Lehman R, Davidson CL. Loss of surface enamel after acid
Angle Orthodontist, Vol 78, No 1, 2008

22.
23.

24.

etching procedures and its relation to fluoride content. Am


J Orthod. 1981;80:7382.
Bohrer J, Gedalia I. Fluoride concentration in enamel treated with 50% phosphoric acid and NaF with subsequent decalcification in acid gel. J Dent Res. 1980;59:10221025.
Freeman JE, Shannon IL. Addition of stannous fluoride to
acid etchant in direct bonding procedures. Int J Orthod.
1981;19:1317.
Hirce JD, Sather AH, Chao EY. The effect of topical fluorides, after acid etching of enamel, on the bond strength of
directly bonded orthodontic brackets. Am J Orthod. 1980;
78:444452.
Davidson CL, Bekke-Hoekstra IS. The resistance of superficially sealed enamel to wear and carious attack in vitro. J
Oral Rehabil. 1980;7:299305.
Mellberg JR, Ripa LW. Fluoride in Preventive Dentistry:
Therapy and Clinical Applications. Carol Stream, Ill: Quintessence; 1983.
Aasende R, Depalola PF, Brudevold F. Effects of daily rinsing and ingestion of fluoride solution upon dental caries and
enamel fluoride. Arch Oral Biol. 1972;17:17051714.
Garcia-Godoy F, Hubbard GW, Storey AT. Effect of fluoridated etching gel on enamel morphology and shear bond
strength of orthodontic brackets. Am J Orthod Dentofacial
Orthop. 1991;100:163170.
Meng CL, Li CH, Wang WN. Bond strength with APF applied after acid etching. Am J Orthod Dentofacial Orthop.
1998;114:510513.
Meng CL, Wang WN, Yeh IS. Fluoridated etching on orthodontic bonding. Am J Orthod Dentofacial Ortho. 1997;112:
259262.
Bishara SE, Chan D, Abadir EA. The effect on the bonding
strength of orthodontic brackets of fluoride application after
etching. Am J Orthod Dentofacial Orthop. 1989;95:259
260.
Wang WN, Sheen DH. The effect of pretreatment with fluoride on the tensile bond strength of orthodontic bonding.
Angle Orthod. 1991;61:3134.
Reynolds EC. Anticariogenic casein phosphopeptides. Protein Pept Lett. 1999;6:295303.
GC Europe Recaldent Tooth Mousse Product Manual. GC
Corporation, Tokyo, Japan.
Bishara SE, Gordan VV, VonWald L, Olson ME. Effect of
an acidic primer on shear bond strength of orthodontic
brackets. Am J Orthod Dentofacial Orthop. 1998;114:243
247.
Cehreli ZC, Kecik D, Kocadereli I. Effect of self-etching
primer and adhesive formulations on the shear bond
strength of orthodontic brackets. Am J Orthod Dentofacial
Orthop. 2005;127:573579.
Jobalia SB, Valente RM, de Rijk WG, BeGole EA, Evans
CA. Bond strength of visibile light-cured glass ionomer orthodontic cement. Am J Orthod Dentofacial Orthop. 1997;
112:205208.
Olsen ME, Bishara SE, Damon P, Jakobsen JR. Evaluation
of Scotchbond multi-purpose and maleic acid as alternative
methods of bonding orthodontic brackets. Am J Orthod
Dentofacial Orthop. 1997;111:498501.
Conover WJ. Practical Nonparametric Statistics. New York,
NY: John Wiley & Sons; 1980.
Chadwick BL, Roy J, Knox J, Treasure ET. The effect of
topical fluorides on decalcification in patients with fixed orthodontic appliances: a systematic review. Am J Orthod
Dentofacial Orthop. 2005;128:601606.
Gwinnett AJ, Buonocore MG, Sheykoleslam Z. Effect of
fluoride on etched human and bovine tooth enamel surfaces

EFFECT OF CPP-ACP ON SHEAR BOND STRENGTH

as demonstrated by scanning electron microscopy. Arch


Oral Biol. 1972;17:271278.
25. Sheykholeslam Z, Buonocore MG, Gwinnett AJ. Effect of
fluorides on the bonding of resins on phosphoric acid-etch
bovine enamel. Arch Oral Biol. 1972;17:10371045.
26. Garcia-Godoy F. Shear bond strength of a resin composite
to enamel treated with an APF gel. Pediatric Dent. 1993;15:
272274.
27. Nakamichi I, Iwaku M, Fusayama T. Bovine teeth as possible substitutes in the adhesion test. J Dent Res. 1983;62:
10761081.

133
28. Oesterle LJ, Shellhart WC, Belanger GK. The use of bovine
enamel in bonding studies. Am J Orthod Dentofacial Orthop.
1998;114:514519.
29. Moriwaki Y, Kani T, Kozatani T, Tsutsumi S, Shimode N,
Yamaga R. The crystallinity change of bovine enamel during
maturation. Jpn J Dent Mat. 1968;9:7885.
30. Yu KC, Chang R. Adhesive restorative dental materials II,
approaches to achieve adhesion. National Institutes of Dental Research, US Department of Health, Education and Welfare. 1966:103131.
31. Reynolds IR. A review of direct orthodontic bonding. Br J
Orthod. 1975;2:171178.

Angle Orthodontist, Vol 78, No 1, 2008

Original Article

Conventional and High Intensity Halogen Light Effects on Water Sorption


and Microhardness of Orthodontic Adhesives
Tancan Uysala; Faruk Ayhan Basciftcib; Yagmur Senerc; Murat Selim Botsalid; Abdullah Demirb
ABSTRACT
Objective: To test the null hypothesis that when the equivalent total light energy is irradiated to
three orthodontic adhesive resins, there is no difference between the microhardness and water
sorption values regardless of the curing light sources.
Materials and Methods: Samples were divided into six groups according to the combination of
three orthodontic adhesives (Kurasper F, Light-Bond, Transbond XT) and two light intensities
(quartz tungsten halogen [QTH] and high intensity quartz tungsten halogen [HQTH]). One half of
each of the 40 samples of three adhesive pastes was polymerized for 20 seconds by a QTH light
source, and the other half was polymerized for 10 seconds by a HQTH light source. Water sorption
was determined and Vickers hardness was established with three measurements per sample at
the top, center, and bottom. Statistical analysis was performed using two-way analysis of variance
(ANOVA) with multiple comparisons (Tukey-HSD).
Results: Statistically significant differences were found among all adhesives for water sorption
and hardness values cured with QTH and HQTH. The HQTH curing unit resulted in higher values
than did the QTH. The highest water sorption values were observed for Kurasper F cured with
HQTH and the lowest value was observed for Transbond XT cured with QTH. For microhardness
Light-Bond cured with HQTH produced the highest values, and Transbond XT cured with QTH
produced the lowest.
Conclusions: When the equivalent total light energy is irradiated to three orthodontic adhesive
resins, there are significant differences between the microhardness and water sorption values
cured with the QTH and HQTH light source. The null hypothesis is rejected.
KEY WORDS: Water sorption; Vickers hardness; Halogen; Composites

INTRODUCTION

bracket placement. The disadvantage of using lightcured materials is the time required for exposing the
adhesive.1 A reduction in the amount of curing time
would be of great advantage to both the orthodontist
and patient.2
PARBC need adequate light output and irradiation
time to obtain an optimal curing level. Incomplete curing of resins results in the increase of water sorption,
a decrease in the hardness, and deterioration of the
mechanical properties of material through the softening of the polymer matrix by unreacted monomer.3
Adhesives used for orthodontic bonding are required to have long-term durability in the oral cavity.
The material is in contact with saliva in a complex environment containing bacterial flora composed of a
many inorganic and organic species. The materials
thus require a certain set of physical properties before
the curing process which include microhardness as
the most important and water sorption, which were related with the strength.4

A wide variety of photo-activated resin-based composites (PARBC) have become commercially available
in the orthodontic field. These are the choice of adhesive for orthodontic bonding because of their ease
of use and the extended time they allow for optimal
Associate Professor and Department Chair, Department of
Orthodontics, Faculty of Dentistry, Erciyes University, Kayseri,
Turkey.
b
Associate Professor, Department of Orthodontics, Selcuk
University, Konya, Turkey.
c
Assistant Professor, Department of Pediatric Dentistry, Selcuk University, Konya, Turkey.
d
Research Fellow, Department of Pediatric Dentistry, Selcuk
University, Konya, Turkey.
niversitesi
Corresponding author: Dr Tancan Uysal, Erciyes U
Dishekimligi Fakultesi, Ortodonti A.D. Melikgazi, Kampus Kayseri, 38039 Turkey (e-mail: tancanuysal@yahoo.com)
a

Accepted: March 2007. Submitted: February 2007.


 2008 by The EH Angle Education and Research Foundation,
Inc.
Angle Orthodontist, Vol 78, No 1, 2008

134

DOI: 10.2319/020507-56.1

135

WATER SORPTION AND MICROHARDNESS OF HALOGEN LIGHTS

MATERIALS AND METHODS

Figure 1. Glass ring molds.

The use of high intensity units has been recommended almost universally,5 since they are able to enhance monomer conversion. Hardness, water sorption, and solubility in water are largely related to the
conversion of monomers incorporated into composites.6 Polymerization by a high intensity quartz tungsten halogen (HQTH) curing unit occurs rapidly. Conversely, some authors do not recommend the use of
high intensity light units because this type of unit induces higher polymerization shrinkage, lower degree
of conversion, and larger residual stress in dental filling composites.7 In recent years many different methods have been studied aiming to improve the physical
properties of PARBC, ie, use of different light activation techniques such as pulse delay,8 soft-start and
pulse cure,9 development of resins,10 and the use of
the incremental filling technique.11
It is believed that adequate PARBC polymerization
and improved mechanical properties may be obtained
in a shorter time when using high power light curing
units. In recent studies many authors compared the
effects of light emitting diodes (LED) and plasma arc
curing lights with conventional curing systems. However, there are few reports on the conventional and
high intensity halogen curing systems,12 especially
their effect on the microhardness and water sorption
properties of PARBC.
The purpose of the present study was to test the
null hypothesis that when the equivalent total light energy is irradiated to three orthodontic adhesive resins,
there are no differences between the microhardness
and water sorption values regardless of the curing light
sources (quartz tungsten halogen [QTH] and HQTH).

One hundred twenty glass ring molds (8.5 mm in


inner diameter and 2 mm in height) were prepared
(Figure 1) using a low-speed saw (Isomet, Buehler Ltd,
Lake Bluff, Ill). The internal surface of the glass rings
were roughened and etched for 5 minutes with hydrofluoric acid (Etch-It, American Dental Supply, Easton,
Pa). The glass molds were then weighed in air and in
water with an electronic balance (Shimadzu AY220,
Shimadzu Corp, Kyoto, Japan) to calculate their density and volume.
Three different commercially available orthodontic
adhesive pastes, Kurasper F (Kuraray, Okayama, Japan), Light-Bond (Reliance, Itasca, Ill), and Transbond
XT (3M Unitek, Monrovia, Calif), were used in this
study (Table 1). Forty samples of each adhesive paste
were placed into the glass molds, which were sandwiched between two glass slides. To ensure that the
adhesive paste would be well distributed within the
mold, a 5-N force was applied for 30 seconds. The
samples were stored in dark and dry conditions at
37C for 24 hours to standardize the environment prior
to the testing procedures after light curing, before they
were weighed both in air and in water to calculate their
density and volume.
One half of each of the 40 samples of three adhesive pastes was polymerized for 20 seconds by a QTH
light source (Hilux 350, Express Dental Products, Toronto, Canada) with a 10-mm diameter light tip. The
other half was polymerized for 10 seconds by a HQTH
light source (Optilux 501, Kerr, Danbury, Conn) with
an 10-mm diameter light tip. Regarding the curing
units, the important parameter is the amount of light
energy of appropriate wavelength emitted during irradiation. This energy is calculated as the product of the
output of the curing unit and the time of irradiation, and
it may be termed energy density (mJcm2). The outputs of the light tips were calibrated by a digital curing
radiometer (Demetron, Danburry, Conn) as 420 mW/
cm2 for QTH and as 850 mW/cm2 for HQTH. At the
start of irradiation, these outputs were measured as
430 mW/cm2 and 865 mW/cm2 for QTH and HQTH,
respectively. However, the light intensity decreased
17.2 mW/cm2 for QTH and 24.7 mW/cm2 for HQTH

Table 1. Orthodontic Adhesive Resins Used in the Present Study


Adhesive
Code

Brand Name

KF

Kurasper F

LB
TX

Light-Bond
Transbond XT

Composition
Bis-GMA, TEGDMA, HEMA, NaF and MF-MMA copolymer containing fluorine, silica filler.
UDMA, TEGDMA, fused silica, sodium fluoride
Bis-GMA, Bis-EMA, TEGDMA, silanated quartz, submicron silica

Batch
Number

Manufacturer

41123

Kuraray, Japan

104160
200401

Reliance, III
3M Unitek, Calif

Angle Orthodontist, Vol 78, No 1, 2008

136

UYSAL, BASCIFTCI, SENER, BOTSALI, DEMIR

Table 2. The Water Sorption and Vickers Hardness Mean Values and Standard Deviations of Three Orthodontic Adhesive Resins Cured With
QTH and HQTH and Multiple Statistical Comparison Resultsa
Light Source
Comparisons
QTH (n 20)
Groups
Water uptake (g
mm3)

Microhardness
(Vickers hardness)

(n 40)

HQTH (n 20)

Mean

SD

Mean

SD

QTH vs
HQTH

Adhesive Resin
Comparisons
Cured With QTH

Adhesive Resin
Comparisons
Cured With HQTH

Group Group Group Group Group Group


A-B
A-C
B-C
A-B
A-C
B-C

Kurasper F

13.35

0.99

14.03

1.06

B
C
A

Light-Bond
Transbond XT
Kurasper F

7.69
5.16
67.63

0.92
0.84
2.24

7.84
5.44
71.91

1.33
1.39
2.11

NS
NS
***

***

***

***

***

***

***

Light-Bond

92.96

2.49

95.28

4.51

NS

***

***

***

***

***

***

Transbond XT

55.10

2.46

55.42

2.70

NS

NS indicates not significant; n, sample size; QTH, quartz tungsten halogen light; HQTH, high intensity quartz tungsten halogen light; and
SD, standard deviation.
* P .05; *** P .001.
a

with usage. The total light energy was calculated with


the mean output values about:
QTH: 420 mW/cm2 20 s 8400 mJ cm2
HQTH: 850 mW/cm2 10 s 8500 mJ cm2
Water Sorption Measurements
Water sorption was determined according to the
method described by Satou et al.13 The diameter and
the thickness of each specimen were measured, and
the volume (V0 ) was calculated. Each specimen was
stored at 37C in a desiccator for 3 days until a constant weight (W0 ) was obtained and subsequently immersed in 10 mL of distilled water maintained at 37C.
Periodically, the specimen was picked up and the surface water was blotted away with paper until free from
visual moisture, then it was reweighed (W1 ). This procedure was continued until the weight change during
1 week became less than 0.32 gmm3. The value of
water sorption (Wsp ) in g/mm3 was calculated using
the following equation:
Wsp (W1 W0 )/V0
Microhardness Measurements
Microhardness measurements were used as indirect
evaluation of degree of conversion.14 Vickers hardness
was determined according to the description by Dietschi et al.15 After water sorption measurements and
polishing, the samples were stabilized parallel to the
base of the hardness measurement device (Matsuzawa Seiki Co Ltd, MHTZ, Tokyo, Japan, serial number:
mh2028) by pressing the sample over a thin layer of
a plasticizing material (Plasticine; Beuhlers, Princeton,
Ind). Vickers hardness measurements were obtained
Angle Orthodontist, Vol 78, No 1, 2008

using a 300-gram load for all specimens. The appropriate load was applied for 30 seconds and the indentation size was recorded 10 seconds later. Vickers
hardness was established with three measurements
per sample at 10 m underneath the sample top surface, at the center of the sample and at 10 m above
the sample bottom.
Samples were divided into six groups according to
the combination of two light intensities and three orthodontic adhesives. For all groups, the average values and standard deviations (SD) were calculated.
Statistical analysis was performed using two-way analysis of variance (ANOVA) (SPSS, Statistical Package
for Social Sciences, Version 10.0, Chicago, Ill) and Tukey HSD tests for multiple comparisons (each adhesive and each curing unit). The level of statistical significance was set at P .05.
RESULTS
The water sorption and Vickers hardness mean values and standard deviations of three adhesive resins
cured with QTH and HQTH and statistical comparisons are shown in Table 2. Water sorption (P .05)
and microhardness (P .001) values irradiated to the
three orthodontic adhesive resins varied significantly
depending on the different curing units used. Two-way
ANOVA revealed significant interaction among the curing unit type and orthodontic adhesives (P .05). The
null hypothesis was thus rejected.
For all adhesives, the HQTH light curing unit resulted in more water sorption than did the QTH (Table 2).
There are increases in water sorption when the specimens were irradiated using the HQTH, but only statistically significant differences were found for Kuras-

WATER SORPTION AND MICROHARDNESS OF HALOGEN LIGHTS

per F. The highest water sorption values were observed for Kurasper F cured with HQTH (14.03 1.06
gmm3) and the lowest value was observed for
Transbond XT cured with QTH (5.16 0.84 gmm3).
All investigated adhesives showed statistically significant differences for water sorption values when irradiated using the QTH and HQTH separately (P
.001).
Microhardness differences among top, middle, and
bottom values in all cured groups irradiated by QTH
and HQTH were not statistically significant. For that
reason average values were used for the Vickers
hardness number for all groups.
All adhesives showed statistically significant hardness differences when irradiated using the QTH and
HQTH (P .001). Vickers hardness obtained with
HQTH was generally superior when compared to the
values obtained with the QTH, but only Kurasper F
showed a statistically significant difference (P .001).
The highest hardness values were observed for LightBond cured with HQTH (95.28 4.51 kg/mm2) and
the lowest value was observed for Transbond XT
cured with QTH (55.10 2.46 kg/mm2).
DISCUSSION
The use of light to polymerize composite resins has
increased in the last few years.2,3,6,8,13 Several light devices have been developed that have greater power
density in the curing region of the visible spectrum,
400500 nm wavelength, which can be used to accelerate the photo-polymerization of composite resin
materials, and to improve the physical properties of the
set composite.16 The most widely used light sources
for PARBC are QTH lights.17 Argon lasers, LED,
HQTH, and xenon plasma arc lamps have all been
shown to achieve rapid polymerization.1820 Studies on
depth of cure, resin hardness, polymerization contraction, strength properties, water sorption, and water solubility have been performed with some of these systems20; however, there is limited published data on
newer curing technologies such as HQTH.12
The HQTH light is capable of producing light of a
greater intensity than that of the QTH light and may
be sufficient for the fast curing of adhesives including
those used for orthodontic bonding purposes. Nomoto
et al21 found that when the comparable total light energy was irradiated to the resin, the curing depth and
the degree of conversion might be similar regardless
of the differences in the light intensity or irradiation
time. In addition, higher light intensity could result in
increased fracture, hardness, and greater flexural
strength of resin, which would translate into greater
bond strength of brackets bonded to teeth.3 With these
effects in mind, this in vitro study was performed to

137
investigate the effects of QTH and HQTH light sources
on mechanical properties such as water sorption and
microhardness of three orthodontic adhesives.
Water sorption is a critical property for PARBC because it increases the volume of the material.22 Moreover, water acts as a plasticizer, increasing the deterioration of the resin matrix. In addition, water sorption
usually affects color stability of composite since watersoluble monomers can penetrate the outer border of
the brackets and lead to colorization of composite
around the bracket base. This phenomenon is esthetically unacceptable.
The degree of cure is one of the critical parameters,
which may influence the physical properties of composite materials,23 and thus the clinical behavior of
light curing materials. Knowing the degree of cure of
resin composites is also essential in terms of residual
monomers and probable allergic susceptibility. 2,24
However, directly measuring the degree of conversion
is not easy. Therefore, similar to Usumez et al,2 the
mechanical property of hardness was evaluated in the
present study to serve as an indirect indicator of the
degree of cure. Microhardness allows for measurements at specific locations within the sample; for this
study, evaluations were made at the top, middle, and
bottom of the specimens. Though hardness values
may not be used for a direct comparison among materials, they are a valuable tool for relative measurements within the same material, and their simplicity
facilitates the evaluation of a large number of specimens,25 making it suitable for comparing different curing techniques.
We used the Vickers hardness values for microhardness measurements. In the literature, both the
Vickers and Knoop methods have been used to evaluate the hardness of resin composites. Knoop hardness is said to be more suitable for polymers, because
Vickers indentation can distort with relaxation of the
materials, whereas the long diagonal of the Knoop indentation is not affected. However, there are neither
scientific data supporting this view nor international
standards or qualifications favoring either of these
methods.2 Hofmann et al26 investigated the association
between Vickers and Knoop hardness and showed a
significant linear correlation, and both may be similarly
appropriate for studying resin composites.
The mechanical properties of PARBC are influenced
by the type and composition of resin matrix, filler type,
filler load, and mode of polymerization.2 A correlation
between volumetric filler content and hardness was
demonstrated by Pilo and Cardash.27 Inorganic fillers
are added to reduce polymerization shrinkage and water sorption, to increase hardness and strength, and
also to impart color characterization to the material.28
Li et al29 reported that changing the level of filler in
Angle Orthodontist, Vol 78, No 1, 2008

138
composite altered the properties of hardness, water
sorption, compressive strength, elastic modulus, and
wear resistance. In this study, composite Kurasper F
showed statistically significant higher water sorption
than the other composites. In addition, the highest
overall mean hardness value was observed for the
Light-Bond specimens. Different results for these composites may be explained by the higher hydrophilicity
of organic matrix resins, different composition/filler
content, and also by their higher content of organic
resins.
There are many studies in restorative dentistry investigating the relationships between curing light type
and mechanical properties of PARBC. The shrinkage
of the resin caused by the rapid curing with high intensity lights was considered a disadvantage for restorative applications, and fast curing can generate excess shrinkage and gap formation along the resinpreparation interface.2 Despite this fact, these types of
reports are rare in the orthodontic field.12,30 Bang et al30
irradiated equivalent total light energy with QTH and
plasma arc units on orthodontic adhesives and found
statistically significant differences in polymerization
characteristics. Present findings indicate that when the
equivalent total light energy was irradiated all three adhesive resins that cured with the HQTH light showed
more water sorption and higher microhardness values
than did the QTH. However, these differences were
statistically significant only in Kurasper F for investigated properties. When looking at the QTH and HQTH
lamp results, there was almost no decrease in hardness in the depth (top, middle, and bottom) of the samples, and no statistically significant differences were
found. The deviation of the results from top to bottom
was generally small, with both curing devices, which
indicates a good reproducibility and reliability of the
curing protocol.
To take osmotic pressure into consideration, acrylic
polymers in the hydrogel matrix immersed in distilled
water should absorb more water than those in saliva.
Nicholson31 showed greater equilibrium water uptake
in pure water than in a salt solution, results which were
consistent with the above theory. Because of these
reasons, clinical conditions may significantly differ
from an in vitro setting and our findings must be interpreted carefully. For clinical significance, the lower water sorption was observed for Transbond XT cured
with QTH, and the higher microhardness was observed for Light-Bond cured with HQTH.
CONCLUSIONS
Statistical analysis revealed significant interaction
among the curing unit type and orthodontic adhesives.
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UYSAL, BASCIFTCI, SENER, BOTSALI, DEMIR

There are increases in water sorption and microhardness when the specimens were irradiated using
the HQTH, but only statistically significant differences were found for Kurasper F.
Curing units with higher intensity improved the hardness values, but differences among top, middle, and
bottom in all cured groups irradiated by QTH and
HQTH were not statistically significant.
Multiple comparison results indicated that water
sorption and hardness characteristics of orthodontic
composites showed statistically significant differences when irradiated with the QTH and HQTH separately.
Recommendations as to which adhesive or light
source should be chosen for a specific circumstance
cannot be done from this study.
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8. Soh MS, Yap AU. Influence of curing modes on crosslink
density in polymer structures. J Dent. 2004;32:321326.
9. Eick JD, Robinson SJ, Byerley TJ, Chappelow CC. Adhesives and nonshrinking dental resins of the future. Quintessence Int. 1993;24:632640.
10. Stansbury JW. Synthesis and evaluation of new oxaspiro
monomers for double ring-opening polymerization. J Dent
Res. 1992;71:14081412.
11. Segura A, Donly KJ. In vitro posterior composite polymerization recovery following hygroscopic expansion. J Oral
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12. Sener Y, Uysal T, Basciftci FA, Demir A, Botsali MS. Conventional and high-intensity halogen light effects on polymerization shrinkage of orthodontic adhesives. Angle Orthod. 2006;76:677681.
13. Satou N, Matsumae I, Khan AM. Surface characteristics
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Angle Orthodontist, Vol 78, No 1, 2008

Original Article

Accelerated Aging Effects on Surface Hardness and Roughness of


Lingual Retainer Adhesives
Sabri Ilhan Ramoglua; Serdar Usumezb; Tamer Buyukyilmazc
ABSTRACT
Objective: To test the null hypothesis that accelerated aging has no effect on the surface microhardness and roughness of two light-cured lingual retainer adhesives.
Materials and Methods: Ten samples of light-cured materials, Transbond Lingual Retainer (3M
Unitek) and Light Cure Retainer (Reliance) were cured with a halogen light for 40 seconds. Vickers
hardness and surface roughness were measured before and after accelerated aging of 300 hours
in a weathering tester. Differences between mean values were analyzed for statistical significance
using a t-test. The level of statistical significance was set at P .05.
Results: The mean Vickers hardness of Transbond Lingual Retainer was 62.8 3.5 and 79.6
4.9 before and after aging, respectively. The mean Vickers hardness of Light Cure Retainer
was 40.3 2.6 and 58.3 4.3 before and after aging, respectively. Differences in both groups
were statistically significant (P .001). Following aging, mean surface roughness was changed
from 0.039 m to 0.121 m and from 0.021 m to 0.031 m for Transbond Lingual Retainer and
Light Cure Retainer, respectively. The roughening of Transbond Lingual Retainer with aging was
statistically significant (P .05), while the change in the surface roughness of Light Cure Retainer
was not (P .05).
Conclusions: Accelerated aging significantly increased the surface microhardness of both lightcured retainer adhesives tested. It also significantly increased the surface roughness of the Transbond Lingual Retainer.
KEY WORDS: Orthodontic adhesives; Orthodontic retainer; Aging; Surface hardness; Surface
roughness

INTRODUCTION

thodontic wire bonded to the teeth with an acid-etch


retained composite.3
Light-cured resin composites are the material of
choice for bonding lingual retainers today, as they offer
ease of application and extended time for wire placement. In contrast to bracket bonding, adhesives used
with lingual retainers remain exposed to the oral cavity, so they need to have certain physical properties
and need to be properly managed before the curing
process.4
Several companies have developed adhesives for
lingual retainer bonding and claim that these adhesives offer ease of application and optimal handling
characteristics to allow the clinician to shape and finish
the adhesive around the lingual retainer wire for maximum patient comfort. These highly filled, light-cured
resins are also said to be a better choice when longevity and durability are required. The use of an adequate thickness of composite with adequate abrasion
resistance placed over the wire has been suggested
to minimize long-term failure of bonded retainers. Rap-

Some form of retention therapy is required to save


the posttreatment tooth position following the active
phase of orthodontic treatment. The first appliances
were based on banded fixed appliances1 followed by
removable retainers.2 Today, many clinicians prefer
bonded fixed retainers that consist of a length of or-

Assistant Professor, Department of Orthodontics, Faculty of


Dentistry, Erciyes University, Kayseri, Turkey.
b
Associate Professor, Department of Orthodontics, Faculty of
Dentistry, Gaciantep University, Gaciantep, Turkey.
c
Associate Professor, Department of Orthodontics, Faculty of
Dentistry, Cukurova University, Adana, Turkey.
Corresponding author: Dr Serdar Usumez, Department of Orthodontics, Faculty of Dentistry, Marmara University, Guzelbahce Buyukciftlik Sok. No: 6, Nisantasi, Istanbul, Turkey 34346
(e-mail: susumez@hotmail.com)
a

Accepted: March 2007. Submitted: November 2006.


 2008 by The EH Angle Education and Research Foundation,
Inc.
Angle Orthodontist, Vol 78, No 1, 2008

140

DOI: 10.2319/112106-473.1

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AGING OF ORTHODONTIC LINGUAL RETAINER ADHESIVES


Table 1. Adhesives and Light Curing Unit Used
Brand
Adhesives
Transbond LR
Light Cure R
Light Curing Unit
Ortholux XT

Company

Lot

3M Unitek, Monrovia, Calif


Reliance, Itasca, Ill

CG/1AK
106060

3M Dental Products,
St Paul, Minn

120277

id wear of the composite in vivo quickly reduces the


overlying thickness of composite, leading to early failure of the retainer.5 Surface hardness is a determinant
of resistance to wear, and thus materials with higher
surface hardness values might be beneficial.
Surface roughness, on the other hand, is important
in terms of avoiding plaque accumulation and providing patient comfort. The effect of aging on restorative
dental composites has been extensively studied.
These studies usually demonstrated significant changes in the surface characteristics, physical properties,
and color of these resins with aging.616 However, in
vivo or in vitro information about the aged lingual retainer adhesives which are supposed to serve for a
long time period in the mouth does not exist.
Therefore, the purpose of this study was to investigate the effect of accelerated aging on the surface microhardness and roughness of two light-cured lingual
retainer adhesives. The null hypothesis assumed that
accelerated aging has no effect on the surface microhardness and roughness of two light-cured lingual retainer adhesives tested.
MATERIALS AND METHODS
Two different composites available for bonding lingual retainers and a visible light source were used in
this study (Table 1).
Sample Preparation
To evaluate surface roughness and hardness, discshaped samples 5 mm in diameter and 2 mm in height
were cured between microscope slides in Teflon
molds for each material tested. The samples were
light-cured with a conventional halogen light for 40
seconds. This exposure time was previously shown to
cure both adhesives adequately.4 Twenty samples
were prepared for each adhesive; 10 of these were
tested right after preparation, and the other 10 were
tested following aging.
Weathering Procedure
Specimens of each material were mounted on a panel
that attached to the frame of an accelerated weathering

tester (QUV, The Q-Panel Company, Cleveland, Ohio)


and stored there for 300 hours. In the weathering tester,
specimens were exposed to continuous ultraviolet (UV)
and visible light, a temperature of 43.3C, and a programmed cycle of 18 minutes of distilled water spray
within each 2-hour period.1724
Vickers Hardness Evaluation
Vickers hardness number (VHN) was measured 24
hours after polymerization for the nonaged specimens
and right after delivery for the aged specimens. The
MHT2 hardness tester (Matsuzawa Seiki, Tokyo, Japan) was used. A load of 300-gram force was applied
for 15 seconds and three indentations of the cure
sides of the samples were performed. The determined
values were averaged to represent the VHN of that
specimen.
Surface Roughness Measurement
Microscope slides were used to provide smooth surface preparation to facilitate the surface roughness
testing. The surface roughness was determined by the
surface analyzer (Surftest Analyzer, Mitutoyo, Tokyo,
Japan). The mean arithmetic roughness (Ra) was
used to assess surface changes. Five measurements
were performed for each specimen. The mean value
of five measurements on one specimen was used as
the Ra of that specimen.
Statistical Tests
The results of surface hardness testing were entered
into an Excel (Microsoft, Seattle, Wash) spreadsheet for
calculation of descriptive statistics. Paired t-tests were
used to analyze the data and compare groups.
Mean values and standard deviations for surface
roughness were calculated for groups. Differences between mean values were analyzed for statistical significance using a t-test. The level of statistical significance was set at P .05.
RESULTS
Vickers Hardness
Mean values of VHN of adhesives tested are presented in Figure 1. The mean VHN of Transbond Lingual
Retainer (TLR) was changed from 62.8 3.5 to 79.6
4.9, and the mean VHN of Light Cure Retainer (LCR)
was changed from 40.3 2.6 to 58.3 4.3 following
aging. Both of these differences were statistically significant (P .001). The amount of change in the VHN was
also significantly different between the groups (P
.001). The null hypothesis was thus rejected.
Angle Orthodontist, Vol 78, No 1, 2008

142

RAMOGLU, USUMEZ, BUYUKYILMAZ

Figure 1. Vickers surface hardness values of Transbond Lingual


Retainer (TLR) and Light Cure Retainer (LCR) before and after accelerated aging. The test results are given above the brackets that
combine the bars. VHN: Vickers hardness number. ***P .001.

Figure 2. Surface roughness values of Transbond Lingual Retainer


(TLR) and Light Cure Retainer (LCR) before and after accelerated
aging. The test results are given above the brackets that combine
the bars. NS: not significant. *P .05.

Surface Roughness

erence point to evaluate the surface roughness, and a


relatively smooth surface was achieved this way. The
effect of aging alone on surface roughness was also
possible to be distinguished because no thick oxygeninhibited layer was present.
While the oral environment is more complex, the
simulated aging treatment is useful for comparing different materials.12,18,21,23,28 In our study, instead of the
thermocycling process, an accelerated aging process
was performed with an aging device to subject samples to both visible and UV light and distilled water
spray to simulate aging. Water spray and visible UV
light have a direct effect on the properties of resins
and may change their physical properties. The manufacturer of the weathering instrument estimates that
300 hours of aging is equivalent to 1 year of clinical
service.11,18
The effect of aging on restorative dental composites
has been extensively studied. These studies usually
demonstrated an increase in hardness5 and surface
roughness,610 discoloration,6,1113 and decreased mechanical properties such as strength and modulus.1416
Initially, when a filled polymer like resin cement is exposed to aqueous aging, the uptake of water occurs
as a diffusion-controlled process.14 Water that is absorbed tends to act as a plasticizer and causes polymer swelling by stretching resin matrix entanglements.
Absorbed water may also break hydrogen bonds within the resin matrix and bound to polymer hydroxyl
groups.29 Such interactions with the resin matrix can
result in a decreased modulus which is a measure of
the stiffness of a given material.30 Water, which has

The mean surface roughness of TLR was changed


from 0.039 m to 0.121 m, and the mean surface
roughness of LCR was changed from 0.021 m to
0.031 m following aging (Figure 2). These results
represent a statistically significant roughening of TLR
with aging (P .05), while the change in the surface
roughness of LCR was not statistically significant. The
null hypothesis was thus rejected in part. The surface
roughness was also different between the groups at
both time points (P .05 at before aging and P .01
at after aging).
DISCUSSION
The accelerated aging process has been used to assess changes in physical characteristics of a range of
materials and to examine color change over
time.11,12,18,20,2426 In our study the effect of accelerated aging on the physical surface characteristics, ie, hardness
and roughness of light-cured lingual retainer adhesives
were examined. Although chemically cured materials are
occasionally used for lingual retainer bonding, the hardness values of the chemically cured composites are considerably less than those of the light-cured ones.4,6 This
is possibly due to factors such as a lower degree of
conversion than the light-cured materials, incorporation
of more air bubbles and nonhomogenous mix due to
hand mixing, and a thick layer of oxygen inhibition on
the surface.8,27 In this study formation of an oxygen inhibited layer was not allowed as the samples were cured
between microscope slides. This provided a better refAngle Orthodontist, Vol 78, No 1, 2008

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AGING OF ORTHODONTIC LINGUAL RETAINER ADHESIVES

entered the polymer through sorption, can also cause


hydrolytic degradation of the resin matrix, the filler/matrix interface, or the filler.15,31 The effects of hydrolysis
are loss of molecular weight and mass, filler debonding, and decreased mechanical properties, such as
strength and modulus.1416
A study by Xu32 suggested the use of strong and
stable fillers as a key microstructural parameter in the
development of strong dental composites that are resistant to long-term water attack. However, no reductions in the surface hardness were recorded in this
study, and these values were even increased significantly. This may be due to the fact that the duration
of water spray period in a 2-hour cycle was about 20
minutes, and the samples were allowed to dry back
during the nonwater-spray phase. This in turn may
imply that the surface hardness values could have
been higher, if the experiments had been conducted
in a totally dry condition.
The results of the present study confirmed the results of previous studies with significant increases in
surface hardness for both materials tested. On the other hand, the effect of aging on the surface hardness
of the two different materials was not identical, and the
LCR from Reliance demonstrated a higher degree of
hardness change. Moreover, only TLR demonstrated
a significant increase of surface roughness after accelerated aging. Increased surface roughness after
accelerated aging has been attributed to wear of the
resin6,7,9 or exposure of interior porosities.6,8,10 No mechanical wearing effect was present in the aging
chamber of the device used. Therefore, the increased
surface roughness of the TLR is most likely caused by
the chemical degradation of the samples or by microscopic crack formations on the surface which appeared during the dry phase of the aging cycle. It is
also likely that the varying results can be attributed to
differences in resin and filler composition, extent of
cure, and testing methods.
A previous study by Usumez et al33 demonstrated
that degree of conversion with Ortholux XT for 40 seconds was 40.3% and 62.7% for TLR and LCR, respectively. This means that the conversion degrees of
resins may have been already different when they
were placed into the weathering chamber, and this
may account for the different responses of two resins
to accelerated aging in part. Because of the relatively
high temperature in the aging chamber, a postcuring
polymerization effect can be expected, with more carbon double bonds converting to single bonds.34 Others
have also suggested that heat treatment improves mechanical properties, such as hardness, wear, and water solubility, because of increased conversion.3537
Again, hardening of the resins after aging can be explained in part with the further possible curing of the

resin samples in the weathering chamber with the effect of light sources. However, it was previously shown
that when these two resins were cured up to their possible maximum (66.9% for TLR and 75.3% for LCR),
their surface hardness values did not reach those recorded after accelerated aging. Therefore, the accelerated aging process must have affected the matrix
structure with mechanisms mentioned above other
than further monomer conversion.
From a clinical point of view, the use of an adequate
thickness of composite with adequate abrasion resistance placed over the wire is essential to minimize
long-term failure of bonded retainers. Rapid wear of
the composite in vivo quickly reduces the overlying
thickness of composite, leading to early failure of the
retainer.5 Surface hardness is a determinant of resistance to wear, and thus materials with higher surface
hardness values might be beneficial for the clinician
and the patient. The results of this study demonstrated
increased surface hardness values for both adhesives
tested after accelerated aging. This may suggest that
these materials might not be more susceptible to wear
under occlusal forces after certain amount of clinical
service, which is 1 year with the proposed test method
in the present study.
On the other hand, increased surface roughness may
indicate an inferior performance in terms of plaque accumulation following this time span. However, these assumptions should be used with caution for three reasons. First, polymeric adhesives used intraorally are
also subjected to microbial degradation38 and are exposed to saliva, acidic beverages, and alcohol-containing liquids, including mouth-rinsing solutions containing
up to 20% alcohol, besides the humidity and temperature changes employed in this study. These factors decrease the glass transition temperature of the material
and induce a plasticizing effect.39,40 Second, the retainer
adhesives are worn continuously and/or polished by
food particles, tongue movements, and tooth brushing
during their clinical service, which were ignored in this
study. Third, the aging test employed in this study is
estimated to be equivalent to 1 year of clinical service,11,18 which is much shorter than the 2 to 3 years
expected of a typical lingual retainer.
CONCLUSIONS
Accelerated aging increases the surface hardness of
light-cured lingual retainer adhesives significantly,
and this effect is not similar for different materials.
Surface roughness is also significantly increased for
the Transbond Lingual Retainer following accelerated aging.
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