October 2019 . Volume 12 .

Number 4

Tooth Autotransplantation Part 3:

Surgical Planning and Technique
Multiple Unerupted Teeth
– an Interesting Challenge
Primary Failure of Eruption
– a Review and Case Report
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October 2019 Orthodontic Update 123

INSIDE THIS ISSUE

125 COMMENT A Atwal and PE Benson

Objective: To understand the importance of research questions(s) and
have some knowledge about what should be included in a protocol for
126 ORTHODONTICS a clinical trial.
Tooth Autotransplantation Part 3: Surgical Planning and Technique Enhanced CPD DO C
H Nazzal, S Barber, Z Jawad, N Houghton and M Duggal
Objective: To describe the assessment of the donor tooth and recipient 150 BOOK REVIEW
site during planning and to highlight pre-surgical considerations, surgical
procedure and post-surgical management of transplanted teeth. 151 ORTHODONTICS
Enhanced CPD DO C Lingual Orthodontics with Customized Functional Appliance
S Premkumar and V Peter
134 ORTHODONTICS Objective: To utilize the advantage of combining lingual orthodontics
Multiple Unerupted Teeth – an Interesting Challenge with custom-made functional appliances and communicate this to the
N Adam, A Flett and C Sandler patients using proper diagnosis and treatment planning.
Objective: To describe the different situations in which a tooth or teeth Enhanced CPD DO C
might fail to erupt and discuss appropriate management plans.
Enhanced CPD DO C
157 ORTHODONTICS
Five Years and Counting…..Reflections on the First Years of Owning a
140 ORTHODONTICS Specialist Practice
Primary Failure of Eruption – a Review and Case Report A Patel
B Harlow, K Parker and S Hodges Objective: To advise on setting up a specialist orthodontic practice.
Objective: To outline the diagnosis and management options of primary Enhanced CPD DO C
failure of eruption.
Enhanced CPD DO C
161 Tricks of the Trade
144 BOOK REVIEW A New Method of Active Tie-Back for Space Closure
R Bangera, RD Naik, AK Patil, ShashiKumar B and PraveenKumar
145 ORTHODONTICS
How to Design and Set Up a Clinical Trial Part 2: Protocols and Approvals 162 CPD QUESTIONS

EDITORIAL DIRECTOR
Professor Jonathan Sandler Nerina Hendrickse Alison Murray
Consultant Orthodontist GDP Consultant Orthodontist
Chesterfield and Winchester Royal Derby Hospital
North Derbyshire Royal Hospital Hants Derby DE22 3NE
Calow, Chesterfield
Derbyshire S44 5BL Professor Anthony J Ireland Andrew Shelton
Consultant Orthodontist Consultant Orthodontist
EXECUTIVE EDITOR Division of Child Dental Health Orthodontic Department
Angela Stroud Bristol Dental Hospital and School Montagu Hospital
Lower Maudlin Street Mexborough S64 OAZ
EDITORIAL BOARD Bristol BS1 2LY
Professor F J Trevor Burke
Birmingham Dental Hospital and Lynda Kirk
School of Dentistry Orthodontic Therapist
5 Mill Pool Way Royal Derby Hospital
Edgbaston Uttoxeter New Road
Birmingham B5 7EG Derby DE22 3NE

CPD in Orthodontic Update in partnership with Cover Picture: ‘Brace your Brackets’: Orthodontic
brackets for a fixed appliance. (Courtesy of Dr Avita
Rath, Lecturer, and Dr Arun Paul, Senior Lecturer,
Faculty of Dentistry, SEGi University, Malaysia).

OU ISSN 1756-6401
October 2019
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Orthodontic Update 125
Comment
Never a dull moment
Jonathan Sandler
The thing I have most loved about orthodontics is that there are always new
clinical challenges and innovative techniques to push forward the frontiers of
the specialty. There is always something to pique the interest of enthusiastic
orthodontists who still get excited about the mechanics and details of tooth
moving.
TADs have been a ‘game changer’ throughout my career. Whilst
previously I firmly believed that it was essential for every orthodontic postgraduate
to be completely fluent in fitting and the use of of headgear, in all its shapes and
sizes, I am not now convinced that this is still essential. Certainly, the average
British patient is generally relatively unimpressed with the whole headgear
proposition, unlike many of their European and North American counterparts . . . or
so we are led to believe!
Of course, there is always the occasional patient, usually home-schooled,
or the offspring of a teacher, for whom the possibility of extraction of healthy
teeth is completely unimaginable. We have all heard that ‘Cynthia or Cedric
couldn’t possibly have healthy teeth removed unnecessarily!’ For these challenging
cases, if treatment is thought necessary, headgear might be the only possibility
for meeting the patients’ (and parents) wishes, but also providing the requisite
space to distalize the buccal segments sufficiently, to allow for full correction of
the malocclusion to Class I. For all the rest, judicious use of TADs, with or without
extractions, makes the need for teaching, and learning, the ‘art of headgear’
virtually redundant. With minimum effort, particularly from the patient, TADs can
offer a solution to a myriad of problems.
Another potential ‘game changer’ for me over the last four or five
years is the Mesialiser, which has drastically changed our approach to patients
with congenital absence of teeth. First suggested by Bjorn Ludwig, that master
clinician and expert of all techniques associated with TADs, this device provides
an opportunity to close space from behind without the unwelcome loss of
anterior anchorage and retraction of the front teeth. Together with the rest of my
Hypodontia team, we now aim to close anterior spaces wherever possible, thus
removing the need for planning adhesive bridges or osseointegrated implants
in many cases, and saving the patient from a lifetime of complex and expensive
restorative dentistry.
What greater gift . . . ?
All articles published in Orthodontic Update are subject to review by specialist referees in the appropriate dental disciplines.
126 Orthodontics October 2019

Enhanced CPD DO C

Hani Nazzal Sophy Barber, Zynab Jawad, Nadine Houghton and Monty Duggal

Tooth Autotransplantation
Part 3: Surgical Planning
and Technique
Abstract: The practical aspects of pre-operative assessment and surgical procedure for autotransplantation are discussed in this part of
the series. The success of tooth transplantation is dependent on case selection, careful planning and a surgical procedure that maintains
viable periodontal ligament cells and intact cementum of the transplanted teeth. A thorough assessment of the donor tooth and recipient
site is vital for successful planning and execution of tooth autotransplantation. The surgical procedure involves atraumatic extraction of
the donor tooth, socket preparation and splinting of the transplanted tooth. Post-surgical procedures include monitoring of pulp and
periodontal healing and restorative camouflage of the donor tooth.
CPD/Clinical Relevance: Surgical planning and procedures are vital to the success of autotransplantation. Orthodontists should be aware of
these factors and bear them in mind when preparing patients for autotransplantation to optimize surgical success.
Ortho Update 2019; 12: 126–133

Surgical planning and technique
are vital aspects to the success of
autotransplantation. A number of key
factors relating to the donor tooth
and recipient site are considered
during assessment and planning for
autotransplantation.
Donor tooth assessment
Crown assessment
Donor tooth assessment is usually
considered in terms of assessment of the
crown and roots. A donor tooth crown
should be assessed for dental caries, crown
anomalies and crown dimension. One of
the main considerations, when assessing
the recipient site, is whether adequate
space exists for the donor tooth. It is
therefore essential that the donor tooth
size is measured accurately at maximum
bulbosity including the maximum bulbosity
and cervical dimension of the crown.
The mesio-distal widths of upper and
lower premolars are usually only 1.5 mm
smaller than that of upper central incisors
(7 mm compared to 8.5 mm at maximum
bulbosity), although the cervical areas are
usually considerably smaller. To manage
this discrepancy it has been suggested
that rotating the donor premolar tooth
approximately 90 degrees improves the
emergence profile when transplanted into
the upper central incisor region (Figure 1).
Root assessment
Donor tooth roots are assessed with
regards to number of roots, stage of
formation, morphology and dimensions in
order to inform recipient site preparation.
Single-rooted donor teeth with a single
root canal system, such as mandibular
second premolars, canines and incisors, are
commonly the preferred choice due to
their single root morphology and high
frequency of single canal (85%) and
single foramen (97.5%). The mandibular
first premolars similarly have a single root
morphology but the frequency of a single
canal is lower (73%) and the likelihood
of a single canal dividing into two apical
foramens is higher (25%) than the
mandibular second premolar. Maxillary
second premolars are less commonly
used as only 40% of cases demonstrate a
single root with single root morphology
canal system.1
Immature teeth are associated
with better long-term success than
mature teeth and present fewer
restrictions in terms of bone height and
tooth positioning. The ideal time for
transplantation is when root formation
is approximately 75% with an apical

Hani Nazzal, BDS, MFDS RCS Ire, PhD, FDS RCS Canada, Lecturer and Locum Consultant in Paediatric Dentistry, University of Leeds (email:
denha@leeds.ac.uk), Sophy Barber, BDS, MJDF(RCS Eng), MSc, MOrth(RCS Ed), Post-CCST Registrar in Orthodontics, Leeds Dental Institute,
Zynab Jawad, BChD, MFDS RCSEng, MSc Orthodontics, MOrth RCSEd, Post-CCST Orthodontics, Leeds Dental Institute, Nadine Houghton,
BDS, MFDS, MDSci, MOrth(RCS Eng), FDS Orth(RCS Eng), Consultant Orthodontist, Bradford Teaching Hospitals Foundation Trust and Monty
Duggal, BDS, MDSc, FDS Paed Dent(RCS Eng), PhD, Professor in Paediatric Dentistry, National University Health System, Singapore.
 October 2019
opening of at least 1 mm to encourage and subsequent extraction was reported
revascularization of the root canal bundle.2 to be 70% less than those teeth with
In these teeth, the risk of transplant failure closed apices.3
For teeth with complete root
formation, careful selection is required
a as the root length can introduce height
restrictions for positioning the donor
tooth within the recipient bone. The
average root length of premolars and
canines is 13–16 mm. Such average root
lengths provide an indication of the bone
height required at the recipient site.
Radiographic assessment
Two-dimensional radiographs,
b such as long-cone periapicals and
orthopantograms (OPTs), are usually
sufficient for assessing donor tooth
morphology and stage of root
development (Figure 2). The use of cone-
beam computed tomography (CBCT)
is gaining popularity for pre-surgical
assessment and can aid planning for
potential donor teeth with unclear root
morphology.
Figure 1. Placement of a premolar transplant
into the socket of a maxillary central incisor Recipient site assessment
postion demonstrating: (a) the difference in the Clinical assessment
mesio-distal crown widths at maximum bulbosity The recipient site should be carefully
and the emergence profile at the cervical level examined to assess bone volume, soft
between the premolar donor tooth and the
tissue morphology and the proximity
contralateral central incisor; (b) the effect of
of adjacent structures. Bone volume is
rotating the donor premolar tooth to improve
assessed clinically by palpation of the
the mesio-distal crown width and emergence
profile.
a b
Figure 2. Radiographic examination showing: (a) potential donor tooth for transplantation to replace a maxillary central incisor. The second premolar was
partially erupted with a single root and canal with incomplete root formation; (b) the transplanted premolar in the maxillary right central incisor position
immediately post-operatively; (c) continued root development 6 months post-operatively.
Orthodontics 127
alveolar ridge in order to identify bony
deficits and soft tissue morphology,
supplemented with appropriate
radiographs (Figure 3). In a growing child,
the alveolar bone is vulnerable to atrophy
following tooth loss. To avoid alveolar
bone loss in the recipient site, attempts
should be made to maintain teeth in
the recipient site, even if the prognosis
of the tooth is poor. Teeth remaining in
the recipient site should be monitored
regularly for infraocclusion, which may
cause a localized obstruction to vertical
bone growth in the region leading to
severe bony defects.
Coronal space is required
between the teeth adjacent to the
recipient site to enable placement of the
donor tooth. Space requirements can be
estimated by measuring the crown of
the donor tooth. The space available in
the recipient site should be measured at
the gingival and incisal level. If the donor
tooth is to be restored prior to definitive
orthodontic treatment, sufficient space
is also required for the restorative
camouflage. In cases with single tooth
transplantation, this can be estimated
by measuring the contralateral tooth. In
cases where a contralateral tooth is not
available, the ideal coronal dimensions
can be estimated from adjacent teeth
using average relative proportions.4
c
 128 Orthodontics October 2019

The occlusion should be
checked in static and dynamic function
prior to or during surgery. This ensures
that there is sufficient occlusal clearance
to allow the transplant to be placed
with minimal occlusal interferences. The
Figure 3. Upper standard occlusal radiograph
used to assess bone levels in the maxillary left
central incisor recipient site.
transplant can be protected by the use of a
removable appliance with posterior buccal
capping if it is not possible to remove
occlusal interferences prior to or during
surgery.
Radiographic assessment
Radiographic assessment is crucial for
assessing bone volume, the health of the
teeth at the recipient site and proximity of
adjacent structures. This assessment usually
involves conventional radiographs (Figures
2 and 3) supplemented with 3-dimensional
imaging, where further details are required.
Radicular infection, infection-related
resorption and any other pathology at
the recipient site must be diagnosed
and appropriately managed in order to
optimize bone quality. The proximity of
adjacent structures, such as adjacent tooth
roots, the maxillary sinus and mental nerve,
will impact on treatment planning.
Preparation for surgery
Preparation for surgery may be considered
in terms of management of bone in
the recipient site, space maintenance
or creation and management of any
pathology associated with failing teeth
in the recipient site. Management of
young patients prior to their entry into
the autotransplantation care pathway
should aim to maintain bone height
and width. This may be difficult in cases
where tooth loss was unavoidable, such
as avulsed teeth that were not suitable
for replantation, forced tooth extraction
following complex injuries or persistent
periapical pathology. Methods for
managing the bone are described further
in the fourth article in this series.
Teeth provide an ideal
natural space maintainer and even teeth
with poor long-term prognosis may be
retained prior to autotransplantation
to maintain space. In sites where the
tooth has been lost, space should
be maintained using a fixed or
removable space maintainer, such as a
temporary resin-bonded bridge or an
upper removable appliance. In cases

a d g

b e h

c f i

Figure 4. Surgical steps involved in transplantation of the mandibular second premolar (LL5) into the maxillary right central incisor (UR1) position: (a) infra-
occluded UR1 judged to have poor prognosis due to replacement resorption following avulsion and replantation; (b) extraction of the UR1 at the time of
the transplantation; (c) atraumatic extraction of the LL5; (d) the use of a surgical template to assess the depth and width of the donor site socket; (e, f)
the use of a surgical bur (e) and osteotomes (f) to modify socket depth and width; (g, h) transplantation of the donor tooth into the prepared socket and
confirmation that there are no occlusal interferences on the transplanted tooth; (i) the transplant is splinted using a titanium trauma splint.
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October 2019
where space has been lost, pre-surgical
orthodontics will be required to recreate
the space, as described in the previous
article.
Pathology in the recipient
site should be managed in order to
ensure optimal bone health at the time
of transplantation. Pre-existing infection
can be managed through disinfection of
the root canal system, use of antibiotics,
extraction of the tooth or surgical removal
of the existing pathology.
Surgical technique
The choice for undertaking the surgical
procedures using local analgesia, sedation
or general anaesthesia will depend on the
patient’s age, co-operation, preference,
medical history and the expected
complexity of the surgery. Careful
discussion with patients and those with
parental responsibilities outlining the
components of the surgical procedure and
the advantages and disadvantages of each
treatment modality is required for informed
consent.
The surgical technique can be
divided into five stages:
1. Extraction and assessment of the donor
tooth;
2. Socket preparation;
3. Socket assessment;
4. Placement of the transplant;
5. Transplant splinting.
1. Extraction of the donor tooth
Extraction of the donor teeth using only
coronal force application is performed
to ensure minimal trauma to the root,
and prevent damage to the periodontal
ligament and cementum. Traumatic
extraction with significant damage to
the periodontal ligament is less likely to
recover and will result in the transplanted
tooth becoming ankylosed. In cases where
there is more than one tooth available for
transplantation, donor tooth selection is
made based on root morphology, stage
of development and anticipated ease of
extraction. Direct visual assessment can be
used to determine the root shape following
extraction. The preferred donor tooth is
then repositioned back into its original
socket to prevent damage to periodontal
ligament cells while the socket is prepared
in the recipient site.
2. Socket preparation
The steps required for socket preparation
depend on the presence or absence of a
tooth in the recipient site. Preparation of
existing sockets is easier than creation of
new ones in an edentulous alveolar ridge.
Orthodontics 131
Socket preparation for a recipient site with a
a poor prognosis tooth is shown in Figure 4.
3. Socket assessment
The socket is assessed during preparation
to ensure that it is able to accommodate
the donor tooth. Traditionally, this was
achieved by transplantation of the donor
tooth into the prepared socket. Several
attempts are usually made before a suitable
socket is created, which risks further
damage to the periodontal ligament cells
and increases the risk of future ankyloses.5
Consequently, different techniques
have been proposed to aid assessment
of socket height and width (Figure 5).
These include pre-surgical radiographic
measurements,2 acrylic stents constructed
using radiographic measurements,6 surgical
b
metal stents constructed using average
7
measurements of premolar teeth and
construction of 3D tooth replicas using
Cone-Beam Computerized Tomography
(CBCT).8 Pre-fabricated surgical templates
assist the surgical component of premolar
transplantation by establishing and
replicating the root dimensions of the
donor premolar tooth. The correct template
is used to assess the width and depth of the
socket preparation prior to placement of c
the transplant in the recipient site.
4. Placement of the transplant
The transplanted tooth should ideally be
seated a few millimetres from the occlusal
plane to prevent occlusal trauma and
damage to the periodontal ligaments. This
has the additional advantage of allowing
the tooth to erupt into a functional position
Figure 5. Different methods of replicating the
with corresponding bone deposition. transplant tooth to aid surgical preparation of
Transplants with complete root formation the socket for the transplant: (a) 3D printed
require root canal treatment, therefore stents developed from a cone beam scan of the
coronal reduction could be performed at donor tooth; (b, c) two different designs of pre-
time of transplantation, if required. On the fabricated surgical templates. The correct size
contrary, particular care should be taken can be selected based on the proportions of the
with immature teeth, as revascularization donor tooth.
is desirable and may be compromised by
enamel reduction. If ideal positioning is not
possible, occlusal reduction of immature
teeth could be undertaken gradually adjacent teeth are available for bonding
to optimize pulp recovery. Positioning a splint, but care must be taken to ensure
immature teeth in relation to the occlusal that the sutures provide adequate
plane is less critical as these teeth have stabilization of the transplanted tooth.
the potential to erupt, encouraging bone The splint should be passive to prevent
growth and improved gingival contour. damage to periodontal cells and attached
to the teeth with composite.
5. Transplant splinting
The transplanted tooth is splinted using Antibiotic prophylaxis
a physiologic splint such as a titanium There is little evidence for use of
trauma splint (TTS) with the transplanted systemic antibiotic administration
tooth splinted to at least one tooth on after transplantation. Although a
either side (Figure 4g). Sutures are reported positive effect has been demonstrated
for splinting teeth, particularly where no in several studies for prophylactic
 132 Orthodontics
a resorption of tooth autotransplantation
b Short-term post-surgical
Figure 6. (a, b) Interim restoration placed on
the transplanted premolar in the maxillary
right central incisor position for the duration of
orthodontic treatment.
a
b treatment, a definitive restoration can be
Figure 7. (a, b) A transplanted premolar
replacing the maxillary right central incisor
(shown in Figure 6) following definitive
restoration. This involved single tooth bleaching
of the premolar transplant followed by
placement of a porcelain veneer.
systemic antibiotics with avulsed
and re-implanted teeth, there is
limited evidence to support their
use in autotransplantation where
the conditions are controlled.9,10 A
recent systematic review and meta-
analysis has shown that the failure rate
and occurrence of infection-related
were 2.5 times and 1.4 times higher in
studies where no systemic antibiotics
have been used, respectively. Therefore,
the use of systemic antibiotics, albeit
controversial, seems to be beneficial in
tooth autotransplantation.
care
Post-operative instructions
Post-surgical instructions for
autotransplant patients are given as
follows:
„ Appropriate analgesia to manage any
post-operative pain;
„ Meticulous oral hygiene to encourage
healing and prevent infections;
„ Use of a Chlorhexidine Digluconate
mouthwash (0.2%) or gel (1%) to
support oral hygiene, particularly during
the first few days post-operatively while
brushing may be difficult;
„ A soft diet is recommended for two
weeks following the procedure to
prevent detachment of the splint and
movement of the transplant;
„ Contact sports are prohibited during
the recovery period.
Pulp and PDL management
Patients are reviewed, following the
autotransplantation, after 7–10 days
to assess recovery and healing. Clinical
examination focuses on:
„ Oral hygiene assessment and
reinforcement;
„ Periodontal healing of transplanted
tooth;
„ Pulp extirpation for teeth
transplanted with complete root
formation;
„ Splint removal with assessment
of transplant mobility and gingival
healing;
„ Mobile transplants or those with
inflamed gingival tissues should be
splinted for a further week;
„ Interim restorative camouflage of the
transplant (Figure 6).
Interim restorative camouflage
At the review appointment, an interim
temporary restoration can be provided
to improve the appearance of the
transplant if required. This has the
advantage of improving aesthetics and
normalizing the coronal morphology
for positioning adjacent teeth; however,
it may also obscure the transplant
morphology during orthodontic
tooth positioning and increase plaque
stagnation. Firm transplants with
October 2019
healthy gingiva can be camouflaged using
direct composite veneers.
Medium term care
Monitoring healing
Transplanted teeth are then followed up
clinically and radiographically following the
same guidelines for avulsed and replanted
teeth. The initial follow-up appointment
is after 7–10 days where splint removal
and the interim composite camouflage
restoration is placed. For transplants with
closed apices, where revascularization is
not expected, pulp extirpation is performed
at this appointment. This is followed by an
appointment 4 weeks post-transplantation
for completion of endodontic treatment
with definitive obturation. The
transplant is then reviewed clinically and
radiographically at 3 months, 6 months and
12 months.
Transplants are assessed in
relation to:
„ Oral hygiene and gingival health;
„ Clinical signs and symptoms of periapical
pathology (pain, tenderness to percussion,
mobility and sensibility testing in immature
teeth);
„ Clinical signs of ankylosis (infraocclusion,
altered percussion sound);
„ Radiographic signs of replacement
resorption, pathology and root resorption.
Definitive restoration
Following completion of orthodontic
provided if required. Composite veneers
are preferable to porcelain veneers
as modification to address continued
growth and gingival maturation is easier.
Adjunctive treatments, such as gingival
re-contouring and tooth bleaching, can
be used to improve the aesthetic outcome
(Figure 7).
Conclusions
Successful autotransplantation relies on
careful pre-surgical assessment of the
donor tooth and recipient site. The recipient
site is prepared to optimize the bone
quality and health. Surgery aims to remove
the donor tooth atraumatically, preserving
the periodontal ligament. The transplant
is placed into the prepared recipient site
and splinted during the healing period. A
standardized review protocol is followed to
ensure that transplant healing is monitored
and timely follow-up orthodontic and
restorative care is provided.
Compliance with Ethical Standards
Conflict of Interest: The authors declare that
October 2019 Orthodontics 133

they have no conflict of interest. of teeth: requirements for Diangellis AJ et al. International
Informed Consent: Informed consent predictable success. Dent Association of Dental Traumatology
was obtained from all individual Traumatol 2002; 18: 157–180. guidelines for the management of
participants included in the article. 6. Clokie CM, Yau DM, Chano traumatic dental injuries: 2. Avulsion
LM. Autogenous tooth of permanent teeth. Dent Traumatol
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7. Day PF, Lewis BR, Spencer RJ,
system. Br Dent J 2004; 197;
Barber SK, Duggal MS. The
CPD Answers for
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2. Andreasen JO, Paulsen HU, Yu Z,
design and development of
surgical templates for premolar
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Bayer T, Schwartz O. A long-term
transplants in adolescents. Int
study of 370 autotransplanted Endod J 2012; 45: 1042–1052.
premolars. Part II. Tooth survival 8. Shahbazian M, Jacobs R, Wyatt 1. C
and pulp healing subsequent to J, Willems G, Pattijn V, Dhoore E,
transplantation. Eur J Orthod 1990; Vinckier F. Accuracy and surgical 2. B
12; 14–24. feasibility of a CBCT-based
3. Almpani K, Papageorgiou stereolithographic surgical guide 3. B
SN, Papadopoulos MA.
Autotransplantation of teeth in
aiding autotransplantation of
teeth: in vitro validation. J Oral
4. C
humans: a systematic review and
meta-analysis. Clin Oral Investig
Rehabil 2010; 37: 854–859. 5. B
9. Day PF, Gregg TA. Treatment
2015; 19: 1157–1179. of Avulsed Permanent Teeth in 6. B
4. Snow SR. Esthetic smile analysis of Children. UK BSPD National
maxillary anterior tooth width: the Clinical Guidelines in Paediatric 7. B
golden percentage. J Esthet Dent Dentistry, 2012.
1999; 11: 177–184. 10. Andersson L, Andreasen JO,
5. Tsukiboshi M. Autotransplantation Day P, Heithersay G, Trope M,

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134 Orthodontics October 2019

Enhanced CPD DO C

Naeem Adam Andrew Flett and Cara Sandler

Multiple Unerupted Teeth

– an Interesting Challenge
Abstract: This paper describes primary failure of eruption and presents some of the theories about the aetiology of this clinical condition.
It also covers single ankylosed teeth as well as cases that present with multiple unerupted teeth. The various approaches to the clinical
management of this not uncommon problem are discussed, along with the pros and cons of some of these techniques.
One difficult clinical challenge is documented, where a 14-year-old patient presented with 19 unerupted permanent teeth and, with the
help of rare-earth magnets and upper and lower fixed appliances, within a two-year period a good result was achieved.
CPD/Clinical Relevance: Clinicians encounter teeth that have failed to erupt on a regular basis. Appropriate diagnosis and treatment
planning of these cases, and subsequent effective clinical management, is imperative to ensure the most favourable outcome for our
patients.
Ortho Update 2019; 12: 134–139

Permanent teeth may fail to erupt because
of obstruction, or disruption, of the
eruptive mechanism. Eruption may be
obstructed by the presence of pathology,
ectopic tooth position, interferences from
adjacent teeth or lateral forces from the
tongue.1 Teeth may also fail to erupt due
to primary failure of eruption (PFE) or
ankylosis. The latter is defined as the fusion
of cementum to bone in at least one area
lacking a periodontal ligament space.2
Primary failure of eruption (PFE)
is defined as incomplete tooth eruption
despite the presence of a clear eruptive
pathway.1 There is no ankylosis and it is the
eruptive mechanism itself that is disturbed.2
This article will review the literature on PFE
and failure of eruption from ankylosis. We
also present a case of multiple unerupted
teeth, treated with the use of neodymium
iron boron magnets, as well as the more
conventional deployment of gold chains to
facilitate orthodontic traction.
Establishing the correct
diagnosis forms the basis of satisfactory
management of unerupted teeth. It is
vital to distinguish obstructive failure
of eruption, PFE and isolated ankylosis.
Not doing so may jeopardize successful
orthodontic management and potentially
cause harm to the patient. This is
particularly pertinent in cases of PFE, where
the injudicious application of traction
may precipitate ankylosis of the offending
tooth and consequent intrusion of adjacent
normal teeth.3
Primary failure of eruption
The term PFE was coined by Proffit and
Vig in their seminal research on the topic.4
It is a rare condition with a prevalence of
0.06%.5 Subsequent research has refuted
some of their initial observations, but the
literature demonstrates consensus on the
following features:1,2,6
„ Posterior teeth are more frequently
affected than anteriors;
„ Teeth posterior to the most anteriorly
affected tooth may be involved;
„ Affected teeth may completely fail to
erupt, or may initially erupt through the
oral mucosa, before ceasing to erupt
further;
„ The occlusion manifests as a lateral open
bite;
„ Involvement can be unilateral or bilateral;
„ Application of orthodontic forces to
the affected teeth sometimes precipitates
ankylosis rather than normal tooth
movement;
„ PFE is associated with a mutation in the
parathyroid hormone 1 receptor (PTH1R)
gene.
Raghoebar et al subdivided
PFE into primary and secondary retention;
primary if the tooth failed to erupt, and
secondary if there was cessation after initial
penetration through the oral mucosa.7
Frazier-Bowers et al described three
different forms of PFE:8
„ Type I, where all affected teeth have
a similar lack of eruptive potential and
a posterior open bite establishes with
worsening severity from anterior to
posterior;
„ Type II, where a more varied eruption
potential is seen between the affected
teeth. In such cases, a tooth distal to the

Naeem Adam, BDS(Hons) MaxFac DCT2, Leeds Dental Hospital (email: naeem.i.adam@gmail.com), Andrew Flett, BDS, MJDF RCS,
MClinDent, MOrth RCS, Consultant Orthodontist, Nottingham University Hospital and Cara Sandler, BDS MaxFac DCT1, Royal Sussex
County Hospital, Brighton, UK.
October 2019
most mesial affected tooth may show
greater, but still inadequate, eruptive
potential;
„ In Type III, subjects have both Type I and
Type II tendencies co-existing in different
quadrants.
Several systemic or syndromic
conditions, such as cherubism and
cleidocranial dysplasia, have failure of tooth
eruption as an identifying feature, and must
be excluded when establishing a diagnosis
of PFE.1 A family history of PFE appears
to be a risk factor for its development,
and inheritance appears to be autosomal
dominant with variable expressivity.9
Earlier research found the level of dental
anomalies, such as hypodontia, to be
considerably higher than average in
individuals with PFE, but more recent
research refutes this.1,6
PFE appears to be associated
with a mutation in the PTH1R gene and,
consequently, genetic testing may assist in
early and accurate diagnosis.10
Even in the absence of a known
genetic, pathological or environmental
factor responsible for failure of tooth
eruption, a true definitive diagnosis of PFE
may only ever be given retrospectively,
after attempts at orthodontic extrusion of
the affected teeth have failed. Management
of PFE is made difficult by the tendency
for affected teeth to ankylose when
orthodontic forces are applied.1 The
literature describes various techniques from
coronal build-ups of the affected teeth
to segmental osteotomy, but treatment
in severe cases is invariably complex and
often multidisciplinary.3 The case presented
here responded well to orthodontic
traction, excluding a diagnosis of PFE.
Figure 1. OPT showing multiple unerupted teeth.
Ankylosis and failure of
eruption
Isolated ankylosis is a rare condition
with a similar presentation to PFE.
A diagnostic feature distinguishing
between the two is that ankylosis
typically affects a single tooth, with
distal teeth being unaffected.1 This
naturally makes diagnosis difficult in
a child in the mixed dentition, as one
cannot be certain of the status of the
unerupted teeth. Partially erupted teeth
that are ankylosed will exhibit a dull
metallic sound when percussed. These
teeth cease to erupt, drift or move,
despite normal adolescent growth or
orthodontic traction. They may further
disturb the occlusion by allowing
adjacent teeth to tilt and opposing
teeth to overerupt. Radiographically,
ankylosis gives the appearance
of relative submergence, and the
periodontal ligament space may be
focally absent.3,11,12
The orthodontic
management of ankylosis differs
significantly from that of primary failure
of eruption. Isolated ankylosis responds
well to treatment and may be managed
by extracting the affected tooth
at the appropriate age, or through
luxation and subsequent orthodontic
alignment.3,12
Multiple unerupted teeth
Delayed tooth eruption (DTE) is defined
as the emergence of a tooth into the
oral cavity at a time that deviates
significantly from the norms established
for different races, ethnicities and
gender.11 The mechanisms and
Orthodontics 135
biological underpinnings of tooth
eruption are presently poorly
understood, however, several
rare diseases and syndromes are
associated with delayed tooth
eruption.13
Occasionally, failure of
eruption of multiple teeth cannot
be attributed to a local or systemic
condition. This is a rare occurrence
and the literature contains relatively
few examples of such cases. Their
orthodontic management is varied,
and differing approaches, applied
with varying levels of success, have
been reported.14,15,16
Orthodontic application of
magnets
Many options are available for the
management of unerupted teeth
and these vary in their invasiveness
and ease of application. The least
invasive is the creation of space to
facilitate spontaneous eruption, and
the next line is surgical exposure of
the unerupted tooth with attachment
of a gold chain to allow application
of orthodontic traction. This latter
approach is probably the most
common approach to impacted
teeth, but it does require a surgical
procedure, usually under general
anaesthetic, and the operator must
provide treatment that is relatively
technique sensitive.
Blechman and Smiley
first described the use of magnets to
achieve orthodontic tooth movement,
and since then magnets have been
used successfully in a wide variety
of orthodontic applications.17,18 An
application for impacted teeth was
first described by Sandler et al and
involved the attachment of paralene
coated, rare earth magnets to the
unerupted tooth using composite
resin, followed by provision of a
removable appliance containing a
larger magnet.19 The magnets must
be correctly placed with opposing
poles approximated, and properly
aligned to ensure optimal direction of
pull. Once they are in place, the only
adjustment required is the occasional
repositioning of the magnet
contained within the removable
appliance, until the two magnets are
almost in apposition.
This method requires
little manual dexterity of either the
operator or the patient. The speed
 136 Orthodontics
a a
b c
d After seeing a Consultant in
Figure 2. (a, b) Dysmorphic features of
hypertelorism and a small, retropositioned
mandible.
e
of tooth movement appears to be as
quick as other methods, and the slowly
increasing, continuous force may be
more physiological. Palatally directed
forces are more readily applied, helping
to ensure that teeth do not erupt
through the labial plate, and that
they end up with an adequate cuff of
attached gingiva on eruption.
Case report
A 14-year-old female patient presented
with delayed eruption of multiple
teeth. Medically she was fit and well
and presented with a caries-free mixed
dentition and excellent oral hygiene.
Her initial complaint was that she was
extremely anxious about the delayed
eruption of her teeth, and had difficulty
chewing on the left-hand side. There
was no relevant family history and
a genetic aetiology had not been
identified.
Figure 3. (a–e) Intra-oral views from initial
presentation.
Diagnosis
A panoramic radiograph (Figure 1)
revealed the presence of 19 unerupted
permanent teeth. The consultant in
dental radiology reporting the OPT
said that he could understand why
some teeth had not erupted. He
noted that the ‘bone on the left side
of the mandible looked a bit dense’,
however, did not suspect osteopetrosis.
The patient also saw a consultant of
paediatric bone care who noted that
there were no concerns regarding her
skeleton.
October 2019
Figure 4. Rare earth magnets embedded in an
upper removable appliance.
Dysmorphic features (Figure
2a, b), such as low set ears, had raised
concerns in the past and she was under
review by a geneticist. However, no
specific diagnosis was made. It had
been noted that she had hypertelorism,
a small mandible, slightly high palate
and hypermobile wrists. There was no
evidence of cranial nerve compression
and fundoscopy was unremarkable.
Clinical Genetics, the patient enrolled
into a research study called Deciphering
Developmental Disorders (DDD). The
initial report from that study said ‘No
plausible pathogenic variants currently
identified’.
The orthodontic diagnosis
was made of Class II incisor relationship
on a mild Class II skeletal base with
slight maxillary hypoplasia, and
mandibular retrognathia, increased
MMPA and lower facial height. She
was still in the mixed dentition, with
retained upper Cs and Ds and multiple
unerupted teeth suffering from primary
failure in eruption (Figures 3a–e).
Treatment plan
The patient was referred to Chesterfield
Royal Hospital for orthodontic
treatment and a plan was devised to
encourage her unerupted teeth into
occlusion. This included extraction of
remaining deciduous teeth, placement
of an upper removable appliance
containing rare earth magnets, and
bonding of opposite pole magnets
to the upper unerupted teeth to
encourage eruption.
Treatment
Orthodontic treatment was carried out
over a 20-month period. Under general
anaesthetic the remaining deciduous
teeth, upper Ds and Cs, were removed
and Neodymium Iron Boron magnets (3
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 138 Orthodontics
a b
c
Figure 5. (a, b) Unerupted teeth in a more favourable position for bonding. (c) OPT showing progress
9/12 into treatment.
a for all practitioners to be familiar
x 3 x 1 mm) were bonded to UL542 and
UR2456. Gold chains were bonded to
the upper left canine, to the lower first
premolars and to the lower left molar,
to aid their eruption by eventually
applying direct traction to the fixed
appliances. An upper removable
b appliance was fabricated containing the
larger magnets (5 x 5 x 2 mm) (Figure
4). Magnetic forces were applied for
7 months until the unerupted teeth
were in a position where attachments
could be placed to allow the direct
orthodontic traction (Figure 5a–c).
The case was re-assessed
c Compliance with Ethical Standards
at this stage with the aid of a CT scan
which showed clear root damage to the
UR2 from the unerupted UR3. It was
therefore decided that the UR2 should
be sacrificed along with the UL3. During
the surgery, the surgeons also removed
a triangle of bone mesial to the LL7 to
Figure 6. (a–c) Upper and lower SWA elastics to
aid eruption and exposed the UR7.
attempt open bite closure. A routine course of
orthodontics now followed involving
October 2019
upper and lower fixed appliances and
attempted correction of the lateral
open bite on the left with red elastics
to Kobyashi hooks. Sadly, these teeth
proved to be resistant to eruption
(Figures 6a–c). An orthognathic
opinion had been sought during
treatment. It was decided that,
although BSSO advancement would
theoretically be possible, the risks
of surgery were high due to thin
mandible and uncertain quality of
the bone. Lower second and third
molars were also present, removal of
which would be required prior to any
osteotomy.
It was decided that
the treatment had been largely
successful, although it was impossible
to achieve full closure of the lateral
open bite. Despite this, the patient
was completely happy with the
results and declined any further
intervention. She was, however, given
the option of reconsidering further
treatment in the future.
Three years after the end
of treatment, the patient was still
delighted with the result achieved,
was really pleased with her smile and
had no wish for further intervention
(Figures 7a–g).
Conclusions
There is a variety of causes for
unerupted teeth and it is helpful
with the various aetiological factors.
It is certainly helpful if they can
distinguish between primary failure of
eruption and ankylosis.
Many different treatment
approaches have been advocated
for the management of unerupted
teeth. In cases of multiple unerupted
teeth, it is worthwhile considering
using rare earth magnets, as multiple
tooth movements can be carried out
simultaneously to bring the teeth to a
point where they can be bonded with
conventional appliances and aligned.
Conflict of Interest: The authors
declare that they have no conflict of
interest.
Informed Consent: Informed consent
was obtained from all individual
participants included in the article.
References
1. Hanisch M, Hanisch L, Kleinheinz
 October 2019
a c
8.
9.
d diagnosis for orthodontic treatment
10.
b e
11.
12.
f diagnosis, and treatment. A literature
13.
g 14.
15.
Figure 7. (a–g) Long term result – 3 years after debond.
16.
J, Jung S. Primary failure of eruption eruption: a possible cause of posterior
(PFE): a systematic review. Head Face open-bite. Am J Orthod 1981; 80:
Med 2018; 14: 5. 173–190.
2. Rhoads SG, Hendricks HM, Frazier- 5. Baccetti T. Tooth anomalies associated 17.
Bowers SA. Establishing the diagnostic with failure of eruption of first and
criteria for eruption disorders based second permanent molars. Am J
on genetic and clinical data. Am J Orthod Dentofacial Orthop 2000; 118: 18.
Orthod Dentofacial Orthop 2013; 144: 608–610.
194–202. 6. Ahmad S, Bister D, Cobourne MT.
3. Sharma G, Kneafsey L, Ashley P, Noar The clinical features and aetiological
J. Failure of eruption of permanent basis of primary eruption failure. Eur J 19.
molars: a diagnostic dilemma. Int J Orthod 2006; 28: 535–540.
Paediatr Dent 2016; 26: 91–99. 7. Raghoebar GM, Boering G, Vissink A,
4. Proffit WR, Vig KWL. Primary failure of Stegenga B. Eruption disturbances of
Orthodontics 139
permanent molars: a review. J Oral
Pathol Med 1991; 20: 159–166.
Frazier-Bowers SA, Koehler KE,
Ackerman JL, Proffit WR. Primary
failure of eruption: further
characterization of a rare eruption
disorder. Am J Orthod Dentofacial
Orthop 2007; 131: 578.e1–11.
Frazier-Bowers SA, Simmons D,
Wright JT, Proffit WR, Ackerman
JL. Primary failure of eruption and
PTH1R: the importance of a genetic
planning. Am J Orthod Dentofacial
Orthop 2010; 137: 160.e1–7.
Decker E, Stellzig-Eisenhauer A,
Fiebig BS, Rau C, Kress W, Saar K,
Ruschendorf F, Hubner N, Grimm T,
Weber BH. PTHR1 loss-of-function
mutations in familial, nonsyndromic
primary failure of tooth eruption. Am
J Hum Genet 2008; 83: 781–786.
Mubeen S, Seehra J. Failure of
eruption of first permanent molar
teeth: a diagnostic challenge. J
Orthod 2018; 45:129–134.
Suri L, Gagari E, Vastardis H. Delayed
tooth eruption: pathogenesis,
review. Am J Orthod Dentofacial
Orthop 2004; 126: 432–445.
Kjær I. Mechanism of human tooth
eruption: review article including a
new theory for future studies on the
eruption process. Scientifica 2014:
341905.
Yildirim D, Yilmaz HH, Aydin U.
Multiple impacted permanent and
deciduous teeth. Dentomaxillofac
Radiol 2004; 33: 133–135.
Nagpal A, Sharma G, Sarkar A, Pai
KM. Eruption disturbances: an
aetiological-cum-management
perspective. Dentomaxillofac Radiol
2005; 34: 59–63.
Sivakumar A, Valiathan A, Gandhi
S, Mohandas AA. Idiopathic failure
of eruption of multiple permanent
teeth: report of 2 adults with a
highlight on molecular biology. Am
J Orthod Dentofacial Orthop 2007;
132: 687–692.
Blechman AM, Smiley H. Magnetic
force in orthodontics. Am J Orthod
1978; 74: 435–443.
Sandler JP. An attractive solution
to unerupted teeth. Am J Orthod
Dentofacial Orthop 1991; 100:
489–493.
Sandler PJ, Meghji S, Murray AM,
Springate SD, Sandy JR, Crow V, Reed
RT. Magnets and orthodontics. Br J
Orthod 1989; 16: 243–249.
140 Orthodontics October 2019

Enhanced CPD DO C

Benjamin Marlow Kate Parker and Samantha Hodges

Primary Failure of Eruption

– a Review and Case Report
Abstract: Partial or complete failure of tooth eruption may be due to several causes, including primary failure of eruption (PFE), and an
accurate diagnosis is essential for appropriate management. This article reviews PFE and the possible treatment options. Case reports of
two patients diagnosed with PFE are presented and their management discussed.
CPD/Clinical Relevance: Primary failure of eruption can be difficult to diagnose and differentiate from other causes of failure of eruption.
This paper highlights the clinical presentation of PFE through a review of the literature and by illustration with two clinical cases.
Ortho Update 2019; 12: 140–142

Failure of eruption of first and second molars is
rare, with the prevalence estimated at 0.01% for
first permanent molars and 0.06% for second
permanent molars.1,2 Eruption failure may
result from a number of causes. These include
mechanical interference with eruption or failure
of the eruptive mechanism of the tooth so that
the expected amount of eruption does not
occur.3 Mechanical failure of eruption (MFE) is
characterized by single tooth anklyosis, whereas
primary failure of eruption (PFE) is a condition
in which unimpeded, non-ankylosed teeth fail
to erupt with an absence of systemic factors.3
Primary failure of eruption is diagnosed based
on its clinical appearance, which is reported to
include the seven features shown in Table 1.3The
last of these clinical features has been disputed.
Advances in gene discovery and identification
have been able to show a heritable basis of this
dental phenotype,4-8 and recently mutations in
parathyroid hormone 1 receptor (PTH1R) have
been identified in several familial cases of PFE.9
Primary failure of eruption has been
characterized further by Frazier-Bowers and
colleagues,7 who described three different types:
„ Type I: showed all affected teeth to have a
similar level of reduced eruptive potential;
„ Type II: included subjects for whom teeth distal
to their most mesially affected tooth had a greater
level, but still inadequate levels, of eruption;
„ Type III: included subjects who had a mixture of
both types of PFE occurring in different quadrants.
1. Posterior teeth are involved more than anterior teeth
2. Involved teeth may erupt partially and cease in eruption
3. Deciduous as well as permanent molars are likely to be involved
4. Involvement may be unilateral or bilateral
5. Ankylosis may be a secondary feature of involved teeth
6. Application of orthodontic forces is likely to cause ankylosis
7. There is no close familial or systemic association
Table 1. The seven features of primary failure of eruption.
Previously, diagnosis between MFE 3. Restorative correction of the occlusion once
and PFE has been difficult due to a lack of clear growth has ceased:
diagnostic criteria in the literature. A flow diagram a. Coronal build-up or onlay of the
was published by Sharma and colleagues to help affected teeth;
clinicians with their decision-making regarding b. A removable prosthesis over
diagnosing PFE and MFE (Figure 1).10 the affected teeth.
4. Extraction of affected teeth and prosthetic
Treatment options replacement.
Treatment of patients with PFE can often be Exposing and bonding teeth
challenging. An interdisciplinary approach is affected by PFE is not advised as treatment via
required when considering the management of orthodontic forces has been suggested to lead
this rare condition. The various treatment options to localized ankylosis.3
include:
1. Accept the infraocclusion; Case report
2. Surgical repositioning of the affected area with Patient 1
a segmental osteotomy once growth has ceased, A 14-year-old boy was referred to the
although limited success has been reported using orthodontic department concerning his
this approach;11 infraoccluded UR6 and LR6 with a resultant

Benjamin Marlow, MOrth RCS(Eng), BchD, MFDS(Ed), Kate Parker, MOrth RCS(Eng) BDS(Hons), BA(Hons), MJDF RCS(Eng), Post-CCST in
Orthodontics (email: mailto:kate.parker3@nhs.net) and Samantha Hodges, BDS(Hons), MSc, FDS, MOrth, FDS(Orth), FHEA, Consultant
Orthodontist, Department of Orthodontics, Eastman Dental Hospital, 256 Gray’s Inn Road, London, WC1X 8LD, UK.
 October 2019
Figure 1. A flow diagram to aid diagnosis of failure of eruption of the first permanent molar tooth/
teeth.10
a and UR7 were all infraoccluded with the uppers
b
c (Figure 3).
Figure 2. (a–c) Intra-oral views of Patient 1
showing a mild lateral open bite on the left and a
marked lateral open bite on the right.
lateral open bite. The patient was concerned
with the lack of eruption of the posterior teeth,
although he did not have any aesthetic or
functional concerns. The patient was medically
fit and healthy and there was no family history of depending on his further vertical alveolar growth the age of 17 are likely to be insignificant and
delayed eruption or failure of eruption.
On examination, the patient
presented with a Class I incisor relationship on a
Class I skeletal base with average vertical facial
proportions. Intra-orally, the patient was in the
permanent dentition. The LR6, LR7, UR5, UR6
more severely affected than the lowers. There
was a buccal crossbite present affecting the UL5
and LL6, with mesial occlusal contact present
between the two. Whilst there was also a degree
of infraocclusion affecting the UL6 and LL6, both
teeth were in contact with the opposing dentition. and left posterior regions was taken to confirm
Intra-oral photographs can be seen in Figure 2.
A radiographic assessment was
conducted which included a dental panoramic
tomograph (DPT) and lateral cephalogram. The
radiographs confirmed the clinical findings and
show the severity of the infraoccluded teeth
The diagnosis of primary failure of
eruption was made based on the non-eruption
of both the UR56 and LR6 and all teeth distal to
these. With mild infraocclusion affecting the UL6
and the non-eruption of the UL7, it was suspected erupted at this point, it was felt that it would
that these teeth were also affected by PFE and, as also be affected by PFE because all teeth distal
such, both will be monitored to assess any further to the most mesially affected tooth are affected.
progression in their eruption. The position of the
infraoccluded teeth was accepted and no active
treatment was undertaken due to the limited
chance of successful eruption under orthodontic
traction. In addition, restorative treatment was not affected teeth.
considered because the patient had no functional
or aesthetic concerns.
The patient was made aware that,
and the amount of infraocclusion, extraction
of the most severely infraoccluded teeth might
be required in the future due to difficulties
in maintaining adequate oral hygiene. The
infraocclusion is being monitored regularly by the should any further vertical growth occur,
patient’s general dental practitioner using serial
Orthodontics 141
study models, repeated intra-oral photographs
and measuring the level of the infraoccluded
teeth relative to the adjacent teeth. Had
the patient wanted restorative treatment to
improve his aesthetics and function, composite
build-ups or onlay restorations could have
been considered as long as growth had been
completed and following determination that the
infraocclusion had stabilized. Due to the severity
of the infraocclusion, it is unlikely that full
correction of the lateral open bite could have
been achieved.
Patient 2
A 17-year-old boy was referred to the
orthodontic department concerning a partially
erupted LR6. The patient’s main concern was
that he had a bad taste coming from this area,
however, he had no aesthetic or functional
concerns. The patient was medically fit and
healthy and there was no family history of
delayed eruption or failure of eruption.
On examination, the patient
presented with a Class II division 2 incisor
relationship on a mild Class II skeletal base with
reduced vertical facial proportions. Intra-orally
the patient was in the permanent dentition. The
LR6 was severely infraoccluded and carious. The
LR7 was partially erupted, mesially angulated
and impacted on the distal aspect of the LR6
and severely carious. The LL7 and the UL6 were
also infraoccluded. There was no contact distal
to the second premolars on the right side and
distal to the first premolars on the left side with
resulting lateral open bites (Figure 4).
A Cone Beam CT (CBCT) of the right
the extent of the infraocclusion and to identify
the proximity of the lower molars to the inferior
alveolar dental nerve (Figure 5). The CBCT
confirmed the failure of eruption of the LR6 and
shows it to be in close proximity to the lower
border of the mandible.
Following the CBCT, the patient was
assessed on the joint orthodontic-paediatric
clinic and diagnosed with PFE affecting the LR6,
LR7, LL7, LL8, UL5, UL6, UL7 and UR7. Although
the LL8 would not have been expected to be
Different treatment options were considered,
including accepting the infraocclusion,
restorative management with either onlays
or removable prosthesis or extraction of the
Whilst the vertical growth of both
the maxilla and mandible for this patient is
not yet complete, any further changes past
certainly would not alter the posterior occlusion
in a substantive way. One of the advantages
of treating the lateral open bites with either
composite onlays or partial dentures is that,
simple occlusal adjustments can be made to
 142 Orthodontics
a b
Figure 3. (a) DPT and (b) lateral cephalogram radiographs of Patient 1.
a d
Figure 4. (a–e) Intra-oral views of Patient 2 showing bilateral open bites.
the composite or acrylic to restore a balanced
occlusion.
The definitive treatment plan was
based on the severity of the infraocclusion and
patient preference and comprised the surgical
extraction of the LR6, LR7, LL7, LL8 and occlusal
onlays for the UL5 and LL6 to establish occlusal
contact. In order to monitor the patient’s
vertical growth, which may give rise to further
infraocclusion of the restored teeth, the patient
will be reviewed by the restorative department.
Should the patient present with an altered
posterior occlusion, the composite restorations
can be contoured or added to in order to
maintain a well-balanced occlusion. Once the
patient has reached the age of 18 and at the
point of growth maturation, he may consider
implants for restoration of the previously
extracted teeth, with or without the extraction
of the infraoccluded and restored teeth.
Conclusion
When faced with failure of eruption, it is
important to be mindful of the true aetiology
given the similar clinical presentations of PFE,
a
MFE and impaction. Impacted teeth should
erupt once the physical obstruction is removed,
however, teeth affected by PFE and MFE will
not. It is important to remember that applying
orthodontic traction to teeth affected by PFE
and MFE will not be successful and, indeed,
may cause ankylosis.3 These two cases highlight
the importance of accurate diagnosis and the
implications for treatment planning.
References
1. Grover PS, Lorton L. The incidence of unerupted
permanent teeth and related clinical cases. Oral
Surg Oral Med Oral Pathol 1985; 59: 420–425.
2. Ireland AJ. Familial posterior open bite: a primary
failure of eruption. Br J Orthod 1991; 18: 233–237.
3. Proffit WR, Vig KW. Primary failure of eruption:
a possible cause of posterior open-bite. Am J
Orthod 1981; 80: 173–190.
4. Bosker H, ten Kate LP, Nijenhuis LE. Familial
reinclusion of permanent molars. Clin Genet 1978;
13: 314–320.
5. Brady J. Familial primary failure of eruption of
permanent teeth. Br J Orthod 1990; 17: 109–113.
6. DiBiase AT, Leggat TG. Primary failure of eruption
in the permanent dentition of siblings. Int J
Paediatr Dent 2000; 10: 153–157.
7. Frazier-Bowers SA, Koehler KE, Ackerman JL,
October 2019
Figure 5. (a, b) A CBCT of Patient 2 showing
the severely infraoccluded LR6 and mesially
impacted LR7.
Proffit WR. Primary failure of eruption: further
characterization of a rare eruption disorder. Am J
Orthod Dentofacial Orthop 2007; 131: 578.e1–11.
8. Frazier-Bowers SA, Simmons D, Koehler K, Zhou
J. Genetic analysis of familial non-syndromic
primary failure of eruption. Orthod Craniofac Res
2009; 12: 74–81.
9. Decker E, Stellzig-Eisenhauer A, Fiebig BS, Rau
C, Kress W, Saar K et al. PTHR1 loss-of-function
mutations in familial, non-syndromic primary
failure of tooth eruption. Am J Hum Genet 2008;
83: 781–786.
10. Sharma G, Kneafsey L, Ashley P, Noar J. Failure
of eruption of permanent molars: a diagnostic
dilemma. Int J Paediatr Dent 2016; 26: 91–99.
11. Susami T, Matsuzaki M, Ogihara Y, Sakiyama M,
Takato T, Sugawara Y, Matsumoto S. Segmental
alveolar distraction for the correction of unilateral
open-bite caused by multiple ankylosed teeth: a
case report. J Orthod 2006; 33: 153–159.
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George Turner
Orthodontist
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When your life stops due to
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on his Dentists’ Provident plan to At Dentists’ Provident, we understand the impact illness or injury
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October 2019 Orthodontics 145

Enhanced CPD DO C

Amarpreet Atwal Philip E Benson

How to Design and Set

Up a Clinical Trial Part 2:
Protocols and Approvals
Abstract: Data from clinical trials involving human participants are essential in establishing an evidence base about the safety and
effectiveness of our treatments. This second article describes the steps involved in designing and setting up a clinical trial, from writing a
protocol to gaining the necessary approvals. Acquiring some knowledge about how to set up a clinical trial will allow the conscientious
clinician to use the most relevant information to provide the highest possible standards of clinical care for his/her patients.
CPD/Clinical Relevance: Even if a clinician is not, has never been, nor is ever planning to be involved in research, he/she should understand
and be able to interpret the data from clinical trials.
Ortho Update 2019; 12: 145–150

This article will describe the steps involved
in designing and setting up a clinical trial,
from writing a protocol to gaining the
necessary approvals.
How to write a protocol
Study setting and location
The number (single or multi-centre),
location (country), types of settings and
care providers involved (eg primary,
secondary, tertiary or community) must
be determined. These will influence the
generalizability and relevance of the trial to
other settings and therefore the ability to
guide clinical practice and policy.1
Eligibility criteria
The main research question will aid
researchers to determine the type of
participants required (Figure 1). Clear
inclusion and exclusion criteria are required
to recruit suitable participants and simplify
implementation of the trial. The eligibility
criteria will allow others to interpret in
which patients the results of the trial will
apply. Baseline participant characteristics
should be collected during the clinical trial
for the same purpose.1
Sample size calculation
All clinical trials involve selecting a group
of individuals (ie the sample), from a
population, usually with a particular
condition (target population). The sample
group is investigated and the results are
used to infer that a similar outcome would
occur in all individuals with that condition,
because it is not practical to include all
individuals with that condition in a study.
Before starting the trial, it is
necessary to try to estimate how many
participants should be included in the
study. The reasons for this are both ethical
and practical. It would be unethical to
start a study unless there were sufficient
participants to have a reasonable chance
of answering the research question posed.
Also, individuals are putting themselves
at risk (however small) when volunteering
to participate in a study with an unknown
outcome, and ethically you would not
want to put more individuals at risk than
is absolutely necessary. Practically, only a
certain amount of funding and time will
be available to run the trial and therefore
it would not be possible to include an
endless number of participants.
There are a number of excellent
articles about how to undertake a sample
size calculation.2 It is common to recruit a
few participants more than the sample size
calculation initially suggests, to account for
an inevitable number being lost to follow-
up, either through withdrawal or dropout.
Recruitment
It is important to describe how participants
will be identified and recruited. The
recruitment process (eg referral, self-

Amarpreet Atwal, BDS Hons, MOrth RCSEd, ISFE Orthodontics, Consultant in Orthodontics, Royal Derby Hospital (email: amarpreet83@
hotmail.co.uk) and Philip E Benson, BDS, FDS(Orth), PhD, Professor and Honorary Consultant in Orthodontics, University of Sheffield,
Claremont Crescent, Sheffield S10 2TA, UK.
146 Orthodontics
Figure 1. Deciding on the study sample for the trial.
Enrolment
Assessed for eligibility (n= )
Randomized (n= )
Allocation
Allocated to intervention (n= )
• Received allocated intervention (n= )
• Did not receive allocated intervention
(give reasons) (n= )
Follow-Up
Lost to follow-up (give reasons) (n= )
Discontinued intervention (give reasons)
(n= )
Analysis
Analysed (n= )
• Excluded from analysis (give reasons)
(n= )
Figure 2. CONSORT flow diagram. (Available from http://www.consort-statement.org).
selection through advertisement,
financial incentives) must be described
in the protocol. Recruitment can
be time consuming and a realistic
amount of time should be allowed
for this. The dates of recruitment
should be defined, as this will affect
the generalizability of the trial (eg
accepted medical and surgical
practices continually change and
this could affect the routine/control
treatment given to patients).1
Interventions
All interventions should be thoroughly
described, including any control
interventions, to allow other
clinicians to reproduce the methods.1
Interventions should only be
administered once the participant has
been enrolled in the trial, according
Exclude (n= )
• Not meeting inclusion criteria (n= )
• Declined to participate (n= )
• Other reasons (n= )
Allocated to intervention (n= )
• Received allocated intervention (n= )
• Did not receive allocated intervention
(give reasons) (n= )
Lost to follow-up (give reasons) (n= )
Discontinued intervention (give reasons)
(n= )
Analysed (n= )
• Excluded from analysis (give reasons)
(n= )
to the chosen method of assignment (ie
matching, non-randomized, randomized
etc).
Blinding
The protocol should describe who will
be blinded (ie unaware of participant
assignment) to the intervention group(s),
including the trial participants, treating
clinicians, and outcome assessors.
Outcomes
Prior to undertaking the trial, the primary
and secondary outcomes must be
predefined.1 It is important to have one
primary outcome (or at most two). This
is the outcome that is judged to be of
single most importance to all stakeholders
and which could be used to answer the
main question/focus of the study.1 The
time point(s) when the primary outcome
October 2019
data are to be assessed should also be
decided. This is used to estimate how
many participants should be recruited to
the trial.
Multiplicity of primary
outcomes, as well as statistical testing,
should be avoided, as this reduces clarity
and increases the risk of spurious findings
(eg finding a statistically significant
difference by chance).1 There can be
several secondary outcomes (eg including
harms), but the same needs to be borne
in mind.
The Core Outcome Measures
in Effectiveness Trials Initiative (COMET)
is an organization which supports the
development of Core Outcome Sets
(COS).3 These are agreed, standardized
sets of outcomes, which represent the
minimum that should always be measured
and reported in clinical trials of a specific
condition. COS allow the results of
different studies to be compared and
combined, as appropriate.
Once the primary and
secondary outcomes have been defined,
it is necessary to determine valid outcome
measurement tools. It is usually best to
use an existing tool that has a proven track
record and has been tested for validity
and reproducibility. This will enhance
quality and allow comparisons with other
studies.1 Other important considerations
include: who will make the assessments;
if there will be any masking of allocation
during measurement (blinding); and if
there will be any means of determining
the consistency of measurements by the
same rater (intra-rater repeatability) and/or
between raters (inter-rater reproducibility).
Follow-up and end-points
The time-points of assessment (frequency)
and the end-point of assessment (duration
of follow-up) should be explicit and
clinically appropriate to answering the
primary research question.
Informed consent
An assessment of capacity must be
performed on all potential participants
within a trial and written informed consent
obtained.1,4,5 Information should usually
be given verbally, through discussion
and in another form (eg written, audio-
visual, etc) which should be outlined in
the protocol. This should include the trial
aims, methods, potential benefits/risks,
post-study arrangements and any other
relevant aspects (eg sources of funding,
possible conflicts of interest, researcher
affiliations, etc.).6 Participants must have
the opportunity to ask questions, told
October 2019
that they do not have to take part, and can
withdraw consent at any time without it
affecting their treatment.
Flow of patients through the trial
The Consolidated Standards of Reporting
Trials (CONSORT) group recommend
explicitly describing the flow of participants
through the study when reporting
randomized trials, including the reasons for
exclusions and loss to follow-up. A CONSORT
flow diagram (Figure 2) must be planned in
the protocol and completed within the trial.7
This will allow others to judge how much the
estimated effect of the intervention might
be over- or under-estimated in comparison
with ideal circumstances.1
Interim analysis and stopping guidelines
This is usually at pre-determined time-points
and involves analysing the interim results,
with or without maintaining the blinding
present.1 If an intervention is showing larger
than expected benefits or harms, or no
important difference, the data monitoring
(and ethics) committee can recommend that
the trial continues, is modified or stopped
earlier than planned.5
Statistical methods
Statistical methods can be used to compare
the groups in the trial for both the primary
and secondary outcomes.1 Additional
analyses, such as subgroup analyses and
adjusted analyses can be undertaken, but
care should be exercised to avoid increasing
the risk of finding spurious results.
An intention-to-treat analysis
is often recommended for RCTs, as any
missing participant data in the analyses
(ie due to exclusion, loss to follow-up
and/or deviations from the protocol) will
compromise the randomization and may
lead to bias.1 An intention-to-treat analysis
involves analysing all participants that
were enrolled and randomized, in the exact
groups to which they were randomized. This
can be quite difficult if there is missing data.1
Solutions might include inputing the final
outcomes or, less favourably, carrying the
last known observation forward.1
Post-trial provisions
Before the trial starts, access to treatments
found beneficial, after the trial has finished,
should be considered and this information
disclosed during the consenting process.5
Obtaining funding and support grants
The cost of the trial should be considered at
the protocol stage. Money can be obtained
from industry (eg new medicinal product,
device or technology), a research funding
body (eg NIHR or Medical Research
Council) or from a charity (eg the British
Orthodontic Society Foundation).
Three types of research costs
are defined by the Department of Health
(DH):8
1. Research costs − these are related
to activities carried out to answer the
research question (eg data collection
and analysis, and are usually met by the
funders of the trial);
2. Treatment costs − these are related to
patient care, and are usually met through
the normal NHS commissioning process;
3. NHS service support costs − these are
related to additional activities, which are
part of the research process, rather than
the treatment (eg consenting patients for
the study) and are usually administered
through the local Clinical Research
Networks (CRNs)).
For a commercial research trial
(eg pharmaceutical company) the NHS
is required to recover all costs, over and
above the standard NHS treatment, from
industry.
Sponsorship
A sponsor is required for any research
involving patients, their tissues or
NHS resources.6,9 The sponsor can be
defined as an individual, company (eg
pharmaceutical company), institution
(eg university hosting the research),
or organization (eg NHS organization),
which assumes overall responsibility for
starting and managing the trial, and is
not necessarily the main funder. These
responsibilities may be shared by joint- or
co-sponsors. A risk assessment is usually
undertaken using the study protocol and
a decision made about whether to grant
sponsorship or not. If successful, a letter
of sponsorship is issued. Sponsorship is
required prior to any other approvals.10
Peer review
Finally, the protocol should be
scientifically peer reviewed by a number
of independent clinicians and preferably
patients as well. It may be necessary to
make changes to the protocol during
the trial, in response to changing
circumstances, but such changes should
be transparent and acknowledged
during reporting, to allow a reasonable
interpretation of the results.1
Approvals required to
commence a trial within the
UK
After the protocol, funding and
sponsorship have been agreed, the
Orthodontics 147
necessary legal permissions and approvals
must be sought.10
Ethical and regulatory considerations
Clinical trials require ethical11 and research
governance6 approval. Other approvals that
may be required include the Medicine and
Healthcare Products Regulatory Agency
(MHRA).12 The process for approval has
been simplified, with an online system
called the Integrated Research Application
System (IRAS).13 This is a single, streamlined
system to apply for permissions for health
and social care research in the UK. With this
system, the information for the trial can
be entered onto one form and IRAS will
automatically update the information onto
all of the relevant approval forms.
IRAS captures the relevant
approvals from the following review bodies:
„ Administration of Radioactive Substances
Advisory Committee (ARSAC);
„ Confidentiality Advisory Group (CAG);
„ Gene Therapy Advisory Committee
(GTAC);
„ Health Research Authority (HRA) for
projects seeking HRA approval;
„ Medicines and Healthcare Products
Regulatory Agency (MHRA);
„ NHS/HSC Research and Development
offices (R&D);
„ NHS/HSC Research Ethics Committee
(REC);
„ Social Care Research Ethics Committee
(REC).
Once completed, the forms are
transferred electronically to the appropriate
organizations, along with any supporting
documentation (eg participant information
sheets and consent forms). Depending on
what is involved in the study, compliance
with other regulatory bodies may be
required including ionizing radiation
(IRMER), Medicines for Human Use (Clinical
Trials) Regulations (2004), etc.
Data protection, patient confidentiality and
Caldicott guardians
Privacy and confidentiality for research
participants and their personal information
are essential.5 Caldicott guardians are
individuals within an organization who
should be notified of all research and
related activities, to ensure that any patient
identifiable information (PII) used complies
with the Caldicott principles,14 Data
Protection Act and General Data Protection
Regulations (GDPR).15
Indemnity insurance
All trials should be covered by some form
of indemnity insurance, either through the
hospital trust or university.
148 Orthodontics
Trial Design
RCT
Diagnostic accuracy studies
Observational studies
Systematic review of trials
Meta-analyses of observational studies
Table 1. Reporting statements for different trial designs. (Available from: http://www.equator-
network.org).
Trial registration
All clinical trials must be registered
on a publically accessible database.1,5
Trial registration and publication helps
prevent duplication, non-publication and
selective reporting of outcomes. There are
several trial registration sites to choose
from and, once registered, a unique trial
registration number is given.
Common trial reference numbers
IRAS number
The IRAS number is generated by IRAS
and will be the primary reference number
for the trial used by REC, HRA and, if
applicable, MHRA.
EudraCT number
It is now compulsory that all Clinical Trials
of Investigational Medicinal Products
(CTIMPs) are registered on the EudraCT
database.16
Clinical trials register number
Acceptable registers include EU Clinical
Trials Register,17 International Standard
Randomized Controlled Trials Number
(ISRCTN) Register18 and ClinicalTrials.gov19
Sponsors number
Generated by the sponsor.
Funders number
Generated by the funder.
Roles and responsibilities of trial team and
committees
Trial team
Chief Investigator: The named Chief
Investigator (CI) is responsible for the
conduct of the research (eg design,
management, reporting) in the UK and, if
at more than one site, the co-ordination
of the Principal Investigators.
Principal Investigator: The
Principal Investigator (PI) is responsible
for his/her own research site.
In a single-site study, the
CI and PI will usually be the same
person. Other members of the trial
Reporting Statement
CONSORT
STARD
STROBE
PRISMA
MOOSE
team might include a trial co-ordinator/
manager, research nurse, data manager,
programmer, site monitor, statistician,
health economist, data entry/clerical
support, etc.
Trial committees
Trial Management Committee: Meets
regularly to ensure that all practical
details of the trial are progressing and
everyone understands the processes.
Trial Steering Committee:
Meets regularly to ensure that the trial
is running well and sends reports to the
sponsor. The majority of its members
must be independent of the trial
(including the chair), and it is desirable to
include experienced trial researchers and
patient representatives.20
Data monitoring (and
ethics) committee: Scrutinizes the study
progression and its members must be
independent of the trial.20
Training requirements for researchers and
Good Clinical Practice (GCP)
The international ethical, scientific and
practical standard for conducting clinical
research is called Good Clinical Practice
(GCP).21,22 All individuals conducting a
trial should be suitably educated, trained
and experienced to perform their tasks.21
GCP compliance reassures the public
that the rights, safety and wellbeing of
research participants are protected and
the research data is reliable.23 Depending
upon each individual’s role within the
trial, there may be a requirement to
undertake GCP training.23
Typical trial time line
A typical clinical trial time line is:
„ Set-up (9 months);
„ Recruitment (2 years);
„ Follow-up (1−3 years);
„ Analysis (6 months).
Dissemination
Once participants have been recruited,
October 2019
data collected and analysed, a report
must be prepared and disseminated,
so the results can be used in clinical
practice. If this is not done, then the
contributions of the researchers and
participants will have been wasted.
There are many ways of publicizing the
results, usually through a conference
presentation and publication in a
suitable academic journal (preferably
open access). There are a number of
statements that outline what should be
included in the report of a clinical trial
to ensure quality and transparency of
reporting. The appropriate statement
to use depends upon the design of the
study (Table 1) and most can be found
on the Equator Network.24
Summary
This second article has described
the steps involved in designing and
setting up a clinical trial from writing
a protocol to gaining the necessary
approvals. Clinicians should be aware of
how research is undertaken. Without a
reasonable knowledge about how data
related to the safety and effectiveness
of treatments is obtained, it would be
challenging to undertake appropriate
evidence-based clinical practice.
References
1. Moher D, Hopewell S, Schulz KF,
Montori V, Gøtzsche PC, Devereaux
P. CONSORT 2010 explanation and
elaboration: updated guidelines
for reporting parallel group
randomised trials. J Clin Epidemiol
2010; 63: 1−37.
2. Petrie A, Bulman JS, Osborn JF.
Further statistics in dentistry. Part 4:
Clinical trials 2. Br Dent J 2002; 193:
557−561.
3. Core Outcome Measures in
Effectiveness Trials Initiative. COMET
initiative 2011−2016. Available
from: http://www.comet-
initiative.org
4. United Kingdom Legislation. Mental
Capacity Act 2005. Available from
https://www.legislation.gov.uk
5. World Medical Association.
Declaration of Helsinki: ethical
principle for medical research
involving human subjects 2013.
Available from https://www.wma.
net/policies
6. Department of Health. Research
Governance Framework for Health
and Social Care 2005. Available
from https://www.hra.nhs.uk
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150 Orthodontics
7. Moher D, Schulz KF, Altman DG.
The CONSORT statement: revised
recommendations for improving the
quality of reports of parallel-group
randomised trials. Lancet 2001;
357(9263): 1191−1194.
8. Department of Health. Attributing
the costs of health and social care
Research & Development (AcoRD)
2015. Available from https://www.
gov.uk
9. United Kingdom Legislation. The
Medicines for Human Use (Clinical
Trials) Regulations 2004. Available
from https://www.legislation.gov.
uk
10. Greene LE, Bearn DR. Setting up a
randomized clinical trial in the UK:
approvals and process. J Orthod
2013; 40: 104−111.
11. NHS Health Research Authority. HRA
Approval. Available from https://
www.hra.nhs.uk
12. Medicines & Healthcare Products
Regulatory Agency. Available from:
https://www.gov.uk
13. Health Research Authority.
Integrated Research Application
System (IRAS). Available from
Book Review
Dental Photography – Portfolio Guidelines.
Krzysztof Chmielewski, ed. Quintessence
Publishing, 2016 (59 pp (spiral bound with
slipcase); 64 illus). ISBN 978-1-85097-297-6.
On first receiving this book, I was
delighted to hold and review the book
due to its outstanding binding and
presentation. The book itself comes in
A4 landscape format, with a solid metal
ring binder and pop-out flip stand for
presentation of selected pages. The first
two pages of the book encompass the
author’s preferred equipment ‘load out’
using a Nikon camera. At the bottom of
these pages are some recommended
alternative cameras, lens, flashes and
accessories options.
The book is split into three
main sections, displaying all necessary
portrait, lips and teeth shots. At the start
of each section the full range of shots are
summarized, which would be useful for
teaching a team in-house. Each selected
photographic image is then displayed
with a high-quality gloss finish, on the
right-hand side, with the remainder of
the page having a tactile matt plastic
finish.
https://www.myresearchproject.
org.uk/Signin.aspx
14. National Data Guardian. Caldicott
Review: Information Governance in
The Health and Care System 2013.
Available from https://www.gov.
uk/government/publications/
the-information-governance-
review
15. European Parliament and
Council. General Data Protection
Regulation 2018. Available
from https://ec.europa.eu/
commission/priorities/justice-
and-fundamental-rights/data-
protection/2018-reform-eu-
data-protection-rules_en#abo
uttheregulationanddataprote
ction
16. European Medicines Agency.
European Clinical Trials Database
(EudraCT) 1995−2016. Available
from: https://eudract.ema.
europa.eu
17. European Union Clinical
Trials Register 1995−2016.
Available from: https://www.
clinicaltrialsregister.eu/ctr-
search/search
Down the left side of each
page is a section suggesting background
set-up, camera type and settings. Along
the bottom of each page is a tips section
consisting of suggestions on how to
position the subject, instructions to give
to the patient and how each shot may
be useful in diagnosis or treatment. The
teeth image section provides additional
information on retractors and contrasters
in order for the reader to achieve
excellence. The quality of the images is
very good, and this book could be used
as an aide-memoire to enable assistants
to capture the perfect shot.
As a keen dental
photographer myself, I understand the
value of taking regular pictures of my
patients’ dentition, to ensure outstanding
results and, in rare cases, identify
problems early on in treatment. This book
added to my knowledge of photography
and provided me with information about
shots I could take, in addition to my
standard set.
However, this book is not for
the novice as there is far more to dental
photography than what is written on
these pages. Producing consistently
superb photos takes practise and some
October 2019
18. International Standard Randomised
Controlled Trials Number (ISRCTN)
Register 2000−2016. Available from:
http://www.isrctn.com/login
19. US National Library of Medicine.
ClinicalTrials.gov 1993−2016.
Available from: https://clinicaltrials.
gov
20. NHS National Patient Safety Agency.
Data Monitoring Committees in
Clinical Trials Guidance for Research
Ethics Committee 2010. Available
from https://www.hra.nhs.uk
21. National Health Research Authority.
Training Requirements for Researchers
– Progress Update 2013. Available
from: https://www.hra.nhs.uk
22. ICH Expert Working Group. Guideline
for Good Clinical Practice E6(R1) 1996.
Available from: https://www.ich.
org/home.html
23. National Institute for Health
Research. Good Clinical Practice
(GCP). Available from: https://www.
nihr.ac.uk
24. Equator Network. Enhancing the
Quality and Transparency of Health
Research. Available from: http://
www.equator-network.org
education over just buying the correct
camera and having the right settings.
Purchase of this book should be seen
as an adjunct to having someone in the
team already adept at photography, or in
preparation for undertaking a hands-on/
educational course. Diligent readers will
find a link to the author’s dedicated ‘dental
photo master’ website where, for an annual
fee of $749/year, you can access videos and
tutorials to compliment this well presented
publication.
Andrew Flett, Consultant Orthodontist
Queen’s Medical Centre, Nottingham
King’s Mill Hospital
Sutton-inAshfield
October 2019 Orthodontics 151

Enhanced CPD DO C

Sridhar Premkumar Varun Peter

Lingual Orthodontics with

Customized Functional
Appliance
Abstract: Every treatment technique in the orthodontic specialty has its own set of advantages. Combining the techniques in an effective
manner could result in a synergistic effect. Two such techniques are lingual orthodontics and functional orthopaedic appliances. This case
report shows the effective and efficient use of a customized functional appliance, along with lingual orthodontics, in the management of
Class II division 1 malocclusion. It emphasizes the importance of combining the benefits of different strategies of orthodontic treatment.
CPD/Clinical Relevance: The use of a customized functional appliance along with lingual orthodontics can produce desirable changes in
Class II division 1 cases and clinicians should be aware of these advantages.
Ortho Update 2019; 12: 151–156

Orthodontic treatment offers our patients
improvement of mastication, speech,
appearance, as well as overall health, comfort
and self-esteem. Many adult patients require
well aligned teeth to improve their aesthetics,
as dental exposure and smile are fundamental
for the aesthetics of the face. The clinical
case presented is an example of treatment
in a case of Class II division 1 malocclusion.
This article describes the use of a customized
functional appliance, along with lingual
orthodontics, in an adult patient with a Class
II, division 1 malocclusion treated without
extraction.
Case report
An 18-year-old female patient reported
to the department of orthodontics with a
chief complaint of protrusive upper front
teeth. No relevant medical and dental
history was elicited. She was a mesomorphic
individual and her facial analysis revealed
an average clinical facial height. The patient
also had a convex facial profile with acute
nasolabial angle, deep mentolabial sulcus
and incompetent lips. Intra-oral clinical
examination revealed a deep overbite
with a Class II molar relation, asymmetric
maxillary and mandibular arches, spaced
anterior dentition, with the lower midline
shifted towards the patient’s right side and
a moderate amount of crowding in the
mandibular premolar region. The upper
incisors were proclined with an overjet of 14
mm (Figure 1).
Investigations
Extra-oral and intra-oral photographs,
study models, lateral cephalometric
radiograph, panoramic radiograph, functional
examination and video recording of the
patient were conducted. She had an atypical
swallowing pattern, the mandible moved
upwards and backwards on closure, and there
was 4 mm of incisal exposure at rest and
100% incisor exposure during smiling.
Diagnostic focus and assessment
Study model analyses confirmed the clinical
findings with the mandibular midline shifted
2 mm towards the patient’s right side.
Cephalometric analyses revealed a Class II
skeletal relationship (ANB = 7˚), maxillary
prognathism (SNA = 86˚) and an orthognathic
mandibule (SNB = 79˚) in relation to the
anterior cranial base. Both maxillary and
mandibular incisors were protruded in
relation to their alveolar base (Table 1). The
case was diagnosed as an Angle’s Class II
division l malocclusion on a Class II skeletal
base attributed to a prognathic maxilla and
an orthognathic mandible with a horizontal
growth pattern associated with proclined
upper and lower incisors and protrusive
upper lips.
Therapeutic focus and treatment
The main goals of the treatment were
to correct the deep bite, to rotate the
mandible clockwise to open the bite, retract
the maxillary anterior teeth to correct the
protrusion, retract the proclined mandibular
incisors and eliminate the functional retrusion

Sridhar Premkumar, MDS, Professor and Head of Orthodontics (email: mailto:dr_premsridhar@yahoo.co.in) and Varun Peter,
Postgraduate Student, Department of Orthodontics, Tamilnadu Government Dental College and Hospital, Chennai, India.
 152 Orthodontics October 2019

a b d

c e

Figure 1. (a–e) Pre-treatment intra-oral and extra-oral views.

Measurements Normal Pre-treatment Post-treatment

Angular
Sella-Nasion-Point A Angle SNA 82° ± 2° 86° 83°
Sella-Nasion-Point B Angle SNB 80° ± 2° 79° 80°
Point A-Nasion-Point B Angle ANB 2° 7° 3°
Mandibular Plane-Frankfort Horizontal Plane Angle 25° 18° 20°
Facial Angle (FH-NPg) 87° ± 3° 87° 90°
Palatal Plane–Occlusal Plane Angle PP–OP 8° ± 2° 9° 9°
Occlusal Plane–Mandibular Plane Angle OP–MP 14° 15° 18°
Upper Gonial Angle (Ar-Go-N) 50°–55° 54° 55°
Lower Gonial Angle (N-Go-Gn) 70°–75° 63° 67°
Incisor Mandibular Plane Angle (IMPA) 90° 112° 109°
Upper Incisor to Nasion-Point A Angle 1 to NA 22° 43° 28°
Lower Incisor to Nasion-Point B Angle T 1 to NB 25° 36° 34°
Interincisal Angle 132° 93° 120°

Linear
AO-BO Difference AO = BO AO>BO by +4 mm AO>BO by +1 mm
Upper Incisor to Nasion–Point A Angle 1 to NA 4 mm 9 mm 5 mm
Lower Incisor to Nasion–Point B Angle T 1 to NB 4 mm 7 mm 7 mm
Convexity of Pt–A 2 ± 2 mm +5 mm +2 mm
Table 1. Cephalometric analysis values.

of the mandible. The patient was concerned
about aesthetics and was apprehensive about
the visibility of brackets. The patient and her
parents were also cautious regarding invasive
procedures like implant-assisted orthodontics
and orthognathic surgery. The patient insisted
on ‘invisible’ fixed orthodontic therapy, to
hide the presence of the device completely.
It was decided to avoid extractions and
mini implants for the patient and to treat
with lingual orthodontics and a customized
functional appliance to eliminate lip trap and
functional retrusion.
The decision taken by young
adults to commit themselves to orthodontic
treatment is a more complex issue than for
the younger age groups, as they have the
demands of their work and broader social
needs to consider. With increasing number
of adult patients seeking orthodontic
treatment,1 lingual orthodontics has become
the ‘aesthetic’ solution for meeting the needs
of these patients.2 The 7th generation lingual
brackets are edgewise brackets specifically
designed for the lingual surface of the teeth.3
The maxillary anterior brackets have a built-in
bite plane which helps minimize accidental
debonding from the lower incisors. The bite
plane effect also allows efficient bite opening
in deep bite cases. It is difficult to visualize
and accurately position the lingual brackets if
they are directly bonded. Indirect bonding is
therefore the standard in lingual orthodontics
and the CLASS (Custom Lingual Appliance
Set-up Service) system was employed for
this patient. A full archwire of 0.016” Copper
Nickel Titanium (Cu-NiTi) followed by 0.017” x
0.017” Cu-NiTi was used for alignment of the
teeth. Torque establishment of the anterior
teeth is necessary prior to en mass retraction,
0.017" x 0. 025" TMA archwires were used
for torque levelling. Sliding mechanics was
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 October 2019
a c
b d
Figure 2. (a–d) Initial stages of treatment and the customized functional appliance.
a c
b d
Figure 3. (a–d) Mid-treatment views taken nine months after commencement of treatment. Reduction
in overjet, opening of bite and Class I molar relation is evident. Posterior teeth require settling.
used for closure of the space (Figure 2).
Compensating curves and gable bends were
placed in the archwires to counteract the
bowing effects. In the detailing stage, 0.016”
TMA archwire was used.
A functional appliance can be
defined as a removable or fixed appliance
which changes the position of the mandible
so as to transmit forces generated by the
stretching of the muscles, fascia and/
or periosteum, through the acrylic and
wirework, to the dentition and underlying
skeletal structures, and favourably changes
the soft tissue environment.4 Deciding which
functional appliance to use can be difficult
with lingual orthodontics. It was therefore
decided to follow the component approach
advocated by Vig and Vig.5 The occlusal
bite block of Clark’s twin block was also
incorporated6 (Figure 2). A construction bite
with a sagittal advancement of 3 mm and
vertical opening of 3 mm was recorded. The
wire components included were a labial bow
for the maxillary arch, which will provide a
retrusive effect to the maxilla. Connecting
wires between buccal shields and lip pads, as
well as interconnecting wire between the lip
pads, were also incorporated. Lip pads in the
Orthodontics 155
mandible, bilateral buccal shields and occlusal
blocks holding the mandible in advanced
position, along with the wire components,
made up the customized functional
appliance. The patient was instructed to
wear the functional appliance for 2–4 hours
for the first two weeks, followed by night-
time wear for the next two weeks. Full-time
wear was recommended after one month of
acclimatization to the functional appliance.
Follow-up and outcome
Favourable clinical results were observed
within 9 months (Figure 3). Bite opening
was evident with reduction in overjet and
improvement of the profile. The bite planes
on the maxillary incisor brackets cause rapid
bite opening, making the lingual appliance
most effective in deep bite cases,7,8 and this
patient has certainly benefited from this. At
the end of the treatment, functional occlusion
was observed with normal overjet, overbite
and adequate intercuspation, with Class I
molar relation and Class I canine relation
bilaterally, nearly coincident midlines, normal
maxillary and mandibular incisor inclination
(Figure 4). Vertical skeletal dysplasia with
deep bite was eliminated and cephalometric
measurements showed maxillary clockwise
rotation and mandibular clockwise rotation,
contributing to improved facial profile.
Maxillary and mandibular incisor axial
inclinations were corrected (Figures 5 and 6;
Table 1). The patient was extremely satisfied
with the treatment results.
Discussion
Adult patients are composing an ever
increasing demographic in orthodontic
practice. According to Proffit there are two
main groups of adults seeking orthodontic
treatment.1 The first group is after some sort
of adjunct orthodontic treatment to facilitate
other dental work, such as pre-prosthetic
orthodontics or implant space preparations.
These patients are usually middle-aged
adults in their 40s and 50s. The second group
is adults after comprehensive orthodontic
treatment. They are usually younger adults
who have always wanted orthodontic
treatment but did not undergo this during
their adolescence as they could not afford
it then. Very few studies had examined
the effect of the removable functional
orthopaedic treatment on young adults and
all those studies searched the effect of the
fixed functional appliances 9,10 McNamara
described the skeletal and dental adaptations
occurring in three adult patients treated with
the functional regulator (FR-2) of Frankel.11
During the treatment, the
co-operation of the patient was good. A full
Angle Class I relationship was achieved and
 156 Orthodontics
a c
b d
Figure 4. (a–d) Comparison of pre-treatment and post-treatment intra-oral views.
a b c d
Figure 5. (a–d) Comparison of pre-treatment and post-treatment extra-oral views.
a b
Figure 6. (a, b) Pre-treatment and post-treatment lateral cephalometric radiographs.
normal overjet and overbite established
with coincident midlines: SNA decreased by
3°; SNB increased by 1°; the upper incisor
teeth were retroclined; the lower incisor
teeth were proclined, with a resultant
increase in inter-incisal angle and an
increase in the total face height in the 18
months of combined lingual orthodontic and
functional appliance treatment. The patient
was followed for one year during retention
and the results were stable. Clinically, the
overall improvement in facial appearance,
and the attainment of a Class I dento-alveolar
relation with stable results, has made this
October 2019
an effective procedure when carried out
with good planning, proper execution and
attention to detail.
Conclusion
Emphasis should be placed on a
thorough understanding of facial
and dento-alveolar discrepancy in
orthodontic treatment planning. A
combination of lingual orthodontics
and customized functional appliance
can expand the scope of treatment
delivery.
Informed consent
The patient has provided written informed
consent.
References
1. Proffit WR. Treatment for adults. In:
Contemporary Orthodontics 3rd edn
Proffit WR, ed. St Louis: Mosby, 2000:
p644.
2. Fritz U, Diedrich P, Wiechmann D. Lingual
technique – patients’ characteristics,
motivation and acceptance. J Orofac
Orthop 2002; 63: 227–233.
3. Garland-Parker L. The Complete Lingual
Orthodontic Training Manual 3rd edn.
Professional Orthodontic Consulting,
1994.
4. Frankel R. Decrowding during eruption
under the screening influence of
vestibular shields. Am J Orthod 1974; 65:
372–406.
5. Vig PS, Vig KWL. Hybrid appliances: a
component approach to dentofacial
orthopaedics. Am J Orthod Dentofacial
Orthop 1988; 90: 273–285.
6. Clark WJ. The twin block technique:
a functional appliance system. Am J
Orthod Dentofacial Orthop 1988; 93:
1–18.
7. Alexander CM, Alexander RG, Gorman
JC, Hilgers JJ, Kurz C, Scholz RP et al.
Lingual orthodontics: a status report.
Part 5. Lingual mechanotherapy. J Clin
Orthod 1983; 17: 99–115.
8. Creekmore T. Lingual orthodontics: its
renaissance. Am J Orthod Dentofacial
Orthop 1989; 96:120–137.
9. Ruf S, Pancherz H. Dentoskeletal effects
and facial profile changes in young
adults treated with the Herbst appliance.
Angle Orthod 1999; 69: 239–246.
10. Chaiyongsirisern A, Bakr RA, Ricky
W, Wong K. Stepwise advancement
herbst appliance versus mandibular
sagittal split osteotomy treatment
effects and long-term stability of adult
class II patients. Angle Orthod 2009; 79:
1084–1094.
11. McNamara JA. Dentofacial adaptations
in adult patients following functional
regulator therapy. Am J Orthod 1984; 85:
57–71.
October 2019 Practice Tips 157

Anjli Patel

Five Years and

Counting…….Reflections
on the First Years of Owning
a Specialist Practice
Abstract: This essay highlights what has helped make our practice successful. I share some advice on how to empower your team and how
to achieve your goals.
Ortho Update 2019; 12: 157–160

In June 2012, I was invited to join a
consultant colleague to purchase a NHS
specialist orthodontic practice. At that
time, I was working as a Consultant
Orthodontist for three days a week and
as an associate in a specialist practice for
one day a week. I had just had my first
child and I liked my work-life balance.
However, NHS contracts are hard to
obtain and this was an opportunity
not to be missed. I was glad to have a
partner to share the load and we worked
well together in the hospital, so I went
for it! We bought a leasehold practice
and four years later bought a house,
converted it into a state
of the art orthodontic practice and
relocated (Figure 1). It was a huge
undertaking but we have not looked
back once.
I wrote this to share what
I have learned along the way to run a
successful and profitable orthodontic
practice.
Be a good leader
Leadership skills are learned throughout
life. As an associate it was easy to
be part of the team and never rock
the boat. Prior to taking over as a
co-principal of the practice, I read
several texts on how to be an effective
leader and run a successful dental
practice. They all said similar things:
have a vision, form a strategy to achieve
your goals and align your team to
it. It took us a few weeks to assert
ourselves in the practice, as we were
new to business and to primary care.
The practice had been run previously
by a single-handed orthodontist who
the staff adored but did not necessarily
work in the same way that we did.
Have a clear vision for your
practice
In the very beginning my business
partner and I drew up lists of where
we wanted to take the business and
where we saw ourselves in five years’
time. We were united in our vision for
the business. We wanted a practice
that would be a pleasure to work in,
that felt like a sanctuary and to create a
modern, yet comfortable environment
where people want to be. Most of all,
we wanted our practice to be about our
patients, making the patient experience
even better.
We bought an existing
specialist practice housed in the ground
floor of an end-of-terrace house. People
politely described it as being ‘bijoux’ and
we knew our business would outgrow
the property. Our plan was to use the

Anjli Patel, BDS, MFDS, MSc, MOrth, FDS Orth, No 1 The Orthodontic Specialists, 1 Station Road, Mickleover, Derby, DE3 9GH, UK (email:
anjlipatel77@gmail.com). www.no1braces.co.uk
158 Practice Tips
Figure 1. The Practice.
Figure 2. Our team that is growing.
four years left on the lease to grow the
business and find a suitable building for
our own future premises. Once we had
found the building, and working with the
nurses and the architect, we could spend
time deciding exactly how to design the
practice so that we were able to achieve
our vision.
Once we moved, our goals
became slightly blurred as we grappled
with the pressures of running a larger
practice with a larger team, many of
whom were new to orthodontics. It was
important though to redefine our vision
and to convey this to our team. Within
days of defining our new plans, we
noticed a big change in our team – they
were excited and more motivated to
help achieve our new goals of growing
the business. The NHS contracts are
changing and our business needs to be
prepared for this.
Look after your staff and
build an unstoppable team
We learnt very quickly that having an
enthusiastic team did more for our
October 2019
business and our psyche. Our policy is to
recruit the right people and to share our
vision for the practice. This empowers
the team to thrive and be ambassadors
for the business. We believe you should
never give anyone a job you would not
do yourself. Make sure you do everything
to achieve your vision and lead by
example (Figure 2).
We started off with a
small team of three part-time staff
and two principal orthodontists. We
have now grown to seven staff, one
orthodontic therapist and two principal
orthodontists. It has not been easy
and two nurse team members left
within their first year. They were leaving
dentistry, which was less of a blow to my
ego.
Two-way communication
is essential in running a business. We
regularly have practice training days and
practice meetings. These days are a great
platform to hear what the team has to
say about what they feel the business
can improve upon and it is vital that all
the team is aware of the core values for
the business and buy into the vision and
mission of the business. We work hard
to create a culture of respect, trust and
support; each member has an opinion
and is listened to. Everybody works
hard but one of the best compliments
we receive from patients is that they
love the feeling of the practice and
camaraderie amidst the team.
Recognition and appreciation
of excellent work makes us all feel good,
and your staff are no different – it will
boost their esteem. We take the team
to conferences, awards ceremonies and
on team-building events. Each team
member has regular appraisals. We
promote training and try to develop
their hospitality skills. They have
incentives to achieve the goals we
have set them, such as getting their
radiography qualification. Their Personal
Development Plans help identify how
they want to develop their careers and
we work with them to accomplish their
goals.
Initially, we wanted
everybody to be able to do every job.
However, as the team grew it was
evident that we needed to give people
defined roles and to work to their
individual strengths. Everyone knows
where they fit within our business and
who to go to for various issues.
Staff management is
notoriously difficult and we are lucky to
have an excellent team. Most of them
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160 Practice Tips
Figure 3. The website.
genuinely love their jobs and it shows!
Provide an excellent
customer experience
A dental practice is only successful if
its clients value the service. Our goal
is to create the best impression to our
clients so that they want to return
and will tell others about us. We want
them to become part of our family. We
have a suggestion book and regularly
ask for feedback. Patients rave about
the ambience in the practice and how
friendly our team is. Our ‘word-of-mouth’
referrals are increasing daily – and we
encourage this, it’s free marketing!
Advertise your business
Get your branding and identity correct.
It is worth spending time to ensure your
website works well and is optimized for
all media (Figure 3).
Patients are the best
advertisers so ask them to spread the
word if they were happy with their
experience. Social media is a very cost
efficient way to tell everyone you are
here. Revise your strategy according
to your capacity – it is not appreciated
when you have a heavy advertising
campaign only to find you cannot cope
with the avalanche of enquiries or
referrals.
Performance management
Test and measure everything. You cannot
change what you don’t measure and
you cannot tell if you are achieving
your goals if you are not testing,
measuring and tracking your results. Key
Performance Indicators (KPIs) make it
easy to keep track of what is happening.
The NHSBSA have set out the KPIs for
PDS contracts. In addition, we had our
own business KPIs, which are reviewed
each business meeting:
„ How many Units of Orthodontic
Activity (UOAs) have we fulfilled?;
„ What is our new to follow-up ratio?;
„ How many active patients do we have
(broken down into when they started
treatment);
„ What is our treatment conversion rate
for private patients?;
„ How many of our free consultations
convert to patients?;
„ How many complaints have we had?;
„ Patient feedback.
For the first three months,
we were appalling at measuring our
performance apart from knowing how
many UOAs we had fulfilled. We carried
out a SWOT (Strengths, Weaknesses,
Opportunities and Threats) analysis and
organized to have monthly business
meetings with the senior members
of the team. We discuss our KPIs. A
top tip is to invest in a good practice
management system that can help
measure performance about patient
numbers, UOA claims, and number of
appointments available, etc at the click
of a button
Stay on top of your
accounting
We are only just beginning to realize
October 2019
that we need to have an annual budget
so we can focus on our vision, strategy
and goals. We tend to look at last year’s
expenses and add a percentage and also
add any new expenses we may need.
Finances are easier to manage
with accounting software. You can get
management accounts with the press
of a button to give you a snap shot of
where you are compared with the year
before. Like everything, the programme
we use took time to learn, but we could
not do without it now. It is easy to work
out how much it costs to run the practice
each hour. That helps us adjust our fees
accordingly.
Get to know your
commissioners and referrers
Try to become involved with your
Local Professional Network (LPN) and
Managed Clinical Network (MCN). It is a
great forum to keep abreast of changes
in commissioning and the needs of the
area. Local dentists are more likely to
refer patients to you if they know your
face. You could offer ‘Lunch and Learn’
sessions, join the Local Dental Committee
(LDC) and attend the local British Dental
Association (BDA) meetings.
Personal goals
At present out business goals take
precedence over our personal goals as
we are still establishing ourselves. We
definitely need to improve our work-life
balance and would like to work less. I
would like to have more time with my
family. We are fortunate in that we’re in
a job that we love but we still need to
get the balance right. I don’t think about
retirement all the time but it still needs
planning – 20 years is what my financial
advisor is suggesting! I have tried to
be realistic about my personal goals as
I would be disappointed if I had set a
target to work two days a week after five
years of buying the practice!
Owning a practice is hard
work and not for everyone but, if carried
out correctly, and with the right team
around you, it can prove to be very
rewarding personally and hopefully
financially in the future!
Acknowledgements
I would like to thank Anne-Marie Smith
and Alison Murray for editing this essay. I
would also like to thank our team and our
families for making our dreams possible.
October 2019
Tricks of the Trade: a New
Method of Active Tie-Back
for Space Closure
The usual method of space closure
by sliding mechanics is by active tie-
backs or elastomeric chain.1 The various
drawbacks encountered with the use
of active tie-backs is laceration on the
buccal mucosa/inner surface of the
cheek, impingement on soft tissue
and gingival overgrowth, thereby
often creating discomfort to patients.
The following is a simple and unique
method of space closure with the help
of sectional 0.019” x 0.025” SS wire
(Ortho organizers) and elastomeric
module (Ormco).
Procedure
1. Cut a piece of 0.019” x 0.025” SS wire
and fabricate hooks on either end with
the help of a bird beak plier (Figure 1).
2. Depending on the requirement
of force levels, there are two ways of
utilizing this sectional wire (Figure 2).
3. Engage an elastomeric module on
one end of the wire, which is engaged
on the molar hook, and the other end
of the wire is free to hook onto the
crimpable hook used for retraction
(Figure 3).
4. When there is a greater distance
between anterior and posterior
segments, engage elastomeric modules
on both ends of the wire, one end
secured to the molar tube and the other
end to the crimpable hook delivering
light continuous forces efficiently
(Figure 4).
5. The length of the sectional wire can
be adjusted during the course of space
closure by shortening one end of the
wire and fabricating a similar hook.
6. The elastomeric module can also be
substituted with separator modules
during higher force requirements.
Rithesh Bangera, Postgraduate student (email: rrbangera14@gmail.com), Roopak D Naik, Associate Professor, Anand K Patil,, Professor
and Head, ShashiKumar B, Associate Professor PraveenKumar, Assistant Professor, Department of Orthodontics and Dentofacial
Orthopedics, SDM Dental College And Hospitals, Sattur, Dharwad, Karnataka, India.
Figure 1. Fabrication of hook on either end of
the wire 0.019’’ x 0.025” SS.
Figure 2. Variation in design for patient comfort.
Figure 3. Placement of active tie-back
(elastomeric module only on one end).
Advantages
1. This technique has simplicity and
efficiency, where force levels can be
adjusted by placing modules on one end or
Orthodontics 161
Figure 4. Placement of active tie-back
(elastomeric module on both the ends).
both ends of the rigid sectional wire.
2. Problems encountered with active
tie-back, such as frequent breakage of
ligature wire or disengagement of the
active tie-back, can be overcome by
using stiffer wire which snugly holds the
crimpable hook and does not compromise
on the forces applied for space closure.
3. Level of patient comfort can be
increased by contouring the sectional wire
according to the arch, thus preventing
impingement.
4. It is easy to fabricate and does not need
special equipment. No extra material
is required as the cut ends of the pre-
formed rigid 0.019” x 0.025” SS wire used
for space closure during sliding mechanics
can be utilized to fabricate this sectional
wire.
5. It can be pre-fabricated in the absence
of patients on their casts. Re-activation
is easy, thereby reducing the overall
chairside time.
Reference
1. McLaughlin RP, Bennett JC, Trevisi
HJ. Systemized Orthodontic Treatment
Mechanics 1st edn. St Louis Missouri:
Mosby Company, 2001: pp254–258.
162 Orthodontic Update October 2019

CPD
A.continuing education

Test your knowledge on the content of the articles published.

The following 7 questions relate to some of the articles carried this month. Only one answer is correct.

To receive CPD credit, answer the questions online at www.orthodontic-update.co.uk

Q1 NAZZAL ET AL 12: 126–133 Q5 HARLOW, PARKER AND HODGES 12: 140–142

The least preferred socket assessment technique is: When considering the treatment options for PFE the following
A. The use of acrylic stents. should be considered:
B. The use of metal stents. A. Teeth affected by PFE will not respond to orthodontic traction.
C. The use of 3 dimensional transplant replicas using 3-dimensional B. Exposure and bonding of teeth affected by PFE has been shown to be
prints. successful.
D. Use of the donor tooth. C. The eruption pathway of teeth affected by PFE is usually blocked,
therefore these teeth usually erupt spontaneously once sufficient space
is created.
Q2 ADAM, FLETT AND SANDLER 12: 134–139 D. Eruption is purely delayed and given time these teeth will erupt
unaided with no intervention.
Primary failure of eruption has a prevalence of:
A. 0.06%.
B. 0.6%.
C. 1%.
D. 0.1%. Q6 ATWAL AND BENSON 12: 145–150

The single streamlined system to apply for permissions for health

and social care research in the UK is called the:
Q3 ADAM, FLETT AND SANDLER 12: 134–139 A. Integrated Research Application System (IRAS).
B. Medicines and Healthcare Products Regulatory Agency (MHRA).
Which of the following is NOT an advantage of using rare-earth C. Independent Research Advanced System (IRAS).
magnets in the method described?: D. Research Ethics Committee (REC).
A. Less dependent on patient and operator dexterity.
B. Faster tooth movement.
C. More physiological, slowly-increasing forces.
D. Palatally directed forces are more readily applied.

Q4 HARLOW, PARKER AND HODGES 12: 140–142 Q7 PREMKUMAR AND PETER 12: 151–156

Primary failure of eruption: The concept of component approach to dentofacial orthopaedics

A. Usually involves anterior teeth. was introduced by:
B. Can only be diagnosed if it occurs bilaterally. A. Clark WJ.
C. Is often associated with a PTH1R mutation. B. Vig PS and Vig KWL.
D. Always presents in conjunction with other systemic factors. C. McNamara JA.
D. Pancherz H.

DEADLINE FOR SUBMISSION: 24 JANUARY 2020

CPD in Orthodontic Update in partnership with
ANSWERS FOR JULY 2019 ON PAGE 133

7 QUESTIONS REPRESENT 4 HOURS OF CPD

Happier patients & healthier operators
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