International Journal of Orthodontics Summer 2023 by internationaljournaloforthodontics

VOLUME 34 | NUMBER 2 | Summer 2023

International Journal of

Orthodontics

Published Quarterly by the

International Association for Orthodontics

In this Issue:

• From Braces to Bytes: The Role of Technology in Modern Orthodontics • Evaluation of Pre-Treatment and Post-Treatment Changes in Lower Anterior Facial Height in Extraction and Non-Extraction Cases: A Digital Cephalometric Study

• Stability of Surgical and Orthodontic Techniques for the Treatment of Patients with Cleft Palate: A Systematic Review A Review and Proposal

• Comparison of Bolton Analysis Between Interproximal Stripping and Mandibular Incisor Extraction to Resolve Lower Anterior Crowding – A Cross-sectional Study

• Surface Roughness Of Stainless Steel Wires Coated with Titanium Dioxide after Exposure to Oral Medium

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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

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

SUMMER 2023  VOLUME 34  NUMBER 2

Features 6

Kruger, Orthodontic Clinician, New Zealand

Evaluation of Pre-Treatment and Post-Treatment Changes in Lower Anterior Facial Height in Extraction and Non-Extraction Cases: A Digital Cephalometric Study, By

From Braces to Bytes: The Role of Technology in Modern Orthodontics, By by Vernon

Dr. Prateek Bhusha, Dr. Madhur Sharma, Dr. Manish Goyal, Dr. Mukexh Kumar, Dr. Saksham Madhok, and Dr. Sumit Kumar

Stability of Surgical and Orthodontic Techniques for the Treatment of Patients with Cleft Palate: A Systematic Review A Review and a Proposal, By Elisa Darqué, Iván Nieto Sánchez, Inés Díaz Renovales, and Patricia Martín-Palomino Sahagún.

Comparison of Bolton Analysis Between Interproximal Stripping and Mandibular

Extraction to Resolve Lower Anterior Crowding – A Cross-sectional Study, By 40 Incisor Dr. Mubassar Fida and Dr. Kanza Tahir

Surface Roughness Of Stainless Steel Wires Coated with Titanium Dioxide after Exposure to Oral Medium, By Homa Farhadifard, Vahid Mollabashi, Abbas Farmany, Hossein Shabani, Ali Reza Soltanian, and Ziba Banisafar

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

Departments 5

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

Growing Beautiful Teeth Chapter 4: It’s Not Just about Teeth, By Estie Bav

Practice Management Tips: Getting More Valuable and Consistent Case Acceptance, By Scott J Manning, MBA; Founder, Dental Success Today

Can We Treat Kids in Mixed Dentition with Clear Aligners? The Benefits of Early Orthodontic Treatment for Kids, By Dr. Stephane Reinhardt, DMD

Tips from the Experienced: The D-Gainer Appliance, Pt. 2, By Dr. Adrian J. Palencar,

MUDr, MAGD, IBO, FADI, FPFA, FICD

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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

Rob Pasch Editor Hello fellow orthodontic practitioners. I am writing this editorial on the first day of summer 2023, the longest day of the year, and I have noticed driving around that there are a lot of dental offices advertising their SMILE IMPROVEMENT services with sidewalk billboards. A lot of offices are offering whitening services as well as tooth alignment, either by clear aligners or braces. It is obvious that consumers are no longer satisfied with conventional services only. Drill and fill doesn’t fit the bill anymore. Consumers want more out of dentistry; they want healthy aligned white teeth with healthy soft tissue support. They want their teeth straightened without the conventional braces look. They are fortunate that technology today will allow them the options of almost invisible orthodontic procedures and the availability of limited speciality services via remote tele dentistry. I originally qualified as an Invisalign TM provider in the year 2000 and again in the year 2010. I have since tested several local (Canadian) laboratory-processed clear aligner systems, and have qualified for a European system as well. This all has made me understand that there is an evolution happening driven by digital technology. The future of orthodontics may not involve brackets as we know them today. Scans, A.I., MRI, 3D X-rays have made for a paradigm shift in dentistry and its delivery to the consumer. The article in this issue from Braces to Bytes shines a light on the future of orthodontics and general dentistry, as well as the delivery in remote areas with services heretofore not available there. Remote supervision by specialists of general practitioners of these procedures will bring availability to and reduce the costs to the consumer. Please read this enlightening article and prepare for the evolution of the profession. I really enjoyed this well-written article and appreciate the glimpse of the future. I have a request to all who read this, and the ask is to please write and submit articles or case reports to the journal, for the journal is YOUR journal and you can make it reflect what is important to you today and in doing so making the journal better for everyone. Also send the journal to your friends and share the knowledge. It is a very good feeling to see your name in print when you submit a case report or clinical article, besides your patients will appreciate it as well. I remain Respectfully Dr. Rob Pasch DDS MSc IBO General Practitioner.

Featured*

From Braces to Bytes: The Role of Technology in Modern Orthodontics by Vernon Kruger, Orthodontic Clinician, New Zealand

Ancient Pioneers: Explorations in Dental Improvement The origins of orthodontics can be traced back to ancient Egypt and Greece, where remarkable advances in dental care occurred between 400 and 300 B.C. In ancient Egypt, the pursuit of dental perfection manifested itself in the ingenious use of catgut, a natural fiber, to bond teeth together. This early form of dental braces aimed to correct misalignments and stabilize teeth, demonstrating the Egyptians’ early understanding of the aesthetics and function of dental health.1,2 Across the Mediterranean, the ancient Greeks embarked on their own investigation into dental advancement. Renowned figures such as Hippocrates, the father of medicine, and Aristotle, the renowned philosopher, contributed to the expanding corpus of dental care knowledge. Their unrelenting pursuit of knowledge led to the invention of numerous techniques, each contributing to the evolution of the art and science of orthodontics.1,2

Dr Vernon Kruger is a registered dentist who has been practicing the art and science of orthodontics for over 40 years, both locally in New Zealand and internationally. He is one of the top 1% of Dr. Vernon Kruger Invisalign providers of more than 100,000 skilled doctors globally. He is also a Certified Senior Instructor at the International Association for Orthodontics with Fellow status membership. Dr Kruger has a holistic philosophy of True Alignment Airway Orthodontics, which emphasizes jaw positioning and size, as well as the improvement of airways, to address the cause of orthodontic issues. He has lectured internationally and in New Zealand frequently, and he provides consulting, training and keynote speaker services to other orthodontic practitioners.

Introduction Orthodontic treatment has been around for centuries, with ancient civilizations using various methods to straighten teeth. Today, digital technology is transforming the field, offering significant advantages in precision, efficiency, and patient experience. Clear aligners have emerged as a revolutionary option in orthodontics, offering advantages such as improved patient comfort and aesthetics. Digital technology has also enabled orthodontic clinicians to provide personalized and precise treatment plans for their patients. However, adopting these innovations requires overcoming challenges related to cost, learning curves, and patient acceptance. This paper explores the transformative impact of digital technology on modern orthodontics and highlights the opportunities and challenges it presents. It also emphasizes the importance of comprehensive training programs, effective patient education, data security, and interdisciplinary collaboration in maximizing the benefits of digital technology and shaping the future of orthodontics.

Etruscans and Romans: Dental Alignment Masters Preceding the Romans, the Etruscans left an intriguing legacy in the field of orthodontics. They created intricate mouthguards that preserved the position of the teeth out of a profound sense of devotion to keeping their deceased loved ones’ dental alignment in place, showcasing their creativity and commitment to dental aesthetics even after death.3 During their time, the Romans, renowned for their architectural prowess and inventiveness, made significant advances in orthodontics. They pioneered the use of golden wires to stabilize misaligned teeth, exemplifying their commitment to dental refinement and functional harmony.1 Recent Times For centuries, traditional braces have dominated the field of orthodontics as the treatment of choice, playing 6

*This article has been peer reviewed

an irreplaceable role in correcting dental misalignments and malocclusions and effectively restoring the form and function of numerous smiles.3 The history of orthodontic treatment is intricately intertwined with the development of dental science. In the early eighteenth century, French dentist Pierre Fauchard introduced an extraordinary invention known as the bandeau, a metal device in the shape of a horseshoe intended to expand the dental arch. This invention ushered in a new era, introducing an abundance of orthodontic possibilities.2,3 In the mid-19th century, the spotlight shifted to Edward Maynard, a notable figure who made pioneering contributions to the field of braces. Maynard’s introduction of the first rubber bands designed specifically for orthodontic use transformed the field, providing a versatile solution to a variety of orthodontic challenges.2,3 Orthodontic advancement continued with the invention of the wire crib in the early 20th century. This meticulously designed device played a crucial role in rectifying overbites and underbites, ushering in a new era in orthodontics and providing orthodontic clinicians with a game-changing instrument for restoring harmonious dental alignment.3 Edward H. Angle’s formulation of the “ribbon arch” technique in the early 1900s marked a significant advancement in the field. Using brackets and archwires, this technique effectively moved teeth into their correct positions. Since then, orthodontic brackets and archwires have undergone numerous developments and improvements, enhancing the precision and effectiveness of treatment.3 This innovation revolutionized orthodontic treatment, presenting a robust and resilient alternative to previous techniques. The harmonious operation of brackets and archwires demonstrated the mastery of orthodontics. One name stands out in this tapestry of progress: Edward Angle, an eminent figure who revolutionized the foundations of orthodontics. Edward Angle’s inventive use of brackets and unwavering opposition to extraction orthodontics cemented his place in dental history.3 As we reflect on this magnificent journey through time, we bear witness to the evolution of braces—an awe-inspiring odyssey intertwining scientific advances, innovation, and unwavering commitment. From the humble beginnings of the bandeau to the miracles of stainless steel, braces have emerged as beacons of

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advantages.6 The 3D printing process has played a pivotal role in the production of these transparent aligners. Through the use of digital scanners and advanced software, orthodontic clinicians can create precise 3D models of their patients’ teeth and design personalized treatment plans. These digital models are then converted into physical aligners using 3D printers, streamlining the manufacturing process and ensuring a high level of accuracy.7 One of the primary advantages of 3D-printed transparent aligners is their aesthetic appeal. Unlike traditional braces, which consist of metal brackets and wires, clear aligners are made of transparent plastic material, rendering them nearly invisible when worn. This discreet nature appeals to adults and adolescents seeking orthodontic treatment without the noticeable appearance of traditional braces.8 In addition to their aesthetic benefits, transparent aligners offer increased comfort and convenience. The aligners are custom-made to fit snugly over the teeth, ensuring a comfortable experience for the wearer. With clean edges and a smooth surface, the likelihood of oral injuries or sores is significantly reduced.9 Oral hygiene is also greatly improved with transparent aligners. Since the aligners are removable, patients can easily maintain their regular oral hygiene routine by brushing and flossing without obstruction. This reduces the risk of plaque accumulation, tooth decay, and periodontal disease, promoting overall dental health during the course of treatment.10 Another notable advantage of 3D-printed transparent aligners is their ability to provide precise and predictable tooth movement. The digital design process allows orthodontic clinicians to visualize the expected outcome and plan each phase of treatment accordingly. The aligners are designed to exert controlled forces on specific teeth, gradually repositioning them into their ideal alignment. This level of precision enhances the efficacy of the treatment and improves the predictability of the final results.11,12,13 The advancements in 3D printing technology have also revolutionized the manufacturing processes associated with clear aligners in orthodontics. Clear aligners can now be produced through thermoforming on 3D-printed models or direct

hope, guiding innumerable individuals toward dental perfection.1,2,3,4 However, with the advent of digital technology and the rise of artificial intelligence models, we find ourselves on the cusp of a potential paradigm shift—an era that could signal the end of braces as we know them. To embrace the opportunities presented by technological advances, we must recognize that change is inevitable. Traditional braces have withstood the test of time, but the future holds the promise of alternative treatment modalities that leverage digital innovations and artificial intelligence, potentially revolutionizing orthodontics.4 What lies ahead on this transformative path to dental perfection can only be revealed over time. As we navigate the ever-evolving landscape of orthodontics, we remain captivated by the historical tapestry that has shaped this remarkable field. It is a testament to the ingenuity and dedication of ancient civilizations and modern pioneers that we continue to strive for dental perfection, improving not only the aesthetics but also the function and overall well-being of countless individuals. Orthodontic Treatment: Embracing a Paradigm Shift The 3D-Printed Clear Aligner Revolution in Orthodontics The field of orthodontics is currently experiencing a paradigm shift with the convergence of 3D printing technology and orthodontic practices. This exciting development has propelled the field in a new and promising direction, offering a host of benefits over conventional orthodontic treatments. To fully comprehend the implications of this methodological breakthrough, it is imperative to explore the world of 3D-printed clear aligners and their potential impact on future clinical practices.5 The introduction of transparent, 3D-printed aligners has undeniably revolutionized the field of orthodontics. The concept of using transparent plastic trays for tooth alignment originated in the 1990s, when two graduates from Stanford University drew inspiration from a plastic retainer. This led to the creation of the pioneering clear aligner system, Invisalign, in 1999. Since then, numerous other clear aligner systems have emerged, each with its own unique characteristics and 8

to closely track the progress of their patients without the need for frequent in-office visits. This advancement holds great promise for patients using transparent aligners, offering them a more convenient and efficient treatment experience while benefiting both orthodontic clinicians and patients alike.21 Remote monitoring technology brings increased convenience and productivity to orthodontic treatment. Through this technology, orthodontic clinicians can remotely monitor the movement of teeth and make necessary adjustments to treatment plans. Patients no longer need to visit the orthodontic clinician’s office for frequent adjustments, saving them time and effort. Instead, orthodontic clinicians can assess progress and make informed decisions using digital scans, photographs, or even video consultations.22,23 Furthermore, remote monitoring technology enhances access to orthodontic specialist care. One of its primary benefits is the ability to connect orthodontic specialists with patients regardless of their geographical location. This means that local dentists can collaborate with experts in the field, bridging the gap between general dentistry and orthodontics. As a result, general dentists can provide orthodontic care that was previously limited to orthodontic specialists. This increased collaboration improves access to specialized care, particularly in regions where specialty orthodontists are scarce.24,25 The incorporation of remote monitoring technology also has the potential to increase the supply of orthodontic care and reduce costs. By allowing general dentists to administer orthodontic treatment under the supervision of remote specialists, the burden on specialist orthodontists is alleviated. This addresses the issue of limited availability and simplifies access to care. As the number of providers grows, competition may lead to lower treatment prices, making orthodontic care more affordable and accessible to a larger number of patients. Moreover, remote monitoring technology overcomes geographical obstacles that may hinder orthodontic treatment, particularly for individuals living in remote areas far from major cities where orthodontic specialists are typically located. By eliminating the need for frequent in-person visits, patients can receive high-quality orthodontic care as long as they have access to a local dentist who can facilitate remote consultations and collaborate with

3D printing, minimizing errors and defects that may occur during manufacturing. Additionally, 3D printing generates significantly less waste compared to subtractive and thermoforming processes, making it a more sustainable option.14,15,16 Various materials, such as epoxy resins, polylactic acid, polyamide (nylon), and glass-filled polyamide, are used in 3D printing for the fabrication of clear aligners. Durability, biocompatibility, and the desired level of transparency for the aligners are a few factors that affect the choice of material.17 Moreover, 3D printing offers increased productivity, accuracy, and environmental sustainability. By employing one or a combination of 3D printing techniques, it is now possible to directly manufacture clear aligners using 3D printing in a single step, eliminating the need for intermediate stages and reducing the overall production time. This streamlined method enhances the effectiveness of clear aligner production.17,18 The precision achievable with 3D printing is a significant advantage in orthodontics. The digital designs are accurately translated into physical aligners, ensuring a precise fit over the teeth. This level of accuracy contributes to the efficacy of the treatment by facilitating predictable tooth movements and optimal outcomes.19 Personalization is another remarkable feature of 3D printing in orthodontics. Orthodontic clinicians can customize the design of clear aligners to meet the unique requirements and treatment objectives of each patient. The ability to create custom aligners for individual patients improves treatment outcomes and enhances patient satisfaction.17,18 From an environmental perspective, 3D printing offers substantial advantages. This additive manufacturing process minimizes waste by precisely depositing materials layer by layer, resulting in efficient utilization and reduced material waste. As a result, 3D printing contributes to a more sustainable method of orthodontic manufacturing.20 Remote Dental Monitoring Using Digital Technology Digital technology has played a transformative role in the field of orthodontics, revolutionizing the way treatments are conducted. One significant impact of digital technology is the introduction of remote monitoring, which allows orthodontic clinicians 9

developing their own 3D-printed dental trays. These companies have made remarkable advancements in improving precision, effectiveness, and patient satisfaction. Several prominent companies in the field of 3D dental scanning include 3Shape, Carestream Dental, Dentsply Sirona, Planmeca, Medit, Straumann, KaVo Kerr, and Shining 3D. It should be noted that this is not an exhaustive list, as there may be additional companies offering 3D dental scanning technology.30 The advantages of 3D intraoral scanning extend beyond precision and convenience. Patients no longer endure the discomfort or messiness associated with traditional dental impressions. Instead, they undergo a streamlined scanning procedure that collects accurate data about their dental structure, enhancing their comfort and understanding of the treatment process.27,28 Orthodontic clinicians and dental laboratories also benefit from simplified workflows. Eliminating production stages like impression materials and plaster models reduces costs, minimizes distortion and inaccuracy, and saves time. Additionally, the lack of transportation requirements contributes to a more environmentally responsible approach.20 The future of 3D intraoral scanning holds great promise as technology continues to advance. Ongoing research and development will lead to even more precise, faster, and user-friendly scanners, improving treatment outcomes. Artificial intelligence and machine learning algorithms will further enhance scan analysis, aiding orthodontic clinicians in detecting anomalies and predicting treatment progression.21,22 The integration of 3D intraoral scanning with 3D printing technologies opens up new avenues for innovation. Custom aligners, retainers, and other orthodontic appliances can be created, expanding treatment options and personalization.20 The potential applications of 3D intraoral scanning extend beyond orthodontics to restorative dentistry, implant planning, and prosthetic fabrication. Its precision and effectiveness make it an invaluable tool across all dental specialties, enhancing patient care holistically.20,31

specialists. This breakthrough ensures that patients in underserved regions have equal access to care compared to those in urban centers.25 The incorporation of digital technology and remote monitoring has truly revolutionized orthodontics, benefiting patients in numerous ways. Increased convenience, expanded access to care, and reduced costs are some of the key advantages. This transformation has led to a more patient-centered approach, empowering individuals from all locations to achieve optimal oral health and well-aligned smiles. 23,24,25 As technology continues to advance, we can expect further innovations and enhancements in orthodontic treatments. Digital technology will play an evolving role in orthodontics, providing orthodontic clinicians with effective tools to improve treatment outcomes and deliver personalized care. The future of orthodontics is promising, with increased accessibility, affordability, and patient satisfaction driven by the ongoing digital transformation in the field.25 Unlocking the Potential of Intraoral 3D Scanning in Orthodontics In recent years, orthodontics has experienced a revolutionary leap forward with the introduction of 3D intraoral scanning technology. This innovative digital tool allows orthodontic clinicians to create precise and detailed 3D models of patients’ teeth and tissues, replacing traditional and uncomfortable dental impressions.26 At the core of this technology is a portable scanner that captures three-dimensional data about a patient’s dental structure. Orthodontic clinicians can now generate highly accurate 3D models of teeth, facilitating customized aligners and braces for optimal treatment outcomes.27 Align Technology Inc., the pioneering manufacturer of Invisalign aligners, has emerged as an industry leader in 3D-printed orthodontics. Their advanced iTero 3D scanning system sets the standard for 3D-printed and manufactured custom aligners. This revolutionary technology has not only transformed traditional orthodontic practices but has also inspired other companies to explore the potential of 3D printing in orthodontics.28,29 Beyond Align Technology Inc., several companies have embraced 3D-printed orthodontics,

Improving Treatment Planning with ThreeDimensional Cone-Beam X-Rays The introduction of 3D cone-beam x-rays 10

and efficacy. By incorporating high-resolution 3D images into their planning process, Align Technologies can tailor their treatment strategies and aligner designs to the specific requirements of each individual patient. This integration ensures a personalized and accurate orthodontic approach, resulting in superior treatment outcomes.35 The combination of 3D cone-beam x-rays, the availability of multiple cone-beam manufacturers, and the incorporation of this technology into treatment planning algorithms by industry leaders all contribute to a comprehensive and well-rounded method of orthodontic care. This sophisticated technology, with its capacity to provide unparalleled insights and detailed views, has become an indispensable component of contemporary orthodontic practices.34 Furthermore, this technology is widely employed in the field of airway orthodontics to more precisely quantify the airway space. It has demonstrated the benefits of mandibular advancement in the treatment of airway space deficiency by accumulating more data. Studies have found that cone-beam computed tomography (CBCT) is a good way to measure how well mandibular advancement appliance (MAA) therapy works to open up the airway in people with obstructive sleep apnea (OSA).36 By utilizing the power of 3D cone-beam x-rays, orthodontic clinicians can provide exceptional care to their patients, optimize treatment outcomes, and ensure their dental and medical health over the long term. As this technology continues to develop, it has the potential to further revolutionize the field of orthodontics and influence the future of treatment planning, ultimately benefiting a large number of individuals seeking orthodontic care.36,37 Multiple providers offer this advanced technology, including Carestream Dental, Dentinger Sirona, Planmeca, Vatech, KaVo Kerr, Gendex, Owandy Radiology, and Morita. These companies are at the forefront of developing and manufacturing 3D dental cone-beam x-ray devices, expanding the accessibility of this technology to orthodontic practices worldwide.38 With the continuous advancement of 3D conebeam x-ray technology, orthodontic clinicians can expect further improvements in image quality, resolution, and diagnostic capabilities. Ongoing research and development efforts are focused on enhancing the efficiency and accuracy of treatment

has brought about a significant revolution in digital imaging in the constantly evolving field of orthodontics. This revolutionary technology has not only surpassed the limitations of traditional 2D x-rays, but it has also provided orthodontic clinicians with a level of precision and accuracy in treatment planning that has never been seen before. By providing a precise and comprehensive visualization of a patient’s teeth, jaw, and adjacent structures, 3D cone-beam x-rays have become an indispensable instrument for orthodontic clinicians everywhere.32 One of the primary benefits of 3D cone-beam x-rays is their ability to reveal invaluable insight into the precise positioning of impacted teeth and their intricate relationship with adjacent roots. Unlike conventional x-rays, which often fail to capture the complexity of dental structures, 3D cone-beam x-rays provide a comprehensive and detailed image. This wealth of information enables orthodontic clinicians to develop highly individualized treatment strategies that maximize outcomes and guarantee the best possible results.33,34 To enhance the benefits of 3D cone-beam x-rays, multiple manufacturers have developed sophisticated cone-beam systems. The i-Cat Cone Beam 3D Dental Imaging System is one such example. With a single 360-degree scan, this cutting-edge technology captures a complete set of x-rays and generates comprehensive 3D images of the teeth. Orthodontic clinicians can examine the oral anatomy in greater detail and make more informed treatment decisions thanks to the level of detail the i-Cat system provides.34 Other industry leaders, such as Planmeca and Carestream Dental, have also made significant contributions to the field with their inventive conebeam systems. These systems provide orthodontic clinicians with intricate views of the oral anatomy, enabling them to obtain a comprehensive understanding of the patient’s dental structure. By incorporating these cutting-edge technologies into their practices, orthodontic clinicians can enhance the precision of their treatment planning and provide patients with more individualized care.34 Align Technologies, a leading provider of clear aligner systems, recognizes the critical role of cone-beam x-rays in treatment planning. They have integrated cone-beam x-ray technology into their treatment algorithms, resulting in enhanced precision 11

exceptional treatment results while prioritizing patient satisfaction and well-being. No longer are clear aligners only for simple orthodontic treatment.43,44 It is evident that clear aligners offer a promising avenue for achieving orthodontic goals. As research and technological advancements continue, the field can further capitalize on the benefits of clear aligners and optimize treatment approaches. There is a lot of room for improvement in the field, however, and it cannot be seen as the final solution yet.45

planning by incorporating artificial intelligence (AI) and machine learning algorithms. These intelligent systems have the potential to analyze vast amounts of data and assist orthodontic clinicians in identifying patterns, predicting treatment outcomes, and optimizing treatment plans for each individual patient.36,37,39 The ongoing integration of 3D cone-beam x-rays into treatment protocols and the cooperation between manufacturers, orthodontic clinicians, and researchers will influence the future of orthodontics. As this technology becomes more sophisticated and widely adopted, it will continue to transform orthodontic practices, enabling orthodontic clinicians to provide personalized, precise, and efficient treatment to their patients.40

The Byte-sized Brilliance of Computer Algorithms in Orthodontics The field of orthodontics is undergoing a remarkable transformation through the integration of computer algorithms into treatment planning. This digital revolution allows orthodontic clinicians to create personalized treatment plans based on cuttingedge digital technologies, resulting in improved precision, efficiency, and patient satisfaction.46 Computer algorithms unlock the potential for individualized treatment by utilizing 3D intraoral scans and 3D cone beam x-rays to generate detailed models of patients’ teeth and jaws and subsequent treatment planning. This enables orthodontic clinicians to tailor treatment plans to address specific dental characteristics such as tooth alignment, mandible shape, mandibular position, and occlusion. These continuously improving algorithms and customizations ensure a patient-centric approach and maximize treatment outcomes.46,47 The incorporation of computer algorithms streamlines the treatment planning process, enhancing productivity in orthodontic practices. By analyzing comprehensive digital models of patients’ dental morphology, orthodontic clinicians gain a clearer understanding and evaluation of treatment options. This digital approach reduces reliance on physical models, accelerating decision-making and minimizing treatment delays.46,47 Align Technology, a leader in this technological revolution, combines digital treatment planning with mass customization and shape engineering based on biomechanical principles. Their innovative computer algorithms provide orthodontic clinicians with a suite of tools and resources to develop unparalleled treatment plans, resulting in superior patient experiences and outcomes.35 Computer algorithms offer orthodontic clinicians

Clear Aligners: A Revolutionary Option in Orthodontics Due to the growing acceptance of the advantages of aligner-based treatments, the orthodontic industry is currently undergoing a significant transformation. Clear aligners have emerged as a revolutionary option in orthodontics, offering advantages such as improved patient comfort, reduced treatment duration, and enhanced aesthetics. Research has identified approximately 27 distinct clear aligner systems, highlighting their increasing popularity and acceptance.41 In particular, clear aligner therapy (CAT) has gained traction among adult patients seeking orthodontic treatment due to its cosmetic appeal and comfortable nature. It has been recognized as a viable alternative to traditional fixed appliances as it offers comparable effectiveness in treating malocclusion. However, clear aligners have demonstrated superiority in achieving segmented tooth movement. Improved outcomes in the clinical effectiveness of clear aligners can be largely attributed to the utilization of fabrication materials, along with advancements in material characteristics and fabrication protocols.42 Clear aligners differ from fixed appliances not only in their fabrication material but also in terms of orthodontic components and biomechanics. Previous research has often overlooked the unique properties of clear aligners, necessitating further investigation into their distinct characteristics. A comprehensive analysis of existing literature provides compelling evidence of the growing prevalence of clear aligners in orthodontic practice. Embracing the future of orthodontics requires acknowledging the transformative potential of clear aligners in delivering 12

numerous advantages that transform their approach to patient care. The advanced visualization capabilities allow orthodontic clinicians to evaluate every aspect of dental structures, improving communication with patients and instilling confidence in the treatment process. Increased treatment planning productivity optimizes workflow management, enabling orthodontic clinicians to devote more time to patient care. The accuracy that algorithms offer improves treatment predictability, fosters trust, and makes informed decision-making easier. Furthermore, these algorithms play a crucial role in tracking treatment progress, ensuring efficiency, and allowing for timely interventions.48 With computer algorithms revolutionizing orthodontic treatment planning, it becomes crucial for orthodontic clinicians to embrace this technology. However, it is important to recognize that algorithms should be seen as a complement, not a replacement, for the expertise and human touch of orthodontic clinicians. Patient concerns, building rapport, and delivering personalized care are still vital aspects that go beyond the capabilities of technology alone. It is crucial for clinicians to be aware of the limitations of this new technology to avoid over-reliance on computer-based treatments without a comprehensive understanding of their current constraints.48 Overcoming Challenges and Embracing Digital Technology in Orthodontics The incorporation of digital technology has revolutionized orthodontics, providing numerous advantages for improving patient care. However, along with these benefits come challenges that need to be addressed to fully realize the potential of digital technology.49 The implementation of digital technology in orthodontics involves various instruments, such as advanced scanners, 3D cone-beam x-ray machines, and computer algorithms. While these innovations can greatly enhance orthodontic procedures, their high costs may deter orthodontic clinicians from adopting them. The initial investment required to incorporate these technologies into a practice can be financially challenging, especially for those with limited resources.50 To address the financial barrier, orthodontic clinicians can explore options like leasing equipment or partnering with imaging centers that offer these

technologies on a pay-per-use basis. Additionally, staying updated on funding opportunities and grants specific to digital technology adoption in orthodontics can provide financial support. By actively seeking alternative financing options, orthodontic clinicians can overcome the cost hurdle and leverage the benefits of digital technology.50 The adoption of digital technology in orthodontics comes with a steep learning curve for some orthodontic clinicians and their staff. Acquiring a comprehensive understanding of digital scanners, 3D cone beam x-ray devices, and complex computer algorithms and software platforms requires time, training, and resources. Without proper training, the potential benefits of these technologies may remain untapped, hindering progress and productivity.49,50 Orthodontic clinicians must invest in training programs that cover all aspects of digital technology implementation. Collaborating with equipment manufacturers, attending specialized workshops, or enrolling in online training courses can help orthodontic clinicians and their staff gain the necessary skills and knowledge. By prioritizing continuous education and providing ongoing training opportunities, orthodontic practices can bridge the knowledge gap and ensure seamless integration of digital technology into their workflows.51,52,53] Ensuring patient acceptance and addressing their concerns is crucial for the successful implementation of digital technology in orthodontics. Some patients may have reservations about transitioning from conventional to digital orthodontic techniques. It is the responsibility of orthodontic clinicians to inform patients about the advantages of digital technology and alleviate any concerns they may have.54 Orthodontic professionals should take the time to explain how digital technology enhances the accuracy and effectiveness of the treatment process. By clearly communicating the benefits of these innovations, such as improved diagnostics, reduced treatment duration, and enhanced outcomes, patients can appreciate their value. Visual aids, such as before-and-after digital scan simulations, can also provide tangible representations of potential outcomes. Encouraging open dialogue and proactively addressing patient concerns will help build patient trust and foster acceptance of digital technology.54 Orthodontic clinicians must be cautious and aware that the general public’s knowledge and awareness 13

of digital technology in the field may surpass their own. It is crucial for clinicians to recognize this reality and take proactive steps to upskill themselves. Failing to do so may result in a loss of credibility and the perception of ignorance in the eyes of their patients. In an era where information is easily accessible, patients may have done their own research and come prepared with questions about digital advancements in orthodontics. By staying up-todate and continuously expanding their knowledge, clinicians can maintain their position as trusted experts and engage in meaningful conversations with their patients. Embracing ongoing learning and professional development is essential to ensuring that clinicians remain at the forefront of technological advancements, reinforcing their expertise, and providing the best possible care to their patients.55 In the realm of orthodontics, the integration of digital technology has made it crucial to prioritize the protection of patient information and uphold data security. As orthodontic practices rely on electronic storage for digital scans, treatment plans, and patient records, it is essential to establish robust security measures to thwart unauthorized access and potential data breaches. Additionally, ensuring data reliability necessitates the implementation of adequate backup systems or cloud storage solutions.49 Orthodontic clinicians should prioritize the implementation of secure systems and comply with industry data protection standards. This includes utilizing encryption methods, regularly updating software and hardware, and restricting access to authorized personnel. Conducting periodic audits and risk assessments can help identify vulnerabilities and proactively address them. Demonstrating a commitment to data security will instill patient confidence and alleviate privacy-related concerns associated with digital technology usage.49 Digital technology in orthodontics not only transforms individual practices but also opens doors for interdisciplinary collaboration. Orthodontic clinicians now have the opportunity to collaborate with other dental specialists and contribute to comprehensive treatment plans. However, to fully harness the potential of interdisciplinary collaboration, effective communication and standardized protocols are essential.57 Orthodontic clinicians should actively seek

opportunities to collaborate with other dental professionals, such as periodontists, oral surgeons, and prosthodontists, to provide patients with comprehensive care. Establishing clear channels of communication, securely sharing digital records, and aligning treatment objectives can enhance patient outcomes and foster synergistic collaboration. By adopting a team-oriented approach and leveraging digital technology as a unifying platform, orthodontic practices can dismantle barriers and deliver patientcentered, comprehensive care.57 Conclusion “From Braces to Bytes: The Role of Technology in Modern Orthodontics” has explored the transformative impact of various digital technologies on the field of orthodontics, including 3D cone-beam x-rays, computer algorithms in treatment planning, and clear aligners. As professionals in the field, it is crucial to embrace modern technology and not be left behind due to outdated thinking or resistance to change. While traditional braces have withstood the test of time, the future holds the promise of alternative treatment modalities that leverage digital innovations and artificial intelligence, potentially revolutionizing orthodontics. By proactively addressing challenges related to cost, learning curves, and patient acceptance through innovative solutions, comprehensive training programs, and effective patient education, orthodontic practices can maximize the benefits of digital technology. In the era of digital advancements, orthodontic clinicians are presented with a remarkable opportunity to enhance the quality of care, enhance treatment outcomes, and propel the field of orthodontics towards new frontiers. References:

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Book Excerpt

Growing Beautiful Teeth Chapter 4: It’s Not Just about Teeth 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.

he modern human is susceptible to having a compromised airway that worsens when the body is in a horizontal position during sleep. When we enter the deeper stages of sleep, our muscles become totally relaxed, almost paralysed, and the throat collapses somewhat. The tongue, which is also a muscle, can become a heavy blob that falls back to block the airway, especially when one is sleeping on the back with the jaw open. Airway blockage will compromise breathing: air intake is reduced and oxygen level in the blood drops. This is referred to as oxygen desaturation. The compromised intake of air during sleep is called sleep apnea. When the blockage is complete, the event is known as Obstructive Sleep Apnea (OSA). OSA happens not only in adults but children as well. We also refer to this condition generally as Sleep Disordered Breathing (SDB) which explains a situation where breathing disorders take place during sleep. SDB and OSA disturb sleep and can affect the child in many serious ways such as growth, learning ability, mood, concentration, social behaviour and is linked to bruxism, and TMD and chronic pain in the older child. So far, the reader has been alluded to the fact that there is more to it than just straight teeth. The upper and the lower jaws should be wide, and forward relative to the cranium, to give plenty of functional space for the tongue, facilitate nasal breathing, reduce the risk for compressing the TMJs, provide good airway and to enhance facial beauty. Here are some more important factors in the equation: sleep and growth for the child.

Parents will be very surprised that studies have found that there is a connection between a child’s narrow palate and bedwetting during sleep.3 We adults know how a night of disrupted sleep or a lack of sleep can affect our state of being the following day. A child who does not sleep well is a miserable child, often with behavioural issues. In fact, more and more research studies and observations are noting the parallel symptoms of ADHD and sleep deprivation. Their learning ability and performance at school is also compromised. Sleep is necessary. It is the time during the 24hour cycle that our body rejuvenates and recharges by flushing out chemical waste in the brain. In a growing child, during the deeper phase of sleep called REM (rapid eye movement) sleep, hormones are made and released which are essential for the child’s growth and development, including the formation of their brain and nervous system. Poor quality sleep will affect the child’s growth. This has become a subject of increasing concern in the health and medical arena as it should. Posture When Sleeping During sleep, the body is lying horizontally and since the muscles of the body become totally relaxed in the deeper phases of sleep, the tongue may fall back and further constrict the oropharynx. This may be made worse in a child with enlarged adenoids and tonsils where the blockage can become quite serious. Airway constriction reduces the intake of air to the body, especially to the high-oxygen- consuming brain. This stresses the brain and, due to a sympathetic nervous response to the stress, the child may not be able to go into the deeper REM sleep that is essential for growth. The child may also have disturbed sleep as the brain directs subconscious actions to gain more oxygen. The child is subconsciously aroused, stirred, unable to enter the REM phase of sleep, wakes, or even wets the bed. When a child sleeps well, he or she will grow better, perform better and potentially make for a happier child. Any difficulty with breathing through the nose can be made worse during the night, and the child may be forced to hang the mouth open all night. Usually, parents will also observe that the child snores and has bad breath upon rising the next morning.

Breathe Well to Sleep Well and to Grow Well I want to draw the parent’s attention to the fact that for your child to grow beautiful teeth, jaw and face, your child needs to sleep well. And breathing well day and night is key to their sleeping well and growing well. Correct daytime breathing through the nose may ensure that this habit is also maintained during sleep. I often ask parents to play the role of a detective and observe how their child sleeps. Is the child able to breathe easily through the nose? Some of the clues to SDB and poor sleep include open-mouth breathing, loud snoring, laboured breathing, tossing and turning, waking during the night, nightmares and bedwetting.1,2 18

Whilst a mild degree of OSA is acceptable in adults, any amount of airway obstruction in a growing child has been considered unacceptable by pediatric sleep professionals. In my practice, I routinely see worn down tooth enamel in children’s teeth, and the teeth may not even be decayed. Usually, these children also have a shortened or underdeveloped upper jaw and/ or they may have throats blocked by large tonsils. They tend to breathe through their mouth, not necessarily with their mouth hanging open, as sometimes this habit is not so obvious outwardly.

This predisposes to TMD which is more common in the child, usually an older child, than it is generally appreciated. Symptoms of TMD include TMJ pain which may also be interpreted as headaches, clicking jaw joints, limitation in jaw opening, jaw locks, and ear symptoms.

Figure 16: Six-year-old’s worn front teeth

The traditional reason given for the cause of tooth clenching and grinding is mental stress or anger. Now, contemporary observations and interpretations of tooth clenching and grinding, or bruxing, explain that when the airway is compromised during sleep, oxygen desaturation or oxygen deprivation triggers a sympathetic fight-or-flight response. This is big stress for the brain. The brain is very sensitive to any fall in oxygen level in the blood and, when detected, it will cause an arousal from sleep and trigger a mouth closure or a gasp in order to reduce the throat constriction and increase air intake in an attempt to restore the oxygen level. Bruxing brings the lower jaw closed tight against the upper jaw, and a protrusion or forward repositioning of the tongue from the throat area to improve the airflow through the throat at the back of the mouth. It is the brain’s effort or attempt to remove the airway obstruction and restore oxygen level for the body. However, the arousal or the stir from a deep sleep to restore breathing will disrupt the sleep. With chronic bruxing, the micro trauma on the TMJ’s can in time dislocate the jaw joints or the condyles from the disk that sits between the bony parts of the jaw joints as illustrated.

Figure 17: Risk for TMD

We all know how cranky we can be if we do not get a good night’s sleep. There is now an appreciation of how sleep disorders can contribute to negative social behaviour in children, behaviours that parallel those observed in ADHD.4,5,6 As mentioned earlier, bedwetting is a symptom of sleep disorder for children. A study as far back as the 1980s had found that treating the narrow upper jaw in children stopped their bedwetting. In adults, a common symptom of OSA is the need to get up and visit the toilet during the night. Similarly, airway compromise stimulates a child to urinate in their sleep.7 The subject of Tonsils and Adenoid that we touched on in chapter 3 is revisited here in relation to sleep disordered breathing. In children one common but not exclusive cause for OSA is enlarged tonsils and/or adenoids. Enlarged tonsils and/or adenoidal tissues at the back of the child’s throat can physically block the airway causing breathing difficulty during sleep. For this reason, the dentist needs to work closely with an ENT surgeon. Sometimes, surgical intervention is needed to open the airway for improved breathing. 19

These soft structures are part of the body’s immune system and, like gate sentries at the back of the mouth, they trap bacteria, viruses or any pollutants in the air that we breathe into our body. Obviously, when air is taken in through the mouth, the filtering effects of the nose are bypassed, and the tonsils will have to work harder to clean the air before it reaches the lungs. Some doctors may argue that these structures will eventually shrink away and therefore advocate against its removal. However, according to the British Lung Foundation there is good reason to have these obstructive structures removed during this important growing stage for the child.8 Parents will have to weigh up the benefits gained by solving the immediate problem of apnea and nightly sleep deprivation, against the negative impact of a surgery under general anesthesia. Encouraging the child to sleep with a closed mouth and to breathe through the nose will ensure that air is cleaned and filtered at the entrance. This is obviously nature’s preferred way. The tonsillar tissues will then not have to deal with an overload situation.

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References

Get cost-effective precision, quality and integrity with wires from Highland Metals – and pair them with our exceptional brackets for even better outcomes.

1 DL Smith et al, Frequency of snoring, rather than apnea – hypopnea index, predicts both cognitive and behavioral problems in young children, Sleep Medicine, 2017 Jun; 34(2017):170-178 2 AR Jackman et al, Sleep-disordered breathing in preschool children is associated with behavioral, but not cognitive, impairments, Sleep Medicine, 2012;13(6):621–631.

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3 U Schütz-Fransson & J Kurol, Rapid maxillary expansion effects on nocturnal enuresis in children: a follow- up study, Angle Orthodontist, 2008 Mar;78(2):201–8 4 S Moore, Sleep-Wrecked Kids: Helping Parents Raise Happy, Healthy Kids, One Sleep at a Time, Grammar Factory, Australia, 2018 5 JA Owens, Neurocognitive and behavioral impact of sleep disordered breathing in children, Pediatric Pulmonology, 2009 May; 44:417– 422 6 H Andersson & L Sonnesen, Sleepiness, occlusion, dental arch and palatal dimensions in children attention deficit hyperactivity disorder (ADHD), European Archives of Paediatric Dentistry, 2018 Apr;19(2):91–97

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7 M Zaffanello et al, Obstructive sleep-disordered breathing, enuresis and combined disorders in children: chance or related association?, Swiss Medical Weekly, 2017 Feb;147:w14400 8 BritLungFoundation, 2013 Feb 12, The effects of OSA, video, viewed 2018 Sep, https://www.youtube.com/watch?v=UuvsYf12Gb8

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Featured*

Dr. Prateek Bhusha Investigation, Resources

Dr Madhur Sharma Supervision, Project Administration

Dr. Manish Goyal Conceptualization, Methodology

Dr. Mukesh Kumar Writing – Original Draft

Dr.Saksham Madhok Writing – Original Draft, Visualization

Dr. Sumit Kumar Writing – Review and Editing

Evaluation of Pre-Treatment and Post-Treatment Changes in Lower Anterior Facial Height in Extraction and Non-Extraction Cases: A Digital Cephalometric Study by Dr. Prateek Bhusha, Dr. Madhur Sharma, Dr. Manish Goyal, Dr. Mukexh Kumar, Dr. Saksham Madhok, and Dr. Sumit Kumar

Abstract: Objective The purpose of this present study was to evaluate pretreatment and post-treatment cephalometric changes in the lower anterior facial height (LAFH) in class I all first premolar extraction cases and compare them with class I non-extraction cases. Materials and Methods: Pre-treatment and post-treatment cephalometric radiographs of 40 Class I normo-divergent patientswere selected and divided into two groups i.e extraction and non-extraction groups. The extraction group included 20 patients (12 females and 08 males; pre-treatment age, 17.4 +/- 3.89 years, treatment duration 24 +/5 months) and non-extraction group also included 20 patients (11 females and 09 males; pre-treatment age, 18.3+/- 3.61 years, treatment duration 19 +/- 5 months). The linear and angular measurements were selected and measured with the help of NEMOCEPH software to see the changes in LAFH. Result The results obtained revealed that there was a significant increase in LAFH in non-extraction group and no significant

Dr. Saksham Madhok

*This article has been peer reviewed

causes anti-clockwise rotation of mandible leading to correction of open bite and a resulting decrease in vertical facial height, more specifically, the lower anterior facial height (LAFH).3,4,5 On the other hand, another group states that there is no change in the LAFH and on the contrary may sometimes cause temporomandibular joint (TMJ) problems due to overclosure of the mandible.6-12 The LAFH is the vertical distance between the anterior nasal spine (ANS) and the menton (Me) points. The two main factors which can affect its height are the increase or decrease in the bone deposition in the baso-alveolar bone through the process of remodelling and other being the variation in the eruption of teeth. It has been proposed by some authors that orthodontic treatment causes an alteration in the lower facial height by extraction or non-extraction treatment philosophy, on the contrary other authors claim that orthodontic treatment doesn’t cause any change in LAFH. Thus, in order to accurately evaluate vertical problems involving skeletal and dental components cephalometric assessment acts as an important tool.2 Standardized cephalometric radiographs help us to diagnose and record pre-treatment skeletal and dental relationships and compare them with post treatment radiographs and evaluate the changes due to orthodontic treatment.13,14 Although this method of cephalometric tracing is widely used, it has several drawbacks ranging from being time consuming to increased chances of errors in landmark identification, tracing, and measurement. Thus, with the advent of computers in orthodontics many of the problems encountered by the traditional methods have been solved as digital cephalometric tracing reduces the frequency of inaccuracies due to operator fatigue, provides standardized, fast, and effective evaluation of lateral cephalograms. There are several advantages of using digital cephalometric software notably - several analyses can be performed simultaneously, helps in generating treatment predictions, allows superimposition of images, digital record keeping which overcomes the problem of film deterioration and lastly it is easy to use.15 The linear parameters are much more affected by magnification error in cephalogram in comparison to angular parameters like y-axis angle, MM angle, MP angle (Fig 1); that’s why we use angular parameters along with linear parameter (ANS – Me) and U6-PP,

change in LAFH in extraction group, although there was no significant difference in facial height when both the groups were compared. Conclusion Thus it can be concluded that both treatment strategies when used judiciously with good anchorage and vertical control do not lead to any significant increase in vertical facial dimension. Keywords Lower anterior facial height, NEMOCEPH, Normo-divergent, Extraction, Cephalometric radiographs. Introduction Extraction of teeth has always been a controversial topic right from the angle era to modern times. Among the various reasons for the removal of permanent teeth, the two major reasons are to reduce bi-maxillary protrusion and for the correction of tooth size/arch length discrepancy. Apart from these two reasons, a third and underappreciated reason for permanent tooth extraction is in order to control the vertical dimension.1 The vertical disturbances can be of two types. One is the anterior teeth fail to contact each other, or open bite; the other condition in there is an excessive vertical overlap of the anterior teeth, or deep bite.2 In order to correct the above-mentioned vertical disturbances, be it open bite or deep bite, it is suggested by several authors that movement of the posterior teeth can be used to treat vertical disturbances. The rationale for such treatment is often based on the “occlusal wedge hypothesis.” According to this hypothesis, the dentoalveolar apparatus can be presumed to be an occlusal wedge, so when bicuspids and molars are distalized or extruded, there is an opening of bite and, on the contrary, when molars are mesialized after extraction of bicuspids, there is deepening of bite. This hypothesis seems to be logical from a biomechanical point of view but orthodontic treatment is performed in an oral biological environment, which has its own complexities. So, it doesn’t come with a surprise that there is a difference in opinion among various authors when it comes to the validity of this hypothesis. One group of authors suggest that extraction and subsequent protraction in order to close space 22

Figure 2: Linear parameters for LAFH. Figure 1: Angular parameters to measure LAFH.

L6-MP to assess changes in pre-treatment and posttreatment LAFH (Fig 2). Hence, the purpose of this present study was to evaluate pre-treatment and post-treatment cephalometric changes in the lower anterior facial height in class I all first premolar extraction cases and compare them with class I non – extraction cases. Material and Methods Materials (Fig 3,4) 1. Cephalostat (PlanmecaProline XC) 2. NEMOCEPH ORTHODONTIC SOFTWARE In this retrospective study, pre-treatment and post-treatment cephalometric radiographs of 40 Class I normo-divergent patientswere selected from the available records of 84 patients which met the selection criteria. Master 2.0 software was used for sample size calculation and the power of the study was taken to be 80% and Confidence Interval (C.I.) was taken to be 95%. The sample size calculation was done as per the article by Hans et al.1 The sample size was estimated to be a minimum of 20 patients. The obtained records were divided into two groups (i.e., extraction and non-extraction groups). The extraction group included 20 patients (12 females and 8 males; pre-treatment age, 17.4 +/- 3.89 years, treatment duration 24 +/- 5 months) and nonextraction group also included 20 patients (11 females and 9 males; pre-treatment age, 18.3+/- 3.61 years, treatment duration 19 +/- 5 months with minimal crowding). All subjects were treated by using Damon

Q metal with banding till second molars in order to increase anchorage along with the use of transpalatal arch and consolidation of posterior segments.In all the extraction cases, Class I (intra-maxillary force) force with the help of Class I elastics was used to close the extraction spaces. After the initial selection, all X-rays were traced by the same investigator and landmarks were identified & all cephalometric measurements(three angular and four linear) used in this study; Y-axis angle, MM angle, MP angle, ANS – Me, U6-PP, L6-MP and Jarabak’s ratio were made with the NEMOCEPH software on a computer and the mean values of those measurements were

Figure 3: Cephalostat (PlanmecaProline).

All Patient Photos Used With Permission

Figure 4: Nemoceph Orthodontic Software.

Figure 5: Linear parameters to measure LAFH.

calculated and statistically compared with post treatment values (Fig 5,6).16 In order to rule out bias, intra class correlation coefficient has been done for both groups that were traced at the same time by the same operator and pre-treatment and post-treatment cephalograms of 10 randomly selected patients were traced by the same operator to eliminate memory bias within a duration of a month. Selection criteria Inclusion criteria: 1. Patient with age between 15 to 25 years. 2. The subjects with full complement of teeth up to first molars in maxillary and mandibular arches without any craniofacial abnormality. 3. Class I normo-divergent malocclusion patients (SN-GoGn, 32°+/-1°). 4. Do not have severe antero-posterior discrepancy (0° <ANB <5°) 5. Vertical discrepancy (0 mm <overbite < 6 mm)

Figure 6: Angular parameters to measure LAFH.

groups in the study (Table 1). The mean of pre-treatment, post-treatment and difference form pre to post treatment was compared between extraction and non-extraction cases using the unpaired t-test for all the parameters i.e: Jarabak ratio, L6-mp, U6-pp, Ans –me, Mpa, Y-axis and Mm angle. (Table 2-8 and figure 7-13 ).There was no significant difference in any of the parameters, except the mean difference from Pre to post treatment was found to be significantly more among NonExtraction group (Table 4 and figure 9). The mean values of all the parameters were compared between pre and post-treatment using the paired t-test in both extraction and non-extraction groups. No significant difference was found in both the groups except the Ans–me and MM angle values which increased significantly from pre to posttreatment in the non- extraction group (Table 9-10 and figure 14-15).

Exclusion criteria: Patients were excluded from the study if they presented with 1. Previous history of orthodontic treatment. 2. Congenitally missing teeth/supernumerary teeth. 3. Patient with history of trauma. 4. Facial asymmetry. 5. Patients with craniofacial syndromes. 6. Patients treated with fixed functional appliances. 7. Patients treated with myofunctional appliances. 8. Patients treated with head gear. 9. Use of Temporary anchorage devices. Results There was a normal distribution of all the variables for both Extraction and Non-Extraction 24

Table 1: Normal distribution of all the variables for both Extraction and Non-Extraction group

Table 2: Statistical measures of jarabak ratio between extraction and non-extraction group using un-paired t test

Table 3: Statistical measures of L6-mp between extraction and non-extraction group using un-paired t test

Table 4: Statistical measures of U6-pp between extraction and non-extraction group using un-paired t test

Table 5: Statistical measures of Ans –me between extraction and non-extraction group using un-paired t test

Discussion There has always been a lot of debate regarding the role of premolar extraction in change in the facial height. The purpose of this study was to investigate the effect of extraction of first premolars on LAFH as there is a lot of controversy when it comes to the role of premolar extraction and change in vertical height. There is a general consensus among orthodontists that pre molar extraction according to the occlusal wedge hypothesis causes an anti-clockwise rotation of the mandible and hence reduces the lower anterior facial height whereas a non-extraction treatment protocol on the contrary causes a clockwise rotation of the mandible and as a result increase in LAFH .The results obtained in this study

Table 6: Statistical measures of Mpa between extraction and non-extraction group using un-paired t test

Table 7: Statistical measures of Y -axis between extraction and non-extraction group using un-paired t test

Table 8: Statistical measures of MM- angle between extraction and non-extraction group using un-paired t test

Figure 10: Graphical representation of Ans –me between extraction and non-extraction group using un-paired t test.

Figure 7: Graphical representation of jarabak ratio between extraction and non-extraction group using un-paired t test.

Figure 11: Graphical representation of Mpa between extraction and non-extraction group using un-paired t test.

Figure 8: Graphical representation of L6-mp between extraction and non-extraction group using un-paired t test. Figure 12: Graphical representation of Y -axis between extraction and non-extraction group using un-paired t test.

Figure 9: Graphical representation of U6-pp between extraction and non-extraction group using un-paired t test.

Figure 13: Graphical representation of MM- angle between extraction and non-extraction group using un-paired t test.

Table 9: Statistical measures of MM- angle between extraction and non-extraction group using un-paired t test

Table 10: Statistical measures of MM- angle between extraction and non-extraction group using un-paired t test

Figure 14: Graphical representation of cephalometric measures for pre –treatment and post –treatment in extraction group using paired t test.

Figure 15: Graphical representation of cephalometric measures for pre –treatment and post –treatment in non – extraction group using paired t test.

tend to differ from the above mentioned effect of premolar extraction on facial height as no reduction in LAFH was to be found in the extraction group but there was a significant increase in LAFH in the nonextraction treatment group. Chua et al devised a study to see whether is there any effect of the type of treatment plan on the patient’s LAFH and for this 174 Class I and II patients were selected who were further divided into extraction and non-extraction patient groups. The outcome of the study came out that there was no notable change in LAFH in extraction group but on the contrary there was notable increase in LAFH in non-extraction group which corroborates with our findings.17 Kocadereli et al devised a study to see whether the extraction of 1st bicuspids had any effect on the facial height. For this, two groups with forty patients each were created, one with 1st bicuspids extraction line of treatment and second with non-extraction and their cephalometric readings were recorded and compared. The results indicated that there was no significant difference in vertical height between extraction and non-extraction cases.6 Staggers et al tested the hypothesis that removal of first bicuspids may result in a decrease of LAFH for which pretreatment and post-treatment cephalographs of forty five Class I patients who were treated by nonextraction treatment plan were compared with thirty eight Class I, first bicuspids removal cases. The cephalogram were digitized and angular along with linear cephalometric parameters were evaluated and results obtained stated that there was a significant increase in LAFH in both the groups.18 Kim T.K et al tested the occlusal wedge hypothesis which states that extraction of second bicuspids and mesial movement of molars leads to decrease in facial height in Class I malocclusion and hypo-divergent facial type. The results obtained revealed that there was no change in vertical height in either of the groups and hence declined the validity of the occlusal wedge hypothesis.7 Hayasaki et al evaluated the changes in facial height in class II and class I malocclusion and found that Jaraback’s ratio between extraction and non-extraction treatment in both Class I and Class II patients was similar and no significant changes between the groups were found.19 Al nimri studied the effects of mandibular first and second premolar extraction cases on vertical facial height and concluded that although there was 27

with non extraction cases and found that LAFH increased in non extraction cases but decreased in extraction group which may be due to difference in characteristics between the study sample, hence direct comparisons between these studies is impossible.5 Similar results were obtained when a systematic review was carried out by Kouvelis et al to see the effects of all 4 first premolar extraction on vertical height of face and was concluded that there was no evidence to claim that extraction of premolar had any effect on the facial height.24 In a meta-analysis by Jain et al to evaluate LAFH in extraction v/s non –extraction cases it was found that there is no statistically significant effect of extraction of four first premolars on lower anterior facial height.25 In the present study digital Cephalometry software, NEMOCEPH, was used to avoid the disadvantages associated with conventional methods namely being more time consuming, magnification error to high-risk of errors in tracing, landmark identification, reproducibility and measurement. Moreover, angular parameters were included in addition to linear parameters to measure the changes the LAFH.16 The results of our study revealed that extraction of maxillary and mandibular first premolars in class I patients did not have any significant change in the facial height which is in accordance to several studies mentioned above.

a mesialization of molar in the second premolar extraction group there was no significant change in the MM angle and facial height in any of the group.20 Similarly, Hans et al devised a study see whether there was any change in LAFH after extraction of four fist molars and compared them with all four first premolar cases and found that no significant cephalometric changes were found in either of the group.21 All of the above mentioned studies indicate similar results that premolar extraction does not have a significant impact on the vertical facial dimensions. This can be explained by the fact that most of the extractions done in class I malocclusion are done to relieve crowding and in bi-max cases rest of the space is utilised for the retraction of anterior teeth and during this retraction if proper anchorage is maintained, there is no or very little mesialization of molars which do not produce any significant change in facial height. In the present study, all the cases selected were skeletally and dentally class I and the extraction spaces were used to relieve crowding and retraction of anterior teeth along with anchorage preservation and vertical position maintenance of posterior teeth which led to insignificant change in facial height which was confirmed by no significant changes in angular and linear cephalometric values (table 8). Another important factor to take into account is seeing the effect the premolar extraction on facial height is growth. Kim et al and Harris et al advocated that change in facial height was due to the presence of residual growth in late teens.7,22 In another study done by Taner-Sarisoy it was put forward that there was no change in the LAFH after extraction of premolars as any mesialization and reduction in facial height by the wedging effect was compensated by the growth potential in the patient. The above mentioned reason doesn’t holds true in our study as the patients selected in our study were well beyond their growth potential with cervical vertebrae in stage 5 (Hassel and Farman) and hence disapproves the theory of wedging effect as there was no significant change in LAFH after extraction of premolars.23 Aras et al evaluated the changes that occurred in patients with open bite after orthodontic treatment and concluded that extraction of second bicuspids and first molars led to an anti-clockwise or closing rotation in AOB patients.3 Beit P et al evaluated the changes in LAFH in extraction of all 4 premolar extraction cases and compared them

Conclusions The purpose of this study was to test the hypothesis that extraction of premolars leads to reduction in LAFH due to “wedging effect” which states that in extraction cases there is mesialization of molars which leads to anti-clockwise rotation of mandible and consequently a reduction in lower anterior facial height. Thus, the following conclusion can be drawn from this study. 1. There is no significant change in LAFH when all four first premolar extraction protocol was followed, hence disapproving the occlusal wedge hypothesis. 2. No significant change in vertical facial height was seen when all four first premolar extraction cases were compared with non-extraction group, concluding that the type of protocol used had a little impact on LAFH.

Data Availability The data underlying this article will be shared on reasonable request to the corresponding author References

1. Hans MG, Kishiyama C, Parker S, Wolf GR, Noachtar R. Cephalometric evaluation of two treatment strategies for deep overbite correction. Angle Orthod. 1994;64:265-76. 2. Al–Zubaidi SA, Obaidi HA. The variation of the lower anterior facial height and its component parameters among the three over bite relationships (Cephalometric study). Al–Rafidain Dent J. 2006; 6(2):106-113. 3. Aras A. vertical changes following orthodontic extraction treatment in skeletal open bite subjects. European journal of orthodontics 24(2002) 407-416. 4. Ramesh GC, Pradeep MC, Kumar GA, Girish KS, Suresh BS. Over-bite and vertical changes following first premolar extraction in high angle cases. J Contemp Dent Pract. 2012;13:812–8. 5. Beit P, Konstantonis D, Papagiannis A, Eliades T. Vertical skeletal changes after extraction and non-extraction treatment in matched class I patients identified by a discriminant analysis: cephalometric appraisal and Procrustes superimposition. Progress in Orthodontics. 2017;18(44):1-10. 6. Kocadereli I. The effect of first premolar extraction on vertical dimension. Am J OrthodDentofacialOrthop1999;116:41-5. 7. Kim TK, Kim JT, Mah J, Yang WS, Baek SH. First or second premolar extraction effects on facial vertical dimension. Angle Orthod. 2005; 75:177-82.

Am J Orthod DentofacialOrthop. 1994;105:19-24. 19. Hayasaki SM, CastanhaHenriques JF, Janson G, de Freitas MR. Influence of extraction and non-extraction orthodontic treatment in Japanese-Brazilians with class I and class II division 1 malocclusions. Am J OrthodDentofacialOrthop. 2005;127:30-6. 20. Al-Nimri KS. Vertical changes in Class II division 1 malocclusion after premolar extractions. Angle Orthod. 2006;76:52-8. 21. Hans MG, Groisser G, Damon C, Amberman D, Nelson S, Palomo JM. Cephalometric changes in overbite and vertical facial height after removal of 4 first molars or first premolars. Am J Or- thod Dentofacial Orthop 2006;130:183-8. 22. Harris Eh, Gardner RZ, Vaden JL. A longitudinal cephalometric study of postorthodontic craniofacial changes. Am J Orthod DentofacialOrthop. 1999;115:77-82. 23. Taner-Sarisoy L, Darendeliler N. The influence of extraction orthodontic treatment on craniofacial structures: evaluation according to two different factors. Am J OrthodDentofacialOrthop1999;115:508-14. 24. Kouvelis G, Dritsas K, Doulis I, Kloukos D, Gkantidis N. Effect of orthodontic treatment with 4 premolar extractions compared with nonextraction treatment on the vertical dimension of the face: A systematic review. Am J Orthod Dentofacial Orthop. 2018;154(2):175-187. 25. Jain AD, Goyal M, Kumar M, Premsagar S, Mishra S,Tomar S.Evaluating the Lower Anterior Facial Height in Patients Treated with Extraction Versus Non-extraction Fixed Mechanotherapy: “A Systematic Review and Meta-analysis”. J Indian Orthod Soc. 2021; Article in press: 1–12.

8. Tulley WJ. The role of extractions in orthodontic treatment. Br Dent J 1959;107:199- 205. 9. Wyatt NE. Preventing adverse effects on the temporomandibular joint through orthodontic treatment. Am J Orthod. 1987;91:4939. 10. Bowbeer GR. The sixth key to facial beauty and TMJ health. Funct Orthod. 1987;4:4-22. 11. Witzig JW, Spahl TJ. The clinical management of basic maxillofacial orthopedic appliances. Littleton (MA): PSG Publishing; 1987. p. 161-216. 12. Farrar WB, Mc Carty WL. A clinical outline of temporomandibular joint diagnosis and treatment. Montgomery (AL): Walker; 1983. p. 84-5. 13. Proffit W.R., Field H.W., Ackerman J.L., Bailey L.T., Tulloch J.F.C. Contemporary orthodontics 4th, C.V.Mosby Co; 2000. 14. Graber TM, Vanarsdall R. Orthodontics. Current principles and techniques 4thEd.St.Louis. Mosby yearbook; 1994. 15. Silva MBG, Sant’Anna EF. The evolution of cephalometric diagnosis in Orthodontics. Dental Press J Orthod. 2013;18(3):63-71. 16. Tikku T, Khanna R, Maurya RP, Srivastava K, Bhushan R. Comparative evaluation of cephalometric measurements of monitor-displayed images by Nemoceph software and its hard copy by manual tracing. Journal of Oral Biology and Craniofacial Research. 2014;4(1):35–41. 17. Chua AL, Lim JY, Lubit EC. The effects of extraction versus nonextraction orthodontic treatment on the growth of lower anterior face height. Am J Orthod DentofacialOrthop. 1993;104:361-8. 18. Staggers JA. Vertical changes following first premolar extractions.

Practice Management

Getting More Valuable and Consistent Case Acceptance by Scott J Manning, MBA Anyone can talk a good game, even diagnosis a lot of treatment, but it’s the yeses that matter. Think about the patients with the most opportunity in their mouths. That’s because they’ve taken the path of least resistance that was offered to them by every practice they’ve ever been to before – including quite possibly yours. Instead, take them on a more worthy walk called the “pathway to health” that leads to an improvement in the quality of life. The patient might not always like hearing the harsh truth, but they’ll really dislike the health that results from the pacifying lies. Since we care about the patients’ quality of life, we care about providing comprehensive dentistry, which means case acceptance matters just as much. Today, I want to make a few tactical points that will help you achieve more valuable and consistent case acceptance. 1. The ultimate yes is arrived at in a culminating fashion by getting lots of little yeses along the way. Yes, on the appointment. Yes, on the investment for the comprehensive exam and new-patient experience. Yes, on the pillars of health. Yes, on the goals of the visit. Yes on the comprehension of current problems. Yes, on the outcomes and benefits of treatment. This is the process of asking questions, educating your patient, creating emotional connection, engaging them in a discussion about your clinical philosophy, and obtaining a clinical yes – all before you even think about treatment presentation. You need to build up a series of yeses to eventually lead to case acceptance yeses. Truly, it should not be difficult to build momentum. It is easy to come up with questions no one could possibly disagree with…

• Health being the patient’s responsibility. • Being proactive rather than reactive. • Saving teeth and function. • Avoiding future problems. • Doing less costly treatment now rather than wait. All of these acknowledgements and affirmations along the way lead to a committed patient who wants the outcome of the dentistry at least as much, or even more so, than you do. This has to be deliberately orchestrated in your practice by everyone. If any one team member fails to advance the patient’s belief and deserve, it will sabotage the entire experience. As a team, evaluate the following… • Where in our process and experience do we need to get more patient buy-in? • Where are we moving too fast and not accomplishing the objective? • Where are we taking the path of least resistance instead of a pathway to health? Understand that patients have to first accept that they deserve more than they have now, that they are worthy of the investment, and that their health is their responsibility. You can help them achieve not just the goals they walked in with but the goals you expanded their mind to see and believe in. 2. Move beyond the idea of just ‘case acceptance’ as the final end point of a patient’s journey. The big lesson from last week is that case acceptance can’t be transactional. It’s not yes or no; there is a continuum that must be managed to strategically engineer the yes on your own terms. Begin to see case acceptance as something that never ends. Just like patient relationships go on and patient education continues. We also never stop looking for 30

happened at the end of the day. Provide a review of the patient outcomes and scheduled treatment by the treatment coordinator so each team member can see the result of their efforts

opportunities to provide health and discover ways we can enhance patients’ lives. This doesn’t need to be a secret either. You should not be bashful or timid about this with your patients. Remember, patients can only say yes to what they have been given an opportunity to say yes to. Give yourself the guilt free permission to always move patients towards optimal health. All it takes is a strong conviction that you are doing what is in their best and a willingness to tell the truth. As I always say, trust is best built through telling the truth and being completely transparent. That’s why you can be bold and direct with your patients.

4. Don’t take no (or maybe) for an answer. It’s up to you to continue the conversation with the patient, to follow-up with pertinent information, to creatively help them afford treatment, or to ensure the entire family is on-board (whether it be parents or spouses). As I reminded you last week, a no is not a never. Some patients need time to think it over or additional visits. Perhaps they default to no as a way to test your conviction. Remember you are not an order taker of patient answers, but instead a facilitator of patient outcomes. No matter what, you can’t give up on a patient… Because you can only help those patients who say yes. As a team, review your follow-up protocols after treatment presentation and assign individual responsibilities to ensure no patients fall through the cracks. This is why an end of day huddle or debrief is so critical. There you have it. These case acceptance tactics are critical to achieving greater results for your practice and providing more life changing dentistry for your patients. This is the when, why, and how you dramatically scale up your conversion on treatment and increase the volume, size, value, and consistency of your yeses.

3. Understand that case acceptance is controllable. It can be orchestrated, facilitated, and predicted. Too many practices operate as if they are at the mercy of everything else. The truth is, patient behavior isn’t hard to forecast, nor are your yeses and outcomes. If you control the variables, you can control the outcomes. That is, if you have the proper expectations and have designed a patient experience that is effective. That includes working through your triangles of trust to ensure the patient is making progress during the visit. You also need to have your treatment coordinator pre-scheduled in order to manage the visits of the day and maximize opportunity. You can’t expect to achieve much if you aren’t prepared for success. As a team, have time blocked to go over what

International Association for Orthodontics’ 2023 Professional Advancement & Instructor Seminars June 9th-11th August 11th-13th October 13th-15th 31

December 8th-10th

Fairfax, VA

Featured*

Stability of Surgical and Orthodontic Techniques for the Treatment of Patients with Cleft Palate: A Systematic Review A Review and a Proposal

By Elisa Darqué, Iván Nieto Sánchez, Inés Díaz Renovales, and Patricia Martín-Palomino Sahagún.

Elisa Darqué is a doctor of dentistry (Alfonso X el Sabio University) and she’s a student in master’s degree in orthodontics (Alfonso X el Sabio University).

Iván Nieto Sánchez is a doctor of dentistry (Alfonso X el Sabio University); MS in Orthodontics (San Rafael Hospital); BS of Dentistry (Complutense University of Madrid); MS Biostatistics and Telemedicine for clinical practice and health management (UNED) Diploma in Lingual Orthodontics (University of Lyon I)

Patricia Martín-Palomino Sahagún PhD in Dentistry (University Alfonso X el Sabio), Master in Orthodontics (University Alfonso X El Sabio), DDS (University Alfonso X El Sabio)

Inés Díaz Renovales PhD in Dentistry University Alfonso X el Sabio, Master in Orthodontics (University Alfonso X el Sabio), DDS (University Complutense Madrid)

Abstract Introduction: Osteogenesis distraction is a medical technique in which surgery is performed to separate the bone, and a bone callus is created between the two segments that will ossify later. Unless stated otherwise, the process begins when incremental traction is applied to the repair callus joining the divided bone segments and continues for as long as this tissue is stretched. It is important to understand this concept to be able to compare it with orthognathic surgery in patients with cleft lip. Objective: The main objective of this study is to examine how the cleft palate could be treated as efficiently as possible. We aimed to compare the stability of distraction osteogenesis versus orthognathic surgery in the treatment of cleft palate through a systematic review. Materials and Methods: A systematic review was carried out on the PubMed and Medline, SciELO, ResearchGate, ScienceDirect, Dialnet, Web of Science, and Cochrane databases for articles published mainly in the last five years. We used the following keywords: “Distraction,” “cleft lip,” “orthognathic surgery,” “maxillary hypoplasia,” “Pierre Robin Syndrome,” “osteogenesis,” “cleft palate,” “cleft lip and palate treatment,” “distraction osteogenesis,” “maxillofacial surgery,” “callus distraction,” “callotasis,” “mandibula distraction,” “osteodistraction,” and “orthopedic surgery.” We added a filter to display articles from 2016 to May 2022. Results: From the 67 articles included in the review, the authors observed a greater recurrence of point A (or decrease of ANB) in patients who had been treated with orthognathic surgery than those who had been treated with distraction. Conclusion: According to the conclusions of several studies, it seems that distraction osteogenesis has better skeletal stability than orthognathic surgery in patients with cleft lip without growth. Moreover, orthognathic surgery has a much more important recurrence in the vertical plane than in the horizontal plane. In conclusion, with osteogenesis distraction, an overcorrection of 30 40% must be made.

*This article has been peer reviewed

Introduction Cleft lip and/or palate is one of the most serious congenital anomalies that affect the mouth and its surrounding structures. A cleft is a congenital abnormal space or gap in the upper lip, alveolus or palate. The term used for this condition is cleft lip. More specifically, the most appropriate terms are cleft lip, cleft palate, or cleft lip and palate. Malocclusions and cleft abnormalities have been described; however, few studies have associated malocclusions with oral clefts.1 Baek et al.2 reported similarities between types of malocclusions and the diverse classification of cleft mouths among Koreans. They also found that the type of cleft significantly influenced the development of a Class III malocclusion. Higher frequencies of crossbite and open bite were reported among patients with clefts. Chopra et al.3 reported that anterior open bite and high overjet were more common among children with clefts.2,3 A cleft lip with or without alveolar involvement was more frequently associated with Class I malocclusion, according to the study by Okoye et al.4 Angle Class I was significantly higher than other classes. According to their study, 20% of the patients had Class III malocclusion, while 12% had Class II.4 These results contrast with the those of Baeck et al.’s study,2 which found that the most frequent malocclusion was Class III, which was found in 72% of the participants.2 To treat this anomaly, two techniques were highlighted. The first of these is osteogenic distraction. It relies on the fact that new bone is formed with the preservation of its strength.5,6 Initially, the bone is transected surgically and allowed recovery time or latency time. This period varies from 0 to 7 days, depending on the surgical trauma. After this procedure, there is a period of activation in which the callus is stretched and new bone is created parallel to the traction vector. This period is also called distraction period. Once the elongation of the callus is sufficient, the activation stops and the consolidation time begins; the mineralization and ossification of the bone callus occurs.5,7 Another technique to treat these patients is orthognathic surgery. Such surgery for the correction of a malocclusion was performed in 1849. The Le Fort I osteotomy is a conventional and standard surgical procedure for the correction of maxillary

Figure 1. Biological effect of distraction. (a) Formation of a hematoma after osteotomy with infiltration of capillaries and granulation tissue. Distraction osteogenesis activation begins with the separation of bone fragments. (b) Strain-stress force elicited by the cellular event cascade. (c) A fibrous interface forms between the bone segments. (d) New bone is formed during distraction. Adapted from author.

hypoplasia in patients with cleft lip palate. However, the risk of recurrence is high in patients with scar contractions. Therefore, maxillary advancement by distraction osteogenesis (DO) in the anteroposterior direction has become more popular. DO is now frequently recommended for the correction of maxillary hypoplasia in patients with a cleft lip palate (CLP). Several studies have shown that there is much less recurrence with DO than with surgery (8.2% vs. 37%, respectively).8 The objective of this study is to evaluate the stability of osteogenic distraction and orthognathic surgery in patients with cleft lip and palate. Materials and Methods This study was conducted and reported according to the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. Eligibility Criteria This systematic review was conducted to observe which of the two techniques has the best stability with patients with a cleft lip. Randomised controlled trials, prospective studies, systematic 33

reviews, case-control studies and cohort studies that compared the effects of an orthognathic surgery and osteogenesis distraction in subjects with a cleft lip were included. Studies published before 2008, those not in Spanish, English, or French, duplicate articles, publications without full text and studies with patients who have had their arms or legs distracted were not included. In addition, studies that did not evaluate patients with unilateral or bilateral clefts were excluded. Case reports, case series and expert opinions were not included in this systematic review. According to the Participants-InterventionsComparisons-Outcome-Study (PICOS) strategy, randomised controlled clinical trials on human patients were included if they met the following selection criteria: • Participants (P): Adult patients or adolescents who have completed their growth with cleft lip and/ or palate. • Intervention (I): Osteogenic distraction. • Comparison (C): Group of patients who have undergone orthognathic surgery. • Outcomes (O): Recurrence (movement of A point in mm) after the intervention and in the long term.

search included articles from 2008 to September 2022. We applied filters for languages (French, English, and Spanish), year of publication (last five years), and types of studies. The following keywords were used: “Distraction,” “cleft lip,” “orthognathic surgery,” “hypoplastic maxilla,” “osteogenesis,” “cleft palate,” “cleft lip and palate treatment,” “distraction osteogenesis,” “maxillofacial surgery,” “callus distraction,” “callotasis,” “maxillary distraction,” “osteodistraction,” and “orthopedic surgery.” Results Study Selection The flowchart of the research selection procedure, in accordance with the PRISMA guidelines, is presented in Figure 2.

Information Sources, Search Strategy and Selection of Studies To carry out an information search on osteogenic distraction and orthognathic surgery in patients with cleft palate, we used PubMed, Web of Science, SciELO, and Cochrane. To find articles that match our search, a search strategy was used. The MeSH terms were elaborated to develop the following equation: (osteogenesis distraction OR maxillary distraction OR osteodistraction) AND (cleft lip AND palate) AND (othognathic surgery OR orthognathic surgeries OR orthopedic surgery). To begin with, the titles and abstracts were evaluated by two evaluators (ED and MC) to reduce errors and choose all the articles that met the search requirements. When the information from the abstract was not sufficient, full texts were read for a complete analysis. The decision to include the articles was made after full texts were analyzed by the two experts. In case of discrepancy, a third reviewer (IN) was called to either accept or reject the article. The

Figure 2. PRISMA flow diagram depicting the selection of the eligible studies.

The electronic-database search identified a total of 174 articles. After eliminating 61 duplicates, 113 studies were screened based on title and abstract to identify potentially eligible articles. This led to the exclusion of 94 publications, and full texts of the remaining 13 articles were retrieved and analysed according to the eligibility criteria. Subsequently, four articles were excluded after full-text assessment because they were retrospective cohort studies.9-12 Finally, eight clinical trials and five systematic reviews were considered eligible for this systematic review.13-25 34

Table 1: Description of the articles used for this systematic review. Realised by the author.

Table 2: Description of the articles used for this systematic review. Realised by the author.

Discussion Summary of Evidence This systematic review elucidates on which treatment has greater stability: orthognathic surgery or osteogenesis distraction. Few articles demonstrate which technique would be the most appropriate to treat a patient with cleft palate. The literature is conflicting regarding intraoperative skeletal movement and higher relapse rates. Our analysis suggests that for every 1 mm of maxillary advancement achieved with surgery, an average of 0.23 mm of recurrence is expected (p 1⁄4 0.007), and for every 1 mm of maxillary vertical descent, a mean recurrence of 0.13 mm is expected (p 1⁄4 0.039). Therefore, DO has been proposed when a greater range of movement is required since it is described as a more stable method.13,14,15 The study by Kloukos et al.16 included 47 participants with a minimum age of 13 years with a mature skeletal growth that required a maxillary advancement of 4 to 10 mm. They used internal

mechanism osteogenic distraction with a buccal cut. The maxilla was fully mobile but was not brought into the final occlusal position. The internal devices were placed and activated a few millimeters apart to gradually position the maxilla. After a three-day wait, activation of 1 mm every day begun until an incisal Class I was achieved. As a control group study, it had patients who had undergone a Le Fort I osteotomy. Surgery was performed with fragmentation of the maxilla. Here, the maxilla was placed in the final occlusal position. One of the conclusions of this article was that, from the patients’ point of view, it was evident that aesthetics would improve regardless of the technique. Patients must be prepared for any recurrence to occur. Regarding stability, osteogenic distraction might be preferable.16,17 Quality-of-life results during treatment suggest that osteogenic surgery might be preferable.16 Ganoo et al.17 found no significant difference between the functional results offered 35

by the conventional orthognathic surgery and those offered by distraction osteogenesis. Similarly, Cheung18 found that distraction provided better skeletal stability, while there was a significant amount of skeletal relapse in the first 12 weeks after a conventional maxillary osteotomy. In the skeletal recurrences of the osteotomy group, a statistically significant vertical recurrence of point A was observed during the second to the twelfth week as compared with that in the distraction group. Statistically significant horizontal recurrence of point A was observed during the eighth to twelfth weeks when the osteotomy group was compared with the distraction group. Anderson et al.19 observed that DO results in a stable position of the maxilla. Conventional orthognathic treatment resulted in recurrence in the sagittal direction and continued downward movement of the maxilla postoperatively in a Le Fort I surgery. Le Fort I with osteogenic distraction and osteogenic distraction of the anterior maxilla have been evaluated for the treatment of maxillary hypoplasia in patients with clefts. Relapse rates were 20%, 12%, and 12%, respectively.20 So, the study by Jiang20 has the same results in terms of DO stability as the previous studies. There were significant improvements immediately after distraction, but during the one-year follow-up, some differences were observed.20 This emphasised the need for an overcorrection of around 35% to 40% for adult patients with CLP.21,22 In a study by Aksu et al.,21 in which 7 adult patients with PLC were treated with OD, after three years, a relapse rate of 22% was observed in the maxilla. Cho and Kyung12 found a relapse rate of approximately 23% during the one- to six-year period after distraction, Baek et al.22 found 21%, while Kanno et al.9 found fewer relapses (approximately 8%) during a follow-up period of 2.8 years. In total, 70% of improvements were stable at long-term follow-up.11 Regarding comorbidities, there were no important differences in clinical morbidities between the osteotomy and distraction groups.18 Quality of life is one of the most important aspects when choosing between the two techniques. DO caused increased anxiety and distress as compared with orthognathic surgery. This is caused by the device itself and the pressure on patients and their families to correctly handle the device, as they were responsible for part of the treatment. However,

in long-term follow-up, patients who had received DO were more satisfied. Therefore, orthognathic surgery offered a better quality of life during treatment for patients; however, DO offered a better quality of life after treatment.17 So, patients with a cleft lip who had undergone DO looked worse during treatment, but after treatment (in the long term), they had higher satisfaction.16,17 Other authors also concluded that DO has no advantage over orthognathic surgery in preventing velopharyngeal incompetence and speech impairment in moderate cleft maxillary advancement.16,23,24 However, Ramanathan25 finds that DO offers an advantage, in that velopharyngeal incompetence can be monitored during the activation phase. Distraction of the anterior part of the maxilla is another alternative to alleviate the disadvantage of worsening speech. There is a lack of agreement among researchers regarding the best time to treat these patients. If early distraction treatment is performed on cleft lip patients before their facial skeletal growth is complete, orthognathic surgery or further distraction may be needed later. Therefore, there are only two options available to treat maxillary hypoplasia in patients aged 11 to 13 years: total or anterior maxillary distraction. Orthognathic surgery can be performed only after complete growth.25 Limitations Choosing articles that concord with the eligibility criteria was difficult. This systematic review did not make a distinction between the use of intern or extern distraction devices. Finally, the follow-up duration was not defined precisely. Conclusion According to the results of this systematic review, in terms of stability, distraction is the treatment of choice in patients with cleft palate without growth. Osteogenesis distraction has better stability than orthognathic surgery. In addition, orthognathic surgery has a much more significant recurrence at the vertical level than at the horizontal level. The best treatment option for children with cleft lip is DO and, more precisely, distraction of the anterior maxilla, as it does not compromise the muscles of the velopharynx. However, it may not prevent future surgery or further distraction. During treatment, orthognathic surgery is 36

preferred by patients, but in the long term, patients are more satisfied with DO. Regarding speech, many researchers agree that neither orthognathic surgery nor distraction seems to bring advantages for velopharyngeal incompetence. However, the distraction would have the advantage of controlling and monitoring the incompetence during the activation of the device. Disclosure of Interest The authors declare that they have no competing interest. References

1. Vyas T, Gupta P, Kumar S, Gupta R, Gupta T, Singh HP. Cleft of lip and palate: a review. J Family Med Prim Care. 2020 Jun 30;9(6):2621-5. DOI: 10.4103/jfmpc.jfmpc_472_20 2. Baek SH, Moon HS, Yang WS. Cleft type and Angle’s classification of malocclusion in Korean cleft patients. Eur J Orthod. 2002;24:64753. 3. Chopra A, Lakhanpal M, Rao NC, Gupta N, Vashisth S. Oral health in 4-6 years children with cleft lip/palate: a case control study. N Am J Med Sci. 2014;6:266-9. 4. Okoye LO, Onah II, Ekwueme OC, Agu KA. Pattern of malocclusion and caries experience in unrepaired cleft lip and palate patients in Enugu. Niger J Clin Pract. 2020 Jan;23(1):59-64. DOI: 10.4103/njcp.njcp_249_19 5. Barber S, Mannion C, Bates C. Distraction osteogenesis part 1: history and uses in the craniofacial region. Orthodontic Update. 2018. Available from: https://www.researchgate.net/ publication/322749139 DOI: 10.12968/ortu.2018.11.1.14. 6. Vale F, Francisco I, Cavaleiro J, Caramelo F, Guimarães A, Brochado J. Distraction osteogenesis in dog with a tooth-borne device: histological and histomorphometric analysis. J Clin Exp Dent. 2020 Jan 1;12(1):e52-e58. DOI: 10.4317/medoral.56491 7. Singh M, Vashistha A, Chaudhary M, Kaur G. Biological basis of distraction osteogenesis: a review. J Oral and Maxillofac Surg Medicine. 2016;28(1):1-7. DOI: 10.1016/jajoms.2015.06.006 8. Kokai S, Fukuyama E, Omura S, Kimizuka S, Yonemitsu I, Fujita K, Ono T. Long-term stability after multidisciplinary treatment involving maxillary distraction osteogenesis, and sagittal split ramus osteotomy for unilateral cleft lip and palate with severe occlusal collapse and gingival recession: A case report. Korean J Orthod. 2019 Jan;49(1):59-69. DOI: 10.4041/kjod.2019.49.1.59 9. Kanno T, Mitsugi M, Hosoe M, Sukegawa S, Yamauchi K, Furuki Y. Long-term skeletal stability after maxillary advancement with distraction osteogenesis in nongrowing patients. J Oral Maxillofac Surg. 2008 Sep;66(9):1833-46. Doi: 10.1016/j.joms.2007.10.013 10. Painatt JM, Veeraraghavan R, Puthalath U, Peter S, Rao LP, Kuriakose M. Profile changes and stability following distraction osteogenesis with rigid external distraction in adult cleft lip and palate deformities. Contemp Clin Dent. 2017 Apr-Jun;8(2):236-243. DOI: 10.4103/ccd.ccd_1164_16 11. Singh SP, Jena AK, Rattan V, Utreja AK. Treatment outcome and long-term stability of skeletal changes following maxillary distraction in adult subjects of cleft lip and palate. Contemp Clin Dent 2012;3:188-92.

12. Cho BC, Kyung HM. Distraction osteogenesis of the hypoplastic midface using a rigid external distraction system: The results of a one-to-six year follow-up. Plast Reconstr Surg. 2006;118:1201-12. 13. Chua HD, Hägg MB, Cheung LK. Cleft maxillary distraction versus orthognathic surgery--which one is more stable in 5 years? Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010 Jun;109(6):803-14. DOI: 10.1016/j.tripleo.2009.10.056 14. Valls-Ontañón A, Fernandes-Ciaccia L, Haas-Junior OL, Hernández-Alfaro F. Relapse-related factors of Le Fort I osteotomy in cleft lip and palate patients: a systematic review and metaanalysis. J Craniomaxillofac Surg. 2021 Oct;49(10):879-890. DOI: 10.1016/j.jcms.2021.09.002. Epub 2021 Sep 10. 15. Ansari E, Tomat C, Kadlub N, Diner PA, Bellocq T, Vazquez MP, Picard A, 2015. Skeletal and soft tissue changes and stability in cleft lip and palate patients after distraction osteogenesis using a new intraoral maxillary device. J. Cranio-Maxillo-Fac. Surg. 43(3) :e323-e328. 16. Kloukos D, Fudalej P, Sequeira-Byron P, Katsaros C. Maxillary distraction osteogenesis versus orthognathic surgery for cleft lip and palate patients. Cochrane Database Syst Rev. 2018 Aug 10;8(8):CD010403. DOI: 10.1002/14651858.CD010403.pub3 17. Ganoo T, Sjöström M. Outcomes of maxillary orthognathic surgery in patients with cleft lip and palate: a literature review. J Maxillofac Oral Surg. 2019 Dec;18(4):500-8. DOI: 10.1007/s12663019-01217-w 18. Cheung LK, Chua HD, Bendeus M. Distraction or osteotomy for the correction of maxillary cleft deformities: which is better? Ann R Australas Coll Dent Surg. 2004 Oct;17:57-63. 19. Andersen K, Svenstrup M, Pedersen TK, Küseler A, Jensen J, Nørholt SE. Stability after cleft maxillary distraction osteogenesis or conventional orthognathic surgery. J Oral Maxillofac Res. 2015 Jun 30;6(2):e2. DOI: 10.5037/jomr.2015.6202 20. Jiang L, Zheng Y, Li N, Chen X, Lu Z, Tong H, Yin N, Song T. Relapse rate after surgical treatment of maxillary hypoplasia in non-growing cleft patients: a systematic review and meta-analysis. Int J Oral Maxillofac Surg. 2020 Apr;49(4):421-31. DOI: 10.1016/j. ijom.2019.08.012. Epub 2019 Sep 14. 21. Aksu M, Saglam-Aydinatay B, Akcan CA, El H, Taner T, Kocadereli I, et al. Skeletal and dental stability after maxillary distraction with a rigid external device in adult cleft lip and palate patients. J Oral Maxillofac Surg. 2010;68:254-9. 22. Baek SH, Lee JK, Lee JH, Kim MJ, Kim JR. Comparison of treatment outcome and stability between distraction osteogenesis and Le Fort I osteotomy in cleft patients with maxillary hypoplasia. J Craniofac Surg 2007;18:1209-15. 23. Chua HD, Whitehill TL, Samman N, Cheung LK. Maxillary distraction versus orthognathic surgery in cleft lip and palate patients: effects on speech and velopharyngeal function. Int J Oral Maxillofac Surg. 2010 Jul;39(7):633-40. DOI: 10.1016/j. ijom.2010.03.011 24. Richardson S, Krishna S, Bansal A. Use of repeat anterior maxillary distraction to correct residual midface hypoplasia in cleft patients. J Korean Assoc Oral Maxillofac Surg. 2017 Dec;43(6):407-414. DOI: 10.5125/jkaoms.2017.43.6.407 25. Ramanathan M, Kiruba GA, Christabel A, Parameswaran A, Kapoor S, Sailer HF. Distraction osteogenesis versus orthognathic surgery: demystifying differences in concepts, techniques and outcomes. J Maxillofac Oral Surg. 2020 Dec;19(4):477-89. DOI: 10.1007/s12663-020-014

Clear Aligners Corner

Can We Treat Kids in Mixed Dentition with Clear Aligners? The Benefits of Early Orthodontic Treatment for Kids By Dr. Stephane Reinhardt, DMD, Director of Education Program for The C.L.E.A.R. Institute Inc., www.theclearinstitute.com

Can we treat kids in mixed dentition with clear aligners? That question is often asked: will children wear the aligners? The answers: Yes and yes! Young patients have been wearing appliances through the years and have excellent compliance. Appliances that are a lot more challenging to wear than aligners (twin blocks, Haas, split plates, quad helix, headgear, etc...). Teeth are not selective; whether it is a primary or permanent tooth, if you apply a constant force and they are not blocked or ankylosed, they will move! With kids, we want to prevent problems, keep space, maintain space and/or regain space that we have lost for some reason. Preventive and interceptive orthodontic treatment is sometimes unclear because it implies that if we do it correctly and intercept a problem, there will be no need for further orthodontic treatment, which is often not true! Intercepting a problem and preventing some issues will be very helpful in reducing the severity of problems but rarely is so successful that later treatment becomes unnecessary. Our responsibility as primary care providers is to see the problems, understand the consequences they could bring and inform the parents/patients about them. Preventive and interceptive orthodontics are essential to ensuring our kids have the best dental future possible. As dentists, we know that the earlier we can identify potential problems and nip them in the bud, our patients will be better off. But why is this so important? Let’s look closer at why preventive and interceptive orthodontics benefit growing children.

environment where your patient&#39;s oral health gets off to a great start. It involves monitoring tooth development and jaw growth to ensure that everything stays balanced as they grow up. This can include using space maintainers to keep teeth from drifting into empty spaces left by baby teeth or using expansion appliances to make room for permanent teeth when needed. What Is Interceptive Orthodontics? Interceptive orthodontics focuses on correcting problems before they become more severe in the future. This type of treatment is usually done between the ages of 6 and 10 because that’s when a child’s mouth is still developing quickly enough for us to make changes relatively easily. It can involve anything from addressing bad habits such as thumb sucking or tongue thrusting to simple procedures like widening palates or removing teeth. Why Is Early Intervention So Important? Early intervention helps us prevent more severe issues from occurring in the future. By taking steps now, we can help ensure our patients have healthy mouths well into adulthood and beyond! Plus, starting treatment early means that a patient’s overall treatment time could be shorter than it would be

What Is Preventive Orthodontics? Preventive orthodontics is all about creating an 38

if an intervention weren’t started until later in life saving time and money! What is essential to know is when to treat, when to wait… and when to use clear aligners. Preventive and interceptive orthodontic treatments are invaluable tools for helping our young patients achieve beautiful smiles in the future! By taking a proactive approach now, we can help them avoid costly procedures in the future while also providing them with confidence-boosting results sooner rather than later! When it comes to helping kids get off on the right foot with their oral health preventive and interceptive orthodontics are key! In every case, when you decide to treat your young patients with phase I or age-appropriate orthodontic treatment, make sure the parents have been made AWARE of the possibilities and options for orthodontic treatment following complete dentofacial development. If you see they don’t understand the problem or don’t see the problem… WAIT! Preventive and interceptive orthodontic treatments are invaluable tools for helping our young patients achieve beautiful smiles in the future! By taking a proactive approach now, we can help them avoid costly procedures in the future while also providing them with confidence-boosting results sooner rather than later! When it comes to helping kids get off on the right foot with their oral health preventive and interceptive orthodontics are key! In every case, when you decide to treat your young patients with phase I or age-appropriate orthodontic treatment, make sure the parents have been made AWARE of the possibilities and options for orthodontic treatment following complete dentofacial development. If you see they don’t understand the problem or don’t see the problem… WAIT!

Can we use clear aligners to treat children in mixed dentition cases? What does the scientific literature say about it? Let’s take a look at the scientific literature: In their article “Comparison between clear aligners and 2×4 mechanics in the mixed dentition: a randomized clinical trial” published in 2022 in the Angle Orthodontist, Vinicius Merino da Silva and al. concluded that clear aligners and 2 x 4 mechanics using fixed metal brackets displayed similar efficacy and efficiency for maxillary incisor position corrections in the mixed dentition. According to their article, the choice of appliance should be guided by the clinician and family preference. Ok, but… what is the best appliance? You might ask. The answer is the same for retention. Same for any treatment. The best appliance is the one the patient will wear! My experience treating kids in mixed dentition with clear aligners is positive. I like it. They like it. They wear it (sometimes a lot better than their parents who are in treatment simultaneously), and they are fun to treat (they are not teenagers yet!). Mechanic is mechanic. By understanding the principles of clear aligner orthodontics combined with growth and development principles, development of occlusion, you’ll define the appropriate age for treatment, and you’ll be able to maintain everything in place until phase II. If you are not entirely comfortable diagnosing and treating phase I patients with clear aligners, if you are not sure how to prevent problems and prepare patients for upcoming phase II treatment, If you want to understand what to observe and monitor in mixed dentition patients and determine the right time or appropriate age for treatment, here are some options for you: If you like online courses, we got you covered with the Preventive and Interceptive orthodontics treatments: when to treat, when to wait and when to use clear aligners. This 8h30 covers all the subjects with complete treated cases with clear aligners. Have fun making the move… and have fun treating kids with clear aligners

Your patient and the parents are ready. You must decide what appliance you are going to use. Clear aligners? Really? Of course! Why not? 39

Featured*

Comparison of Bolton Analysis Between Interproximal Stripping and Mandibular Incisor Extraction to Resolve Lower Anterior Crowding – A Cross-sectional Study By Dr. Mubassar Fida and Dr. Dr. Kanza Tahir Dr. Mubassar Fida graduated from Nishtar Medical College: Multan, Punjab, PK. Residency in Orthodontics from Alvi Dental Hospital: Karachi, Sindh, PK.Membership in Orthodontics European Orthodontic Society: London and American Association of Orthodontists: Creve Coeur, Missouri, US, and Fellowship in Orthodontics from College of Physicians. MS in community dentistry. He has authored many indexed original research articles and has also presented his work at various national and international forums. He has received numerous awards for his research presentations both internationally and nationally. Dr. Kanza Tahir graduated wrom Liaquat University of Medical and Health Sciences, Jamshoro in 2017. After passing her FCPS part-1, her interest in Orthodontics led her to acquire residency in a well-known institution of Pakistan. Currently, she is working on three research work projects related to orthodontics.

Abstract Background/Objective: The debate between the two treatments of crowding – whether to extract teeth or use a non-extraction method – has not yet seen a universal winner among modern orthodontists. This study aimed to evaluate the differences in Bolton Ratio (BR) of patients with mild-moderate crowding treated with mandibular incisor extraction or interproximal reduction passing the American Board of Orthodontics – Objective Grading System (ABO-OGS) criteria. Materials and methods: A cross-sectional study was conducted in a tertiary care hospital. Preand post-treatment dental casts were utilized to calculate the BR. Posttreatment dental casts and panoramic radiographs were used to determine the ABO-OGS scores of interproximal reduction (IPR) and mandibular incisor extraction (MIE) groups. A total sample size of 40 was required for the study with 20 cases in each group. The Wilcoxon signed-rank test was used to compare pre- and post-treatment Bolton changes. The MannWhitney U test was used for comparison between IPR and MIE group. Linear Regression was used to determine the association among variables. Results: In comparison between IPR and MIE groups, statistically significant differences (p ≤ 0.05) were seen in post-treatment anterior Bolton. Statistically significant differences were also reported for alignment, buccolingual inclinations, and occlusal contact scores. On linear regression, the difference in ABO-OGS scores increased by 4.4 units in the IPR group. Conclusions: Pre-treatment anterior maxillary excess led to increased overjet scores. Mandibular incisor extraction caused maxillary anterior Bolton excess which raised the overjet scores. Increased ABO-OGS alignment scores were found in the interproximal reduction group. Keywords: Mandibular crowding, ABO-OGS, Bolton analysis 40

*This article has been peer reviewed

Introduction Correct alignment of teeth is one of the essential goals of orthodontic treatment.1 An attractive smile and accurate alignment of the front teeth are the focal objectives for individuals pursuing orthodontic treatment.2 The anterior region displayed on smile is unique to every individual face and is composed of three components: dental, gingival, and soft tissue components. The dental component comprises the anterior teeth alignment, position, size, shape, and color.3 With an advancing age, soft tissues tend to sag, increasing the lower incisors’ show.4 In adults, the mandibular incisor region is most susceptible to patients’ dissatisfaction and is a cause of concern due to increased exposure of lower incisors on smile.5 The last three decades have revealed that individuals over 20 years mostly exhibit late mandibular crowding.6 Initially, Begg shed some light on the cause of late lower incisor crowding that inadequate interproximal enamel reduction (IPR) may be an element, whereas Müller proposed that crowding may be caused by increased pressure from the buccinator muscle due to inappropriate lowered tongue posture.7 However, Corruccini associated the lack of space with a gradual decrease in the size of the craniofacial structures.8 Different approaches are available to resolve mandibular crowding depending on the severity, which may involve exodontia, interproximal wear, dental expansion and distraction osteogenesis of the mandibular symphysis.9,10 According to Ileri et al,10 a PAR index assessment indicated that malocclusions improved by extracting mandibular incisor where there was mandibular anterior Bolton discrepancy in which the anterior ratio was equal to 81.7 ± 4.5. This suggests that in cases in which there is non-significant mandibular Bolton excess, the best substitute may be interproximal stripping.11,12,13 It is crucial for a satisfactory outcome to establish which method gives a better post-treatment outcome. By utilizing the American Board of Orthodontics – Objective Grading System (ABO-OGS) discrepancy index and comparing the pre- and post-treatment Bolton ratio (BR), our aim was to establish which method gives better treatment outcomes. Furthermore, this study can help future researchers to derive a range of BR in MIE or congenitally missing lower incisor cases. Our primary objective was to study the differences in BR between patients treated by MIE and IPR. The secondary objective of this study was to determine the components of ABO-OGS that led to higher scores in

both groups. Materials and Methods: After obtaining approval from the departmental ethical review committee (2022-5939-16676), a cross-sectional study was conducted on a sample size of 40 (N) in a tertiary care hospital. Data were collected using the pretreatment and post-treatment dental casts. The mesiodistal widths of each tooth from first molar to the contralateral first molar were obtained using a digital vernier caliper to obtain overall BR. For anterior BR, mesiodistal widths of all teeth from canine to its antimere were obtained. The overall and anterior BR were calculated by the formulas reported in the original Bolton study.14 After calculating the BR, we utilized the post-treatment dental casts and panoramic radiographs to measure the ABO-OGS scores. All the eight criteria were precisely measured by following the guidelines provided by ABO in 1999 using a marking chart provided by Saini P et al.15 in their study. Each component was precisely measured and scored according to the ABO-OGS criteria. The passing criterion was a cumulative score of less than 25. The sample size was calculated with OpenEpi® software v. 3.01, using the findings of Ileri et al.10 who reported a standard deviation of overall ratio for the MIE group to be 2.9 and for non-extraction group 2.0 with a mean difference of 2.5. Keeping α = 0.05 and a power of 80%, at least 16 (n) subjects were required in each group. With 10% inflation, the total sample size for each group was 20. Since we had two groups – Group 1 (IPR) and Group 2 (MIE) – a total sample of 40 (N) was required. The dental casts included in our study had the following criteria: the casts with a crowding of 2-6 mm, good quality dental casts and radiographs, dental casts that had a complete pre and post-treatment record, nonextraction fixed mechanotherapy cases that followed IPR of both arches and cases with single MIE with no other extractions. The exclusion criteria were cases with crowding of greater than 6 mm, cases with multiple extractions, and any dental model with effects of parafunctional habits on the dentition. Casts of patients with abnormal tooth morphology of the maxillary lateral incisors and lower second premolars or any other teeth were excluded. Dental casts with any missing teeth were also excluded. Statistical Anaylysis Data were analyzed using SPSS software (version 23.0). Shapiro-Wilk test was used to determine the 41

normality of the data which showed a non-normal distribution. Frequencies were reported for categorical variables such as gender. Descriptive statistics median and interquartile range (IQR) were reported for age and ABO-OGS scores. Wilcoxon signed-rank test was used to compare pre- and post-treatment Bolton changes within each of the IPR and MIE groups. Spearman’s correlation was used to determine the correlation amongst the variables. Mann-Whitney U test was used for comparison between IPR and MIE groups. Linear regression was carried out to determine the association among variables. Intra-class correlations (ICC) were applied to determine the intra-examiner reliability by measuring the pre- and post-bolton ratios at 2 weeks interval. A p-value < 0.05 was considered statistically significant.

Table 3: Comparison between IPR and MIE

Results: Demographics: In this study, dental casts of 20 males and 20 females were studied (Table 1). The median ages of IPR and MIE groups were 18.91 years (16.31, 21.68) and 19.05 years (18.57, 20.85), respectively (Table 2). There was a comparable gender distribution between the two groups. A comparison between IPR and MIE groups was done with a statistically significant difference found in post-treatment anterior BR (Table 3). Statistically significant differences between the IPR and MIE groups were also found for alignment with median scores of 6.00 (3.25, 7.75) and 3.00 (2.00, 5.00) respectively. Statistically significant values were revealed for buccolingual inclinations with median scores of 9.00 (8.00, 10.00) and 6.50 (5.00, 8.75) for the IPR and MIR groups, respectively.

Table 4: Comparison of Pre- and Post-treatment Bolton

Significant differences were also observed for occlusal contacts (p = 0.006) and interproximal contacts (p = 0.040). The ABO-OGS median scores for the IPR group was 38.00 (33.00, 42.70) and for the MIE group was 34.50 (29.00, 39.75) (p = 0.05). MIE group had better median scores for alignment, occlusal contacts, and buccolingual inclinations. However, the IDR group scored better in interproximal contacts (p = 0.040). The comparison between both groups revealed that the overall ABO-OGS scores were better for the MIE group however, they were statistically non-significant. Comparison between the pre-treatment and posttreatment BR showed statistically non-significant differences between the two groups (Table 4). Spearman correlation showed that pre-treatment anterior Bolton had a highly significant (p < 0.001) negative and a very strong correlation with the pretreatment maxillary arch excess (Table 5). Post-treatment anterior Bolton was found to be significantly (p = 0.050) correlated with the pre-treatment anterior Bolton.

Table 1: Gender distribution

Table 2: Gender distribution

Table 5: Spearman correlation

Table 6: Spearman correlation

Pre-treatment anterior Bolton had a significant negative and weak correlation with overjet scores (Table 6). Post-treatment anterior Bolton had a significant positive and a weak correlation with marginal ridges scores, indicating that the maxillary excess led to higher marginal ridges scores. Alignment had a highly significant (p ≤ 0.001) positive and a moderate correlation with the buccolingual inclinations (Table 7). Poor alignment scores led to increasing in buccolingual scores. Moreover, the buccolingual scores had a highly significant (p ≤ 0.001) and a positive strong correlation with the ABO-OGS scores. The raised buccolingual scores also led to increased ABO-OGS scores. Interproximal contacts (IPC) had a statistically significant (p = 0.021) positive and a weak correlation with the root position (RP). Increased IPC scores led to higher root positioning scores. Moreover, the RP scores had a significant positive and a very weak correlation with the buccolingual inclinations. Higher RP scores led to increased buccolingual inclination scores. The RP, marginal ridges, and buccolingual scores led to increase in the ABO-OGS scores.

Table 7: Spearman correlation

Table 8: Spearman correlation

Discussion Orthodontic treatment focuses on providing an aesthetic smile and optimal oral functions by carrying out an individualized treatment plan. Over the years of the orthodontic profession, many different treatment modalities have been put forward, each with its own merits and demerits.16 Two commonly applied methods of gaining space in moderate crowding cases are interproximal reduction and exodontia. The current study aimed to differentiate 43

have been suggested in the literature.20 Studies suggest careful consideration of the pre-treatment condition of malocclusion with a focus on the indications mentioned in the preceding paragraphs. Some studies have suggested the use of the modality only in cases of significant mandibular tooth material excess. A recent study suggested the evaluation of the BR after leveling and alignment have been performed during MIE treatment.21 This analysis allows the quantification of the maxillary excess that has been created by the treatment modality, which leads to an accurate correction of the tooth material excess. Once the tooth material excess has been mitigated, the occlusal relations would be ideal including the overjet and canine relationship.22 On assessing the linear regression analysis, the relationship between anterior and overall BR was analyzed with the treatment modalities. Anterior BR difference when assessed along with MIE as reference showed significant results in the IPR group. (β = -2.50, 95% C.I: -4.03,-0.98) This signifies the maxillary excess that is observed after MIE treatment and the mandibular excess seen after IPR. Clinicians should evaluate BR both in the anterior and overall, during the finishing stages of treatment so that ideal occlusal relationships can be obtained. When the relationship of ABO-OGS scores along with the treatment modality was assessed, IPR treatment modality was found to be associated with higher ABOOGS scores when MIE was kept as a reference. (β = 4.4, 95% C.I: 0.25,8.54) These results show that better occlusal and functional results as analyzed using the ABO-OGS index can be obtained with MIE. These differences can be attributed to the amount of space that can be obtained with MIE as compared to IPR which involves judicious removal of 0.25mm of each interproximal surface in the anterior region. These differences can also be attributed to the decreased number of teeth involved in the analysis in the MIE group as one tooth is extracted. This leads to one less tooth analyzed for the overjet, alignment, root parallelism and interproximal space components of the ABOOGS as compared to the IPR group. This may lead to a decreased total ABO-OGS score in the IPR group which might not be attributable to the functional relationships in post-treatment but is instead due to the mismatch in the number of teeth analyzed. The current manuscript aimed to differentiate between the IPR and MIE treatment modalities in lieu of the BR that is present in pre- and post-treatment.

between the BR after IPR and MIE treatment modalities along with differences in ABO-OGS scores attained posttreatment. We rejected our null hypothesis, as significant differences were observed in the anterior BR after IPR and MIE treatment. MIE has been a frequently contested treatment modality in orthodontic literature and practices. The controversy lies in the inherent side effects of the treatment modality including but not limited to; increased overjet, increased overbite, decrease in lower intercanine width, class III canines, loss of canine guidance and anterior BR excess in the maxilla at post-treatment.17 Due to these side effects, some practitioners tend to avoid using MIE as a treatment modality. In the current study, a significant difference was observed between the two groups when analyzing the post-treatment anterior BR. IPR group had a minimal mandibular excess, whereas the MIE group had maxillary tooth material excess at posttreatment. These findings are in agreement with Illeri et al.10 who found differences in the anterior BR after nonextraction and MIE treatment. While there are many side effects to MIE therapy, when used in light of its indications, it has been demonstrated to be an efficient treatment modality in solving mild to moderate anterior mandibular crowding. MIE can be indicated in well balanced soft tissue profiles, interdigitated posterior occlusion, minimal overbite and edge to edge overjet cases.18 In our study, MIE group had better ABO-OGS scores as compared to the IPR group and the statistical difference was found to be nearly significant. This is in agreement with a study conducted by Safavi et al.18 who used PAR improvement percentages to observe the effect of MIE treatment modality. They reported significant improvement with the MIE treatment modality with greatly improved PAR percentages. The reasons cited in their study that led to a decrease in PAR improvement percentages were overjet scores and midline discrepancy scores. When observing the ABO-OGS components used in our study, we also found significant differences in overjet scores between the two treatment modalities with the MIE group having higher scores for this component. However, these findings were in contrast with Maaz and Fida,19 who reported lower PAR and Index of Complexity, Outcome and Need (ICON) scores in MIE when compared to non-extraction. It is important to state that even though lower scores were obtained than non-extraction, the MIE group still had greatly improved PAR percentages and outcomes assessed by ICON. Many solutions to the drawbacks presented by MIE 44

Certain limitations existed in our study, it being a single center study with a purposive sampling design. The study finds its strength in the sampling; the cases included were treated under two different consultants which helped mitigate operator bias in our study. MIE treatment modality allowed better ABO-OGS scores, but certain limitations exist in its execution which can be managed by careful analysis of the BR. Ideal BR at the end of treatment allows ideal finishing of the occlusion which is functionally stable and aesthetically pleasing. Conclusions: 1) Pre-treatment anterior Bolton maxillary excess led to increased overjet scores 2) Mandibular incisor extraction caused maxillary anterior Bolton excess which raised the overjet scores. 3) Increased ABO-OGS alignment scores were found in the interproximal reduction group.

reduction. Prog Orthod. 2022;23:9-15. 14. Bolton WA. The clinical application of a tooth-size analysis. Am J Orthod. 1962;48:504-29. 15. Saini P, Maurya RK, Singh H. Time-saving scoring chart for the American Board of Orthodontics’ objective grading system. APOS Trends Orthod. 2020;10:262-5. 16. Moon S, Mohamed AMA, He Y, Dong W, Yaosen C, Yang Y. Extraction vs. Nonextraction on soft-tissue profile change in patients with malocclusion: A systematic review and meta-analysis. Biomed Res Int. 2021;2021:1-11. 17. Zhylich D, Suri S. Mandibular incisor extraction: a systematic review of an uncommon extraction choice in orthodontic treatment. J Orthod. 2011;38:185-95. 18. Safavi S, Namazi A. Evaluation of mandibular incisor extraction treatment outcome in patients with bolton discrepancy using peer assessment rating index. J Dent. 2012;9:27-34. 19. Maaz M, Fida M. Comparison of treatment outcomes as assessed by 3 indexes in subjects with Class I malocclusion treated by 3 different methods: A cross-sectional study. Am J Orthod Dentofacial Orthop. 2022;161:537-41.

References

20. Kamal AT, Shaikh A, Fida M. Improvement in peer assessment rating scores after nonextraction, premolar extraction, and mandibular incisor extraction treatments in patients with Class I malocclusion. Am J Orthod Dentofacial Orthop. 2017;151:685-90.

21. Sang SH, Chooryung SA, Yoon J, Woo JC, Kimc J. Long-term follow-up of a patient with deepbite and severely resorbed maxillary central incisors treated by maxillary premolar and mandibular incisor extraction. Am J Orthod Dentofacial Orthop. 2022.

1. Sabri R. Orthodontic objectives in orthognathic surgery: state of the art today. World J Orthod. 2006;7:177-91. Soh J, Wang ZD, Zhang WB, Kau CH. Smile attractiveness evaluation of patients selected for a U.S.-based board certification examination. Eur J Dent. 2021;15:630-8.

3. Sarver DM. The importance of incisor positioning in the esthetic smile: the smile arc. Am J Orthod Dentofacial Orthop. 2001;120:98-111.

22. Joseph R, Valinoti. Mandibular incisor extraction therapy. Am J Orthod Dentofacial Orthop. 1994;105:107-16.

4. Drummond S, Capelli J Jr. Incisor display during speech and smile: Age and gender correlations. Angle Orthod. 2016;86:631-7. 5. Aydoğdu E, Özsoy OP. Effects of mandibular incisor intrusion obtained using a conventional utility arch vs bone anchorage. Angle Orthod. 2011;81:767-75.

BR=Bolton ratio ABO-OGS = American Board of Orthodontics – Objective Grading System

6. Zigante M, Pavlic A, Morelato L, Vandevska-Radunovic V, Spalj S. Presence and maturation dynamics of mandibular third molars and their influence on late mandibular incisor crowding: A longitudinal study. Int J Environ Res Public Health. 2021;18:100-70.

IPR:Interproximal reduction MIE: Mandibular incisor extraction

7. Antoszewska-Smith J, Bohater M, Kawala M, Sarul M, Rzepecka-Skupień M. Treatment of adults with anterior mandibular teeth crowding: reliability of Little’s Irregularity Index. Int J Dent. 2017;17:50-7.

IPC: Interproximal contacts Al = Alignment

8. Varrela J. Masticatory function and malocclusion: A clinical perspective. Semin Orthod. 2006;12:102-9.

MR = Marginal ridges

9. Almeida NV, Silveira GS, Pereira DM, Mattos CT, Mucha JN. Interproximal wear versus incisors extraction to solve anterior lower crowding: a systematic review. Dental Press J Orthod. 2015;20:66-73.

BI = Buccolingual inclinations

10. Ileri Z, Basciftci FA, Malkoc S, Ramoglu SI. Comparison of the outcomes of the lower incisor extraction, premolar extraction, and nonextraction treatments. Eur J Orthod. 2012;34:681-5.

OJ = Overjet

11. Jangra VK, Sharma A, Sharma R, Sharma S. Mandibular expansion in orthodontics: A review. Int Health Res J. 2022;6:6-10.

IPC = Interproximal contact, RP = Root position

OC = Occlusal contacts OR = Occlusal relationship

12. Frindel C. Clear thinking about interproximal stripping. J Dentofacial Anom Orthod 2010;13:187-99. 13. Hariharan A, Arqub SA, Gandhi V, Kuo C, Uribe F. Evaluation of interproximal reduction in individual teeth, and full arch assessment in clear aligner therapy: digital planning versus 3D model analysis after

Tips from the Experienced

The D-Gainer Appliance Part 2

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.

As I alluded to in in the previous article, if the second deciduous molars are firm, it is an advantage, because two deciduous molars and two permanent molars create a reasonable anchorage for proclination and bodily movement of four incisors. However, when we have only first permanent molars available, there will be a distal moment (tipping) on the molars as the expression of the Third law of Newton (for every action is equal and opposite reaction). If no movement is desired on the permanent molars, the author suggests cemented maxillary TP arch and mandibular Lingual arch as an anchorage. If distal tipping and bodily movement of first molars is desirable, the D-gainer appliance can create an amazing amount of space by distalization of the first molars, mesialization of the incisors and spontaneous transverse development. When inserting the .018 SS arch wire into the molar tubes observe the anterior portion. The arch wire is most often below the bracket slots of the incisors because of inherent mesial tipping during the eruption of the molars. This will result in slight intrusion of the incisors, which is desirable in closed bite cases. However, this is not desirable in an anterior open bite case. In the case where more bodily movement of incisors is required, rather than labial moment (proclination), the author suggests: 1. Use rectangular arch wire, i.e., a .016x022 SS 2. Use negative torque incisor brackets, or 3. Reverse the incisor brackets from +17°, +8° to -17°, -8°, or

4. Apply negative crown torque to the rectangular arch wire with Torquing pliers with the key, or Ross torquing pliers from the lateral incisor to the lateral 5. Carefully monitor the labial aspect of the gingival margins and the attached gingiva for recession and dehiscence

References:

Dr. Derek Mahony, lecture attendance

Palencar A. J. Personal PP presentations

Featured*

Surface Roughness Of Stainless Steel Wires Coated with Titanium Dioxide after Exposure to Oral Medium By Homa Farhadifard, Vahid Mollabashi, Abbas Farmany, Hossein Shabani, Ali Reza Soltanian, and Ziba Banisafar

Homa Farhadifard1 Assistant Professor, Orthodontic Department, school of dentistry, Hamadan University of Medical Sciences, Hamadan, Iran

Vahid Mollabashi Associate Professor, Orthodontic Department, Dental Faculty and Dental Research Center, Hamadan University of Medical Sciences, Hamadan, Iran

Abbas Farmany 3 Dental Reaserch Center, Hamadan University of Medical Sciences, Hamadan, Iran

Hossein Shabani Private practice, Hamadan, Iran

Ali Reza Soltanian Modeling of Noncommunicable Diseases Research Center, Department of Biostatistics and Epidemiology, School of Public Health, Hamadan University of Medical Sciences, Hamadan, Iran

Ziba Banisafar Assistant Professor, Orthodontic Department, school of dentistry, Hamadan University of Medical Sciences, Hamadan, Iran

Abstract Introduction: Orthodontic wires as a most important orthodontic component are affected in the oral cavity. This study is investigated the effect of clinical application of titanium dioxide coating on reducing the surface roughness of orthodontic wires after exposure to the oral environment. Methods: In this clinical study, 16 patients participated in the aged range 12–25 years. A titanium dioxide coating layer was deposited on 0.018΄ stainless steel orthodontic wires by physical vapor deposition method. Scanning electron microscopes was done to check the accuracy of coating. The coated wires assigned to one arch and the opposite arch received an uncoated wire as control. After one month of intraoral exposure, wires were removed from the patient’s mouth and 10 mm of the wire was cut from the distal of canine to the mesial of premolar bracket. The AFM analysis was used to scanning the surface of the wires. Result: Man-Whitney test showed that the mean surface roughness of coated and uncoated wires in Ra number (Z=-2.53, p=0.011) and Rq number (Z=-2.638, p=0.007) was significant difference among the two groups. Wilcoxon test showed there was no difference between the mean surface roughness in the maxilla and in the mandible in each group (p>0.05). Conclusion: According to the results of this study, modifying the surface of orthodontic wires with titaniumdioxide reduces their surface roughness. Keywords: Orthodontic wire, Titanium dioxide, Atomic force microscopy, Surface roughness Introduction Orthodontic treatment is one of the most effective methods to correct the position of the teeth. One of the most important orthodontic components of fixed appliance therapy is orthodontic wires, which control tooth movement (material). In the oral cavity, 47

*This article has been peer reviewed

orthodontic wires are affected by the salivary flow and fluids and foods consumed temperature fluctuations and forces caused by the chewing process and orthodontic appliance, which results in the creation of friction and biological corrosion. These conditions affect the performance of orthodontic components and can lead to changes in microstructure, surface topography and mechanical properties.6,7 It is important for clinicians to identify these substance changes and evaluate their clinical behavior. An important item related to the effective sliding mechanics of teeth by orthodontic wires is surface roughness, which can be associated with several clinical factors, including bacterial accumulation, friction, biocompatibility, color stability, health and aesthetic (scalo). There is a positive relationship between corrosion, wire surface roughness, and ion release in the oral cavity environment (Firas Elayyan). Increased surface roughness increases the frictional forces due to the strengthening of the contact surface between the bracket and the wire, which leads to a 50% reduction in effective orthodontic forces and reduces the quality of orthodontic treatment, especially in situations where we need to correct more than 2 mm (David Normando). On the other hand, surface roughness and irregularities of surfaces increase the tendency of orthodontic wires to corrode, and the release of ions following corrosion is a worrying source of side effects on the human body that affect the oral mucosa, immune system, and its biological function and can cause allergies and systemic disorders (ghasemi, amini). Coating orthodontic appliances using nanotechnology is one of the available methods to change the surface properties, including reducing surface roughness (material). Nanotechnology and the materials science and engineering are less than 100 nanometers in size. By improving the mechanical and physical properties of materials, this technology has revolutionized the fields of medicine and dentistry in the fields of diagnosis and treatment. In the past decade, the use of nano-oxide films has been considered, and among them, titanium dioxide has gained attention due to its specific properties. Titanium dioxide is an inorganic white substance that is thermally stable, non-flammable, has low solubility and is chemically neutral. There are various methods for measuring the level of surface roughness, which have the disadvantage of being invasive and the possibility of damage to the surface during scanning. Therefore, the demand for noninvasive

and non-destructive methods based on optical methods is increasing. Atomic force microscopy (AFM) is the most suitable tool for measuring surface topography that can provide three-dimensional information of surface morphology without direct interference. According to what has been said about the importance of surface roughness and its effects, this study investigated the effect of clinical application of titanium dioxide coating on reducing the surface roughness of orthodontic wires after exposure to the oral environment. Materials and Methods: In this study, 32 wires placed in patient’s mouth during four weeks (16 coated wires and 16 uncoated wires) and divided randomly in each patient’s jaws. Eight coated wires in the maxilla and eight coated wires in the mandible were placed. The uncoated wires were placed in the opposite jaw as control group in the same patient. At selected times the wires were removed from the patient’s mouth (after four weeks of intraoral exposure). The wire was cut from the distal of canine to the mesial of premolar and separated (10 mm) and removed by water and cotton rolls and placed in small tubes for sampling, then the samples were transferred to the laboratory and the surface roughness of each piece of wire was calculated with an AFM microscope. This study was blind for evaluator of surface roughness in the samples. Preparation and coating of wires: In this study, the physical vapor deposition (PVD) was used to coat the wires. For this purpose, the first step was to get a suitable metal surface, so any covering layer or crust such as grease and dirt from the surface of the wire was removed by alcohol and then the wires entered the coating stage: 1. Ultrasonic cleaning in ethanol and acetone bath for 15 minutes, 2. Ultrasonic cleaning in water–NaOH solution for 20 minutes, 3. Rinsing with distilled water for 15 min. An E-gun thermal method at 5,000 W and 1 Å/ second was used for coating the wires with a 100 mm layer of TiO2. Vacuum-chamber pressure was 0.00002 mbar before the start of the coating process and 0.00005 mbar during coating. The chamber temperature was set at 300°C. SEM Analysis To check coating quality and integrity, one of the 48

wires was randomly selected. The sample was first glued between two silicon wafers with a mixture of super glue and Bakelite (for conductivity). After the adhesive had dried, the sample was ground using P800, P100, and P2400 sandpaper to obtain a uniform cross-section. Then, a smooth cross-section of the sample was prepared using a (Leica EM TIC 3X, Sweden (ion mill) instrument. To check the accuracy of coated orthodontic wires, a wire was randomly selected. This study was performed by Scanning Electron Microscopes (SEM) (JEOL JSM7800F Prime) at Chalmers university of technology in Sweden (Figure 1). EDS analysis method was also used to analyze and detect the chemical elements in the coating layer (Figure 2).

Figure 1. SEM microimage of stainless steel orthodontic wires surface with magnification of: a) ×3500 b) ×9000

Figure 2. SEM and EDX of wires: a) SEM of coated wires, b) EDX of coated wires, c) SEM of un-coated wires, d) EDX of un-coated wires.

AFM Analysis Results: Typical AFM of uncoated and coated stainless steel orthodontic wires surface is presented in Figure 3. According to Kolmogorov–Smirnov test the surface roughness values in the studied groups, (with and without titanium oxide layer in the maxilla and in

Figure 3. Typical AFM of a) uncoated and b) coated stainless steel orthodontic wires surface

the mandible) did not follow a normal distribution. Therefore, nonparametric Wilcoxon test was used to compare that among the groups (p<0.05). This test also showed that there was no difference between the mean surface roughness in the maxilla and in the mandible in each group. In addition to these comparisons, the mean surface roughness of coated and uncoated wires in Ra number was investigated by Man-Whitney test, and it was observed that there was significant difference among the two groups (Z=-2.53, p=0.011). The test also showed that there was a significant difference in the mean surface roughness of coated and uncoated wires in Rq number (Z=2.638, p=0.007). Orthodontic wires are one of the most important components of conventional orthodontic appliances. The surface roughness of orthodontic wires is a crucial factor in determining the effectiveness of directed tooth movement on the wire. It was shown that surface properties affect both the performance and biocompatibility of orthodontic wires. In addition, surface topography can alter the aesthetics, corrosion, plaque accumulation, and performance of orthodontic components, and above all, surface roughness affects the coefficient of friction. The use of an efficient method to change the levels of orthodontic appliques to improve performance in the oral cavity has been made possible by the introduction of nanomaterials. The use of nanoparticles to reduce the frictional forces between two metal surfaces has been emphasized as excellent solid phase lubricants. The presence of nanoparticles on the modified surfaces acts as a spacer and reduces the number of surface irregularities that are in contact with each other, leading to a lower coefficient of friction. This study aimed to evaluate the property of TiO2-coating to reduce the surface roughness of 49

treatment. In the present study, PVD method was used to cover the wires. Surfaces coated using PVD method have excellent abrasion resistance, friction-coefficient reduction, excellent adhesion, and stability in different environments which shows the superiority of this method over other methods.33,32 Radio Frequency magnetron sputtering method was used in the study by Keerthi et al. for the coating process, which is performed at a lower temperature than the vapor deposition method, and therefore applicable for coating nickel-titanium wires that lose structural memory at high temperatures. Other controversial aspects of the Radio Frequency magnetron sputtering method include its applicability to a wide range of materials and the simplicity which layer thickness can be controlled by the sputtering method. The sputtering method makes controlling the layer thickness very simple. The bombardment of the surface with high-energy ions, which causes surface damage, is one of the method’s drawbacks.33,

orthodontic wires and the results showed that coated orthodontic wires have significantly less surface roughness. Although there are few studies on the impact of TiO2-coating on the surface roughness of orthodontic stainless steel wires in the literature, a number of studies have reported data that are close to ours: Ghasemi et al. investigated the antimicrobial effect, friction, and surface roughness of orthodontic brackets coated with silver nanofilm and titanium oxide. The brackets were coated with vapor deposition method with 60- and 100-µm films of silver and titanium oxide. The results showed that all 4 groups of coated brackets had reduced surface roughness and bacterial growth. These outcomes are in agreement with our study. Keerthi et al. studied the effect of titanium dioxide coating on the surface roughness of nickeltitanium wires and its influence on Streptococcus mutans adhesion and enamel mineralization. The results showed that Streptococcus mutans adhesion was significantly reduced in the coated wires as compared with the uncoated wires (p=0.001). Also, TiO2- coating on nickel-titanium orthodontic wires reduced their surface roughness.30 Musavi et al. studied the effect of coating on the surface roughness of orthodontic wires on 25 wires including NiTi Memory wire as a control group, Orthocosmetic Elastinol, Perfect, Imagination, EverWhite. Significant differences existed between uncoated and coated wires regarding surface roughness values of NiTi (p<0.01), being higher for the uncoated wires. In our study, wire coating was associated with a reduction in surface roughness, which was consistent with the results of this study, and both studies recommended orthodontic wire coating to achieve less surface roughness. Many studies have identified kerogen as a factor in increasing the surface roughness of wires after placement in patients’ mouths. From the results of these studies, it can be concluded that the surface roughness of coated wires related to their kerogen is less likely to be lower.23,31 On the other hand, Chois et al. showed that the friction force increases with increasing surface roughness between the wire and the brackets.22 Therefore, less surface roughness of TiO2 coated stainless steel wires can apply a more balanced force to the teeth during treatment and be effective in achieving the desired orthodontist

An important issue regarding the application of nanomaterials in human samples is their biocompatibility. The toxicity of nanoparticles is directly related to their size.35 In this study, the application of nanotechnology is in the form of a nanoscale coating made by PVD and its corrosion is much less than that of TiO2, which naturally occurs on titanium implants. In addition, the oral exposure limit of TiO2 in the age range of 7–69 years is 1.6 μg/kg, which considering the characteristics mentioned so far, the release of some of it in saliva is not important.27 Mollabashi et al., showed that the survival rate of L929 fibroblast cells in the stainless steel orthodontic wires surface coated with TiO2 thin film was 90.3%±9.5% and for the uncoated-wire group 86.6%±8.1%. There was not a significant difference between the coated-wire and control group. Measurement of titanium concentration in saliva samples also revealed that there was no substantial difference in the amount of titanium released in saliva before and after the wire was inserted in the mouth for various periods of time in all four groups of patients involved in the study. Fatani et al. assessed the biocompatibility of titanium dioxide–coated brackets on the human gingival fibroblast (HGF) cell line with MTT assays 50

in vitro. All coated brackets had higher OD values, which indicated that the survival rate of HGF cells around the coated brackets was higher than that of uncoated brackets.28 Suggestions: 1. There is an important issue about coating applainces. The durability and longevity of titanium oxide coating is not yet clinically determined. The importance of the effect of reducing surface roughness by titanium dioxide coating on other orthodontic appliances, including brackets, is overshadowed by their clinical application. If the time-dependent effect is desired, the simultaneous use of coated wires and brackets (taking into account the absence of subtle changes in dimensions) is recommended. 2. The present study did not perform heavy mechanotherapy when the wires were inserted into the patient’s mouth, leading to mechanical deterioration of the wire coating. However, further studies are needed to investigate the mechanical stability of the titanium dioxide coating under mechanical loading during the treatment. Conclusion: According to the results of this study, modifying the surface of orthodontic wires with TiO2 reduces their surface roughness.

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International Journal of Orthodontics Summer 2023

Articles inside

Surface Roughness Of Stainless Steel Wires Coated with Titanium Dioxide after Exposure to Oral Medium

The D-Gainer Appliance Part 2

Comparison of Bolton Analysis Between Interproximal Stripping and Mandibular Incisor Extraction to Resolve Lower Anterior Crowding – A Cross-sectional Study

Can We Treat Kids in Mixed Dentition with Clear Aligners? The Benefits of Early Orthodontic Treatment for Kids

Stability of Surgical and Orthodontic Techniques for the Treatment of Patients with Cleft Palate: A Systematic Review A Review and a Proposal

Getting More Valuable and Consistent Case Acceptance

Evaluation of Pre-Treatment and Post-Treatment Changes in Lower Anterior Facial Height in Extraction and Non-Extraction Cases: A Digital Cephalometric Study

The Perfect Pairing for Best-in-Class Results

For Better Results, TRUST G&H

From Braces to Bytes: The Role of Technology in Modern Orthodontics

Author Guidelines