NTO13 1 封面

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1 NEWS & TRENDS IN ORTHODONTICS Jan. 1 Vol A new method of placing Orthodontic Bone Screws in IZC Dr. John Lin Nonsurgical and Nonextraction Treatment of a Skeletal Class III Adult Case Dr. Etsuko Kondo The Secrets of Excellent Finishing Tips from Dr. Tom Pitts Dr. Tom Pitts presented the secrets of excellent finishing in Taipei on Nov. 15, News & Trends in Orthodontics is an experience sharing magazine for worldwide orthodontists. Download it at

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3 EDITORIAL NTO Editorial LIVE FROM THE MASTER 04 A New Method of Placing Orthodontic Bone Screws in IZC 08 Nonsurgical and Nonextraction Treatment of a Skeletal Class III Adult Case FEATURE 14 Dr. Tom Pitts Secrets of Excellent Finishing Change is all we need Last month, I received an from Dr. Tom Pitts. He shared with me his excitement of converting to Apple. He wrote, It will be a learning curve and take some time, but life is a journey. Dr. Tom Pitts, a 68-year-old orthodontic master, is willing to make a complete switch from PowerPoint to Keynote in his digital presentation. Such a change takes not only time, but most importantly, courage. We all have heard about those life-turning changes people make in their lives. When we try to follow these examples and aren t quickly rewarded, we might end up feeling worse. The problem, of course, is not that change is impossible, but that it does not come easily. It takes years for the most important change to be made. In this issue we will feature Dr. Pitts lecture in Taiwan in November. Dr. Pitts approach to the Damon system is quite different from the way you may have known. This may not seem easy to follow, especially the way he positions the brackets. However, it has proven to be one of the best quality and most efficient. Major changes in life will not be finished in one day, but it can certainly start today. If a-68-year-old master has the courage to make such changes in the digital field, why should I have second thoughts in doing so in my orthodontic practice? NEWLY RELEASED 23 OrthoBoneScrew PERSPECTIVES 24 The ABO Discrepancy Index: A Measure of Case Complexity 28 American Board of Orthodontics: Objective Grading System for Dental Casts and Panoramic Radiographs ( Part I ) CASE REPORT 32 Early Treatment of Multiple Missing Teeth CLINICAL PEARL 34 Apically Positioned Flap in Exposing an Impacted Maxillary Central Incisor 36 Dental Morphological Relation to the Bonding Position VOICES FROM THE ORTHODONTIC WORLD 38 Motto in Orthodontics UNSOLVED MYSTERY 40 Ankylosed Upper Posterior Teeth Chris Hwai-Nan Chang, DDS, PhD, Publisher Consultant Dr. Eugene W. Roberts 03 Contributors (from left to right) : Dr. Hong Po Chang, Consultant Dr. Ming Guey Tseng, Consultant Dr. John JJ Lin, Consultant Dr.Johnny JL Liao, Consultant, Dr. Chris HN Chang, Publisher, Editors (from left to right) : Yi Yang Su, Chih Yuan Wu, Hao Yi Hsiao, Michel Ho, Tom Pitts, Chris HN Chang, Yu Lin Hsu, Chuan Wei Su, Chiung Hua Huang, Ksiao Long Wang, Shu Fen Kao, Yu Lung Lee, Chien Kang Chen, Shou Xin Kuang Guest Editor Dr. Rungsi Thavarungkul From left to right Yu Lin Hsu, Associate Editor Chih Yuan Wu, Chief Editor Tzu Han Huang, Associate Editor Shang Chen Chiu, Associate Editor Please send your articles to [email protected]

4 NTO 13 LIVE FROM THE MASTER A New Method of Placing Orthodontic Bone Screws in IZC 04 The infrazygomatic crest (IZC) is an ideal site in the maxilla to p l a c e o r t h o d o n t i c miniscrews. Fig.1 IZC is an area of cortical bone at the zygomatic process of the maxilla. It is a palpable bony ridge running along the curvature between the alveolar and zygomatic processes of the maxilla. In younger patients, it is located between the maxillary second premolar and first molar, whereas it is above the maxillary first molar in adults. Liou s computed tomographic study ( reference 1 ) of the IZC placement of screw over the mesiobuccal root of the upper first molars suggested that insertion of orthodontic bone screws in the IZC for adults should be at the 14 to 26 mm above the maxillary occlusal plane and the maxillary first molar, and at an angle of 55 0 to 70 0 to the maxillary occlusal plane. ( Fig.1 ) The author followed the referenced guide line and used a 2 mm x12 mm stainless steel orthodontic bone screw. At first the orthodontic bone screw was inserted perpendicular to the bone surface to about 1 to 1.5 mm deep over the mucogingival junction around mesiobuccal root of the upper first molar. Then the author changed the orthodontic bone screw s direction at an angle of 55 0 to 70 0 to the maxillary occlusal plane before drilling the orthodontic bone screw into the IZC bone region. The strength and sharpness of the stainless steel orthodontic bone screw requires neither incision nor tissue punch. Self-drilling is sufficient. ( Fig.2 ) Clinically the author observes the IZC bone over the mesiobuccal root of upper first molars is quite thin in many cases. Recently cone beam CT images have shown that the buccal bone over the mesiobuccal root area of the upper second molar is much thicker than the buccal bone over the mesiobuccal root area of the upper first molars. Both a patient s CT ( Fig.3 ) and a dry skull with part of the sinus wall removed ( Fig.4 ) can confirm such a finding. The cone beam CT images study ( reference 2 ) of Chen also provided a favorable proof. So nowadays the author prefers to place orthodontic bone screws in the IZC area over the mesiobuccal root area of upper second molar, instead of first molar. From a clinical case ( Fig.5 ) we can see a 2mm x12mm stainless steel orthodontic bone screw was placed over IZC above the mesiobuccal root of upper second molar. The PA cephalometrics showed the orthodontic bone screw was away from the root. From the panoramic radiograph it revealed the orthodontic bone screw was over the mesiobuccal root of upper second molar. The cone beam CT image suggested a 2mm x 12mm orthodontic bone screw made a good bicortical engagement. The tip of a orthodontic bone screw just penetrated about 1mm into the sinus. ( Fig.5 ) This is a case ( Fig.6 ) that a 2mm x 10mm orthodontic bone screw was placed over the right upper edentulous area. After placing the IZC orthodontic bone screw, the patient complained about sinusitis on the right side and was diagnosed by an ENT doctor. The author suspected it was caused by the insertion of the screw. For a more thorough No incision No tissue punch No pre-drilling Self-drilling Fig.2

5 LIVE FROM THE MASTER NTO 13 Dr. John Jin-Jong Lin MS, Marquette University Consultant of NTO President of TAO ( 2000~2002 ) Author of Creative Orthodontics diagnosis, the author sent the patient to have a cone beam CT taken. The result showed the short 2mm x 10 mm orthodontic bone screw provided only mono cortical engagement, without touching the sinus wall at all. When tracing back the patient s past history, it turned out she has suffered chronic sinusitis. The latest sinusitis occurred simply coincided with the IZC placement of the orthodontic bone screw. From the panoramic view of the cone beam CT it clearly showed radiopaque shadow on the lower part of the sinus. ( Fig.6 ) Regarding soft tissue, the author try to limit the placement of the IZC orthodontic bone screw only over attached gingiva zone. On Fig.7, the zone of attached gingiva is quite narrow on the right buccal size of the case C. After placing the orthodontic bone screw, the head would almost touch the buccal tube which m a d e i t i m p o s s i b l e t o distalize the whole upper dentition. The case A, B and the left buccal of the case C all have enough attached gingiva for the IZC placement of the orthodontic bone screw. Fig.4 The upper case of Fig.8, a 16-year-and-3-month-old female came for treatment. Her soft tissue had enough attached gingiva, but the orthodontic bone screw became loose and failed in one week. The cone beam CT found out the sinus floor was very low. Even though it s a bicortical engagement, the engagement was only about 2~3mm on the solid bone wall. No wonder it failed. ( upper Fig.8 ) The lower case of Fig.8 was a 29-year-2-month-old male patient. A similar case of the same IZC orthodontic bone screw with only around 2~3mm bicortical engagement. However, the orthodontic bone screw stayed in place for more than 6 months and distalized the whole upper arch. When comparing the two cases ( Fig.8 ), it clearly showed that a bicortical engagement only needs 2~3mm on a mature adult bone. However, if the patient was young and the bone was not mature, then it d be easily result in failure. These two cases also demonstrated that the perforation of sinus wall happened quite often. However, as long as the aseptic procedure was performed during screw placement, one should not worry about sinus perforation by the orthodontic bone screw. We can observe similar successful results from miniplate fixation of the sinus wall on Le Fort I cases on the orthognathic surgery patients. 05 2mm x 12mm bicortical engagement Fig.3 Fig.5

6 NTO 13 LIVE FROM THE MASTER 06 Even though we can place IZC orthodontic bone screw over mucosa easily, but it is usually not ideal in the long run. In this case ( Fig.9 ) the orthodontic bone screw was placed over mucosa region. Two months later, soft tissue piled up due to the movable mucosa around the screw head. As time went on the screw head became totally embedded in the soft tissue and caused severe cellulitis. Sugawara s study ( reference 3 ) the distalization of the whole upper arch showed the distal movement of the crown by 3.78mm and the root by 3.2mm with the use of min-plate system. Liaw s study ( reference 4 ) on the whole upper arch distalization revealed the distal movement of the crown by 2.8mm and the root by 1.4mm with the IZC placement of the orthodontic bone screws. Even though the amount of distalization seems less in the orthodontic bone screw group, clinically it is a very useful adjunct ( see reference ) The mini-plates are not only more expensive but also involve quite a comprehensive surgery. Patients have to suffer from severe pain, swelling and a removal surgery afterwards. Comparing to mini-plate, the orthodontic bone screw is a very simple procedure. Orthodontists don t have to refer to other specialists to perform this easy and economical procedure. In conclusion the new IZC placement (over mesiobuccal root of upper second molars) is a very useful clinical adjunct. Fig.6 7 Summary of the new IZC placement: It s outside of the root area. Unlike inter-radicular placement, the size has to be limited to 1.2mm~1.5mm. Instead using a 2mmx12mm stainless orthodontic bone screw for bicortical engagement avoids root damage and caused almost no fracture to the screw. It can be as an excellent anchorage unit as inter-radicular placement of orthodontic bone screws. It s much better than inter-radicular placement of orthodontic bone screw for distalization of the whole upper arch. The 2mx12mm stainless steel orthodontic bone screw requires neither incision nor tissue punch. Self-drilling is sufficient. IZC placement over mesiobuccal root area of upper second molar is better than over that of the upper first molars. Better be placed over the attached gingiva area. Contra indicated for patients of a very young age and with low sinus floor among the roots of maxillary molars. Using about 10~12oz (or gm ) to distalize the whole upper arch. An excessive force will result in failure!

7 LIVE FROM THE MASTER NTO 13 Fig.8 Fig.9 References: Liou EJ, Chen PH, Wang YC, Lin JC. A computed tomographic image study on the thickness of the infrazygomatic crest of the maxilla and its clinical implications for mini-screw insertion. Am J Orthod Dentofacial Orthop 2007; 131:352-6 Chen PJ, Kuang SH, Lin JJ and Wong YK. Bone thickness of the infrazygomatic crest for orthodontic implant placement. Poster, Annual Meeting of Taiwan Association of Orthodontists, 2008 Sugawara J et al. Distal movement of maxillary molars in nongrowing patients with the skeletal anchorage system. Am J Orthod Dentofacial Orthop 2006; 129: Liaw YC, Lin JJ and Kuang SH. Whole arch distalization with TAD system. Poster, Annual Meeting of Taiwan Association of Orthodontists, 2008 Lin JJ. Mini-screw or Mini-plate, which is better for whole upper arch distalization. News and Trends in Orthodontics Vol. 5, P1-2, 2007 Lin JJ. The limitation of whole upper arch distalization. News and Trends in Orthodontics. Vol. 8, P.1, 2007 Lin JJ. 2mm Bone screw vs. MIA, extra-radicular placement vs. intra-radicular placement. News and Trends in Orthodontics. Vol. 9, P.1-5, 2008 Lin JJ. Non-extraction, Non-surgery Treatment of Class II open bite with long face syndrome case. News and Trends in Orthodontics. Vol. 12, P.4-5, 2008 Lin JJ. Creative Orthodontics: Blending the Damon System & TADs to manage difficult malocclusions. Taipei: Yong Chieh Ltd, Poggio PM, Incorvatic, Velo S, Carano A. Safe Zones : A Guide for Miniscrew Positioning in the maxillary and Mandibular Arch. Angle Orthod 2006;76:

8 NTO 13 LIVE FROM THE MASTER Nonsurgical and Nonextraction Treatment of a Skeletal Class III Adult Case 08 The patient A 19-year-old Japanese female came in our clinic for consultation. Her chief complaints included anterior cross bite, speech and chewing dysfunction, dished-in face and TMJ symptoms. She appeared in good health with no contributory medical history. The patient has hereditary Class III malocclusion from her mother. She presented a long-lower facial height and a concave profile. Her upper lip appeared short and tight with flattened lower lip. Diagnosis The cephalometric analysis indicated this was a case of skeletal Class III malocclusion. The maxilla was retruded (SNA; 76.0, MEAN; 81.5 ±3.1 ). The mandibule was in an average position (SNB; 78.0, MEAN; 78.2 ±3.1 ). The patient also had a narrow maxillary dento alveolar arch, causing occlusal interference in the posterior area. The intra-oral examination revealed that the tongue was unable to lift up to reach the palate. She also had habitual anterior placement of the tongue with mouth breathing. The mandibular posterior teeth were mesiolingual tiilted, creating an excessive posterior vertical occlusal dimension (ANS-PNS to GoGn; 30.0, MEAN; 26.3 ±6.3 ) and mandibular rotated open (SN to GoGn; 43.0, MEAN; 34.5 ±6.1 ). According to these findings, this skeletal class III malocclusion combined with TMD symptoms had been aggravated by functional and environment factors as well as growth, development and genetic factors. Therefore, the form and function of the joint may be adversely affected in skeletal class III malocclusion by the structural and functional asymmetry. Treatment Plan A treatment plan was made to treat this malocclusion only orthodontically with Damon 3 brackets and reshaping of the maxillary and mandibular dento-alveolar arches. The expansion of maxillary arch was assisted by use of removal palatal expansion plate. The reshaping technique aimed to restore harmony and function of the tongue, perioral, and chewing muscles. Such procedure could also reestablish the proper functions of nose ç Fig 1. Pre-treatment ( 19Y8M )

9 LIVE FROM THE MASTER NTO 13 breathing without extraction or surgical intervention. The total active treatment time was 14 months. Begg type and tooth positioner was adopted for retention. Appliances used included the followings : Damon 3 brackets, removal maxillary expansion plate, lift up tongue training with chewing gum. Discussion and Summary This case was skeletal class III malocclusion with complicated maxillary and mandibular dento-alveolar arch form disharmony, abnormal tongue behavior, mouth breathing and TMD. This case, which was originally classified as a surgical case by other orthodontists, was successfully treated solely orthodontically by uprighting and intruding mandibular posterior teeth to reconstruct the functional occlusal plane. As a result, this case was treated without pushing the patient to receive extractions or surgical therapy. These revealed that the key factors of occlusal improvement were creating a favorable environment, reshaping the dento-alveolar arches and creating adequate tongue space to open the air way and to establish nasal respiration with effortless lip closure. Therefore, functional recovery that restored the harmony of the tongue, perioral chewing muscle activities and the creation of normal nasal breathing are the best way in achieving successful treatment during short active treatment time. Especially for the skeletal class III malocclusion cases, a low friction brackets with light force wire is necessary to stimulate the functional recovery. Light force and low friction system cannot offer optimal torque expression for all teeth. If such appliance is used to correct the malocclusion, we need additional force to create torque. Therefore, the best way to achieve functional recovery during treatment is by using light force and low friction brackets. The light force and low friction system needs additional forces generated by tongue, perioral, masticatory and neck muscle functions. Thus, the normal nasal respiration and normal swallowing pattern can be achieved with the lip closed effortlessly. 09 Fig 1. Post-treatment ( 20Y11M )

10 NTO 13 LIVE FROM THE MASTER Pre-treatment ( 19Y8M ) Start of treatment ( 19Y9M ) months into active treatment ( 20Y5M ) months into active treatment ( 20Y7M ) Post-treatment ( 20Y11M ) Active treatment time : 14 months Fig.2: Intra-oral photographs from pre-treatment to post-treatment

11 LIVE FROM THE MASTER NTO 13 Class III molar and canine relationship with 0 mm overjet and overbite. The tongue was unable to be positioned up to the Mx. dento-alveolar arch. The patient also showed habitual anterior placement of the tongue and mouth breathing. These created a narrow Mx. arch with posterior cross bite, causing interferences in the posterior area and TMD. Active treatment was started with Damon 3 brackets and removable Mx. expansion plate, in conjunction with short class III and canine triangle elastics. Uprighted & Intruded The Max. dento-alveolar arch has been reshaped to eliminate occlusal interferences in the posterior area and TMD symptoms. The Max. posterior teeth were uprighted and intruded with distalizzation of the Mand. arch. Short class III and canine triangle elastics also made part of the contributions. As a result, antero-posterior occlusal disharmony was almost corrected in only 8 months. O.J. and O.B. became 1.0mm respectively. The tongue achieved a normal posture and nasal breathing was established. After starting MFT with lift up tongue training, a lower lingual frenectomy was performed. Then, the Max. expansion plate was removed and lift up tongue training continued. Plate removed & Gum training start The patient was instructed to put the tongue within the Max. arch and to bite anything as hard as possible. Antero- posterior and vertical skeletal occlusal disharmonies were almost corrected to Class I canine and molar relationships with 1.5 mm O.J. and 2.0 mm O.B.. Furthermore, adequate tongue space with favorable incisor inclination accompanied an improvement in speech dysfunction were also achieved months after treatment started, all elastics were discontinued for the final two months. Another 3 weeks later, since the tongue and other peperioral muscles seemed to be adapted to the new enenvironment, the Max. appliance has been removed. 14 months after treatment started, a stable occlusion with class I canine and molar relation with matched midline, normal O.J. and O.B. ( 1.5 and 2.0 mm respectively ) were achieved. There were no recurrent TMD symptoms and jaw movement appeared smoothly without any interferences. The Max. appliance was removed. Active treatment time was 14 months.

12 NTO 13 LIVE FROM THE MASTER Fig.3-A: CT image at pre-treatment and post-treatment Axial TCT image at post-treatment revealed all teeth held within the cancellous bone of the alveoli, by balanced tongue pressure and the perioral and masticatory muscles. The alignment was satisfactory and the arch fits the shape of a relaxed tongue. Pre-treatment ( 19Y8M ) Post-treatment ( 20Y11M ) Fig.3-B-1: CT image at pre-treatment and post-treatment Sagittal CT image at post-treatment revealed the tongue was able to be positioned within the maxillary arch, and the air way was opened, establishing nose breathing with the lips close effortlessly. As a result, favorable interincisal angle, beautiful lip and neck profile were achieved. Pre-treatment ( 19Y8M ) Post-treatment ( 20Y11M ) Pre-treatment ( 19Y8M) Post-treatment ( 20Y11M) Fig.3-B2: 3D image at pre-treatment and post-treatment Lateral 3D image at post-treatment revealed a stable occlusion established with posterior support. The long axes of maxillary and mandibular posterior teeth being perpendicular to the functional occlusal plane. Fig.3-C: 3D image at pre-treatment and post-treatment Lateral 3D image at post-treatment revealed a stable occlusion established 12 with posterior support that the long axes of maxillary and mandibular posterior teeth were perpendicular to the functional occlusal plane. The Key ridge (normal line at inferior apex of the zygomatic arch) goes through the bifurcation point of the mesiobuccal and distobuccal root of the maxillary first molar. Pre-treatment ( 19Y8M ) Post-treatment ( 20Y11M ) Fig.4: 3D image frontal at post-treatment revealed that Right-sided deviation of the mandible was improved with a matched midline in occlusion. Pre-treatment ( 19Y8M ) Post-treatment ( 20Y11M )

13 LIVE FROM THE MASTER NTO 13 Fig.5: Curved MPR CT image at post-treatment revealed both condyles were in comparable position within the articular fossae, indicating that normal function had been attained after treatment. Pre-treatment ( 19Y8M ) Post-treatment ( 20Y11M ) Fig.6 : Functional findings: Comparison of electromyogram (EMG) record from pre-treatment to post-treatment Post-treatment EMG record revealed that both the Masticatory muscles (MM) and Temporal muscles (TM) achieved favorable bilateral balance after active treatment. Pre-treatment ( 19Y8M ) Post-treatment ( 20Y11M ) Pre-treatment Post-treatment The functional occlusal plane moved down 17 posteriorly during treatment by uprighting and intruding mandibular posterior teeth. As a result, the long axes of both maxillary and mandibular posterior teeth were corrected to perpendicular to the functional occlusal plane, establishing posterior support with minimal and balanced loading of the TMJs. The upper incisors crown inclined labially, providing proper incisal guidance and freedom of mandibular movement in all direction. As a result, temporomandibular problems were solved during treatment. Superimposition of pre-treatment and post-treatment References 1. Graber TM. Orthodontics. Principles and Practice. Philadelphia: Saunders, 1966: Graber TM, Vanasdall RL, Vig KL. Orthodontics: Current Principles and Techniques (ed 4). St. Louis: Elsevier, Graber TM. Dentofacial Orthopedics with Functional Appliances. St Louis: Mosby; 1997: Kondo E. Nonsurgical nonextraction treatment of skeletal Class III open bite: Its long-term stability. Am J Orthod Dentofacial Orthop 2000;117: Kondo E. Nonsurgical and nonextraction treatment of s skeletal Class III patient with severe prognathic mandible: Long-term stability. World J Orthod 2001;2: Kondo E. Occlusal stability in Class II, division 1, deep bite cases followed up for many years after orthodontic treatment. Am J Orthod Dentofacial Orthop 1998;114: McNamara JA. A method of cephalometric evaluation. Am J Orthod 1984;86: Kondo E. Muscle Wins treatment in Orthotontics-Muscle and Respiration are key factors of orthodontics treatment). Ishiyaku Publishers, INC st ed. 9. Kondo E. Muscle Wins treatment in Orthotontics-Muscle and Respiration are key factors of orthodontics treatment). DaehanNarae Publishers Co., Lin John Jin-Jong, Creative orthodontics Blending the Damon System & TADs to manage difficult malocclusions

14 NTO 13 FEATURE Dr.Tom Pittsʼ Secrets of Excellent Finishing 14 New Esthetic Model Fig. 1 Fig. 2

15 FEATURE NTO 13 Best Esthetics Possible FH Fig Fig. 3 ( Smile line ) ( Smile arc ) Fig. 4

16 NTO 13 FEATURE 16 Arch Development, Proper Torque, and Smile Arc Protection Passive Active Fig. 6 Bracket Placement, Working Arch Wires and Finishing Fig. 7

17 FEATURE NTO Fig. 8

18 NTO 13 FEATURE 18 Early Light Short Elastics

19 FEATURE NTO Fig. 9

20 NTO 13 FEATURE 20 Extraction mechaniccs

21 FEATURE NTO 13 Fig. 10 ~ 21

22 NTO 13 FEATURE 22 Retention References Fig Tom Pitts lecture in Taipei 11/15/ Chang CHN. Beethoven Orthodontic Mobile Learning Program. Advanced Damon Course No. 4: Dr. Pitts secrets of fininshing. 2008; Newton s A Ltd, Taiwan.

23 NEWLY RELEASED NTO 13 The Dream Screw for the Next Generation s Orthodontists OrthoBoneScrew Beethoven Orthodontic Center OrthoBoneScrew (OBS) has a double-crossed rectangular slot on its neck. This x inches rectangular slot provides a versatile use of orthodontic mechanics. A x wire in dimensions can be secured in the slot firmly. Case report of palatal impacted canines: Demonstration of OBS application Yi Yang Su, Chris Hwai-Nan Chang, Beethoven Orthodontic Center X X 0 M 2 M Mechanics Design : A 24-year-and-7-month-old male had one maxillary right impacted canine located on the palatal side. Firstly, we uncovered the impacted canine to allow auto-eruption. Secondly, we extracted the maxillary right 1 st premolar. After the canine erupted, a rotating force system was created by a 3D lever arm stretching out from the right side of OBS, and an elastic chain connecting to the left side of OBS. Once the impacted canine moved within the reach of a wire, a.014 CuNiTi was then placed for further alignment. Finally, the impacted canine was successfully moved into the arch. OrthoBoneScrew Corporate Headquarters Newton s A 2F, No. 25, Jiangung 1 st Rd, Hsinchu, Taiwan 300 Tel: Fax: M 7 M 8 M

24 NTO 13 PERSPECTIVES The ABO Discrepancy Index: A Measure of Case Complexity 1. Overjet Overbite 3. Anterior Open Bite

25 PERSPECTIVES NTO Lateral Open Bite 5. Crowding 6. Occlusion Buccal Posterior Crossbite 8. Lingual Posterior Crossbite

26 NTO 13 PERSPECTIVES S N A B MP 9. ANB angle 10. SN-MP 11. L1-MP 12. Others 26 Reference 1. Thomas J : The ABO Discrepancy Index: A Measure of Case Complexity. Am J Orthod Dentofacial Orthop 2004;125: The American Board of Orthodontics Clinical Examination Guide. Third Edition May May Chang CHN. Beethoven Orthodontic Mobile Learning Program. Advanced Damon Course No. 4: Dr Pitts secrets of finishing. 2008; Newton s A Ltd, Taiwan.

27 PERSPECTIVES NTO 13 DISCREPANCY INDEX WORKSHEET CASE # PATIENT TOTAL D.I. SCORE OVERJET (Rev. 9/22/08) 0 mm. (edge-to-edge) = 1 pt. 1 3 mm. = 0 pts mm. = 2 pts mm. = 3 pts mm. = 4 pts. > 9 mm. = 5 pts. Negative OJ (x-bite) 1 pt. per mm. per tooth = Total = OCCLUSION Class I to end on = 0 pts. End on Class II or III = 2 pts. per side pts. Full Class II or III = 4 pts. per side pts. Beyond Class II or III = 1 pt. per mm. pts. additional Total = LINGUAL POSTERIOR X-BITE 1 pt. per tooth Total = BUCCAL POSTERIOR X-BITE 2 pts. per tooth Total = OVERBITE 0 3 mm. = 0 pts mm. = 2 pts mm. = 3 pts. Impinging (100%) = 5 pts. Total = ANTERIOR OPEN BITE 0 mm. (edge-to-edge), 1 pt. per tooth then 1 pt. per additional full mm. per tooth Total = LATERAL OPEN BITE 2 pts. per mm. per tooth Total = CROWDING (only one arch) 1 3 mm. = 1 pt mm. = 2 pts mm. = 4 pts. > 7 mm. = 7 pts. Total = CEPHALOMETRICS (See Instructions) ANB 6 or -2 = 4 pts. SN-MP 38 = 2 pts. Each degree > 38 x 2 pts. = 26 = 1 pt. Each degree < 26 x 1 pt. = 1 to MP 99 = 1 pt. Each degree > 99 x 1 pt. = OTHER (See Instructions) Total = Supernumerary teeth x 1 pt. = Ankylosis of perm. teeth x 2 pts. = Anomalous morphology x 2 pts. = Impaction (except 3 rd molars) x 2 pts. = Midline discrepancy ( 2 pts. = Missing teeth (except 3 rd molars) x 1 pts. = Missing teeth, congenital x 2 pts. = Spacing (4 or more, per arch) x 2 pts. = Spacing (Mx cent. diastema 2 pts. = Tooth transposition x 2 pts. = Skeletal asymmetry (nonsurgical 3 pts. = Addl. treatment complexities x 2 pts. = Total = 27

28 NTO 13 PERSPECTIVES American Board of Orthodontics Objective Grading System for Dental Casts and Panoramic Radiographs ( Part I ) 28 Introduction and Background Fig. 1

29 PERSPECTIVES NTO 13 Criteria and Rationale Alignment 2. Marginal Ridges 4. Occlusal Relationship 29 Marginal ridge - CEJ - Bone Level Cusp-embrassure within 1mm

30 2. NTO 13 PERSPECTIVES 5. Occlusal Contacts 7. Interproximal Contacts 8. Root Angulation L buccal cusp U palatal cusp Functional Cusps Overjet 30 Parallel to one another & Perpendicular to the OP Functional cusp to fossae Contact to lingual surface Referecnce 1. Casko JF, et al: Objective grading system for dental casts and panoramic radiograph. Am J Orthod Dentofacial Orthop 1998;114: Chang CHN. Beethoven Orthodontic Mobile Learning Program. Advanced Damon Course No. 4: Dr. Pitts secrets of finishing. 2008; Newton s A Ltd, Taiwan.

31 PERSPECTIVES NTO 13 31

32 NTO 13 CASE REPORT Early Treatment of Multiple Missing Teeth ~ Response for Unsolved Mystery 32 A healthy 5 year and 10 month old girl was brought to our clinic for a routine check up. Panoramic X-rays showed a total of 11 missing permanent teeth. The missing teeth were #18,15,14,24,28,38,35,34,44,45,48. In addition, there was an ectopic eruption of her upper right 1 st permanent molar. Her primary dentitions were in solid Class I occlusion and her lower first permanent molars were about to erupt. The lower permanent central incisors were halfway erupting and came in contact with her upper primary central incisor with a lower midline shift 2 mm to the left. The treatment goals were to keep all the permanent teeth in occlusion and to preserve the dental alveolar bone for future implant. Parents were informed the advantages and disadvantages of early treatment, and that their daughter would need at least 3 implants when she reached adulthood. An upper Schwartz appliance with thin occlusal coverage was worn by the patient only at night. Her mother was instructed to turn the expansion screw once a week ( 1 turn = y10m 7y9m 7y9m 7y9m 12y8m 12y8m

33 CASE REPORT NTO 13 14y7m mm ) for upper arch development and to allow the permanent molars and incisors to erupt into a better occlusion. The patient was very cooperative with the treatment. The appliance was active for 8 months and she wore the appliance as a retainer until she lost her upper right primary 2 nd molar. At the age of 7 years and 9 months, her 1 st molars had fully erupted. At this time a new appliance was made to distalize her upper right 1 st molar in order to create the space for a #15 implant in the future. At the age of 10 years and 8 months, a fixed appliance was placed on the upper arch. At the time her mother requested closure of all the upper space so that her daughter would require only two lower implants in the future. The patient had worn the upper fixed appliance for 2 years with multiple no-show appointments. The fixed appliance was removed at the age of 12 years and 8 months. An upper Hawley retainer and a lower 3-3 spring retainer were worn at night only. There was no fixed appliance put on her lower arch. We have since obtained a reasonable occlusion and esthetic result. 33-5y10m - 14y7m

34 NTO 13 CLINICAL PEARL Apically Positioned Flap in Exposing an Impacted Maxillary Central Incisor 34 Excisional Uncovering Closed Eruption Techniques Apically Positioned Flap Fig. 1 Fig. 3 Fig. 2 3D panoramic radiograph

35 CLINICAL PEARL NTO 13 蘇乙洋醫師 ( 左 ) 貝多芬矯正課程講師 新洋牙醫診所 張慧男醫師 中 貝多芬矯正中心負責人 邱上珍醫師 右 貝多芬矯正課程講師 Apically Positioned Flap 的術式設計及討論 1. 首先將門牙區先以 open coil spring 維持住所需的空間 而後如 a b 所示 Fig. 4 在埋伏齒兩側由 apical 往 coronal 方向做兩 條平行切線 此兩平行切線的設計可使之後 flap 往根間向移動 時 避免 flap 兩側出現縫隙 以利傷口癒合 2. 接著在 coronal 方向約等同於相對應牙或鄰接牙的 free gingival magin 處以 internal bevel incision 方式作一水平切線 Fig. 4 c and Fig. 5 如此的設計可以使我們保留最大量的角化牙 Fig. 4 齦 此外 水平切線的兩側要距離 papilla 約 3 mm 避免直接 切到 papilla 造成日後鄰牙可能的牙齦萎縮 3. Fig. 5 由 coronal 方向以 partial thickness 方式逐漸翻開 flap 當接觸到 牙齒時轉為 full thickness flap 露出門牙 直到整個門牙的 CEJ 之上均已暴露出為止 4. 將 button 黏在門牙的 labial side 上 並接上 elastic chain 以利 後續的矯正牽引 Fig 將 flap 往 apical 方向移動 可能的話 將 flap 的水平切線對齊 在 Mucogingival Junction 的位置而後縫合 Fig. 7 ) 6. 由咬合面可以看到暴露出的左上門齒 以及往根間方向移位的 flap Fig 術後請患者以漱口水 chlorhexidine 一天三至四次漱口 並持 35 續回診進行後續的矯正治療 結論 Apically positioned flap 是在處理上顎頰側埋伏齒露出時 很常應用的術式 只要掌握描述的幾個原則 : 1. Mimic the nature growth 模擬牙齒的自然生長的形式 Fig Eruption from mucosa should be avoided 避免牙齒從 mucosa 長出 3. 3 mm away from papilla 不要 cut papilla 切線離 papilla 3 mm 相信您一定可以得心應手的進行相關處理 並達到理想治療效 果 References 1. Hsiao HY. 3D Control of An Ectopic Tooth. News and Trends in Orthodontics 2008;9: Kokich VG. Surgical and Orthodontic Management of Impacted Maxillary Canines. Am J Orthod Dentofacial Orthop 2004; 126: Chang CHN. Beethoven Orthodontic Mobile Learning Program. Advanced Damon Course No. 1: Impacted Tooth. 2008; Newton s A Ltd, Taiwan. Fig. 8 Fig. 7

36 NTO 13 CLINICAL PEARL Dental Morphological Relation to the Bonding Position Do you have problems bonding the upper first premolars? Do you feel its unusual anatomy affects accuracy of the bonding position? Do you need detailing bending frequently at the finishing stage? After this article, we hope you no longer will have problems bonding the upper first premolars. Mesial/Distal angulation on the buccal view of the upper first premolar In most cases, because of the different length of the mesial and distal slopes of the upper first premolars, it gives us the illusion that the tooth is tilting ( Fig. 1 ). Therefore, we should not use mesial or distal buccal slopes as reference to position the bracket. Instead, we should use the marginal ridge ( blue arrow ) as reference. If there is no marginal ridge discrepancy between adjacent teeth, we should position the occlusal part of the bracket base parallel to the marginal ridge ( Fig. 2 ). Mesial/Distal position on the occlusal view of the upper first premolar In the normal alignment of upper premolars, the line between the buccal cusp ridge and the central grove is not anatomically parallel. Because of this character, it is likely for clinicians to put the bracket at a more mesial location ( Fig. 3 ) and cause a break of the alignment of the central grove. Therefore, it is suggested to put the bracket more distally (still on the height of contour) parallel to the central grove ( Fig. 4 ). Vertical position When we consider the vertical position, the first thing we should notice is that there are different cusp lengths over the buccal side from canine to molar. In addition, there is usually some asymmetrical attrition on the adult dentition. Thus, it is unwise to use them as reference. Therefore, we should use the marginal ridge or the contact area in a healthy periodontium as reference (Fig. 5). After determining the proper premolar position, we can use upper first premolars to place the canine bracket and then transfer it to the canine bracket position. The vertical position of the distal contact area should be on the same level of the marginal ridge of the upper first premolars. Fig. 1 Fig. 3 Fig. 2 Fig Conclusion Bonding is the most important step in the pre-adjusted appliance mechanics. Precise bonding can reduce the need for wire bending and the complexity of finishing and detailing. However, there are many morphological characters that affect the bonding position. In this article, we discussed some morphological characters of upper first premolars and their relations to the bonding position. We hope it will help you achieve a more accurate bonding position on the next bonding appointment. References 1. Tom Pitts lecture in Taipei 11/15/ Wheeler s Dental Anatomy, Physiology, And Occlusion six edition 3. Chang CHN. Beethoven Orthodontic Mobile Learning Program. Advanced Damon Course No. 4: Dr Pitts secrets of finishing. 2008; Newton s A Ltd, Taiwan. Fig. 5 ( ) ( ) ( )

37 ipod touch NEW Beethoven Orthodontic Mobile Learning Program

38 NTO 13 VOICES FROM THE ORTHODONTIC WORLD Orthodontic Motto Keynote Pages imovie iphoto ~ ~

39 VOICES FROM THE ORTHODONTIC WORLD NTO 13 Orthodontics is not hard, if you know how to position brackets!

40 NTO 13 UNSOLVED MYSTERY Unsolved Mystery : Ankylosed Upper Posterior Teeth X 20 X 1 The pursuit of excellence is a never-ending journey. NTO aims to provide a platform for world-wide orthodontists to exchange and share their clinical experience so together we can move further and faster. From last year on we were opening a column to publish difficult cases that our readers encountered in their practice. We invite our colleagues to brainstorm and share with us your clinical analyses and treatment plans. Our consulting team will together review these ideas and select the best one to be published in the next issue. NTO will give out a box of the latest OrthoBoneScrew as a token of appreciation to the orthodontist whose plan is selected. The complete set includes one handle, 2 blades and 20 pieces of screws in a carrying box, and is worth of USD A 32-year-old male complained about posterior open bite on the left side. From the panoramic and cephalometric radiograph, we found #17, #26, #27, and #28 did not erupt fully, which were suspected of ankylosis. Besides, deep bite was observed. We appreciate many of our colleagues have been sharing with us your clinical insights and look forward to seeing more responses from our readers. Please send your treatment plans to [email protected] by February 28, 2009.

41 UNSOLVED MYSTERY NTO 13 Response for Unsolved Mystery ( NTO 12 ) The unsolved mystery published in the 12 th issue of NTO received a wide range of responses from our readers and we are pleased to facilitate such an enthusiastic participation of learning and sharing. After a thorough discussion among our consultants, we are glad to report that Dr. Hong-Po Chang ( ) s treatment plan is most recommended among all the received proposals. He will receive one super set of OrthoBoneScrew which includes 20 screws ( no squared-holes ), 2 blades, one handle and one container. We have also selected two quality treatment plans provided by Dr. Chiung Hua Huang and Dr. Huan-Wen Chen ( ), each of who will receive 10 screws in appreciation of their generous contribution to our collective learning. Dr. Chang s Treatment Plan 1. Firstly, leveling and alignment of maxillary dentition should be performed, by-passing the ankylosed canine. Vertical elastics may be used to achieve intercuspation except the canine. 2. The ankylosed canine can be freed merely by light luxation, breaking the area of ankylosis and an immediate continuous force can be used to position the tooth orthodontically into the arch. The orthodontic force must be reactivated every 10 days if the elastomeric chains are used. Surgical luxation of ankylosed teeth to break the ankylosis and allow orthodontic movement of the tooth has been used with considerable success ( Newton 1957, Albers 1986 ). The patient should understand that the treatment may either not produce movement of the tooth or result in the need for endodontic treatment. 3. An alveolar distraction osteogenesis and immediately reposition the dentoalveolar structure might be considered if surgical luxation followed by orthodontic traction of the ankylosed canine failed. 4. Otherwise extract the ankylosed canine and restore with a bridge or a dental implant later, when growth had ceased. Dr. Hong-Po Chang School of Dentistry, Kaohsiung Medical University, Taiwan Dr. Huang s Treatment Plan U3 ~ 3 High Q brackets Plan I 1. Rebond #15 to correct mesial tilted root and to create space for corticotomy. 2. Corticotomy of the ankylosed canine. 3. Put OBS on R't buccal shelf ( between #46 & #47 ). 4. Starting Class II elastics to pull down the ankylosed canine and distalize R't upper dental segment. 5. Use power chain from R't lower posterior main archwire to OBS in order to slightly intrude and correct torque of #43 ~ #46 which is resulted from previous vertical elastic. Plan II If the ankyloed canine still failed to come down, try surgical luxation or autotransplantation to bring the canine into occlusion. Dr. Chiung-Hua Huang Dr. Chen s Treatment Plan 1. Remove main wire of the upper arch 2. Self-adjustment for a period of time ( Upper right segment may be downward ). 3. Put OrthoBoneScrew at the upper right side to distalize #15, #16, # Inter-arch elastics for correction of #11, #12, #41, # Treatment of ankylosed canine: Single Tooth Subapical Osteotomy ; wire elastics ( The most importance is blood supply ) 6. Treatment of retrusion of labiomental fold Jasper Jumper, Forsus, etc. Dr. Huan-Wen Chen 41

42 Newton s A 2009 iwork Pages ~ iwork Keynote ~ ilife ipod ipod + itunes ~ ilife imovie + idvd ~ Keynote series 1 1. Keynote :00~17:00 Keynote series 2 Dr. Kokich :00~17:00 Keynote series :00~17: ilife + iwork ~2 6 09:00~17:00 International Keynote, OBS & Damon Workshop Keynote, Management OrthoBoneScrew & Damon 2009/3/02 ~ 3/05 International Dentists

43 all diameter length squared-hole code 2 mm 12 mm No OBS mm 12 mm Yes OBS 2.4 OBS

44 An excellent instructive and reference text for postdoctoral orthodontic students and specialist clinical orthodontists. Definitely recommended reading! Alex Jacobson, associate editor of AJODO Effective Keynote Presentation Workshop---Series One ( Dec. 18, 2008 )