0090 Vol 27 No 1 May 2011_2

ContentsEditorial1 What is a journal?

Craig Dreyer

Obituary2 Gerald Richard Dickinson (1940-2010)

Original articles4 A comparison of shear bond strength of immediate and delayed bonding of brackets to FRC bars using various

orthodontic adhesivesFarzin Heravi, Saied Mostafa Moazzami, Navid Kerayechian and Elham Nik

10 The effects of the Pendulum distalising appliance and cervical headgear on the dentofacial structuresEbubekir Toy and Ayhan Enacar

17 Comparison of dietary intake between fixed orthodontic patients and control subjectsAlireza Sarraf Shirazi, Majid Ghayour Mobarhan, Elham Nik, Navid Kerayechian and Gordon A. Ferns

23 Evaluation of primary surgical outcomes in New Zealand patients with unilateral clefts of the lip and palateHannah C. Jack, Joseph S. Antoun and Peter V. Fowler

28 The effects of various surface treatments on the shear bond strengths of stainless steel brackets to artificially-aged composite restorationsLadan Eslamian, Ali Borzabadi-Farahani, Nasim Mousavi and Amir Ghasemi

33 A systematic review of the association between appliance-induced labial movement of mandibular incisors and gingivalrecessionTehnia Aziz and Carlos Flores-Mir

40 Skeletal, dental and soft tissue changes in Class III patients treated with fixed appliances and lower premolar extractionsElham S.J. Abu Alhaija and Susan N. Al-Khateeb

46 Presence of cariogenic streptococci on various bracket materials detected by polymerase chain reaction Smitha Pramod, Vignesh Kailasam, Sridevi Padmanabhan and Arun B. Chitharanjan

52 Effectiveness and acceptability of Essix and Begg retainers: a prospective studyArun G. Kumar and Anchal Bansal

Case reports57 Orthodontic management of ectopic maxillary first permanent molars: a case report

Jadbinder Seehra, Lindsay Winchester, Andrew T. DiBiase and Martyn T. Cobourne63 Alignment of an ectopic canine with mini-implant anchorage: a case report

Priyanka Sethi Kumar, K. Nagaraj, Ruchi Saxena and Juhi Yadav69 Treatment of a Class III patient: a case report

Rahman Showkatbakhsh and Abdolreza Jamilian

Letters74 Optimal force

Brian W. LeeControl 21 Stress-Breaking BracketFelix Goldschmied

General 76 Book reviews83 Recent publications89 New products91 Calendar

AustralianOrthodontic JournalVolume 27 Number 1, May 2011

Australian Orthodontic Journal Volume 27 No. 1 May 2011

Australian Orthodontic Journal Volume 27 No. 1 May 2011 1

Editorial

In November 2010, I had the opportunity and privilege of attending a short course for editors ofmedical journals which was held in Oxford, England.The weather was cold and grey, heralding the snowand freezing temperatures that were to affect Europein the weeks ahead. The atmosphere on the course waseducational and convivial as twenty-four other newlyappointed medical editors of highly prestigious medical journals were educated in the craft of editing.

The consulting and publishing company providingthe course introduced, in sequence, the four areas ofthe process that are crucial to journal production.Editing consideration needs to be given to theowner(s) of the journal (in this case the AustralianSociety of Orthodontists), the authors (whose manu-scripts are assessed for publication), the readership(who need to be informed) and the public (who sup-port the journal either through advertising or legalservices). With research communication changingdramatically in the electronic age, all need to be managed carefully and flexibly for a journal to survive.

Apart from defining a profession, a primary purposeof a journal is the dissemination of information andthe advancement of knowledge. However, research hasindicated that journals are not good at persuading clinicians to change and improve their practice. Wordson paper rarely lead directly to change. Slowly journalshave begun to look less like traditional scientific periodicals and more like popular magazines, withshorter articles, brief summaries and graphics. Aperusal of this current issue will attest to this fact.

During the Editors Course, the participants wereinvited to consider the precise definition of a journaland, as an example, to consider what distinguishes theAustralian Orthodontic Journal from a newsstand mag-azine. Both publish articles to inform special interestgroups. In the case of the AOJ, orthodontic informa-tion is provided for clinicians, but in the case of amagazine, content information targets a different butselective interest group. The AOJ carries advertise-ments and most magazines derive income from theiradvertising spreads which may be the means by whichtheir success is judged. Both are supported by a pro-prietary group. In the case of the AOJ, it is the ASO,but in the case of a magazine, it is likely to be a

publishing company whose purpose is business. Toquote Richard Smith,1 a past editor of the BritishMedical Journal, journals are about the fundamentalbusiness of disseminating science rather than makingsocieties or publishers rich. While newsstand maga-zines also disseminate knowledge, they are largely ofpecuniary benefit to the publishing company.

Both types of publication pass through an editorialprocess and/or an editorial panel which provides a policy framework and is responsible for content.However, the significant and important differencebetween the two types of publication is that submittedmanuscripts/papers to a scientific journal are carefullypeer reviewed to determine their suitability for publica-tion. While the purpose of peer review is to advise onthe merits of a manuscript, it does not necessarilyguarantee quality. It does mean that a process of self-regulation has been undertaken and a submitted paperhas been evaluated and advanced along the editorialpathway. A valued panel of reviewers serves the AOJand ensures that critical peer-review remains the fundamental and important difference between a scientific journal and a magazine.

With concern, the process of peer review is currentlyunder scrutiny because it is said to apportion spuriousweight to a published article and can delay publica-tion. To combat this, an open review system has beensuggested in which the authors and the reviewersnames are known. This creates the possibility offavouritism, fraud or the denigration of rival research.This will not be pursued and the current system ofclosed review will prevail for the AOJ.

A good journal should be an asset to the scientificcommunity. On the world stage of scientific journals,the Australian Orthodontic Journal is a small player.Nevertheless, it is a journal of the Australian Society ofOrthodontists and therefore belongs to the member-ship and subscribers. It is published to educate andinform, to encourage debate, set agendas and draw atten-tion to innovation, but essentially to make people think.

So, what do you think . . . ?

Craig Dreyer

Reference1. Smith R. The trouble with medical journals. J R Soc Med

2006;99:115-19.

What is a journal?


Gerry Dickinson was born in St Arnaud, a countrytown in Victorias wheat belt. He had a rural up-bringing and acquired many bush skills during hisformative years. From St Arnaud, Gerry went to boardat St Patricks in Ballarat for his secondary schooling.

In 1959 he commenced Dentistry at MelbourneUniversity and was resident and later studentPresident at Newman College. Gerry graduated in1963 and almost immediately commenced hisMasters degree in Orthodontics. In those years, thecourse was 4 years part-time. During this time and foryears after, Gerry tutored in Anatomy. It remained oneof his favourite subjects.

After achieving his Masters in 1968, Gerry went intopractice with Alan Parker in Spring Street inMelbourne. He subsequently went solo with helpfrom Paul Buchholz and Anne-Marie Vincent at 2 Collins Street, and in 1969 Gerry went to LosAngeles with Bill Chalmers and did a long course inRicketts lightwire edgewise philosophy and tech-nique, which had a large impact on Gerrys clinicalpractice. He was a dedicated orthodontist and despite

his protracted illness, he was still seeing his patientsuntil he retired at the end of May last year.

Gerry made a massive contribution to the professionof Dentistry, to the specialty of Orthodontics and tothe University of Melbourne. He was an active member of the Australian Dental Association. From1967 to 1978, Gerry served on the FluoridationCommittee of the ADAVB. Together with GavanOakley, he was instrumental in achieving the fluorida-tion of Melbournes water supplies. This is arguablythe greatest Public Health measure ever seen inMelbourne. He served on the ADAs ProfessionalProvident Funds policy advisory committee for overtwo decades and in 2000 received the BranchsDistinguished Service Award for this and his work onthe 1993 ADA Congress.

Gerry gave more than 30 years of continuous serviceto the Australian Society of Orthodontists, commenc-ing in 1975 on the Victorian Branch Executive,through to 2007, when he retired from the Chair ofthe ASO Foundation for Research and Education.Between those years Gerry was Chairman of Congress

Obituary

Gerald Richard Dickinson1940 2010


OBITUARY

3

in 1984 and ASO Federal President from 1993 to1996. In 2006 he was awarded Honorary LifeMembership of the ASO.

Gerry has been involved with the University ofMelbourne almost continuously from student days in1959, then as a teacher in Anatomy andOrthodontics and later on Faculty. More recently hehad been involved as a board member of theCooperative Research Centre for Oral Health Sciencewhere he had worked closely with Professor EricReynolds. He was instrumental in securing a largedonation which will form the nucleus of a trust fundto support the Orthodontic Chair at the MelbourneDental School. He was also a Fellow of theInternational College of Dentists and was to be theincoming President. His overall contribution to theprofession has been second to none.

Gerry had many interests outside Dentistry. He was akeen skier, both downhill and cross country, andcompeted in many marathon ski races in the FallsCreek and Mt Hotham area. He was also a keen runner and had a sub 3-hour marathon to his credit.

He competed in many pier to pub swimming eventsand was an Anglesea surfer, a competent scuba diverand an astute fisherman. He was a member ofVictoria and Barwon Heads Golf Clubs, an avid roadcyclist and a proud supporter of The Cats. Gerrytravelled extensively throughout the world, but heloved Central Australia. Every year, with great enthu-siasm, he planned a 4WD expedition with familyand friends, to explore the Kallakoopah, the Simpsonand other remote regions of the centre.

In 1964 he married Anne Louise Liddy and they had4 children, Sarah, John, Jane and Andrew. There arenow 5 grandchildren and he was proud of all of them.Together with Annie, he developed a large grazingproperty near Colac and in the last 15 years or so,returned to his rural roots.

Everything Gerry did, he did with enthusiasm andpassion. He will be greatly missed by all who knewhim.

John Armitage

Introduction

Fibre reinforced composite (FRC) is a conglomerateof S-glass fibres, a Bis-GMA matrix and unfilledresins that produce a glass-like, highly resistant struc-ture.1 It has the same colour as enamel, which appealsto patients who prefer aesthetic appliances. This tech-nology was developed and may be used for periodon-tal splinting of teeth, endodontic post and cores, fixed

prosthodontic appliances and as a mechanism to stabilise traumatised teeth.26

In orthodontics, FRCs have been used as bondedretainers, space maintainers, splints and as anchorageadjuncts during active tooth movement.7,8 Foranchorage, the FRC bars can unite several teeth into a single unit. The bars are tooth-coloured andattachments can be directly bonded (Figure 1).9 The

Australian Orthodontic Journal Volume 27 No. 1 May 2011 Australian Society of Orthodontists Inc. 20114

A comparison of shear bond strength of immediateand delayed bonding of brackets to FRC barsusing various orthodontic adhesives

Farzin Heravi,* Saied Mostafa Moazzami, Navid Kerayechian* and Elham Nik+Department of Orthodontics and Dental Research Center,* Department of Operative Dentistry and Dental Research Center, Mashhad Universityof Medical Sciences, Iran and Department of Pediatric Dentistry, School of Dentistry, Ahvaz University of Medical Sciences,+ Ahvaz, Iran

Background: Fibre reinforced composite bars (FRC) have applications as bonded retainers, space maintainers and anchor-age/movement units. However, the bond strength of attachments to FRC anchorage bars is unknown.Aims: To compare the shear bond strengths of brackets bonded immediately to FRCs with different orthodontic adhesive systemsand bonded with the same adhesives after a 48-hour delay, abraded with a diamond bur and etched with phosphoric acid.Method: One hundred and five recently extracted upper premolars were randomly assigned to seven groups (N = 15 teeth pergroup). FRCs were bonded to the buccal surfaces of the teeth and stainless steel orthodontic brackets were bonded to the FRCswith the following adhesive systems: Group 0 (Tetric Flow); Groups 1, 2 and 3 (Immediate bonding with chemically cured, no-mix and light cured composites, respectively, the bars covered with Tetric Flow); Groups 4, 5 and 6 (Bonding to FRCsdelayed 48 hours, then bonded with chemically cured, no-mix and light cured composites, respectively, the bars covered withTetric Flow). The FRC bars in Groups 4, 5 and 6 were abraded with a coarse-grit diamond bur before bonding the attachments to the bars. The shear bond strengths (SBS) were measured with a universal testing machine, and the adhesiveremaining on the teeth after debonding was scored with the Adhesive Remnant Index (ARI). Data were analysed using analysisof variance (ANOVA), Duncans post-hoc and Fishers Exact test.Results: There were no statistically significant SBS differences between Groups 0 (Mean SBS: 9.56 MPa), 1 (Mean SBS: 9.74MPa), 2 (Mean SBS: 10.72 MPa) or 3 (Mean SBS: 9.54 MPa). Groups 4, 5 and 6 (Bonding delayed by 48 hours) hadSBSs of 11.79 MPa, 11.63 MPa and 13.11 MPa, respectively, and were significantly higher than the SBSs in Groups 1, 2and 3 (Immediate bonding). There were no significant differences in ARI scores among the groups.Conclusions: The mean SBSs in all groups fell within the clinically acceptable range (> 7 MPa). The combination of a 48-hourdelay between placement of an FRC bar and bonding an attachment, abrading the FRC with a diamond bur and etching withphosphoric acid resulted in higher bond strengths.(Aust Orthod J 2011; 49)

Received for publication: December 2009Accepted: May 2010

Farzin Heravi: [email protected] Mostafa Moazzami: [email protected] Kerayechian: [email protected] Nik: [email protected]

BOND STRENGTHS OF BRACKETS TO FRC BARS


disadvantages are that the bars cannot be used in allstages of comprehensive orthodontic treatment andthere is limited information on the bond strengths ofattachments to the bars, particularly if bonding isdelayed and the surface of the FRC bar is abradedbefore bonding.9,10

The present study aimed to determine the SBS valuesof brackets bonded to FRC bars with a flowable com-posite and three conventional orthodontic adhesives(chemically cured, no-mix and light cured resin composites).

Material and methods

One hundred and five non-carious human upper pre-molars were used in this study. Teeth with hypo-plastic areas, enamel cracks or irregularities or treatedwith chemical agents were excluded. The extractedteeth were randomly divided into seven equal groupsand were stored in distilled water at room tempera-ture until required. All teeth were bonded and testedwithin 2 months of extraction.

The teeth were carefully mounted in self-cure acrylicblocks so that their labial surfaces were parallel to theshearing force. The buccal surfaces were cleaned andpolished with a non-fluoridated pumice and rubberprophylactic cups, washed with water and air dried.The buccal surfaces of the teeth were etched for 30seconds with 37 per cent phosphoric acid gel (3MDental products, St. Paul, MN, USA), rinsed withwater for 30 seconds and dried with a blast of oil-free

air for 20 seconds, until the etched surfaces appearedfrosty white.

A thin layer of Margin Bond (Coltne/Whaledent,Altstatten, Switzerland) was applied to the etched sur-face and thinned by gently blowing air on the resinfor 10 seconds. The resin was cured with an Astralis 7visible light unit (Ivoclar, Vivadent, Schaan,Liechtenstein) with the intensity of 780 mW/cm2 for20 seconds. A layer of flowable resin (Tetric Flow,Ivoclar, Vivadent, Schaan, Liechtenstein) was appliedto the enamel. A glass fibre FRC bar, pre-impregnat-ed with Bis-GMA (Interlig ngelus, Londrina, PR,Brazil), was cut with scissors to the size of an uppercentral incisor stainless steel edgewise bracket andplaced in the centre of the crown. Pressure wasapplied to the FRC to express excess resin, which wasremoved with an explorer. The flowable resin wasthen light cured for five seconds.

Stainless steel, central incisor edgewise brackets (3MUnitek, St. Paul, MN, USA) with a mean bondingsurface area of 12.54 mm2 were bonded to the FRCs(Table I):

1. Group 0 (TF: Tetric Flow): a flowable compositeresin was applied to the bracket base and the bracketpositioned on the FRC. The composite resin waslight cured on the mesial (20 seconds) and distal (20seconds) sides of the bracket bases.

2. Group 1 (CC-IB: chemically cured, immediatebonding): a layer of Tetric Flow resin was applied tothe FRC to completely cover the fibre bar and light

Table I. Summary of the adhesive systems and the time delay in bonding attachments.

Bonding

Groups Immediate Delayed

Group 0 (TF) *Group 1 (CC-IB) *Group 2 (NM-IB) *Group 3 (LC-IB) *Group 4 (CC-DB) *Group 5 (NM-DB) *Group 6 (LC-DB) *

TF, Tetric Flow; CC, chemically cured (Concise); NM, no mix (Unite);LC, light cured (Transbond XT); IB, immediate bonding; DB, delayedbondingDelayed 48 hours, abraded with diamond bur and etched with phos-phoric acid

Figure 1. FRC used to form posterior anchor units.

cured for 40 seconds. The brackets were bonded tothe FRC bar with a chemically cured composite resin(Concise, 3M Dental Products, St Paul, MN, USA).During curing the brackets were pressed firmly inplace and excess adhesive was removed with anexplorer.

3. Group 2 (NM-IB: no-mix, immediate bonding):the FRC was covered with Tetric Flow and light curedfor 40 seconds as in Group 1. The brackets werebonded to the FRC bars with a no-mix compositeresin (Unite, 3M Unitek, Monrovia, CA, USA).Primer was applied to the surface of the FRC bar andthe bracket. The adhesive was then applied to thebase of the bracket and the bracket positioned on thecovered FRC bar.

4. Group 3 (LC-IB: light cured, immediate bonding):the FRC was covered with Tetric Flow as in Groups 1and 2 and light cured for 40 seconds. The bracketswere bonded to the FRC bars with Transbond XT(3M Unitek, Monrovia, CA, USA). A thin layer ofprimer (Transbond XT primer, 3M Unitek) wasapplied to the covered FRC bar and a layer ofTransbond XT composite resin placed on the base ofthe bracket. The brackets were positioned on theFRC bar and pressed firmly into place. Excess adhe-sive was removed with an explorer before curing. The complex was cured for 40 seconds with the light-curing protocol used in Group 0 (20 seconds on themesial side and 20 seconds on the distal side of thebracket base).

5. Group 4 (CC-DB: chemically cured, delayedbonding): the FRC was again covered with TetricFlow as in Groups 1, 2 and 3. The samples were thenstored in distilled water at room temperature for 48hours. The surface of the covered FRC bars was

abraded with a high-speed coarse-grit diamond bur(No.534, SS White Lakewood, NJ, USA) irrigatedwith a water spray, etched with 37 per cent phos-phoric acid for 10 seconds, washed thoroughly withwater and air dried. A thin layer of primer (Marginbond) was applied to the surface and thinned by gently blowing air on the resin for 10 seconds. The primer was then light cured for 20 seconds andthe brackets were bonded to the surface with thechemically cured composite resin (Concise) used inGroup 1.

6. Group 5 (NM- DB: no-mix, delayed bonding): theFRC bar was covered in Tetric Flow as in Group 4.The brackets were bonded to the covered FRC bars(after the surface of the bars had been abraded) witha no-mix composite resin (Unite), according to themanufacturers instructions.

7. Group 6 (LC-DB: light cured, delayed bonding):the procedure used in Groups 4 and 5 was followed.The brackets were bonded to the FRC bars (after thebars had been abraded) with the light cured compos-ite resin (Transbond XT) used in Group 4 andaccording to the manufacturers instructions.

Debonding procedureAfter bonding, all samples were stored in distilledwater at room temperature for 24 hours. The speci-mens were mounted in a universal testing machine(Zwick GmbH, Ulm, Germany) and the bracketsdebonded with shear load applied to the bracket baseby a blade at a crosshead speed of 1 mm/min. Themaximum load required to debond the fibre bar wasrecorded in newtons (N) and converted to mega-pascals (MPa).

Residual adhesiveAfter debonding the brackets, the buccal surfaceswere examined at x10 magnification and the amountof adhesive remaining on the tooth recorded usingadhesive remnant index (ARI).11 The criteria for scoring were 0, no adhesive on the tooth; 1, less thanhalf of adhesive on the tooth; 2, more than half of theadhesive on the tooth; and 3, all adhesive on the tooth.

Statistical methodThe Kolmogorov-Smirnov test was used to determineif the data were normally distributed. The mean SBSswere compared with an analysis of variance

HERAVI ET AL


Table II. The shear bond strengths of the groups.

Groups N Mean SD Range Test*(MPa) (MPa) (MPa)

Group 0 (TF) 15 9.56 3.08 5.71 - 16.31 aGroup 1 (CC-IB) 15 9.74 1.52 8.09 - 13.05 aGroup 2 (NM-IB) 15 10.72 1.67 8.15 - 14.50 a, cGroup 3 (LC-IB) 15 9.54 1.87 6.58 - 13.39 aGroup 4 (CC-DB) 15 11.79 1.82 8.41 - 15.37 b, cGroup 5 (NM-DB) 15 11.63 2.33 8.51 - 17.06 b, cGroup 6 (LC-DB) 15 13.11 1.98 8.88 - 16.52 b

*Groups with the same letters are not significantly different from eachother



(ANOVA) and Duncan post-hoc test. The ARI scoresamong the different groups were compared withFishers Exact test. All statistical analyses were per-formed using the SPSS software package (SPSS forwindows, version 15, SPSS Inc, Chicago IL, USA). Ap < 0.05 was considered significant.

Results

The results of this study demonstrated that Group 6had a higher mean SBS value (13.11 1.98 MPa)compared with the other groups (Table II). Groups 4,5 and 6 had similar SBS values (p > 0.05). Group 0(TF) had a mean SBS value of 9.56 3.08 MPawhich differed significantly from Groups 4 , 5 and 6,but not Groups 1, 2 and 3. The mean shear bondstrengths of all groups exceeded 7 MPa, the shearbond strength regarded as clinically acceptable.12

The ARI scores for the 7 groups are given in Table III.There were no significant group differences in thelocations of the bond failures (p = 0.8), regardless ofthe adhesive material, and the delay in bonding andsurface treatment of the FRC. Bond failure occurredmainly within the bonding material.

Discussion

The bond strengths of orthodontic attachmentsbonded to FRC bars with conventional orthodonticadhesives was examined in the present study. Previousstudies have assessed the physical properties but not

the effectiveness of different methods of bondingattachments to the bars.2,1319 It was found that thebond strengths of the six orthodontic adhesives thatwere examined exceeded the minimum 7 MPa bondstrength for clinical use.12 The combination of delay-ing bonding for 48 hours, abrading the surface of thebar with a coarse grit diamond bur and then etchingwith phosphoric acid resulted in high SBSs, but thedelay is unlikely to be acceptable to many cliniciansand patients.

Orthodontic attachments and FRC bars may bebonded in a one-step procedure with the flowablecomposite resin used in the study, but the attach-ments were inclined to drift until the resin wascured.9 Contradictory reports exist in the literatureregarding the shear bond strengths of flowable resinscompared with conventional orthodontic adhesives.Several investigators have reported that the SBSs offlowable resins are significantly lower than the SBS ofTransbond XT while others have reported similarbond strengths to Transbond XT.2023 The findings ofthe present study support the view that attachmentsbonded to FRC bars with conventionally chemicallycured, no-mix and light cured orthodontic adhes-ives (Concise, Unite, Transbond XT) will result inacceptable SBSs.

In several groups, bonding to the FRC bar wasdelayed for 48 hours, in order to mimic clinical situ-ations. In this circumstance, the bar was abraded with

Table III. Distribution of ARI scores.

Groups ARI Fishers0 1 2 3 Exact

(Per cent) (Per cent) (Per cent) (Per cent) test*

Group 0 (TF) 1 (6.7) 3 (20) 8 (53.3) 3 (20) aGroup 1 (CC-IB) 1 (6.7) 3 (20) 11 (73.3) 0 (0.0) aGroup 2 (NM-IB) 1 (6.7) 6 (40) 8 (53.3) 0 (0.0) aGroup 3 (LC-IB) 1 (6.7) 4 (26.7) 8 (53.3) 2 (13.3) aGroup 4 (CC-DB) 1 (6.7) 6 (40) 8 (53.3) 0 (0.0) aGroup 5 (NM-DB) 1 (6.7) 7 (46.7) 7 (46.7) 0 (0.0) aGroup 6 (LC-DB) 1 (6.7) 5 (33.3) 8 (53.3) 1 (6.7) a

Total 7 34 58 6

ARI scores: 0, no adhesive remaining on tooth; 1, less than half of adhesive remainingon tooth; 2, more than half of adhesive remaining on tooth; 3, all adhesive remainingon the tooth* Groups with the same letter are not significantly different from each other. FishersExact test: 12.24, p = 0.83

a diamond bur and its surface etched with phosphor-ic acid to determine changes in bond strength.Together these steps resulted in significantly higherbond strengths for the chemically cured (Concise)and light cured resins (Transbond XT) but not theno-mix resin (Unite). It was considered that the abra-sion and etching removed by-products of the poly-merisation process and/or contamination by foodsand drinks in the 48-hour period.24 For the no-mixadhesive, the delay and subsequent surface treatmenthad little effect on bond strength, possibly becausethe solvents in this adhesive were ineffective inpreparing the surface of the FRC for bonding andenhancing bond strength.

Etching the surface of an orthodontic adhesive withphosphoric acid has been advocated by clinicians formaking composite additions and bonding ortho-dontic attachments.24 Abrasion with a diamond burmay have smoothed the surface of the bars andenhanced micromechanical retention and also mayhave removed food, polymerisation and degradationproducts. The solvents in the uncured orthodonticresins appear to have removed the products as no sig-nificant differences in the bond strengths of theimmediate (Group 2) and delayed (Groups 4 and 5)groups were found.

The majority of the attachments failed cohesively andthere were no significant ARI differences between thegroups. However, in Groups 3 (Transbond XT,immediate bonding) and 6 (Transbond XT, delayedbonding), all of the adhesive was left on the tooth sur-face in 13 and 6 per cent of the teeth, suggesting thatthe curing light may not have reached the resin in thedeepest parts of the bonding pad. Of the bracketsbonded immediately with Tetric Flow, 20 per centalso failed at the bracket interface, suggesting that thisadhesive did not have the cohesive strength of theorthodontic adhesives.

Conclusions

The following conclusions may be drawn from thisstudy:

Orthodontic brackets bonded immediately to FRCbars with either a flowable adhesive or various orthodontic adhesive systems that had adequate bondstrengths.

The bond strengths were significantly greater for thechemically cured (Concise) and light cured

(Transbond XT) adhesives when bonding wasdelayed 48 hours and the surfaces of the Tetric Flowcovered bars were abraded with a diamond bur andetched with phosphoric acid.

No significant differences in ARI scores were foundamong the groups.

Corresponding author

Dr Navid Kerayechian Department of OrthodonticsSchool of DentistryMashhad University of Medical SciencesMashhadIranTel: +98 511 8419814Fax: +98 511 8829500Email: [email protected]

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24. Rathke A, Tymina Y, Haller B. Effect of different surfacetreatments on the composite-composite repair bondstrength. Clin Oral Investig 2009;13:31723.

Introduction

Dentoalveolar Class II malocclusions may be treatedby the distal movement of the maxillary teeth.Treatment options range from extra-oral appliances,such as cervical headgear, to an ingenious collectionof intra-oral devices designed to move the maxillaryteeth distally. These appliances use magnets, wiresprings, orthodontic screws and Class II intermaxil-lary traction to achieve their objectives.111 The intra-oral treatment methods rely less on patient com-pliance for success compared with the extra-oralappliances, and in the absence of mini-screws, deriveanchorage from the maxillary teeth and/or the hardpalate. A frequent side effect of an intra-oral approachto molar distalisation is a loss of anterior anchorage.

Although the dental and skeletal effects of thePendulum intra-oral appliance have been pre-viously reported,1,2,1217 only one randomised trialhas compared the skeletal and dental effects of intra-and extra-oral treatment approaches.10,18,19 There-fore, the aim of the present study was to compare theeffects of an intra-oral distalising appliance and cer-vical headgear on the dentofacial structures of adolescents.

Subjects and methods

The subjects comprised 30 consecutive patients,referred to the Department of Orthodontics,Hacettepe University, who fulfilled the followinginclusion criteria:

Australian Orthodontic Journal Volume 27 No. 1 May 2011 Australian Society of Orthodontists Inc. 201110

The effects of the Pendulum distalising applianceand cervical headgear on the dentofacial structures

Ebubekir Toy* and Ayhan EnacarDepartment of Orthodontics, Inn University, Malatya* and the Department of Orthodontics, Hacettepe University, Ankara, Turkey

Background: Headgears are effective in distalising maxillary molars, but success depends on patient compliance and tolerance. Intra-oral distalising appliances are simple to construct and use and may be a better alternative for patients who arenon-compliant or cannot tolerate headgear.Aims: To compare the Pendulum (PEN) appliance and cervical headgear (CHG) on distal movement of maxillary first molars inpatients requiring maxillary molar distalisation. Methods: Thirty patients were randomly divided into two groups. Both groups had comparable occlusal and cephalometriccharacteristics before treatment. Fifteen patients (9 girls, 6 boys) with a mean age of 11.45 1.54 years (Range:8.5813.50 years) were treated with Pendulum appliances and 15 patients (10 girls, 5 boys) with a mean age of 11.72 1.24 years (Range: 9.5813.33 years) were treated with a Ricketts-type CHG. A pilot study of four patients estimated that thetime required to distalise the maxillary molars with the Pendulum appliance was five months. Therefore, the end of treatmentrecords for the CHG group were taken after 4.96 0.35 months. Lateral and postero-anterior cephalometric radiographswere taken of both groups at the start (T1) and end of distalisation/treatment (T2). Changes in cephalometric measurements inthe two groups were compared with Wilcoxon and Mann-Whitney U tests.Results: Measurements indicated that U6-ANS distance, overjet and U1-APo distance increased, U6-PP angle and U6-PTV distance reduced, and the molar relationship improved more in the PEN group compared with the CHG group. Statistically, significant right molar left molar differences were found between the two groups. Distalisation produced significant sideeffects, resulting in distal tipping of the first molars and an increase in overjet, whereas the CHG reduced the overjet.Conclusion: The Pendulum appliance was more effective than the CHG in distalising the maxillary first molars. (Aust Orthod J 2011; 1016)

Received for publication: October 2009Accepted: July 2010

Deceased

Ebubekir Toy: [email protected]

EFFECTS OF PENDULUM APPLIANCE AND CERVICAL HEADGEAR


1. Skeletal Class I malocclusion with a bilateral ClassII molar relationship.

2. Radiographic confirmation that at least one thirdof the roots of the unerupted maxillary second molarshad developed.

3. Nonextraction treatment plan.

4. Good oral hygiene.

5. No or minimal crowding in the mandibular dentalarch.

6. No signs of a temporomandibular joint disorder.

The subjects were randomly allocated to either agroup treated with an intra-oral Pendulum appliancewith a midline expansion screw (PEN) or a grouptreated with a Ricketts-type cervical headgear(CHG).20 The 15 subjects in the PEN group (9 girls,6 boys) had a mean age of 11.45 1.54 years (Range:8.5813.50 years) and the 15 subjects in the CHGgroup (10 girls, 5 boys) had a mean age of 11.72 1.24 years (Range: 9.5813.33 years). A pilot studyon four subjects in the PEN group established thatthe Pendulum appliance distalised the maxillarymolars in 5 months. Therefore progress records weretaken as close as possible to 5 months after the appliances were fitted (4.96 0.35 months).

The subjects in the PEN group received an appliancesimilar to that described by Hilgers.2 A palatal acrylicbutton was anchored to the maxillary first and secondpremolars with bonded occlusal rests. A midlinescrew and bilateral 0.032 inch TMA cantileversprings (Ormco Corporation, Glendora, CA, USA)were inserted into lingual sheaths on the first molar

bands (Figure 1). The springs were initially activated90 degrees, and the subjects were monitored at three-week intervals. The appliance was left in situ until themolars were in a slightly overcorrected (Class III)position,21 which, on average, took 4.83 0.96months (Range: 3.436.40 months). To prevent aposterior crossbite from developing, the subjects wereinstructed to turn the expansion screw a quarter turn,once a week.

The CHG group received an appliance described byRicketts et al. to distalise the maxillary molars.20It was activated to deliver 500 g of force and the subjects were requested to wear the appliance for1214 hours per day, especially at night. Progressrecords were taken after 4.96 0.35 months of treat-ment. The subjects were monitored at three-weekintervals and the headgear was adjusted when clinically indicated.

Figure 1. The Pendulum appliance.

Figure 2. Lateral cephalometric measurements:1. U6-PP: posterior angle between molar axis and the palatal plane(degrees) 2. U5-PP: posterior angle between premolar axis and palatal plane(degrees) 3. U1-PP: posterior angle between upper incisor axis and palatal plane(degrees) 4. U6-ANS: distance from the line constructed through the upper first molarto palatal plane to ANS (mm)5. U6-PTV: distance from upper first molar distal surface to PTV (mm)6. Molar relation: distance between mandibular first molar distal surface andmaxillary first molar distal surface measured along the occlusal plane (mm) 7. Incisor overjet (mm) 8. U1-APo: angle between the axis of the upper incisor and APo line(degrees)9. U1-APo: tip of the upper incisor to APo line (mm)10. U6 mesial root-ANS (mm) 11: U6 distal root-ANS (mm)12: Tilt of the occlusal plane: angle between occlusal plane and corpus axis(degrees)

TOY AND ENACAR


Cephalometric analysis Lateral, basilar and postero-anterior cephalometricradiographs were taken at the start of treatment (T1)and after completion of molar distalisation (T2) or, inthe case of the CHG group, after 4.96 0.35 monthsof treatment. The basilar cephalometric radiographswere taken with the mouth fully open.

The cephalometric radiographs were traced andmeasured using Jiffy Orthodontic Evaluation (JOE)digitising software (Rocky Mountain Orthodontics,Denver, CO, USA). Conventional lateral and pos-tero-anterior cephalometric measurements wereapplied (Figures 2 and 3). The distalising and rota-tional effects of both appliances were measured on thebasilar cephalometric radiographs (Figure 4).

Statistical analysis Shapiro-Wilks and Levenes variance homogeneitytests were used to test the normality of the data. Asthe data were not normally distributed and there wasno homogeneity of variance between the groups, theintra-group comparisons were performed with thenon-parametric Wilcoxon test and intergroupchanges were analysed with the Mann-Whitney U test.

All statistical analyses were performed using theStatistical Package for the Social Sciences, version13.0 for Windows (SPSS Inc., Chicago, IL, USA).

Error of the method Two weeks after the first measurements, 45 films (15postero-anterior, 15 lateral and 15 basilar radio-graphs) were selected at random and remeasured bythe same investigator and a paired t-test was appliedto the first and second measurements. There were nostatistically significant differences between the firstand second measurements. Pearson correlation analyses were applied to the same measurements, thehighest r value was .997 for U6-PTV and the lowestr value was .930 for the lower lip to aesthetic planedistance.

Results

The results are presented in Table I.

Pendulum group The lower anterior face height (LAFH) angle (p =0.001), maxillary depth angle (p = 0.041), lower lip-E plane (p = 0.007) and upper lip length (p = 0.021)

Figure 3. Postero-anterior measurements:1. R6-L6 width: distance between the buccal sur-faces of the right and left first molars (mm) 2. Maxillary width: distance between right and leftjugular points (mm)

Figure 4. Basilar measurements: A. R6 distance: distance from the perpendicular to the maxillary right firstmolar and the anterior margin of the foramen occipitale, measured along themidsagittal plane (mm)B. R6 rotation: anterior angle between axis of the maxillary right first molarand midsagittal plane (degrees)C. L6 distance (mm)D. L6 rotation (degrees)

increased significantly during treatment. Of the dentoalveolar measurements, the U6-PP angle (p = 0.001) and the U6-PTV distance (p = 0.001)reduced, the molar relationship (p = 0.001)improved, and the U6-ANS distance (p < 0.001),incisor overjet (p = 0.024) and U1-APo distance (p = 0.001) increased.

The R6 distance (p = 0.001) and L6 distances (p =0.001) reduced and R6-L6 width (p = 0.001), maxil-

lary width (p = 0.006) and L6 rotation (p = 0.029)increased significantly. The maxillary right first molarrotated approximately 4.5 degrees.

CHG groupThere were no statistically significant skeletal or softtissue changes. Of the dentoalveolar measurements,only the U6-PP angle, U5-PP angle and U1-PP angledid not change significantly.



Table I. Dentofacial changes after distalisation with Pendulum (PEN) and cervical headgear (CHG) appliances.

Variables PEN group CHG group

Mean difference p* Mean difference p* p(T2-T1) (T2-T1) PEN vs CHG

Skeletal and soft tissue measurements Total facial height (degrees) 0.79 0.140 -0.14 0.995 0.436Lower anterior face height (degrees) 1.63 0.001 0.28 0.460 0.267Mandibular arch (degrees) 0.62 0.590 0.12 0.865 0.567Mandibular plane angle (degrees) 0.65 0.164 0.15 0.887 0.389Facial axis (degrees) -0.60 0.061 0.23 0.650 0.056Maxillary depth angle (degrees) 0.66 0.041 0.00 0.944 0.250Lower lip-E plane (mm) 0.65 0.007 0.75 0.221 0.713Upper lip length (mm) 0.79 0.021 0.00 0.910 0.217Nasolabial angle (degrees) 0.17 0.977 -3.83 0.281 0.412

Dentoalveolar measurements U6 -PP (degrees) -15.10 0.001 0.90 0.616 0.000U5-PP (degrees) 0.93 0.496 1.80 0.092 0.870U1-PP (degrees) 1.67 0.112 -0.53 0.529 0.116U6-ANS (mm) 4.07 0.001 1.73 0.001 0.001U6PTV (mm) -3.69 0.001 -0.77 0.038 0.000Molar relation (mm) -3.55 0.001 1.08 0.025 0.001Incisor overjet (mm) 0.54 0.024 -0.82 0.005 0.000U1-APo (degrees) 2.10 0.052 -1.67 0.016 0.001U1-APo (mm) 1.05 0.001 -0.62 0.006 0.000U6-Mesial root-ANS (mm) 0.47 0.427 2.10 0.003 0.037U6-Distal root-ANS (mm) -0.17 0.691 1.80 0.003 0.007Occlusal plane (degrees) 0.75 0.514 2.58 0.005 0.161

Upper molars measurements R6-L6 width (mm) 3.17 0.001 0.93 0.213 0.015Maxillary width (mm) 1.43 0.006 2.10 0.002 0.455R6 Distance (mm) -3.87 0.001 -2.10 0.002 0.008R6 Rotation (degrees) 4.43 0.100 10.06 0.001 0.081L6 Distance (mm) -4.00 0.001 -1.87 0.002 0.000L6 Rotation (degrees) 6.87 0.029 8.36 0.001 0.575

Significant differences are in boldp* Wilcoxon testp Mann-Whitney U test

All maxillary molar measurements, except the R6-L6width, changed significantly during treatment.

Intergroup comparisonsThere were no statistically significant skeletal or softtissue changes. There were six statistically signifi-cant dentoalveolar differences: U6-ANS distance (p = 0.001), U6-PTV distance (p < 0.001), molarrelationship (p = 0.001), incisor overjet (p < 0.001)and U1-APo distance (p < 0.001). In all cases thechanges in the PEN group were greater than thechanges in the CHG group. Importantly, both rightand left molars distalised approximately 2 mm morein the PEN group compared with the CHG group.

Discussion

Many intra-oral molar distalisation appliances havebeen designed to minimise or eliminate the need forpatient cooperation. In the present comparative studyof different appliances, postero-anterior and basilarcephalometric radiographs were added to standardrecords to assess transverse, rotational and distalisingeffects on maxillary molars.

As an example of a non-compliant device, thePendulum appliance efficiently distalised the maxil-lary molar teeth to a Class I relationship without theneed for patient cooperation. Furthermore, only oneactivation period was required. These are distinctadvantages of the appliance when compared withother mechanistic approaches requiring patient com-pliance, such as CHG and Class II elastics.

Studies of the effects of the Pendulum appliance usually do not use a control group because the obser-vation period is invariably short (4.83 0.96 monthsfor the Pendulum and 4.96 0.35 months for theCHG, in the current study) for normal growthchanges to play a significant role in the treatmentresult.4,7,1416,18,22 Previous studies describing theappliance have revealed that approximately 45months of treatment time has been adequate.3,23Joseph and Butchart3 reported that Pendulum appli-ance treatment time ranged from 1.5 to 5 months.Angelieri et al.23 found that the mean time for distal-isation of the maxillary molars was 5.85 months.While accepting these published time periods, thepresent study required confirmation of the effectivetime period to take second records and apply theresult to gathering progress records of the CHG

group. At the end of the pilot study, it was confirmedthat a five-month treatment period was adequate.

The amount of distal movement of the maxillary firstmolars was higher and more rapid with the Pendulumappliance compared with the CHG and was a signif-icant finding of the current study.24 As seen on thelateral cephalograms measured by U6-ANS, the cor-rection of the Class II relationship was achieved bymaxillary first molar distalisation of 4.07 mm in thePendulum appliance group and 1.73 mm in theCHG group. The amount of molar distalisation wasstatistically greater in the Pendulum group than inthe CHG for each subject. Overcorrection is desirablebecause it has been noted that molar anchorage lossinvariably occurs during retraction of the premolars,the canines and especially the incisors.25 The distali-sation values generated by the Pendulum applianceagree with those previously reported by Ghosh andNanda,14 Byloff and Darendeliler,15 Bolla et al.8 andGelgor et al.24 However, the mean molar distalisationvalue of 1.73 mm for the CHG group was less thanthe data of Hubbard et al.,26 who found 2.4 mm ofKloehn type CHG movement in four months.

A potentially undesirable effect of Pendulum appli-ance treatment is excessive distal tipping of the upperfirst molars. According to the U6-PP measurement,the maxillary first molars were tipped distally 15.1degrees in the Pendulum and 0.9 degrees in the CHGgroup. Gosh and Nanda,14 and Byloff andDarendeliler15 found tipping, as a result of thePendulum appliance treatment, to range from 8.3and 14.5 degrees. The value of 15.1 degrees of tipping of the first molar was similar to the 14.5degrees of distal tipping described by Byloff andDarendeliler,15 when the original Pendulum designwas evaluated. The small amount of molar tipping inthe CHG group was contrary to the findings ofRingenberg and Butts,27 who reported substantialtipping. Byloff and Darendeliler15 attempted to cor-rect molar tipping by incorporating an uprightingbend in the Pendulum spring after distalisation of themolar had been completed. The uprighting bendappeared to be successful in uprighting the roots ofthe tipped molars, but has the potential to increaseanchorage loss.

The Pendulum appliance group suffered mildanchorage loss as defined by maxillary incisor pro-trusion (U1-APo mm) (mean differences 1.05 mm)and increased overjet (mean differences 0.54 mm).

TOY AND ENACAR


No clinical importance was attributed to the changesbecause of their minor nature. U5-ANS, U1-PP andU1-APo angles showed no statistically significantchanges during treatment. Anchorage loss, as definedby the significant maxillary incisor proclination andconcomitant increase in overjet has been clearlyshown previously.15 The present study determined acomparatively smaller increase in overjet.

The possible bite-opening effect of CHG is wellknown, and so any appliance that is capable of distal-ising molar teeth without adversely altering the ver-tical dimension is advantageous in the treatment ofhigh-angle Class II and/or dentally crowded patients.Distalisation and tipping of the upper first molars canresult in molar extrusion relative to the palatal planeand therefore affect face height. In the present studyand in agreement with previous reports, thePendulum appliance produced clockwise mandibularrotation, demonstrated by statistically significantincreases (1.63 degrees) in LAFH.1,17 In addition, astatistically significant increase (0.66 mm) in maxil-lary depth was seen in the same group. However, overthe short time frame of treatment, no statistically sig-nificant skeletal differences were observed in the CHGgroup. According to Ghosh and Nanda,14 a smallbackward rotation of the mandible (Mean 1.09 ) wasreported following CHG use. While there was a trendtoward an increase in the mandibular plane angleobserved after treatment, it was not statistically sig-nificant. In the opinion of Ngantung et al.,28 theincrease in LAFH during treatment was a result ofnormal vertical craniofacial growth. Burkhardt et al.29explained the change as an increase in inclination of the mandibular plane as a result of Pendulumappliance effects.

An advantage of CHG is that as molar distalisationoccurs, distal movement of the maxillary incisors alsotakes place. This implies a decrease in overjet, whichis a desired aim in the treatment of Class II division 1malocclusions. However, when the maxillary molarsare distalized by an intra-oral appliance, anchorageloss or forward movement of the anterior teeth is like-ly.14,15,3033 The maxillary incisors were proclined by2.1 degrees and protruded by 1.05 mm by the Pen-dulum appliance and retroclined by 1.67 degrees andretruded by 0.62 mm in the CHG group. A similaramount of mesial and distal movement of maxillaryincisors was observed by Bondemark and Karlsson19for intra-oral and extra-oral appliances. Escobar et

al.34 and nag et al.35 described distal incisor move-ment in their implant-supported Pendulum appli-ance groups. In contradistinction, Taner et al.18found that incisors showed a significant amount ofproclination due to molar distalisation followingPendulum appliance treatment. In support of Taneret al.,18 additional authors9,14,30,36 have reported pro-clination of anterior teeth during molar distalisationwith intra-oral mechanics.

Conclusion

The findings demonstrated that the Pendulum appli-ance was more effective than CHG in producing distal movement of the maxillary first molars. Thedistalisation time and rate of movement were sig-nificantly shorter with the Pendulum appliance compared with CHG. However, this gain in molardistalisation was at the expense of significant sideeffects, including molar tipping and anchorage loss atthe incisors. CHG treatment produced more uprightmolar distalisation and a decrease in overjet. Molardistalisation occurred without any significant changesto the mandibular plane angle. To achieve success-ful results, the effects of each treatment modality on dentofacial structures need to be taken into individual patient consideration.


Dr Ebubekir ToyInn niversitesi, Dishekimligi FakltesiOrtodonti Anabilim Dal, Kamps 44280 MalatyaTurkeyEmail: [email protected]

References 1. Hilgers JJ. The pendulum appliance for Class II noncompli-

ance therapy. J Clin Orthod 1992;26:70614.2. Hilgers JJ. The pendulum appliance: an update. Clinical

Impressions 1993;2:1517. 3. Joseph A, Butchart CJ. An evaluation of the pendulum

distalizing appliance. Semin Orthod 2000;6:12935.4. Gianelly AA, Vaitas AS, Thomas WM. The use of magnets to

move molars distally. Am J Orthod Dentofacial Orthop1989;96:1617.

5. Gianelly AA, Bednar J, Dietz VS. Japanese NiTi coils used tomove molar distally. Am J Orthod Dentofacial Orthop1991;99:5646.

6. Locatelli R, Bednar J, Dietz VS, Gianelly AA. Molar distal-ization with superelastic NiTi wire. J Clin Orthod 1992;26:2779.

7. Haydar S, Uner O. Comparison of Jones jig molar distaliza-tion appliance with extraoral traction. Am J OrthodDentofacial Orthop 2000;117:4953.



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8. Bolla E, Muratore F, Carano A, Bowman SJ. Evaluation ofmaxillary molar distalization with the distal jet: a compari-son with other contemporary methods. Angle Orthod 2002;72:48194.

9. em TT, Yksel S, Okay C, Glsen A. Effects of a three-dimensional bimetric maxillary distalizing arch. Eur JOrthod 2000;22:2938.

10. Altug-Atac AT, Erdem D. Effects of three-dimensionalbimetric maxillary distalizing arches and cervical headgearon dentofacial structures. Eur J Orthod 2007;29:529.

11. Keles A, Isguden B. Unilateral molar distalization withmolar slider (two case reports). Turk Ortodonti Dergisi1999;12:193202.

12. Bennett RK, Hilgers JJ. The pendulum appliance: creatingthe gain. Clinical Impressions 1994;3:1418.

13. Snodgrass DJ. A fixed appliance for maxillary expansion,molar rotation, and molar distalization. J Clin Orthod1996;30:1569.

14. Ghosh J, Nanda RS. Evaluation of an intraoral maxillarymolar distalization technique. Am J Orthod DentofacialOrthop 1996;110:63946.

15. Byloff FK, Darendeliler MA. Distal molar movement usingthe pendulum appliance. Part 1: clinical and radiologicalevaluation. Angle Orthod 1997;67:24960.

16. Byloff FK, Darendeliler MA, Clar E, Darendeliler A. Distalmolar movement using the pendulum appliance. Part 2: theeffects of maxillary molar root uprighting bends. AngleOrthod 1997;67:26170.

17. Bussick TJ, McNamara JA. Dentoalveolar and skeletalchanges associated with the pendulum appliance. Am JOrthod Dentofacial Orthop 2000;117:33343.

18. Taner TU, Yukay F, Pehlivanoglu M, Cakirer B. A compara-tive analysis of maxillary tooth movement produced by cer-vical headgear and pend-x appliance. Angle Orthod 2003;73:68691.

19. Bondemark L, Karlsson I. Extraoral vs intraoral appliancefor distal movement of maxillary first molars: a randomizedcontrolled trial. Angle Orthod 2005;75:699706.

20. Ricketts RM, Bench RW, Gugino CF, Hilgers JJ.Bioprogressive therapy. Rocky Mountain Orthodontics,Denver, 1979; pp. 7192, 24954.

21. McNamara JA Jr, Brudon WL. Orthodontic and orthopedictreatment in the mixed dentition. Needham Press, 1993;1029.

22. Kinzinger GS, Fritz UB, Sander FG, Diedrich PR. Efficiencyof a pendulum appliance for molar distalization related tosecond and third molar eruption stage. Am J OrthodDentofacial Orthop 2004;125:823.

23. Angelieri F, Almeida RR, Almeida MR, Fuziy A.Dentoalveolar and skeletal changes associated with the pen-dulum appliance followed by fixed orthodontic treatment.Am J Orthod Dentofacial Orthop. 2006;129:5207.

24. Gelgor IE, Karaman AI, Buyukyilmaz T. Comparison of 2distalization systems supported by intraosseous screws. Am JOrthod Dentofacial Orthop 2007;131:161.e18.

25. Gelgor IE, Buyukyilmaz T, Karaman AI, Dolanmaz D,Kalayci A. Intraosseous screw-supported upper molar distal-ization. Angle Orthod 2004;74:83850.

26. Hubbard GW, Nanda RS, Currier GF. A cephalometric eval-uation of nonextraction cervical headgear treatment in ClassII malocclusions. Angle Orthod 1994;64:35970.

27. Ringenberg QM, Butts WC. A controlled cephalometricevaluation of single-arch cervical traction therapy. Am JOrthod 1970;57:17985.

28. Ngantung V, Nanda RS, Bowman SJ. Posttreatment evalua-tion of the distal jet appliance. Am J Orthod DentofacialOrthop 2001;120:17885.

29. Burkhardt DR, McNamara JA Jr, Baccetti T. Maxillary molardistalization or mandibular enhancement: a cephalometriccomparison of comprehensive orthodontic treatment includ-ing the pendulum and the Herbst appliances. Am J OrthodDentofacial Orthop 2003;123:10816.

30. Bondemark L, Kurol J. Distalization of maxillary first andsecond molars simultaneously with repelling magnets. Eur JOrthod 1992;14:26472.

31. Bondemark L. A comparative analysis of distal maxillarymolar movement produced by a new lingual intra-arch Ni-Ticoil appliance and a magnetic appliance. Eur J Orthod 2000;22:68395.

32. Papadopoulos MA, Mavropoulos A, Karamouzos A.Cephalometric changes following simultaneous first and sec-ond maxillary molar distalization using a non-complianceintraoral appliance. J Orofac Orthop 2004;65:12336.

33. Fortini A, Lupoli M, Giuntoli F, Franchi L. Dentoskeletaleffects induced by rapid molar distalization with the firstclass appliance. Am J Orthod Dentofacial Orthop 2004;125:697705.

34. Escobar SA, Tellez PA, Moncada CA, Villegas CA, LatorreCM, Oberti G. Distalization of maxillary molars with thebone supported pendulum: a clinical study. Am J OrthodDentofacial Orthop 2007;131:5459.

35. nag, G, Sekin , Diner B, Arikan F. Osseointegratedimplants with pendulum springs for maxillary molar distal-ization: a cephalometric study. Am J Orthod DentofacialOrthop 2007;131:1626.

36. Keles, A, Saynsu K. A new approach in maxillary molar dis-talization: intraoral bodily molar distalizer. Am J OrthodDentofacial Orthop 2000;117:3948.

Introduction

Adolescence is a period of profound physiological andpsychosocial change that is also associated withaltered nutritional needs.1 Adolescents are vulnerablebecause of increased dietary requirements during thisperiod when changes in lifestyle and food habitsgreatly affect nutrient intake.2 In addition, adoles-cents are typically involved in orthodontic treatment,during which modified nutritional needs are requiredbut poor dietary behaviour is likely.3 It is acceptedthat orthodontic treatment causes pressure sensitivity

to the teeth which leads to pain, discomfort and func-tional limitations.47 The mastication of hard foods istherefore difficult for patients and there is a tendencyfor soft foods to be eaten. The avoidance of hard-to-chew natural foods usually involves the elimination ofsolid foods such as raw vegetables and fresh fruit,811stringy foods such as meat1214 and dry foods such asbread or bagels12,13 from the diet.

A previous examination of patient nutrient intakebefore and after orthodontic adjustment reported adecrease in the intake of copper and manganese and

Australian Society of Orthodontists Inc. 2011 Australian Orthodontic Journal Volume 27 No. 1 May 2011 17

Comparison of dietary intake between fixed orthodontic patients and control subjects

Alireza Sarraf Shirazi,* Majid Ghayour Mobarhan, Elham Nik,+ Navid Kerayechian

and Gordon A. FernsDepartment of Pediatric Dentistry and the Dental Research Center;* Cardiovascular Research Center and Biochemistry and Nutrition ResearchCenter, Mashhad University of Medical Sciences, Mashhad, Iran; Department of Pediatric Dentistry, Ahvaz University of Medical Sciences,Ahvaz, Iran;+ Department of Orthodontics, Mashhad University of Medical Sciences, Mashhad, Iran and the Institute for Science andTechnology in Medicine, University of Keele, United Kingdom

Background: Adolescence is a period of rapid physiological and psychological development which is associated with anincreased demand in nutritional requirements. Orthodontic therapy is also commonly initiated during this phase of life and nutritional intake may also change during treatment. Aims: To compare the nutrient intakes of adolescents wearing fixed orthodontic appliances and a control group matched forage and gender.Method: A total of 180 patients aged between 15 and 17 years participated in this study (90 in the study group and 90 controls). Demographic data were collected by questionnaire and dietary intake was assessed using a 24-hour memory recalland was analysed using Dietplan6 software (Forestfield Software Ltd, UK). Comparisons between groups were assessed by theIndependent sample t - test and the SPSS was used for statistical analysis.Results: Orthodontic patients consumed a similar number of total calories, protein and carbohydrate (p > 0.05); however, theyhad a greater intake of total fat, saturated fat, monosaturated fat, polysaturated fat, linolenic fat, linoleic fat and cholesterol andsignificantly lower intake of fibre, chromium and beta-carotene (p < 0.05) compared with the Control group. The intake ofother macro- and micro-nutrients did not differ significantly between groups.Conclusions: Adolescents receiving orthodontic treatment have an altered dietary intake that can be harmful to their health. As adolescents are at a critical stage of development and dietary intake is of particular importance, it is recommended that targeted nutritional guidance is provided to patients during orthodontic treatment.(Aust Orthod J 2011; 1722)

Received for publication: August 2010Accepted: December 2010

Alireza Sarraf Shirazi: [email protected] Ghayour Mobarhan: [email protected] Nik: [email protected] Kerayechian: [email protected] A Ferns: [email protected]

SHIRAZI ET AL


a possible detrimental effect on the rate of toothmovement.15 Orthodontists recommend that patientsavoid hard foods that may cause appliance damagewhich, in turn, may affect nutrient intake. Moreover,occlusal changes during treatment may also impairmastication and patients may cope by altering theirdiet or by swallowing coarse particles leading to diges-tive disorders. In both circumstances, impaired dietaryintake may increase nutrition-induced disease risks.16

In 1981, Nanda and Hickory3 stated that, althoughorthodontists rarely see manifestations of nutritionaldeficiencies in their patients, suboptimal levels of certain nutrients are common and may affect the bio-logic response of tissues. It has been reported thatbetween 17 and 72 per cent of orthodontic patientsmay have suboptimal levels of ascorbic acid and adeficiency may affect the connective tissue of theperiodontal ligament and the formation ofosteoid.17,18 In addition, nutritional stress to the periodontium, coupled with the irritation of ortho-dontic bands and brackets, may cause an altered gingival response.3

There are few reports that have examined the effectsof orthodontic treatment on a patients diet.Therefore, the aim of the present study was to com-pare the dietary intake of individuals receiving ortho-dontic treatment with healthy teenagers who weregender and age matched.

Material and methodsSubjectsTwo groups totalling 180 adolescents aged 15 to 17years participated in the study. Each group contained90 individuals; 31 boys and 59 girls in theOrthodontic treatment group and 34 boys and 56girls in the Control group. The sample was derivedfrom teenagers seeking orthodontic treatment in theMashhad Faculty of Dentistry, Mashhad, Iran. Thesocioeconomic status of the two groups was com-parable and comprehensive orthodontic treatment ofthe test group had been implemented for at least sixmonths prior to the nutritional assessment. Orthog-nathic surgery patients were excluded from the study.

The Control group comprised individuals between15 to 17 years of age, who were eligible but yet toreceive orthodontic treatment. Patients in the con-trol group who had active dental disease were alsoexcluded from the study.

All patients provided informed consent and partici-pation in the study was approved by the EthicsCommittee of the Research Council of MashhadUniversity of Medical Sciences.

Anthropometric assessmentMeasurements of the height (in centimetres) andweight (in grams) were performed in all subjects.Height was measured to the nearest millimetre with awall-mounted Harpenden stadiometer (Holtain Ltd,Croswell, Crymych, UK) and weight was measuredwith electronic scales (Model 1609N; TanitaCorporation, Tokyo, Japan) to the nearest 0.1 kg.Body mass index (BMI) in kg/m2 was also calculated.

Dietary assessmentA questionnaire was designed to collect demographicdata (age, gender) as well as information regardingthe 24-hour dietary recall. A trained interviewerasked subjects in a face-to-face interview, to recall anddescribe every item of food and drink consumed over the previous 24 hours.2 The recording of foodsand beverages for individuals who were ill at thescheduled time for dietary assessment were postponedto the next appointment. Individual nutritionalintakes were assessed with the use of Dietplan6 soft-ware (Forestfield Software Ltd., UK) which cananalyse and identify macro and micro nutrient intake.

Statistical analysisThe results obtained from the Nutrition AnalysisSoftware were entered into the SPSS software for statistical analysis. Comparisons of macro-and micro-

Table I. Demographic data of the orthodontic patients and the controlsubjects.

Orthodontic group Control group p*

N = 90 N = 90

Age (years) 15.95 1.40 15.91 1.38 0.348Weight (kg) 53.85 8.93 54.60 9.20 0.766Height (cm) 162.80 7.55 159.85 7.53 0.178BMI (kg/m2) 20.55 2.56 21.58 2.24 0.435

Values expressed as Mean SD* Students t - testBMI, body mass index

nutrient dietary intake between the Orthodonticgroup and the Control group were assessed by theIndependent sample t-test with a Bonferroni correc-tion for multiple measurements. A p value < 0.05 wasconsidered significant.

Results

The descriptive statistics including the means andstandard deviations of demographic data (in bothgroups) are presented in Table I. The mean values ofage, height, weight and BMI of the Orthodonticgroup were not significantly different from theControl group (p > 0.05).

Comparison of the macronutrient intakesThe orthodontic patients had a markedly greaterintake of total fat (p = 0.011), cholesterol (p = 0.004),saturated fat (p = 0.002), monosaturated fat (p = 0.04), polysaturated fat (p = 0.043), linoleic fat(p = 0.039), linolenic fat (p = 0.045) and significant-ly lower intake of fibre (p = 003) in comparison withthe Control group, but consumed a similar numberof calories, protein and carbohydrate (Table II).

Comparison of the micronutrient intakesThe mean intakes of chromium (p = 0.024) and beta-carotene (p < 0.001) in the Control group were

DIETARY INTAKE COMPARISONS


Table II. Dietary intake of calories and macronutrients of orthodontic patients and control subjects.

Calories/Macronutrients Mean intake p*Orthodontic group Control group

N = 90 N = 90

Food energy (kcal) 1703.66 608.92 1634.68 738.130 0.492

Fat Total fat (g) 69.88 35.33 56.54 34.93 0.011Cholesterol (mg) 232.26 186.74 166.05 111.090 0.004Saturated fat (g) 23.39 14.03 17.75 9.700 0.002Monounsaturated (g) 20.77 11.40 17.01 13.10 0.040Polyunsaturated (g) 20.31 13.81 16.16 13.79 0.043Oleic fat (g) 12.86 9.79 10.88 12.11 0.227Linoleic fat (g) 18.11 13.68 14.11 12.29 0.039Linolenic fat (g) 0.91 1.26 0.58 0.90 0.045EPA-Omega 3 (g) 0.003 0.017 0.0001 0.0010 0.068DHA-Omega 3 (g) 0.02 0.086 0.008 0.010 0.222

CarbohydratesTotal carbohydrates (g) 212.08 85.270 226.32 112.57 0.337Sugar (g) 63.58 39.81 74.62 49.65 0.100Glucose (g) 9.04 9.67 020.98 105.85 0.288Galactose (g) 3.30 3.00 3.71 5.56 0.538

Fibre Dietary fibre (g) 9.47 7.04 12.70 9.370 0.007Soluble fibre (g) 0.20 0.25 0.39 0.58 0.003Insoluble fibre (g) 1.46 2.03 2.57 3.47 0.009Crude fibre (g) 4.22 3.04 4.92 4.37 0.215

Protein (g) 69.29 29.78 66.57 34.19 0.568

Values expressed as Mean SD* Students t -test, significant values in boldEPA, eicosapentaenoic acidDHA, docosahexaenoic acid

SHIRAZI ET AL


significantly higher compared with the Orthodonticgroup. The nutrition analysis indicated that therewere no significant differences between two groups in the intake of other vitamins and trace elements(Table III).

Discussion

The most important finding of this study was the sig-nificantly higher intake of fat and lower intake offibre in the Orthodontic group compared with theControl group. In addition, the intake of chromiumand beta-carotene was lower in the Orthodonticgroup relative to the Control group. Furthermore, theintake of saturated, monosaturated and polysaturatedfat and cholesterol was significantly higher in theOrthodontic group.

Consistent with the present findings, Riordan15showed that the intake of fat was higher after ortho-dontic adjustment. However, the differences thathave been previously reported did not reach statisticalsignificance. This may be possibly related to the smallsample size (10 participants; 3 boys, 7 girls betweenthe ages of 12 and 16 years) and the short time ofintervention in the earlier study.

Saturated fatty acids are reported to be a risk factorfor atherosclerosis and increased cholesterol and saturated fatty acid intake increases the risk of cardio-vascular disease.1921 In addition, it is known that adiet high in fat is associated with obesity, which inturn increases the risk of hypertension,22 cardiovas-cular disease and noninsulin-dependent diabetes.23,24Further concern was noted in the dietary intake of

Table III. Dietary intake of vitamins and trace elements (Micronutrients) of orthodontic patients and control subject

Vitamins, minerals and Mean intake p*trace elements Orthodontic group Control group

N = 90 N = 90

Sodium (mg) 2533.49 1287.97 2267.21 1677.78 0.231Potassium (mg) 2513.76 1089.15 2860.09 1682.35 0.099Iron (mg) 9.47 4.59 9.11 5.92 0.648Calcium (mg) 1007.68 583.72 1033.16 891.85 0.820Magnesium (mg) 253.50 122.54 258.14 136.03 0.809Phosphorus (mg) 1231.85 587.50 1237.29 891.76 0.961Zinc (mg) 8.78 4.08 8.39 5.00 0.569Copper (mg) 1.13 0.87 1.14 1.15 0.935Manganese (mg) 2.96 2.39 3.05 1.75 0.765Chromium (mg) .016 .018 .026 .034 0.024Vitamin A (Ug) 0 834.87 1055.91 767.40 704.67 0.612Beta-Carotene (Ug) 072.10 114.70 278.34 528.57

fibre which was lower in orthodontic patients com-pared with control subjects. Fibre has been shown tohave beneficial physiological functions in the gastro-intestinal tract and in reducing the risk of coronaryartery disease and cancer.2 Fibre binds bile acids andincreases the excretion of bile acid-derived choles-terol. It also prevents dietary fat and cholesterol absorp-tion by the binding of bile acids to fat and lipids.2

Chromium is involved in insulin secretion and alsosupports normal cholesterol levels. Chromium deficiency results in insulin resistance and lipidabnormalities have also been reported.2,24 Foods richin beta-carotene protect the cells from the damagingeffects of free radicals, provide a source of vitamin A,enhance the functioning of the immune system andmaintain a healthy reproductive system. Food sourcesof beta-carotene include sweet potatoes, carrots,spinach, turnips and green leaf vegetables.2,25,26 It ispossible that the significant difference in caroteneintake between the groups was due to the low con-sumption of hard vegetables (especially carrots) inorthodontic patients during the treatment. The lowerintake of fibre and vitamin C (although not sig-nificantly different) in orthodontic patients in com-parison with control subjects is consistent with thisfinding. Riordans15 results demonstrated that theintake of copper and manganese decreased signifi-cantly after orthodontic adjustment; however, in thepresent study, although the intake of these two elements was lower in the Orthodontic group, thedifference was not statistically significant.

The results of Riordans15 study of the dietary changesand nutrient intake before and after orthodonticadjustment reflected the short study time frame.Alterations in nutrient intake are likely to occur overlonger-term orthodontic treatment. Past studies havedemonstrated that an adaptation to pain and discom-fort occurs during the first week after the placementof the orthodontic appliances.2732 In the presentstudy, the 24-hour memory recall was obtainedapproximately three or four weeks after the ortho-dontic adjustment visit, at a time when patients wereexperiencing little pain and pressure sensitivity.However, the results indicated that nutrient intakehad been affected and likely due to poor dietarybehaviour established during the treatment ratherthan from short-term discomfort.

A limitation of the present study is its cross-sectionaldesign. It is not possible to be certain that the

associations between fixed orthodontic therapy andthe nutrient intake of the patients are directly related.The 24-hour recall method of data collection requiresindividuals to remember the specific amounts of food consumed in the previous 24 hours.2 Patientsdid not anticipate that their diet was being analysedand therefore ate normally. However, the inability toaccurately recall and the uncertainty regarding thepatients normal intake, produce possible flaws in themethodology.2

According to Proffit,33 patients with severe malocclu-sion often have difficulty in normal mastication.These individuals have learnt to avoid certain foodsthat are hard to incise and chew, and may have problems with cheek and lip biting.33 Therefore, it ispossible that an altered nutrient intake during ortho-dontic treatment could be due to the malocclusionand not the orthodontic therapy per se. Therefore, toeliminate this bias, matched control subjects wereselected and assessed from individuals who wereawaiting orthodontic therapy.

Conclusions

Fixed orthodontic therapy may have an associatedbearing on the nutrient intake of patients. In the pres-ent report, the most important changes were in theintake of foods containing fats and fibre.

A significantly higher intake of fat and lower intake offibre were characteristics of orthodontic patients incomparison with a matched Control group. This mayincrease the risk of cardiovascular diseases and cancerin these patients.

It is recommended that nutritional guidance be pro-vided to orthodontic patients and in this respect, thehelp of a dietitian may be worthwhile.


Associate Professor Majid Ghayour MobarhanCardiovascular Research CenterBiochemistry and Nutrition Research CenterFaculty of MedicineMashhad University of Medical SciencesMashhadIranTel: +98-511-8828573Fax: +98-511-8828574Email: [email protected]

DIETARY INTAKE COMPARISONS


References 1. Heald FP, Gong EJ. Diet, nutrition, and adolescence. In:

Shils ME, Olson JA, Shike M, Ross AC, eds. Modern nutri-tion in health and disease. 9th ed. Baltimore: LippincottWilliams and Wilkins; 1999. pp. 85567.

2. Mahan LK, Escott-Stump S. Krauses food and nutritiontherapy. 12th ed. St. Louis: Elsevier Health Sciences; 2008.

3. Hickory W, Nanda R. Nutritional considerations in ortho-dontics. Dent Clin North Am 1981;25:195201.

4. Utomi IL. Challenges and motivating factors of treatmentamong orthodontic patients in Lagos, Nigeria. Afr J MedMed Sci 2007;36:316.

5. Bernab E, Sheiham A, de Oliviera CM. Impacts on dailyperformances related to wearing orthodontic appliances.Angle Orthod 2008;78:4826.

6. Sergl HG, Klages U, Zentner A. Pain and discomfort duringorthodontic treatment: causative factors and effects on com-pliance. Am J Orthod Dentofacial Orthop1998;114:68491.

7. Sergl HG, Klages U, Zentner A. Functional and social dis-comfort during orthodontic treatment-effects on complianceand prediction of patients adaptation by personality vari-ables. Eur J Orthod 2000;22:30715.

8. Wayler AH, Kapur KK, Feldman RS, Chauncey HH. Effectsof age and dentition status on measures of food acceptabil-ity. J Gerontol 1982;37:2949.

9. Brodeur JM, Laurin D, Vallee R, Lachapelle D. Nutrientintake and gastrointestinal disorders related to masticatoryperformance in the edentulous elderly. J Prosthet Dent1993;70:46873.

10. Joshipura KJ, Willett WC, Douglass CW. The impact ofedentulousness on food and nutrient intake. J Am DentAssoc 1996;127:45967.

11. Garcia RI, Perlmuter LC, Chauncey HH. Effects of denti-tion status and personality on masticatory performance andfood acceptability. Dysphagia 1989;4:1216.

12. Hildebrandt GH, Loesche WJ, Lin CF, Bretz WA.Comparison of the number and type of dental functionalunits in geriatric populations with diverse medical back-grounds. J Prosthet Dent 1995;73:25361.

13. Hildebrandt GH, Dominguez BL, Schork MA, Loesche WJ.Functional units, chewing, swallowing, and food avoidanceamong the elderly. J Prosthet Dent 1997;77:58895.

14. Baxter JC. The nutritional intake of geriatric patients withvaried dentitions. J Prosthet Dent 1984;51:1648.

15. Riordan DJ. Effects of orthodontic treatment on nutrientintake. Am J Orthod Dentofac Orthop 1997;111:55461.

16. Ngom PI, Woda A. Influence of impaired mastication onnutrition. J Prosthet Dent 2002;87:66773.

17. Cheraskin E, Ringsdorf WM. Biology of the orthodonticpatient. I: Plasma ascorbic acid levels. Angle Orthod 1969;39:1378.

18. Cheraskin E, Ringsdorf WM. Biology of the orthodonticpatient. II: Lingual vitamin C test scores. Angle Orthod1969;39:3245.

19. Willett WC. Diet and health: what should we eat? Science1994;264:5327.

20. Steinberg D, Witztum JL. Lipoproteins and atherogenesis.Current concepts. JAMA 1990;264:304752.

21. Willetts J, Balster RL, Leander JD. The behavioural phar-macology of NMDA receptor antagonists. Trends PharmacolSci 1990;11:4238.

22. Sjostrom CD, Lissner L, Wedel H, Sjostrom L. Reduction inincidence of diabetes, hypertension and lipid disturbances

after intentional weight loss induced by bariatric surgery:the SOS Intervention Study. Obes Res 1999;7:47784.

23. Gumbiner B. The treatment of obesity in type 2 diabetesmellitus. Prim Care 1999;26:86983.

24. Anderson RA. Chromium in the prevention and control ofdiabetes. Diabetes Metab 2000;26:227.

25. Agarwal S, Rao AV. Carotenoids and chronic diseases. DrugMetabol Drug Interact 2000;17:189210.

26. Krinsky NI. Carotenoids as antioxidants. Nutrition 2001;17:81517.

27. Ngan P, Kess B, Wilson S. Perception of discomfort bypatients undergoing orthodontic treatment. Am J OrthodDentofac Orthop 1989;96:4753.

28. Bergius M, Berggren U, Kiliaridis S. Experience of pain dur-ing an orthodontic procedure. Eur J Oral Sci 2002;110:928.

29. Jones M, Chan C. The pain and discomfort experienced dur-ing orthodontic treatment: a randomized controlled clinicaltrial of two initial aligning arch wires. Am J OrthodDentofac Orthop 1992;102:37381.

30. Scheurer PA, Firestone AR, Burgin WB. Perception of painas a result of orthodontic treatment with fixed appliances.Eur J Orthod 1996;18:34957.

31. Sergl HG, Klages U, Zentner A. Pain and discomfort duringorthodontic treatment: causative factors and effects on com-pliance. Am J Orthod Dentofacial Orthop 1998;114:68491.

32. Polat O, Karaman AI. Pain control during fixed orthodonticappliance therapy. Angle Orthod 2005;75:21419.

33. Proffit WR, Sarver DM, Ackerman JL. Orthodontic dia-gnosis: the development of a problem list. In: Proffit WR,Fields Jr HW, Sarver DM, eds. Contemporary Orthodontics.4th ed. St.Louis: Mosby; 2007. pp. 167233.

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Introduction

It is important that treatment outcomes of patientswho present with cleft lip and palate are regularlyevaluated, to ensure quality and consistency of patientcare, as well as allow outcome comparisons betweendifferent cleft care centres.13 For clinical audits to beconducted effectively, emphasis should be placed onthe development of methods of assessing treatmentoutcomes.4 Previous reports have recommendedindices that assess arch relationships and one sug-gested method is to measure the degree of crossbitefor individual teeth in order to calculate an overallscore.5,6 However, this method can be cumbersome

and time-consuming and inaccurately represent theoverall severity of the malocclusion. It is possible thata mild generalised irregularity may yield a higherscore than a more severe but localised anomaly.4

An effective method used in a number of multicentreaudits to assess dental arch relationships in completeunilateral cleft lip and palate patients (UCLP) is theGoslon (Great Ormond Street London and Oslo)Yardstick.7,8 Unlike other indices, the GoslonYardstick assesses the difficulty of orthodontic cor-rection as well as the severity of malocclusion. Themeasure has been shown to be simple and reliablewhen used by calibrated examiners.7,9,10 It allows

Australian Society of Orthodontists Inc. 2011 Australian Orthodontic Journal Volume 27 No. 1 May 2011 23

Evaluation of primary surgical outcomes in NewZealand patients with unilateral clefts of the lipand palate

Hannah C. Jack,* Joseph S. Antoun* and Peter V. FowlerOrthodontic Department, School of Dentistry, University of Otago, Dunedin* and the Oral Health Centre, Christchurch Hospital,Christchurch, New Zealand

Objective: To evaluate and compare the primary surgical outcomes of complete unilateral cleft lip and palate (UCLP) patients intwo New Zealand cleft care centres.Methods: This is a retrospective study of two providers of cleft care in New Zealand: Centre A in the North Island and CentreB in the South Island of New Zealand. Pre-orthodontic study models were evaluated from 28 UCLP patients from Centre A withprimary surgical repairs performed between 19871999 and 31 UCLP patients from Centre B with primary surgical repairsperformed between 19842000. Dental arch relationships were measured using the Goslon Yardstick. A Goslon score of 1 isconsidered to be an excellent outcome, whereas a score of 5 is a very poor treatment outcome.Results: Intra- (Kappa: 0.84 0.93) and inter-examiner (Kappa: 0.63 0.69) reliabilities revealed good to very good agree-ment between examiners using the Goslon Yardstick. The mean Goslon score for Centre A was 3.5, with no cases in Group 1,five cases in Group 2 (17.9 per cent), nine cases in Group 3 (32.1 per cent), 11 cases in Group 4 (39.3 per cent) and threecases in Group 5 (10.7 per cent). The mean score for Centre B was 3.1, with one case in Group 1 (3.2 per cent), nine casesin Group 2 (29.0 per cent), eight cases in Group 3 (25.8 per cent), 11 cases in Group 4 (35.5 per cent) and two cases inGroup 5 (6.5 per cent). There were no statistically significant differences between the two centres (p > 0.05). Conclusions: The outcome scores from the two cleft centres, based on historic records, were disappointing and higher thanexpected. It is recommended that a review of primary surgical protocols be implemented to ensure outcomes comparable withinternational standards. The results provide useful benchmarks for future comparisons of treatment. (Aust Orthod J 2011; 2327)

Received for publication: June 2010Accepted: December 2010

Hannah C. Jack: [email protected] S. Antoun: [email protected] V. Fowler: [email protected]

JACK ET AL


categorisation of dental arch relationships in the latemixed or early permanent dentition stage into fivediscrete categories. The anteroposterior relationshipof the arches is of greatest clinical importance as itreflects the underlying skeletal relationship.Generalised dental crowding and irregularity is rela-tively less important. Accordingly, Goslon Groups 1and 2 (excellent/good result) have occlusions thatrequire simple orthodontic treatment or none at all,while Group 3 (fair result) requires complex ortho-dontic treatment to correct malocclusions, although agood result can be anticipated. In contrast, GoslonGroups 4 and 5 (poor/very poor result) have poordental arch relationships and often require orthog-nathic surgery to correct underlying skeletal disharmonies.4,7

Previous studies have suggested a higher rate of non-syndromic orofacial clefts in New Zealand comparedwith European studies.1113 Previously reported NewZealand data has revealed an incidence of 1.5 to 1.94per 1000 live births in patients of Europeandescent1113 and 2.26 per 1000 live births in patientsof Maori descent.12 In contrast, the incidence in theUnited Kingdom and in most parts of Europe rangesfrom 1.28 to 1.81 per 1000 live births.14,15 The relatively high incidence of non-syndromic orofacialclefts in New Zealand further illustrates the impor-tance of auditing and assessing the outcome of primary surgery, in order to achieve sustainability ofimproved cleft care standards.

Treatment outcomes of cleft care in New Zealandhave not been previously audited using the GoslonYardstick. Therefore, the aim of this study was toevaluate and compare the primary surgical outcomesof complete unilateral cleft lip and palate (UCLP)patients in two New Zealand cleft care centres usingthis Yardstick. A secondary objective was to comparethe New Zealand findings with those from theEurocleft study1,7 which examined primary surgicaloutcomes in six European centres. It is expected thatthe data will provide a useful baseline against whichfuture national clinical audits may be compared.

Materials and methods

An audit of primary surgical treatment outcomes inNew Zealand children with complete UCLP was car-ried out in June 2008. The study included twoproviders of cleft care identified as Centre A in theNorth Island and Centre B in the South Island of

New Zealand. The sample consisted of 28 UCLPpatients presenting consecutively for alveolar bonegrafting from Centre A from 19871999, and 31UCLP patients presenting consecutively for alveolarbone grafting from Centre B from 19842000.

All had a history of non-syndromic complete uni-lateral cleft lip and palate, with surgical lip repaircompleted approximately 3 months after birth andpalate repair approximately 9 months after birth.Patients with Simonarts bands were excluded and allpatients were reassessed prior to commencing ortho-dontic treatment.

Dental study models were obtained from the ortho-dontic clinics of the dental departments of the tworespective hospitals,

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