International Journal of Orthodontics Winter 2023 by internationaljournaloforthodontics

VOLUME 34 | NUMBER 4 | Winter 2023

International Journal of

Orthodontics

Published Quarterly by the

International Association for Orthodontics

In this Issue:

• Ipsilateral auto-transplantation and subsequent orthodontic movement for ectopically erupted teeth as part of orthodontic treatment planning • Treatment of Growing Male Patient with Skeletal Class II Jaw Bases With Retrognathic Mandible And Class Ii Division 1 Malocclusion (PRE-ADOLESCENT) USING TWIN BLOCK APPLIANCE: A CASE REPORT • Fixed Functional Appliance with Skeletal Anchorage System (FFA-SAS) – An Exemplary Comparative Review • A Fixed Twin Block

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Table of Contents Editor

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

Managing Editor

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

International Journal of

Orthodontics

WINTER 2023  VOLUME 34  NUMBER 4

Features 6

Ipsilateral auto-transplantation and subsequent orthodontic movement for ectopically erupted teeth as part of orthodontic treatment planning, by Rob Pasch DDS,

Treatment of Growing Male Patient with Skeletal Class II Jaw Bases With Retrognathic Mandible And Class II Division 1 Malocclusion (PRE-ADOLESCENT) USING TWIN BLOCK APPLIANCE: A CASE REPORT, By Dr. Sujit Zadake, Dr Trupti Nakhate, and Dr.

IBO, MSc,

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

Suresh Kangane

Fixed Functional Appliance with Skeletal Anchorage System (FFA-SAS) – An Exemplary Comparative Review, By R. Thangabalu, R. Anjana, and A. Udhayan

35 A Modified Fixed Twin Block, by Dr. Varun Gupta and Dr. Gyan P Singh Departments

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:

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Writer’s Guidelines

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

Tips from the Experienced: The Eyelet,Part 2, By Dr. Adrian J. Palencar, MUDr, MAGD,

Growing Beautiful Teeth Chapter 6: The Clues to Look for in Your Child, By Estie

IBO, FADI, FPFA, FICD

Bav `

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

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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

skill to be learned and put into practice. Release of responsibility via informed consent should not be relied upon. In reality, every team member needs to be involved in the assessment, instruction, motivation, checking, ongoing education, nutrition, and all other aspects of oral home care Rob Pasch Editor before, during, and after orthodontic treatment. It becomes an opportunity to better a patient’s oral condition for life. Technology is helping in this regard, the use of electric toothbrushes, fluoride rinses and toothpastes, frequent hygiene appointments, oral hygiene and compliance triaging on orthodontic adjustment visits, etc., help make orthodontics more satisfying. So, what is it to be offence or defense? In my practice and by no means am I suggesting that everyone should follow this, I employ both offence and defense. My oral hygiene protocol starts with a clean mouth and preorthodontic oral hygiene education where the parents (if the patient is a minor) are present. The patient’s oral hygiene is triaged, a score given and recorded every time they visit for their adjustment appointment, the parent is informed of the score, if they fall short of a clean mouth score than a conversation is started to enlist the parents help to elevate the score on the next visit. If the score is clean then praise is given, some offices have prizes and you may implement this as well. Present day resources like YouTube and videos embedded in our offices website help with the education part. I have recently started sharing my digital business card on which oral hygiene and dietary videos are embedded with the patients, this seems to be helping for everyone has a smartphone today, so all the parent has to do is check the mouth. The contemporary practice of orthodontics is changing, however communication still rules and the more transparent you are with the help of staff and technology the better the orthodontic outcomes will be.

Editorial Hippocrates wrote circa 410 BCE that “The doctor must be able to tell the antecedents, know the present, and foretell the future – must mediate these things, and have two special objects in view with regard to disease, namely to do good or to do no harm. The art consists in three things – the disease, the patient, and the doctor. The doctor is the servant of the art, and the patient must combat the disease along with the doctor.” Looking back on this year and all the patients seen and treatments performed, it has come to me that being able to perform orthodontics and doing it well is just a small part of what we do daily. Moving teeth and guiding facial and dental development is just a small aspect of our skillset. The management of oral hygiene, by educating and motivating patients so that oral hygiene can be brought under control before treatment is started, is in my opinion the most important aspect of orthodontic treatment, and if not adequate ideally should delay or eliminate planned treatment. However, if treatment is ongoing and oral hygiene becomes inadequate early debonding and treatment cessation becomes the best option lest scars of treatment remain permanently. Although these problems are mainly due to patient negligence and non-compliance these negative outcomes are not great practice builders nor do they engender the admiration of colleagues and parents. Intent of treatment has shifted over time and has assumed a more defensive posture, in today’s busy practices it appears that the goal of many practitioners is to get the appliances on as rapidly as possible and deal with the effects of poor oral hygiene during or after the treatment. The shift from being aggressive with oral hygiene practices (offensive) to being reactive (defensive)may be expedient, but it doesn’t always serve the best interest of the patient and the practice. The goal of all orthodontic practitioners should be to guide the patient through the orthodontic process and exit when treatment is complete without telltale signs of hard or soft tissue scarring such as decay, white spots lesions, gingival enlargement, etc., encouraging patient cooperation will continue to be important during the retention phase of treatment as well, encouraging patients to do things most would not choose to do on their own is an important

Yours for accredited GP orthodontic education and better patient care I Remain Respectfully Dr. Rob Pasch DDS MSc IBO General Practioner 5

Featured*

Ipsilateral auto-transplantation and subsequent orthodontic movement for ectopically erupted teeth as part of orthodontic treatment planning By Rob Pasch DDS, IBO, MSc, Toronto, Canadan iversity College of Dentistry and Hospital

Rob Pasch DDS, IBO, MSc

Objective: The objective of the thesis is to determine how successful planned auto-transplantation and orthodontic movement is as part of orthodontic treatment planning in young patients when the aim is to correct the ectopic ipsilateral eruption of teeth coupled with retained deciduous teeth that should have exfoliated normally had the permanent teeth erupted properly without succedaneous positioning problems. In this context, not only will the efficacy of different available methods be analyzed, including timing of orthodontic force application to the transplanted tooth, but also the effect of patient selection and donor tooth criteria on the outcome. These factors will be used to attempt to develop guidelines for auto-transplantation in this patient group.

Dr. Rob Pasch is an alumnus of Queens University and a graduate of Toronto Faculty Dentistry 1982. Dr. Pasch earned a physics exemption and graduated with honors in orthodontics in the GP program. Dr. Pasch has always been interested in pursuing his orthodontic education. He graduated from the Orthodontic mini residency at University of Toronto, earned his International Board of Orthodontic Diplomate Status, and a Masters in Special Orthodontics from the University of Duisburg-Essen.

Introduction: The earliest report of transplantation of teeth was in ancient Egyptian times where slaves were forced to give up their teeth for the Pharaohs. This practice of allografting was abandoned since rejection due to bio incompatibility was commonplace, and this custom was eventually replaced with autotransplantation. This procedure was described in the book “Treatise on the natural history and diseases of the human teeth,” written in 1778 by Dr. John Hunter, in which he described transplanting a human tooth into a cock’s comb, apparently with some success. Transplantation of teeth has seen its utilization wax and wane over the millennia. The cases in today’s literature deal mainly with auto transplantation of molars, utilizing third molars to replace failing first or second molars, or the reimplantation of accidentally avulsed teeth, usually anteriors. This report will focus on the planned ipsilateral autotransplantation and subsequent orthodontic movement 6

*This article has been peer reviewed

for ectopically erupted teeth as part of orthodontic treatment planning when these cases present. Ipsilateral ectopic eruption of some teeth (usually maxillary canines and mandibular incisors, or transmigrant mandibular canines whose eruption crosses the mid-line) into unusual intra-arch positions away from their normal positions, and the subsequent malalignment of the dentition, may result in prolonged treatment time to correct only one or two teeth in the dentition, whereas the rest of the dentition maybe perfectly aligned. Treatment options for these teeth include: 1. Orthodontic alignment and subsequent recontouring, 2. Surgical trans-plantation with or without endodontic treatment, 3. Extraction and implant replacement, 4. Monitoring, and 5. Extraction and maintaining the deciduous tooth, with recontouring of this tooth later on. Upper canines that erupt between the first and second ipsilateral bicuspids or lower lateral incisors that erupt distal to the ipsilateral canines are some examples of common orthodontic intra-arch ectopic situations that prolong orthodontic treatment, increase cost, and potentially increase comorbidities regarding the tooth in question. Autogenous Tooth Transplantation (ATT) has been extensively researched in the literature and has reported success rates of 95% -100% when cases are prudently selected and technique guidelines are followed. ATT will result in a shorter overall treatment time, better aesthetic result, and reduced cost of treatment. ATT also allows the alveolus to mature in a normal fashion with continued bone development in height and width, during mixed dentition stages. The cases that lend themselves to the autotransplantation consideration will, in most cases, have a retained deciduous tooth, where the permanent successor should have erupted, but instead the permanent tooth has erupted elsewhere ipsilaterally and does not have a fully matured root apex. Further, the patient is healthy with good oral hygiene and able to follow instructions, plus able to attend for procedures. In a situation like this, conventional treatment may allow the ectopically-erupted tooth to remain where it is, extract the retained deciduous tooth, and align the dentition to the best dental position allowable, then using subsequent restorative procedures to aesthetically alter the crowns of these aligned, malpositioned teeth to approximate the desired contours and

interdigitation of close to normalcy after the orthodontic treatment is completed, by using restorative techniques. An alternative plan would be to extract the ectopically-erupted tooth and plan for replacement of that tooth with an implant after the patient is of age and the alveolus has matured and stopped developing. This means that the patient may have to wear a retainer with an artificial tooth to fill the gap while maturation proceeds until an implant can be placed successfully, usually after the patient turns 16-25 years of age, for females and males respectively. However, the alveolar maturation in this scenario stops and will result in an underdeveloped alveolar arch segment. Both of these treatment plans lack aesthetic satisfaction and increase the overall costs and treatment time of the case. The consideration of orthodontic auto-transplantation when the case is diagnosed may result in a shorter treatment time, better aesthetics, and the knowledge of having all teeth properly placed in their correct biological position with normal alveolar development. The current literature has not addressed these situations, but rather addressed the larger area of generalized planned auto-transplantation utilizing third molars to replace failing first or second molars, usually when the patient is older. Newer studies have been published that show stellar success when late mixed dentition autotransplantation procedures are planned to correct succedaneous ectopic maleruption. Materials and Methods: A computer literature search in the English language of electronic databases was performed using Google Scholar and PubMed utilizing the advanced option with the following search terms: (autotransplantation); (Autotransplantation AND teeth AND success AND failures); (Orthodontic autotransplantation); (Teeth AND transplantation); (Autogenous AND tooth AND transplantation); (Pulp tissue regeneration AND periodontal tissue regeneration); and (Ectopic eruption frequency): (Periodontal ligament regeneration AND autogenous transplantation). To reduce the number of articles, the following filters were used: Meta-analysis; Humans. Sixty-four articles were found, including some studies via the “similar articles” option and excluding eight irrelevant studies as illustrated below. A total of 40 clinical studies and reviews were finally chosen for inclusion in this review.

Main inclusion criteria: Studies that reported on the indication, success/ survival rate and surgical procedure of autologous ipsilateral autotransplantation

Harvard citation rules were used for the writeup and bibliography. This literature and case report review investigated the ipsilateral auto-transplantation and subsequent orthodontic movement for ectopically erupted teeth as part of orthodontic treatment planning, with the aim determining the overall success rate of the method and how this success is influenced by patient and donor tooth criteria. We found the success rates of transplants to be highly variable, with a notable effect of patient and donor toothselection criteria.

• Relevant studies that were published in the last 25 years (few studies of ipsilateral ATT plus orthodontic movement are before that; relevant case reports are within the last 10 years) • Relevant animal studies that reported on orthodontic force applications (as a knowledge base) • Case reports and literature reviews reporting at least one of the following: survival rate (short or long term), success rate, pulp condition, tooth mobility, presence of ankylosis, and root resorption of autotransplanted teeth with complete or incomplete root formation

Success of autotransplantation Planned ATT is very successful compared with the overall success rates for tooth transplantation in general. Successful planned autotransplantation involves a correlation between successful pupal regeneration/ reinnervation and successful periodontal ligament regeneration both which are dependent upon an atraumatic sterile technique in a healthy patient with an uncompromised donor tooth. Our study has found that planned ATT carries a success rate of between 15-100%. The 15% success rate was reported by Dr. Texeira in 200636 reporting on two patients involving transplantation of lower molars, the remaining 418 cases described by a variety of other authors, (Table 1) reported success rates of between 71% and 100% and involved molars, bicuspids and canines.

• Canine auto transplantations • Success rates of ipsilateral ATT after orthodontic movement with a mean follow-up period of at least one year Main exclusion criteria: • Articles that were presented in a language other than English • Articles that were not accessible in print • Case reports and literature reviews that we published more than 25 years ago • Studies reporting autotransplanted teeth in patients with systemic diseases, syndromes, cysts or tumors

Table 1: 2002-2020

• Studies examining tooth autotransplantation associated with maxillary sinus lifting • Studies with oroantral fistulae Extracted data: • Animal studies to determine forces and timing used to move ATT • Literature reviews with large number of subjects to identify ranges of success • Definition of success related to ATT • Endodontic recommendation pre-ATT • Recipient socket preparation techniques • Subjects age and gender • Root morphology and apex anatomy of ATT • ATT stability measured in years

years. These reports indicate that reduced iatrogenesis by being mindful of reduced surgical transplantation air time will favour ATT success rates. No reports have been published studying the effects on ATT success rates when surgical transplantation air time increased. Different clinical techniques were analyzed and correlated with the eventual ATT success rate. Table 2 shows that avulsions, extractions, curettage of sockets, and surgical exposures prior to transplant procedures were found to have no effect on the ATT success rate. Effects of sterility/decontamination/ disinfection on ATT success rates increase when a near sterile technique utilizing preoperative Chlorhexidine rinse, dental prophylaxis, and draping of the field with rubber dam or optragate dams will reduce site contamination. No studies have been done testing this hypothesis; it is just reported that proper site hygiene must be observed. Failing this, the planned ATT procedure should be reconsidered. Non-sterile operating fields may lead to contamination, which will result in inflammatory resorption, and may lead to external resorption of the root due to osteoclasts action or internal resorption when the odontoclasts respond to necrotic pulpal debris and resorb the dentine from within. Replacement resorption (Ankylosis) occurs when

Generally, success rates improved (84%-100%) when there was successful pulpal regeneration and reinnervation, which usually occurred when the apical diameter of the transplanted tooth was greater than 1mm as reported by Ong et al 2016,27 Schmidt and Cleverly 2012,32 Akkocaoglu and Kas-boglu, 2004.4 Successful PDL regeneration was found to occur first during the healing phase after which pulpal regeneration and reinnervation was established with positive vitality tests as early as six months after the procedure. Successful periodontal ligament regeneration is higher when the donor tooth’s cementum is not in direct contact with osteoclasts of the prepared receiving socket. A passive fit of the donor tooth in the receiving socket with some mobility assures this and leads to higher rates of successful PDL regeneration, which will in turn lead to higher rates of pulpal re-innervation and ATT success. The ATT success rate decreased when resorptive PDL processes prevented pulpal reinnervation and endodontic procedures needed to be carried out as a result to prevent outright ATT failure. The reason for this would be the initiation of pulpal internal abscess formation with external PDL break-down and osseous socket destruction due to infective resorption. For this reason, it had been recommended by some authors to endodontically treat all transplanted teeth 4 weeks after transplant procedures to ensure PDL attachment success, and prevent tooth loss. Successful PDL regeneration with no ankylosis or infective resorption as evidenced by Periapical Xrays after the transplant procedure leads to successful pulpal reinnervation with 100% ATT success. Some cases resorptive PDL processes will indicate a need for pulpal endodontics; this procedure will reduce the ATT success rate to 15%-84%. The correlation between PDL regeneration and Pulpal reinnervation means that in clinical practice, frequent followup appointments with Xray examinations are needed after ATT to ascertain no resorptive processes are present. Successful PDL regeneration and atraumatic prompt clinical techniques are closely related. Alexander et al 201016 reported ATT air time of <1 minute, yet had 100% ATT success. Kulkarni and Lee 201619 and Kim and Kulkarni 202020 reported ATT air time of < 30 seconds, and also had 100% ATT success. Roden et al 201329 reported ATT airtime of < 5 min with a difficult trans-plantation procedure and reported ATT 100% success rate as well. Kim et al 201616 used saline soaked gauze to wrap the donor tooth, no report of ATT airtime yet reports 100% success rate after seven

Table 2: The Different Clinical Techniques

there is a failure of the PDL to regenerate. This was shown to be primarily the result of iatrogenesis, root damage and excessive airtime during the procedure.36 Patient and donor tooth criteria were found to be critical for the success rate. In general, the success rate

decreased when the patients’ age increased. Chugh et al7 2012 transplanted a molar with a fully-formed root for a 16-year-old female with 100% success. Texeira et al 200636 transplanted molars with fully formed roots for a 21-year-old male with 15% success: a reduction of 85% for a five-year age difference. Further studies regarding age effects on the ATT success outcomes are required. Other factors influencing ATT success are uncontrolled diabetes, recreational drug use, smoking and vaping, poor oral hygiene, and uncontrolled periodontal disease.8,26,27 These conditions are contra-indications to ATT success (vitality); no studies in this review dealt with subjects with these influencers. In general, the case reports and literature reviews deal mainly with transplanting third molars into failing first- or second-molar locations, or the transplantation of lower bicuspids into avulsed central incisor locations. Generally, success rates climbed from a low of 15% when the donor tooth apex was closed <1mm, to a low of 84% when the donor tooth’s apex was open > 1mm for a difference of 450%. Other tooth/patient characteristics that influence ATT success rates as reported by Ustad et al 201337 and Mendes and Rocha 200422 who determined that such factors like poor recipient sites and poor tooth characteristics as well as anatomy reduces ATT success (vitality). Their data show that teeth with decay or unusual root anatomy, and periodontal or pulpal breakdown are poor candidates for transplantation procedures. Recipient sites with poor osseous architecture and health, as well as narrow bucco-lingual anatomy, are likewise poor sites for transplantation procedures.

correlated by the studies of Ong et al 2016:27 1. ATT is suitable option for late mixed dentition (continue alveolus development with ongoing skeletal growth) 2. ATT can develop normal proprioception and thermal responses 3. ATT can be successfully moved orthodontically 4. ATT preserves alveolar volume 5. ATT reduces extensive treatment time 6 ATT reserves ATT vitality There is no question that this technique of ipsilateral auto-transplantation and subsequent movement for ectopically-erupted teeth as part of orthodontic treatment planning is extremely operator sensitive, with the surgeon’s skill, experience, and careful manipulation of the donor tooth being vital for success. This technique is not taught during formal dental or specialist training. Unfortunately, many clinicians lack the required proficiency in performing this procedure. Some clinicians in Europe, particularly in Scandinavia and Poland, appear to be very proficient in this surgical technique and report excellent success rates. Of late, some practitioners in Canada have reported this technique and, contrary to the accepted consensus that success rates decrease when mature donor teeth are transplanted, these authors have reported a 100% success rate when ipsilateral autotransplantation procedures were performed to correct succedaneous ectopic malocclusions with surgical recipient socket preparation and mature teeth. The studies that outline the way to successfully transplant ipsilaterally ectopically-erupted fully-formed teeth into their proper arch position are small and show techniques that result in successful outcomes. These dental problems are in the minority of orthodontic eruptive anomalies and pose severe problems for the diagnosing dental teams. The canine transposition surgeries reported on by Kulkarni and Lee 201619 and Kim and Kulkarni 202020 involved canines in adolescents – early permanent dentitions and late deciduous dentitions (since the second molars had not erupted yet). These diagnostics and treatment selections gleaned by knowledge of the myriad of transplantation procedures that had gone before reported on here to illuminate the difficulties and obstructions to a perfect success rate. This report also evaluated animal studies, which outlined timing of ideal post-transplant orthodontic force application. This report discussed the variables relating to ATT success from iatrogenesis to patient health and tooth

Advantages and limitations of the method/ predictability/reliability of results (including limitations of the study) There are success data that span up to 41 years where the transplanted teeth are functioning well.9 The data that deals with ipsilateral transplantation and subsequent orthodontic movement is smaller and has a shorter success time – seven years at 100% for both recipient site preparation techniques. The recommendations gleaned from this literature and case report review are as follows. To ensure success for the correction of ipsilateral auto-transplantation and subsequent orthodontic movement for ectopically-erupted teeth as part of orthodontic treatment planning, the following additional advantages and successes have been identified and 10

criteria considerations. This study reported on what recommendations were found to consider when diagnosing the rare ipsilateral ectopic eruptive case and design suitable treatment for it. The low number of data presented here is not problematic in itself, but rather hopefully instills an appetite to repeat the clinical steps and report on the results so the data base for these interesting cases increases and this knowledge will permeate the profession.. The recommendations gleaned from this literature and case report review are as follows: There needs to be a medically and dentally healthy patient without uncontrolled diabetes, recreational drug use, smoking and vaping, poor oral hygiene, or uncontrolled periodontal disease.8,26,27 If these conditions are present, they are contraindications to ATT success (vitality); no studies in this review dealt with subjects with these influencers. Ustad et al 201337 and Mendas and Rocha 200422 determined the influence of patient factors, such as poor recipient sites and poor tooth characteristics and anatomy on ATT success (vitality). Their data show that teeth with decay or unusual root anatomy and periodontal or pulpal breakdown are poor candidates for transplantation procedures. Recipient sites with poor osseous architecture and health as well as narrow buccolingual anatomy are likewise poor sites for transplantation procedures. The younger the patient, the better chance of ATT success. The donor tooth anatomy should match the recipient – in this case, the ipsilateral transplant corrects the malerupted tooth. CBCT scans may be used to measure and plan the procedure regarding the size correlation of the donor versus the recipient site. Alternative mock surgical models of the donor tooth may be fabricated to facilitate the preparation of the recipient implant socket site. There should be 1/2 to 2/3 completed root formation with an immature apex. Kulkarni and Lee 2016,19 Chugh et al. 2012,7 Alexander et al. 2010,16 Kim and Kulkarni 202020 found that if the root is 1/2 to 2/3 formed, the degree of pulpal re-innervation is between 84% and 100%. If the root formation is shorter or longer than the range of 1/2 to 2/3, the degree of re-innervation can be as low as 15%. (Texeira et al 2006) However, recent case reports by Kulkarni and Lee 2016,19 and Kim and Kulkarni 202020 found 100% pulpal reinnervation success of ipsilateral transplanted mature canines with fully-formed roots and closed apexes. There needs to be atraumatic extraction and reduction of iatrogenesis during the procedure to result

in increased ATT success and reduced patient discomfort post procedure. Be cautious to preserve the PDL and Hertwig’s epithelial root sheath as well as the apical portion of the developing tooth bud. Studies show that replacement resorption or ankylosis results from direct osteoclast contact with the cementum of the donor tooth from either a very tight socket fit or trauma which damaged and eliminated the existing PDL cells or Hertwigs epithelial root shield cells of a developing root apex. Be mindful of reducing open-air transfer exposure, and donor tooth PDL trauma before placing the donor tooth passively into the prepared socket. This reduction will increase the viability of the donor tooth PDL and also minimizes either inflammatory or replacement resorption.33,35,36 Ensure that the recipient socket preparation is as near sterile as possible. Pre-procedure Chlorhexidine rinse, prophylaxis of the quadrant, pre-procedure scaling, and debridement are all considered steps towards ATT success. Be mindful of reducing post-transplant trauma and ensure excellent oral hygiene. All authors prescribed reduced iatrogenesis and ensured excellent oral hygiene. The recommendation is that if oral hygiene is not acceptable prior to the procedure, the case will not be done. Observe at least a two-week healing time before applying orthodontic forces to the ATT. Several authors have reported stellar results for ipsilateral and unilaterally transplanted teeth. (Table 3 The dental vitality tests from these cases show that these ATT teeth all tested normally after the ATT procedure. These authors reported moving the implanted teeth orthodontically two to 12 weeks after the implant was allowed to heal, utilizing flexible splints for ATT stability. Several retention devices and protocols have been Table 3: Reported results for results for ipsilateral and unilaterally transplanted teeth

reported by authors that use these procedures to retain their results; some do not at all. The devices reported are removable retention or fixed retention by either flexible or preformed stainless steel arch wires or by crown and bridge restorations that incorporate the ATT.

Orthopaedics, Vol 157, issue 1 pp 80-90 (sourced through PubMed and Google Scholar) 6. Bishara Samir (1998), “Clinical Management of impacted Maxillary Canines” Seminars in orthodontics, Vol 4, No. 2 pp 87-98 (sourced through PubMed and Google Scholar) 7. Chugh Ankita, Aggarwal Rashmi, Chugh Vinay Kumar, Wadhwa Puneet, Kohli Munish, (2012), “Autogenous Tooth Transplantation as a Treatment Option”. International Journal of Clinical Paediatric Dentistry;5(1):87-92 ( sourced through Google Scholar) 32

Conclusions The management of ipsilaterally ectopic succedaneous eruption problems may pose a significant problem for the dental team. This review of recent cases reports that ATT of successfully transplanted mature ectopic canines, which were subsequently orthodontically moved to ideal position resumed all normal vital signs without endodontic treatment or subsequent ankylosis, provides a reason for optimism. The data for this type of treatment is small but it points the way toward successful treatment for these eruption problems. The critical take-home messages are that this procedure is ideally suited for healthy young patients with good oral hygiene who are able to attend appointments and follow instructions, as well as presenting with these rare ipsilaterally-retained deciduous teeth that provides a natural recipient site, and a donor tooth that has normal anatomy and is not involved with periodontal breakdown. When this procedure is completed with minimal iatrogenesis and a minimum two-week healing period is observed before instituting gentle orthodontic forces (which has been shown to minimize the chance of ankylosis), a good chance of success is obtained.

8. Clokie Cameron M.L. DDS PhD FRCD© Dip ABOMS, Yau Deirdre M. B.Sc. DDS, Chano Laura DDS. (2001), “Autogenous Tooth Transplantation: An Alternative to Dental Implant Placement?” J Can Dent Assoc. ; 67:92-96 (sourced trough PubMed and Google Scholar) 9. Czochrowska Ewa Monika; (2018), “Off the beaten track Solutions: Autotransplantation of teeth” The international journal of aesthetic dentistry Vol 13, Number 2, pp 234-239 (sourced through PubMed and Google Scholar) 10. Devi T.P., Singh WT, Sanjeeta N. Singh NR. (2014), “ Immediate autotransplantation of immature third molar with regeneration of recipient site using autologous platelet rich fibrin” Journal of Medical Society, Vol 28, No. 3, pp. 196-199 2014. (Sourced through Google Scholar) 11. Dohan DM. Choukroun J. Diss A. Dohan SL., et al. (2006), “Platelet rich fibrin (PRF): a second generation platelet concentrate. Part 1: technological concepts and evolution” Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontics, Vol. 101, no. 3, pp. e37-e44, 2006 (sourced through Google Scholar) 12. Edetanien B.E. Azodo C.C, Egbor P.E. Akpata O. (2009) “Autogenous Tooth Transplantation in Adult Orofacial Cleft Deformity”: A case report Journal of Postgraduate Medicine Vol 11, No 1 pp65-69 (sourced through Google Scholar) 13. Grayson Ian, DDS MMSC FRCD© Diplomate ABE and Ren Tina DMD; (2019) “Autogenous tooth transplantation: A viable treatment Option” Ontario Dental Journal, June, pp 34-37 (sourced through Google Scholar) 14. M. Howlader MMR, Begum,S.,Naulakha D., (2006) “Autogenous Tooth transplantation from ectopic position: A Case report and review of literature “;Journal of Bangladesh College of Physicians and Surgeons, 24(2) pp79-85 (sourced through Google Scholar)

References:

1. Abu-Hussein Muhamad, Watted Nezar,Abdulgan Azzaldeen.; (2015),“Autogenous tooth transplantation - Reality or not”, International journal of biomedical science IJBS Volume 02 issue 4 pp722729 (sourced through Google Scholar)

15. Kalavitrinos Michael, Benetou Vassiliki, Bitsanis Elias, Sanoudos Mattheos, Alexiou Kinstantina Tsiklakis Kontantinos Tsolakis Apstolos I. (2020) “ Incidence of incisor root resorption associated with the position of the impacted maxillary canines: A cone-beam 33 computed tomographic study”, American Journal of Orthodontics and Dentofacial Or-thopaedics”, Vol 157, Issue 1, PP 73-79. (sourced through PubMed and Google Scholar)

2. Asgary Saeed, and Ehsani Sara; (2012), Autotransplantation of a third molar with complete root development - a case report ; International Journal of surgical re-search; 1(1): pp1-6 (sourced through Google Scholar) 3. Ahmad Tahir, Wakeel Syed, Hussain Shajah Rehman Shaista; (2017) “Auto-Transplantation of Mandibular Third Molar: A Case Re-port” Journal of Science Oral and Maxillo Facial Surgery, Volume 7 issue 1 pp 28-33, Government Dental College JK (BDS) RUHS(MDS) (sourced through Google Scholar)

16. Keightley Alexander J. Cross David L. McKerlie Robert A. Brocklebank Laetitia, (2010), “Autotransplantation of an immature premolar, with the aid of cone beam and com-puter aided prototyping: a case report “Dental Traumatology, (26) pp 195-199 (sourced through Google Scholar) 17. Kim, Sunil DDS MSD, Shin Su-Jung, DDS MSD PhD, Park Jeong-Won, DDS MSD PhD. Kim Sunjai, DDS PhD. Hwang Soonshin DDS MSD, Kim Kyung-Ho DDS MSD PhD, Chung Choorying J. DDS PhD. (2016), “Long-term stability of autotransplanted premolars as a substitute for molars in adults.” JOE - vol 42 number 8, pp 1286- 1290 ( sourced through PubMed and Google Scholar)

4. Akkocaoglu Murat and Kasaboglu Oguzcan, (2005) “Success rates of autotransplanted teeth without stabilization by splints; a long term clinical and radiological follow up” British Journal of Oral and Maxillofacial Surgery Vol 43, Issue 1, Feb 2005 pp 31-35 (sourced through Google Scholar) 5. Alemam Asma A. Abu Alhaija Elham S. Mortaja Khakid AlTawachi Akram. (2019); “Incisor root resorption associated with palatally displaced maxillary canines: Analysis and prediction using discriminant function analysis” American Journal of Orthodontics and Dentofacial

18. Kokai Satoshi, Kanno Zulsei, Koike Srina, Uesugi Shunsuke, Takahashi Yuzo, Tak-shi Ono, Soma Kunimichi. (2015), “Retrospective study of 100 autotransplanted teeth with complete root formation and subsequent orthodontic treatment.” AJO-DO Vol 148 issue 6 pp 982-989 (sourced

through PubMed and Google Scholar) 19. Kulkarni, G. and Lee, L. (2016), “Vital Autotransplantation and orthodontic treat-ment of a transmigrant mandibular canine.” Paediatric Dentistry V 38 (no1) pp e1-e4 (sourced through PubMed and Google Scholar) 20. Kim, Eui Clara, and Kulkarni G. (2020) “Vital Autotransplantation and Orthodontic Treatment of Ectopic Maxillary Canines”. Paediatric Dentistry 2020;42(1):55-7 (sourced through PubMed and Google Scholar) 21. Kim Euiseong DDS MSD PhD, Jung Jae-yong DDS, Cha in-Ho DDS MSD PhD, Kum Kee- Yeon DDS MSD PhD Lee Seung-Jong DDS MS (2005), “Evaluation of the prog-nosis and causes of failure in 182 cases of autogenous tooth transplantation”; )ral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;100:112-9 34 22. Mendes, Rui Amaral DMD and G. Rocha Germano DMD PHD, (2004) “Mandibular Third Molar AutoTransplantation - Literature Review with Clinical Cases”; J Can Dent As-soc. 70(11): pp 761-766 (sourced through PubMed and Google Scholar) 23. Marques-Ferreira Manuel, Botelho Maria Filomena, Abrantes Margarida, Oliveiros Barbara, Carrilho Eunice Virginia. (2010), “Quantitative scintigraphic analysis of pulp revascularization in autotransplanted teeth in dogs “ Archives of Oral Biology Vol 55 is-sue11 PP 825-829 (sourced through Google Scholar) 24. Marques-Ferreira Manuel, Rabaça-Botelho Maria-Filomena, Carvalho Lina, Oliveiros Barbara, Palmeirão-Carrilho Virginia. (2011),“Autogenous tooth transplantation: Evaluation of pulp tissue regeneration.” Med Oral Patol Oral Cir Bucal. ;16 (7): e984-9. (sourced through PubMed and Google Scholar) 25. Mao, Jeremy J DDS MSD PhD and Nah, Hyun-Duck DMD MSD PhD. (2004): “Growth and development: Hereditary and Mechanical modulations” American Journal of Orthodontics and Dentofacial Orthopedics ; 125: 676-89 (sourced through PubMed and Google Scholar)

32. Schmidt Samuel K DDS and Cleverly David G. DDS ,(2012), “Tooth auto transplan-tation an overview and case study,” Journal of Northwest dentistry; 91(4) pp 29-33 (sourced through PubMed and Google Scholar) 33. Strbac Georg D. DDS PHD, Schnappauf Albrecht DI, Giannis Katharina DMD , (2016), ”Guided autotransplantation of teeth: A novel Method using Virtually Planned 3 di-mensional Templates”. Journal of Endodontics Vol 42 Issue 12, PP 1844-1850 (sourced through PubMed and Google Scholar) 34. Tsukiboshi Mitsuhiro, (2002) “Auto transplantation of teeth: requirements for pre-dictable success”, Dental Traumatology; ; 18: pp 157-180 (sourced through Pubmed and Google Scholar) 35. Tsukiboshi, Mitsuhiro, (1993), “Autogenous Tooth Transplantation: A Reevaluation”. Source: International Journal of Periodontics & Restorative Dentistry , Vol. 13 Issue 2, p120-149. 30p. (sourced through PubMed and Google Scholar) 36. Texeira C.S. Pasternak Jr. B. Vansan L.P. Sousa-Neto D. (2006), “Autogenous transplantation of teeth with complete root formation: two case reports’” International En-dodontic Journal 39(12);pp977-985 (sourced through PubMed and Google Scholar) 37. Ustad Farheen, Ali FM. Kota Z. Mustafa A. Khan M. (2013) “Autotransplantation of teeth: A Review”, American Journal of Medical and Dental Sciences 2013, 1(1): pp 25-30 (sourced through Google Scholar) 38. Yang Yun, Bai Yuxing, Li Song, Li Jianning, Gao Weimin, Ru Nan. (2012) “Effect of Early Orthodontic Force on Periodontal Healing after Autotransplantation of permanent 36 incisors in Beagle dogs” Journal of Periodontology 83(2) pp 235-241 (sourced through PubMed and Google Scholar) 39. Yanpiset K.. and Trope M, (2000), “Pulp revascularization of replanted immature dog teeth after different treatment methods” Endodontics & Dental Traumatology; 16:(5) pp 211-217 (sourced through PubMed and Google Scholar)

26. Nimčenko, Tatjana, Omerca Gražvydas, Varinauskas Vaida, Bramanti Ennio, Sog-norino Frabrizio Cicciù Marco. (2013), “Tooth autotransplantation as an alternative treat-ment option; A literature review” Dental Research Journal 10(1) pp1-6 (sourced through PubMed and Google Scholar) 27. Ong, D. Itskovich Y. Dance G. (2016); “ Autotransplantation: A Viable treatment option for adolescent patients with significantly compromised teeth” Australian Dental Journal; volume 61 Issue 4, pp 396-407 (sourced through Google Scholar) 28. Park Jae Hyun, Tai Kiyoshi, Hayashi Daisuke, (2010), “Tooth autotransplantation as a treatment option; a review” Journal of clinical paediatric dent. vol 35 issue 2 pp 129-136 (sourced through PubMed and Google Scholar) 29. Roden David R. DMD, MD,, and Mark Yanosky DMD MS; (2013) “Autotransplantation: The Vital Option for Replacement of missing anterior teeth in the developing dentitionm.” Seminars in Orthodontics Vol 19 Issue 1 PP 13-23 (sourced through Google Scholar) 35 30. Singh, Geeta, Mohammad Shadab, Das Somdipto, Mahajan Nitin, Pradesh Uttar. (2014); “ Autologous Tooth Transplantation: Report of 5 cases” J Adv Med Dent Scie;2(1): pp140-145 ( sourced through Google Scholar) 31. W. Robindro Singh, et al. (2015),“post-odontoma autotransplantation of an impacted tooth: a case report” Journal of Oral Biology and cranofac Research, Vol. 5, no. 2 pp 120-123 (sourced through PubMed and Google Scholar)

Tips from the Experienced

The Eyelet 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.

Quite frequently the maxillary second molar has erupted in bucco- version, and there is minimal space to bond the buccal tube. Even if the buccal tube is successfully bonded, the patient may not be able to tolerate it. Therefore, the last resort is bonding an eyelet. The author would like to share with you the case, where he was desperate to help the patient. The patient arrived as a TM dysfunction patient for finishing the case with the SWA. The patient presented herself with the mandibular orthotic (Anterior Repositioning Splint) in therapeutic position. In this position, the patient reported great amelioration of signs and symptoms of TM dysfunction. It was necessary to bracket entire maxillary arch for the forced eruption (elevation) of mandibular posterior sextants. The patient was an adult female, hyperdivergent with extremely hypertonic peri-oral muscles. The teeth in question for bonding were #17(2) and #27(15). We started with a standard molar tube, continued with mini – molar tube, and the patient could not tolerate either one. She developed uncomfortable lacerations and precipitated few emergency appointments. Finally, we bonded an eyelet on the buccal aspect of both second molars and the patient was comfortable. She could not tolerate a bendback (cinch), therefore the author cut off the end of the arch wire with the small football shaped diamond bur. References: 1. The author’s personal experience and research 2. Cerum Ortho Organizers Catalogue, E8

Featured*

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

Dr Trupti Nakhate

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

Abstract Among all the malocclusions Class II malocclusion is one of the most common problems affecting growing as well as non-growing individuals around the globe. About one-third of the patients coming for orthodontic treatment have this type of malocclusion. Twin block appliance is most commonly used in Class II Div I malocclusion cases as it is less bulky as compared to other monobloc appliances. Twin block appliance is effective for correction of Class II malocclusion as well as mandibular retrognathism. Correction of problems through this appliance is based on various factors such as selection of the case, age of the patient and patients’ compliance. This appliance is indicated in patients having retruded mandible with positive virtual treatment objective (VTO), it will enhance the growth of the mandible and improve the patients’ profile. The profile changes and treatment results were demonstrated. With proper case selection and good co-operation, we can obtain a significant result with the Twin block appliance. Keywords: retrognathic mandible, Twin-block appliance, removeable myofunctional appliance, Class II Introduction Malocclusion can be defined as the presence of an anomalous relationship between upper and lower teeth of either dental or alveolar origin.1 The type of malocclusion can be classified as Class I (normal occlusion), Class II (distal occlusion), Class III (mesio occlusion) with or without displacement and maxillary contraction.2,3 These alteration can be associated with habits such as thumb sucking, mouth breathing, atypical swallowing, and labial interposition which if continuously repeated can lead to functional anomalies of orofacial musculature.4,5 To solve this problem, we can refer to myo-functional or fixed appliance therapy to recover the normal function of oral musculature.6,7 Myofunctional therapy plays a key role in the treatment. For success of treatment such type of interdisciplinary approach is crucial to avoid any relapse which can occur after orthodontic treatment.8,9 This report represents a case treated with myofunctional therapy followed by fixed mechanotherapy.10 15

*This article has been peer reviewed

Case SD, a 13-year-old growing male patient, reported with the chief complaint of forwardly placed teeth in upper front region of jaw. Cervical vertebral maturation index-3 (CVMI-3). Had class II division 1 malocclusion and skeletal class II jaw bases with vertical growth pattern. Intraoral finding shows proclined upper incisor with crowding in lower incisors. Deviation of lower dental midline by 3mm towards left side of upper dental midline. Nonextraction treatment involved growth modulation of the mandible by the functional appliance for the correction of mandibular retrusion followed by comprehensive orthodontic treatment for the finishing of occlusion. The treatment used was twin block and pre-adjusted edgewise appliance (MBT prescription, 0.022" × 0.028" slot) were used to correct the malocclusion. Section 1: Pre-treatment Assessment Patient details • Initials: SD • Sex: Male • Date of birth: January 13, 2005 • Age at start of treatment: 13 years • Patient’s complaint: Forwardly placed upper front teeth • Relevant medical/dental history: No relevant medical and dental history Clinical examination: Extra oral features (Figure 1) Head form: Mesocephalic Face form: Mesoprosopic Facial symmetry: Apparently symmetrical. Smile arc: Consonant Facial profile: Convex Lips: incompetent with 8mm interlabial gap

Figure 1: Pre-treatment extraoral photographs: (a) Frontal view with lips at rest, (b) Frontal view with smile, (c) Right profile view and (d) Three-quarter view

Clinical examination: Intraoral features [Figure 2]. Soft tissues: Mucogingival attachment of frenum Oral hygiene: Fair Erupted teeth present: All teeth are present except third molars General dental condition: • No carious tooth • Crowding in the lower anterior region.

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

Occlusal features [Figure 2]: • Proclined upper anteriors. • Incisor relationship: Class II Division 1 • Overjet (mm): 14 mm • Overbite: 4 mm • Centrelines: - Facio maxillary centered - Facio mandibular shifted to left by 3 mm - Maxillo mandibular discordant by 3 mm. • Left buccal segment relation: Class II • Right buccal segment relation: Class II • Crossbites: None • Ovoid maxillary and mandibular arch • Bolton discrepancy Overall-83.87% (normal-91.3%) Anterior-74.46% (normal-77.2%) (Approximately 1.66 mm mandibular teeth material excess). General Radiographic Examination Orthopantomogram (OPG) Lateral cephalogram (Figure 3) Pretreatment radiographic finding • No missing teeth • No obvious dental pathology • CVMI Stage 3 Other Special Tests/Analyses

relation also suggests a Class II skeletal base relation due to the small mandible (mandibular length = 92 mm). Position of the chin (facial angle = 73°) is backward in relation to the Frankfort-horizontal plane. The Frankforthorizontal plane angle, SN-Go-Gn, and facial height ratios is increased suggesting downward and forward mandibular growth pattern. Maxillary and mandibular incisors are proclined with reduced interincisal angle.11,12 The positions of the upper and lower lips are slightly forward in relation to the esthetic line (E-line). The nasolabial angle is more than normal. CVMI shows stage-3 of skeletal maturation (acceleration stage, >65% pubertal growth still remaining).13 Diagnostic Summary A 13-year growing male patient in the CVMI stage-3of skeletal maturation with Class II Division 1 malocclusion on Class II skeletal base, vertical growth pattern, proclined upper anteriors, crowding in the lower anterior region, lower dental midline deviation to left side by 3 mm.

FIG 3: Pre-treatment radiographs (a) Lateral cephalogram with teeth in occlusion, (b) Orthopantomogram

Problem List • Class II skeletal relationship (mandibular deficiency)

Clinical VTO: Positive (Figure 4)

• Class II dental relationship • Lip incompetent • Convex profile • Rotation with 14,15,24,25,35,45 • Proclination of upper incisors • increased Deep bite • increased overjet • Lower midline deviation • Severe crowding in the lower anterior region. Objectives of Treatment

FIG 4: Extraoral photographs showing positive clinical VTO a) Mandible at rest b) Clinical VTO

• Interception of Class II skeletal relationship (mandibular growth modulation)

Pretreatment Cephalometric Findings and Their Interpretation Various pretreatment cephalometric findings are described in Table 1. The maxillary base is normally placed, and mandible is backwardly positioned (SNA = 78°, SNB = 68°) in relation to the anterior cranial base. The ANB angle is high (ANB = 10°) suggesting Class II skeletal base relation. Wit’s appraisal (AO−BO = 8 mm) and other parameters for sagittal maxillo-mandibular

• Achieving Class I canine and molar relationships • Achieving proper maxillary arch form • Correction of upper incisor proclination • Correction of deep bite by extrusion of lower posterior teeth • Matching the lower dental midline to the upper dental midline 17

Table 1: Cephalometric findings at various stages of orthodontic treatment

• Alignment of arches.

• September 8, 2018: Expansion of the upper arch started.

Treatment Plan

• March 3, 2019: Trimming of the posterior bite-block done.

• Nonextraction

• August 25, 2019: Use of Twin-block appliance discontinued; U/L impression made; extra- and intraoral photographs recorded (Figure 6 and 7)

• Interception of Class II skeletal relationship by functional appliance • Expansion of maxillary arch with slow expansion device. Appliances: Growth modulation of mandible by Twinblock appliance and finishing of occlusion with preadjusted edgewise appliance (MBT Prescription, 0.022” slot). Special anchorage requirements: Rick-A-Nator in maxillary arch post functional appliance therapy. • Minor adjunctive surgery: None • Major adjunctive surgery: None

Fig. 6: Intraoral photographs with twin block: a) Maxillary occlusal view b) Mandibular occlusal view c) Anterior view d) Right buccal view e) Left buccal view

• Additional dental treatment: None • Proposed retention strategy: Maxillary and Mandibular - Lingual bonded retainer from canine to canine and removable retainer to be worn during night time only for 1-year. • Additional notes on treatment plan: None. • Prognosis for stability: The prognosis for the stability is good. Section 2: Treatment Progress • Treatment commenced on July 9, 2018; with Twinblock appliance.

Fig. 7: Extraoral photographs post myofunctional therapy: a) Frontal view with lips at rest, (b) Frontal view with smile, (c) Right profile view and (d) Three-quarter view

• February 14 July 2018: Twin-block appliance was delivered; extra- and intra-oral photographs recorded (Figure 5).

Fig. 8: Post-myofunctional treatment radiographs (a) Lateral cephalogram with teeth in occlusion, (b) Orthopantomogram

• August 26, 2019: Bands were placed in first molars; bonding done; U-0.016” and L-0.016” NiTi wire ligated with ligature wire; rickanator placed in U-arch. (Figure 9)

Fig. 5: Intraoral photographs with twin block: a) Maxillary occlusal view b) Mandibular occlusal view c) Anterior view d) Right buccal view e) Left buccal view

Fig. 9: Extraoral photographs post myofunctional therapy: a) Frontal view with lips at rest, (b) Frontal view with smile, (c) Right profile view and (d) Three-quarter view

• September 1, 2019: patient reported with displaced rickanator replacement was done; U & L- 0.018 NiTi ligated. • November 9, 2019: U/L 0.017 x 0.025” NiTi wire ligated. • February 2, 2020: U/L 0.019 x 0.025” NiTi wire ligated; couple created to derotate 45. • February 26, 2020: U/L-0.019 x 0.025” stainless steel wire ligated; to use Class II elastics. • August 25, 2020: Bracket repositioning done with 31& 45; Intraoral and extraoral photographs taken, U/L Alginate impression made. (Figure 10 and 11)

Fig.12: Post treatment radiographs (a) Lateral cephalogram with teeth in occlusion, (b) Orthopantomogram

Section 3: Posttreatment Assessment Occlusal Features

Fig.10: Extraoral photographs post treatment a) Frontal view with lips at rest, (b) Frontal view with smile, (c) Right profile view • Various occlusal features at the end of orthodontic and (d) Three-quarter view

treatment are shown in Figure 10.

• Incisor relationship: Class I • Overjet (mm): 2 mm Overbite: 2 mm • Centerlines: Coinciding • Left buccal segment relationship: Class I • Right buccal segment relationship: Class I • Cross bites: None • Displacements: None Fig.11: Intraoral photographs post treatment: a) Maxillary occlusal view b) Mandibular occlusal view c) Anterior view d) Right buccal view e) Left buccal view

• Functional occlusal features: Mutually protected occlusion

Post functional Cephalometric Findings and Their Interpretation Various cephalometric findings at the end of functional appliance therapy are described in Table 1. There was a restriction in the forward growth of maxilla. Mandibular position and length were improved by the functional appliance therapy. The Class II skeletal relationship was improved. The mandible was rotated marginally in downward and backward direction. However, the posterior and anterior face heights were increased proportionately. The upper incisors were tipped palatally, and lower incisors were proclined by the Twin-block appliance. The soft tissue relationship was improved.14,15 The Pitchfork analysis showed 75% skeletal and 25% dental contribution for the molar correction, and overjet correction was due to 56% skeletal and 44% dental contribution (Figure 12). Section 3: Posttreatment Assessment Occlusal Features • Various occlusal features at the end of orthodontic treatment are shown in Figure 10. • Incisor relationship: Class I • Overjet (mm): 2 mm Overbite: 2 mm • Centerlines: Coinciding • Left buccal segment relationship: Class I • Right buccal segment relationship: Class I • Cross bites: None • Displacements: None • Functional occlusal features: Mutually protected occlusion • Other occlusal features: None • Complications encountered during treatment: None. Radiographs Recorded Toward/at End of Treatment

Post-treatment Cephalometric Findings and Their Interpretation Various post-treatment cephalometric finding are described in Table 1. The sagittal position of the maxilla and maxillary length were decreased and effective maxillary length were increased moderately over the treatment period. The sagittal position of the mandible was improved by 6° whereas mandibular length and effective mandibular lengths were increased by 10 mm and 15mm, respectively, during the treatment. The FMA, SN-Go-Gn, basal plane angle was decreased marginally during the treatment, whereas the total anterior and posterior face heights were increased respectively, during the treatment. The change in the position of upper and lower incisors was very prominent. During the treatment, upper incisors were tipped palatally by 17° in relation to the SN-plane and 16° in relation to the NA-line. Lower incisor to the mandibular plane angle did not increase. A 3° increase of the inter-incisal angle was found. Nasolabial angle decreased after treatment. The position of the upper lip and lip strain was improved during the treatment. Section 4: Critical Appraisal • Myofunctional appliance therapy was planned for this patient. As the patient had retrusive mandible and protrusive maxilla, the mandibular advancement was done by using twin block appliance. • Treatment complemented facial growth. Class I molar relationship, good intercuspation, normal overjet and overbite were achieved. Optimal functional occlusion was achieved. Myofunctional therapy followed by fixed orthodontic treatment. Good alignment was achieved and arch forms were well co-ordinated. No alveolar bone loss was observed. Good balance between hard and soft tissue was achieved. In this case, lower right second premolar was in crossbite. Fixed lingual retainer was planned in upper and lower arch.

Radiographs recorded • OPG to assess root paralleling: August 25, 2020 [Figure 12] Lateral cephalogram with teeth in occlusion: august 25, 2020 [Figure 12].

Financial support and sponsorship - Nil. Conflicts of interest - There are no conflicts of interest.

Relevant radiographic finding • Analysis of OPG revealed acceptable root paralleling at the end of treatment. All third molars were in normal development. Lateral cephalogram showed the normal inclination of upper and lower incisors, however; chin was still deficient. 21

References

1. Clark WJ. The twin block technique. A functional orthopaedic appliance system. Am J Orthod Dentofacial Orthop. 1988;93(1):118. 2. Graber TM, Rakosi T, Petrovic A. Dentofacial orthopaedics with functional appliances. 2nd ed. St Louis: Mosby, 1997. 3. O’Brien K, Wright J, Conboy F, et al. Effectiveness of treatment for Class II malocclusion with the Herbst or twin-block appliances: a randomized, controlled trial. Am J Orthod Dentofacial Orthop. 2003;124(2):128-137. 4. O’Brien K, Wright J, Conboy F, et al. Early treatment for Class II Division 1 malocclusion with the Twin-block appliance: a multicenter, randomized, controlled trial. Am J Orthod Dentofacial Orthop. 2009;135(5):573-579. 5. Mills JR. The effect of functional appliances on the skeletal pattern. Br J Orthod. 1991;18(4):267-275. 6. Singh GD, Hodge MR. Bimaxillary morphometry of patients with class II division 1 malocclusion treated with twin block appliances. Angle Orthod. 2002;72(5):402-409. 7. Harradine NW, Gale D. The effects of torque control spurs in twinblock appliances. Clin Orthod Res. 2000;3(4):202-209. 8. Lee RT, Kyi CS, Mack GJ. A controlled clinical trial of the effects of the Twin Block and Dynamax appliances on the hard and soft tissues. Eur J Orthod. 2007;29(3):272-282. 9. Lund DI, Sandler PJ. The effects of Twin Blocks: a prospective controlled study. Am J Orthod Dentofacial Orthop. 1998;113(1):104-110. 10. Rowland H, Hichens L, Williams A, et al. The effectiveness of Hawley and vacuum-formed retainers: a single-center randomized controlled trial. Am J Orthod Dentofacial Orthop. 2007;132(6):730737. 11. Little RM. Stability and relapse of mandibular anterior alignment: University of Washington studies. Semin Orthod. 1999;5(3):191204. 12. Chadwick SM, Banks P, Wright JL. The use of myofunctional appliances in the UK: a survey of British orthodontists. Dent Update. 1998;25(7):302-308. 13. Savitha, Sathyaprasad & B, Amogha. (2023). Correction of Class II Malocclusion using Twin Block Appliance: A Case Series. International Journal of Science and Research (IJSR). 11. 14. Sharma NS. Management of a growing Skeletal Class II Patient: A Case Report. International Journal of Clinical Pediatric Dentistry. 2013 Jan;6(1):48-54. 15. Clark, William. (1982). The Twin Block traction technique. European journal of orthodontics. 4. 129-38.

Book Excerpt

Growing Beautiful Teeth Chapter 6: The Clues to Look for in Your Child 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.

n the previous chapters, I advised parents to take simple steps early to give their child the best chance to grow straight teeth, beautiful jaw and face, and have broad, winning smiles. Keeping an eye on this important area of growth that is usually referred to as dentofacial growth must continue throughout the child’s early years, especially in the first 6–8 years of their life. Sometimes, when growth is not tracking right, redirection will be easier when the child is young and their structure is amazingly adaptable. The child will also have fewer outside social influences to deal with at that time of life. So, what are the clues that growth may not be heading in the right direction? A child’s growth in the cranium and jaw is already 80% complete by the time they are 8 years of age, or even earlier in girls. Because of this, the clues also present themselves early. By being aware of them, you will be able to take steps early and intercept an undesirable growth trend that otherwise could lead to bigger and more costly related health issues in the future. As a general dentist, I treat adults in my practice and I can confirm that these growth problems, if left untreated, will not solve themselves as the child transitions into adulthood. Just as we are observing an increase of a need for tooth straightening, there is also an all-time high prevalence of chronic pain associated with the jaw, head and neck as well as a high prevalence of obstructive sleep apnoea (OSA) or breathing related sleep issues seen in the adult population. Could these be associated? Parents will save money and heartache by mitigating complicated treatments for their child when growth problem is allowed to develop unchecked. The clues to look out for are: • narrow upper jaw or maxilla • abnormal bites • functional issues - poor oral muscle habits and posture - poor breathing patterns - nose, throat and ear issues • unsatisfactory facial profile • if parent(s) of the child have any of the above conditions • parent(s) having Sleep Disordered Breathing These issues often do not occur in isolation but can be present together to varying degrees because, in some way, they are all linked to inadequate maxilla growth. I highlight the more common dental clues below. Children with the dreaded Bucky Beaver look

(bucked-tooth) are prone to injuring their upper-front teeth. While it seems logical to blame the upper teeth that appear to be sticking out, it is in fact more common that the cause is a mandible trapped too far back because the upper dental arch is too tapered. Beware of any treatment that aims at retracting the upper-front teeth back to match up with the ill-positioned mandible. See Figures 6 and 8 in Chapter 2. Often, the lower lip will get caught in the large space behind the erupting upper incisors, thus perpetuating the large overjet. Tooth crowding is a red flag for an undersized jaw. One of the most common concerns for parents is to notice a new, permanent lower-front tooth (incisor) erupting behind the baby teeth crowded out of alignment. Crowding of lower incisors when the maxilla is not large enough…

Fig.19: Crowding

Other common areas for crowding include the upper incisors and canines as these adult teeth begin to come through. Overbite, underbite, deep bite and crossbite: In primary dentition, the upper-front teeth normally overlap or cover the outside of the lower-front teeth by about 20–30% of the height of these lower incisors. This is called a (normal) overbite. As they transition to adult dentition the front teeth overbite should reduce to approximately 10- 15% of the height of the lower incisor. (See Figure 5 in Chapter 2.) Too much overbite (above 30%) is referred to as a deep overbite, or simply a deep bite. Too little or no overbite would also indicate an undersized upper jaw. The upper teeth should not meet edge-on with the lower teeth. (Explained further below) 24

The analogy is a hat box that should have a lid that is just slightly larger (the upper dental arch) to cover the lower half of the box (lower dental arch). If the lid is too small, then the two parts will not fit together properly. A hat box must have correct sized lid, and not too small “S”

A subtle indication of an underbite is when the upper incisors do not show as much as the lower-front teeth when smiling. Normally, when smiling, the upper incisors should show more than the lower. A deep bite is when the upper teeth overlap the lower teeth by more than 30%. The deeper the overbite, the less the lower-front teeth will show when the child close the teeth together.

b. Deep overbite and lack of spacing in a 5 year old

a. Deep (100%) overbite in a 9 year old

Fig. 20: Hat box and lids

A crossbite results when the overlap is reversed; that is, the upper teeth fit inside to the lower teeth. The cause is a disproportion in jaw sizes, with the upper being relatively undersized. The crossbite may be located between the front teeth. The lay term for this is an underbite. This is often present in a child who has a genetic predisposition to a strong lower jaw growth. Left side cross-bite

a.Edge to edge front teeth (no overbite), also called an underbite

d. Deep overbite 10 year-old

c. Deep overbite 7 year-old

Fig. 23: Deep bite

When an overbite is completely lacking – that is, the baby front teeth meet edge to edge as the child closes the jaws together – parents often erroneously think this is how it should be. This is an early clue that upper jaw growth is insufficient. See Figure 16 in Chapter 4. In a gummy smile, there is excessive display of the pink gums above the upper-front teeth, as if the whole upper dental arch has grown too far down. This can be seen even in the very young and in adults as well. Growth in a downward direction keeps the lower jaw and tongue down and back back and predisposes the child to having a restricted airway and TMD.

Left side cross-bite and edge to edge bite - signs of a small maxilla relative to the mandible

This 8 year old girl shows only her gum and no upper teeth when she smiles…..

Fig. 21: Left side crossbite

This 3 year old girl is showing early signs of maxilla deficiency and vertical growth pattern

3 yearold with a gummy smile

4 yearold with gummy smile

Fig. 24: Gummy smiles – excessive gum display in the

Edge to edge front teeth with no overbite, common sign of a under-sized maxilla, relative to the mandible

Fig. 22: Right side crossbite

upper arch. An open bite is usually the result of a prolonged sucking of the dummy or the child’s thumb or finger. Prolonged placement of these items between the front teeth prevent the teeth from coupling or to close together.

Your family dentist should be able to monitor and advise you in this regard.1 Just a word of caution here: if there is a bad tongue habit where the tongue thrusts forward constantly pushing against the upper-front teeth, this can splay or spread the front teeth apart resulting in larger gaps. This is not normal either. Usually, in this instance, the upperfront teeth will assume a jutting forward appearance. This undesirable tongue habit is also known as an infantile swallow or a tongue-thrust habit. Other poor mouth habit red flags include excessive drooling, mouth-breathing, mouth hanging open constantly, dried flaky lips or swollen and reddish lips (especially the lower), messy eating with food spilling out of the mouth, and difficulty in swallowing food (with tongue thrusting out). A child should be trained to chew their food with their mouth closed and with no talking. Parents should enforce this habit by setting a good example in doing the same. Parents and dentist may need to work closely with a dedicated orofacial myotherapist to retrain the use of these mouth muscles. Parents often report to me that they can hear their child grind teeth loudly during the night. The child will have flattened and worn teeth, with significant loss of tooth enamel. An underdeveloped upper jaw presents an increased risk for airway restriction, which is usually worse during sleep. The child may have some degree of SDB or apnea which in turn predisposes the child to tooth clenching and grinding. (Refer to chapter 4 for more details.) Edge-to-edge front teeth and bruxing during sleep are red flags for SDB which should alert the parents to seek early intervention to help the upper jaw grow more. Seek help from your dentist to manage this issue early. (See Figure 16 in Chapter 4.) Does your child experience breathing difficulties? Look out for where the mouth stays open all the time or if there is a constant blocked nose. A referral to an ENT surgeon would be warranted. Snoring during sleep should be investigated to rule out any SDB. Clues to disturbed sleep include daytime tiredness and excessive yawning, and social behaviour parallel to those in children with ADHD.2,3 Adenoid face refers to a facial appearance displaying a narrow and long face usually associated with an openmouth breathing habit due to chronic nasal blockages and enlarged adenoids which prevents the child from breathing through the nose.

This is a problem worth treating early. An open bite can also be the result of a severe openmouth breathing habit and poor swallow patterns that allow the tongue to constantly sit between the incisors. Prevent an open bite by encouraging mouth closure at a young age. Open bite in an 7 year-old

Open bite in a five year old Note how tongue sneaks between front teeth, a functional issue common in open bites

Open bite in a 57 year-old

Fig. 25: Open bites

Teeth leaning inwards (inadequate proclining, or retroclining) forms an undersized dental arch and a mismatch between the two arches will result. This may be evident in the primary teeth and when the adult upper incisors are coming through. Note direction of tooth axes…

Retroclined teeth (leaning inwards) in primary and adult dentition. Smaller dental arches result.

Fig. 26: Retroclined teeth.

The less obvious clue to an undersized palate or upper jaw is the lack of spacings between the child’s primary teeth. From about the age of 4 years, the jaw should grow larger to prepare for the arrival of the second set of larger teeth and, during the transition, the smaller baby teeth will appear too tiny for the growing jaw with the front baby teeth showing plenty spacings between them. If spacing is not obvious, then this is an early warning that the jaw may not be growing to its maximum potential. It may be difficult for the parents to know just how much spacing is normal between the child’s growing teeth. 26

The midface or cheeks are flat with poor muscle tone. Because of the insufficient midface structure, venous circulation is affected, and so these kids tend to have dark or bluey shadows below the eyes (known as venous pooling). The constant open-mouth habit tends to be associated with a receded chin and convex facial profile. [

parents can be lulled into a false sense of security thinking that all is fine when they do not see any evidence of crowding. Even though these narrow teeth may need less dental arch space, the child still needs a well- developed palate and wide dental arches to accommodate the tongue! The extreme of such narrow teeth would be a lack of these teeth altogether, a condition known as ‘dental agenesis’ or congenitally missing teeth. Parents often ask if these missing lateral incisors will ultimately need to be replaced with a bridge or implant, and the answer is Yes, because we need to develop the palate and dental arch for a balanced face and to create sufficient room for the tongue and to optimize structural space for optimal breathing. These goals will create the space meant for the lateral incisors so that the missing teeth can be reinstated with artificial tooth replacements. Fortunately, with modern restorative technology, a beautiful, natural looking incisor can be constructed, and a good outcome can be assured; usually, the restorative phase is done in adulthood when growth is completed. The permanent second bicuspids are also commonly congenitally missing. This is one good reason to have a PAN radiograph taken for a complete scan of the child’s developing teeth. When detected early, it can inform the special need to preserve the deciduous tooth that is not going to be replaced. Despite that a child may appear to have well aligned teeth, parents still need to keep a look out for other clues to growth deficiency.

Poor maxilla development-jaws set back Poor vein drainage = venous pooling, shadow below eyes Tired droopy eyes, white below iris showing Flat cheeks, bags below eyes Blocked nose >> snuffy, rhinitis, Mouth-breathing Long and narrow face

Fig. 27: Adenoid face Shape and size of teeth. A question I often get asked is that can the jaw be too small and the teeth too large? This is a widely held belief and perhaps an excuse given for removal of teeth that are blamed to be taking up too much space. The reality is that the incidence of such freakish disproportion is extremely rare in nature. My motto is to develop the jaw first before considering if it is necessary to remove healthy teeth. By contrast, the permanent teeth can sometimes turn out to be too small (the technical term is ‘microdontia’) and this is commonly presented as a pair of very narrow or peg-shaped upper lateral incisors. For good looks, these teeth will need to be cosmetically built out (we do this later in adulthood) so that the size of these skinny teeth will be proportional and harmonious with the other permanent incisors. Such a balance will improve the smile and fit in with our goal for optimally wide dental arches that can satisfactorily accommodate the tongue. Beware that these disproportionally skinny lateral incisors do not take up as much space and therefore

References

1 Helpful reference for dental growth chart: https://www.pinterest. co.uk/pin/503699539556188735/?lp=true 2 JA Owens, Neurocognitive and behavioral impact of sleep disordered breathing in children, Pediatric Pulmonology, 2009 May; 44:417– 422 3 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

Featured*

Fixed Functional Appliance with Skeletal Anchorage System

(FFA-SAS) – An Exemplary Comparative Review by R. Thangabalu, Anjana Rajagopalana, and A. Udhayan

Abstract Fixed functional appliances (FFAs) in conjunction with Skeletal anchorage devices have been proposed to enhance skeletal effects and reduce dentoalveolar effects like proclination of the lower incisors. In this exemplary review, we have discussed in detail about skeletal, Dentoalveolar, and Soft tissue effects when FFD is used with Skeletal anchorage.

Dr. Thangabalu Assistant Professor Dept. of Orthodontics and Dentofacial Orthopaedics Vinayaka Mission’s Sankarachariyar Dental College, Salem

Anjana Rajagopalan Research Associate, Dept. of Dentistry, AIIMS, Bathinda

Keywords: Class II malocclusion; Fixed Functional Appliance; Miniscrews, Miniplates; Skeletal Anchorage; Growth.

A. Udhayan Assistant Professor Dept. of Orthodontics and Dentofacial Orthopaedics Vinayaka Mission’s Sankarachariyar Dental College, Salem

Introduction Class II malocclusion is one of the most frequent problems encountered in orthodontics and is evident in one-third of patients seeking orthodontic treatment.1 It is the distal relationship of the mandible related to the maxilla with a combination of different dental and skeletal components viz. maxillary skeletal excess, maxillary dental excess, mandibular skeletal deficiency, and mandibular dental deficiency that affects facial aesthetics and functional status of the patient adversely.2 The overall global prevalence of Class II was 19.56% and 23.11% in permanent and mixed dentition respectively. The universal rationale for seeking orthodontic treatment by such patients has been mandibular retrognathism.2 According to McNamara (1981), the most the

*This article has been peer reviewed

most common feature of Class II malocclusion is retrognathism of the mandible rather than protrusion of the maxilla which can be managed by functional appliances in growing patients and by surgery in adult patients.3 Disadvantages of removable appliances; like bulky and loose in the mouth, so they are not easy for patients to use; thus, insufficient patient cooperation occurs.4 Same repeats when Emil Herbst5 introduced the appliance in 1909 which corrects the class II malocclusion with the aid of a removable splint but most of the patients did not comply with the use of removable appliances. So thus leads Herbst to develop an appliance with a view to permanently moving the mandible forward with the aid of a fixed appliance, regardless of patient’s compliance. After 1930, the Herbst appliance was seldom used, being rediscovered by Pancherz in 1979.6 Since that wide range of fixed functional appliances had been developed till date. common feature of Class II malocclusion is retrognathism of the mandible rather than protrusion of the maxilla which can be managed by functional appliances in growing patients and by surgery in adult patients.3 Disadvantages of removable appliances; like bulky and loose in the mouth, so they are not easy for patients to use; thus, insufficient patient cooperation occurs.4 Same repeats when Emil Herbst5 introduced the appliance in 1909 which corrects the class II malocclusion with the aid of a removable splint but most of the patients did not comply with the use of removable appliances. So thus leads Herbst to develop an appliance with a view to permanently moving the mandible forward with the aid of a fixed appliance, regardless of patient’s compliance. After 1930, the Herbst appliance was seldom used, being rediscovered by Pancherz in 1979.6 Literature shows proclination of lower incisors with fixed functional appliances is unavoidable.7,8 To counteract this, a skeletal anchorage system was introduced to reinforce the anchorage with FFA. However, skeletal anchorage presents certain drawbacks: these are invasive treatments that require minor surgery both to insert and remove them, and some of the components are not stable throughout the treatment.9 Post-operative inflammation, irritation of adjacent tissues in contact with the mini screws, and buildups of food scraps in the area are also reported as side effects.10 Despite these adverse effects, the use of skeletal anchorage for the treatment of skeletal

class II malocclusion continues to spread. The purpose of this exemplary review is to investigate the effectiveness of the skeletal anchorage system in the treatment of class II malocclusions due to Mandibular retrusion. Tool: Lateral cephalogram and CBCT data have been used to evaluate the treatment effects. 1. Sagittal Skeletal Effects 1a. Sagittal Effects a) Mandibular length, b) Maxillary length, c) SNA, d) SNB, and e) ANB angles Mandibular length: both conventional and skeletal anchorage systems significantly stimulated mandibular growth. Turkkahraman et al. described this result as due to the anterior and downward force vector of the appliance and consequent adaptational growth in the mandibular condyle. In the study conducted by Aslana et al. there was no significant effects on mandibular growth, this may be due to the resistance of mini-screws to forward force direction of the Forsus appliance8 and 6-month treatment duration period may not be enough time for mandibular growth.8,11 However, Elkordy et al., and Gandedkar et al. showed significant differences in mandibular length between the two systems of anchorage due to they had used miniplate-anchored FFA; the significant difference could have been due to the direct application of orthopedic forces to the bone that transmitted a downward and forward force vector to the condyles. Maxillary length and forward growth of the maxillae was inhibited in both groups, and this ‘‘high-pull-headgear’’ effect of fixed functional appliances.11–13 Angle SNA, in both the systems, angle SNA decreased significantly. This is may be due to posteriorly directed forces acting on the maxilla “high-pull -headgear” effect, which may effectively restrict the forward growth of the maxilla. Angle SNB significantly increased in both the anchorage systems due to the forward displacement of the mandible the but skeletal anchorage system didn’t produce any significant additional effect.12,14,15 Three studies16-18 suggested that this may be due to 29

the backward rotation of the mandible. Elkordy et al. suggested that an increase in the angle SNB will be masked by the posterior rotation of the mandible. The results of the angle SNB, SNA, and ANB changes, indicate no superiority in the combined use of skeletal anchorage and FFA in the achievement of additional skeletal effects.

posterior facial height was significantly increased in the skeletal anchorage system when compared to the conventional anchorage system and Turkkahraman et al.13 found that posterior facial height significantly increased more in conventional than the skeletal anchorage system. According to Turkkahraman et, al.13 new forward position of the mandible by appliances enhances the condylar growth vertically and increases both posterior and anterior face height.

1b. Vertical Effects i. Angle SN-MP ii. Total (N-Me) and Lower Anterior Facial Height (ANS-Me) iii. Posterior Facial Height (S-Go)

2) Dental Effects Upper incisor inclination U1-HRL,8 U1-SN,12 U1 inclination,14 PP-U1,13,15,16 U1-NA11,31 and Ls-PP17 were the parameters used to measure the treatment changes in the inclination of the upper incisor. There was greater retroclination of the upper incisor in both techniques but skeletal anchorage system shows slightly greater than a conventional system. The distally directed force of the appliance transmitted through the heavy archwire to the maxillary incisors in both treatment techniques could have caused their significant retrusion.8,11,12

Angle SN-MP Studies8,11–14,16,18 stated that angle SN-MP increased more in the skeletal anchorage system. According to Turkkahraman et al.13 Celikoglu et al12 and Elkordy et al.,16 this might be due to the miniplate anchorage producing forward and downward forces of the appliance were directly transmitted to the anterior skeletal base of the mandible, causing more significant posterior rotation and the center of force application in the skeletal anchorage was located more downward vertically compared with the conventional anchorage system. This might be another reason for increased mandibular rotation with the skeletal anchorage system.

Lower incisor inclination. L1-MP,8,12,13,15,16 L1 inclination,14 L1-NB,11,18 and Li-GoGn17 were the parameters used to measure the treatment changes in the inclination of the lower incisor. Studies8,11,12,14–18 showed that significantly greater amount of proclination of lower incisors in conventional anchorage systems than in skeletal anchorage systems. The study by Tukkahraman et al.13 (2016) showed that statistically significant retroclination of 2.86±4.83 mm with the skeletal anchorage system and proclination of 13.37±5.01 mm with the conventional anchorage system (P<0.001). This outcome was considered very important because it was believed to reflect the mandibular arch anchorage loss, which was the most limiting factor for the achievement of skeletal effects by FFA therapy. It was reported in previous reports that none of the available removable or fixed FFA could fully manage this anchorage loss problem. Results from this review showed the significant reduction of the lower incisor proclination when skeletal anchorage was used, possibly because of the pressure of the maxillary incisors and lower lip.8,12,13,15,16 According to Elkordy et al.14 the introduction of mini-implants with rigid attachment to the mandibular canines resulted in remarkable favorable changes in limiting the proclination of the mandibular incisors and

Total (N-Me) and Lower Anterior Facial Height (ANS-Me) The studies8,11,13 evaluated the change in effective total anterior facial height and they stated that anterior facial height was significantly increased in the skeletal anchorage system when compared to conventional anchorage system. According to Eissa et al.,11 this might be due to downward and forward forces from the appliance which resulted in a new mandibular position that enhanced vertical condylar growth and, subsequently, increased lower facial height. However contrary to this Turkkahraman et al.13 reported a significant increase in effective maxillary length (Co-A) may be due to adaptational growth in the mandibular condyle. appliance which resulted in a new mandibular position that enhanced vertical condylar growth and, subsequently, increased lower facial height. Posterior Facial Height (S-Go) Aslan et al.8 and Elkordy et al.14 stated that

in conventional Forsus the pushrod was inserted distal to the mandibular canines thus lead to more proclination of mandibular incisors. Contrastly, Cacciatore et al.19 placed the pushrod distal to the mandibular first premolar, which limits the mandibular incisor proclination. This might give rise to the question of whether the distal placement of the pushrod could have resulted in reduction of the unwanted mandibular incisor mesial movement; this question requires further studies. According to Eissa et al.11 incisor protrusion was observed in both treatment techniques, this difference might be attributed to the size of the wire segment used for connecting the miniscrew with the Mandibular canine bracket. As far as the type of skeletal anchorage used is concerned, a highly significant subgroup difference was evident due to the different modes of anchorage. Miniplates resulted in more reduction of lower incisor proclination than mini-screws when used with FFA. Overjet Studies10,11,15,17,18,19 showed that greater reduction of overjet in the skeletal anchorage system than conventional anchorage system. Aslan et al.8 and Eissa et al.11 reported that overjet correction was completely dentoalveolar in both treatments, mostly by retrusion of maxillary incisors in the skeletally anchored group and lower incisor protrusion in the conventionally anchored group. Overbite Studies 11,18,19 stated that efficacy of overbite reduction was greater in the skeletal anchorage system than conventional system. Studies8,13,15 stated that there was a significant overbite reduction in the conventional system than the skeletal anchorage system due to a combination of insignificant greater relative intrusion of mandibular incisors and less extrusion of maxillary incisors.8 Maxillary first molar Maxillary anteroposterior position molar movements were evaluated by U6-VR,8,14,16 U6Ptv,11 and Ms-OLp.17 Studies8,11,14,16 stated that distal movement of molars was greater in skeletal anchorage systems than conventional system, which can be attributed to the distal vector of force of the appliance. Consequently, distal movement of the maxillary dentition was more apparent in the skeletal anchorage system group due to increased anchorage

of the mandibular dentition by mini-screws; the force constructed by functional appliance was mostly transmitted to the posterior maxillary dentition.8,11,13,14 Conversely, Manni et al.17 (2019) .stated that mesial movement of maxillary molars of 0.8 ±3.1 mm has occurred with skeletal anchorage system, in traditional FFAs, molars usually move distally because of anchorage loss, whereas using a skeletal reinforced anchorage, a mesial movement of 0.8 mm was observed and distal movement of molars of 0.9 ±3.1 mm with conventional system (P>0.05) due to distal vector of force of the appliance. Mandibular molars L6-VR8,14,16 and Mi-OLp17 were the parameters used to measure the anteroposterior position of the mandibular first molar. Three studies8,14,16 stated that mesialization was found to be greater in the conventional system than the skeletal anchorage system but not significant between the two anchorage system (P>0.05). This significant mesialization of mandibular molars with a conventional anchorage system could be explained by the significantly greater mandibular incisor proclination, which in turn created more space for the mandibular molars to tip mesially.14,16 On the other hand, the mesial movement was reduced in the skeletally anchored technique due to increased anchorage of mandibular dentition with mini-screws.8 On the contrary, the study by Manni et al.17 (2019).reported that mesial movement of mandibular molars is greater with the skeletal anchorage system than with the conventional system, which may due to loss of mandibular anchorage during treatment with Herbst appliances which can be prevented by using interradicular miniscrew anchorage. Soft tissue changes i. Upper lip position, ii. Lower lip position, and iii. Nasolabial angle. Upper lip position Lbsup-VRL,8,12,15, Ls-S13 Ls-E11 were the parameters used to evaluate the changes in upper lip position. Studies19 stated that there was a significant retrusion in both systems; this significant retrusion was due to heavy distalizing forces acting on the upper arch and the resultant retrusion of the upper incisors. The two techniques did not differ regarding changes 31

in the upper lip.11,13,15 Lower lip position Lbinf-VRL,8,12,15 Li-S,13 Li-E11 were the parameters used to evaluate the changes in lower lip position. Studies8,11–13,15 stated that there was a significant protrusion of the lower lip in the conventional system than the skeletal anchorage system and this difference was mainly due to changes in the position of the lower incisors, which were directly reflected on soft tissue.11 All the studies reported significant retrusion of the lower lip with skeletally anchored treatment except one study by Celikoglu et al.12 which reported forward movement of the lower lip with skeletal-anchored functional appliances. This contradictory finding might be related to the variance in soft tissue reference lines, treatment start time, soft tissue thickness, and different treatment mechanics. According to Eissa et al. there were no significant changes in the lower lip in both techniques, this might be due to variations in soft tissue reference lines and measurements.13 Nasolabial angle The nasolabial angle was significantly increased in both treatment techniques. This may be attributed to retrusion of the maxillary incisors, allowing the upper lip to move posteriorly.11 Conclusion 1. Both skeletally anchored FFA and conventional orthodontic/orthopedic appliances are equally effective in the stimulation of mandibular growth and inhibition of maxillary growth. 2. Undesirable dentoalveolar effect was minimized with the skeletal anchorage system, especially lower incisor protrusion was minimized. 3. Both interventions resulted in retraction of the upper lip due to heavy distalizing forces acting on the upper arch 4. Protrusion of the lower lip occurred with conventional and retrusion with Skeletally anchored. References

1. Proffit WR, Fields HW, Moray LJ. Prevalence of malocclusion and orthodontic treatment need in the United States: estimates from the NHANES III survey. Int J Adult Orthodon Orthognath Surg. 1998;13(2):97–106.

4. Bilgiç F, Başaran G, Hamamci O. Comparison of Forsus FRD EZ and Andresen activator in the treatment of class II, division 1 malocclusions. Clin Oral Investig. 2015 Mar;19(2):445–51. 5. Hanks SD. Trying to get out of the 20th century: a partial translation of Emil Herbst’s 1910 text. World J Orthod. 2000 Fall;1(1):9-16. 6. Pancherz H. Treatment of class II malocclusions by jumping the bite with the Herbst appliance. A cephalometric investigation. Am J Orthod. 1979 Oct;76(4):423–42. 7. Luzi C, Luzi V, Melsen B. Mini-implants and the efficiency of Herbst treatment: a preliminary study. Prog Orthod. 2013 Jul 31;14:21. 8. Aslan BI, Kucukkaraca E, Turkoz C, Dincer M. Treatment effects of the Forsus Fatigue Resistant Device used with miniscrew anchorage. Angle Orthod. 2014 Jan;84(1):76–87. 9. Upadhyay M, Yadav S, Nagaraj K, Nanda R. Dentoskeletal and soft tissue effects of mini-implants in Class II division 1 patients. Angle Orthod. 2009 Mar;79(2):240–7. 10. Manni A, Mutinelli S, Pasini M, Mazzotta L, Cozzani M. Herbst appliance anchored to miniscrews with 2 types of ligation: Effectiveness in skeletal Class II treatment. Am J Orthod Dentofac Orthop. 2016 Jun;149(6):871– 80. 11. Eissa O, El-Shennawy M, Gaballah S, El-Meehy G, El Bialy T. Treatment outcomes of Class II malocclusion cases treated with miniscrew-anchored Forsus Fatigue Resistant Device: A randomized controlled trial. Angle Orthod. 2017 Nov;87(6):824–33. 12. Celikoglu M, Buyuk SK, Ekizer A, Unal T. Treatment effects of skeletally anchored Forsus FRD EZ and Herbst appliances: A retrospective clinical study. Angle Orthod. 2016 Mar;86(2):306–14. 13. Turkkahraman H, Eliacik SK, Findik Y. Effects of miniplate anchored and conventional Forsus Fatigue Resistant Devices in the treatment of Class II malocclusion. Angle Orthod. 2016 Nov;86(6):1026–32. 14. Elkordy SA, Abouelezz AM, Fayed MMS, Attia KH, Ishaq RAR, Mostafa YA. Three-dimensional effects of the mini-implant-anchored Forsus Fatigue Resistant Device: A randomized controlled trial. Angle Orthod. 2016 Mar;86(2):292–305. 15. Ozbilek S, Gungor AY, Celik S. Effects of skeletally anchored Class II elastics: A pilot study and new approach for treating Class II malocclusion. Angle Orthod. 2017 Jul;87(4):505–12. 16. Elkordy SA, Abouelezz AM, Fayed MMS, Aboulfotouh MH, Mostafa YA. Evaluation of the miniplate-anchored Forsus Fatigue Resistant Device in skeletal Class II growing subjects: A randomized controlled trial. Angle Orthod. 2019;89(3):391–403. 17. Manni A, Migliorati M, Calzolari C, Silvestrini-Biavati A. Herbst appliance anchored to miniscrews in the upper and lower arches vs standard Herbst: A pilot study. Am J Orthod Dentofac Orthop 2019 Nov;156(5):617–25. 18. Gandedkar NH, Shrikantaiah S, Patil AK, Baseer MA, Chng CK, Ganeshkar SV, Kambalyal P. Influence of conventional and skeletal anchorage system supported fixed functional appliance on maxillomandibular complex and temporomandibular joint: A preliminary comparative cone beam computed tomography study. Int Orthod. 2019 Jun;17(2):256-268. 19. Cacciatore G, Alvetro L, Defraia E, Ghislanzoni LTH, Franchi L. Active-treatment effects of the Forsus fatigue resistant device during comprehensive Class II correction in growing patients. Korean J Orthod. 2014 May;44(3):136–42.

2. Alarashi M, Franchi L, Marinelli A, Defraia E. Morphometric analysis of the transverse dentoskeletal features of class II malocclusion in the mixed dentition. Angle Orthod. 2003 Feb;73(1):21–5. 3. McNamara JA. Components of class II malocclusion in children 8-10 years of age. Angle Orthod. 1981 Jul;51(3):177–202.

Practice Management

Avoid This Common New Year Planning Mistake by Scott J Manning, MBA We talk here about beginning with the end in mind and I will tell you I don’t think enough Doctors take it literally enough. While it is a perfect time of year to be reflective and future focused at the very same time, beginning with the end in mind is something that should happen every single day. I gave one of the most vivid descriptions of what makes one Doctor successful and another Doctor struggling to break through in last week’s Report. If you studied it carefully, I broke it down in both the tangible and intangible, that was attitude and behavior – how you think and what you do. When both are in complete alignment with a clearly defined plan to achieve your goals, you are on your way to realizing your potential while experience a lifestyle balance. The alternative, of course, is misalignment. In particular, an inadequate (or completely absent) plan that just doesn’t add up no matter how hard you try. This is the biggest problem for doctors who get stuck in the cycle of working harder and harder but getting less and less. They end up burnt out from the grind and lack any resemblance of balance in their personal lives. The fact is you can have a great attitude, be a nice person, even “do the work” and still come up short, wondering why it’s so hard or not as rewarding as you’d hoped. That’s actually very common. In fact, that is the norm. Anything else is the exception and yet doctors try to fix it with what they know… more of the same. This is because they get stuck going through the motions, caught in the cycle of the month, chasing their overhead, and trapped in the routine. It can be hard to look up from that.

But not for you, because you see the bigger picture. That bigger picture is where beginning with the end in mind is at. Here’s the most interesting part, back to the story of those two doctors, so similar in every way yet so different in their dramatically different results, lifestyle, peace of mind, financial independence, and personal fulfillment, it is because every doctor has their own vision of success. For 2024, some see their “end” as actually a transition plan to prepare their practice for sale. For others it is exactly the opposite. Then there are doctors that are wanting the practice to be less dependent on them or others who are really excited about bringing in a new procedure or getting more comprehensive cases. So many different paths for so many different doctors. The real question is what do you want to be different with your business next year than it was this year. Wait, don’t answer that yet. Because, the only way you can honestly answer it is by first clearly seeing your “end in mind” and then working backwards to make sure that every thought, every action, and every decision in regards to your schedule, team, patients, prices, insurance, treatment planning, and every thing else – is leading you deliberately towards your goals. Allow me to be more blunt… When I first ask you to tell me your goals for next year, I am very certain you will have some but I also know one of the very first places your mind goes is to your practice. And I get it because that is what serves as the vehicle in your life that takes you everywhere you want to go. 33

This only way you can honestly answer it is by first clearly seeing your “end in mind” and then working backwards to make sure that every thought, every action, and every decision in regards to your schedule, team, patients, prices, insurance, treatment planning, and every thing else – is leading you deliberately towards your goals.

Here is where you should start focusing… on yourself, your life, your family – defining what is on the life list before you define what is on the practice list. It has to go in that order. If it doesn’t, you know exactly what happens, because it happens to the majority of doctors and it happened to the doctor on the losing end of the story I told from the past two weeks. What happens is there is less room left on the life list when the practice goes first. When you begin with the end in mind of your life experience – everything from daily routine to checking off your bucket list – you then will have all the motivation and energy to make the practice deliver. Now we can do my reverse engineering principles not just in theory but in actuality and we can define down to the dollar what your practice profit must be to deliver on your income, savings, wealth building, debt reduction, and everything else. We can calibrate it to the hour, the day, the team member, the operatory, and (I know some people get weak in the knees when I say it – but yes) even to the patient. Though that is NOT the point or the purpose and we never look at the patients as anything but true and genuine relationships. However, unless you want to run a 24 hour convenience store and pack them in like sardines, you need a math and money formula that adds up properly for your profit which means that it has to be filled up with patients that will equate to, invest in, and desire the dentistry. To me, that’s fun stuff. It might be overwhelming to you, it might be uninteresting to you, none the less, if you want to have a purposeful AND profitable practice then you have to make smart decisions about it. Do you know how much profit most doctors get out of their practice? Aside from the most accurate answer which is – NOT MUCH. Especially if you factor in a salary paid to the doctor doing the dentistry. Even if that is you, you can live off of it but you can’t get rich on it. You can’t become financially independence and “work by choice” without the profit piece. Most doctors get ‘what’s left’ and then figure out what to do with it. That’s their profit and therefore every decision in their life is reactive in “if there’s enough money.”

That’s no way to live, no way to practice, and no way to run a business. That is certainly the fastest way to lead to a loss of motivation and an attitude just waiting for the weekend or the vacation or the holidays or the end of the year. You deserve better. And next week I will breakdown exactly the “begin with the end in mind” decisions that should be made about your practice and all the components of it when you compare this year to next year and you decide to create the future you want instead of just what happens. Your challenge today is: put yourself first – focus on life outside the practice and set your personal goals to orchestrate the perfect year (that story we talked about you writing last week). Then reverse engineer that into determining how your practice fits into that puzzle. This is a worthy objective rather than just trying to arbitrarily “grow” your practice or make changes for the sake of changes or even worse just waking up next year and walking into more of the same being frustrated with the results (or lack thereof). Instead, doctors like you who are here reading this looking for an edge get to choose to make the most of your new year. Use it to your advantage by having clarity about your goals and beginning with the end in mind. That begets the question… What will you make of this year or what will this year make of you? 34

Featured*

A Modified Fixed Twin Block by Dr. Varun Gupta and Dr. Gyan P Singh, King George’s Medical University, Lucknow, Uttar Pradesh, India

Resident, Department of Orthodontics and Dentofacial Orthopaedics, Faculty of Dental Sciences, King George’s Medical University, Lucknow, Uttar Pradesh, India

Gyan P. Singh Professor, Department of Orthodontics and Dentofacial Orthopaedics, Faculty of Dental Sciences, King George’s Medical University, Lucknow, Uttar Pradesh, India

Dr. Varun Gupta

Dr. Gyan P. Singh

Abstract The conventional Twin Block appliance was modified for growth modification and correction of malocclusion in the growing skeletal Class II patients with non-compliant behaviour. The modifications can be easily managed by the clinician at the same time being comfortable for the patient. This modified appliance was fabricated for a skeletal Class II patient and it delivered favourable results in short period of time, proving its efficiency and scope for further use. Introduction Functional appliances are used to treat skeletal Class II problems by redirecting mandibular growth into a more favourable direction; improving aesthetics and functions in growing individuals. The removable functional appliances, relying heavily on patient’s cooperation, evidence stating up to 49% of noncompliance rates.1 Fixed functional appliances come with their own limitations namely expensive armamentarium, difficulty in fabrication and adaptation, frequent breakage, tissue irritation, etc. If somehow dependence on the patient’s cooperation can be reduced, achieve Class II correction will be achieved without unwanted lengthening of the functional phase. Keeping this in mind, we designed a functional appliance which is a modification of Twin Block appliance that enables us to fix it on the maxillary and mandibular arches without hampering the basic mechanism of Twin block appliance, i.e., the occlusal inclined plane. The mechanism of action of the Twin block appliance is very similar to the natural dentition. The upper and lower bite-blocks effectively alter the occlusal inclined plane to induce favourably directed occlusal forces by causing a functional mandibular displacement.2 Appliance Design The appliance consists of upper and lower blocks. The inclines were kept at 70°, mesial to mandibular first molar to allow its eruption. Wire framework of maxillary arch consist of bands on

Dr. Saksham Madhok

*This article has been peer reviewed

in a similar fashion as upper appliance were made (B). Also eyelets made up of the SS wire were soldered on the disto-buccal aspect of the second premolar band (C, E). Curing of the appliance was done in a usual manner with the 70° of the occlusal inclined plane. Appliance delivery: The appliance was finished, polished, and cemented using Glass Ionomer cement on maxillary and mandibular arches of a patient with Class II molar relation bilaterally (G), skeletal Class II base (ANB = 8°, Wits = +3 , App-Bpp = 9 mm) with average growth pattern (FMA= 22°) and just prior to pubertal growth spurt (CVMI-3). Lingual buttons were bonded on the buccal surface of the mandibular first molar for tying the lower appliance through the eyelet using ligature wire 0.009” SS, to enhance the anchorage value to reduce the inevitable flaring of the lower incisors (F). The above mechanics can be discontinued to free the mandibular molars to facilitate their eruption as per clinical need. The maxillary block was trimmed using an air-rotor headpiece with carbide bur on subsequent visits to allow mandibular molars to erupt (H). Appliance is designed in such a manner that full advantage of all functional forces applied to the dentition including the forces of mastication can be utilized. The patient was instructed to brush twice daily with fluoridated toothpaste and a fine-tip interproximal brush was given to maintain adequate oral hygiene around the expansion screw and lingual

maxillary first molar with the 0.36” SS wire soldered on the palatal aspect of the band which will be used to unite the component of the both sides and to enhance the retention of the cold cure acrylic material. Additionally, four strands of 0.010” ligature wire were spiralled and adapted on the central fossa of the maxillary first molar and second premolar, distal end of which was soldered to molar band, this spiral ligature will trap the acrylic within it and will provide more retention to the appliance (A). Pin-head clasps made of 0.032” SS were added between canine and first premolar to resist the lifting of the appliance during the expansion (D). An expansion screw (Standard screw for upper - 14 mm, Leone, Italy) was incorporated using cold-cure resin between the region of first and second premolars, the direction of the activation of the screw was kept opposite to that of the regular removable expansion appliance, to facilitate the activation of the screw inside the oral cavity (F). Wire framework of mandibular arch contains bands on second premolars, a lingual holding arch of 0.036” stainless steel soldered to improve the anchorage and gain skeletal advancement. Occlusal extensions of the same wire with ligature wire wound

Fig.A: Wire framework for maxillary arch; occlusal view Fig. B: Wire framework for mandibular arch; occlusal view Figure G – Intraoral buccal view; Pre- Class II molar relation both sides

Fig. C: Wire framework for mandibular arch; lateral view Fig.D: Maxillary block with expansion screw and pinhead clasps

Figure H – Intraoral buccal view showing occlusal reduction of maxillary block, not more than 0.5 mm, to allow mandibular molar eruption

Figure I – Intraoral buccal view showing occlusal reduction of maxillary block, not more than 0.5 mm, to allow mandibular molar eruption

Fig.E: Mandibular block with eyelets and lingual arch Fig F: Intraoral photos with appliance cemented

arch. Keeping in mind the fixed nature of the appliance, Betadine gargle was also recommended to be used throughout the functional phase of the treatment. Advantages: Major advantages of this modified Twin Block appliance includes that being fixed in nature; it reduces the need for patient compliance, provide the required nature of the orthodontic/ orthopaedic fore in continuous manner for full expression of the growth as per objective of the treatment plan. Thus, improving the profile of the patient (J) also can be assessed in Lateral cephalogram (K). Superimposition at SN clearly shows that the sagittal correction has been achieved from the contribution of skeletal changes in the mandible (L) rather than the dentoalveolar effect by most fixed functional appliances.

Figure J – Profile view; Pre (left) and Post (right), following appliance removal after 7 months

Figure K – Lateral cephalogram; Pre (left) and Post (right); 7 months following placement of modified twin block

Figure L – Superimposition at SN; (black – pre, blue – stage)

References

1. Caldwell S, Cook P. Predicting the outcome of twin block functional appliance treatment: A prospective study. Eur J Orthod 1999; 21:533-539 2. Clark WJ. The twin block technique: A functional orthopaedic appliance system. Am J Orthod Dentofac Orthop 1988; 93(1):1-18