Tạp chí chỉnh nha OPUS tháng 03+04/2014 Vol 5 No.2

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March/April 2014 - Volume 5 Number 2

William (Bill) Harrell, Jr, DMD

John L Hayes, DMD, MBA

Paul Humber, BDS, LDS RCS, DipMCS

Laurence Jerrold, DDS, JD, ABO

Chung H Kau, BDS, MScD, MBA, PhD, MOrth, FDS, FFD,

Shalin R Shah, DMD (Abstract Editor)

Lou Shuman, DMD, CAGS

Larry W White, DDS, MSD, FACD

CE QUALITY ASSURANCE ADVISORY BOARD

Dr Alexandra Day BDS, VT

Julian English BA (Hons), editorial director FMC

Dr Paul Langmaid CBE, BDS, ex chief dental officer to the Government

for Wales

Dr Ellis Paul BDS, LDS, FFGDP (UK), FICD, editor-in-chief Private

Dentistry

Dr Chris Potts BDS, DGDP (UK), business advisor and ex-head of

Boots Dental, BUPA Dentalcover, Virgin

Dr Harry Shiers BDS, MSc (implant surgery), MGDS, MFDS, Harley St

referral implant surgeon

PUBLISHER | Lisa Moler

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is part of the specialist publishing group Springer Science+Business Media The publisher’s written consent must be obtained before any part

of this publication may be reproduced in any form whatsoever, including

photocopies and information retrieval systems While every care has been

taken in the preparation of this magazine, the publisher cannot be held

responsible for the accuracy of the information printed herein, or in any

consequence arising from it The views expressed herein are those of the

author(s) and not necessarily the opinion of either Orthodontic Practice US or

the publisher.

In today’s image-conscious world, professional adults who did not have the opportunity for treatment while they were growing up are flocking to orthodontic offices These new orthodontic patients are happy with their results posttreatment, according to a recent American Association of Orthodontists (AAO) survey of individuals who, as adults, had orthodontic treatment provided by orthodontists:

• Of adults surveyed, 75% reported improvements in career or personal relationships, which they attributed to their improved post-orthodontic treatment smiles

• Citing newfound self-confidence, 92% of survey respondents say they would recommend orthodontic treatment to other adults

The AAO recently debuted a public relations initiative, the Adult Patient Hall of Fame

The Hall of Fame celebrates the choices of adult professionals who have compelling stories and who pursued orthodontic treatment from AAO member orthodontists Inductees include Amielle Zay Abshire, a private jet pilot in her early 30s who flies celebrity and high-profile passengers around the world and wanted to greet them with a wonderful smile Another inductee, Dr Steven Couch, is an ophthalmologist affiliated with Washington University in St Louis, one of the most prestigious medical centers in the country Dr Couch did not have orthodontic treatment as a youngster, and in his early 30s felt the time was right

The number of adult orthodontic patients increased 14% from 2010 to 2012, to a record high of 1,225,850 patients ages 18 and older More men are also opting for orthodontic treatment As of 2012, 44% of adult patients were male, a 29% increase as compared to 2010 survey results These data are from the 2012 AAO’s “The Economics of Orthodontics” survey.The AAO is working to ensure that all adults who are candidates for orthodontic treatment seek out qualified orthodontists when they are ready to begin The AAO Consumer Awareness Program, which began in 2006, has utilized national advertising in all types of media, as well

as public relations campaigns and social networking initiatives, to educate the consumer as to the orthodontist’s unique qualifications In 2012, the Consumer Awareness Program expanded its focus beyond reaching parents of children and teens to messaging and media placements intended for adults who could benefit from treatment

Ads from the 2012-2013 My Life My Smile My Orthodontist.® campaign appeared in national media outlets in the United States and Canada and regional outlets in Puerto Rico The ads continued the core message that orthodontists are specialists with advanced training in straightening teeth and aligning jaws, with many of the ads showcasing adult patients

The 2013-14 My Life My Smile My Orthodontist.® campaign is taking a similar approach and will reach nearly 350 million consumers by this summer Adult patients are also profiled in a series of professionally produced testimonial videos that the AAO makes available for member use and are showcased on the AAO consumer website — mylifemysmile.org

Data indicate that the My Life My Smile My Orthodontist.® campaign is having a positive impact on adult patient decisions about orthodontic treatment In 2010, Millward Brown, a research company retained by the AAO, began conducting consumer research designed to

track consumer decisions about orthodontic treatment before and after the launch of the My

Life My Smile My Orthodontist.® campaign in 2012

Adults wearing braces and receiving treatment from orthodontists increased from 76% in

2011 to 83% in the third quarter of 2013 Adults utilizing clear aligners and receiving treatment from orthodontists increased from 56% to 59% during the same time period The Adult Patient Hall of Fame and other current initiatives were designed to help expand these positive trends

Materials from the My Life My Smile My Orthodontist.® campaign are not just for use by the AAO They are also available to develop customized advertising for member practices and/

or for use on member websites and social media pages Many AAO members use association materials in local promotion of their practices Dr James “Jep” Paschal, current chair of the AAO Council on Communications, recently offered some insightful remarks on this topic

“The value of the Consumer Awareness Program (CAP) program for the individual orthodontist is more than just marketing your practice, although the materials are often very effective for that purpose,” said Dr Paschal “It provides an opportunity to reinforce the AAO’s national campaign and help shape the thinking of the public so that when people think of orthodontic treatment, they automatically think of an orthodontist.”

To learn more about the AAO Consumer Awareness Program and customizable marketing materials, visit the AAO member website www.aaoinfo.org

Dr Gayle GlennGayle Glenn, DDS, MSD, has an orthodontic practice in Dallas, Texas, and is president of the American Association of Orthodontists

AAO consumer messaging impacts adults’ orthodontic treatment decisions

TABLE OF CONTENTS

Clinical

Posterior occlusal guides

Drs Larry W White and Kim Fretty discuss simple, inexpensive, and patient-friendly supplements to the Class II corrector armamentarium 18

Research

Evaluating the diagnostic value of lateral cephalogram radiographs

Drs Jay V Patel, Harold Slutsky, Jeffrey Godel, Jie Yang, and James

J Sciote study the necessity of lateral cephalograms for orthodontic diagnosis . 28

Occlusal philosophy:

investigating the reasons orthodontists have for occlusion preference

Drs Colin M Webb and Donald

J Rinchuse delve into functional occlusal schemes . 32

Dr Stuart Frost

Technology, creativity, and patient care are hallmarks of Dr Frost’s practice

Management of Class 2 non-extraction patients: part 8

Drs Rohit C.L Sachdeva, Steve Moravec, and Takao Kubota discuss the

application of SureSmile® technology in the management of patients presenting

with Class 2 malocclusions

ON THE COVER

Cover photo courtesy of Dr Thomas S Shipley Article begins on page 52

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4 Orthodontic practice Volume 5 Number 2

Case study

Class I impinging deep bite with

crowding

Dr Colin Gibson presents a case that

previously would need fixed-appliance

therapy 37

Banding together

Thu’s story

After 2 decades, a postcard from

a former patient proves to Dr Jerry

Clark that changing a smile also

maxillary and mandibular

first molars in relation to facial

pattern

Drs Lindsay E Grosso, Morgan

Rutledge, Donald J Rinchuse, Doug

Smith, and Thomas Zullo investigate

buccolingual inclinations of patients

with dolichofacial, brachyfacial, and

mesofacial vertical facial growth

patterns 43

The biology of orthodontic tooth

movement part 3: the importance

of magnitude

Dr Michael S Stosich delves into

the clinical consequences of force

3 reasons you need to re-evaluate your digital marketing strategy

Diana Friedman discusses ways to keep online marketing strategies fresh 60

Industry news

Groundbreaking clinical trial evaluates faster tooth movement with clear aligner treatment using

OrthoAccel® Technologies, Inc., enrolls first patients to start 12-week orthodontic evaluation 64

Buccolingual inclinations

of maxillary and mandibular first molars in relation to facial pattern

DIGITAL SOLUTIONS

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What can you tell us about your

background?

My father was a dentist, and my twin

brother and I would go down to his office

when we were teenagers and fool around

in his dental lab We knew we would be

dentists when we graduated from high

school I have three brothers-in-law that

are dentists as well After graduating

from dental school at the University of the

Pacific School of Dentistry (UOP), I worked

with my father for 5 years before going

back to school I spent a year doing a

TMJD fellowship in Rochester, New York I

learned how to read MRIs and make splints

to treat patients who suffered from acute

and chronic pain After that, I completed

my orthodontic residency at Eastman

Dental Center I have been in practice

for 13 years, and my passion is creating

beautiful smiles

Why did you decide to focus on

orthodontics?

I have always had a fascination with the

creating process, especially in dentistry

I loved cosmetic restoration cases as

a general dentist, but I wanted more

I wanted to be able to create a beautiful

smile without grinding the teeth down

and adding porcelain to create the smile

The other motivation for me to go into

orthodontics was the fact that patients

want to be at the orthodontist They love

braces, and it is fun to see them so excited

about improving their smiles Going to work

each day is a pleasure! Not a downer!

How long have you been

practicing, and what systems do

you use?

I have been practicing for 13 years with the

Damon™ System

Who has inspired you?

I have been inspired by Dr Dwight Damon

and Dr Tom Pitts I learned early on in my

career which orthodontists had the most

beautiful cases Dwight and Tom are two

of the best orthodontists in the world

What is the most satisfying aspect

of your practice?

The most satisfying aspect of my practice

is the end result It is very satisfying when

treatment is finished, the final shaping of the smile and teeth are done, and seeing the patients so happy with their new smiles

Professionally, what are you most proud of?

I love teaching, especially love to teach the residents at UOP in the orthodontic department I am also very proud of being able to teach other orthodontists how to

be better at using the Damon System and share what I have learned over the past 13 years

What do you think is unique about your practice?

Our practice treats about 50 percent adults

We pride ourselves on communicating with them Additionally, we are now using Ormco’s Lythos™ Digital Impression

System to streamline our workflow and eliminate PVS impressions, which has helped us enhance the patient experience and make our practice a state-of-the-art digital environment for efficient treatment

What has been your biggest challenge?

The biggest challenge in practice is the business side of orthodontics Also, working with staff members and assembling the right team players and keeping them motivated to succeed

What would you have become if you had not become a dentist?

I would have become a plastic surgeon I love helping others make positive changes

in their lives, and I could have enjoyed that

PRACTICE PROFILE

What is the future of orthodontics and dentistry?

I still believe that the future of dentistry as a whole is bright The future of orthodontics lies in technology Patients are willing to pay for technology, and they recognize the practices that continually are striving

to keep up on the latest advances in orthodontics

What are your top tips for maintaining a successful practice?

The most important tip for maintaining a successful practice is patient care Not just being good at straightening teeth, but taking care of the patient from the initial phone call to the day the braces come off

What advice would you give to budding orthodontists?

I would encourage young budding orthodontists to ask themselves three questions What kind of an orthodontist do you want to be? What kind of orthodontics

do you want to do? Where do you want to

be in 5 years? Write it down!

What are your hobbies, and what

do you do in your spare time?

I enjoy going to the lake and wake surfing

I love to golf, ride mountain bikes, and motorcycles In my spare time, I like to watch football

Top Ten Favorites

1 Beautiful smiles

2 Damon™ Q brackets

3 i-CAT® cone beam 3D imaging

4 Lythos™ Digital Impression System

5 G25 Nautique wakeboard boat

8 Orthodontic practice Volume 5 Number 2

ORTHODONTIC CONCEPTS

Introduction

The Class 2 malocclusion does not simply

manifest itself as a sagittal problem of

the craniofacial complex Its etiology and

manifestation is a result of a blending of

a complex of elements that also have

a temporal and functional component

Careful dissection, planning, and

manage-ment of the contributing factors, and

the three-dimensional recognition of the

morphological and spatial components

of the presenting malocclusion play a

significant role in the efficient and effective

care of these patients Table 1 provides

a list of high-level factors that need to be

considered in formulating a plan of care for

a Class 2 patient

The focus of this paper is limited to

discussing the application of SureSmile®

of patients presenting with Class 2

malocclusions by discussing specific

patient histories

II Application of SureSmile in treatment

of patients with Class 2 malocclusion

In general, SureSmile technology provides

five major functionalities in aiding the

orthodontist in managing the care of Class

2 patients (Sachdeva) These are:

A Decision support with 3D simulations

These simulations provide a visual interface for the orthodontist to understand the severity of the presenting a problem in 3D Furthermore, it augments the doctor’s ability to plan the nature of Class 2 correction This may be orthopedic and or dentoalveolar in nature The magnitude of

the correction designed in the simulation

is based upon the doctor’s mental model, reality, research findings, patient’s expectations, and expected participation

in care, and also the doctor’s skills Recognition of the contributory factors that potentially aid in the correction of the malocclusion and the directionality of

Management of Class 2 non-extraction patients: part 8

Drs Rohit C.L Sachdeva, Steve Moravec, and Takao Kubota discuss the application of SureSmile®

technology in the management of patients presenting with Class 2 malocclusions

Rohit C.L Sachdeva, BDS, M Dent Sc, is

the co-founder and Chief Clinical Officer at

OraMetrix, Inc He received his dental degree

from the University of Nairobi, Kenya, in 1978

He earned his Certificate in Orthodontics and Masters

in Dental Science at the University of Connecticut in

1983 Dr Sachdeva is a Diplomate of the American

Board of Orthodontics and is an active member of the

American Association of Orthodontics He is a clinical

professor at the University of Connecticut, Temple

University, and the Hokkaido Health Sciences Center,

Japan In the past, he held faculty positions at the

University of Connecticut, Manitoba and the Baylor

College of Dentistry, Texas A&M Dr Sachdeva has over

80 patents, is the recipient of the Japanese Society for

Promotion of Science Award, and has over 160 papers

and abstracts to his credit

Visit Dr Sachdeva’s blog on

http://drsachdeva-conference.blogspot.com All doctors are invited to

join the “Improving Orthodontic Care” discussion blog

Please contact improveortho@gmail.com for access

information.

Table 1: Considerations in the management of Class 2 patient treatment

Table 2: Strategies for using SureSmile targeted precision therapeutics to manage the tion of a Class 2 condition in a patient (Sachdeva)

Volume 5 Number 2 Orthodontic practice 9

their displacement supports the clinician’s

decision in selecting and designing the

appropriate appliance and therapeutic

approach in managing care Additionally,

various treatment scenarios may be

planned, and the optimal design selected

Figure 1: Gives an overview of the two most common Clinical Pathway Guidelines – Protocol A

and Protocol B developed by Sachdeva Figures 2A-2C: Patient PK is an example of Protocol A for Class 2 correction 2A Initial 2B Class 2 correction is initially achieved using conventional mechanics with

the Forsus™ spring Note the distal movement of the upper first molar to correct the Class 2 molar relationship is achieved prior to engaging SureSmile technology Once the correction is achieved, a mid-treatment scan is taken, and a SureSmile archwire is designed to correct the residual malocclusion

Figure 3: Patient BK An example of Protocol B using a lower hybrid SureSmile archwire

Patient presents with a Class 2 subdivision 1 left 3A Initial intraoral photographs 3B An

initial 017” x 025” NiTi hybrid lower SureSmile archwire has been designed It is active

anteriorly to correct the crowding and passive in the buccal segments to hold them stable

A Forsus™ spring is being used unilaterally on the left to correct the Class 2 Similar to the

lower archwire, the upper archwire is also designed as a hybrid archwire

Figure 4: Patient SK 4A Initial intraoral records show that patient presents with a Class 2 Div 1 Subdivision right 4B Initial panoramic radiograph

B Communication

The visual interface provides an extremely valuable and persuasive approach to enhance the learning experience of the patient with regard to her affliction and also discusses the virtual plan in an interprofessional environment

10 Orthodontic practice Volume 5 Number 2

ORTHODONTIC CONCEPTS

5A: Patient SK A Virtual Diagnostic Model (VDM) (Note: The model was scanned

a few months post initial photographs The patient shows a more severe Class II

relationship in the right buccal segment than is reflected In the intraoral images.)

5B: VDM (blue) vs VDS (white) are shown The initial step in the Virtual Diagnostic tion (VDS) entailed simulating asymmetric orthopedic changes to partially correct the Class 2 on the right side while maintaining the Class 1 relationship on the left Also, in the inset table, one notes the amount of corrective displacement required to achieve the desired orthopedic effect

Simula-5C: VDS shows post orthopedic correction 5D: VDM (blue) and VDS with dentoalveolar and orthopedic changes (white) The next step

in the simulation involves dentoalveolar correction of the Class 2 malocclusion Also, note the slight archwidth changes planned to accommodate for the new mandibular position

5E: VDS shows post orthopedic and dentoalveolar correction

5F: Shows the nature and magnitude of displacements of the dentition to correct the

“dental portion” of the malocclusion

Figures 6A-6C: Patient SK 6A Virtual diagnostic model 6B Shows correction of midline of VDM through orthopedic

simulation 6C The archwidths were corrected through dental movement as a continuum of orthopedic simulation

D Targeted precision therapeutics

SureSmile targeted precision appliances may be used in six different ways (Sachdeva) (Table 2) to manage the correction of the Class 2 malocclusion

E Outcome evaluation

SureSmile visual tools may also be used very effectively to measure treatment outcome and implement the findings into

a continuous quality improvement initiative

in the practice

II Clinical Pathway Guidelines for managing patients with Class 2 malocclusion

Effective use of SureSmile technology mandates the management of a patient

12 Orthodontic practice Volume 5 Number 2

ORTHODONTIC CONCEPTS

Figures 7A-7F: Patient SK Shows the clipping plane in different segments to show the archwidth changes in the VDS

with orthopedic correction and VDS with dentoalveolar and orthopedic changes 7A and 7D Clipping plane at the second

bicuspid level 7B and 7E Clipping plane at the first molar level 7C and 7F Clipping plane at the second molar level

Figure 8: Patient SK Shows staged linear movements used to monitor the patient’s overjet, crowding, midline correction, and archwidth changes This

is also a useful tool for the patient to monitor progress of care

Figures 9A-9B: Patient SK 9A Mid-treatment intraoral photos at the time of Therapeutic scan 9B Mid-treatment X-rays (Note: Correction achieved with use of asymmetric Forsus™

appliance.)

by following processes that are defined

by Clinical Pathway Guidelines (CPG) Exceptions to CPG occur to suit individual’s needs; however, in most situations, they provide a reasonable approach to navigate the care of a patient in a systematic and progressive manner

Common to all Clinical Pathway Guidelines (CPG) to manage patients with Class 2 malocclusion is the use of the decision support system to plan care at the onset of treatment The type and timing in use of SureSmile precision archwires varies and is driven by the dictates of the plan (Figure 1)

Class 2 Clinical Pathway Guidelines (Sachdeva) broadly fall under two categories: namely, a Protocol A and Protocol B These are shown in Figure 1

Volume 5 Number 2 Orthodontic practice 13

Figures 11A-11C: Patient SK 11A Final intraoral photos at debond 11B Virtual Final Model (VFM) 11C Final panoramic radiograph

14 Orthodontic practice Volume 5 Number 2

ORTHODONTIC CONCEPTS

RefeRences

1 White L, Sachdeva R Transforming orthodontics-Part 1

of a conversation with Dr Rohit Sachdeva, Co-founder and

Chief Clinical Officer of Orametrix Inc by Dr Larry White

Orthodontic Practice US 2012;3(1):10-14.

2 White L, Sachdeva R Transforming orthodontics-Part 2

of a conversation with Dr Rohit Sachdeva, Co-founder and

Chief Clinical Officer of Orametrix Inc by Dr Larry White

Orthodontic Practice US 2012;3(2):6-10.

3 White L, Sachdeva R Transforming orthodontics-Part 3

of a conversation with Dr Rohit Sachdeva, Co-founder and

Chief Clinical Officer of Orametrix Inc by Dr Larry White

Orthodontic Practice US 2012;3(3):6-9.

4 Sachdeva R BioDigital orthodontics: Management

of Class 1 non–extraction patient with “Fast–Track”©–

six month protocol: Part 5 Orthodontic Practice US

2013;4(5):18-27.

5 Sachdeva R, Kubota T, Hayashi K BioDigital orthodontics: Management of Class 1 non–extraction patient “Standard–Track”©– nine month protocol: Part 6

Orthodontic Practice US 2013;4(6):16-26.

6 Sachdeva R, Kubota T, Hayashi K BioDigital orthodontics: Management of space closure in Class I

extraction patients with SureSmile: Part 7 Orthodontic

8 Sachdeva R BioDigital orthodontics: Diagnopeutics with

SureSmile technology: part 3 Orthodontic Practice US

2013;4(3) 2013;4(3):22-30.

9 Sachdeva R BioDigital orthodontics: Outcome

evaluation with SureSmile technology: Part 4 Orthodontic

Practice US 2013;4(4):28-33.

10 Sachdeva R BioDigital orthodontics: Planning care with

SureSmile Technology: Part 1 Orthodontic Practice US

2013;4(1):18-23.

Figures 12A-12B: Patient SK Outcome Evaluation 12A VFM (green) superimposed on the Initial VDS (white) Note: The final result is quite similar to the proactively planned treatment 12B VDM (green) compared with the VFM (white) Note: The asymmetric change in the mandible achieved with the unilateral use of Forsus™ helped correct the asymmetry in the buccal occlusion as well as the midline

III Patient SK history —

Protocol A

The following is a description of the

management of a patient presenting with

a Class 2 Div 1 Subdivision right using

Protocol A Patient SK presented as a

12-year-old male pre-peak velocity The

initial records of the patient are shown in

Figure 4

The SureSmile decision support

system was used to design a 3D treatment

plan for the patient The plan, as shown

in Figure 5, considered both orthopedic

and dentoalveolar displacements Figure

6 shows a close-up view of the midline

correction and the archwidth changes as a

result of both orthopedic and dentoalveolar

movements In deciding the amount of

archwidth changes, one needs to consider

the buccolingual axial inclinations of

the molar and premolars in the buccal

segments shown in Figure 7 An additional

aspect in planning the care for patient SK

involved developing incremental milestones

to evaluate the progress of care as shown

Both upper and lower 017” x 025”, Af35ºC NiTi SureSmile prescriptive archwires were installed 8-weeks post Therapeutic scan and backed up with light Class 2 elastic wear (The wire should have been installed a month earlier, but this was not possible because the patient missed

an appointment.) The SureSmile active treatment phase lasted 3 months, and the patient was debonded 4 months from the initial installation of the SureSmile archwires

An outcome evaluation for the patient was performed by superimposing the

models representing different stages shown in Figures 12 and 13

Conclusions

Effective management of Class 2 correction requires careful planning and execution SureSmile technology provides a valuable technology platform to extend the skill sets of an orthodontist to accomplish these goals Future papers will discuss a spectrum of patient histories showing the versatility of using SureSmile technology in treating patients with Class 2 malocclusions governed by the philosophy and principles

Figures 13A-13F: Patient SK Outcome Evaluation 13A and 13D Clipping plane at the second bicuspid level 13B and 13E Clipping plane at the first molar level 13C and 13F Clipping plane at the second molar level 13A-13C VTM (white) vs VDS (green) and 13D-13F VFM (white) vs VDS (green) Note upper left segment is minimally tipped The left side is tipped and expanded buccally more than the right side

OP

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Posterior occlusal guides

Abstract

Class II malocclusions make up a large

part of the difficult orthodontic maladies

that clinicians must correct Traditional

techniques, such as elastics, headgears,

and removable functional appliances, have

recently been supplanted with so-called

noncompliant appliances that are fixed

in the mouth, requiring patients to use

them 24 hours per day While these fixed

appliances have had remarkable success,

the non-acceptance by many patients, the

frequent breakage, and considerable cost

have discouraged many orthodontists from

routinely using them Posterior occlusal

guides (POGs) offer a simple, inexpensive,

and patient-friendly supplement to the

Class II corrector armamentarium

Introduction

For several decades, European

orthodon-tists successfully used removable

functional appliances far more extensively

than their American counterparts for the

treatment of Class II malocclusions This

was probably due to the fixed appliances

that appealed more to early leaders in

American orthodontics, such as E.H Angle

and Calvin Case Over the past 4 decades,

European clinicians have endorsed fixed

appliances far more than in the past

Although removable functional appliances have seemingly lost much of their appeal throughout the world, those of the fixed variety enjoy remarkable popularity, e.g., Herbst1, MARA2, MPA3, Forsus4, and so on

The fixed functional appliances’

large allure rests upon their cemented attachments that must remain in the mouth Doctors have enjoyed using these since they obligate patients to wear them until corrections take place Because of this feature, they have acquired the cognomen

of noncompliant appliances However, anyone who has treated orthodontic patients for a minimum of time knows that

Posterior occlusal guides

CLINICAL

Drs Larry W White and Kim Fretty discuss simple, inexpensive, and patient-friendly supplements to the Class II corrector armamentarium

Larry W White, DDS, MSD, graduated from

Baylor Dental College and then served for

2 years in the U.S Air Force Dental Corps

He returned to Baylor Dental College and

received a graduate degree in orthodontics,

and then practiced in Hobbs, New Mexico, for 31 years

He was the first director of the University of Texas

Health Science Center in San Antonio’s orthodontic

residency program Dr White has published more

than 100 professional articles, authored several books

about orthodontics, and edited numerous professional

publications He is a Diplomate of the American Board

of Orthodontists and a Fellow in the American College

of Dentists Dr White has authored over 100 clinical

articles, lectured in 35 countries, and was editor of the

Journal of Clinical Orthodontics for 17 years

Kim Fretty, DDS, is a senior resident at Texas A&M

University, Baylor College of Dentistry, Dallas, Texas

Figure 1: Note the clear Triad occlusal overlay on the mandibular premolar that reinforces posterior anchorage during space closure

Figure 2: Schematic of original Class II subdivision malocclusion with midline deviation

Figure 3: Posterior teeth with Triad Gel templates that advance the mandible unilaterally and correct the midline, overjet, and overbite

Figure 4: Left occlusal template removed to allow dentoalveolar adaptation

Figure 5: Right occlusal template removed when midline and occlusion stabilize Figure 6: Triad Gel

a high level of compliance is needed for patient acceptance of the noncompliant mechanisms There is nothing a clinician can put in patients’ mouths that they cannot remove — one way or another Although many patients have used these noncompliant apparatuses successfully, there are large numbers that have refused to use them or have succeeded in developing into “serial destroyers.” These latter patients break

so many appliances that it finally results in doctors seeking alternate therapies

Several features of noncompliant appliances bear responsibility for patient non-acceptance:

Even with their recent popularity

among orthodontists, these Class II

appliances have a number of negative

Theory, technique, and therapeutic examples

Dr Birte Melsen and Dr Giorgio Fiorelli5 were using Triad® Gel (Dentsply) to augment anchorage by increasing occlusal pressure on the anchor or reactive part

of the orthodontic appliance (Figure 1) when Dr Fiorelli6 discovered he could

Figure 7: Triad leaf Figure 8: Original Class II subdivision with a midline

discrepancy

Figure 9: Class II subdivision with midline, overjet, and overbite corrected and Triad Gel added to the occlusal surfaces of the mandibular left posterior teeth

Figure 10: Completed therapy with corrected midline,

overjet, overbite, and Class I occlusion on both sides Figure 11: Typical Class II mixed dentition Figure 12: Maxillary primary second molar removed to accommodate mandibular template

Figure 13: Maxillary primary second molar sliced to

accommodate mandibular template Figure 14: Mixed dentition malocclusion Figure 15: Left side with primary molar removed and template in place

CLINICAL

reposition the mandible and correct slight midline deviations, overjet and overbite discrepancies along with Class II subdivisions by building up the posterior teeth with Triad Gel while holding the mandible in the new position that corrected the midline, overbite, and overjet (Figures 2-7)

Light-cure Triad Gel is supplied in

a tube with a variety of colors, but many who use this technique prefer a more viscous product Other clinicians express

a preference for the Triad material that comes as a sheet and is commonly used

to make Hawley retainers or splints The sheet’s viscosity prevents it from spreading uncontrolled and gives the operator more time to review its placement before curing with the light Either of these Triad materials

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22 Orthodontic practice Volume 5 Number 2

CLINICAL

will form a useful occlusal guide, and the

selection will depend on the clinician’s

experience and choice Other materials,

such as bonding composites, glass

ionomer cements, and others, can also

serve successfully for POGs

The posterior occlusal guides, which

Dr Fiorelli fortuitously developed, act

somewhat akin to fixed functional

appli-ances that can cause temporomandibular

fossae and dentoalveolar remodeling7-9

He reveals this strategy with the following

images of patient therapy (Figures 8-10)

Interestingly, a colleague of Dr Fiorelli,

Dr Paola Merlo6, expanded on this idea

of posterior occlusal guides and came up with a brilliant idea for intercepting Class II malocclusions in the mixed dentition She either removes or slices the distal portion of the maxillary second primary molar, which allows her to build up a template of Triad Gel on the lower dentition that encourages the mandible to slide forward Figures 11-

17 illustrate how she guides these patients into Class I occlusion

Figure 16: Occlusal view of clear Triad Gel templates Figure 17: Maxillary occlusal view showing sliced primary molar

Figure 18: Self-etching sealant used for a

shallow etch A deep etch makes the removal of

Triad more difficult

Figure 19: Self-etching sealant mixture for application to the occlusal surfaces of the mandibular posterior teeth

Figure 20: Curing of Triad Gel Note the anterior incisal wax bite to hold corrected bite steady during the light cure

Figure 21: Cured Triad Gel on the mandibular molar occlusal surface Note the maxillary molar indentations of the altered bite

Figure 22: Patient with a Class II subdivision malocclusion and an anterior crossbite

of tooth 2.2

Figure 23: Before treatment, cephalometric tracing and the Visualized Treatment Objective (VTO) illustrates the needed incisor positioning (cross-hatched teeth)

Maxillary incisors are exactly on the A Line and need only slight torquing to achieve an ideal position and a slight extrusion The mandibular incisors need a slight protraction and intrusion for ideal incisal position

POG technique and application

The following Class II subdivision patient will illustrate one technique for applying POGs (Figures 18-21)

Patient therapy

The images shown in this article display a sequence of photos during the orthodontic therapy for a Class II subdivision patient us-ing Posterior Occlusal Guides (POGs) The patient’s models display a firm Class I oc-clusion on the right side, a Class II occlu-sion on the left side, a lingually displaced maxillary left lateral incisor in crossbite, and

a maxillary midline deviation to the left The patient used 022 Insignia™ brackets sup-plied by Ormco™ Ostensibly, the Insignia formula builds first, second, and third order

24 Orthodontic practice Volume 5 Number 2

CLINICAL

movements within the brackets and also

supplies customized arch wires for the

pa-tient

Figure 22 illustrates the original

malocclusion, while Figure 23 displays the

initial cephalometric tracing combined with

the Visualized Treatment Objective (VTO)

The VTO shows that the maxillary incisors

lie exactly on the A Line10 and need no

facial or lingual movement with only a slight

amount of torque to correctly position the

roots and crowns; and they need only

slight extrusion The lips have contours that

closely conform to the Holdaway ideals.11,12

The mandibular incisors can move facially a

slight amount with minimum intrusion

Figures 24-31 show a series of photos

from the initiation of treatment through

completion of therapy It took 4 months for

the Class II side to correct into a Class I No

typical Class II mechanics, e.g., elastics,

functional appliances, or headgears were used during this first phase of treatment

The patient used light Class II elastics on the left side for a couple of months near the end of therapy, but no other Class II mechanics were used at any point

Figures 32A and 32B illustrate the after cephalometric tracing and the super-imposition of the before treatment and after treatment cephalometric tracings

The superimpositions were made by superimposing on the line S-N at the most anterior part of the sella turcica as suggested by Melsen.5 Some mandibular terminal growth is expressed by a downward and forward movement The maxillary incisors extruded and essentially stayed in place anteriorly-posteriorly The mandibular incisors intruded but stayed in place anteriorly-posteriorly The maxillary molars moved forward slightly but did

Figure 24: Models of Class II subdivision patient Figure 25: Patient at treatment initiation with Triad POGs

Figure 26: Patient with POGs after 1 month of therapy Figure 27: Patient with POGs after 2 months of therapy

Figure 28: Patient with POGs after 3 months of therapy Figure 29: Patient with POGs after 4 months of therapy No elastics have been used

not extrude, while the mandibular molars showed little movement at all Although the maxillary and mandibular incisors moved more than the VTO forecast, the extrusion and position of the maxillary incisors were the movements indicated by the prediction

as was the slight amount of crown inclination The mandibular incisors did not display the slight forward movement forecast by the VTO, but they did intrude

as needed The lips remained essentially unchanged and conform to the Holdaway norms for Caucasian females

Discussion and conclusion

These therapies show the potential and effectiveness of posterior occlusal guides, and their ease of application should soon result in their adaptation by many orthodontic clinicians Compared with any

of the available functional Class II correctors

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26 Orthodontic practice Volume 5 Number 2

CLINICAL

or other Class II therapies, POGs offer

several advantages such as the following:

• ease of application

• avoidance of impressions and a

subsequent lab technique

Although its disadvantages seem few,

here are the most notable:

• their need to be replenished and

supplemented as the mandible retracts

• their need of occlusion to function

• their lack of constant pressure as

provided by many functional appliances

The limited and isolated therapies

displayed in this paper don’t provide

ironclad affirmation for their inclusion in

the orthodontic armamentarium But it is

difficult to avoid the conclusion that difficult

problems seem to resolve with their use

At this time, no collection of treated patients exists Without such a reservoir

of POG therapies, their effects will require conjecture and some extrapolation

Specifically, we need to know if they anteriorly displace the mandibular dentition, retract the maxillary molars, change the occlusal plane, extrude the maxillary incisors, bend the mandible, or remodel condyles among other inquiries.13

I and Class II sides, but that two-thirds

of the asymmetry is dentoalveolar.14 This suggests that POGs will work primarily

by rearranging the dentition through dentoalveolar remodeling with these malocclusions

Fortunately, the POGs represent the least invasive Class II corrector in existence

Patient acceptance is excellent, and none has reported any discomfort Since they are bonded to mandibular posterior teeth, they work 24 hours a day, which accounts for their efficiency and effectiveness Any breakage repairs quickly and easily Just

as with other functional appliances, POGs need additions occasionally as they affect their changes But the added Triad bonds easily to the original by simply priming the cured material with a bonding sealant before light curing — but only after re-assuring the overbite, overjet, and midline

Upon removal, the occlusal spaces once occupied by the POGs quickly resolve by the subsequent eruption of the involved posterior teeth

Compared with other Class II

Figure 30 Final photos of corrected Class II subdivision malocclusion Figure 31: Before and after photos of patient treated with POGs

Figure 32A: After treatment

cephalometric tracing Figure 32B: Before and after treatement

cephalometric superimpositions

RefeRences

1 Pancherz H Treatment of class II malocclusions

by jumping the bite with the Herbst appliance

A cephalometric investigation Am J Orthod

1979;76(4):423-442.

2 Eckhart JE, White, L.W Functional Nonextraction

Treatment Clinical Impressions 2009;17(1):32-34.

3 Coelho Filho CM Mandibular protraction

appliances IV J Clin Orthod 2001;35(1):18-24.

4 Jones G, Buschang PH, Kim KB, Oliver DR Class

II non-extraction patients treated with the Forsus Fatigue Resistant Device versus intermaxillary

elastics Angle Orthod 2008;78(2):332-338.

5 Melsen B, Fiorelli G Biomechanics in

Orthodontics Denmark: Aarhus; 2013.

6 White LW Orthodontic Pearls, A Clinician’s Guide

Dallas, TX: Taylor Publishing Co.; 2012.

7 Voudouris JC, Woodside DG, Altuna G, Kuftinec

MM, Angelopoulos G, Bourque PJ Condyle-fossa modifications and muscle interactions during herbst

treatment, part 1 New technological methods Am J

Orthod Dentofacial Orthop 2003;123(6):604-613.

8 Woodside DG, Altuna G, Harvold E, Herbert M, Metaxas A Primate experiments in malocclusion and

bone induction Am J Orthod 1983;83(6):460-468.

9 Woodside DG, Metaxas A, Altuna G The influence

of functional appliance therapy on glenoid fossa

remodeling Am J Orthod Dentofacial Orthop

1987;92(3):181-198.

10 Alvarez A The A line: a new guide for

diagnosis and treatment planning J Clin Orthod

2001;35(9):556-569.

11 Holdaway RA A soft-tissue cephalometric analysis and its use in orthodontic treatment

planning Part I Am J Orthod 1983;84(1):1-28.

12 Holdaway RA A soft-tissue cephalometric analysis and its use in orthodontic treatment

planning Part II Am J Orthod 1984;85(4):279-293.

13 Cozza P, Baccetti T, Franchi L, De Toffol L, McNamara JA Jr Mandibular changes produced

by functional appliances in Class II malocclusion: a

systematic review Am J Orthod Dentofacial Orthop

2006;129(5):599, e1-12, e1-6.

14 Minich CM, Araújo EA, Behrents RG, Buschang

PH, Tanaka OM, Kim KB Evaluation of skeletal and dental asymmetries in Angle Class II subdivision malocclusions with cone-beam computed

tomography Am J Orthod Dentofacial Orthop

2013;144(1):57-66.

correctors, they seem to have few disadvantages, but this is early into their introduction, and it will take more experience with more clinicians to discover their limitations and specific applications.OP

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ACCOUNT: Lily Nachinson

PRODUCTION: Tina Anderson

PROOFER:

Introduction: There remains a discord

among orthodontists regarding the

usefulness of a lateral cephalogram

radiograph as a part of diagnostic

records for treatment planning Today,

orthodontists take diagnostic lateral

cephalograms largely based on a personal

preference, rather than following any

evidence-based approach for determining

whether taking the radiograph will affect

treatment planning The aim of this study

is to identify patients with the type of

malocclusion for which the availability of

a lateral cephalometric radiograph will

affect the treatment plan This would

prevent patients whose treatment plan

would not benefit from a diagnostic lateral

cephalogram from receiving unnecessary

ionizing radiation

Methods: The data for this study

were obtained from responses to two

questionnaires, conducted 5 weeks apart,

to 5 orthodontists with clinical experience

Primarily, the orthodontists were required

to treatment plan 20 cases, twice, once

with full diagnostic records, including a

lateral cephalometric radiograph, and once

without

Results: Based on the data, it was found

that for about 67% of patients who had a

lateral cephalometric radiograph taken that this X-ray does affect the treatment plan

These patients presented with bilateral, sagittal dental malocclusions, matching significant soft-tissue profile disharmony and at least one arch with a moderate arch length discrepancy

Conclusions: A larger follow-up study

is suggested to further investigate the relationship between malocclusion, lateral cephalometric radiographs, and treatment planning

Introduction and literature review

The American Association of Orthodontists has provided a set of clinical practice guidelines that include a recommendation for which pretreatment diagnostic records should be taken prior to comprehensive orthodontic treatment This “gold standard”

for diagnostic records consists of intraoral and extraoral photographs, dental casts, intraoral and/or panoramic radiographs, and cephalometric radiographs and/

or cone beam computed tomography (CBCT).1 However, some studies have demonstrated that the efficacy of diagnostic cephalometric radiographs

to treatment plan orthodontic cases is not proven.2,3 While some suggest that lateral cephalograms provide useful diagnostic information for certain types of malocclusions, there is no evidence that routine use on all patients is necessary.4 At present, there is no basis for a cost-benefit analysis for the routine use of cephalometric radiographs with regard to their effect on quality of treatment or predictability of results.5 Therefore, there is a large degree

of uncertainty among orthodontists as

to when cephalometric radiographs are needed Questions that surround the efficacy of clinical diagnosis and treatment may be answered by epidemiological studies, but such research has not been conducted for orthodontics There is a lack of evidence to support the routine acquisition of lateral cephalograms, even though they appear to be diagnostically critical in certain cases.4

Dental X-rays comprise the most

frequent artificial source of ionizing radiation to people living in the United States.6 Ionizing radiation causes the production of micronucleated cells, which have been linked with an increased risk

of cancer.7 Any given dose of ionizing radiation may cause cancerous changes, and no dose threshold exists below which radiation is known to be predictably safe.8 Exposure to ionizing radiation is the most consistent environmental risk factor currently known for meningioma, and dental radiographs could be associated with an elevated risk to develop intracranial meningioma, especially in young patients

on whom X-rays are taken frequently.6

It is difficult to demonstrate a clear cause-and-effect relationship between dental X-rays and malignancy due to the extended latent period, which can extend from 10 to 20 years.1 There is, however,

a general consensus that clinicians should

be selective as to which radiographs they take on patients Each X-ray provides information that benefits the diagnosis and treatment plan.8,9,10 These considerations are all the more poignant with increased public attention on the potential danger

of dental radiographs Such is the case in recent years with a highly publicized article

in The New York Times and research that

links dental radiographs with meningioma.7

Our purpose of this study is to determine the necessity of lateral cephalograms for orthodontic diagnosis

We surveyed five orthodontists on the need for a lateral cephalogram to determine diagnosis and treatment plan

Evaluating the diagnostic value of lateral cephalogram radiographs

RESEARCH

Drs Jay V Patel, Harold Slutsky, Jeffrey Godel, Jie Yang, and James J Sciote study the necessity of lateral cephalograms for orthodontic diagnosis

Jay V Patel, DMD, MS, is in private practice in Atlanta,

Georgia Dr Patel conducted this project for fulfillment

of the Master’s Degree in Oral Biology at Temple

University Graduate School during his orthodontic

residency last year.

Harold Slutsky, DMD, is an Adjunct Clinical Professor

of Orthodontics at the Kornberg School of Dentistry,

Temple University, Philadelphia, Pennsylvania.

Jeffrey Godel, DDS, is Interim Chair of Orthodontics,

Department of Orthodontics, Kornberg School of

Dentistry, Temple University.

Jie Yang, DMD, MS, is Chair of Oral and Maxillofacial

Radiology, Kornberg School of Dentistry, Temple

University.

James J Sciote, DDS, MS, PhD, is Professor of

Orthodontics, Kornberg School of Dentistry, Temple

University.

T1 20 80 100 80% of the time neededT2 33 67 100 67% of the time needed

Table 1: Need for cephalogram for diagnosis

20 cases reviewed by five orthodontists T1 = cephalogram available T2 = no cephalogram 5 weeks later

This approach helped us identify certain types of

malocclusions for which this radiograph was not

needed

Methods and materials

Twenty patients were selected from the orthodontic

private practice of Harold Slutsky, DMD For a

period of several months, Dr Slutsky evaluated the

orthodontic records of new patients to determine,

in his opinion, if a lateral cephalogram was

necessary for diagnosis and treatment Patients

were classified into two groups, either in need of

the radiograph or not From this list, 20 random

patients were selected for study, with 10 from each

group Subjects selected for this study ranged in

age from 9-26 years, had full permanent dentitions,

and were treatment planned for comprehensive

fixed orthodontic therapy Diagnostic records

consisted of the following:

1 plaster cast orthodontic study models trimmed

to the American Board of Orthodontics

specifications

2 photographs, which included five intraoral

photographs, including left, center, and

right intraoral views, as well as maxillary and

mandibular occlusal views; and three extraoral

photographs, which included facial profile, full

face smile, and full face somber

3 panoramic radiograph

4 lateral cephalogram that was traced and had a

digitized cephalometric analysis

The plaster casts were scanned to produce

a virtual copy All records were stored in digital

formats for diagnostic evaluations in the study

Five orthodontists from private practice with a

minimum of 5 years of clinical practice experience

were chosen to participate in the study These

practitioners had different educational backgrounds

and years of experience to represent a cross

section of orthodontists University Institutional

Review Board approval and informed consent

from the orthodontists for their participation as

study subjects were obtained After consent, each

orthodontist was sent the de-identified record

sets of the 20 patients and asked to complete a

few diagnostic questions for each patient (Table

1) After a period of 5 weeks, the orthodontists

were asked the same questions; however, at the

second time point, the lateral cephalogram and

digitized cephalometric analysis were omitted For

the second evaluation, the order of the 20-subject

record sets was scrambled

Statistical analysis

A McNemar test was used to determine if there

was a significant change in the perceived need

for a cephalogram between T1 and T2 A nested,

random effects model was used to determine if

there is any significant change in treatment plan,

controlling for the availability of a cephalogram

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30 Orthodontic practice Volume 5 Number 2

RESEARCH

between T1 and T2 Chi-square analysis

and an inter-class correlation coefficient

were used to show any statistically

significant difference in treatment plan

between orthodontists

Results

The orthodontists made decisions

regarding diagnosis and treatment with (T1)

and without (T2) lateral cephalograms and

tracings We compared differences in their

opinions regarding the necessity of lateral

cephalograms and tracings to formulate

treatment plans at the two time points At

T1, 80% of the time cephalograms were

considered necessary, and at T2, 67% of

the time cephalograms were necessary

(Table 1) A McNemar test determined that

there was a significant change (chi-square

= 9.00, p = 0.002) in the perceived need for

a cephalogram between T1 and T2 At T2,

when cephalograms were not available,

there was slightly greater perception that

the radiographs were not necessary

Patterns emerged in the responses at the

two time points For some of the patients,

cephalograms were always necessary

at T1 and T2, while for others patients,

cephalograms were often not necessary at

T1 and never necessary at T2 (Table 2)

Examples of patients where

cephalo-grams were always needed are illustrated

by patients number 12 and 18 Patient 12 was diagnosed with a Class II malocclusion due to a retrognathic mandible In addition, the vertical dimension expressed a short lower face height, which creates a palataly impinging overbite with pronounced mandibular incisor crowding (Figure 1)

Patient 18 was diagnosed with a Class III malocclusion with an anterior crossbite and impacted maxillary right canine (Figure 2) An example of where a cephalogram was not needed is illustrated by patient number 17 He was diagnosed with a Class

I malocclusion with maxillary diastema, mild mandibular incisor crowding, and mild mandibular posterior spacing (Figure 3)

Discussion

A survey of five orthodontists at two time points with 20 sets of records for orthodontic treatment demonstrated that the majority of diagnosis and treatment planning decisions require the use of a lateral cephalogram However, 20% to 33% of the time, cephalograms were not necessary There was also a significant difference in the need for cephalograms if present, or absent, at the time of clinical decision making Orthodontists were more inclined to feel that a lateral cephalogram

was not necessary for treatment planning when it was not part of diagnostic records The orthodontists we surveyed decided that cephalograms were usually necessary

to make diagnostic decisions for patients who had Class II and Class III malocclusions (Figures 1 and 2) Class I malocclusions with minor dental irregularities were most often identified to not need a cephalogram for diagnosis (Figure 3) Since only five orthodontists were surveyed, no definitive conclusions can be drawn without larger sample sizes However, the data do suggest that there are characteristic presentations of malocclusions for which cephalometric diagnostic information is not necessary to arrive at a treatment plan

It is important to extend this study to include larger patient numbers and ortho-dontic participants to address the question

of when cephalometric radiographs are necessary, given the potential biologic risk inherent in ionizing radiation From epidemiologic surveys conducted on the incidence of malocclusion, it is known that approximately 60% of malocclusions are Class I.11 If we can identify the facial and dental characteristics of malocclusions that

do not require cephalometric radiographs,

we can reduce radiation exposure and risk for ionizing radiation in some patients In

Figure 1: Pretreatment composite photographs for Patient

12 12-year 3-month Hispanic, Skeletal Class II, dental

Class II

Figure 2: Pretreatment composite photographs for Patient

18 10-year 11-month Hispanic, Skeletal Class I, dental Class III

Figure 3: Pretreatment composite photographs of Patient

17 10-year 10-month Hispanic, Skeletal Class II, dental Class I

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order to estimate the number of patients that could

be included in this group, future studies should

have a distribution of malocclusion classifications

that is representative of malocclusion incidence

in the general population A continued interest in

research similar to this study will be of great benefit

to the well-being of orthodontic patients and may

help change orthodontists’ misconceptions about

when and why to take lateral cephalograms It

is believed that a large number of orthodontists

routinely take these radiographs on all patients

as a type of defensive medicine For these

orthodontists, the lateral cephalogram is taken so

that, in case of a medical malpractice claim, they

will not be accused of failing to meet the standard

of care Unfortunately, since it is not taken for

medical necessity, trusting patients are exposed

to ionizing radiation for the wrong reasons

Conclusions

• Cephalograms are needed for orthodontic

diagnosis and treatment in a majority of cases

• Up to 33% of patients did not require

cephalograms for diagnosis and were

characterized with Class I malocclusions and

minor dental irregularities

• A larger follow-up study is needed to further

investigate the relationship between

maloc-clusion, lateral cephalogram radiographs, and

treatment planning

• In the future, it should be possible to identify a

group of subjects for whom lateral cephalograms

will not be necessary, which will decrease the

risk of ionizing radiation

Acknowledgments

We gratefully acknowledge the five orthodontists

who participated in this study and research

assistant, Damian Mariano, who assisted in all

aspects of this study in its entirety

The authors have no financial, economic,

or professional interests that have influenced

positions presented in this article

RefeRenCes

1 American Association of Orthodontists Clinical Practice Guidelines

for Orthodontics and Dentofacial Orthopedics St Louis, MO: American

Association of Orthodontists 2008.

2 Bruks A, Enberg K, Nordqvist I, Hansson AS, Jansson L, Svenson

B Radiographic examinations as an aid to orthodontic diagnosis and

treatment planning Swed Dent J 1999;23(2-3):77-85.

3 Han UK, Vig KW, Weintraub JA, Vig PS, Kowalski CJ Consistency of

orthodontic treatment decisions relative to diagnostic records Am J Orthod

Dentofacial Orthop 1991;100(3):212-219.

4 Devereux L, Moles D, Cunningham SJ, McKnight M How important are

lateral cephalometric radiographs in orthodontic treatment planning? Am J

Orthod Dentofacial Orthop 2011;139(2):e175-181.

5 Nijkamp PG, Habets LL, Aartman IH, Zentner A The influence of

cephalometrics on orthodontic treatment planning Eur J Orthod

2008;30(6):630-635.

6 Claus EB, Calvocoressi L, Bondy ML, Schildkraut JM, Wiemels

JL, Wrensch M Dental x-rays and risk of meningioma Cancer

2012;15;118(18):4530-7

7 Angelieri F, Carlin V, Saez DM, Pozzi R, Ribeiro DA Mutagenicity and

cytotoxicity assessment in patients undergoing orthodontic radiographs

Dentomaxillofac Radiol 2010;39(7):437-440.

8 Abbott P Are dental radiographs safe? Aust Dent J 2000;45(3):208-213.

9 White SC, Mallya SM Update on the biological effects of ionizing

radiation, relative dose factors and radiation hygiene Aust Dent J

2012;57(suppl 1):2-8.

10 White SC, Mallya SM Update on the biological effects of ionizing

radiation, relative dose factors and radiation hygiene Aust Dent J

2012;57(suppl 1):2-8.

11 Emrich RE, Brodie AG, Blayney JR Prevalence of Class I, Class II and

study J Dent Res.1965;44(5):947-953.

OP

Objective: The aim of this study was

to survey orthodontists to investigate if

and why they preferred certain functional

occlusal schemes

Methods: An email invitation from the

American Association of Orthodontists,

AAO Partners in Education, was sent to

a random sample of the AAO members in

the United States and Canada (n = 2,300),

requesting participation in a 14-question

online survey (Survey Monkey) There was a

total of 111 orthodontists who participated

in the survey

Results: It was found that 68% of

orthodontists do not believe that there

is one functional occlusal scheme that is

ideal for all patients The majority (71%)

of orthodontists disagree or strongly

disagree that occlusion is the primary

cause of temporomandibular disorders

(TMD) The overwhelming majority (94%)

of orthodontists believe that TMD and

genetics, plus psychosocial factors, were

either strongly correlated or moderately

correlated The vast majority (82%) of

orthodontists believe that if they did not

share the same occlusal philosophy as

their referring dentists, then the referring

dentist would be less likely to refer patients

to them

Conclusions: This survey demonstrated

that the majority of orthodontists believe

that there is no functional occlusal scheme

that is more ideal than another, and

that referring dentists do play a role in

orthodontists’ decisions on occlusion

Introduction

There is much controversy in the

orthodontic community as to which

functional occlusal scheme is optimal for patients When determining which scheme

to use, there are many different factors that practitioners can consider Esthetically, orthodontists can examine the facial type (mesofacial, brachyfacial, dolichofacial) and soft tissue (smile arc) to determine which occlusal scheme appears to have the most harmonious form with the face.1

Functionally, orthodontists can examine the chewing kinematics to determine which functional occlusal scheme a patient would most benefit from.1 Historically, the orthodontic profession has taken an approach that believed any occlusion that deviated away from the “ideal” mesiobuccal cusp of the maxillary first molar in the buccal groove of the mandibular first molar, minimal overjet and overbite, and canine protected occlusion to be considered non-optimal or “diseased.”2,3

Many graduating dentists are taught that canine protected occlusion is the ideal functional occlusal scheme, and that all patients should possess this occlusal scheme.4 In 1958, D’Amico5 found that when canines were in contact, there was

an immediate interruption of the tension

of the temporal and masseter muscles, and therefore, the magnitude of force was reduced In 1985, Schneikert6 found what he believed was evidence that canine teeth are designed to be “guardian teeth.”

He cited their corner position, their large size, the length of their roots, and the fact that they are the last primary tooth lost as evidence proving that they were designed

to guard the rest of the occlusion.6 Similar

to D’Amico5, Schneikert6 also found that because the canine is located far away from the “hinge” of the temporomandibular joint (TMJ), the canine is in a more favorable position to bear lateral forces

The argument for group function tends to be that distributing lateral force through three or more teeth lessens the amount of force on any one tooth and avoids subjecting the canine to the entire brunt of the force.1 In studies performed

by O’Leary, Shanley, and Drake7 and McAdam,8 it was found that teeth in

group function showed less mobility than teeth in canine protected occlusion In the 1970s, Isaacson9 introduced a biological concept of occlusion that focused on determining what types of occlusions were most beneficial to individual patients

— i.e., patients with anterior teeth that were periodontally compromised would benefit best from an occlusion that removed forces from these teeth So, based on Issacson’s9 view, patients with periodontally compromised canines should probably not be set up to have canines protect their occlusion

Historically, the balanced occlusion scheme has had much less support in the dental community, although this may not

be true today While most would agree that balancing side interferences can be detrimental to the dentition and the TMJs, all balancing side contacts do not have to

be interferences According to Ash10, “A balancing side contact is not a balancing side interference if it does not interfere with function nor cause dysfunction …

or … injury to any of the components of the masticatory system.” There seems to

be no concrete evidence that indicates that a balanced occlusal scheme without interferences is not suitable for most people.11,12 Some researchers have even found that the balanced occlusal scheme may give an advantage to TMD patients.13

In 1990, Minagi13 evaluated 430 dental students and observed a highly significant correlation between the absence of contacts on the non-working side and the increase of joint sounds with age There are even epidemiological data that have demonstrated that balanced occlusion may

be the most prevalent functional occlusal scheme in Class I normal occlusions.19-31

The orthodontic literature is equivocal with regard to which functional occlusion predominates in nature D’Amico,5 Ismail and Guevara,14 and Scaife and Holt15 all found that canine protected occlusion (CPO) was more common, while MacMillan,11

Shuyler,16 Alexander,17 and Beyron18 found predominance of group function occlusion However, the natural occurrence of

Occlusal philosophy: investigating the reasons

orthodontists have for occlusion preference

RESEARCH

Drs Colin M Webb and Donald J Rinchuse delve into functional occlusal schemes

Colin M Webb, DDS, MS, MBA, is a Private

Practice orthodontist in Charlotte, North

Carolina.

Donald J Rinchuse, DMD, MS, MDS, PhD,

is Professor and Program Director, Seton

Hill University Center for Orthodontics,

Greensburg, Pennsylvania.