nto_vol_12

NEWS & TRENDS IN ORTHODONTICS Oct. 1

Non-extraction, Non-surgical Treatment on Class II Open Bite Long Face Syndrome Case Dr. John Lin

Utilization of a Third Molar in Orthodontic Or thodontic Treatment of Skeletal Class III Adult Case Ca se with Lateral Dviation Dr. Etsuko Kondo

Three Keys to Maximize the Power of Damon System Tips from Dr. Tom Pitts

From left to right: Dr. Chris Chang, Dr. Tom Pitts, Dr. John Jin-Jong Lin at the Dr. Tom Pitts s Clinic !

News & Trends in Orthodontics is an experience sharing magazine for worldwide orthodontists. Download it at http://orthobonescrew.com.

Vo l . 1 2

2008

EDITORIAL

03

NTO 12 

Editorial LIVE FROM MASTERS

04

Non-Surger y, Non-Extraction Treatment Treatment Series I : Class II Open Bite Long Face Syndrome Case

06

Non-Surger y, Non-Extraction Treatment Treatment Series II : Severe Class III Open Bite Case FEATURE

08

Three Keys to Maximize the Power of Damon System : Tips from Dr. Tom Pitts

12

Treatment Effects of Muscle Wins ! Method PERSPECTIVES

The Art of Appreciation Many years ago my mentor Dr. Eugene Roberts told me that  to appreciate any achievement achievement you have to step back and look at it from a distance. It was not long ago had I really understood what he meant.

18

Utilization of a Third Molar in Or thodontic Treatment of  Skeletal Class III Adult Case with Lateral Deviation CASE REPORT

24

The Application of Orthodontic Bone Screw Anchorage in a Severe Class II Adolescent Patient NEWLY RELEASED

As I reviewed two master pieces of orthodontic textbooks written by Dr. Etsuko Kondo and Dr. John Lin, I was amazed by   their impressive achievement. achievement. Some of their cases have been followed over 30 years. They are the living testimonies for these  two great orthodontists’ or thodontists’ commitment and dedication to their  patients and our profession. Their records and results are tr uly  inspirational and so are their treatment philosophies.

32

OrthoBoneScrew VOICES F ROM THE ORTHODONTIC WORLD

34

Orthodontic Motto PRODUCTS REVIEW

36

Preliminar y Evaluation of Vector Vector TAS TAS CLINICAL PEARL

This issue we will feature these two giants in our profession.  With each over 30 years’ experiences they both continue to reinvent themselves and bring in cutting-edge technology in orthodontics. The way they use the self-ligated light force system and orthodontic bone screws are very worth investigating. I have been a student of Dr. Lin Lin for over 20 year s. What stunned me the most in reviewing his book was just how little I had grasped his  treatment philosophy and techniques. This is a great example of 

38

Bone Reduction in Management of Impacted Teeth Teeth UNSOLVED MYSTE RY

40

Ankylosed canine

how you need to keep a certain distance in order to appreciate a high mountain. For years, the giant has been right besides me and I simply didn’t see him.

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!

!

!

03 

! Chris! Hwai-Nan ! ! Chang, ! DDS, PhD, Publisher 

Consultant Dr. Eugene W. Roberts

Editors (from left to right) : Chuan Wei Su, Hao Yi Hsiao, Yu Lin Hsu, Chih Yuan Wu, Shu Fen Kao, Chien Kang Chen, Chris Chang, Ksiao Long Wang, Shang Chen Chiu, Yi Yang Su, Tzu Han Huang

Guest Editor  Dr. Rungsi Thavarungkul

!"#$%&'()*+,-./0 Please send your articles to [email protected]

Contributors (from left to right) : Dr. Chris HN Chang, Publisher, Dr. Johnny JL Liao, Consultant, Dr. John JJ Lin, Consultant

Chuan Wei Su (middle), Chief Editor  Tzu Han Huang, Yu Lin Hsu  Associate Editor 

NTO 12 

LIVE FROM MASTERS

Non-Surgery,, Non-Extraction Non-Surgery Non -Extraction Treatment Series I : Class II Open Bite Long Face F ace Syndrome Case

This is a case of severe Class II open bite with only

molars gradually. Before intruding the upper molars with

molar contacts. Features of this patient include narrow upper 

orthodontic bone screws and TPA, the author tried to use two

arch, right side unilateral crossbite, severe deficient and

infrazygomatic orthodontic bone screws to distalize the

retrognathic mandible. This is a typical case of long face

upper dentition to correct the Class II with big overjet to

syndrome.

Class I occlusion.

Also it is worth noting that the right

Traditional orthodontic treatment usually corrects the

unilateral crossbite was early corrected with the use of coil

open bite by extraction of premolars and accepts the original

spring retraction on right side. In addition, the upper narrow

long face and the retrognathic mandible.

arch was beautifully expanded by the right side cross-elastics

However, the author specializes in treating open bite

in only 2 months.

using an orthodontic mechanism which resembles to the

With merely 3 months’ retraction of the whole upper 

surgical technique, Le Fort I. This mechanism is then

dentition, the open bite dramatically reduced and the

referred as “slow Le Fort I TPA” TPA” and is consisted of TPA and

mandible rotated upward and forward. At the age of 21y5m

orthodontic bone screws. It enables the intrusion of upper 

the patient’s overjet has reduced significantly. The author 

04 

20y9m

21 y 2m

21y5m

2 1y 8 m

20 y 9m

2 1y 2 m

21y5m

2 1y 8 m

LIVE FROM MASTERS

NTO 12 

Dr. John Jin-Jong Lin, MS Marquette University Consultant of NTO President of TAO ( 2000~2002 ) Author of “ Creative Orthodontics”

then inserted two buccal shelf orthodontic bone screws to

II and open bite, orthodontists can provide more non-extraction

retract the lower dentition. The technique of slow Le Fort I

treatment options.

TPA was adopted to intrude the upper molars. It could also enhance the retraction of the whole upper dentition. At the age of 21y8m the anterior open bite almost totally closed without using any anterior vertical elastics. The mandible rotated to a much more ideal position. What can we learn from this case :

Slow Le Fort I TPA is quite useful to intrude the upper  molars, but it’s not as efficient as the infrazygomatic crest orthodontic bone screws. If this case were treated by premolar extraction at the  beginning of treatment, it would have been very difficult to achieve such a dramatic change. Nowadays with very powerful

Slow Le Fort I TPA 

weapons as orthodontic bone screws available to correct Class

The center of rotation of the whole maxillary dentition is near the apical of  upper premolars. The infrazygomatic orthodontic bone screws should be  placed around the cervical region of upper molars. A coil spring should be hooked between upper lateral and canine which suggests the direction of the force is below the center of rotation; The combined mechanism then creates a clockwise rotation of the whole maxillary dentition. Anteriorly the incisors will  be extruded. ( It’s d esirable for correction of the open bite. For gummy smile  patients orthodontic bone screws shou ld be inserted over the apical region of  the incisors to prevent extrusion). Posteriorly it creates a “Le Fort I-like” impact on the maxillary molars, which is good for the rotation of the mandible.

The cephalometric tracing clearly shows the dramatic impact of the maxillary molars. It explains why the profile improved significantly after  distalization of the whole upper dentition; The chin b ecame more prominent compared with the original retrognathic chin. Also it is worth noticing that the upper incisors extruded due to the clockwise rotation of the whole maxillary dentition. Fortunately this patient didn’t have gummy smile p rior to the treatment. If the patient had a gummy smile, orthodontic bone screws should be inserted over the incisor area to prevent extrusion of upper incisors.

05 

NTO 12 

LIVE FROM MASTERS

Non-Surgery, Non-Extraction Treatment Series II : Severe Class III O en Bite Case

A severe CIII asymmetry and open bite case came for 

the coil springs were then adopted to retract the whole lower 

consultation. The author proposed to treat with surgical

dentition distally. Initially about 12 oz of force was applied on

correction but the patient insisted in using orthodontic treatment

the right and 10 oz of force on the left side.

only. Facial asymmetry did factor in when choosing the treatment options.

The center of rotation of the whole lower dentition is near  the apical region of bicuspids. The force direction is above it.

Two 2 mm x 14 mm stainless steel orthodontic bone screws

When the counter-clockwise rotation of the occlusal plane

were placed over buccal side between lower first and second

happened, it meant not only the whole dentition was distalized,

molars. After 2 months of alignment using the Damon system,

 but also the lower molars were tipped back and the lower 

06 

18y5m

18y10m

19y4m

19y9m

LIVE FROM MASTERS

NTO 12 

anterior teeth were extruded. After 10 months of distalization

Conclusion : Until orthodontic bone screws severe Class

using orthodontic bone screws, the CIII malocclusion was

III cases could only be treated with the combination of 

corrected to Class I and the open bite closed. During 10

traditional orthodontics and orthognathic surgery. The

months of retraction by orthodontic bone screws, no anterior 

distalization of the whole lower dentition using buccal shelf 

 box or vertical elastics were used. The major open bite was

orthodontic bone screw offers a very powerful treatment

mostly corrected by rotation of the occlusal plane. After 

option for treating severe Class III cases.

orthodontic bone screws and Damon treatment, not only occlusion but also the facial appearance were improved significantly.

07 

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18y7m !

19y9m

For a detailed descriptio n of of slow Le Fort I please refer to the author’s book: “Creative Orthodontic s: Blending the Damon System & TADs to Manage Difficult Malocclusion”.

!

I’d like to thank my orthodontic colleague, Dr. Liaw, Yaw-Shen, who did the cephalometric studies of molar distaliz ation with me and offered the precise tracing of this case.

!

I’d like to thank my best orthodontist friend, Dr. Rungsi Thavarun gkul, from Thailand, who drew the beautiful diagram to illustrate the mechanism of the whole maxillary dentition distalization beautifully.

!

I’d like to thank my periodontist colleague, Dr. Huang Yi-Hao, who successfully placed the buccal shelf OrthoBoneScrew for this patient.

NTO 12 

FEATURE

3 Keys to Maximize the Power of Damon System Tips from Dr. Tom Pitts

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08 

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FEATURE

NTO 12 

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NTO 12 

FEATURE

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NTO 12 

FEATURE

Treatment Effects of Muscle Wins ! Method Using Damon Brackets in Skeletal Class III cases

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12  Low tongue !

Epiglottis turns down !

Larynx!Constricted airway  !

Low and forward tongue position for open airway and respiration !

Narrow larynx

Abnormal swallowing and respiration !

Epiglottis turned down

Malocclusion is induced and aggravated.

Low tongue causes epiglottis to turn down, constricting larynx and airway.

Tongue pull down and Dorsum of  tongue cannot reach palate

Narrow airway

Fig. 1 Relationship between tongue position and respiration

FEATURE

NTO 12 

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13 

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Fig. 2 Tongue training with gum chewing

NTO 12 

FEATURE

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72°

14 

ANB -3.0° Pre-treatment 19Y11M

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86°

ANB 1.0° Post-treatment 21Y11M

Fig. 3 Reconstructing occlusal plane by upright and intruding lower posterior teeth

FEATURE

NTO 12 

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!

30 Anchorage Bend !

. . . . Pre-treatment 14Y4M

Reconstruction of the functional occlusal plane

Short Class III Elastics

Establishing posterior support Lower 1st molar Uprighting & Intruding Backward movement of  mandibular arch

. . . .  Active treatment 14Y10M

Fig. 4 Force system and effects, Open bite Class III case

Increasing premaxilla height

15 

NTO 12  FEATURE

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Class II Deep Bite Case 16 

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Fig. 6  What type of occlusion established at the end of  active treatment in Class III cases can achieve long term stability ?

†‡&Í&ˆ‰Š€Q‹Œ€Ž-‘’€“”

17 

NTO 12 

PERSPECTIVES

Utilization of a Third Molar in Orthodontic Treatment of Skeletal Class III Adult Case with Lateral Deviation

A 28-year-old Japanese male came in our clinic for  consultation. He appeared in good health with no contributory medical history. The patient has hereditary Class III malocclusion from his maternal side of family. He presented a long-lower facial height and a concave profile. His lower lip appeared protruded and the nasolabial angle was favorable at 106.0°. His chief complaints included anterior cross bite, speech and chewing dysfunction, dished-in face and TMD symptoms.

Diagnosis The cephalometric film indicated this was a skeletal Class III malocclusion. The patient also had a narrow maxillary dento alveolar arch and TMD symptoms. The intra-oral examination revealed short lingual and upper labial frenum attachment. The maxilla was retruded ( SNA : 76.0°, MEAN : 81.5°±3.1° ). The mandible was in an average position ( SNB : 79.0°, MEAN : 78.2°±3.1° ). The molar and canine presented a Class III relation with -2.0 mm overjet and 1.0 mm overbite. Maxillary left 2nd molar was over erupted, causing occlusal interference in the posterior area which then resulted in a 4.0 mm mandibular deviation to the right side in the central occlusion. The patient has a short lingual frenum, which prevents his

18 

tongue from being positioned within the maxillary arch. It also causes the anterior placement of the tongue and mouth  breathing. A narrow maxillary dento-alveolar arch was the result of the same caused and consequentially led to posterior  cross bite on the both sides. The mandibular posterior teeth

Ext.

were mesiolingual tilted, creating an excessive posterior vertical dimension ( ANS-PNS to GoGn : 33.0°, MEAN : 26.3°±6.3° ) and a mandibular shift when opening ( SN to GoGn : 46.0°, MEAN : 34.5°±6.1° ). This skeletal Class III malocclusion combined with TMD symptoms had been aggravated by functional and environment factors as well as growth and genetic factors. Therefore the form and function of the joint might be adversely affected due to the structural and functional asymmetry. Fig. 1 Pre-treatment ( 28Y0M ) 2006.02.01

PERSPECTIVES

NTO 12 

!"# $%&'() *)+,)- !!.- /0! 1)(2)-  3454+ $,6%)"647 8)4", 9)" %0: ;)"7,  3)'"+47 )9  <"%0),)+%6=& >'%0)" )9? @'&=7: ;6+& A 1":4%B:+% 6+ C76+6=47 <"%0),)+%6=& D

Treatment Plan An orthodontic treatment plan was made to treat this malocclusion with Damon 3 brackets and reshaping of the maxillary dento-alveolar arches. This reshaping technique aimed to restore harmony of the tongue, perioral and chewing muscles. Such  procedure could also reestablish the proper functions of nose  breathing without surgical intervention. The extraction of the left maxillary 2nd molar was required and the extraction space could be replaced by the maxillary left 3rd molar. The total treatment time was 27 months. Begg type and tooth  positioner was adopted for retention. Appliances used included the followings: Damon 3 brackets, removable maxillary expansion  plate, and MFT with chewing gum.

Discussion and Summary The case presented here, which was originally classified as a surgical case, was successfully treated solely orthodontically. One of the most crucial contributing factors to the success of this treatment was the reshaping of the maxillary dento-alveolar arch. This reshaping successfully widened his tongue space and reestablished normal respiration as result of a more opened air way; furthermore, it improved his swallowing functions and allowed his

0

lips close effortlessly. Both maxilla and maxillary arch performed a forwarddownward movement. The mandibular arch distalized and the mandibular posterior teeth were turned upright and intruded. These helped to reconstruct the functional occlusal plane and to establish favorable anteroposterior, vertical skeletal and occlusal relationships. The tongue and masticatory muscle training, that was constant vigorous gum chewing during and after treatment, was effective in stimulating normal chewing function, respiration and swallowing. The light force and low friction features of the Damon  brackets were of particular importance in the stimulation of  functional recovery. However, this system cannot create optimal torque for all teeth. If this passive appliance is used to correct malocclusions, we need another force to create additional torque. Therefore, the best way to correct malocclusion is through restoration of normal functions, respiration and swallowing. It can reduce active treatment time and provide a long-term occlusal

Fig. 1 Post-treatment ( 30Y3M ) 2008.05.14

stability.

19 

NTO 12 

PERSPECTIVES

 Pre-treatment ( 28Y0M ) 2006.02.01

Start of treatment ( 28Y0M ) 2006.02.15

12 months into active treatment ( 29Y0M ) 2007.02.06 

20 

 Post-treatment ( 30Y3M ) 2008.05.14

 Active treatment time : 27 months

3 months post-treatment ( 30Y6M ) 2008.08.24 Fig. 2 Intra-oral photographs from pre-treatment to post-treatment

PERSPECTIVES

NTO 12 

The intra-oral examination revealed short lingual and upper  labial frenum attachment which caused the tongue unable to be  positioned within the Mx. dentoalveolar arch. The molar and canine presents a Class III relation with -2.0 mm overjet and 1.0 mm overbite. Maxillary left 2nd molar was over erupted, causing occlusal interference in the posterior area which then resulted in a 4.0 mm mandibular deviation to the right side in central occlusaion. Such deviation also led to TMD symptoms

The treatment began by bonding Damon 3 brackets and wearing a removable Mx. expansion plate, in conjunction with short Class III and canine triangle elastics. 12 months later, anterior cross bite was almost corrected. Then a lingual frenectomy was performed after the myo-functional training ( MFT ) started which aimed to lift up tongue.

Uprighted & Intruded

The Max. dentoalveolar arch was reshaped which together  resolved occlusal interference in the posterior area and TMJ symptoms. The mandibular posterior teeth were turned upright and intruded by distalizing the mand. arch. Short Class III and canine triangle elastics were also adopted. As a result, antero  posterior and vertical skeletal occlusal disharmony were almost corrected in 12 months. O.J. and O.B. became 1.5 mm respectively. The tongue achieved a normal posture and nasal  breathing was improved. Then the Max. expansion plate was removed. Note the left maxillary second molar was extruded.

24 months later, all elastics were discontinued for the final three months. 3 weeks later, since the tongue and other   perioral muscles seemed to have adapted to the new environment. The Max. appliance removed. 27 months later, a stable occlusion with Class I canine and molar relation was established. The midline was on and the O.J. and O.B., were 1.5 mm and 2.0 mm respectively. There were no recurrent TMD symptoms and the jaw movement appeared smoothly. The treatment time was 27 months.

Stable occlusion was maintained.

21

NTO 12 

PERSPECTIVES

Fig. 3-A CT image at pre-treatment and post-treatment

The post-treatment axial CT image revealed all teeth were held within the cancellous bone of the alveoli. The alignment was satisfactory and the arch fits the shape of a relaxed tongue. There was a good balance between the relaxed tongue, the perioral and masticatory muscles.

 Pre-treatment ( 28Y0M) 2006.02.01

 Post-treatment ( 30Y3M) 2008.05.14

Fig. 3-B-1 CT image at pre-treatment and post-treatment

The post-treatment sagittal CT image indicated the tongue was able to be  positioned within the maxillary arch. The air way was expanded, and also nose breathing and lip closing were improved. The interincisal angle appeared more favorable.  Pre-treatment ( 28Y0M) 2006.02.01

 Pre-treatment ( 28Y0M) 2006.02.01

 Post-treatment ( 30Y3M) 2008.05.14

 Post-treatment ( 30Y3M) 2008.05.14

22  Fig. 3-B2 3D image at pre-treatment and post-treatment

The post-treatment lateral 3D image showed a stable occlusion with posterior support. The long axes of maxillary and mandibular   posterior teeth were perpendicular to the functional occlusal plane. The normal line on the inferior apex of the zygomatic arch ( the Key ridge ) went through the bifurcation point of the mesiobuccal and distobuccal root of the maxillary first molar.

Fig. 4 The post-treatment frontal 3D image indicated the mandibular 

deviation to the right was improved and the midline was coincident.

 Pre-treatment ( 28Y0M) 2006.02.01

 Post-treatment ( 30Y3M) 2008.05.14

PERSPECTIVES

NTO 12 

Fig. 5 The post-treatment CT image curved MPR showed both condyles in

comparable positions in the articular fossae, indicating that normal functions have been attained after the treatment.

 Pre-treatment ( 28Y0M ) 2006.02.01  Post-treatment ( 30Y3M ) 2008.05.14

Fig. 6  Functional findings: Comparison of electromyogram ( EMG ) record from pre-treatment to post-treatment

The post-treatment EMG record revealed that both Masticatory muscles ( MM ) and Temporal muscles ( TM ) achieved favorable bilateral  balance as a result of the treatment.  Pre-treatment ( 28Y0M ) 2006.02.01  Post-treatment ( 30Y3M ) 2008.05.14

Both maxilla and maxillary arch performed a forward-downward Pre-treatment

movement. The mandibular arch distalized and the mandibular posterior 

Post-treatment

teeth were turned upright and intruded. As a result, the functional occlusal plane ( F. Occp !AB ) tilted downward by 12.0° during the treatment. The long axes of maxillary and mandibular posterior teeth were perpendicular to the functional occlusal  plane. The crown of upper incisors inclined labially which provided a proper  incisal guidance and freedom of mandibular movement in all directions. As a result, temporomandibular problems were resolved by the establishment of  optimal functional loading and the elimination of prematurity. This treatment restored functional occlusion and favorable antero posterior and vertical skeletal occlusal relationships in the absence of an orthognathic surgery.

References 1. Graber TM. Orthodontics. Principles and Practice. Philadelphia: Saunders, 1966:249-325. 2. Graber TM, Vanasdall RL, Vig KL. Orthodontics: Current Principles and Techniques (ed 4). St. Louis: Elsevier, 2005. 3. Graber TM. Dentofacial Orthopedics with Functional Appliances. St Louis: Mosby; 1997:3-12. 4. Kondo E. Nonsurgical nonextraction treatment of skeletal Class III open bite: Its long-term stability. Am J Orthod Dentofacial Orthop 2000;117:267-287. 5. Kondo E. Nonsurgical and nonextraction treatment of s skeletal Class III patient with severe prognathic mandible: Long-term stability. World J Orthod 2001;2:115-126. 6. 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;114:611-630. 7. McNamara JA. A method of cephalometric evaluation. Am J Orthod 1984;86:449-469. 8. Kondo E. “Muscle Wins” treatment in Orthotontics-Muscle and Respiration are key factors of orthodontics treatment). Ishiyaku Publishers, INC 2007 1st ed. 9. Kondo E. “Muscle Wins” treatment in Orthotontics-Muscle and Respiration are key factors of orthodontics treatment). Daehan Narae Publishers Co., 2008. 10.Lin JJJ, Creative orthodontics: Blending the Damon System & TADs to manage difficult malocclusions. Taipei: Yong Chieh Ltd, 2007.

23 

NTO 12 

CASE REPORT

The Application of Orthodontic Bone Screw Anchorage in a Severe Class II Adolescent Patient

Introduction Orthodontic bone screw anchorage has been applied in many clinical orthodontic conditions successfully. Some of them are maximal retraction in protrusion cases, Class II correction, Class III correction, and molar distalization in crowding cases. Moreover, molar intrusion in molar elongation or open bite cases, deep bite correction, midline correction, and the correction of canting occlusal plane and posterior crossbite. In many situations, the anchorage requirement is not critical in adolescent patients because of favorable growth potential. Some orthodontists are worried that the use of orthodontic bone screw in adolescent patients may interfere with the growth of the adolescent  patients. In this case report, the author put orthodontic bone screws in non-tooth bearing area of the adolescent  patient, without incurring any complication and got a good treatment result. Orthodontic Bone Screw anchorage is a  powerful tool in severe Class II adolescent cases.

24 

SNA

80

SNB

71

ANB

9

SN-MP

38

U1-SN

118

L1-MP

103

Fig. 2  Pretreatment cephalometric film, ANB is 9 degrees which showed skeletal class II relationship. SN-MP is 38 degrees, with divergent mandibular plane. U1-SN is 118 degrees, and L1-MP is 103 degree, showing flared upper  and lower incisors.

Fig. 1  Pretreatme nt extraoral view, obvious perioral   protrusion and lip incompetency were noted.

Fig. 3  Pretreatment panoramic film. It revealed #55, #65, and  #75 has not shedded and there are developing permanent tooth buds beneath them. The tooth bud of right mandibular third  molar has been noted.

Fig. 4 Pretreatment intraoral view, Overjet and overbite are quite large. Both sides are Class II occlusion.

CASE REPORT

Dr. Yu-Ching Chou Beauty Forever Orthodontic Clinic

NTO 12 

Dr. Johnny Joung-Lin Liao Beauty Forever Orthodontic Clinic

Clinical Examination

Radiographic Examination

The 10-year-old boy’s chief complaint was

Cephalometric analysis:

excessive maxillary protrusion. Extraoral frontal

ANB was 9 degrees which showed a skeletal

view showed mild facial asymmetry with mandible

class II relationship. SN-MP was 38 degrees, with

deviating to left side, perioral protrusion, lip

divergent mandibular plane. U1-SN was 118

incompetency, and no gummy smile ( Fig. 1 ).

degrees, and L1-MP was 103 degree, showing flared

Extraoral lateral view showed maxillary protrusion,

upper and lower incisors ( Fig. 2 ).

chin retrusion, acute nasolabial angle and

Panoramic film:

imbalanced perioral soft tissue. Intraoral frontal view

It revealed that #55, #65, and #75 had not

showed flared upper incisors and deep bite with 4.5

shedded and the permanent tooth buds were

mm overbite. Intraoral occlusal view showed both

developing in the bone. The tooth bud of right

upper and lower arches were symmetrical ovoid

mandibular third molar was noted.

shape. There was no space deficiency in upper arch,

Diagnosis and Treatment Plan

 but there was 1.5 mm deficient in lower arch. Bilateral class II occlusion was noted. The overjet was 12 mm.

According to the above examinations, the  patient showed a severe Class II occlusion composed

25  Fig. 5 The patient started to wear high-pull  headgear at the beginning of orthodontic treatment. He was suggested to wear the headgear over 12 hours per day.

Fig. 6  2 months of treatment, the patient started to wear a functional  appliance all day long except eating and brushing. During nights, he continued to wear headgear.

Fig. 7   Ext rao ra l vie w af ter 1Y 5M  orthopedic treatment. The effectiveness  seemed to be limited.

Fig. 8  Intraoral view after 1Y5M orthopedic treatment. Overjet is still  quite large and occlusion is still in Class II.

NTO 12 

CASE REPORT

of maxillary protrusion and mandibular retrusion. His

 pull headgear to suppress the forward and downward

mandibular plane angle was beyond average so he had a

growth of maxilla. Also we utilized functional appliance

tendency of vertical growth. In addition, his upper and

to facilitate the forward growth of mandible. In the

lower incisors were flared, and the overjet and overbite

orthodontic phase, we planned to correct the patient’s

were quite large. The treatment plan included the

severe malocclusion with full-mouth edgewise fixed

 primary orthopedic phase and the secondary orthodontic

appliance and orthodontic bone screws. As to his facial

 phase. In the orthopedic phase, we intended to use high-

Fig. 9 The superimposition of cephalometric films showed  the ineffective result of orthopedic treatment. It may come  from the insufficient wearing time.

SNA

80

SNB

71

ANB

9

SN-MP

41

U1-SN

118

L1-MP

96

Fig. 10 Cephalometric film after 1Y5M orthopedic treatment.

26 

2004/02/13

2004/06/04

2004/04/03

2004/07/09

Fig. 11 After extracting upper 1 st  and lower 2nd bicuspids, fixed  appliance was applied, and miniscrews were inserted at the upper infrazygomatic crest, Ni-Ti coil spring was applied.

2004/07/09

2004/07/09

Fig. 12  Deep overbite would impede the retraction of  anterior teeth, lever arms were applied to intrude anterior  teeth. The result of bite opening was noted.

CASE REPORT

NTO 12 

asymmetry, since the patient and his parents did not have

2004/06/04 The bilateral lever arms were applied in both

any complaints about this problem and it was still

arches for bite opening and avoiding the spatial

acceptable, and there was no simple ways to correct it,

interference of upper and lower incisors during space

therefore we decided to neglect the problem.

closure. ( Fig. 11 )

Treatment Procedure 2002/03/27 

The patient started to wear high-pull

headgear and was suggested to wear over 12 hours per  day. ( fig. 5 ) 2002/05/26 

The patient started to wear functional

appliance all day long except eating and tooth brushing. He continued to wear headgear during sleep. ( Fig. 6 ) 2003/08/15 After a 17-month orthopedic treatment, the effectiveness was considered limited. ( Fig. 7-10 ) 2004/02/13 After the extraction of the upper first and lower second premolars, an upper fixed orthodontic appliance was applied. ( Fig. 11 ) 2004/02/20 Orthodontic bone screws (J-Screw, Bio-Ray Biotech Corporation, Taiwan) were inserted at upper   posterior area ( infra-zygomatic crest ), meanwhile, the anterior teeth were retracted by Ni-Ti coil spring. 2004/04/03 The lower fixed orthodontic appliance was applied. ( Fig. 11 )

2004/07/09 The decreased overbite was noticed, and space closure continued. ( Fig. 11-12 ) 2005/04/29 Because the chain of action of the retraction force was applied much lower than the center of  resistance of the whole upper dentition, the overbite deepened and the occlusal plane steepened during space closure. The upper incisors cannot be retracted smoothly due to the overbite interference, and consequently Class I occlusal relationship cannot be achieved. 2005/05/27  A orthodontic bone screw was inserted subapical to upper incisors, locating inferiorly to ANS ( anterior nasal spine ). A 0.012 inch ligature wire was extended from the neck beneath the platform of the screw and a hook was formed at the end of the ligature wire. Thus, the intrusive force to upper incisors can be applied  by connecting the hook and the main archwire with an elastic chain ( Fig. 14 ). 2005/07/01 The overbite is obviously opened wider than  before. ( Fig. 14 )

2005/03/04 Fig. 13 All the extraction spaces are closed, but dental midlines did not  coincide. The anterior teeth were obviously dumped and overbite was deepened. It was still Class II occlusion on left side.

27 

2005/05/27

2005/07/01

2005/11/25

2006/01/20

Fig. 14  An upper anterior subapical orthodontic bone screw was inserted. A 0.012 inch ligature wire was extended from the neck of the screw and a hook was formed at the end of the ligature wire. Thus, the intrusive force to upper incisors can be applied by connecting of the hook and the main archwire with an elastic chain.

NTO 12 

CASE REPORT

2005/11/25 After bite opening, retraction of the upper 

There seemed no difference between the usage of 

dentition therefore can be continued to achieve class I

orthodontic bone screw in adults and this adolescent

occlusion. ( Fig. 15 )

 patient. The bone density is not significantly lower, and

2006/03/24 In the finishing stage, interarch elastics are

no screw failure happened during the treatment. The

applied. ( Fig. 16 )

success rate of orthodontic bone screw in adolescents

2006/06/30 Debonding.

needs to be evaluated in further studies.

The total treatment course is 4Y3M. The orthopedic

When utilizing posterior orthodontic bone screw

 phase took 1Y11M, and the orthodontic phase took 

anchorage to retract upper anterior teeth, a force system is

2Y4M. The patient’s profile improved significantly, and

created that retracts the posterior teeth. It is unlike those

the ideal Class I occlusion was achieved. ( Fig. 17-21 ).

in conventional orthodontic treatment, where posterior 

Discussion

teeth are protracted by the counterforce of retracting

During the mixed dentition stage, we used headgear  and functional appliance to provide orthopedic treatment. Although we took advantage of his growth peak, the treatment result of orthopedic phase seemed limited. It might be due to the insufficient wearing time. The main improvement of this case resulted from teeth extraction, and the use of orthodontic bone screw to open the bite and retract upper dentition to the extreme. The use of orthodontic bone screw anchorage in this adolescent did not cause any adverse effect to his skeletal development.

incisors. In addition, the force of retracting the anterior  teeth from orthodontic bone screw is applied coronally to the center of resistance of the whole upper dentition, so the deepening of the overbite is much more significant than it is in traditional cases. It results from that the exaggerated Curve of Spee, which is usually utilized to avoid bite deepening in traditional treatment, is unable to intrude the anterior teeth. Instead, accompanying the force applied from orthodontic bone screws, it produces a tip back and intrusive movement of the posterior teeth. The undesirable rotation of the occlusal plane impede the

28 

2005/07/01

2006/03/24

2005/11/25

2006/03/24

Fig. 15 The overbite had been opened and the occlusal plane was much adequate. The left side occlusion was much close to Class I  relationship.

Fig. 16  It was quite close to an ideal occlusion. The patient was asked to wear inter-arch elastics.

CASE REPORT

NTO 12 

Fig. 17  The post-treatment extraoral view revealed much coordinated and natural appearance of his perioral soft tissue.

Fig. 18  Post-treatment panoramic film revealed accept able  parallelism of roots. There are three third molars which should be extracted in the future.

Fig. 19 The post-treatment intraoral view. The orthodontic bone  screws were removed in this appointment.

SNA

80

29 

Fig. 20 Cephalometric superimposition of this patient. The upper  incisors was retracted about 12 mm and intruded about 3.5 mm. The mandible had an obvious growth of around 8 mm downward  and forward.

SNB

71

ANB

9

SN-MP

41

U1-SN

118

L1-MP

96

Fig. 21  Post-treatment cephalometric film showed an obvious improvement of the skeletal Class II relationship. The upper incisors had been corrected to a much more ideal inclination.

NTO 12 

CASE REPORT

 backward movement of the upper incisors and

the unpredictable growth amount of the patient.

consequently make impossible the ideal Class I

Therefore, a large amount of teeth movement is

occlusion. Therefore, an anterior subapical

needed to compensate the patient’s skeletal

orthodontic bone screw, combining a hook made of 

discrepancy, and the orthodontic bone screw

ligature wire and elastic chain, provides an

anchorage plays an important role in these cases. In

intrusive force to upper incisors. This combination

adolescent patients who need powerful anchorage

of retraction and intrusion force system is

in orthodontic treatment, orthodontic bone screw

especially important when a large amount of 

anchorage should be taken into consideration

anterior retraction is expected. ( Fig. 22 )

undoubtedly.

Conclusion Generally

adolescent

patients

have

considerable growth potential, and thus, the requirement for anchorage is not very critical. In some adolescent cases with much skeletal discrepancy, although we will try orthopedic treatment, the effect and result are determined by

30 

Fig. 22  Diagrammatic representation of forces encountered  in the second stage in this case. When using posterior  orthodontic bone screw anchorage to retract upper anterior  teeth, a force system is created that retracts the posterior  teeth. It is unlike those in traditional orthodontic treatment,  posterior teeth are protracted by the counterforce of  retracting incisors. In addition, the force of retracting the anterior teeth from orthodontic bone screw is applied  coronally to the center of resistance of the whole upper  dentition, so the deepening of the overbite is much significant  than it is in traditional cases. It results from that the exaggerated Curve of Spee, which is usually utilized to avoid  bite deepening in traditional treatment, is unable to intrude the anterior teeth. Instead, accompanying the force applied   from orthodontic bone screws, it produces a tip back and  intrusive movement of the posterior teeth. The undesirable rotation of the occlusal plane impede the backward  movement of the upper incisors and consequently make impossible the ideal Class I occlusion. Therefore, an anterior   subapical orthodontic bone screw, combining a hook made of  ligature wire and elastic chain, provides an intrusive force to upper incisors.

NEWLY RELEASE D

NTO 12 

The Dream Screw for the Next Generation’s Orthodontists

O rtho B one S crew Beethoven Orthodontic Center

OrthoBoneScrew (OBS) has a double-crossed rectangular  slot on its neck. This 0.018 x 0.025 inches rectangular slot  provides a versatile use of orthodontic mechanics. A 0.07 x 0.025 wire in dimensions can be secured in the slot firmly.

 A case report demonstrating an OBS application of  labial and palatal impacted canines Te-Wen Lai, Hao-Yi Hsiao, Chris Hwai-Nan Chang, Beethoven Orthodontic Center 

Mechanics Design : This

13-years-and-8-months-old

male

adolescent had two maxillary impacted canines. The right one was located palatally between #11 & #12 but the left one transposed labially between  Excisional uncovering to allow auto-eruption

#21 & #22 with little chance for self-correction.

 Apical Positionally Flap

Firstly we created space by placing Damon  brackets and NiTi opening spring between #11 & #14, #21 & #24 without engaging adjacent tooth during switching. Secondly we considered two

31

different surgical techniques to expose these two Screw: 3mm from suture

impacted canines. Finally we designed a 3D lever  arm in conjunction of  OrthoBoneScrews to pull

 Force systems: backward--> outward --> downward 

them out. With the aid of  OrthoBoneScrews as intraoral skeletal anchorage, we can prevent undesirable movement. 4 months in treatment 

OrthoBoneScrew Corporate Headquarters

2F, No. 25, Jian-Jhung First Road, Hsinchu, Taiwan 300 Tel: +886 3 5735676

Fax: +886 3 5736777

Contact: [email protected]

NTO 12 

NEWLY RELEASE D

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避免刮傷周圍 軟組織

提供三維矯正 力量

避免橡皮筋發 生彈脫

32 

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NTO 12 

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NTO 12 

VOICES FROM THE ORTHODONTIC WORLD

O rthodontic M otto Dr. Eugene W. Roberts

The biggest room in your house is the room for improvement !

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VOICES FROM THE ORTHODONTI C WORLD

NTO 12 

Dr. Larry White

Steal idea shamelessly ! Dr. Tom Pitts

Begin with the end in mind !

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35 

NTO 12 

PRODUCT REVIEW

Preliminary Evaluation of  Vector TAS  Dr. John Jin-Jong Lin

Design

Advantage

Disadvantage

No sharp edges from wire slots or hex bolts

--

More demonstration is required to better  illustrate this feature.

Screw head

36 

A small, neat, beautiful system A special delta-shape head

Fit no traditional springs but the Ormco delta spring.

Thread forming vs. Thread cutting

Beautiful diagram

The two diagrams look similar. The explanation is not clear enough.

Delta coil springs

Excellent and unique design Preventing dislodge

Procedures of spring placement should  be in two diagrams to make them more clearly.

Asymmetric buttress

Innovative description

The diagram of the blue screw seems upside down.

Self-ligating lock

Excellent lock, seems the only one in the TADs market.

--

Asymmetric buttress thread design

Innovative description

More clinical data is needed to demonstrate its effects.

Tissue suppression stops

Innovative description

Clinically this design is not a key determinant of preventing soft tissue inflammation

Titanium 6-4

--

Titanium Alloy or TiAl6V4 may be more formal

PRODUCTS REVIEW

NTO 12 

Usage

Advantage

Disadvantage

Self-tapping

--

It’s a common feature of TADs

Potential surgical cases treated without surgery

Very good statement for TADs

More clinical data is needed to demonstrate its effects

Madajet

Creative idea

More clinical data is needed to demonstrate its effects

Allows mid-treatment adjustment without removal of attachment

--

More demonstration is required to better  illustrate this feature

Attachments

Two coil spring can be attached on one screw.

--

Clinical testimony

--

More clinical data is needed

Atlas

Easy for the novice

 Not detailed enough, ie: mucosa area,  paramedial mid-palatal suture area

Price

--

About 2.5 to 3 times more expensive than Asian screws

Selling in kits only

Convenient for beginners.

Inconvenient for advanced users unable to purchase screws individually.

You can get more information about vector in Ormco s web site : www.ormco.com/index/ormco-products-vector !

37 

NTO 12 

CLINICAL PEARL

Bone Reduction in Management of Impacted Teeth There are some important principles in treating impacted teeth successfully. We have discussed the usage of the cone beam CT, adequate surgical uncovering procedures, and specific mechanics with OrthoBoneScrew in NTO Vol. 9. Now we turn to another principle- bone reduction. Mechanism of Bone Resorption

Tooth movement requires bone remodeling. Bone remodeling is a complex process involving the coordination of activities of cells from the osteoblasts and osteoclasts, which form and resorb the bone and cause the tooth movement. Bone remodeling usually starts with the bone resorption. Sodek clearly describes the mechanism of osteoclastogenesis and osteoclastic bone resorption ( Sodek et al., 2000 ). Bone resorption requires the recruitment of osteoclast, which is produced by the monocyte/ macrophage lineage of hematopoietic cells. Theses osteoclasts were regulated by the stimulated osteoblasts through the M-CSF and RANK/RANKL/OPG system and further process the matrix degradation through the proton transport ( Teitelbaum et al., 2000 ). This complicated bone resorption process takes time. If the anticipated resorbed  bone volume is large, it will be a very long process. Therefore, to facilitate the orthodontic treatment in this

Fig. 1

situation, the active bone reduction with the aids of “osteo-burs” should be considered. Rationale of Bone Reduction

Kokich claims that some cases of unsatisfied movement of impacted teeth were resulted from the insufficient bone removal during the uncovering procedure ( Kokich 2004 ). When dental follicle is deflated and removed during the uncovering, the enamel of the impacted crown comes into contact with the bone. Further resorption will only occur through pressure necrosis, which will  be a slow process. Therefore, when performing the uncovering procedure, we not only need to focus on the elimination of the covering bone to CEJ, but more importantly we need to remove the bone on the route of traction. Keys to Speed Up the Movement of Impacted Tooth

Take the following case for an example ( Fig. 1 ). When performing this uncovering procedure, we first located the impacted tooth and removed all the egg-shell covering bone down to CEJ. Then we further  evaluated the design of mechanics. An outward, backward and downward mechanical movement were anticipated by applying of a lever arm extending through the OrthoBoneScrew with square holes ( See

Fig. 2

 page 31 ). We further removed the bone structure lying on this moving route using a surgical carbide bur and a high speed handpiece ( Fig. 2 ). This allowed the impacted tooth move faster.

Conclusion

Management of impacted teeth is a common situation in orthodontic treatment. Bone resorption occurs through pressure

38 

necrosis during the remodeling process; however, it is a slow process. When a surgically uncovering procedure is indicated, the reduction of the bone covering the teeth and on the traction route can help teeth erupt and move to the anticipated position significantly faster and reduce overall treatment time. Reference 1. Hsiao H Y. 3D Control of An Ectopic Tooth. News and Trends in Orthodontics 2008;9:8-9. 2. Sodek J. Molecular a nd Cellular Biology of Alveolar Bone. Periodontol 2000. 2000 Oct;24:99-126. 3. Teitelbaum SL. Bone Resorption by Osteoclasts. Science. 2000 Sep 1;289(5484):1504-8. 4. Kokich VG. Surgical and Orthodontic Management of Impacted Maxillary Canines. Am J Orthod Dentofacial Orthop 2004; 126: 278-83. 5. Chang CHN. Beethoven Orthodontic Mobile Learning Program. Advanced Damon Course No. 1: Impacted Tooth. 2008; Newton’ s A Ltd, Taiwan.

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NTO 12 

LIVE FROM THE MASTER

NTO 12 

UNSOLVED MYSTERY

Unsolved Mystery Ankylosed Canine

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 this issue on we are opening a new column to publish difficult cases that our readers encounter 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

X 20

X1

worth of USD 1500.

A 18 year-old female patient complained about open bite. There was no contact from the right 2nd premolars to the left 1st premolars. As the orthodontic wire sequencing proceeded, we found out that the right upper canine remained at the original position from the  beginning to the 23rd month. It was suspected that the right upper  canine was ankylosed. We encourage all of our colleagues to draw from your clinical experience and develop a treatment plan of yours to share with us. Please send your proposals to  b e e t h . o v e n @ m s a . h i n e t . n e t b y

40 

 November 31, 2008.

23 months into active treatment ( 21Y4M )

UNSOLVED MYSTERY

NTO 12 

Response for Unsolved Mystery

The unsolved mystery published in the 11th 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. Ching-Huei Hong ( !"# )’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. Jin-Lai Chang$%&'(and Dr. Chiung Hua Huang$)*+(, each of who will

receive 10

screws in appreciation of their generous contribution to our collective learning.

Dr. Hong s Treatment Plan ’

1. Apply four SSC on lower primary molars to enhance chewing function. 2. Extract the upper left 1st primary molar. 3. Move upper canines to achieve Class I relationship. 4. Maintain by an upper removable denture including lateral incisors and premolars until reaching 18-20 years of age.

41

5. When switching to fixed protheses, there are two options for consideration. Option I : put implants in replacement of the removable denture. 2nd orthodontic treatment will be delivered if necessary. Option II : r emove all the ankylosed primary teeth and begin the 2nd orthodontic treatment combined with implants for full mouth rehabilitation.

!"#$%&'()*+,-./01 時 間：98年元旦 7：00 am 組 數：球賽限 40 組（恕不接受現場報名） 地 點：東方日星高爾夫球場 （原啟寶高爾夫球場） 諮詢專線：03-5735676 黃思涵 小姐 傳真號碼；03-5736777 報名方式：四人組隊或單獨報名皆可 !"#$%$"&$'()*+ 上網查詢： www.beethoven-teeth.com.tw

www.newtonsa.com.tw orthobonescrew.com

Dr. Ching-Huei Hong

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Order: (03) 5735676 Winnie Liu OBS web site: orthobonescrew.com Newton’ s A web site: www.newtonsa.com.tw

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