International Journal of Orthodontics Fall 2023 by internationaljournaloforthodontics

VOLUME 34 | NUMBER 3 | Fall 2023

International Journal of

Orthodontics

Published Quarterly by the

International Association for Orthodontics

In this Issue:

• A Case Report for Correction of Class I Malocclusion with Anterior Openbite and Lower Anterior Crowding Treatment with RMZ Spring • Total Maxillary Arch Distalization with Bone Screws in Infrazygomatic Crest: A Clinical Cephalometric Study • A Survey of Trends and Preferences in Orthodontic Retention

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Table of Contents Editor

Rob Pasch, DDS, MSc, IBO Mississauga, Ontario, Canada E-mail: paschrob@rogers.com

Managing Editor

Allison Hester 8305 Pennwood Dr. Sherwood, AR 72120 E-mail: allisonhijo@gmail.com

International Journal of

Orthodontics

FALL 2023  VOLUME 34  NUMBER 3

Features 10

A Case Report for Correction of Class I Malocclusion with Anterior Openbite and Lower Anterior Crowding Treatment sith RMZ Spring, by Dr. Sujit Zadake, Dr. Jyotsna Chate, Dr. Suresh Kangane, Dr. Anand Ambekar, and Dr. Yatishkumar Joshi. MIDSR Dental College, Latur, India

Consultants

Adrian Palencar, ON, Canada Michel Champagne, QC, Canada Dany Robert, QC, Canada Scott J. Manning, USA Mike Lowry, AB, Canada Edmund Liem, BC, Canada Yosh Jefferson, NJ, USA G Dave Singh, CO, USA Monika Tyszkowski, IL, USA William Buckley, OH, USA

International Journal of Orthodontics, copyright 2020 (ISSN #1539-1450). Published quarterly (March, June, September, December) by International Association for Orthodontics, 750 North Lincoln Memorial Drive, #422, Milwaukee, WI 53202 as a membership benefit. All statements of opinion and of supposed fact are published on the authority of the writer under whose name they appear and are not to be regarded as views of the IAO. Printed in the USA. Periodical postage paid at Milwaukee, WI and additional mailing offices. Subscription for member $15 (dues allocation) annually; $40 U.S. non-member; $60 foreign. Postmaster: Send address changes and all correspondence to:

International Journal of Orthodontics 750 North Lincoln Memorial Drive, #422 Milwaukee, WI, USA 53202 Phone 414-272-2757  Fax 414-272-2754 E-mail: worldheadquarters@iaortho.org

Total Maxillary Arch Distalization with Bone Screws in Infrazygomatic Crest: A Clinical Cephalometric Study, By Dr. Piyush Sanjay Patil

A Survey of Trends and Preferences in Orthodontic Retention, By Dr Amina Malik, Dr Rozina Nazir, Dr. Usman Ahmed, and Dr. Tania Arshad, Foundation Un

Departments 4

Writer’s Guidelines

Editorial: By Dr. Rob Pasch, DDS MSc IBO, Editor

Growing Beautiful Teeth Chapter 5: When to Start, By Estie Bav

Practice Management Tips: The Biggest Decision You Will Ever Make in Your Professional Life, By Scott J Manning, MBA; Founder, Dental Success Today

34 41

Tips from the Experienced: The Eyelet,Part 1, By Dr. Adrian J. Palencar, MUDr, MAGD,

IBO, FADI, FPFA, FICD

Clear Aligners Cornder: Using Clear Aligners and Elastics: A Great Combination!, by Dr. Stephane Reinhardt, DMD

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Visit the IAO online at www.iaortho.org

AUTHOR’S GUIDELINES FOR THE INTERNATIONAL JOURNAL OF ORTHODONTICS POSTED ONLINE AT www.iaortho.org. Past IAO publications (since 1961) available online in the members only section at www.iaortho.org.

Author Guidelines

MANUSCRIPT SUBMISSION Manuscripts are to be submitted electronically at www. editorialmanager.com/iaortho. If the manuscript is written in a language other than English, the author(s) must submit an English translation. The author may also submit a copy in his or her native language that will published in the online version only with a mention in the printed issue that the article is available online in his or her own language. The manuscript must be original and submitted exclusively to IJO. The Journal invites authors to submit: • Clinical reports • Technique articles • Review articles • Case reports

REVIEW AND EDITING PROCESS Editor. Articles will initially be reviewed by the editor. If author fails to adhere to the guidelines set forth, manuscript will be returned to the author for revision and correction. Peer review. Articles in IJO are subject to an anonymous peer review process. Reviews may take up to eight weeks to complete. Decision. Once the reviewing consultants have completed their critiques, the editor examines their comments and makes a decision to accept, accept with minor revisions, revise and resubmit, or reject. Editing. IJO reserves the right to edit manuscript for conciseness, clarity, and stylistic consistency. The author has final approval before publication. Questons? Contact Managing Editor, Allison Hester at allisonhijo@gmail.com, 501-517-1620.

MANUSCRIPT FORMAT Abstract. Must include a short abstract no more than 50 words that describe the significance of the article. Keywords. Must include keywords to help categorize the article. Length. Manuscript should be no longer than 15 doublespaced pages, excluding figures and illustrations. Tooth Numbering. The numbering of teeth should be international numbering. (US numbering can be added and put in parentheses.) Non-English Manuscripts. Authors are encouraged to submit the manuscript in languages other than English for posting on the IAO website. A mention will be added to the English version published in the International Journal of Orthodontics, directing readers online for other translations. Illustrations. Images must be available electronically as separate files. High quality digital images must be presented in one of the following formats: .tiff, .eps,.jpg, or .pdf with resolution of a minimum 300 dpi. Images must not be embedded in software programs such as Word or Power Point. The names on the digital files for photo/illustration files should match the manuscript reference. For example, if manuscript copy references Figure 1, electronic file should be titled Figure 1.jpg. No more than 16 photographs, figures, & illustrations are recommended; if greater than 16, IJO has the right to select and limit the number if necessary. Figures must be clearly referenced as to their placement in the manuscript. Brief captions for the figures, identified by number, must be provided. All images must be titled. Radiographs must be of superior quality. References. References must be included and authors are responsible for the accuracy of references. Manuscripts without them will be returned. Cite references in the text as endnotes and number them consecutively. Citations must be referenced in the following style: Periodical: 1. Sim JM, Jefferson Y, Dillingham SE, & Keller DC. Diagnosing an orthodontic patient using three different analyses. IJO 1990; 1(4):101-106. Book: 2. Fonder AC. The Dental Physician. 2nd ed. Rock Falls, IL; Medical Dental Arts; 1985:25-82. World Wide Web site: 3. Health Care Financing Administration. 1996 statistics at a glance. Available at: http://www.hcfa.gov/stats/stathili.htm”. Accessed Dec. 2, 1996. Products: Any products mentioned in the manuscript should be footnoted disclosing the company name and address.* *XYZ Orthodontic Co., 123 Main St., Los Angeles, CA 90000.

AUTHOR RESPONSIBILITIES Copyright transfer. IAO holds the copyright for all editorial content published in the journal. All accepted manuscripts become the permanent property of the IAO, and may not be published elsewhere in full or in part, in print or electronically, without written permission from the IAO. Reprint permission. The author is responsible for obtaining written permission from the publisher, or the person or agency holding the copyright for any material that is reproduced from a published source. Consent forms. Any patient clearly identified in the article must sign a form indicating his or her consent to be depicted in the article. It is the author’s responsibility to confirm consent. Author’s photo and bio. The author(s) must submit a headshot (preferably professional) and current biographical sketch. If author holds a teaching position, the title, department, and school should be included. Any position or relationship with a dental manufacturer must be identified. The sketch should include rank or title and station of authors who are in federal service, and should be limited to 60 words or less. Conflict of interest. The author will identify any conflicts of interest upon submission of any articles.

4 35

REPRINTS The International Journal of Orthodontics provides the corresponding author a final electronic copy of the Journal in which the article appears as well as an electronic copy (.pdf) of the pages where the article appears. Requests for individual reprints of the article should be directed to Chris McKay, IAO, 414-272-2757 or at chris@iaortho.org. Patients have a right to privacy that should not be infringed without informed consent. Identifying information, including patients’ names, initials, or hospital numbers, should not be published in written descriptions, photographs, and pedigrees unless the information is essential for scientific purposes and the patient (or parent/guardian) gives written informed consent for publication. Informed consent for this purpose requires that a patient who is identifiable be shown the manuscript to be published. Authors should identify Individuals who provide writing assistance and disclose the funding source for this assistance. Identifying details should be omitted if they are not essential. Complete anonymity is difficult to achieve, however, and informed consent should be obtained if there is any doubt. For example, masking the eye region in photographs of patients is inadequate protection of anonymity. If identifying characteristics are altered to protect anonymity, such as in genetic pedigrees, authors should provide assurance that alterations do not distort scientific meaning and editors should so note. (Source: International Committee of Medical Journal Editors (“Uniform Requirements for Manuscripts Submitted to Biomedical Journals”), February 2006). 35

Editorial

Reflecting on an interesting last few months in which our association took it upon itself to defend general practitioners who choose to practice orthodontics. The Readers Digest version of this event was the posting of a Bachelor/Bachelorette video parody created by the AAO as an advocacy social media message, which suggested clinical superiority of their group, this message is in contravention of their code of ethics, which states among other things, that “no statements should suggest superiority relative to other practitioners.” This video parody did just that, and in doing so, created diversion, confusion, and separation within our professional ranks. It is our belief that all of us should be held to the same “standard of care, operating within their respective codes of conduct” and that any licensed dentist who can achieve that “standard of care” and “code of conduct criteria” should be allowed to practice orthodontics without harassment. The IAO’s response letter to this social media video follows, in which you can read the IAO’s membership’s response to the AAO on the following pages.

Rob Pasch Editor

Featured*

A Case Report for Correction of Class I Malocclusion with Anterior Openbite and Lower Anterior Crowding Treatment sith RMZ Spring by Dr. Sujit Zadake, Dr. Jyotsna Chate, Dr. Suresh Kangane, Dr. Anand Ambekar, and Dr. Yatishkumar Joshi. MIDSR Dental College, Latur, India

Dr. Sujit Zadake MDS Orthodontics, Lecturer, MIDSR Dental College Latur, India

Dr. Jyotsna Chate MDS Orthodontics MIDSR Dental College Latur, India

Dr. Suresh Kangane MDS Orthodontics, HOD ,Professor and PG Guide, MIDSR Dental College Latur, India

Dr. Anand Ambekar MDS Orthodontics, Professor and PG Guide, Dental College, Latur, India

Dr. Yatishkumar Joshi MDS Orthodontics, Professor and PG Guide, Dental College, Latur, India

Abstract A case report is presented with Class I malocclusion, moderate lower anterior crowding, mandibular dental midline shift and anterior open bite seen. The adult orthodontic case was treated comprehensively with the extraction of the lower central incisor. Remarkable improvements were achieved in facial profile, axial anterior inclination, aesthetic smile, and mandibular midline correction in a short treatment time. Thus, it is concluded that lower incisor extraction in moderate lower anterior crowding and anterior open bite cases yield better and stable results with minimal intervention in the selected case. The main reason to seek orthodontic treatment is esthetics. Black triangles after lower incisor extraction are one of the commonly occurring malocclusions which causes esthetic compromises. Relapse is unavoidable while treating such cases. This relapse can be controlled only when there is translatory root movement in the mesial direction. Very little literature is available for the correction of black triangles. The spring is fabricated using 0.018 A J Wilcock stainless steel special plus wire containing three helices. This trihelical spring’ is a simple, effective, aesthetic, and biologically compatible device with excellent root control to treat root divergence and black triangle. Keywords: extraction, diastema, crowding, Black triangles movement, Root divergence Introduction The main goal of orthodontic treatment is to obtain a normal relationship of the teeth with facial structures. Angle emphasized that the preservation of all dental units was necessary to achieve facial balance, harmony, and aesthetics. However, subsequent studies related to the stability of results pointed the necessity of tooth extractions in order to correct certain malocclusions. The lower incisor inclination possesses great importance in orthodontic diagnosis and treatment planning. Orthodontists realize that maintaining all dental units to correct malocclusions is not always possible. Extraction of a selected permanent tooth is necessary in severe crowding cases. Great controversy exists between extraction and non-extraction treatment protocol. Several approaches for crowded mandibular anterior teeth are distal movement of posterior teeth, lateral movement of canines, labial movement of incisors, 10

*This article has been peer reviewed

interproximal enamel reduction, removal of premolars, removal of one or two incisors, and various combinations of the above.1 More important than the different types of a procedure or the philosophies of treatment, the types and degree of malocclusion, the patient’s age, the patient’s desires, and the skill of the orthodontists are the most influential in the outcome of the procedure. The incident of malocclusion commonly occurs in equal or greater rate in adults than in children or adolescents. Among all malocclusions, crowding is the most common complication in adults, and is found in around 24% of females and 14% of males in India. It mainly occurs when there is misbalance among supporting bony structures and tooth size mass. Choice of treatment for crowding depends on age of the patient, periodontal status and the severity of crowding. To achieve best results, it is important to decide how we manage each case of crowding. The problem may be solved by extracting teeth in both arches or without extraction. The degree of the malocclusion and the number of teeth extracted also affect the treatment duration.2 The interdental papilla plays a key role in anterior esthetics. With the loss of supporting alveolar bone, connective tissue and epithelial attachment is compromised. Multidisciplinary strategies are available for prevention and management of black triangles. These spaces have a negative impact on esthetics, function, phonetics and facilitates food retention affecting periodontal health. Black triangles are the embrasures cervical to the interproximal contact which are not filled by gingival tissue. The prevalence of posttreatment open gingival embrasures in an average adult orthodontic population is about 38%. Uribe et al showed that more than two-thirds of the patients who had a mandibular incisor extracted had a black triangle embrasure at the end of treatment.4 Case Report A 30-year-old female patient presented with chief complaint of maligned teeth in lower front region of jaw, had Class I malocclusion on Class II skeletal base (due to receding chin) with average growth pattern and average face-height ratio. The upper incisors were Proclined, and spacing seen in upper incisors with lower dental midline shifted to right side by 1mm. There was 1.5 mm arch length discrepancy (crowding) in the mandibular arch. There was 1.6 mm excess teeth material (Bolton

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discrepancy) in the mandibular arch as compared to the maxillary arch, anterior open bite of 2mm seen and tongue thrust habit present. extraction treatment followed by comprehensive orthodontic treatment for the finishing of occlusion. The preadjusted edgewise appliance (MBT prescription, 0.022" slot) were used to correct the malocclusion. The fixed bonded retainer in maxillary and mandibular arch along with removable Hawley’s retention plate were given for retention. RSection‑1: Pre-treatment Assessment Patient details Initials: Tejashri Pandurang Birajdar Sex: Female • Date of birth: 26 January 1987; age at start of treatment: 30 years

FIG 2: PRE-TREATMENT INTRA-ORAL PHOTOGRAPHS (a) Right buccal view, (b) Anterior view, (c) Left buccal view, (d) Maxillary occlusal view, and (e) Mandibular occlusal

• Patient’s complaint: Forwardly placed upper front teeth and malaligned teeth in lower front region • Relevant medical/dental history: No relevant history • Clinical examination: Extraoral features • Head form: Mesocephalic • Face form: Mesoprosopic • Facial symmetry: No gross facial asymmetry seen • Smile type: Cuspid type • Smile arc: Consonant • Facial profile: Convex Lips: competent

• Incisor relationship: anterior openbite

General dental condition:

• Overjet (mm): 3 mm

• No carious tooth

• Overbite: -2mm Centrelines:

• Restoration in 46

• Facio‑maxillary‑ centered

• Crowding in the lower anterior region; spacing: 12 11 21 22

• Facio‑mandibular‑shifted to right by 1 mm • Maxillo‑mandibular‑discordant by 1 mm.

Mandibular arch:

• Crossbites: None

• Total tooth material =94 mm • Discrepancy (crowding) =1.5 mm. Occlusal features:

Other occlusal features: • Narrow maxillary arch and ovoid mandibular arch • Bolton discrepancy Overall‑93% (normal‑91.3%) Anterior‑80.4% (normal‑77.2%)

Figure 1:PRE-TREATMENT EXTRA-ORAL PHOTOGRAPHS : (a) Frontal view with lips at rest, (b) Right profile view, (c) Frontal view with smile, and (d) Three quarter view

(Approximately 1.5 mm mandibular teeth material excess). Pre-treatment radiographs recorded: 12

• • • 2019

Pre-treatment Cephalometric Findings and Their Interpretation Various pre-treatment cephalometric findings are described. The maxillary base is normally placed, and mandible is backwardly positioned (SNA = 82°, SNB = 72°) in relation to the anterior cranial base. The ANB angle is high (ANB = 10°) suggesting Class II skeletal base relation. Wit’s appraisal (AO−BO = 5 mm) and other parameters for sagittal maxillo‑mandibular relation also suggests a Class II skeletal base relation due to the small mandible (mandibular length = 70 mm). Position of the chin (facial angle = 83°) is backward in relation to the Frankfort‑horizontal plane. The Frankfort‑horizontal plane angle, SN‑Go-Gn, are increased suggesting vertical growth pattern. Maxillary and mandibular incisors are proclined with reduced interincisal angle. The positions of the upper and lower lips are slightly forward in relation to the esthetic line (E‑line). The nasolabial angle is more than normal.

Orthopantomogram (OPG) – January 21, 2019 Lateral cephalogram – January 21, 2019 Intraoral periapical (IOPA) views – January 21,

Pre-treatment radiographs: (a) Orthopantomogram, (b) Lateral cephalogram with teeth in occlusion, Unerupted teeth: all teeth are present Other relevant radiographic findings:

Diagnosis: Diagnosis revealed skeletal Class II jaw base relation, with average growth pattern, dentoalveolar Angle’s Class I malocclusion with proclination in the upper teeth and mild crowding in the lower teeth, proclined upper and lower incisors with anterior open bite. She had convex facial profile and competent lips. Study cast analysis revealed Pont’s index calculated value more than that of measured value suggestive of maxillary expansion is indicated/required. Boltons ratio suggestive of mandibular total tooth material excess. Cephalometric analysis reveals Class II skeletal jaw bases, micrognathic maxilla and micrognathic mandible, hyperdivergent (Vertical) growth pattern. Analysis of records showed that she had an Angle’s Class I molar relationship on a Class II skeletal base with vertical growth pattern.

FIG 3 :PRE-TREATMENT STUDY MODEL PHOTOGRAPHS (a) Right buccal view, (b) Anterior view, (c) Left buccal view, (d) Maxillary occlusal view, and (e) Mandibular occlusal

Problem List 1. Skeletal Class II jaw base relation. 2. Anterior open bite 3. Mild crowding in the lower arch. 4. Midline diastema 5. Reduced overjet and overbite 6. Narrow upper arch. 7. Proclination of upper and lower anteriors. 8. Deep curve of spee. 9. Convex facial profile.

FIG 4 :PRE-TREATMENT a) LATERAL CEPHALOGRAM RADIOGRAPH . AND (b) PANORAMIC

• •

No missing teeth No obvious dental pathology.

Table 1: Various pre-treatment cephalometric findings

Aims and Objectives of Treatment 1. Achieving skeletal class I jaw base relation. 2. Maintaining Class I molar and canine relationship. 3. Achieving normal overjet and overbite. 4. Alleviation of lower crowding. 5. To expand upper arch. 6. To correct proclination of upper and lower anteriors. 7. Levelling of curve of spee. 8. Achieving harmonious, soft tissue profile. Treatment alternatives Levelling and alignment followed by proximal stripping in lower arch by Fixed mechanotherapy – MBT .022” slot. As patient was not willing to undergo proximal stripping, extraction treatment plan decided. Treatment progress Prior to the orthodontic treatment, scaling was done and an impression was taken for the study model. After that, the treatment was started with banding of first molars, Initially bonding of brackets and buccal tubes using 0.022’’ slots preadjusted edgewise brackets MBT (McLaughlin, Bennett, and Trevisi) prescription in the upper and lower arch. Orthodontic tooth movement has always been limited to action reaction reciprocal force mechanics in anchorage control. The current case was managed with the maximum anchorage system (Group A anchorage) as the present case was of Angle’s class I malocclusion on Class II skeletal base with upper incisor proclination and mild crowding in the lower anterior segment. Initially, the maxillary arch was banded and bonded, and a transpalatal arch was placed on the maxillary first molars to increase anchorage. Shortly afterward, the mandibular arch was banded and bonded after extraction of 41. Initial leveling was accomplished with .016-in nickel-titanium archwires. The archwires were cinched to avoid proclining the maxillary and mandibular incisors during levelling. Black triangles after lower incisor extraction is one of the commonly occurring malocclusion which causes esthetic compromises. Relapse is unavoidable while treating such cases. This relapse can be controlled only when there is translatory root movement in mesial direction.

Figure 5: RMZ spring ligated with ligature wire

Figure 9: Activated RMZ spring

Figure 6: RVG after placement of RMZ spring

Figure 10: Forces generated after engagement in brackets

Figure 7: Root up-righting with RMZ spring

Activation There are two ways to activate the Zadakes-W-spring, • Opening of two peripheral helices by 0.5mm. • Closing of one middle helix by 0.5mm. Root up righting was achieved within 3 months with 0.5mm activation per month. (Fig 11) and again RVG (Radiovisiograph) was taken to check for root resorption. (Fig 12)

Figure 8: RVG after root uprighting Figure 11: POST-TREATMENT STUDY MODEL PHOTOGRAPHS (a) Right buccal view, (b) Anterior view, (c) Left buccal view, (d) Maxillary occlusal view, and (e) Mandibular occlusal

Figure 16: 30 MONTHS FOLLOWUP EXTRA-ORAL PHOTOGRAPHS a) Frontal view with lips at rest, (b) Right profile view, (c) Frontal view with smile, and (d) Three quarter view Figure 12: POST-TREATMENT INTRA-ORAL PHOTOGRAPHS (a) Right buccal view, (b) Anterior view, (c) Left buccal view, (d) Maxillary occlusal view, and (e) Mandibular occlusal

Mechanism of Action Round wire will cause a root up righting and free tipping of incisors in distal direction. The roots of the incisors will be convergent at the end of tipping. 0.019” × 0.025”segmented stainless steel archwire was tightly ligated for a month to achieve better torque control. Lower central incisor space closure was achieved by using E -chain. Settling was done by using 0.014” NiTi wire and triangular settling elastics were also given for proper occlusion. After getting satisfactory overbite and overjet, class I molar and canine relationship had been attained. Almost two year later, all the fixed appliances were removed. The case was debonded after 24`months of active treatment. Fixed bonded retainer was given for both arches along with removable Hawley’s retainer.

Figure 13: POST -TREATMENT EXTRA-ORAL PHOTOGRAPHS a) Frontal view with lips at rest, (b) Right profile view, (c) Frontal view with smile, and (d) Three quarter view

Treatment results The patient’s profile had significantly improved. There was a significant reduction in the soft tissue facial convexity. Class I dental occlusion was maintained bilaterally Ideal overjet and overbite achieved with maximum intercuspation. The nasolabial angle showed a great improvement from its pretreatment value. Openbite correction and diastema closure done.

Figure 14: FIG 14: POST-TREATMENT (a) LATERAL AND (b) PANORAMIC CEPHALOGRAM

Post Treatment Assessment Extraoral analysis showed that the profile improved. Regarding Intraoral the occlusion, bilateral molar and canine Class I with ideal overjet and overbite (2 mm) was achieved. The misalignment/ malalignment resolved in both arches. spontaneous closure of the space between teeth occurred. The post retention records showed good stability. The retention protocol was fixed bonded retainer

Figure 15: 30 MONTHS FOLLOWUP INTRA-ORAL PHOTOGRAPHS (a) Right buccal view, (b) Anterior view, (c) Left buccal view, (d) Maxillary occlusal view, and (e) Mandibular occlusal

along with removable Hawley’s retainers for both arches after the end of the therapy. Followup was taken for every three months over two yrs and six months. After two years of retention, there was no relapse tendency of anterior open bite. During this time an acceptable occlusion, aesthetic facial and smile view was maintained. The outcome of this results indicated a long- term stability of the occlusion (Figure 9).

months with 0.5 mm activation per month and again RVG (Radiovisiograph) was taken to check for root resorption. Round wire will cause a root uprighting and free tipping of incisors in the distal direction. The roots of the incisors will be convergent at the end of tipping. 0.019 × 0.025”segmented stainless steel archwire was tightly ligated for a month to achieve better torque control. The post retention records showed good stability. The retention protocol was fixed bonded retainer along with removable Hawley’s retainers for both arches after the end of the therapy.

Discussion The interdental papilla plays a key role in anterior aesthetics. With the loss of supporting alveolar bone, connective tissue and epithelial attachment are compromised. Multidisciplinary strategies are available for the prevention and management of black triangles. These spaces have a negative impact on aesthetics, function, phonetics, and facilitate food retention affecting periodontal health. Black triangles are the embrasures cervical to the interproximal contact which are not filled by gingival tissue. Furthermore, anterior open bite is known as one of the severe occlusal traits and proper management depends on the severity of the skeletal discrepancies. The high relapse tendency of anterior open bite cases is approximately 20% whether it is corrected by surgical or nonsurgical. There is not obvious justification for this instability and the complex interaction of all possible etiologic factors of the open bite cases. If the management does not address the possible etiologic factor, relapse is more prone to happen. So overcorrection is highly recommended for this type of malocclusion and should incorporate upper and lower fixed retainers.7 This case report is presented with Class I malocclusion, moderate lower anterior crowding, mandibular dental midline shift and anterior open bite seen. The adult orthodontic case was treated comprehensively with the extraction of the lower central incisor. Remarkable improvements were achieved in facial profile, axial anterior inclination, aesthetic smile, and mandibular midline correction in a short treatment time. Reverse‑M‑Zadake (RMZ) spring consist of three coils, each of 3 mm in diameter, one at the center and two at the periphery giving it an appearance of the alphabet ‘W’. Two arms emerge from respective helices with anti‑tip bends of 35°.Root uprighting was achieved within 3

CONCLUSION RMZ spring is a novel design fabricated by using 0.018 inch A J Wilcock special plus wire for the management of root divergence after lower incisor extraction. References

1. Sah JK, Mishra P, Shrestha RM, Gupta A. Treatment of Class I Malocclusion with a Lower Incisor Extraction: A Case Report. Orthodontic Journal of Nepal. 2018 Oct 13;8(1):58-62. 2. Alam MK, Nowrin SA, Shahid F, Haque S, Imran A, Fareen N, Sujon MK, Zaman S, Islam R, Nishi SE. Treatment of Angle class I malocclusion with severe crowding by extraction of four premolars: A case report. Bangladesh Journal of Medical Science. 2018 Sep 19;17(4):683-7. 3. Van der Geld P, Oosterveld P, Van Heck G, et al. Smileattractiveness. Self-perception and influence on personality. Angle Orthod. 2007;77:759–765’ 4. Uribe F, Holliday B, Nanda R. Incidence of open gingivalembrasures after mandibular incisor extractions: a clinicalphotographic evaluation. Am J Orthod DentofacialOrthop. 2011;139(1):49-54. 5. Kurth JR, Kokich VG. Open gingival embrasures afterorthodontic treatment in adults: prevalence and etiology.Am J OrthodDentofacOrthop. 2001;120(2):116–123. 6. Ko-Kimura N, Kimura-Hayashi M, YamaguchiM, et al. Somefactors assciated with open gingival embrasures followingorthodontic treatment. Aust Orthod J. 2003;19:19–24. 7. Zadake SN, Joshi Y, Kangane S, Ambekar A. Reverse-M-Zadake spring–A novel design for the management of root divergence. International Journal of Orthodontic Rehabilitation. 2021 Oct 1;12(4):164

Book Excerpt

Growing Beautiful Teeth Chapter 5: When to Start Estie Bav is an active member and senior instructor of IAO. She graduated BDSc from the University of Western Australia, and practises in her own private family dental surgery in Melbourne Australia. In November 2018 she published her first book titled “Growing Beautiful Teeth,” primarily targeting parents, grandparents, teachers or any child health carer to look out for early signs of dental growth issues. It informs the unaware the importance and impact of teeth and jaw on other areas of health such as breathing, sleep, posture, and even behaviour. Currently the dental profession tends to “supervise and wait” for growth issues to become complex and expensive to correct….” “My concern is that most parents miss out on basic and important dento-facial growth information until too late.” The book was designed to be a helpful resource for your patient to read, and for introducing the subject to younger dentists and allied health professionals who may not be familiar with the teeth-occlusion-airway-TMJsleep paradigm. Her message is to get involved with a child’s dentofacial-airway development early. Growing Beautiful Teeth is available from any major online booksellers, or at • www.drestiebav.com • www.growingbeautifulteeth.com She can be reached at estie@drestiebav.com

How my book can be helpful…. It takes time to educate parents on the benefits of treating dental growth issues early and explaining what signs we look for. In writing this book in simple language I hope to bring an awareness to the larger parent community, which will in turn save my dental colleagues chairside time. This book would be a helpful resource for the waiting room, and for introducing the concept to younger colleagues joining your practice.

o avoid having crowded and crooked teeth in adulthood, the child’s jaws need to grow wide and forward to provide room for permanent teeth, which are much larger than the deciduous or milk teeth. Jaw growth is a process that begins from birth and parents have a significant role in stimulating this growth. We have discussed how the earlier we keep a lookout and keep steering growth on the right track, the better. The younger the child, the easier it is, as their skeleton is more adaptable. Many ancient cultures have exploited this flexibility; for example, Chinese foot-binding, Burmese neck elongation and South American skull elongation. For the jaws, breastfeeding is the first action in the stimulation for growth, well before any tooth erupts in the mouth. Importance of Breastfeeding The new born has no teeth; however, nature is so clever to design breastfeeding not just as a way for the baby to get fed with the right nutrients, but also as a stimulus for good dental development. Instinctively, the baby’s mouth closes neatly over the mother’s breast nipple to form a seal, whilst the forward part of the tongue cups under the nipple, and the back part moves up and down against the palate to create a vacuum in the mouth that draws the milk from the breast. The baby then holds the milk momentarily before swallowing, following a rhythmic sequence of suckleswallow-breathe (through the nose). This rhythmic pumping of the baby’s lower jaw, and pressing of the nipple by the tongue against the palate stimulates the jaws and the midface structure to grow. The mother’s nipple is the perfect mould for the baby’s mouth whilst the jaw, tongue and mouth muscles make the perfect pump. Feeding posture: The aim is to facilitate a good oral seal by the baby’s lips and tongue around the breast to prevent air leakage and intake, and to enable nasal breathing. With breastfeeding the baby can be held more upright, keeping its neck and body straight and overextension of the neck is prevented. The nose should be next to the breast. Holding the baby more upright prevents milk from flowing back up towards the oesophagus resulting in a reflux. Keeping the ear above mouth level prevents backflow of milk into the ear that may cause ear infection. Just the right feeding amount: Overfeeding can lead to reflux or regurgitation of milk from the baby’s stomach. Studies have found that babies need very little

milk, about the size of its fist, at any one time. This may be reassuring for some mothers who are concerned that they do not have enough milk for the baby. If the milk flows too fast, then it can cause stress for the baby in keeping up the feed-swallow-breathe rhythm. Breastfeeding gives the baby a better control of rate of milk flow. In my practice, I have observed that despite the baby having been breastfed, there may still be issues with underdeveloped jaws and/or tooth crowding as the child’s teeth begin to appear. This is because there are always many layers of environmental and genetic influence on jaw and teeth growth. Nonetheless, breastfeeding is still an early insurance for the maxilla to grow unhindered. It will help reduce any negative impact so that even if there may be a need for a correction of any shortcoming, the corrective measures will be easier. Growth and development of the jaw-face-teeth complex is not so much an evolutionary change that requires many generations, but rather it is an adaptation influenced by the functioning of the tongue and cheek muscles which commences early in infancy. Mother’s Health During Pregnancy Before birth, it is important for the pregnant mother to maintain good health to pass on the benefits as well as reduce any unwanted stress to the foetus, particularly by: • breathing well through the nose • ensuring adequate restorative REM sleep • paying attention to diet and ensuring adequate nutrition • reducing any risk of high blood pressure • reducing any need for taking medication. • avoiding alcohol Towards the third trimester of pregnancy, there is an increased risk for a temporary development of OSA for the mother. This condition can lead to oxygen desaturation, arousal and disturbances and high blood pressure during sleep which should be assessed and treated by the family doctor and with a referral to a sleep physician as necessary.1,2 Some treatment with medication for the mother has been linked to the development of various tooth enamel defects for the child. These defects can be visible on front teeth and unsightly. Tooth enamel defects can occur during the early stages of tooth formation. The child’s baby teeth are affected by factors occurring from the 19

second trimester of pregnancy, whilst permanent or adult tooth defects can arise from factors occurring at or soon after birth, and up to five years of age. Breast Milk: Some mothers pump their breast milk and store it in bottles so their baby can feed on demand when the mother may have to go to work. Remember that this is more than about the contents of the milk. It is also about the baby suckling the mother’s nipple to express the breast milk. It is about the baby’s tongue and the breast nipple fitting snugly against the baby’s palate in order to stimulate the development of the palate, and ultimately the dentofacial structure, to its full potential.

were invented. Observations have been made that in cultures where breastfeeding is the normal and only available practice, and especially if the community live entirely on natural and non-processed food, the child tends to grow beautiful wide jaws that can accommodate all 32 adult teeth, including the wisdom teeth. Tooth crowding is rare, in contrast to what we see in our modern culture. Mothers’ milk is also the perfect formula for the infant that no commercial product can substitute. This milk is free, is always freshly made, and provides all the nutrients, proteins, fat, carbs, vitamins and even antibacterial agents the child needs without any risk of malnutrition and/or allergy to a non-human formula ‘milk’. However, I qualify here that the mother needs to ensure that she is on a balanced diet that provides all the minerals and nutrients she needs for herself and to pass onto the baby via her milk. WHO’s concern: On the Australian ABC Radio midday news in October 2017, it was reported that Australian mothers of newborns are lagging behind in breastfeeding. The international rate for breastfeeding is 40%, whilst in Australia only 10 to 15% of mothers breastfeed their baby up to 6 months. This report was given by Dr Howard Sobel, head of Child Health and Nutrition. He is also the southeastern regional representative of the World Health Organisation (WHO). He said, ‘Babies who are not breastfed entirely are 10 times more likely to be sick and to die, at least in poorer countries. Fast feed infant formulae may be equated to junk food with all its artificial contents.’ Breastfeeding can reduce chronic diseases: A research done by ANU’s Australian Centre for Economic Research on Health, published in 2010 in the International Journal of Public Health Nutrition had found that breastfeeding can reduce the risk of chronic diseases.3 The study was set out to assess the public health significance of premature weaning of infants from breast milk on the risk of chronic illnesses in later life. The study mapped the public health impact of premature weaning from breastfeeding over a period of five decades in Australia. The research showed that negative attitudes to breastfeeding may have contributed to a rise in chronic disease in Australia especially among disadvantaged families.

Is Bottle Feeding Good Enough? Mothers who bottle feed their babies would need to keep in mind the importance of the position and posture of the baby during feeding, the rate of flow from the holes made in the teat, the shape, length and firmness of the teat for an effective suckle by the baby. Also check the nutritive content of the nonhuman milk formulae and the freshness of the milk stored in the bottle. The baby breathes and swallows more easily when breastfeeding because the milk flow from the breast is controlled by the baby’s suckling and not by gravity as with bottle feeding. The consensus is that it is not possible to find a milk bottle and teat that can be as effective as a human nipple and breast. The rhythmic pressing of the lower jaw and tongue and mother’s nipple against the palate and the contraction of the cheek muscles create the stimulus for the growth of the palate. A well-developed palate is broad and flat and does not encroach into the nose cavity or impairs airway that is so important for proper nasal breathing. Generally, it is recommended that a newborn be breastfed exclusively for at least 6 months and partially up to 12 months or much longer for good dentofacial growth and general good health for the baby. In Asia, where I was born and brought up, it was not uncommon for a family to hire a ‘wet nurse’ to feed the baby should the mother not be able to breastfeed the child for any reason such as illness. This would have been the normal child care practice in the past before bottles, teats and baby formula 20

During the 1960s, 90% of people were weaned off breastfeeding before they were six months old due to unsupportive health policies and negative public attitude in the post-war years. These people would now be in their 50s and 60s. The researchers suggested that from what they know about the effects of premature weaning, a significant proportion of the current burden of chronic disease might have been avoided had they been breastfed longer. They also suggested more should be done to promote breastfeeding past the age of six months to combat the risk of chronic disease in the future. The researchers found that there are few preventative health interventions like breastfeeding that shows consistent, long-term effects in reducing chronic disease. As previously mentioned, in communities where breastfeeding is the only way, the child has welldeveloped dental arches. Other dentists and medical professionals have made similar observations and wrote about their concerns with the current trend away from breastfeeding, albeit from slightly different approaches.4,5 In summary, the benefits of breastfeeding for a child include nutritional, immunological, emotional, psychological and the practice is also foundational to dentofacial growth. Pure breastfeeding for at least six months is positively associated with good dental arch development that will give a reduced chance of developing dental malocclusion. Could it be that in our modern civilisation, where breastfeeding is no longer the only option and is less popular, that we’re seeing a concomitant rise in the prevalence of crooked teeth? Mothers are encouraged not to give in to formula and bottle feeding too readily.

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Tongue-tie Tongue-tie is an important topic relating to breastfeeding, dentofacial growth and development, and other significant health issues. A tied tongue, or tongue-tie, is often heard of but its significance seemingly poorly understood.6 The medical term is ‘ankyloglossia’ and in more recent times it is also referred to as ‘tethered oral tissues’ or TOT. It refers to the abnormally tight oral tissue attachment under the tongue that anchors or tethers the tongue to the floor of the mouth, limiting

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the movement of the tongue. There are varying degrees of tongue-tie and movement limitations. There are also ‘lip-ties’ that tether the upper or lower lip to the respective gum area of the jaw. Tongue-ties are common. Whenever there is any issue with breastfeeding, such as pain experienced by the mother and/or an inability for the baby to latch on for an effective feed, the underside of the tongue should be inspected for any tight restriction by running a finger under the tongue, then all around to detect any restriction to the finger movement. A tethered tongue can cause the baby to struggle to stretch its tongue forward to cup under the nipple. This can render the mouth seal ineffective, and the baby ends up sucking in and swallowing air. Aerophagia can cause distension of the baby’s tummy, discomfort and pain and reflux. Tongue-tie can also cause pain for the mother as the baby struggles and compensates with its jaw or emerging teeth for an effective latch. This is one reason for many mums to give up breastfeeding. In fact, tongue-tie can also affect and cause frustration for the mum and baby equally with bottle feeding. Other clues to this restrictive tether include the heart-shaped appearance of the tongue when the baby cries and has its mouth open, or an obvious firm attachment of the tongue tip by the tie, or the appearance of a white coating of milk residue on the back of the tongue indicating an ineffective swallow due to the restriction.

tied-tongue, but we were taught to do this only in an older child or adult with a speech impediment. There was no concern for the fact that a tied-tongue prevents a newborn from suckling the mother’s breast effectively nor that this should be assessed for an early release as soon as it is observed. Surgical techniques for releasing a tied tongue include the use of surgical scissors, scalpels or laser knife (also known as ablation). Normally, this is released under some local analgesia. The younger the baby, the easier to treat and with less disruption. In fact, the release is even performed without local analgesia in the newborn. It is a simple procedure with no report of adverse events. Immediately following the release, the baby can return to the mum’s breast, to be comforted by the improved ease of suckling. In an older child, local analgesia will be required, and scarring may be a side effect. Also, pre- and postsurgery stretching exercises are required for a good outcome. The tissue that ties the tongue to the floor of the mouth is known as the frenum or frenulum. And the surgical release and removal of a tight frenulum is therefore referred to as a ‘frenulectomy’ or abbreviated to ‘frenectomy’. A most simple procedure that does not involve any removal of tissue at all is also called a ‘frenotomy’. Other terms used for procedures for releasing a tied-tongue are revision or division of the tongue. If left untreated, tongue-ties can encourage a disconnect between the tongue and the palate, lead to orofacial myology disorders and therefore affect dentofacial growth and development. Other ramifications may include speech and eating impediments, negative behavioural and social impact. It has now been observed that tongue-tie is linked to airway problems, specifically OSA in children.7 The significance and importance of tied-tongues are so much appreciated in Brazil that they passed a national health regulation in 2004 requiring that every newborn’s frenulum be inspected and, if necessary, be released for improved breastfeeding and the benefit of proper dentofacial growth and development of an optimal airway. I heard that in ancient times, immediately following birth the midwife would routinely check

Tongue-tie release: When I was a dental student, I learnt surgical techniques to release a

Various tongue-ties from infant to older adult

Figure 18: Tongue-ties.

under the newborn’s tongue for any tongue-tie and she would not hesitate to nick a tethered tongue using her fingernail if necessary. It does seem barbaric to us but perhaps these ancient people were wiser than we care to appreciate, and they would have been successful for thousands of years practising what was good for the baby. Lip-ties: It is common to see a smile showing a gap between the middle permanent upper- front teeth. These teeth are separated by a thick band of oral tissue which also ties the upper lip to the upper jaw bone and can restrict the movement of the lip. Similar to a tongue-tie, a lip-tie in the newborn can interfere with effective breastfeeding, though according to some doctors who treat these conditions, a lip-tie may be secondary to the tonguetie. So, look out for tongue-ties first. As teeth erupt into the mouth, a lip-tie can interfere with proper oral muscular function, preventing teeth from being effectively swiped clean by the tongue and lips and thus causing tooth decay. Therefore, children should be inspected for this restriction and have the lip-tie released as necessary. I recommend the book SOS 4 TOTS by Dr Lawrence A. Kotlow to learn more details about these tissue tethers. Adults with tongue-ties: In my dental practice nowadays, I look out for tongue-ties in all my patients. I see a great number of adults (approximately 60%) with varying degrees of tether. Releasing a tongue-tie was obviously not the trend when these adults were born. I observe that most of these adults also have underdeveloped jaws, sleep-disordered breathing, TMD and poor dental occlusion. Of course, a frenulectomy can be done at any age and adults who have had this done are known to report a sense of release in their upper body girdle, ease of stretching, improved breathing and sleeping, and/or reduction of chronic pain.

see That Sugar Film.) Beware that there is much hidden sugar in processed and packaged food that is commonly touted as healthy. These include cereals, fruit juices and low-fat dairy products. Some food can be allergenic and may cause nose congestions and blockages. Parents should take the opportunity whilst the child is very young and still under the parents’ control to get them used to eating real, natural foods that does not come out of a packet or a tube. There are many dietary guidelines on the internet and since I am not a dietitian, I am not able to be giving detailed advice on what your family should be eating. Parents should make educated decisions for the child on what to eat and set examples of good eating habits and food choices. Nevertheless, I generally recommend: • to not add sugar to your child’s food and drinks • that consumption of foods containing sugar should be minimised and your child must learn that this type of food is not for daily consumption • to train your child to enjoy food that is natural and to consistently develop such a healthy habit • to have your child learn that water is a great drink on its own • that your child needs sufficient amounts of fatsoluble vitamins such as vitamin D, A and K2 to aid absorption of calcium for the growth of teeth and bones • to read Dr Steven Lin’s book called The Dental Diet for a more comprehensive dietary guideline. It is important to note though that jaw muscle development, like many other areas of the body, relies on good exercises. So, the more chewing of fibrous or sinewy foods, such as raw fruit, vegetables and meat, the better. Baby food may be cooked soft especially for when the teeth are just starting to come through but, as soon as possible, give a piece of lamb chop or chicken drumstick for the child to hold and to gnaw. A piece of raw carrot or any piece of vegetable which is crunchy or chewy may also be suitable. These are foods that our hunter-gatherer ancestors gave to their children and, according to findings, they had wide, strong jaws with plenty of room for all their teeth. Real and natural food is best.

Real Food for Great Teeth When the infant transitions from breastfeeding to eating solid food as teeth begin to erupt, the child should be given real food with good nutritional value and food with various textures to learn to chew. There is an increasing awareness of the harmful effects of sugar on not just teeth but also on general health. (Anyone who has not yet seen it should 23

Thumb or Dummy Sucking Discourage thumb or finger sucking habits from a young age. These harmful habits tend to stay with the child for far too long and can be challenging to get rid of. When teeth begin to come through, any such lingering finger or thumb sucking habits can cause distortion in tooth alignment, resulting in an open bite or the bucked teeth appearance. Thumb sucking can distort the maxilla, forming an exaggerated narrow V-shape. It can drive the mandible back distally. And it obviously works against the Big 3 principle. There is an explanation offered that a child wants to suck their thumb or finger because it provides comfort from the contact with the palate. An alternate view is that the child does this as a need to swallow to suppress an urge to reflux. Whatever may be triggering these habits, they should be promptly discouraged. There are healthier ways to replace these sucking habits. Of course, the child should be using the tongue instead. The earlier we start on any such habit correction, the easier it will be. Apart from OM Therapy (see Chapter 7), there are some helpful tools to use under the guidance of the parents and dentist. For example, Myo Munchee (https://myomunchee.com) is a great little oral device that is particularly suitable for young children from 2–5 years old. When worn, it helps stimulates salivary flow, cleans teeth, trains to keep the mouth closed and to exercise lips and jaw muscles – all necessary for optimal dentofacial growth. Myobrace (https://myobrace.com) is another excellent product line which is designed to help the child achieve the Big 3. If possible, do not replace the thumb with a dummy (also known as pacifier in some countries) although, admittedly, the dummy may be easier to get rid of than the thumb or finger. It can also cause an open bite, distorts tooth alignment and works against the Big 3 principle.

as early as possible. Parents should set a good example. Flossing between your child’s back teeth (deciduous molars) can and should be carried out by parents regularly. Summary • Breastfeed for at least 6 months, ideally 12 months or even longer. • Feeding with a bottle is not quite the same. The artificial teat does not have the same structure as a mother’s breast nipple. It is not just about getting the best nutrients from the mother’s milk, it is also about the suckling as a stimulation for palate growth. • Tongue tether? Ensure baby’s tongue can move freely to enable a good latch onto mother’s nipple. • Transition to real, unprocessed food with various textures for the baby to learn to eat properly. No mushy food from a tube. Teach the baby to eat with mouth closed and to chew properly. • Observe and encourage the Big 3. • Teach baby to always breathe through the nose by keeping the mouth closed, but make sure nose is not easily blocked. Check tonsils and avoid any food that may promote production of mucus. • Avoid or be prepared to terminate the need to use a dummy or pacifier early. • Prevent early loss of baby teeth: maintain low exposure to sugar and practise good dental hygiene. References

1.J Dominguez et al, Recognition of obstructive sleep apnea in pregnancy survey, International Journal of Obstetric Anaesthesia, 2016; 26: 85–7. 2. LM O’Brien et al, Hypertension, Snoring, and Obstructive Sleep Apnea During Pregnancy: A Cohort Study, BJOG, 2014 Dec; 121(13): 1685–1693. 3. JP Smith & PJ Harvey PJ, Chronic disease and infant nutrition: is it significant to public health?,Cambridge University Press, 2011;14(2):279–89. 4 BG Palmer, 2003 Mar 4, The Uniqueness of the Human Airway, Sleep Review, viewed 2018 Sep, http://www.sleepreviewmag. com/2003/03/the-uniqueness-of-the-human-airway/

Preventing Early Loss Early loss of baby teeth, especially back teeth, may allow neighbouring teeth to creep into the space that is now empty, which can result in crowding and crookedness when adult teeth later attempt to erupt into the assigned space. This can be prevented by good oral hygiene which should be taught to children

5. SY Park, Sleep, Interrupted, Jodev Press, USA, 2012, p.17 6 DMB Hall & MJ Renfrew, Tongue tie, Archives of Disease in Childhood, 2005 Nov; 90;1211–1215 7. C Guilleminault, S Huseni & L Lo, A frequent phenotype for paediatric sleep apnoea: short lingual frenulum, ERJ Open Research, 2016 Feb:00043-2016

Featured*

Total Maxillary Arch Distalization with Bone Screws in Infrazygomatic Crest: A Clinical Cephalometric Study by Dr. Piyush Sanjay Patil

Dr. Piyush has graduated in dentistry from Terna Dental College, Mumbai, and currently pursuing his Masters in Orthodontics from Bharati Vidyapeeth Hospital, Sangli

Abstract To evaluate the efficacy of IZC bone screws and skeletal, dental and soft tissue cephalometric changes produced by total arch distalization of maxilla using Infrazygomatic Crest bone screw as anchorage. Materials and Methods A prospective sample of 13 patients (5 females and 8 males) who underwent total maxillary arch distalization treatment with Infrazygomatic Crest bone screw as anchorage system.Lateral cephalograms at the beginning of treatment (T0) and after class II molar correction (T1) were obtained. To compare cephalometric changes, paired t-test was used. A significance level of 5% was used. Results: Class I molar and class I canine relation was achieved in all patients. The IZC bone screw provided Molar distalization of 4.17 mm and intrusion of 1.25 mm with distal tipping of 3.7°. Significant Maxillary incisor retraction of 4.58mm and retroclination of 7.91° was observed. The upper lip in relation to E line was retracted by 1.1mm. Conclusion: Effective skeletal, dental, and soft tissue treatment results were achieved using IZC bone screw for total maxillary arch distalization. Keywords: Total Maxillary Arch Distalization , Infrazygomatic Crest, Bone Screw

Dr. Piyush Sanjay Patil

*This article has been peer reviewed

1. Patients age of 12 and above

Introduction Class II malocclusion is one of the most prevalent types of malocclusion in orthodontic practice, being observed in 38% to 50% of patients.1 It has been related to less favourable perceptions of facial and dental esthetics, contributing negatively to the quality of life and self-esteem of patients. The treatment for patients with Class II Division 1 malocclusion with skeletal maxillary excess can be either surgical or camouflage. Surgical correction is considered only in severe form of Class II malocclusion. On the other hand, in camouflage treatment, the upper premolars are extracted to resolve crowding, retract the incisor, and provide Class I canine relation.2 Another way of camouflage treatment is Molar distalization. However, the options for each require considerable cooperation of patients to fulfill their real goals.3 To overcome dependence on patient compliance, temporary anchorage devices (TADs) were introduced placed between the roots of posterior teeth to promote the retraction of anterior teeth.4,5 However, mini-screw have some major problems, such as a high rate of failure, interference with the path of tooth movement, and impingement on the roots of adjacent teeth.6 To overcome unwanted side effects, recent techniques such as maxillary arch distalization by bone screws are more effective and give good results. The Infrazygomatic crest (IZC) has been an obvious choice for bone screw insertion because of the thickness of the cortical plate and its distance from the dental arch. Its ability to be placed high up in the maxillary sulcus, i.e., in the infrazygomatic (IZ) area, allows unobstructed tooth movement during retraction.7 There were no prospective studies evaluating the effects of maxillary dentition distalization with bone screw implanted in the IZC. Therefore, the objective of this study was to evaluate the efficacy of IZC bone screws and skeletal, dental and soft tissue cephalometric changes produced by total arch distalization of maxilla using Infrazygomatic Crest bone screw as anchorage.

2. Patients with Angle’s class II division I malocclusion. 3. Protrusion of maxillary anterior teeth (3mm ≤ overjet ≤ 9mm) 4. Patients with straight profile 5. Angle’s class II molar due to molar mesialization 6. Patients having all permanent teeth erupted (except the third molar). 7. Patients with good oral hygiene. The subjects with the following conditions were excluded from the study: 1. Patients with a history of long-term medication of non-steroidal anti-inflammatory drugs and hormone supplements. 2. Syndromic or systemic diseases. 3. Periodontally compromised teeth. 4. Missing any anterior teeth. 5. Grossly carious teeth. 6. Extraction other than the third molar. Initially, all the essential orthodontics diagnostic records, i.e., orthopantomogram (OPG), lateral cephalogram (T0), study models, and intraoral and extraoral photographs, were taken. Orthodontic treatment was carried out with 0.22 slot MBT prescription and initial alignment and leveling till 19 × 25 stainless steel wire. Lignox 2% A was administered near the miniimplant sites. The two posterior IZ screws (Dentos, size 2 mm × 12 mm) were inserted between the first and second molar and 2 mm above the mucogingival junction in the alveolar mucosa that was directed at 90° to the occlusal plane (OP). After the initial notch in the bone, the screwdriver direction was changed by 55° to 70° toward the teeth and driving the screw to the IZ area of the maxilla. The bone screw was screwed in until only the head of the screw was visible outside the alveolar mucosa (Figure 1). PA view radiographs were taken to check the angulation and the height of insertion of bone screws, also the position of the bone screw in buccal direction for correct vector force application (Figure 2). There was no noticeable pain and discomfort to the patients post bone screw placement. The screws were loaded immediately with NiTi coil spring and a force of 300gm per side from mini-implants was applied in the anterior region to crimpable hooks (9mm) placed between lateral incisor

Materials and Methodology The present study was a prospective clinical cephalometric evaluation study. It involved 13 patients reporting to the Department of Orthodontics and Dentofacial Orthopedics for orthodontic treatment at Bharati Vidyapeeth Dental College And Hospital, Sangli, Maharashtra. Case selection for the study was done based on the following criteria: 26

total maxillary arch using IZC as anchorage was seveb to eight months. Post-distalization diagnostic aids i.e. orthopantomogram (OPG), lateral cephalogram (T1) , study models intraoral and extraoral photographs, were taken.(Figure 5) Lateral cephalograms were traced using Dolphin Imaging software (version 11.7, Dolphin Imaging and Management Solutions, Chatsworth, California). A total of two soft tissue, six skeletal, and dental measurements were made. Figure 1: Bone screw placement in Infrazygomatic Crest

Figure 5: Post distalization lateral cephalogram

Figure 2: PA view to check angulation of bone screw

and canine(Figure 3). The patients were recalled every 4 weeks, and the screws were checked for signs of mobility or infection. Out of 13 patients only two patients (male) showed unilateral bone screw failure on the left side. Primary investigation showed poor oral hygiene as a cause for failure of bone screws. The distalizing force was continued till class I molar and canine relation was attained(Figure 4). The average time for distalization of

Cephalometric Parameters : The lateral cephalogram were taken in a centric occlusion at T0 and T1. Sella – Nasion (SN) and Palatal plane (PP) was taken as horizontal plane and perpendicular to Palatal plane (PP) through Pterygomaxillary fissure point was taken as vertical plane(Figure 6) (Figure 7).

Figure 3: Distilization using NiTi coil spring

Figure 4: Class 1 molar and Class 1 canine relation post distalization

Figure 6: Cephalomatic analysis

Palatal plane – U6 crown: Vertical position of maxillary first molar Palatal plane – U7 crown: Vertical -position of maxillary second molar. Results: Present study evaluated the treatment effects of full arch distalization of maxilla using infrazygomatic crest implants (Dentos). Various parameters were used to evaluate the distalization. Data were analysed using SPSS software v.23 (IBM Statistics, Chicago, USA) and Microsoft office 2017. All characteristics were summarized descriptively. For continuous variables, the summary statistics of mean ± standard deviation (SD) were used. The difference of the means of analysis variables between two time points in same group was tested by paired t test. If the p-value was < 0.05, then the results were considered to be statistically significant otherwise it was considered as not statistically insignificant. SNA angle observed from pre and post distalization was statistically significant with p > 0.05 which indicate that the anteroposterior position of the maxilla with regard to cranial base is significantly changed. There was a statistically significant increase in ANB angle (p>0.05). Skeletal linear measurement of N ⊥ - Point A showed a statistically significant decrease from pre and post distalization. Both skeletal angular and skeletal linear measurements of mandible (SNB angle and N ⊥ Point B) showed statistically non significant change post distalization (Figure 8).

Figure 7: Cephalomatic analysis

Skeletal Angular Measurement: SNA: The Anteroposterior relationship of the maxillary basal arch to the anterior cranial base SNB: The Anterior limit of the mandibular base arch in relation to anterior cranial base ANB: The Maxillomandibular relationship to cranial base. N perpendicular - Point A: Sagittal position of maxillary base N perpendicular - Point B: Sagittal position of mandibular base Skeletal Linear Measurement: Ptm – Point A: Sagittal position of maxillary base Dental Angular Measurements : SN – U1 : Inclination of upper incisor to cranial base SN – U6 : Inclination of upper first molar to cranial base SN – U7 : Inclination of upper second molar to cranial base Dental Linear Measurements: In sagittal plane: Ptv – U1: Sagittal position of maxillary central incisor Ptv – U6: : Sagittal position of maxillary first molar

Figure 8: Skelatal cephalomatic changes

Ptv – U7 : : Sagittal position of maxillary second molar. In vertical plane: 28

The dental linear measurements of PTV-U1, PTV-U6 and PTV-U7 were found to be statistically significantly. Maxillary incisor retraction of 4.58 mm was seen.

Table 1: Conventional Cephalometric Analysis Of The Treatment Effects Of IZC “TOTAL MAXILLARY ARCH DISTALIZATION WITH BONE SCREWS IN INFRAZYGOMATIC CREST: A CLINICAL CEPHALOMETRIC STUDY.” PARAMETERSS FOR

PRE

POST

DISTALIZATION OF

TREATMENT

T2-T1

P value

Remark

SNA

84.04

0.99

81.03

1.38

-2.27

0.99

0.00012

SNB

78.56

0.79

78.66

0.96

0.1

0.5

0.5651

ANB

5.08

1.3

2.7

1.91

-2.38

1.15

0.00027

N ⊥ - Point A

4.95

0.53

3.63

0.43

-1.32

0.46

P<0.01* S*

N ⊥ - Point B

4.8

0.45

4.98

0.49

0.1

0.26

0.059

PTV – Point A

56.67

1.91

54.51

2.27

-2.16

0.66

P<0.01* S*

U1-SN

115.16 3.29

107.25 2.26

-7.91

3.08

P<0.01* S*

U6 - SN

77.16

1.26

73.66

1.30

-3.5

1.31

P<0.01* S*

U7 - SN

68.33

1.61

63.91

1.67

-4.42

0.9

P<0.01* S*

PTV – U1

57.58

1.67

0.85

-4.58

1.16

P<0.01* S*

PTV – U6

1.47

26.83

1.89

-4.17

1.02

P<0.01* S*

PTV – U7

17.30

1.18

16.11

1.43

-1.19

0.7

P<0.01* S*

PP – U6

1.34

20.75

1.48

-1.25

0.62

P<0.01* S*

PP – U7

17.3

1.18

16.11

1.43

-1.19

0.77

P<0.01* S*

Upper lip – E line

1.74

0.38

-0.95

1.03

-2.69

1.10

P<0.01* S*

Lower lip – E line

3.43

0.68

1.7

0.72

-1.7

0.82

P<0.01* S*

MAXILLARY ARCH

Figure 9: Dental cephalomatic changes

Distalization of the maxillary first molar was observed as 4.17 mm along with distal tipping of 3.7°. Distalization of 1.19 mm was observed with the second molar along with increased distal tipping of 4.42° Significant retroclination of the maxillary incisor (7.91°) was seen post distalization. Statistically significant amount of intrusion is seen with maxillary first and second molars (1.25mm and 1.19mm) (Figure 9). observed (p> 0.05). (Figure 10) (Table 1)

Table 1: Conventional Cephalometric Analysis Of The Treatment Effects Of IZC

Figure 10: Dental cephalomatic changes

Discussion: Orthodontics in its century of existence has had a lot of landmarks in its evolution, but very few can match the clinical impact made by recently introduced orthodontic Bone Screws. The advent of orthodontic Bone Screws has widened the horizon of orthodontic treatment where borderline extraction and surgical cases can now be treated with non-extraction and non-surgical approaches. Angle SNA was reduced by 2.27° post total maxillary arch distalization. Comparing with the present study Lee SK et al8 observed a clinically non significant reduction in Angle SNA of 1.07° using modified C palatal plate. Treating class II division 1 malocclusion with gummy smile Shaikh et al9 used IZC Bone Screw for en masse distalization and anterior mini-implants for intrusion. 1.1° reduction of SNA angle was observed which was found to be statistically non significant. In a recent study done by Rosa et al10, Angle SNA was reduced by 0.45° which was statistically non significant although in the same study the authors observed statistically significant change in ANB angle. Bechtold et al11 performed en masse distalization 29

using inter-radicular mini-implant and observed no significant skeletal maxillary effects. Doruk et al12 in his case report showed a decrease in SNA angle from 79° to 78°. There was a significant decrease in PTVPoint A (2.16 mm) that depicts the correction of dentoalveolar class II pattern. Statistically significant results were observed by Shahani et al13 and Shaikh et al9 with a similar reduction of 1.89 mm in PTV- Point A. Statistically significant changes in N ⊥ Point A were observed (1.32mm) in the present study. On the contrary, Lee SK et al8 observed no statistically significant changes in N ⊥ Point A with 0.85 mm. ANB angle showed a statistically significant change of 2.38°. Coincident with the present study Rosa et al10 observed a change of 0.75° in ANB angle. SNB angle and PTV – Point B both showed a slight increase of 0.1° which was statistically non significant. These results were in accordance with studies done by Shaikh et al,9 Rosa et al,10 Doruk et al.12 Molar distalization of 4.17 mm and intrusion of 1.25 mm were observed. The maxillary incisors were retracted 7.91 mm. Wilson Rosa et al10 found similar results using Infrazygomatic Crest implant with molar distalization of 4.7 mm and intrusion of 1.22 mm. Similarly, Wu et al.14 found distalization of molars (3.5 mm), intrusion of the molars (2.1 mm), and also retraction (4.3 mm) and extrusion (3.8 mm) of the maxillary incisors during a mean treatment time of eight months using IZC bone screw. Various other case reports showed effective en masse distalization of total maxillary arch.12,15 A similar magnitude of dental changes was showed by Bechtold et al.11 who achieved 4.2 mm of distalization and 3.4 mm of retraction of incisors using Inter-radicular mini-screw. Comparing the modified C-palatal plate (MCPP) with inter-radicular mini-screws, Lee et al.8 obtained greater amounts of distalization (4.2 mm) and intrusion (1.6 mm) with less distal tipping of the first molars (2°) and more extrusion of the incisors using MCPP. An important factor that influenced the results was the relationship between the line of action of the force from bone screw to the crimpable hook and the position of the centre of resistance (CR).16 The IZC Bone Screws promoted a clockwise rotation of the maxillary occlusal plane because the line

of force passed below the CR. But in this present study this force vector was counteracted by long crimpable hooks (9 mm). This prevented rotation of the maxillary occlusal plane. The differences in the amount of tooth displacement seemed to be due to the vertical position of the bone screw and the height of the hooks and variations in the direction of the force vector.7,17 The bone screw were implanted in the IZC approximately 14-16 mm above the occlusal plane and the length of the hook was 9 mm. In the vertical linear measurements, maxillary molar intrusion of -1.25mm with first molar and -1.19mm with second molar was observed. Although the intrusion observed in maxillary second molar (-1.19) was less in comparison to study done by Shahani et al13 (2.5mm) and similar to Lee SK et al8 (-1.18). This was the result of biomechanics that was applied in the present study where height of crimpable hooks were 9mm leading to force vector passing through CR of maxillary dentition and achieving en masse bodily distalization of the maxillary arch.17,18 In the previous studies due to the reduced height of crimpable hooks and vector force passing below the CR, molar intrusion was seen which was not favourable for deep bite corrections.10,14,17 The Upper lip - E line was reduced by 2.69 mm which was statistically significant. Similar results were observed by Shaikh et al9 who showed a upper lip retraction of 2.1mm. Shahani et al13 observed a statistically significant change in Upper lip- E line (0.54 mm). This retraction of the upper lip greatly improved the profile of the patient and helped the patient to achieve lip competence. The lower lip – E line reduced by 1.7 mm which was statistically significant, which improved the position of lower lip in relation to the upper anteriors. Conclusion 1. Class I molar and Class I canine relation was achieved with total maxillary arch distalization using infrazygomatic crest bone screw as anchorage. 2. Effective molar distalization of -4.17 mm was observed after en-masse distalization of maxillary arch. 3. Significant maxillary incisor retraction of -4.58 mm was achieved.

References 1. Almeida MR, Pereira ALP, Almeida RR, Almeida-Pedrin RR, Silva Filho OG. Prevalence of malocclusion in children aged 7 to 12 years. Dental Press J Orthod. 2011;16(4):123–131. 2. Graber LW Vanarsdall RL Vig KWL. Orthodontics : Current Principles & Techniques. 5th ed. Philadelphia PA: Elsevier/Mosby; 2012.

Orthodontics. 2020 Apr 6:445-54. 17. Sung EH, Kim SJ, Chun YS, Park YC, Yu HS, Lee KJ. Distalization pattern of whole maxillary dentition according to force application points. The korean journal of orthodontics. 2015 Jan 1;45(1):20-8. 18. Khan J, Goyal M, Kumar M, Kushwah A, Kaur A, Sharma M. Comparative evaluation of displacement and stress distribution pattern during maxillary arch distalization with Infra Zygomatic Screw-A three dimensional finite element study. International Orthodontics. 2021 Jun 1;19(2):291-300.

3. Umale V, Jalgaonkar N, Patil C, Gangadhar MB, Sheth S. Molar distalization–A review. Indian Journal of Orthodontics and Dentofacial Research. 2018 Jul;4(3):146-50. 4. Cope JB. Temporary anchorage devices in orthodontics: a paradigm shift. InSeminars in orthodontics 2005 Mar 1 (Vol. 11, No. 1, pp. 3-9). WB Saunders. 5. Melsen B. Mini-implants: where are we?. Journal of clinical orthodontics. 2005 Sep 1;39(9):539 6. Giudice AL, Rustico L, Longo M, Oteri G, Papadopoulos MA, Nucera R. Complications reported with the use of orthodontic miniscrews: A systematic review. Korean Journal of Orthodontics. 2021 May 25;51(3):199-216. 7. Almeida MR. Biomechanics of extra-alveolar mini-implants. Dental Press Journal of Orthodontics. 2019 Sep 5;24:93-109. 8. Lee SK, Abbas NH, Bayome M, Baik UB, Kook YA, Hong M, Park JH. A comparison of treatment effects of total arch distalization using modified C-palatal plate vs buccal miniscrews. The Angle Orthodontist. 2018 Jan;88(1):45-51. 9. Shaikh A, Jamdar AF, Galgali SA, Patil S, Patel I, Sushilamma M. Efficacy of Infrazygomatic Crest Implants for Full-arch Distalization of Maxilla and Reduction of Gummy Smile in Class II Malocclusion. Dent Pract. 2021 Oct 1;22(10):1135-43. 10. Rosa WG, de Almeida-Pedrin RR, Oltramari PV, de Castro Conti AC, Poleti TM, Shroff B, de Almeida MR. Total arch maxillary distalization using infrazygomatic crest miniscrews in the treatment of Class II malocclusion: a prospective study. The Angle Orthodontist. 2023 Jan;93(1):41-8 11. Bechtold TE, Kim JW, Choi TH, Park YC, Lee KJ. Distalization pattern of the maxillary arch depending on the number of orthodontic miniscrews. The Angle Orthodontist. 2013 Mar;83(2):266-73. 12. Doruk C, Cankaya O, Guvenc I. Non-extraction treatment of skeletal class II adult patient with total maxillary arch distalization. TURKISH JOURNAL OF ORTHODONTICS. 2015;28(4).. 13. Singh G, Gupta N, Goyal V, Singh R, Izhar A, Walia S, Singhal C. En masse distalisation of maxillary arch using TADs (IZC); passive self-ligating appliance v/s clear aligner–a comparative cephalometric study. Journal of Contemporary Orthodontics. 2019 Jul;3(3):11-7. 14. Wu X, Liu H, Luo C, Li Y, Ding Y. Three-dimensional evaluation on the effect of maxillary dentition distalization with miniscrews implanted in the infrazygomatic crest. Implant Dentistry. 2018 Feb 1;27(1):22-7. 15. Yezdani AA, Chatterjee P, Kumar SK, Padmavathy K. Correction of Class II Skeletal Malocclusion with an Infra-Zygomatic Crest Bone Screw Approach. Indian Journal of Public Health Research & Development. 2019 Dec 1;10(12) 16. de Almeida MR. The Biomechanics of Extra‐alveolar TADs in Orthodontics. Temporary Anchorage Devices in Clinical

Practice Management

The Biggest Decision You Will Ever Make in Your Professional Life by Scott J Manning, MBA

Each morning, a new day dawns filled with both challenge and opportunity – and if you’re one of the few, the proud who honor and respect this noble profession, more accurately the “calling” of Private Practice Dentistry, you’ll see it as yet another chance to roll up your sleeves and make many good things happen. But when that day ends, the stadium clears, and the scoreboard clock winds down to zero, what can you as head coach point to as the key factor in assessing the final tally? Was it the amount of busyness experienced inside the walls of your practice? The flurry, the hubbub, the rush from patient to patient, the mad dash to fully pack the day with activity? Was it all about the “doing” of the stuff we call Dentistry? I guarantee it wasn’t, not by a long shot, even though this sort of expectation and analysis does mesh well with what’s considered conventional wisdom nowadays. The answer does not lie in more activity. Nirvana, Heaven, the Promised Land does exist, but it’s attainable only to those who recognize busyness as a symptom, not a strategy. The true path appears when you abandon Activity for Accomplishment. Tasks for Results. Actions for OUTCOMES. What does it matter if you invest minutes, hours, days, weeks, months, or years into activities that fail to move the needle either for your patient’s ultimate health or your practice’s financial future? Back when Microsoft was king of the hill, someone calculated that if Bill Gates spotted a $100 bill on the ground, it wouldn’t have been worth his

time to stop and pick it up. It’s a perfect illustration of the importance of time and the mindset we must rigorously develop, nurture, and guard against every assault. Greatness doesn’t just happen, it rises and grows and thrives in an environment where it’s both welcomed and nurtured, which is why it’s so rarely embraced or seen. And a misguided focus and overattention on filling every moment of every day with “something/anything,” regardless of strategic value, is why so few doctors – probably 20% or less – experience true greatness via a practice designed from the ground up around their goals, dreams, and values, while the other 80% remain mired in mediocrity and frustration. The secret, the key, the true North Star for this kind of practice requires persistent FOLLOWTHROUGH on all fronts, an all-hands-on-deck effort that involves every team member pulling for every patient to ensure no one gets left behind. The greatest reason why such a team, even though fully empowered, fully engaged, fully in line with the greater mission and greater good, would fail to achieve overwhelming success – boils down to one simple reality of life and existence. Inertia It’s a universal law, noted by Newton, that a body in motion will stay in motion and a body at rest will stay at rest. Thus, every team and every individual has an inherent, natural, tendency to quit too early… stop short… give up… when the moment demands otherwise. And the demands of each moment, when viewed objectively and outside the fog of “busyness for the 32

This isn’t about micromanaging or inserting yourself into every interaction and decision. It’s about making a stand to make sure what’s promised equals what’s delivered – and that’s the very minimum acceptable standard.

sake of busyness,” require focus and energy and total integrity to ensure that the greater goal is never sacrificed or left to wither on the vine. We must make certain a patient’s far better tomorrow doesn’t get shortchanged by a shortsighted fixation on doing merely what insurance will fully cover and then no more, regardless of the ultimate consequences. This means committing to complete health treatment planning without scrimping or cutting corners or letting them wander off without the wise counsel they need to make wise decisions. How does this play out in what happens in the moment? With every patient interaction outside your practice – from that initial phone call, the very first time they speak with a team member who listens to their needs, answers their questions, and makes sure they are embraced into the fold as a real human being whom you’d never abandon to randomly disappear into oblivion. With every conversation within your practice – as you establish the triangle of trust for that patient so they know they will be served at the highest level of compassion, professionalism, and care every step of their journey to comprehensive health. With every interaction regarding money – ensuring total clarity about not only responsibility, but also the ultimate value brought into that patient’s life – far beyond “clean, drill, and fill” – instead, constantly reaffirming a transformational vision of just how much better health and life and self-worth can become. These aren’t merely instances of one-off banter between doctor, team, and patient – they reflect a dedicated commitment to follow through to ensure that what’s been promised actually takes place: from the smallest commitment to the greatest. Full on integrity from beginning to end, alpha to omega. What I’m referring to goes beyond a few platitudes or even motivational posters on the wall. This must be embedded deep within culture, expressed in every action of every day. From the morning huddle to the daily wrap-up, there must be follow-up on commitments made to assess progress towards accomplishments and results. Ultimately, it’s your hand at the wheel. Therefore, the bottom line is that you must think through where you yourself are taking things too easy, where you

yourself are giving away too much control. This isn’t about micromanaging or inserting yourself into every interaction and decision. It’s about making a stand to make sure what’s promised equals what’s delivered – and that’s the very minimum acceptable standard. Thus, we come to what I call: “The Biggest Decision You Will Ever Make in Your Professional Life…” • Don’t just do what’s easy, do what matters. •Apply this to your Team… • Apply this to all your Relationships… • Apply this to the Comprehensive Health you provide… And most importantly of all… Apply this to your GOALS… because they provide the focal point for every decision and every action. This brings me to the critical understanding that not every “action, goal, responsibility” is equal or worth the same. Seek wisdom and clarity to recognize what matters most. You’re only able to follow through to your utmost ability on opportunities of the absolute highest value by removing or minimizing that which is of low value. RUN THROUGH THE FINISH LINE in everything you deem worthy enough to say, commit to, and do – go all in on everything that matters most. Every moment is precious. Once gone, it’s gone forever. Do not allow it to pass unappreciated and undervalued. Maximize each and every one. 33

Tips from the Experienced

The Eyelet Part 1

By Dr.Adrian J. Palencar, MUDr, MAGD, IBO, FADI, FPFA, FICD

Dr. Adrian J. Palencar Dr. Palencar is an IAO Master Senior Instructor, IAO Education Committee Examiner, and a Consultant to the IJO and Spectrum Ortho.

3. Flat - round metal base 3.5 mm diameter, with soldered eyelet 4. Tooth eruption appliance. Flat - round or curved - rectangular metal base, gold plated, or metal Nickel-Lite material Eyelet. It is attached to either gold plated, silver or Metal Nickel-Lite chain.The lumen in the eyelets is round and it accepts up to a .021 x .025 arch wires. It is easy to attach power thread, ligature tie and any arch wire.

In the many orthodontic courses, the author has attended or presented, not too much attention was given to the humble Direct Bond Eyelet. After being pushed to the corner at the start of the SWA (Straight Wire Appliance) on the TMD patient, the author, who never used an Eyelet before (except with the chain as a traction for eruption of an impacted tooth) researched further this topic. Direct Bond Eyelet 1. Tooth coloured composite with a rectangular flat base 2. Metal Nickel-Lite material with a rectangular curved base 3.75 x 3.0 mm

References: 1. 2.

Cerum Ortho Organizers Catalogue, E 8 Website search

Featured*

A Survey of Trends and Preferences in Orthodontic Retention By Dr Amina Malik, Dr Rozina Nazir, Dr. Usman Ahmed, and Dr. Tania Arshad, Foundation University College of Dentistry and Hospital

Dr Amina Malik PGT BDS Data Collection and Manuscript Writing Orthodontics Department, Foundation University College of Dentistry and Hospital

Dr Rozina Nazir (HOD) BDS, FCPS, MHPE Professor Conception, Design of Study Orthodontics Departmen, Foundation University College of Dentistry and Hospital

Dr Usman Ahmed Assistant Professor) BDS, FCPS, MOrth Data analysis and Interpretation Orthodontics Department, Foundation University College of Dentistry and Hospital

Dr. Tania Arshad Assistant Professor BDS, FCPS Data Analysis and Interpretation Orthodontics Department, Foundation University College of Dentistry and Hospital

Abstract Introduction: Retention is required after every orthodontic treatment. However, there is no consensus among the orthodontists on a single type of retainer or the time for which retention has to be continued. This survey aims to highlight the most common choices of retainers and the retention protocol among the orthodontists of Pakistan. Materials and Methods: This cross-sectional descriptive study was conducted using a wellconstructed and pilot tested validated survey instrument 5 used to identify the most commonly used retention protocols and orthodontic retainers suggested by orthodontists in Pakistan. Survey questionnaire consisted of 20 questions and was shared through Google forms with 119 orthodontists throughout the country. Information was gathered regarding types of retainers, duration of time for wear, prescribed use of fixed retainers, number of debonds per year and appointment schedules. Results: Out of 119 orthodontists, 98 (82.35%) responded during a four-week period. Most commonly used retainers were reported to be vacuum formed retainers (VFRs) in maxillary arch (65.3%) and fixed lingual retainers in mandibular arch (61.2%). Post retention appointments varied with the number of years in practice and volume of patients debonded, along with type of prescribed retainer. Conclusions: This study is the first to describe retention protocols and the scheduling of retention appointments in Pakistan. VFRs have been most popular for retention among orthodontists of Pakistan. Keywords: Orthodontic retainers, choice of retainers, retention protocol, retainers

*This article has been peer reviewed

Introduction: After orthodontic treatment, the dento-alveolar structures remain dynamic and are subject to changes especially during the third and fourth decade, if not throughout life.1 This is because the teeth may be unstable in their new position and tend to move back due to tension in periodontal ligament and gingival fibers, particularly the supragingival and transeptal fibers. Sometimes final occlusion also affects the stability of the orthodontic outcome, with unwanted displaced occlusal contacts and forces from orofacial musculature along with ongoing growth all forcing the teeth back to their position.2 Retention is the only way to resist these changes and ensure long-term stability of the achieved treatment results making it an essential part of orthodontic treatment plan.3 Most of the retainers being used in orthodontics fulfil these primary functions so the choice of retainers primarily remains on other biologic properties of individual appliances such as maintenance of optimal oral hygiene, distribution of functional forces on all teeth, periodontal health and aesthetics. Many studies shed light on relative effectiveness of different appliances;4 however, there is no consensus on most effective protocol or on duration of time for wearing of retention device. Due to absence of scientific evidence, selection of retainer is often based on individual preference. Selection of retainer shows a marked geographical variation with maxillary Hawley’s or vacuum-formed retainers (VFR) and mandibular fixed lingual retainers (FL) with full-time wear of removable retainers (RR) most popular in the USA.5 In Australia and New Zealand, mandibular fixed and maxillary vacuum-formed retainers are shown to be the most preferred combination, while a preference for the use of fixed retainers in both arches has been shown in Netherlands.6 The most commonly used retainers among Iraqi orthodontists in the upper arch is a combination of VFRs and fixed retainers; fixed retainer was predominant in the lower arch.7 The duration of orthodontic retainer wear has been a long-debated topic in orthodontics.4 Due to occurrence of relapse several years after orthodontic treatment, many orthodontists are shifting from removable temporary retention towards permanent retention to ensure long term stability of post-treatment tooth positions.7 However, prolonged retention has shown to pose problems in the periodontium and dental hard tissues; therefore, it is very important to study the possible side

effects of long-term use of fixed and removable retainers on supporting tissues of oral cavity.8 The purpose of this study was to find out the most popular retainer and retention protocol used by orthodontists of Pakistan. The study included all certified orthodontists of Pakistan registered with “Pakistan Association of Orthodontists” (PAO) working in good practice with the association. Materials and Methods: Ethical approval was sought from Ethical Review Committee of Foundation University College of Dentistry and Hospital. A pre-validated survey questionnaire5 including questions regarding commonly used retainer devices and protocols was shared via text message through an online link of Google forms. Closing time of survey was four weeks. A reminder was sent two weeks before the link closed. The survey consisted of 20 questions, which were divided into sections to determine information regarding sample demographic details, most commonly used maxillary and mandibular retainers, questions related to retainer follow-ups, and a few highlighting the typical schedule for retainer checks. The questionnaire was shared with 119 certified orthodontists who were members of Pakistan Association of Orthodontists and were in good standing status treating patients all over the country. Experience of orthodontists ranged from less than one year to more than 20 years. Statistical Analysis: Data were exported into SPSS (version 21.0; SPSS, Chicago, 111) for statistical analysis. Data was analysed using descriptive stats. Responses to questions were grouped based on the frequencies and percentages. Chi square test was used to associate descriptive variables with choice of retainer along with use and P value of ≤ 0.05 was considered statistically significant. Results A questionnaire was sent to 119 certified orthodontists, out of which 98 responded by the end of four weeks, providing a response rate of 82.35%. Their time of practice varied from less than one to more than 20 years with number of debondings varying from less than 150 cases to more than 300 cases. The demographic details of the study participants are shown in Table 1, showing there were more male orthodontists (59.2%) with majority orthodontists (59.2%) having experience 36

of six to 15 years. Orthodontists’ preference for maxillary, mandibular retainers is shown in Figure 1 with the majority of orthodontists showing preference for VFRs in maxillary arch (65.3%) and bonded lingual retainers in the lower (61.2%). Table 1: Demographic characteristics of certified orthodontists in the study

Characteristic

Female

Table 2: Retention and Post Retention protocols in Maxillary and Mandibular Arches

n (%)

Sex Male

Table 2 shows details of retention and post retention protocols schedule prescribed by orthodontists. Of those participating orthodontists, 95.9% recommended full-time wear of maxillary removable retainers. For the part-time wear of maxillary removable retainers, 32.7% of respondents recommended 16 hours of wear per day, whereas 34.7% were in favour of about eight hours

Attitude Towards Maxillary Removable Retainers

n (%)

58 (59.2)

Q6: If maxillary removable retainer is given, is full time wear(20h) prescribed Yes

94 (95.9)

40 (40.8)

04 (4.1)

Years of practice

Q7: Duration for wearing maxillary removable retainer <3 months

12 (12.2)

3-9 months

62 (63.2)

0-5 years

8 (8.2)

>9 months 24 (24.5) Q8: Duration for wearing maxillary retainer part-time wear (less than 20h)

6-15 years

58 (59.2)

About 16 hours/day About 8 hours/day Tapering from 16 hours/ day to occasional wear

34 (34.7) 32 (32.7) 20 (20.4)

16-25 years

20 (20.4)

Tapering from 08 hours/ day to occasional wear

07 (7.1)

Patient decides amount of wear time

05 (5.1)

Attitude Towards Mandibular Removable Retainers

n (%)

>25 years

12 (12.2)

Q10: If mandibular removable retainer is given, is full time wear(20h) prescribed

Number of debonds

Yes

80 (81.6)

<150

86 (87.8)

No Q11: Duration for wearing mandibular removable retainer

18 (18.4)

150-300

8 (8.2)

<3 months 3-9 months

16 (16.3) 66 (67.3)

>300

4 (4.1)

>9 months 16 (16.3) Q12: Duration for wearing mandibular retainer part-time wear (less than 20h) About 16 hours/day About 8 hours/day Tapering from 16 hours/ day to occasional wear

16 (16.3) 20 (20.4) 40 (40.8)

Tapering from 08 hours/ day to occasional wear

18 (18.3)

Patient decides amount of wear time Questions regarding discontinue use of Removable Retainer

04 (4.1) n (%)

Q13: Instruct to stop wearing removable retainers No, wear retainers forever

38 (38.7%)

Yes, <2 years after debond Q14: Instruct to have fixed retainers removed

60(61.2%)

Yes 28 (28.6%) No 70 (71.4%) Q15: If yes in Q14 When do you instruct to have fixed lingual retainer removed?

Figure 1: Orthodontists’ Preference for Maxillary and Mandibular Retainers

<2 years after debonding

2(7.1)

2-5 years after debonding >5 years after debonding After 3rd molars are extracted

12(42.9) 14(50) 0

of wear per day. Regarding the mandibular removable retainer, 83.3% of respondents recommended full-time wear. For the part-time wear of mandibular removable retainers, 40.8% of respondents recommended 16 hours of wear per day in the start and gradually tapered to occasional wear. Of respondents, 59.2 % recommended maxillary retention for three-to-nine months, whereas 20.4% recommended it more than nine months. For the mandibular retainers, 66% of the respondents recommended a duration of three-to-nine months, whereas only 16% were in favour of more than nine months. For the duration of fixed retainers in general, 71.4% of the total respondents did not recommend its removal after five years, as compared to 16.3% who recommended its removal within two-to-five years. Table 3 summarizes retention check appointments for maxillary and mandibular arches. Many orthodontists (53.1%) kept first appointment for checking retainers oneto-two months after debonding, with significant decline over follow-up appointments from the second-to-fifth appointment.

Table 4 shows summary of chi square tests. The results were significant, with number of debonds and most commonly used maxillary retainers (P value=0.00). Three variables showed significant results with gender, i.e. mandibular removable retainer full-time wear (P value =0.02). Instructions to stop wearing removable retainers (P value =0.02), fifth appointment after debonding (P value =0.04). Fourth appointment after debonding (P value =0.00) and fifth appointment after debonding (P value =0.00) showed significant results with years of practice. Fifth appointment after debonding also showed significant result with number of debonds (P value =0.05). Second appointment after debonding showed significant result when compared to most commonly used mandibular retainer (P value =0.04). Retention is an important part of orthodontic treatment about which orthodontists have varying views. Out of 98 respondents, 59.2% were male orthodontist with majority (59.2%) having over six to 15 years of experience. A Table 4: Summary of Chi square Tests

Table 3: Retention Check Appointments for Maxillary and Mandibular Arches Retention checks protocol

Variables

n (%)

First appointment after debonding <4 weeks after debonding

34(34.7)

1-2 months after debonding

52(53.1)

>2 months after debonding

4 (4.1)

No retention appointment; patient dismissed

8 (8.2)

Second appointment after debonding <3 months after the first appointment

4 (4.1)

3-5 months after the first appointment

11(11.2)

>6 months or greater after the first appointment

11(11.2)

No second appointment; patient dismissed

72(73.5)

Third appointment after debonding <6 months after the second appointment

2(2)

6-11 months after the second appointment

7(7.1)

>1 year after the second appointment

8(8.2)

No fourth appointment; patient dismissed

81(82.7)

Fourth appointment after debonding <6 months after the third appointment

1(1)

6-11 months after the third appointment

1(1)

>1 year after the third appointment

8(8.2)

No fourth appointment; patient dismissed

88(89.8)

Fifth appointment after debonding <6 months after the fourth appointment

1(1)

6-11 months after the fourth appointment

1(1)

>1 year after the fourth appointment

6(6.1)

No fifth appointment; patient dismissed

90(91.8)

Q1 Gender

χ2=2.5 p-value=0.48

χ2=2.4 p-value=0.29 χ2=3.2 p-value=0.79

χ2=0.27 p-value=0.87 χ2=4.5 p-value=0.61

χ2=1.3 p-value=0.51 χ2=5.3 p-value=0.50

χ2=48.8 p-value=0.00*

χ2=5.6 p-value=0.23

Q2 Years of practice

χ2=2.5 P-value=0.48

Q3 Number of debonds

χ2=2.4 p-value=0.29

χ2=3.1 p-value=0.78

Q4.Most commonly used maxillary retainer

χ2=0.26 p-value=0.87

χ2=4.5 p-value=0.61

Q5 Is Full time wear of maxillary removable retainer prescribed (more than 20 hours) Q6 Maxillary removable retainer full time wear

χ2=2.8 p-value=0.09

χ2=2.9 p-value=0.41

χ2=0.58 p-value=0.75

χ2=0.20 p-value=0.89

χ2=3.3 p-value=0.18

χ2= 5.9 p-value=0.42

χ2=4.24 p-value=0.37

χ2=7.35 p-value=0.11

Q7 Maxillary removable retainer part time wear protocol Q8 Most commonly used mandibular retainer

χ2=3.3 p-value=0.18

χ2=5.9 p-value=0.42

χ2=4.2 p-value=0.37

χ2=2.8 p-value=0.09

χ2=1.3 p-value=0.51

χ2=5.2 p-value=0.50

χ2=5.6 p-value=0.22

χ2=4.1 p-value=0.38

Q9 Is Full time wear of mandibular removable retainer prescribed (more than 20 hours) Q10 Mandibular removable retainer full time wear

χ2=0.03 p-value=0.84

χ2=6.72 p-value=0.80

χ2=1.98 p-value=0.98

χ2=6.4 p-value=0.59

χ2=5.4 p-value=0.02*

χ2=2.1 p-value=0.55

χ2= 2.9 p-value=0.22

χ2=1.1 p-value=0.56

Q11 Mandibular removable retainer part time wear

χ2=2.5 p-value=0.65

χ2=16.9 p-value=0.15

χ2=1.9 p-value=0.98

χ2=6.5 p-value=0.59

Q12 Instructions to stop wearing removable retainers Q13 Instructions to get fixed lingual retainers removed at any time Q14 When do you instruct them to get them removed

χ2=5.4 p-value=0.02*

χ2=2.1 p-value=0.56

χ2= 2.9 p-value=0.22

χ2=1.3 p-value=0.51

χ2=1.13 p-value=0.57

χ2=1.2 p-value=0.26

χ2=1.2 p-value=0.75

χ2=1.9 p-value=0.38

χ2=1.4 p-value=0.50

χ2=1.4 p-value=0.48

χ2=0.14 p-value=0.93

χ2= 4.9 p-value=0.54

χ2= 2.8 p-value=0.23

χ2=1.3 p-value=0.52

χ2= 3.2 p-value=0.52

Q15 1st appointment after debonding

χ2=2.6 p-value=0.4

χ2=12.3 p-value=0.19

χ2=4.7 p-value=0.57

χ2=7.5 p-value=0.27

χ2=6.3 p-value=0.38

Q16 2nd debonding

appointment

χ2=1.2 p-value=0.75

χ2=10.5 p-value=0.3

χ2=7.4 p-value=0.28

χ2= 2.9 p-value=0.81

χ2=13.1 p-value=0.04*

Q17 3rd appointment after debonding

χ2=2.4 p-value=0.48

χ2=9.7 p-value=0.36

χ2=6.9 p-value=0.32

χ2=5.1 p-value=0.52

χ2=4.4 p-value=0.61

Q18 4th appointment after debonding

χ2=2.5 p-value=0.48

χ2=28.8 p-value=0.00*

χ2=1.5 p-value=0.95

χ2=2.3 p-value=8.9

χ2=7.8 p-value=0.24

Q19 5th appointment after debonding

χ2=8.3 p-value=0.04*

χ2=23.9 p-value=0.00*

χ2=12.5 p-value=0.05*

χ2=3.5 p-value=0.73

χ2=7.3 p-value=0.29

χ2=4.1 p-value=0.38

*Shows statistically significant result with p value ≤ 0.05

greater percentage of male orthodontists (37.7%) use mandibular fixed lingual retainers than female orthodontist in mandibular arch. Male orthodontists reported to have debonded more patients per year than female orthodontists (59.1%). These findings are in accordance with the study by Valiathan.5 Gender was an important variable as three variables showed significant results with gender, i.e. mandibular removable retainer full-time wear (p=0.02), instructions to stop wearing removable retainers (p=0.02), and fifth appointment scheduled after debonding (p=0.04), indicating that more male orthodontists recommended these. Fourth appointment (p=0.00) and fifth appointment (p=0.00) showed significant results with years of practice indicating that orthodontists with experience in range six to 15 years recommended more recall visits. Fifth appointment also showed significant result with number of debonds (p=0.05), as the number of debonds were less than 150, orthodontists were more likely to schedule a fifth appointment. According to this study, the most preferred retainers are VFRs for maxillary arch and fixed lingual for mandibular arch. The results were significant with number of debonds and most commonly used maxillary retainers (p=0.00), indicating lesser experienced dentists with debonds less than 150 preferring VFRs. The results of this study are comparable to a number of studies which have been conducted all over the world. According to a study by Lasance SJ et al9 published in 2016, orthodontists in Saudi Arabia, New Zealand most preferred upper retainer used was the Hawley retainer (65.7%) unlike this study most commonly preferred retainer was VFR for maxillary arch and fixed lingual retainer for mandibular arch. Choice of fixed lingual retainer for mandibular arch by Saudi orthodontists is in agreement with our study but choice of Hawley retainer for maxilla is not.10 Similar results were shown by another study by Andriekute et al,11 which was published in 2017, who evaluated mostcommonly used retainers and retention protocols used by orthodontists of Lithuania. Their first-choice option for the maxillary arch was Hawley retainer and fixed retainer for mandibular arch. This too was in opposition to the results of our study in which majority of orthodontists have preferred VFR in maxilla. On contrary, a study done by Meade et al12 showed the inclination of Australian orthodontists towards thermoplastic retainers in case of the maxillary arch (39.4%) and bonded lingual retainers in the mandibular arch (38.5%). The choice of fixed retainer in mandibular arch by Pakistani orthodontists matches with the results of all these studies.13

According to the current study, the most preferred choice of orthodontists in Pakistan is VFRs in maxillary arch. A study which took place in Ireland by Wild J et al14 found VFRs to be the most common retainer choice in the maxillary and mandibular arches with full-time wear followed by part-time wear of removable retainers. A study published in India15 claimed that Hawley’s retainer in maxillary arch and fixed retainer in mandibular arch were the most chosen retainers. VFR was preferred because of immediate delivery, but problem of breakage and discoloration were reported. Orthodontists of the USA prefers Hawley or VFR in the maxillary arch and the bonded retainer in the lower arch.16 In Norway, a combination of bonded and removable retainers in the upper arch is used along with bonded retainers in the lower arch.17 This finding that bonded retainers are preferred in lower arch coincide with our findings. According to a trial which was funded by the Saudi Swiss Consultant Dental centre, VFR was more acceptable than Hawley’s retainer in appearance, speech, confidence and comfort.18 This is consistent with the findings of this study. Eight questions were regarding retention schedule prescribed by orthodontists. Of the orthodontists, 95.9% recommended full-time wear of maxillary removable retainers. For the part time wear of maxillary removable retainers, 32.7% of respondents recommended 16 hours of wear per day, whereas 34.7% were in favour of about eight hours of wear per day. According to the literature,19 most of the orthodontists prefer to advise full-time removable retainer wear both in the maxillary and the mandibular arches but some recommend part-time wear. Questions 16 to 20 shed light on the appointment schedule for retention checks protocol following debonding. Of the orthodontists, 53.1% recommended the first appointment within one-to-two months of debonding, whereas 34.7% preferred it to be within four weeks. The majority of the respondents recommended no further appointments for retention checks. In the present study majority of orthodontists (50%) recommended wear of fixed lingual retainer for more than five years indicating lifetime retention. This recommendation is to achieve long term stability and maintain alignment of teeth. In a study by Zachrisson it was recommended to use fixed lingual retainers till the third molars erupt due to post-pubertal growth and dental changes that occur during that time.20 Second appointment scheduled after debonding showed significant result when compared to most commonly used mandibular retainer (p=0.04), 39

indicating fewer orthodontists calling for second appointment after giving fixed retainer. Like many survey studies response rate was high 82% but not 100%. However, the questionnaire was sent to PAO members which is the largest orthodontic association in the country, the non-responders would not have differed from the responders substantially in this study. Since there was no similar study carried out previously in Pakistan, we were not able to conclude if there was a shift in retention practices in the country over the period of past years or not. Also this questionnaire does not include malocclusion specific retention protocol. This study also does not take the viewpoint of patients regarding retention awareness and appointment follow ups. So further studies can be carried out to cater for the above mentioned limitations. In conclusion, orthodontists in Pakistan reported Vacuum Formed Retainers as most popular for retention in maxillary arch and fixed lingual retainers in mandibular arch. Conclusions: This study is the first to describe retention protocols and the scheduling of retention appointments in Pakistan. VFRs are most popular for retention in maxillary arch and fixed lingual in mandibular arch among Orthodontists of Pakistan. Most orthodontists recommended wear of fixed lingual retainer for more than five years indicating lifetime retention. The retainers were checked by the majority at the first appointment after debonding but the response significantly decreased in further months to check the retainers. The results of the present study may also allow clinicians to compare their practice to others with similar gender and experience. Acknowledgement: We are thankful to the orthodontists who participated in this study. References:

1. Proffit, W.R. & White Jr, R.P. Combined surgical-orthodontic treatment: how did it evolve and what are the best practices now? Am. J. Orthod. 2015 May 1;147(5):S205-15 2. Millett D. The rationale for orthodontic retention: piecing together the jigsaw. Br. Dent. J.2021 Jun; 230(11):739-49.

5. Valiathan, M. & Hughes, E. Results of a survey-based study to identify common retention practices in the United States. Am. J. Orthod. 2010 Feb 1;137(2):170-7 6. Jin, C., Bennani, F., Gray, A., Farella, M. & Mei, L. Survival analysis of orthodontic retainers. Eur. J. Orthod 2018 Sep 28;40(5):531-6. 7. Abid, M.F., Al-Attar, A.M. & Alhuwaizi, A.F. Retention protocols and factors affecting retainer choice among Iraqi orthodontists. Int. J. Dent. 2020 ,Oct 23. 8. Di Venere D, Pettini F, Nardi GM, Laforgia A, Stefanachi G, Notaro V, Rapone B, Grassi FR, Corsalini M. Correlation between parodontal indexes and orthodontic retainers: prospective study in a group of 16 patients. Oral Implantol. 2017 Jan;10(1):78. 9. Lasance SJ, Papageorgiou SN, Eliades T, Patcas R. Post-orthodontic retention: how much do people deciding on a future orthodontic treatment know and what do they expect? A questionnaire-based survey. Eur. J. Orthod. 2020 Jan 27;42(1):86-92. 10. Almuqbil S, Banabilh S. Postretention phase: Patients’ compliance and reasons for noncompliance with removable retainers. Int J Orthod Rehabil. 2019 Jan 1;10(1):18. 11. Andriekute A, Vasiliauskas A, Sidlauskas A. A survey of protocols and trends in orthodontic retention. Prog Orthod. 2017 Dec;18(1):1-8. 12. Meade MJ, Millett D. Retention protocols and use of vacuumformed retainers among specialist orthodontists. J. Orthod 2013 Dec;40(4):318-25. 13. Nagani NI, Ahmed I. Effectiveness of Two Types of Fixed Lingual Retainers in Preventing Mandibular Incisor Relapse. J. Coll. Phys. Surg. Pak. 2020 Mar 1;30:282-6. 14. Wild J. Patient preference and compliance between Hawley retainers and vacuum-formed retainers following orthodontic treatment. University of Louisville; 2013. 15. Gupta N, Rohmetra A. Patient Preference and Compliance between Hawley Retainers and Vacuum-Formed Retainers following Orthodontic Treatment. Journal of Advanced Medical and Dental Sciences Research. 2020 May 1;8(5):119-29. 16. Pratt MC, Kluemper GT, Lindstrom AF. Patient compliance with orthodontic retainers in the postretention phase. Am J Orthod Dentofacial Orthop. 2011 Aug 1;140(2):196-201. 17. Vandevska-Radunovic V, Espeland L, Stenvik A. Retention: type, duration and need for common guidelines. A survey of Norwegian orthodontists. Orthodontics: The Art & Practice of Dentofacial Enhancement. 2013 Mar 1;14(1). 18. Al-Jewair TS, Hamidaddin MA, Alotaibi HM, Alqahtani ND, Albarakati SF, Alkofide EA, Al-Moammar KA. Retention practices and factors affecting retainer choice among orthodontists in Saudi Arabia. Saudi Med. J. 2016 Aug;37(8):895. 19. Meade, M.J. & Millett, D. Retention protocols and use of vacuumformed retainers among specialist orthodontists. J. Orthod 40, 318-325 (2013). 20. Zachrisson BU. Multistranded wire bonded retainers: from start to success. Am J Orthod Dentofacial Orthop 2015 Nov 1;148(5):7247.

3. Steinnes, J., Johnsen, G. & Kerosuo, H. Stability of orthodontic treatment outcome in relation to retention status: an 8-year follow-up. Am. J. Orthod. 2017 Jun 1;151(6):1027-33. 4. Johnston, C. & Littlewood, S. Retention in orthodontics. Br. Dent. J. 2015 Feb;218(3):119-22.

Clear Aligners Corner

By Dr. Stephane Reinhardt, DMD, Director of Education Program for The C.L.E.A.R. Institute Inc., www.theclearinstitute.com

Using Clear Aligners and Elastics: A Great Combination! Since the introduction of elastics in orthodontics by Calvin Case in 1892, they have proven to be a valuable tool for achieving effective tooth movement. With the rising popularity of clear aligners and their integration into comprehensive treatment planning by general dentists, the question arises: Can we use elastics with clear aligners? The answer is a resounding yes! Let’s explore why elastics are beneficial when used with clear aligners and how to incorporate them effectively. Clear aligners have revolutionized orthodontic treatment, providing patients with a discreet and comfortable alternative to traditional braces. However, there are certain tooth movements and cases that can benefit from the additional forces generated by elastics. Elastics produce light continuous forces when stretched, making them ideal for achieving various orthodontic goals. Incorporating elastics with clear aligners allows dentists to enhance their treatment plans and achieve optimal results. When using elastics with clear aligners, the principles remain similar to those with traditional braces. Elastics can be employed to facilitate anterior-posterior correction, distalization, space closure, extrusion and intrusion, rotation, traction, and midline correction. They become a versatile tool in the orthodontic toolbox, providing additional forces to guide tooth movement effectively. To ensure the desired results, it’s important to understand the composition and classification of elastics. Manufacturers offer a range of intraoral elastics in different sizes and forces. The force of an elastic is typically measured in ounces and can range from 2oz to 8oz, depending on the desired effect. Light, medium, and heavy force elastics are available, with the thickness of the elastic determining the tension it creates when stretched. While the empirical rule of 3 suggests that stretching an elastic to 3 times its inner diameter results in the specified force, it is advisable to use instruments like Dontrix or Corex for accurate force measurement. The versatility of clear aligners is further enhanced by their compatibility with elastics. Two basic methods can

be employed: hooks or cutbacks. Hooks enable direct attachment of the elastics to the aligner, allowing forces to be transferred across the entire arch. Cutbacks, on the other hand, facilitate bonding buttons on specific teeth for elastic use. Choosing between hooks and cutbacks depends on the desired treatment goals. If the focus is on jaw movement alone, hooks directly attached to the aligner are suitable. However, if both jaw and tooth movement are desired, buttons bonded to the teeth provide better control. In cases where the elastics were not initially planned in the ClinCheck, additional hooks or cutouts can be added using specialized pliers or scissors. When using hooks, it’s crucial to consider anchorage. The force generated by the elastics will attempt to dislodge the aligner, so providing anchorage on the teeth where the elastics are attached is essential. A rectangular attachment perpendicular to the line of force of the elastic is recommended to ensure stability. With bonded buttons, anchorage is not an issue, and the position of the button can be adjusted mesially or distally to achieve the desired effect on the tooth. Incorporating elastics with clear aligners enables dentists to provide specialized care and address more complex cases. By understanding when and how to use elastics correctly, optimal outcomes can be achieved while maintaining the comfortable and aesthetic advantages of clear aligner treatment. Remember, a solid diagnostic and treatment planning foundation is key to success in any orthodontic treatment or dental procedure.