Journal 2009

JAOSWin09 1/19/09 11:01 AM

JAOSWin09 1/19/09 11:02 AM

www.orthodontics.com Winter 2009 5

Volume 9, Issue 1 CONTENTS JAOS WINTER 2009

This peer-reviewed journal ispublished as the official publicationof the American Orthodontic Society

and the Academy of Gp Orthodontics.

On the cover: Dr. James E. McIlwain providescomprehensive pediatric dental care, specializing inorthodontics. Dr. McIlwain explains to patient SamanthaScott the Rapid Palatal Expander appliance and how it willhelp her to achieve a beautiful smile. He has been inpractice for more than 20 years and never has lost thequest for new advancements in early patient treatment.Individual attention and comprehensive care for eachchild are foremost priorities in his routine of treatment.McIlwain Family Dentistry is located in Tampa, FL.

26

32

16

22

Features16 Impacted Incisors in Mixed Dentition

By Juan Carlos Echeverri, DDS

22 The Changing Face of Growth ModificationBy Leonard J. Carapezza, DDS

26 The Benefits of Early TreatmentBy Jeffrey H. Ahlin, DDS

32 Early Transitional Dentition TreatmentBy Chris Baker, RN, DMD

Departments8 Ortho Industry News

12 OrthobitesInterceptive Orthodontics: Early Treatment in OrthodonticsBy David W. Jackson, DDS, FAGD

38 AOS Membership News

42 AGpO Membership News

46 Patient’s Page Oral Health and Diabetes

JAOSWin09 1/19/09 11:02 AM

6 Winter 2009 JAOS

ASSOCIATION STAFF

Cynthia Bordelon AGpO Executive Director Academy of Gp Orthodontics22233 Ridge Road, Suite 101Rockwall, TX 75087(800) 634-2027fax: (888) 634-2028

Tom Chapman, CAE AOS Executive DirectorAmerican Orthodontic Society11884 Greenville AvenueSuite 112Dallas, TX 75243(800) 448-1601fax: (972) 234-4290

EDITORIAL STAFF

Greg Cannizzo, DDS.................AGpOEditor

Jordan Balvich, DMD ......................AOSCo-Editor

Jim Mcllwain, DDS, MSD ..........AOSCo-Editor

Lisa A. Wright..................AOS/AGpOManaging Editor Email: [email protected]

EDITORIAL REVIEW BOARD

Azita Anissi, DDS ..............................AOSRobert Allen, DDS..........................AGpORon Austin, DDS............................AGpOChris Baker, RN, DMD......................AOSEugene Boone, DDS.......................AGpODan Dandois, DDS ........................AGpOFred, Der, DDS ...............................AGpOCorina Diaz-Bajsel, DDS ................AGpODrew Ellenwood, DDS ...................AGpODebra Ettle-Resnick, DDS .................AOSJoe Fallin, DDS...............................AGpORobert G. Gerety, DDS......................AOSEdward Gonzalez, DMD ...................AOSSam Gutovitz, DDS........................AGpOArt Gutierrez, DDS............................AOSRoy Holexa, DDS ...........................AGpODavid W. Jackson, DDS ....................AOSThomas Jacobson, DDS .................AGpOKyle McCrea, DDS .........................AGpOMitchell S. Parker, DDS.....................AOSLeslie R. Penley, DDS.....................AGpOKurt Raack, DDS ............................AGpOJon Romer, DDS................................AOSJoseph R. Schmidbauer, DDS............AOSRobert Shirley, DDS .......................AGpOBarry Sockel, DDS..........................AGpOJuan J. Solano, DDS ..........................AOSKurt, Stodola, DDS.........................AGpODavid Thorfinnson, DDS..................AOSWalter Tippen, DDS.......................AGpOHelen B. Tran, DDS........................AGpOMichael Wilkerson, DDS ...............AGpOWilliam Wyatt, DDS .........................AOS

Greg Cannizzo, DDS, CDE, JAOS Editor3617 Municipal Drive, McHenry, IL 60050Phone: (815) 344-2282 • Fax: (815) 344-5815Email: [email protected]

EDITOR’S WELCOME

During this past year, change was morethan just an election slogan. As the firstdecade of the new century comes to aclose, change is everywhere. Entire compa-nies have disappeared resulting in thou-sands losing their jobs and benefits.Consumer confidence appears to be in atail spin. So how can we navigate throughthese times of change as storm cloudshave begun to build on the horizon? Theanswer to that would be attitude. You getto decide how this “economic soft spot”will affect you. As Helen Keller once said“When one door of happiness closes,another opens, but often we look so longat the closed door that we do not see theone which has been opened for us.”

Attitude will be the compass thatguides us through economic storminessand uncertainty. One of my favoritestories on attitude begins with…Onceupon a time; there was a monk who ran.Everyday the monk would lace up hisrunning shoes and head out along apopular local path. He always keept tohimself, preferring to train alone. Asother runners passed him or ran by himthey would nod, say hi, or ask how hewas doing. But the monk was rarelyfriendly and he scowled wheneveranybody asked him why he ran. Heusually mumbled his answer so that noone could hear. He never offered to pacea fellow runner or talk about his train-ing, he kept his work out and knowledgeof running and training to himself.

Everyday, a missionary would lace uphis running shoes and head out along aneighboring popular path. The mission-ary was more outgoing and he ran with asmile on his face. As other runners passedhim or ran by him, he would greet themby name and ask how their training wasprogressing. The missionary was alwaysenthusiastic and ready to talk about how

great runningwas, and hewould gladlyanswer anyonewho asked why he ran (sometimes hewould tell people even if they didn’t ask!)He spoke of the mental and physicalhealth benefits of running and how hecould do it for the rest of his life. Hewould educate and help others with theirtraining showing them how to improveand be better runners. Soon, he had thewhole village running and enjoying everystep of it.

If you start to feel an economic slowdown, take the opportunity to use thatextra free time to reconnect with yourcore patients of record. Don’t get stuckstaring at the closed door. Like themissionary, lace up and take the extratime to connect with the people aroundyou. Talk with your patients and recon-nect. Be enthusiastic, educate them.People buy from people they like. Makesure everyone in your practice andcommunity knows you offer compre-hensive care including orthodontics.

So, in 2009, reconnect not only withyour patients but also with your fellowmembers of the AOS and AGpO. Thisyear’s joint meeting will be this August 20-22, 2009 in Chicago. Make a point toattend this year and touch base withcolleagues and friends. They are yourvillage. Being part of the annual meetinggives you a chance to pick up so manyorthodontic pearls, participate in the bestCE available for Gps and pedodontistswho do orthodontics, and talk to others inyour community.

I’ll be looking for you in Chicagowhere we will enjoy every step of thegreatest meeting this year.

Advertiser IndexAcademy of Gp Orthodontics ....................45

American Orthodontic Society ..................41

ClassOne Orthodontics ................................2

Dolphin Imaging........................................37

Johns Dental Labs ................................30, 35

Journal of Orthodontics..............................31

Myofunctional Research ............................21

Ordont Ortho Labs ......................................9

Ortho Arch ................................................11

Ortho Organizers ......................................47

Ortho Technologies....................................19

Parkell ........................................................48

Rocky Mountain Orthodontics ....................4

Space Maintainers ........................................3

Vector Dental ............................................29

Wild Smiles ................................................10

JAOSWin09 1/19/09 11:02 AM


PUBLISHED BY

Wright Publishing Group, Inc.726 Pasadena Avenue SouthSt. Petersburg, FL 33707(727) 343-5600www.wrightgrp.com

ADVERTISING SALES & ANNUALMEETING EXHIBIT MANAGER

Kimberly PriceIntegrity Media Group4006 Majesty Palm CourtTampa, FL 33624Phone: 813-466-5521Fax: 813-864-4454E-mail: [email protected]

ADVERTISING & EDITORIAL POLICY

The American Orthodontic Societywelcomes advertising in its publications asan important means of keeping theorthodontic practitioner informed of newand better products and services for thepractice of orthodontics. Such advertisingmust be factual, dignified, tasteful andintended to provide useful product andservice information. These standards applyto all product-specific promotional mate-rial submitted to the American Orthodon-tic Society. The publication of an advertise-ment is not to be construed as an endorse-ment or approval by the AmericanOrthodontic Society unless the advertise-ment specifically includes an authorizedstatement that such approval or endorse-ment has been granted. The fact that anadvertisement for a product, service orcompany has appeared in an AmericanOrthodontic Society publication will notbe referred to in collateral advertising. TheAmerican Orthodontic Society reserves theright to accept or reject advertising at itssole discretion for any product or servicesubmitted for publication.

COPYRIGHT

© 2009. Journal of the AmericanOrthodontic Society. The material ineach issue of the JAOS is protected bycopyright. None of it may be duplicated,reprinted or reproduced in any mannerwithout express written consent fromthe publisher. All inquiries and/orrequests should be submitted in writingto Wright Publishing Group, Inc. or viaemail at [email protected].

SUBSCRIPTIONS

The Journal of the American OrthodonticSociety is a benefit of membership forcurrent American Orthodontic Society andAcademy of Gp Orthodontics members.Annual subscriptions to the quarterly jour-nal (4 issues per year) are available at a rateof $40/year for US residents, $80 USD/yearfor Canada and $100 USD/year interna-tionally. Back issues are available at a rateof $5 per copy until supplies run out.To subscribe to the JAOS, please visitwww.orthodontics.com.

CONTRIBUTOR BIOGRAPHIES

Dr. Leonard Carapezza has over 25 years of clinical experiencein pediatric orthodontics and operates a successful private practice inWayland, MA. He has degrees from Brandeis University and theUniversity of Medicine and Dentistry of New Jersey. He served as aTeaching Fellow at the Harvard School of Dental Medicine andreceived a certificate in Pediatric Dentistry from Children’s Hospital.Dr. Carapezza is currently an Associate Clinical Professor at TuftsUniversity, School of Dental Medicine and a contributing editor tothe Journal of Clinical Pediatric Dentistry. His lecture experienceincludes the Senior Certified Instructor for both the AmericanOrthodontic Society (AOS) and International Association forOrthodontics (IAO).

Dr. David W. Jackson graduated from Baylor College ofDentistry in 1978. Dr. Jackson, a member of AOS and AGpO aswell as other professional organizations, operates two highlysuccessful practices in Farmersville and Rowlett, Texas andemploys over 25 people. He lectures extensively for the AmericanOrthodontic Society and the International Association forOrthodontics. His insight to the real world of orthodontics in thegeneral practice is honest and informative. Find out about upcom-ing seminars at orthoplusseminars.com.

Dr. Juan Carlos Echeverri is the owner of Echeverri DentalCenter in Houston, TX. Fluent in English and Spanish, he has madepresentations in Colombia, Venezuela, Spain and USA in prosthesis,implants and orthodontics and dental education for patients.Echeverri is the creator and director of the dental educationoutreach program for the schools surrounding his practice. He is amember of the Greater Houston Dental Society, Texas DentalSociety, American Orthodontic Society, American Dental Associationand Academy of General Dentistry.

Dr. Jeffrey H. Ahlin has served on the Board of Directors and asan officer of the American Orthodontic Society and currentlyserves on the Board of the AOS Foundation. He is a board certifieddiplomate of the AOS and of the American Academy of PediatricDentistry. He has published over 50 papers in professional journalsand two textbooks. He has taught at Harvard Schools of DentalMedicine and Tufts Dental schools for 20 years and lives inGloucester, MA with his wife and two children.

Dr. Chris Baker, through her practice in pediatric dentistryand orthodontics in Lexington, KY, and as a national lecturerand author, enjoys her passions - connecting with the parentsand child patients, educating professionals and parents in state-of-the-art dental care and management to meet the needs oftoday’s parents and children. Dr. Baker’s greatest opportunities liein providing diagnosis and treatment of poor craniofacial growthpatterns and airway obstructions in children as early as possibleto optimize each child’s beauty and aesthetics. Dr. Baker is anAOS Board Examiner and Vice-president of the Society.

JAOSWin09 1/19/09 11:02 AM

8 Winter 2009 JAOS

ORTHO INDUSTRY NEWS

KOMET USA’s adhesive remov-ing instruments were developedas special instruments fororthodontists to remove toughadhesive residue. A study withRalf Radlanski, DDS, at theUniversity of Berlin, shows theseinstruments remove adhesivequickly, and thanks to theirspecial toothing, without damag-ing the enamel.

At low contact pressure, theinstruments operate with low vibra-tion and achieve perfectly smooth

surfaces while generating minimalheat. This is due to its innovativeblade geometry. Its twisted blades,made of durable tungsten carbide,are suited for precise reduction ofsoft materials and assure smoothoperation providing maximumtreatment comfort.

In order to avoid the risk ofdamaging the gingiva, all adhe-sive removers are provided withsmooth, non-cutting tips, and thesafety chamfer at the head’s endeliminates the formation ofgrooves. The tapered instrumentis available for contra-angle andturbine handpieces. TheH22ALGK is designed specificallyfor canines and long anteriorteeth, and the egg-shape(H379AGK) instrument is suitedfor the palatinal reduction ofadhesive in the lingual technique.

KOMET is a recognized world-wide leader in the production ofhighly specialized and precisedental rotary instruments. Formore information about adhe-sive removing instruments,please call 888-556-3887 or visitwww.komet-usa.com.

A new alginatealternativeimpressionmaterialfromKettenbachLP wasintroducedto the U.S.dentalmarket latelast year. Silgi-nat® is designed for avariety of indications suchas: anatomical models, opposingmodels, fabrication of temporary

crown and bridges, fabricating simpleremovable prosthetic restorations,

orthodontic appliances, splints andcase study models, or for most

purposes where an alginate couldbe used.

Silginat® was designedwith a low-tear resistance to

avoid dislodging restorationsor orthodontic appliance inadver-

tently. The material also has a highdimensional stability so modelimpressions can be kept for weeksand poured multiple times. Silgi-nat® is also highly thixotropic andflows properly under pressure.

Silginat® is available in twodelivery systems – 362-mL foil bagsfor Kettenbach’s Plug & Press®automatic dispenser (5:1 ratio); and38-mL cartridges (1:1 ratio) with anoptimal volume for a single full-arch or two quadrant impressions.The total set time for Silginat®,when dispensed in cartridges, is 2minutes, 30 seconds. When Silgi-nat® is dispensed in foil bags, it hasa total set time of three minutes.

For more information aboutSilginat® alginate alternative, pleasecall 877-KEBA-123 or visitwww.kettenbachusa.com.

Alginate Alternative: Designed for a Variety ofIndications Including Orthodontic Appliances

New Adhesive Removing Instruments

Dolphin 3D OffersVolume Stitching

Offering the ability to “stitch”together two separate volumetricdatasets to construct a larger view, thisnew feature brings the full view of 3Dtechnology to a larger demographic ofpractitioners. “Not all dental special-ists have access to large field of view(FOV) cone beam CT devices,” saysKen Gladstone, manager of Dolphin’simaging software products. “But, thereare times these doctors want a largerview, for example both condyles orthe entire arch.” The new VolumeStitching feature allows the practi-tioner to import two separate, smallerscans and “stitch” them together tocreate a single, larger FOV volumeDICOM dataset. “Volume stitching isthe perfect tool for smaller field ofview systems to generate larger andmore useful volumes,” he adds.

Dolphin products are backed withround-the-clock, personalized techni-cal support. For more information,visit www.dolphinimaging.com.

JAOSWin09 1/19/09 11:02 AM


Sirona introduced the new Multi-Motion headrest as an availableoption with the Sirona C8+ dentaltreatment center. This innovativeheadrest comfortably secures thepatient’s head in a natural positionand allows the practitioner optimalviews of previously inaccessible areas.

Designed in accordance withSirona Dental System’s ErgonomicsProgram, the MultiMotion headrestcan be tilted and rotated in anydesired direction, enabling bothpatient and practitioner to remainin the optimal ergonomic positionthroughout any procedure. With asingle, one-handed motion, thepractitioner can easily adjust theheadrest to gain visual access to allfour quadrants. Switching from theupper to lower jaw is now quick andsimple. The MultiMotion headrestimproves workflow during basictreatment scenarios, challengingendodontic procedures and anytimea treatment or location specificinstrument is required.

Recently, the MultiMotion headrestreceived the 2008 iF Product DesignAward in the “Medicine/Health+Care”category. The 26-member jury evalu-ated the entries on the basis of thefollowing criteria: design quality,workmanship, choice of materials,degree of innovativeness, environ-mental compatibility, functionality,ergonomics, visualization of use,safety, brand value/branding anduniversal design.Visit www.sirona.comfor more information about Sironaand its products.

ORTHO INDUSTRY NEWS

ErgonomicHeadrestReceives

Design Award

RMO’s® Indirect Bonding system(IDB) provides clinicians a simple andconsistent solution for maximizingpractice efficiency while significantlyimproving the patient bonding expe-rience. The system allows forextremely accurate bracket placementunder convenient setup conditionsworking on a study model, and mostof the procedures can be conductedby staff persons with modest training.RMO’s® RMbond start-up kit is aturnkey system that includes all of thematerials necessary to begin IndirectBonding for your patients immedi-ately. For more information, pleasevisit www.rmortho.com.

Improve Bonding Experience

JAOSWin09 1/19/09 11:02 AM

10 Winter 2009 JAOS

ORTHO INDUSTRY NEWS

The Thornton Adjustable Posi-tioner® 3 (TAP® 3), available fromAccutech Orthodontic Lab, Inc., is amandibular advancement device thatimproves breathing and eliminatessnoring in 95 percent of all patients.The TAP® 3Appliance alsohelps preventconditionsthat arelinked tosleep apneasuch aschronicsleepiness,high-bloodpressure, heartattack, stroke,heartburn,morningheadache and depression. It treatsthese conditions without the need forsurgery, continuous positive airwaypressure (CPAP) or medication.

The TAP® 3 is a custom-madeadjustable appliance that is wornwhile sleeping. The appliancetrays, similar to whitening trays,snap on over the upper and lowerteeth, and hook together. Thedesign is based on the same princi-ple as cardiopulmonary resuscita-tion (CPR). The airway must be

opened to allow air to passthrough the throat. The AmericanAcademy of Sleep Medicine recom-mends oral appliances like theTAP® 3, as a first line of treatmentin cases of mild and moderate

sleep apneaand in cases ofsevere apneawhen CPAPhas notworked.

The TAP® 3holds thelower jaw in aforward posi-tion so that itdoes not shiftor fall openduring thenight. This

prevents the airway from collaps-ing. The TAP® 3 is the onlymandibular advancement devicethat can be adjusted by the patientor practitioner while in the mouth.The device provides doctorsnumerous options to create thebest, customized treatment solu-tion for their patients.

For more information aboutAccutech or the TAP® 3 Appli-ance, please visitwww.accutechortho.com.

Appliance Opens Blocked Airways Doctors Find AWay To Make

Early TreatmentFun For Patients

WildSmiles brackets are creating abuzz in the world of orthodontics.Presenting a revolutionary concept toenhance your practice by offeringpatients the opportunity to createtheir own orthodontic appliance, thepatented stainless-steel designs,which are currently available inflower, heart, star, soccer ball, footballand diamond shapes, were developedby Dr. Clarke Stevens, a board certi-fied orthodontist in Omaha, NE.WildSmiles is about helping ortho-dontists promote their practice in funand exciting new ways, while realiz-ing that patient-centered and patient-driven health care is paramount. Thebrackets straighten teeth with preci-sion and can be mixed and matchedto give everyone a truly unique smile.They also can incorporate color elas-tic ties for added individuality.

WildSmiles appliances werecreated from Dr. Stevens’ desire tomake orthodontics fun —- he hasalways had a keen interest in servingpatients and creating a positive envi-ronment to care for them. “I devel-oped WildSmiles brackets becausepatients love to make choices.Patients, parents, grandparents andfriends all enjoy choosing and evenreferring, because of WildSmiles,”said Stevens. And price should not bea concern, as there is virtually nocost difference to the patient, accord-ing to Dr. Stevens. “WildSmilesBrackets are placed cuspid to cuspidin the maxillary arch only. Their costis identical to other esthetic bracketslike porcelain brackets so the patientsneed not pay more.”

WildSmiles Brackets have beenengineered to provide optimumaesthetic and functional benefits,including a patented design, accurateprescription, straight wire style (theirversion of “Roth”), torque in base, 80grade mesh bonding base, Axial Place-ment Technology, compoundcontoured surfaces and no sharpcorners that provide easy bondingclean-up. For more information,please contact Davin Bickford at 402-505-8311 or visit wildsmiles4you.com.

JAOSWin09 1/19/09 11:02 AM

JAOSWin09 1/19/09 11:02 AM

12 Winter 2009 JAOS

ORTHOBITES

As I lecture throughout the United States, I amconstantly asked if Phase I (interceptiveorthodontic treatment) is really necessary oreven indicated at all. Some doctors are very

passionate about the value of early treatment, expandingthe “parking lot” for the permanent teeth, correctingtransverse and sagittal issues early and holding the spacefor the permanent teeth to erupt. Other doctors are justas opinionated against interceptive orthodontics, statingthat it is just a waste of the parents’ money and time,when everything can be accomplished in Phase II or“plain Jane” orthodontic care when the child is 11 to 12years old.

Here are some of my thoughts about this topic. Firstand foremost, are you following the “golden rule”? Doyou feel you are doing the right thing for the patient,parents and yourself? If the child has a relatively goodsmile, borderline Class II which has a 50 percent chanceof becoming a Class I as the lower E’s exfoliate, exhibits anormal overbite/overjet has adequate room for the

permanent teeth to erupt, and exhibits little or no maxil-lary constriction, then interceptive orthodontics wouldnot be indicated.

My prerequisites in my practices for interceptiveorthodontics are the following:

1. Does the child demonstrate severe sagittal issues –full step class II or III?

2. Does the child have a crossbite?

3. Is there an airway issue?

4. Are there social issues involved – are peers makingfun of the child’s teeth?

5. Am I doing a service for the child and parents?

It is a fact that grade school age children aremore compliant than middle school children, andmiddle school children are more compliant thanhigh school adolescents. It is also a fact that youngpeople are more conscious of their appearance and

FIG. 1 FIG. 2

By David W. Jackson, DDS, FAGD, IBO

Peer pressure and influence has never been so paramount in youngpeoples’ daily lives than it is today. With that said, I would like to showyou a few cases in which I opted to perform interceptive orthodonticsand to explain the reasons why.

Ear ly Trea tmen t i n Or thodon t i c s

InterceptiveOrthodontics

JAOSWin09 1/19/09 11:02 AM

teeth than I was when I was a youth (and yes, I canrecall that far back). In my generation, we woreblue jeans, white t-shirts, and high top black tennisshoes in grade school. We began to wear white jeansand white high top tennis shoes in middle school.And in high school, white or black worked. Today’syoung people face a much more complex schoolmaze to negotiate. Designer clothes, the right shoes,the latest of the latest in fashion, and yes, even theteeth and smile come into everyday interaction atschool. Peer pressure and influence has never beenso paramount in young peoples’ daily lives. Withthat said, I would like to show you a few cases inwhich I opted to perform interceptive orthodonticsand to explain why.

Case #1 involves a 7.6 year-old female in whichshe and the parents did not like her smile. (Figures1-6) I had treated her older brother, the family hadbeen in practice for over 20 years (and still is), thepatient was in cheerleading activities, and her smilewas an integral component of her social activities.

Dentally, she had malposed anterior central incisors,gapping in the anterior teeth, dental Class II,normal overbite, slight overjet, slight crowding, herupper right central incisor overlapping her upperright lateral incisor, and constriction in the maxillaand mandible. She exhibited some airway issues:venous pooling, minor mouth breathing, grade 3tonsils and allergies. Her cephalometric values werewithin normal limits. I opted to treat her inceptivelyby placing an upper Nitanium Palatal Expander(NPE – Ortho Organizers) and a lower laboratoryfabricated Williams appliance to gain transversewidth. A referral to an ENT was also advised. Note:Whether the parents follow through with an ENTevaluation does not change my approach. I know ifI can widen the palate, I can cause room for thepalatal shelves to fall down and increase the airwayspace. I also banded the sixes and anterior teeth andplaced prefabricated utility arch wires (Ortho Orga-nizers) to enhance the smile as that was the parent’smajor concern to begin with. Treatment time was 15months. At the end of Phase I, I placed a FixedRemovable Lingual Arch (Ortho Organizers) andheld the lower arch until I evaluated for Phase II.

After three years, I did treat patient in Phase IIfor 18 months. Was Phase I necessary? I could havesurely corrected the issues with only one treatmentphase, bypassing Phase I. However, the patientwould have continued with constriction in thearches and a smile less than the parents desired.

FIG. 3

FIG. 6

FIG. 4

FIG. 5


ORTHOBITES

JAOSWin09 1/19/09 11:29 AM

14 Winter 2009 JAOS

Case #2 is what I hope is a pretty apparent reasonfor interceptive orthodontics. (Figures 7 – 12) I always

treat crossbites as soon as possible. This young manwas 9.4-years-old when his parents bought him in foran orthodontic evaluation. He had an obvious ante-rior crossbite, maxillary and mandibular crowding,and minor transverse issues. Dentally, he was a Class I.This type of anterior crossbite is often created by the

ORTHOBITES

FIG. 8

FIG. 13

FIG. 9

FIG. 10

FIG. 11

FIG. 12

FIG. 7

JAOSWin09 1/19/09 11:30 AM

upper anterior teeth erupting on top of the loweranterior teeth, and the uppers erupting lingually tothe lowers creating a pseudo Class III appearance.

My favorite way to correct this type of malocclusion isto employ the prefabricated utility arch wires previously

mentioned, advancing the upper utility arch wire bybending the step down segments of the arch wires from90 degrees to 45 degrees. This creates additional archlength and tips the upper anterior teeth forward and overthe lowers. Occasionally, lower composite pads arerequired on the lower sixes to open the bite, however,because we have our mouth open most of the time, oftenthey are not required. Correcting the underbite usuallytakes less than one month to accomplish. As a sidecaveat, by increasing the arch length of the arch wire andtying it into the anterior, a transverse expansion effect iscreated. I placed a FRLA for retention. The total treatmenttime was 15 months. The patient did not require Phase II.

Case #3 shows a young female, age 8.6, with a full stepClass II dental malocclusion. (Figures 13-18) Again,cephalometric measurements were within normal limits.Her dental age was advanced in comparison to herchronological age. I opted to treat her with utility arch-wires and a mandibular advancement appliance, the TwinForce appliance (Ortho Organizers). I kept her in thisappliance for six months, and then continued to keep herlower jaw forward by employing one medium Class IIelastic per side on the utility archwires for an additionalsix months. The elastics were from the lower first molarhooks to prefabricated posts crimped onto the upperprefabricated utility archwire. I placed a FRLA for reten-tion. The total treatment time was 12 months. The patientdid not require Phase II. Results were very pleasing.

In summary, one has to ask oneself: Am I helpingthe patient with interceptive orthodontics? I alwaysstress to the parents and the patient that interceptiveorthodontics does not mean that full blown orthodon-tic care will be avoided. I do tell them that my goalwith interceptive care is to minimize or eliminatefuture orthodontics, but I make no guarantees. Am Ialways successful with this goal? Of course, I am not.

We, as orthodontic caregivers, should shoot for theideal, but accept that reality exists and there are surelysituations beyond our control. Do the right thing withyour patients. What the right thing is depends uponyour orthodontic belief system and clinical experi-ence. I hope this orthobite column provides yousome beneficial insight in your practice and life.

FIG. 15

FIG. 16

FIG. 14

FIG. 17

FIG. 18


ORTHOBITES

JAOSWin09 1/19/09 11:30 AM

16 Winter 2009 JAOS

Frequently pediatric andgeneral dentists are facedwith a child that has anincisor that fails to erupt in

the expected manner. The parentswill usually ask when will the tootherupt and why is it taking so long.The doctor will also question whythe eruption of the tooth is delayedand how they can assist andmanage the situation. This articlewill describe the rationale behindthe diagnosis process and how tomanage the situation from a surgi-cal and orthodontic perspective.

Having impacted incisors hasmany consequences for the childpatient. Several or all of the belowmay affect the patient:

� Esthetic compromise.

� Improper development of the dentition.

� Improper formation of alveolar bone.

� Space loss in the arch formation.

� Improper root formation.

� Disturbance of the eruption potential.

� Anterior-Posterior discrepancies.

� Possible facial asymmetry.

� Self-esteem issues.

As we evaluate the child who isbetween 7 to 12 years of age, it isimportant to keep in mind thatthe incisor transition should becomplete by 8 years of age. Thisallows the establishment of themid-mixed dentition of perma-nent molars and incisors alongwith the deciduous segment ofprimary teeth (C-D-E) .

What does this mean in our clin-ical and radiographic exams? If thepatient who is being examined hasalmost all of his incisors, except for

one or two, we need to askourselves why? Is the delay normaldue to slow eruption, or is there adental, bone or soft tissue interfer-ence? Did the tooth or teeth runout of eruption force? A compre-hensive clinical and radiographicexam will allow the dentist to deter-mine the possible cause. (Fig 1) Thebest x-rays for this kind of evalua-tion in the anterior area is a Periapi-cal x-ray. It will be superior to apanoramic film in its imaging clar-ity involving this area.

Fig 1, (Initial Exam/documentation)

inImpacted Incisors Mixed Dentition: Surgical & Orthodontic Management

Impacted Incisors Mixed Dentition: Surgical & Orthodontic Management

By Dr. Juan Carlos Echeverri, D.D.S.

Using a patient treatment case and images, a clinician presentsguidelines for the diagnosis of impaction of a permanent incisor toothwith a combination of orthodontics and surgical techniques.

JAOSWin09 1/19/09 11:30 AM

Some of the causes for theseeruption problems will includesupernumerary teeth, missing teeth,tooth size/shape anomalies, ankylo-sis, pathologic lesions, etc. Each andevery one of these will interfere andbe involved in the impaction ofincisors. (Fig 2)

The most common cause for theimpaction of incisors is the presenceof supernumerary teeth. The follow-ing reported statistics make them afactor that we must consider in ourdaily diagnosis and treatment plan-ning. Impacted incisors are:

� Reported in up to 3.6 percentof children

� Occur 10:1 in the maxillavs. mandible

� Occur 2:1 in boys vs. girls

� Usually due to a single Mesio-dens 80% of the time and two ormore 20% of the time. Mesodensusually present with cone-shapedcrowns with a single root

� More than 90 percent arelingually or palatally malpositioned

� Approximately 75 percentremain unerupted and needsurgical removal

� Can be responsible for delayederuption of permanent teeth,over-retention of primary teeth,displaced teeth, diastemas,abnormal root resorption, follic-ular or dentigerous cysts, andresultant malocclusion.

If we as the treating or referringdentist decide to proceed in thecorrection of the problem, we mustkeep several parameters in mind.These are as follows:

� Remove the mesodens obstruc-tion when no harm will come todeveloping permanent teeth(wait for eruption of first perma-nent molars)

� Prefer to wait until there is 2/3root development of the adjacentpermanent teeth

� Patient age and potential forcooperation also factors in delay-ing surgical intervention

� Watchful waiting allows timefor possible eruption of thesupernumerary, and the avoid-ance of surgical exposure

� When removed, the exposureof permanent teeth with theprovision of an eruption channelis recommended

� Up to 80 percent of permanentmaxillary teeth will sponta-neously erupt after the supernu-merary is removed

� Orthodontic treatment is oftennecessary to make room forunerupted teeth and to positionthem properly.

Taking into account that it isalmost for sure that orthodontictreatment will be needed with thepatients that have had supernumer-ary teeth it is important to defineinterceptive orthodontics. Intercep-tive Orthodontics: Recognition ofdeveloping malocclusion factors andimplementation of treatment proce-dures to eliminate or minimize theireffects on the final occlusion.

To face the problem of retainedteeth, we must: 1) diagnose reten-tion of one or several incisors. 2)determine the cause of the reten-tion. 3) If it is a supernumerarytooth or teeth, we must thenproceed to remove the cause, if it iswithin the scope of our abilities. 4) re-evaluate the need fororthodontic treatment.

The orthodontic treatment willbe used to create the space for theproper eruption of thetooth/teeth and for the actualphysical guidance of thetooth/teeth into position.

Case StudyUsing all

of the aboveinformation,let’s demon-strate all ofthe principlesmentionedwith thefollowingcase report:

Patient isa healthy,femaleHispanicwho is 7 years of age at her firstpresentation. Her X-ray of the ante-rior teeth show a normal presenta-tion of teeth with Stainless Steelcrowns on # E, F and G. (Fig 3)

One year later, the x-ray of heranterior teeth (PA) shows #8 is ina delayed eruption pattern,compared to #9. Teeth #E & Fhave been exfoliated. (Fig 4)

In February 2007, the x-ray showsa deviation of tooth #8 with the roottouching #6 and the crown deviatedfrom its eruption path. (Fig 5)

Fig 2. (Periapical image of supernumerary teeth)

Fig 3, April 2005 Anterior recall PA X-ray

Fig 4. May 2006, 8 years of age

Fig 5. Periapical X-ray 2007


JAOSWin09 1/19/09 11:30 AM

At this time, the treatingdoctor speaks to the parentsabout the need for an orthodonticconsultation and interceptivetreatment. (Fig 6) The patient hasorthodontic records taken in May2007 and an orthodontic plan isdeveloped consisting of:

� Phase I (orthodontic records)

� Correct midline and createspace for tooth #8.

� Create the anchorage for the traction of #8

� Localize tooth with x-raysusing the SLOB rule (SameLingual Opposite Buccal)

� Surgical intervention to locatethe tooth and place an attach-ment on the coronal portion ofthe impacted tooth.

� Bring the impacted tooth intothe arch and occlusion

� Place the patient in phase I retention

Bands are placed on maxillarymolars and brackets on all avail-able teeth including primaryteeth, as described by Dr. RobertGeretty. Arch wire sequence asdescribed by Dr. David Jacksonwas used (.14 NiTi, .18 NiTi, .20SS) and coil spring force was usedwith the .20 Stainless Steel archto open the space for # 8 and

correct the maxillary dentalmidline. (Fig 7)

In February 2008, the patientwas intebateded using oral seda-tion, to expose #8 and place anattachment on the tooth. An enve-lope flap was created using the T2electrode tip with the SensimaticElectrosurge 600SE (Parkell, Inc.)The flap was reflected with aperiostal elevator and the soft tissuecovering the tooth was removedwith a soft tissue curette. The toothwas located with its incisal edgepointing toward the opposite direc-tion and the lingual surface wastoward the buccal.

The tooth has an almost 180degree rotation from its normalposition. Hemostasis is achievedusing Astringent X ( Ultradent)and pressure on any bleedingareas. The tooth surface wascleaned with alcohol impregnatedpellets and air dried. The surfacewas etched with 37% ortho phos-phoric acid and “Single bond”adhesive (3M) was placed on theetched surface. The pad wasloaded with orthodontic bracketcement (Unitek) and the pad witha gold chain attached (Ortho-Traction Pads) was attached onthe tooth on its lingual surface asclose as possible to the incisaledge. (Fig 8)

The chain portion is pulledtoward the arch wire and cutshort by approximately 2 mm.The chain is then tied to the archwire using .030 elastic thread byOrtho Organizers Inc., creatingtension on the chain. At thismoment a third incision is madeto allow the flap to be placedback on the bone for first inten-sion healing.

The flap is sutured using Cat Gutsutures and the patient is placed onanalgesics, antibiotics and clorhexi-dine mouth wash to prevent painand infections. (Fig 9) The patient isthen seen one week later as a surgicalfollow-up visit, and then every twoweeks to reactivate the elastic ligature.

The position of the tooth ismonitored by the length of thechain links remaining. These linksare counted at the initial place-ment, and are monitored with peri-apical x-rays as needed. (Fig 10)

The tooth was guided intoposition until the pad link wasreached. (Fig 11) Due to thelingual placement of the pad, anew connection on the toothhad to be achieved. This newattachment would allow thetooth to be guided into thecorrect angulation.

18 Winter 2009 JAOS

Fig 7. Sept

2007 Coil

spring on

0.20SS

Archwire

Fig 6. Clinical presentation of # 8 impacted,patient is 9 years old

Fig 8. Attached Pad and chain to tooth

Fig 9. Flap closed and sutured

Fig 10. Monitoring movement counting links

Fig 11. Pad level reached

JAOSWin09 1/19/09 11:30 AM


A soft tissue diode laser (ZapLaser) was used to remove the softtissue covering the buccal surface.Total hemostasis is achieved bycombining the laser and theastringent agent. A bracket is

placed on the buccal aspect. Thearch wire with a coil spring main-taining the space between teeth#7 and #9 is maintained and apower chain with an unevennumber is used to continue guid-ing the tooth into position, as perthe technique taught by Dr.Gerety. (Fig 12)

One month later, the lingualpad is removed and the powerchain traction is replaced by a.014 NiTi arch wire to continuewith a constant activation as thedistance is now much reduced.(Fig 13)

This arch wire is used untiltooth #8 has reached the samelevel of teeth #7, #9,and #10.This arch wire is then replaced inthe arch wire sequence with a.018 NiTi followed by a 16 x 22NiTi. These last arch wires areused to correct the position andthe torque of the tooth before thepatient is placed in final reten-tion. A panoramic film (Fig 14)was taken in the last sequence ofthe orthodontic therapy to check

Fig 12. Chain of 5 directing tooth into position

Fig 13. .014 NiTi Archwire

Fig 14. September 08, Panoramic forradiographic control

JAOSWin09 1/19/09 11:30 AM

20 Winter 2009 JAOS

all teeth and structures involved. Normal structuresare observed. An individual periapical film is takenof #8. (Fig 15)

Root dilaceration is evident and probably causedby the original mal position of the tooth.

The combined orthodontic therapy allowed forthe correction of the occlusal plane, the anteriorincisor alignment, the anterior open bite, the under-developed alveolar bone and the esthetic challengefor the patient. (Fig 16,17) Once the patient, parentsand doctor are satisfied with the position of theteeth, including the impacted tooth, the patient willbe placed in a retainer for six months. This isadequate time to retain the position of the teeth,and avoid interference with growth, as this treat-ment was performed in early mixed dentition as aphase I treatment.

In conclusion, this article presented guidelinesfor the diagnosis of impaction of a permanentincisor tooth. It elaborated on the role of supernu-merary teeth in the impaction of permanentincisors. It showed using a patient treatment caseand images, how the tooth is diagnosed, located andtreated with a combination of orthodontics andsurgical techniques to bring the impacted tooth intothe oral cavity.

Fig 16. intraoral view 17 months of treatment

References: Straight Wire Concepts: Diagnosis and Technique, byRobert G. Gerety, 8th Edition, September 2004

The Next Steps, a Three Session Continuum in Orthodon-tics, by Dr. David W. Jackson, 2006

Comprehensive Advances Series: Concepts and Techniquesfor the Orthodontic Practitioner, by Dr. Larry White & Dr.William E. Wyatt, Sr. 2008

Orthodontic and Orthopedic Treatment in the MixedDentition, by James A. McNamara, Jr., William L Brudon,Needham Press, Inc 1993

The Handbook of Pediatric Dentistry, Third Edition, TheAmerican Academy of Pediatric Dentistry edited by ArthurJ Nowak & Paul S Casamassimo, Chapters 10 and 11.

Fig 15. Pa x-ray showing dilaceration of root

Fig 17. Extra oral view

JAOSWin09 1/19/09 11:30 AM

JAOSWin09 1/19/09 11:30 AM

22 Winter 2009 JAOS

Evidence-based clinical dentistry has become thenew “paradigm”. Randomized clinical trials(RCT) are considered to be the gold standard toacquire evidence. The first dental randomized

clinical trials funded by The National Institute ofDental and Craniofacial Research dealt with earlyClass II treatment. The results of these studies claimeffectiveness of the early treatment Class II. Thelingering question posed by these studies was the effi-ciency of treatment in a conventional specializedorthodontic practice.

The case report presented in this article is the resultof the continuum of treatment of an early Class II Divi-sion I case published in the Spring 2006 (Volume 6 Issue2) of the Journal of the American Orthodontic Society.

CharacteristicsAn efficacious solution was found to this malocclu-

sion which displayed common Class II characteristics:

� Maxilla – narrow – tapered – constricted arch form� One-half to full Class II molar relationship� Mesial lingual rotation of the maxillary molars� Improper over-bite relationship� Improper over-jet relationship� Incompetent lip seal� Retruded position of the mandible

Strategy & ProtocolDo the benefits of early treatment as shown by this

specific treatment strategy and protocol justify theintervention in the early mixed dentition stage ofdevelopment when compared with treatment in thelate mixed or early permanent dentition? The comple-tion of this case report attempts to put into focus therisk/benefit ratio of early versus late treatment.

C l a s s I I M a l o c c l u s i o n

The ChangingFace of GrowthModification

An Experience–Based, Evidence Approach to Treatment Timing: Mother Helps Daughter to Achieve A Healthy SmileBy Dr. Leonard Carapezza

Fig. 1a: S.K. 8y 1m11-11-2004 pre tx.orthodontic recordsfacials and intra-orals

S.K. /M.K.

JAOSWin09 1/19/09 11:30 AM

Review – 1st Phase Treatment (Fig.1a,b)Orthodotic records were taken 11-11-2004 on a

healthy 8.11-year-old Caucasian female, named SK.Treatment commenced on12-22-2004 with the use of aNitanium Palatal Expander (NPE). The NPE accom-plished arch development and distal rotation of themaxillary first permanent molars.

Treatment proceeded two months later with basicUtility Arch Wire Mechanics. These mechanics estab-lished the early treatment objectives of proper over-bite, over-jet, molar relationship, lip seal and skeletalrelationship. Serial guidance was started on 7-5-05 withthe utility arch wires remaining as space maintainers.

Finishing PhaseThe finishing phase with the continued use of a

fully programmed pre-adjusted straight arch appliancebegan on 9-1-06. (Fig .2) The treatment continued withleveling, aligning and rotation with proper attainmentof molar, cuspid and midline. Inclusion of bracketingof the permanent second molars was accomplishedduring that time period. Final tip, torque and biteopening were completed on 4/15/08. (Fig.3 ) The casewas debracketed and retention records were then takenon 4/24/08. (Fig.4 a,b,c,d,e)

Fig 4a: S.K. 11y 6m4-24-08 post tx facial

and intra-orals

Fig. 2: S.K. 9y 11m 9-01-06 Start of finishing phase

Fig. 3: S.K. 11y 6m 4-15-08 F.T.T.B.O.

Fig. 4b: S.K. 11y 6m 4-24-08 post tx panelipse film

Fig. 4e: S.K. 11y 6m 4-24-08 post tx study models

Fig. 1b: S.K.8y 1m

11-11-04pretreatment

studymodels

Fig. 4c: S.K. 11y 6m 4-24-08 posttx cephalometric film


Fig. 4d: S.K. 11y 6m4-24-08 post tx

cephalometric tracing

JAOSWin09 1/19/09 11:30 AM

24 Winter 2009 JAOS

Fig. 5: Levels of evidence

Retention PhaseA maxillary Hawley retainer was placed for the upper

arch to be worn full time six months and then sixmonths during bed time. A 4x4 lower fixed retainer isto remain until the summer of the junior or senior yearof high school when an evaluation of third molarremoval would be recommended. This customary reten-tion strategy and protocol has resulted in a close tozero base problem of lower anterior relapse.

DiscussionThere are educators who use the results of the Class

II Randomized Clinical Trials to fortify their beliefs thatthere are no benefits to Early Class II Treatment.

The everyday practitioner starts off at a disadvantagebecause it is impractical, if not impossible, to conductrandomized clinical trials in a private practice setting.These trials with large monetary grants are relegated tothe University under the auspices of a much protectedguild with the temptation of strong bias and early treat-ment protocols of their choosing. McNarmara statedwhen the focus is on early Class II treatment, it is falseto say that all treatment protocols are the same.

The private practitioner has to rely on the integra-tion of the best research evidence available combinedwith clinical expertise and patient values. At thepresent time, there is a minimum of so called “BestEvidence” in the orthodontic literature.

At the base of the hierarchy of evidence is the casereport, but this is the foundation upon which the levelsof the best evidence grows. (Fig.5 ) So, the best thehands-on practitioner can do at this time is to rely onthe best available evidence to befound in one’s practice.

Experience-based EvidenceAn on-going clinical research

project for the author has beentaking orthodontic records of theparents of his pediatric orthodonticpatients. Most, if not all, ofthese parents had conven-tional orthodontic treatment

20 to 30 years ago. The mother (M.K.) of the Early ClassII Treatment Case being presented in this article is oneof those parents. (Fig. 6,7a,b)

ConclusionIn this important paradigm shift, the clinical

judgment of a skilled practitioner and thepatient’s/parents’ individual preferences and valuesshould be given equal weight with the best evalua-tive scientific evidence in the decision makingprocess of whether to treat early or late. (Fig.9 )

There are three generally-accepted deliverysystems in orthodontic care: growth modification bynecessity needs early treatment, late Class II treat-ment which presently is the gold standard of theorthodontic specialty and spoken of as camouflagetreatment (accepting the skeletal pattern andmaking the teeth fit) and orthognathic surgerywhen the above can not be accomplished.

Fig. 6: M.K. 14y 8m 9th grade:headgear, 4 bicuspid ext.

Fig. 7a: M.K. 40y 5m 2-23-06 facials and intra-orals

Fig. 9: Evidence baseddecision

making process

Fig. 7b: M.K.40y 5m2-23-06

McNarmara analysis

JAOSWin09 1/19/09 11:30 AM


Proffit has stated that “clinical decisions such as theoptimal time to start treatment are inevitably difficultbecause of the variability between patients and theuncertainty about growth and treatment response.”

The proposal from the author is to put fully docu-mented early treatment versus late treatment on the

same playing field and allow the orthodontic practi-tioner and consumer to judge the risk/benefit ratioof both of these approaches. The best clinical proto-cols should be based on the study of short term-longterm treatment outcomes.

References:Tulloch JF, Phillips C., Proffit WR. Benefit of early Class II treatment:

Progress report of a two-phase randomized clinical trial. Am JOrthod Dentofacial Orthop 1998; 113: 62-72.

Ghafari J, Shofer FS, Jacobsson-Hunt U, Markowitz DL, Laster LL.Headgear versus functional regulator in the early treatment ClassII, Division I malocclusion: A randomized clinical trial. AMJOrthod Dentofacial Orthop 1998: 113: 51-61.

Keeling SD, Wheeler TT, King GJ. et al. Anteroposterior skeletal anddental changes after early Class II treatment with bionators andheadgear. Am J Orthod Dentofacial Orthop 1998: 113L 40-50.

Proffit WR. Tulloch JF. Preadolescent Class II problems: Treat now orwait? AM J Orthod Dentofacial Orthop 2002: 121: 560-562.

Andrews LF. The Straight-wire appliance. J Clin Orthod 10: Feb –Aug 1976.

Gianelly, AA., One-phase versus Two-phase Treatment. Am J OrthodDentofacial Orthop 1995: 108: 556-9.

University of North Carolina. RCT Class II, NIDCR RO1 typegrant. DE-08708 (UNC owns Data – not Federal Gov). “Writtenrequest from Tufts Department of Pediatric Dentistry forspecific data denied.” September 22, 2005.

McNamara JA. The Dr. Herbert J. Margolis Memorial Lectureship.Tufts Dent. Cont. Ed. April 12, 2008

Forrest, JL and Miller, S. A.: Evidence-Based Decision Making: ATranslational Guide for Dental Professionals. Lippincott,Williams and Wilkins, Philadelphia, 2008.

Papadopoulos. MA and G Kiaouris, I.: A Critical evaluation ofmeta-analysis in orthodontics, Am. J. Orthod. 131: 589-599,2007.

Carapezza L.J. Objectifying treatment of Malocclusion. J Pedod 1990; 15: 5-12.

I am the mother of SK and here is my orthodontic story: I started wearing head-gear sometime around age 11 then finishing up with braces at about age 16. I remember that I had 10 baby teeth and four adult teeth pulled in preparation for,and during the course of, my braces.When I remember my junior high school andhigh school years, I remember that I had braces. I remember that my food at lunch gotstuck in them and that I had to make sure everything was all clear before smiling. Iremember having a night brace and having to sleep with it all the time. I remember italways popping off at night and worrying that I would have it forever if I could not getit to stay on when it was supposed to. I also remember worrying that if I had to have itforever, I would have to take it on sleepovers with me. While I write this, I am certainlylaughing at myself now, but it is funny how the mind of a kid works.

It has come to my attention over the years that many of the constant and dailyheadaches that I have had for years could be attributed to the positioning of my jawbecause four of my adult bicuspids were removed, possibly unnecessarily due to latetreatment. Fortunately, the headaches are mostly controlled with daily medicine. I havebeen told that I could have surgery to have my jaw realigned, which I will opt not todo. I remember the exact day that SK’s orthodontist looked at my jaw and asked me,without any prior knowledge, how long I had had daily headaches. When I told him the headaches were for aslong as I could remember, he told me that SK had my original jaw structure but because of early treatment, her jawwould grow properly and remain properly aligned, resulting in no headaches. Possibly eliminating headaches frommy daughter’s future is an enormous gift, and we will always be thankful for it.

However, this gift did not come without research. When our dentist advised us in 2004 that SK, age 8,needed braces we went to two orthodontists, both of whom advised us to wait until SK’s permanent bicuspidscame in, which would be at approximately age 11 or 12. After further discussions with our dentist, we were sentto our current orthodontist for braces. SK is now 11 and her braces are coming off. Her teeth are beautiful andher smile is infectious. She always lights up a room when she enters it, but now there is even more of a shinebecause her teeth are not something you normally see on an 11-year-old. All her friends are starting to getbraces and even though they are all 11 or 12 years old, they are getting teeth pulled to correct the crowding.

SK is done at the time we were told to start her braces. I share our story with as many people as I canbecause it is such a positive one. I want as many people to get to take advantage of her experience as possible.It just does not appear that there is a downside at all. There is a small part of me that would like to bring SK tothe original orthodontists and have SK smile and ask them if they still think we should wait.

Fig. 8: S.K. 11-year-old (May 08)post treatment smile

A Mother’s Point of View Regarding Early Treatment

JAOSWin09 1/19/09 1:36 PM

26 Winter 2009 JAOS

The benefits of early treatment of all typesof malocclusion have been long debated.Both sides of the argument make salientpoints. The detractors of early treatment

argue that waiting until all the permanent teethhave erupted is less traumatic and less expensive forthe patient than starting in the early mixed denti-tion. In addition, proponents of one phase treat-ment emphasize that patient management is easierfor the clinician.

Early treatment proponents claim that correcting aspecific problem early leads to a less complicated PhaseII treatment. Specific claims are made that open bites,deep bites, cross bites and Class II and III relationshipsare more easily treated in the mixed dentition. If apatient with a deep overbite Class II malocclusion alsosuffers from temporalis muscle headaches, then someauthors strongly recommend early treatment to allevi-ate the patient’s pain and suffering.1, 2

Perhaps more importantly, investigators have linkeddeep bite Class II malocclusion with problems of snor-ing, sleep apnea, hypertension, and other serious medi-cal conditions.3 The early treatment advocates alsoclaim that there is a psychosocial benefit to correctingobvious facial disharmony and oral-facial habits beforeschoolmates have a chance to be critical or tease the

T H E B E N E F I T S O F

Open Bite Dental By Jeffrey H. Ahlin, DDS

Fig.1: Katie with open biteat age 7

The long-term stability of the orthopedic and orthodonticresults in this case demonstrate that early treatment hasa place in a clinician’s treatment decisions. Withjudicious use, early therapy should not prolongtreatment or be uncomfortable or costly for the patient.

JAOSWin09 1/19/09 1:36 PM


patient.4 The obvious financial benefit to the patient orparents is that a more serious surgical procedure couldwell be avoided.

The patient presented here, Katie N. (Fig. 1), cameto our office at age 7 with a history of pacifier use forover three years. There was a very evident deforma-tion of the premaxilla. The patient had no othermedical considerations and was taking no medica-tions. In addition to her malocclusion, the patient’sdental history included small occlusal incipientlesions on her first molars.

Katie’s anterior open bite was 9mm. with bilateralposterior cross bite. Her mother stated that Katie “usedto love her pacifier” and was having some difficultyeating her food. Some of the patient’s school friendswere beginning to make derisive comments. Katie’smother was informed of a corrective course of actionand treatment plan.

Mrs. N. was initially reticent about committing to atwo-phase treatment plan. However, after a definitivetwo-phase plan of treatment was explained to thepatient’s mother, including the time period and thestability of the results, she agreed to go ahead withKatie’s treatment. Mrs. N. was assured that with goodpatient cooperation, Katie would have a beautiful resultwith a full smile. The mother was also informed that

her daughter would mostlikely need a secondphase of therapy withfull orthodontic bracketswhen all of her perma-nent teeth had erupted.

The Phase I treatmentplan for Katie includedmaxillary expansion withtwo removable appliances,(fig. 3) over 10 monthsand eight maxillary brack-ets for four months inorder to reduce the open bitemalocclusion and correct the cross bite. This phase oftreatment lasted for 20 months. The second maxillary

expansion appli-ance had poste-rior occlusalcoverage. AHawley retentionappliance wasplaced and thepatient was re-photographed atage 10. (Fig. 4 & 5)

E A R L Y T R E A T M E N T

& Facial Deformity

Fig.2: Katie’s anterior occlusionat age 7

Fig.3: First appliance

Fig.4: Katie at age 10

Fig.5: Age 10 occlusion

JAOSWin09 1/19/09 1:37 PM

Fig.6: Occlusion at age 20

After the completion of the first phaseof treatment, Katie had a much moreacceptable appearance. Her cross bite andopen bite had been corrected and she wasmore comfortable about her facial appear-ance in school and with her ability toincise food with her anterior teeth.However, Katie still had a Class II molarand canine relationship with a 3.5mm.overjet. After Phase I correction, a Hawleyappliance was placed. Katie wore theHawley retainer during the 15-month rest-ing phase.

Maxillary and mandibular brackets wereplaced at age 12, after all the permanentteeth (except third molars) had erupted. Anarch wire sequence beginning with an .014NiTi wire with nickel titanium distalizingsprings to the maxillary second molars wasplaced in order to lock in a Class I molarrelationship. After the mandibular arch hadan .018X.025 arch placed, interarch Class IIlight 1/4” elastics were worn with a.016X.016 maxillary arch until a Class Icanine relationship was achieved. Thedistalizing springs on the maxillary archwere advanced one tooth per visit until thespace was distal to the canines. Powerchain elastics were used to close in thecanines to a Class I canine relationship.(Figures 6 & 7).

Fig.7: Katie at age 20 (full face)

28 Winter 2009 JAOS

JAOSWin09 1/19/09 1:37 PM

CLEAN AND SAVE!~ Specializing In Orthodontic Cleaning Services ~

BRACKET CLEANING SERVICES - Your bracketsare completely cleaned and polished. We also offer awide range of sorting to suit your needs, prices 10¢ to45¢ each.

B A N D S I Z I N G A N D C L E A N I N G - Sizingsystems from the manufacturer and style of your choicemarked onto the band that will be completely cleanedand polished, $1.35 each.

THESE SERVICES PLUS A LOT MORE! - Pleasecall for your brochure and mailing label. Remember toask about our FREE CLEANING OFFER ANDVALUABLE COUPONS! !

CALL 1-800-343-3212

P.O. BOX 3360, SAN DIMAS, CA 91773-7360 (909) 394-0910www.vectordental.com [email protected]

DENTAL CORPORATION

SAVINGS

LOSSES

JAOSWin09 1/19/09 1:37 PM

30 Winter 2009 JAOS

A Class I molar and canine relationship wasachieved in 12 months. Figure 6 shows the anteriorocclusion at age 20, seven years post-treatment fromphase II. The panoramic films, taken at ages 7 and 16(Figures 8 & 9), show the dental development withexcellent root parallelism and no developing thirdmolars. The patient’s mother declined cephalometricpre- and post-treatment films in order to minimizeradiographic exposure to the patient. Dental retentionincluded a lower lingual bonded twisted wire andremovable maxillary Hawley retainer. The patient stillwears the maxillary retainer occasionally while sleep-ing. (Figure 7 is a final full face of Katie at age 20).

The long-term stability of the orthopedic andorthodontic results (figure 7) demonstrates that earlytreatment has a place in our treatment decisions. Withjudicious use, early therapy should not prolong treat-ment, be uncomfortable or costly for the patient. Theuse of early treatment regimes could also avert the needfor some surgical procedures for our patients.

References:1. Ahlin, J. H., Atkins, G., A screening procedure for differentiating tem-

poromandibular joint related headache. J. Headache 1984; 24: 216-221.

2. Ahlin, J. H., The theoretical and practical application of a remold-able craniomandibular appliance. Int. J. Orthod. 1984: 22: 21-23.

3. Roux, F., D’Ambrosio, C., Mohsenin, V., Sleep related breathingdisorders and cardiovascular disease. Am J Med 2000; 108: 396-402.

4. Shoroog, A., Locker, D., Streiner, D.L., & Thompson, B., Impact of self-esteem on the oral-health-related quality of life of children withmalocclusion. J Orthod. & Dentofacial Orthoped. 2008. 134: 484-489.

Fig.8: Panorex taken at age 7

Fig.9: Panorex taken at age 20

JAOSWin09 1/19/09 1:37 PM


JAOSWin09 1/19/09 1:37 PM

32 Winter 2009 JAOS

Both in skeletal and dental growth and devel-opment, and in development of occlusion,there are times when the extraction ofprimary teeth may be an important treatment

consideration. The dramatic possibilities of well-timedextractions can change your patients’ lives by:

� decreasing risk of and preventing ectopic teeth,

� preventing rotated/crowded incisor positions,

� improving the natural eruption of permanentteeth and decreasing the risk of impaction ofpermanent teeth,

� reducing orthodontic treatment time and sequelae,

� improving gingival health and overall dental health.

Incisor Crowding & Alignment InstabilityIncisor crowding/rotations are a common occurrence

with various negative sequelae and may be preventablein patients through primary canine extractions. Ectopiccanines or impactions can be a devastating occurrencein relationship to a normalized occlusion in ourpatients, andalthough oftentreatable, theycan result innegative seque-lae, includinggreatly extendedtreatment times.

The chal-lenges involvedwith crowded

Early TransitionalDentition TreatmentEarly TransitionalDentition TreatmentBy Dr. Chris Baker, RN, DMD

It has been estimated that 50,000 patients are born in the U.S. everyyear who will develop at least one impacted canine that will requireorthodontic attention by age 10.

JAOSWin09 1/19/09 1:37 PM

incisors - instability of anterior tooth alignment and ahigh post-orthodontic treatment relapse rate inmandibular incisors - involve first the shrinking archlength in our culture. Today’s children exhibit frequentincisor crowding and less arch length than their grand-parents did 50 years ago.

Today, the incisors in the transitional dentitionhave a high rate of relapse, rotations and crowding;even bicuspids and canines often exhibit rotations.[Little] Esthetic concerns are more prevalent, and func-tional contacts are diminished, resulting in an impacton occlusal harmony and TMJ health with the growthof the aging skeleton

The etiologies of mandibular incisor crowdingrelapse include:

� leaving teeth rotated and allowing interseptal fibersto develop memory for crowded positions

� late forward mandibular growth and aging growthchanges, causing crown uprighting (lingualization)and tipping of the mandibular incisors

� Not holding ideal tooth positions with a lingualarch until all permanent bicuspids and canines haveerupted.

� Not wearing retainers long enough.

How do I reduce the risk of crowding?You can reduce the risk of rotated and crowded incisors

through the following possible treatment options:

� Extract primary teeth if needed. If you make spacefor permanent incisors to erupt and becomestraight naturally, almost always the natural erup-tion will be into an aligned position. This requiresextraction of primary teeth as needed before theeruption of permanent teeth is complete. Once theDEJ of the erupting tooth passes the alveolar level,the intra-septal and trans-septal fibers are estab-lished and tend to cause relapse of the incisor tothe eruptive position. If the eruptive position wasone of rotation, the incisor will most likely relapseto that position even after orthodontic correction.Derotation of teeth just after emergence in themouth implies correction before the transseptalfiber arrangement has been established. In refer-ring to the Dugoni study, Zacchrison says, “Thesepositive results may be related to the stage ofdevelopment of the transseptal fibers. Kusters andcolleagues showed the transseptal fibers do notdevelop until the CEJ of erupting teeth pass thebony border of the alveolar process.” Foster andWiley found that extraction of primary canineshad no detrimental effect on the eventual width ofthe permanent canines. Numerous studies havedocumented that mandibular incisors tip linguallyas a result of serial extraction, but orthodonticcorrection of lingual tip is stable while incisorderotation is not.

� Straighten permanent teeth if needed, assoon as they have erupted and it is feasible. Thesooner the tooth is aligned (straight), the morelikely the developing fibers will help hold the toothin the aligned position.

How do you straighten the teeth? First, extractprimary teeth as needed, allow natural eruptive posi-tioning and then evaluate the need for furtherorthodontic movements. Then, use a lingual holdingarch if orthodontic treatment is not begun as soon asall incisors have erupted. Keep the arch in place untilorthodontic treatment is begun.

It is a good option is to provide Phase I treatment assoon as incisors are erupted: band the six-year molars,bracket the incisors, apply sectional and/or looped wire(.014SS or TMA .0175 x .0175) from lateral incisor tolateral incisor, using utility arch wire (UAW) to correctarch length and position incisors and molars.Expand/tip as neededto an idealized incisorpositions and overbiteand overjet. Createcanine space, correctmolars to Class I anduse elastics as needed(Class II from kobiashihooks on the maxillarypermanent lateralincisors to mandibularsix-year molars andClass III from kobiashihooks on the mandibu-lar lateral incisors tomaxillary six-yearmolars.) After Phase Itreatment is completeduse a lower lingualholding arch as aretainer with distalextensions to holdincisor positions, anduse an upper DoyleHawley design remov-able retainer. Both ofthese retainers shouldbe worn until all eruption is complete. At that time,remaining treatment needs (Phase II) can be evaluated.

Note mandibular permanent lateral incisors and canines will not fit in thespace of the primary laterals and canines. Extraction of the primary teethallows the laterals to erupt and become well-aligned/straight.


JAOSWin09 1/19/09 1:37 PM

34 Winter 2009 JAOS

� Expand and correct arch length as early as feasible.

� Utilize holding arches in the transitional dentitionto maintain arch length until all permanent bicus-pids and canines have erupted.

� Maintain the patient’s original arch form (evidencedon mandibular arch). When the dental arch form ischanged with orthodontic tx, there is a post-reten-tion change to its pretreatment shape. In nearlyevery case, arch length intercanine width and inter-molar width changes prove unstable and return topre-tx dimensions. [Shapiro]

� Compliance with retainer wear, of course.

� Plan extraction of third molars if they areimpacted, in poor position or if space is insufficientfor their eruption.

Extractions as part of treatment forinsufficient arch length : It is important to do aclinical evaluation and diagnosis to evaluate the timingrecommended for extraction of primary canines toprevent crowding and rotations of incisors.

� Evaluate the space and position of permanentincisors at the time the primary central incisors arebeginning to exfoliate.

� Consider extractions if: 1) the primary incisorshave exfoliated, space appears inadequate and thepermanent incisors are not erupting or are erupt-ing ectopically; 2) the primary incisors have notexfoliated, space appears inadequate and thepermanent incisors are not erupting; 3) the perma-nent incisors are erupting lingually to the primaryincisors; 4) the permanent central incisors areerupted and space appears inadequate for thepermanent lateral incisors.

� Timing of extractions should be as soon as the spaceshortage and/or malposed incisors have been identi-fied. Remember that most lower incisor teeth willcorrect their rotated positions naturally if the spaceis adequate and if the eruption is early enough thatthe CEJ of the erupting tooth has not passed theheight of the alveolar bone.

� Treatment Planning: The parent may be presentedwith three options for the child patient:

� Do nothing now. Allow natural eruption, allow-ing rotations/crowding to remain and considerorthodontic correction later. This option increasesthe likelihood of crowded/rotated incisors andorthodontic relapse in the child’s lifetime.

� Extract whichever teeth are in the way of thecentral incisors (usually the primary lateralsand maybe the primary centrals) and plan to

extract primary canines when the permanentcentral incisors are ready to erupt. This meanstwo episodes of local anesthesia, but the eden-tulous spaces are not as large until permanentlaterals erupt.

� Extract (canine to canine) any primary teeththat are in the space the permanent centralsand laterals will need. This requires only oneepisode of local anesthesia, but does createlarger spaces in esthetic planning until thepermanent laterals erupt.

Children seem to have almost no post-operativeconcerns or complaints after the extraction of primaryincisors and canines. And they and their parents arepleased to see the beautiful smile with beautifulstraight teeth.

Ectopic Unerupted TeethWe can find references going back to Edward Angle

in his publication in 1907 involving treatment ofectopic unerupted teeth. Today, Andreasen points outthat eruption fails 1 out of 5 times (20%). This meansthat out of 52 eruptions in each patient (20 primaryand 32 permanent teeth), statistically 10+ teeth willbe ectopic.

Ectopic teeth may increase the risk of:

� Functional distur-bances such asimpactions,resorption ofadjacent rootsand poor occlu-sion.

� Inadequateattached gingivae.

� Decreased esthet-ics such as gingi-val margindiscrepancies.

� Future problemsincluding insuffi-cient attachedgingivae.

� And impactedteeth and relatedsequelae.

� The need forcomplex andlengthyorthodonticmechanicswith increasedtreatmenttime of at

JAOSWin09 1/19/09 2:32 PM

least 1-2 years,surgicallyplaced attach-ments, boxloops andballistasprings, molardistalizingappliances andTAD’s (tempo-rary anchorage

Leite points out that of the population that haseruption abnormalities of maxillary permanent canines,85% are palatal, and have adequate arch length while12.5% resorb incisor roots as they erupt.

The literature tells us that resorbed lateralincisors adjacent to impacted canines typicallyhave normal crown size. In the majority of cases,87% of aggressive lateral incisor root resorption,there is normal mesiodistal crown size of thelateral incisors. Peg-shaped, small or missing lateralincisors have been shown to be a predisposingfactor in shorter root length and can result inpalatal canine impactions. It is speculated that thenormal-sized and early developing lateral incisorroots obstruct the deviated eruption path ofcanines and consequently stand a greater chance ofbeing damaged by resorption.


About Extraction of Primary CaninesEricson and Kurol found that in cases of extrac-

tions of primary canines that 78% of ectopic erup-tion changed to normal. Two-thirds of those changedto normal within six months. The remainderchanged to normal within 12 months. After 12months, there was no further improvement inpermanent canine positions.

The possibilities you offer your patients when youextract primary canines include:

� decreased ectopic eruption

� decreased impaction of permanent teeth

� reduced risk of impaction sequelae such as intrusionof adjacent teeth and root resorption/pulpal prob-lems of adjacent teeth

� reduced orthodontic treatment time and sequelae

12.5% resorb incisors

JAOSWin09 1/19/09 2:32 PM

36 Winter 2009 JAOS

Extraction asPart of Treat-ment of EctopicUnerupted Teeth:

It is important todo a clinical evalua-tion and diagnosis toevaluate the timingrecommended forextraction of primarycanines to preventimpaction, failure oferuption andother sequelae.

First, evaluateand diagnose theunerupted ectopicpermanent

tooth/teeth. On the radiograph, evaluate theextended long axis of the permanent canine. At thetime of eruption of lateral incisors, take a panoramicradiograph. Draw a long axis of the uneruptedcanine (figure 1) and extend past the occlusal plane.If the extended long axis passes more than one adja-cent crown width, (figure 2) consider bilateralextraction of primary teeth. Bilateral extractionshelps maintain midline positions.

Secondly, recommend extraction if the extended longaxis passes more than one adjacent crown width. (figure 2)The extended long axis passes not only the lateral incisorat one crown width, but also into the central incisorcrown. Extended long axis evaluation may give us the abil-ity to predict the majority of unfavorable eruptive paths ofpermanent canines earlier than previous analyses. Thisanalysis is done in the early rather than the late transi-tional dentition and includes mid-alveolar paths that maypredispose laterals to root resorption. Treatment planningnote: Always extract bilaterally to prevent midline shift!

At the American Association of Orthodon-tists’ (AAO) Early treatment conference, Feb.2002, researchers reported that.:

“An ongoing study shows that the early extractionof primary canines will prevent the need for surgicalexposure in as many as 80% of these patients – if theyare diagnosed [and treated} early enough.”

“Lesson learned: Diagnose and consider the need forearly treatment due to the severity of complicationsthat can be caused by unerupted and impacted teeth.”

It has been estimated that 50,000 patients are bornin the U.S. every year who will develop at least oneimpacted canine that will require orthodontic attentionby age 10. Most are palatal, but this does not eveninclude a high percentage of canines that do erupt, butinto ectopic/poor positions.

By extracting primary teeth appropriately and judi-ciously, you can transform lives!

References:Behrents, Rolf G. Growth in the aging craniofacial skeleton. Monograph17,Craniofacial Growth Series. Center for human growth and development.Uof Michigan . Ann Arbor . 1985.

Brin I, Becker A, Zilberman Y. Resorbed lateral incisors adjacent to impactedcanines have normal crown size. Am J Orthod Dentofacial Orthop. 1993 Jul;104(1): 60-6.

Dugoni SA et al. Early mixed dentition treatment: post-retention evaluation ofstability and relapse. Angle Orthodontist 65(5) 1995. 311-320.

Ericson S, Kurol J. Radiographic assessment of maxillary canine eruption inchildren with clinical signs of eruption disturbances. Eur J Orthod. 1986Aug;8(3):133-40.

Ericson S, Kurol J. Early treatment of palatally erupting maxillary canines byextraction of the primary canines. Eur J Orthod. 1988 Nov;10(4):283-95.

Ericson S, Kurol J. Resorption of maxillary lateral incisors caused by ectopiceruption of the canines. A clinical and radiographic analysis of predisposingfactors. Am J Orthod Dentofacial Orthop. 1988 Dec;94(6):503-13.

Foster H and Wiley W. Arch length deficiency in the mixed dentition. AJO1958. 68:61-8.

Ericson S, Bjerklin K, Falahat B. Does the canine dental follicle cause resorp-tion of permanent incisor roots? A computed tomographic study of eruptingmaxillary canines. Angle Orthod. 2002 Apr;72(2):95-104.

Ericson S, Kurol J. Incisor root resorptions due to ectopic maxillary caninesimaged by computerized tomography: a comparative study in extracted teeth.Angle Orthod. 2000 Aug;70(4):276-83.

Kusters ST , Kuijpers-Jagman AM, Maltha JC. An experimental study in dogsof transseptal fiber arrangement between teeth which have emerged inreotated and non-rotated positions. J Dent Res. 1991.70: 192-197.

Leite L. Eruption abnormalities of maxillary permanent canines. JSSPD 6?3) 2000.

Leivesley WD. Minimizing the problem of impacted and ectopic canines.ASDC J Dent Child. 1984 Sept-Oct;51(5):367-70.

Little, RM. Stability and relapse of mandibular anterior alignment: Universityof Wash Studies . Seminars in Orthodontics. 5(3) September, 1999. 191-204.

Little, RM. Stability and relapse: Early treatment of arch length deficiency.AJODO 121(6) 578-581. June 2002.

Shapiro P. Long term observation of orthodontically treated patients.Mandibular dental arch form and dimension treatment and post-treatmentchanges. AJODO 1974: 66:411-430.

Turpin DL. Early treatment conference alters clinical focus. Am J OrthodDentofacial Orthop. 2002

Turpin DL. Where has all the arch length gone? Editorial, AJODO March, 2001. 201.

Warren JJ, Bishara SE. Comparison of dental arch measurements in theprimary dentition between contemporary and historic samples. Am J OrthodDentofacial Orthop. 2001 Mar;119(3):211

Zachrisson BU. Important aspects of long-term stability. 1997 JCOSept;31(9): 562-583.

Fig. 1

Fig. 2

Before extractions of MX primary canines

After extractions of MX primary canines

JAOSWin09 1/19/09 1:37 PM

JAOSWin09 1/19/09 11:08 AM

38 Winter 2009 JAOS

Tier Advancement Orthodon-tic Review Course AND theFinancial Strategies Course willbe taught in Dallas on April 3-4,2009. To help you advance fromAchievement to Fellowship to Diplo-mate, we offer a two-day educationalcourse designed to increase yourorthodontic skills. We have alsoadded the highly popular one-dayFinancial Strategies course.

Dr. David Jackson’s “MissingPiece of Your Practice” Compre-hensive Orthodontic EducationProgram is set to begin in KansasCity and San Diego during March.This four-session course for generaland pediatric dentists will focus onlearning and implementing a provensystem for orthodontic diagnosis andtreatment.

Train your staff with Kay Gerety’sStraight Wire for Assistants tobe conducted in Dallas and Atlantain February and March as well as the

Advanced Straight Wire forAssistants conducted in Dallas inMarch. This course is a perfectcomplement to Dr. Gerety’s compre-hensive courses. However, Kay’sknowledge of GP orthodontics andexperience as a clinician makes hercourses valuable whether or not youare a present or former student ofDr. Gerety.

Learn intermediate concepts andtechniques from two outstandingpractitioners and teachers, Dr. BillWyatt and Dr. Larry White, begin-ning in Dallas in January. Expand yourorthodontic skills with a combinationof lecture, case review, wire-bending,and hands-on typodont workshops.

Learn the orthodontic basics withDr. Leonard Carapezza beginningin March in Wayland (Boston), MA.Both the beginning and advancedcourses provide a systematic orthodon-tic approach to treating patients usingthe Straight Wire philosophy.

The AmericanOrthodontic Society

2008-09 Officers& Directors

PresidentArturo R. Gutierrez, DDS

President-Elect & JAOS Co-Editor

Jordan J. Balvich, DMD

Vice PresidentChris Baker, RN, DMD

Secretary-TreasurerJohn N. Hanchon, DDS

Immediate Past PresidentJon P. Romer, DDS

Board of DirectorsAzita Anissi, DDS

Debra Ettle-Resnick, DDSRobert G. Gerety, DDSMitchell S. Parker, DDS

Juan J. Solano, DDSDavid M. Thorfinnson, DDS William E. Wyatt, Sr., DDS

Board of ExaminersChris Baker, RN, DMDRobert G. Gerety, DDS

W. Edward Gonzalez, Jr., DMD, PADavid W. Jackson, DDS

Joseph R. Schmidbauer, DDS

Executive DirectorThomas N. Chapman, CAE

JAOS EditorGreg Cannizzo, DDS

AOS MEMBERSHIP NEWS

AOS Course Corner

ATTENTIONAccording to Society bylaws, any active member of the AOS may bring new business or old

business before the Board for consideration. The next meeting of the Board of Directors is sched-uled for April 2, 2009 at the Addison Crowne Plaza Hotel in Dallas. If you have items for Boardconsideration, please fax to the AOS office 972-234-4290 no later than Friday, March 6, 2009.

In a ceremonyduring the recentAmerican Associa-tion of DentalEditors AnnualMeeting in SanAntonio, Dr. GregCannizzo ofMcHenry, Illinois,received designa-tion as a CertifiedDental Editor(CDE).To receive this award, you mustcomplete 30 hours of continuingeducation in approved subject areasrelated to writing, editing andcommunications. Dr. Cannizzobecame only the 26th person to earnthis distinction and the second Editorof the JAOS to be so recognized.

In 2004, the late Dr. RogerRupp, the Journal’s initial Editor,

became the fourthperson to be certified.Dr. Cannizzo has asuccessful generaldental practice inMcHenry, IL. He andwife Linda are theparents of two boysand two girls. He hasbeen the Editor of theJournal since January

2005 and was the Co-Editor prior to that, as well aspast-president of the AGpO. Allof us affiliated with the Ameri-can Orthodontic Society areproud of Dr. Cannizzo for thisaccomplishment and hiscommitment to make The Journalof the American Orthodontic Soci-ety the finest GP orthodonticpublication available today.

Dr. Greg (at left) Cannizzo earnsCDE designation.

JAOS Editor Earns Top Honor

Details on all of our AOS courses can be found atwww.orthodontics.com or by calling 800-448-1601.

JAOSWin09 1/19/09 11:08 AM


AOS MEMBERSHIP NEWS

New Vice-President and Directors Elected

Retention of membershipis both the most important,and yet, the most challeng-ing job for a professionalassociation. In tougheconomic times, when everypractice expense must bescrutinized, we know thecost of AOS membership is

questioned and renewed based on the perceivedvalue that membership adds to your practice. I havebeen a member of AOS for 16 years and myorthodontic practice has grown each year as a directresult of the support and education this organiza-tion has provided. The AOS is my “go to” organiza-tion for orthodontics and I want it to be yours.Here’s what we offer that deserves your continuedand committed membership in the AmericanOrthodontic Society:

We are... The largest “member-based” orthodon-tic educational organization in America. Coursecontent is always determined by the Society and notby special interest groups. This allows our membersto attend high-value education-FIRST programs, allrecognized by the ADA Continuing EducationRecognition Program.

We are… The voice for GP orthodontics. Wher-ever we see discriminatory practices that threaten tolimit your right to practice, we’re there for YOU andALL Society members.

We are… The top publisher in GP orthodontics.The Journal of the American Orthodontic Society isstuffed with “take-away” orthodontic pearls AND infor-mation on the latest in technology and industry trends.

We do… Provide an achievable, but rigorous,path for tier advancement. Want to increase yourpatient base, while improving your orthodonticskills? Follow our Society credentialing programfrom Achievement to Fellowship to Diplomate.

We do… Have the best patient information mate-rials for your practice. Krames Communicationspublications, the leader in the patient informationindustry, are available to you AT OUR COST.

Most importantly… The AOS is large enough tobe a voice in the industry, but small enough to valueyour membership on an individual basis. In today’sworld, that alone is worth the cost of membership.

If you’ve not done so...RENEW NOW. Even better,renew and bring a colleague along. You will experi-ence the AOS Advantage! Have a happy and prosper-ous 2009. R. Gutierrez, DDS

Valuable Membership Benefits

RENEW YOUR DUES TODAY AND ENSURE YOU ARE INCLUDED IN OUR 2009 MEMBERSHIP AND REFERALDIRECTORY. RENEW ONLINE AT WWW.ORTHODONTICS.COM or CALL THE AOS OFFICE AT 800-448-1601.

Arturo Gutierrez, DDS AOSPresident

During the recent Annual Meeting in New Orleans, thegeneral membership elected two new directors and a newvice-president in accordance with the bylaws of the Society.

The new Vice-President who willbecome the Society President in 2010is Dr. Chris Baker. Dr. “Chris” is aDiplomate, Board Examiner, SeniorInstructor and Board Member. She is aregistered nurse who received herDMD from the University of Kentucky,then both her certificate in pediatricdentistry and her fellowship in the

Department of Orthodontics from the University ofConnecticut. She served on the University of Connecti-cut faculty in the department of pediatrics for eightyears and currently serves on the faculty of the Univer-sity of Kentucky while also practicing in Lexington, KY.Dr. Baker teaches comprehensive courses in both basicand advanced orthodontics.

Elected for a term of four years as a Director is Dr.Azita Anissi. Dr. Anissi is a general dentist practicing inRochester, NY. She graduated from the State University

of New York at Buffalo Dental School in1990 and is currently teaching the resi-dency advancement program atRochester General Hospital. More than30 percent of her practice is dedicatedto orthodontic treatment. Dr. Anissireceived her Diplomate from the AOS atthe New Orleans Annual Meeting thispast October.

Elected for a term of four years asa Director is Dr. Dave Thorfinnson.Dr. Thorfinnson graduated from theUniversity of Minnesota in 1988 andpractices in East Grand Forks, MN.He has been a member of the AOSsince 1992 and received his Fellow-ship in 2007. He is a member of theAmerican Dental Association,

Minnesota Dental Association and past president ofthe NW Minnesota District Dental Society, where hehas been involved with the district Ethics andBylaws committee and peer review.

Dr. Chris Baker

Dr. David M. Thorfinnson

Dr. Azita Anissi

JAOSWin09 1/19/09 11:08 AM

40 Winter 2009 JAOS

AOS MEMBERSHIP NEWS

JAOSWin09 1/19/09 11:08 AM

JAOSWin09 1/19/09 11:08 AM

42 Winter 2009 JAOS

AGpO MEMBERSHIP NEWS

Academy ofGp Orthodontics

2009 OfficersPresident

Drew Ellenwood, DDS

President ElectMarc Dandois, DDS

Vice PresidentThomas Jacobsen, DDS

Secretary - TreasurerSam Gutovitz, DDS

Immediate Past-PresidentKeith Wilkerson, DDS

Board of DirectorsEugene Boone, DDS

Greg Cannizzo, DDS

Corina Diaz- Bajsel, DDS

Fred Der, DDS

Kyle McCrea, DDS

Kurt Raack, DDS

Kurt Stodola, DDS

Helen Tran, DDS

Advisory Board

Ron Austin, DDS

Joe Fallin, DDS

Roy Holexa, DDS

Leslie R. Penley, DDS

Bob Shirley, DDS

Barry Sockel, DDS

Walter L. Tippin, DDS

Executive DirectorCynthia Bordelon

www.academygportho.com

Board ExaminationFellowship Award Recipient

This year, the Academy recognized Dr. Fred Der of Keswick, Ontario,Canada who achieved Fellowship status by passing the Fellowship BoardExamination. Dr. Der is the host dentist of the comprehensive two-year,hands-on orthodontic course taught in his office by Dr. Roy Holexa.

The Acacdemy ofGp Orthodontics

2009 Spring ReferesherThe Academy of Gp Orthodontics is pleased to present the 2009

Spring Refresher Course featuring speakers on Tip-Edge Plus andOrthodontic Appliances. This two day event will take place March 27thand March 28th at the Crowne Plaza Hotel in Addison Texas. Featuredspeakers and topics will include Dr. Richard Parkhouse on the Tip –Edge Plus Bracket. Dr. Edward Joneson will speak on The Tip – EdgeExperience – It makes more sense, and Paul Ruzicka of Ordent Laborato-ries speaking on Orthodontic Appliance Designs and Adjustments. Toregister call the Academy headquarters at 800-634-2027. Don’t miss thisopportunity to improve and refresh your orthodontic skills and networkwith other dentist and Pedodontists who practice orthodontics.

JAOSWin09 1/19/09 11:08 AM

www.academygportho.com Winter 2009 43


Recently, my parents were talking about the current sour times and their incredible, shrinkingretirement. I gave my mother a fright by telling her I was heavily invested in a small companyand that if it went bust, so would I. She anxiously said I needed to immediately diversify. Too late,I told her, I was too entangled in this group. However, I knew the CEO, and I thought I’d still justmake it. My father had to tell her the small company was my dental practice.

This is our investment: Ourselves, our practices. Right now, that is probably the best place formoney. I have to remind myself to take time to sit quietly and think on my goals, to look from afarand evaluate and then come close to organize and refine. During spring cleaning, I jettison the trash; in my practice, Iwork to keep the fat trimmed and the weeds out. Though, it’s not all about building that better mousetrap. Investing inbecoming a better dentist means pressing to become a better me all around. I have to keep connected to my patients ashumans, to my staff as partners in service, and to my family as my touchstone. And remember, the one next to you. Thatis, don’t take your spouse for granted as your spouse is the most valuable asset in your human portfolio.

My daughter, a sophomore in college, asked me recently about the economy and what to do. I told her the bestplace to be during an economic bad time is in school. So it is with you and me. Now is not the time for panic –and believe me I’m one to panic – but to invest in our education. I advise you, and it’s just as good as you’ll getfrom any financial guru, to plan and save now to attend the joint annual meeting of the AGpO and the AOS inChicago, August 20-23, 2009. This will be a fantastic investment in honing your skills and becoming more effec-tive in your orthodontic practice.

Even earlier in 2009 is the Academy’s Spring Refresher. It will be held in Dallas on March 27 and 28. On thefirst day, the agenda includes Dr. Edward Jones who will lecture on Diagnosing the Maxilla and Paul Ruzicka, Pres-ident of Ordont, who will lecture on Appliance Designs and Adjustments. On Saturday, Dr. Richard Parkhouse, ourTip-Edge friend from Wales, will lecture on Tip-Edge Plus.

Hopefully, this can be an ongoing tradition to keep us connected to each other and the best in orthodonticcontinuing education. Meanwhile, strap yourself in the roller coaster. Soon the ride will be over.

Drew Ellenwood, DDS

Dr. Drew EllenwoodAGpO President

Your Practice:A Safe Investment in Tumultuous Times

Recently, 12 doctors finished their comprehensive two-year, hands-on course in Kreswick, Ontario, Canada. Alldoctors qualified for the Associate Fellowship level of the Academy of Gp Orthodontics Tier AdvancementProgram. All recipients completed the Academy’s 12–session comprehensive hands–on course and earned a mini-mum 155 CDE hours in Orthodontics and related topics. Also completed was a minimum of three cases during thehands–on course, followed by passing a written and oral examination administered by course instructor Dr. RoyHolexa and host dentist, Dr. Fred Der.

Back row, left to right:Dr. Younes, Trenton, ONDr. Holexa, Fountain Hills, AZDr. Parhar, Edmonton, ABDr. Bencak, Lasalle, ONDr. Yu, Keswick, ONDr. Der, Keswick, ON

Front row, left to right:Dr. Hartwig-Villa,

Cambridge, ONDr. Hildago, London, ONDr. Yu, Keswick, ONDr. Young, South

Porcupine, ON

Graduates not shown:Dr. Arrieta, Toronto, ON Dr. Jeong, Toronto, ON Dr. Leung, Burlington, ONDr. Wan–Chow–Wah,

Richmond Hill, ON

12 Complete Tier Advancement Program

JAOSWin09 1/19/09 11:08 AM

The Academy of Gp Orthodon-tics 20th Annual Meeting wasrecently held in Dallas, TX. It wasa successful celebration of educa-tion and connection with friends,colleagues and industry partners.

Dr. Lori Trost, Dr. Keith Wilker-son, Dr. Ralph Garcia, Dr. LarryKotlow, Dr. Leslie Penley, Dr. RonAustin, Dr. Roy Holexa, and Dr.Robert Allen spoke on topics thatchallenged and inspired the meet-ing attendees. This years topics ofAirways, Minor Tooth Movement,TMD, Lasers and Tip Edge Pearlsprovided for three full days ofsome of the best continuingeducation available.

The Saturday night dinner andAwards Banquet with dancing atthe Copper Bottom Grille, gaveeveryone a chance for remember-ing, recreation and reunion. Nextyear’s annual meeting will be heldas a combined event in Chicago ILon August 20 – 23, 2009 with theAmerican Orthodontic Society.

MEMBERSHIP RECIPIENTSMark Dandois, DDSHector Garza, DDSRoy Holexa, DDS

Tom Jacobsen, DDSLeslie Penley, DDS Bob Shirley, DDSBarry Sockel, DDS

FELLOWSHIP RECIPIENTFred Der

AGpO AWARD FORJOURNALISTIC

CONTRIBUTIONSJeffrey Gerhardt, DDS

44 Winter 2009 JAOS


AGpO Presents Awards at 20th Annual Meeting

JAOSWin09 1/19/09 11:08 AM

JAOSWin09 1/19/09 11:08 AM

&

46 Winter 2009 JAOS

JAOS PATIENT’S PAGE

Diabetes is a great concern for both the medicaland dental professions. Millions of Americansare affected each year by this disease. Overthe last two decades there has been a thirty to

forty percent increase in diagnosed cases of diabetes,especially among overweight children and adolescents,since obesity is a major risk factor. But how candiabetes affect your oral health?

The Centers for Disease Control defines diabetes as adisease in which blood glucose levels are above normal.Most of the food we eat is turned into glucose-or sugar-for our bodies to use for energy. The pancreas producesa hormone called insulin to help glucose absorb intothe cells of our bodies. When you have diabetes, yourbody either doesn’t make enough insulin or can’t useits own insulin as well as it should. This causes sugar tobuild up in your blood.

Diabetes can cause serious health complications,including heart disease, blindness, kidney failure, andlower extremity amputations, and it is the sixth lead-ing cause of death in the United States. Some classicsigns of diabetes are excessive appetite, excessivethirst, and excessive urination, but the condition mayalso cause weight loss, irritability, drowsiness, andfatigue. Diabetes, as well as any other medical condi-tion, should be reported to your dentist so thatproper care can be delivered.

When diabetes is not controlled it can lead to anumber of dental complications because the highglucose levels in saliva may help bacteria thrive in themouth. Diabetes also reduces the body’s resistance toinfection, and the body’s tissues, including the gums,are likely to be affected. The most common andpotentially harmful oral health problems associatedwith diabetes are gingivitis, periodontitis and rapidloss of the bone that supports the teeth. According tothe American Dental Association periodontitis is oftenlinked to the control of diabetes. Patients who haveinadequate blood sugar control appear to developperiodontitis more often and with greater severity.

These patients also lose more teeth than patients whohave good control of their diabetes.

Diabetes can also affect the amount of saliva in themouth, leading to dry mouth and resulting in anincreased risk for cavities. Recurrent canker sores, whitepatches on the cheeks, and fungal infections can be anindication of poor glycemic control in a diabeticpatient. Taste may also be altered in diabetic patients,making it difficult to maintain a proper diet.

Patients with poorly controlled diabetes are at anincreased risk of other complications, such as infectionsand reduced healing. This may make it necessary forthem to take antibiotics prior to certain dental proceduresincluding oral surgery. For patients taking insulin, it maybe necessary to consult with their physician in order toincrease the dosage in the case of an oral infection. It isalso important for your dentist to know if you takeinsulin because the use of local anesthetic can influencethe effects of insulin and can result in hyperglycemia.

So, if you have diabetes, make sure you take care ofyour teeth and gums. You may require more frequentvisits to the dentist and more rigorous follow-up treat-ment to ensure optimum dental health. To offset thegreater risk of gingival and periodontal problems, it isvital to control your blood glucose levels and to brushand floss daily. Finally, seek regular dental care to helpkeep your mouth healthy and to obtain advice on howto manage your diabetes.

Oral Health

Diabetes

This message is brought to you by your dentist, a proud member of the American Orthodontic Society and the AGpO.

JAOSWin09 1/19/09 11:09 AM


JAOSWin09 1/19/09 11:09 AM

Journal 2009

Documents

Transcript of Journal 2009