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PRESENTATION SUMMARIES

Presented by Dr. Anthony Gianelly (March 9, 2007). Summarized by Linda Huynh, DDS
Dr. Gianelly spoke on four important topics during his lecture: the bi-dimensional edgewise orthodontic technique, Class II non-extraction/non-cooperation-based treatment approaches, prole and smile analysis, and space management in the mixed dentition and timing of treatment. He repeatedly emphasized the importance of evidence-based research in his treatment decisions. BI-DIMENSIONAL TECHNIQUE n a 1993 survey in the JCO, clinicians cited maintaining incisor torque as one of the most difcult things to do during treatment. Dr. Gianelly uses a unique bracket system: brackets of two dimensions within the same arch. On the centrals and laterals are 018X025 slot brackets, and on the canines and posterior teeth are 022X028 slot brackets. Filling the slot in the front allows for torque maintenance, whereas an undersized wire in the back allows for easy retraction and bodily sliding mechanics. The vertical slot in the bracket allows for an array of auxiliaries, such as uprighting springs. faster with continuous forces (Owman-Moll, AO 1995) and prior to the eruption of the 7s (Carlson, AO 2006), and thus treatment in the mixed dentition/terminal phases is critical. NiTi coils of 100g are used (200g if the 7s are present) for distalization. He also bands the 4s for anchorage, and lasso-ties the 5 to the 4 to increase anchorage; once the 6 is distalized, the lasso tie is cut to allow the 5 to drift back. A removable Nance appliance is used for moderate anchorage cases. Dr. Gianelly uses a TPA, cuts it in the middle into two pieces (making it easier to insert), bends it away from the tissue, and then adds acrylic to the center. When he observed red tissue underneath the acrylic, he can then remove it and rebase it with Triad dualine reline material. A Nance appliance, however, will allow some loss of anchorage (less than 2mm). In a maximum anchorage case, temporary anchorage devices (TADs) can be placed on the palate. In a noncooperating patient, four TADs are used: two in the palate to distalize the molars, and then two more on the buccal near the molar after retraction (provide buccal anchorage to bring the rest of the teeth back). Where the screws are placed depends on the patients bite; in a deep bite, the screws are placed higher to allow for an intrusive vector. PROFILE ANALYSIS Treatment planning is usually performed according to the mandibular incisor. Dr. Gianelly presents an alternative way of looking at the prole: use the maxillary lip position. Dr. Gianelly looked at pictures of models and found that no two lower faces looked alike; the area of commonality was the maxillary lip. Talass (AJO-DO 1987) found that if you retract the maxillary incisors 6mm, the maxillary lip will come back 4mm (1.5:1 ratio). Dr. Gianelly urges you to look at the patients maxillary lip, but factor in how much overjet reduction is needed to decide whether it is enough to improve the lip. He found that while 31% needed some lip adjustment prior to treatment, only 3% needed it after orthodontic treatment and overjet. In addition, if the maxillary lip is in a favorable position, he tries to treat non-extraction. SMILE ESTHETICS Does extracting result in less esthetic smiles? Dr. Gianelly says no. In his AJO-DO 2003 study, he looked at 25 post-retention records of extraction and non-extraction patients with conventional orthodontic treatment (no
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For incisor retraction, the anchorage control is from Class II elastics (headgear is another option; however compliance is needed). 300g forces are needed to retract the incisors bodily. However, this also drives the lower arch forward; prevention of labial movement of the incisors is done by incorporating lingual crown torque into the archwire a minimum of 10 degrees, and also with uprighting springs (which drives the crown distally). The question arises of how torque is controlled in the posterior region with an undersized wire (018X022). The answer: customize where we want to ll the slot by rotating the wire. For example, if torque is needed in the canine region, then a 90-degree bend is made mesial to the canine bracket, and another 90-degree bend is made distal to the canine bracket; thus the strip of wire in the canine bracket is now 022X018 and full engagement is achieved. CLASS II NON-EXTRACTION, NON-COOPERATION BASED TREATMENT APPROACH Dr. Gianelly believes that you should be close to 95-100% Class II non-extraction treatment if you start in the late mixed dentition, based on his system to drive the molars back to Class I, and thus only dealing with a spacing problem. This correction is done by distalizing molars, retracting the incisors bodily with sliding mechanics, and lingual crown torque in the lower incisors. The 6s move
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expansion) and found no change in arch width. In studies in which it was found that extractions narrow the arches, the width was measured at the canine and molar for both extraction and non-extraction cases; Dr. Gianelly argues that the width must be measured at a constant arch depth because sometimes the 6s come forward and thus the molar width appears more narrow. He asked 50 people to rate smiles on an esthetic scale of 1-10, and found no signicant difference between extraction and non-extraction smiles. He advises that smile esthetics should never enter in the decision to extract. Negative space in the buccal corridor is also an important topic in smile esthetics. Ritter (AO 2006) found that the negative space did not inuence the esthetic evaluation of smile photos both for orthodontists and lay people. Moore (AJO-DO, 2005) computer-modied smile photos to include buccal corridors and found that lay people preferred smiles without the negative space. However, Dr. Gianelly noted that the computer added space in the buccal corridors by narrowing the width of the smile; thus another variable (narrow smile) was introduced. He thinks that a study should be conducted to maintain the smile width and create buccal corridors past it, in order to be more objective. SPACE MANAGEMENT Dr. Gianelly believes that space management and arch length control can solve most mixed dentition crowding. Taking advantage of the space available in the arch is critical. From his studies, he found that the primary canine was 1mm smaller than the permanent canine, and the primary rst molar was 1mm larger than the permanent rst premolar; thus the C & D are roughly equivalent in size to the 3 & 4. In addition, the size of the D was about the size of the permanent 2nd premolar, so the difference in size between the D & E is the available space in the arch (a large discrepancy is a good sign!). The Leeway/E-space went as high as 2.5mm per side, and thus with minimal crowding, resolution could take place by holding this space. Another one of Gianellys studies had 107 patients with an average crowding of 4.8mm, who were treated solely with a lingual arch. Sixty-eight percent of the patients had resolution of crowding just by holding the arch length. Eighty-seven percent of his patients had resolution of crowding with an additional arch length increase, gained with the use of a lip bumper; a maximum of 2mm (1mm per side) of arch expansion has been shown to be stable. Murphy (AO 2003) found that 90% of the change with a lip bumper occurred in the rst 300 days. Dr. Gianelly likes to begin treatment with the presence of the 4s in the late mixed dentition. There are two instances in which he will begin treatment earlier than this: early loss of a primary canine (everything will shift to that side), and stripping of the incisor gingiva. In these two instances, the primary canine(s) are removed and a lingual arch is placed.

TIMING OF TREATMENT The most common problems in orthodontics are with crowding, Class II malocclusions, Class III malocclusions, crossbites, and habits. Dr. Gianelly believes the latter three are justication for treating a patient early, whereas the rst two can be treated late in the mixed dentition. Dr. Gianelly addressed various controversies with onestage versus two-stage treatment: 1. Self-concept: Many studies have shown that there is no increase in the patients selfconcept with two-stage/early treatment; one study (OBrien, AJO-DO 2003) showed it to be transitory. Root resorption: Two studies (Mavragani, EJO 2002) have found that if treatment is started when the apices of teeth are not fully formed, there will be less root resorption. Trauma: Wheeler (AJ-DO 2006) found that two-phase treatment had no effect on the incidence of trauma. Koroluk (AJO-DO 2003) found that most incidences of trauma were craze lines, which were treated at a very low cost. Dr. Gianelly did not see trauma routinely (approximately 3-4% of the time), and that there was no relationship between overjet and trauma in the 500 patients he studied. Orthopedic effect: Studies have shown a greater response with functional appliances after 10.5 years old. Headgear had a maximum orthopedic effect near the pubertal growth spurt (at Sesamoid bone formation). Thus, for maximum skeletal effects, early treatment is not desirable. Better outcome: Four studies have shown that at the completion of treatment, both groups (one-stage and two-stage) were essentially identical both cephalometrically and in model analysis.

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A study in Indiana in 2005 concluded that the disadvantages of early treatment were prolonged treatment time, worse comprehensive clinical assessment score, and a higher incidence of premature termination of treatment due to patient burnout. Dr. Gianelly wanted to stress the importance of avoiding patient burnout. Dr. Gianelly concludes that the best time to treat Class I and Class II malocclusions is in the mixed dentition after the loss of the rst primary molars (given that there is no early loss of the Cs, no gingival stripping of the incisors, and no crossbites). In all cases, the E space is critical to space management.

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