528 Readers’ forum
May 2005
REFERENCES
1. Gargiulo AW, Wentz FM, Orban B. Dimensions of the dentogin-
gival junction in humans. J Periodontol 1961;32:261.
2. Levine RA, McGuire M. The diagnosis and treatment of the
gummy smile. Compend Contin Educ Dent 1997;18:757-62.
3. Kokich VG. Esthetics: the orthodontic-periodontic restorative
connection. Sem Orthod 1996;2:21-30.
4. Sallum EJ, Nouer DF, Klein MI, Goncalves RB, Machion L,
Wilson Sallum A, et al. Clinical and microbiologic changes after
removal of orthodontic appliances. Am J Orthod Dentofacial
Orthop 2004;126:363-6.
Authors’ response
We appreciate Dr Jarjoura’s interest in and comments on
our article, and we are pleased to have an opportunity for
further comment, which might help clarify some of the issues
that concerned him. Of course, we did not intend to mislead
readers, but our article was prepared for the section in the
Journal called TECHNO BYTES, and the focus was a new
technology, not textbook periodontics. The points about
biologic width and the need for probing are indeed accurate
and valid, and it is useful to remind the reader of those
principles.
Dr Jarjoura mentioned disproportionality in crown height
secondary to incisal attrition. Although we acknowledged the
principle in our article, we did not present related cases.
However, the issue does raise a practical debate. In cases of
incisal attrition, Dr Jarjoura suggests that the teeth should be
orthodontically intruded and restored in some fashion, prob-
ably with laminate veneers. The practical issue is that the
attrition might be mild, and gaining 1 to 2 mm of crown
height and manicuring the incisal edges might be the treat-
ment of choice so the patient can avoid restorations. Another
practical matter is the simple fact that not all patients will
approve a treatment plan that involves more treatment or
expense than they can tolerate.
The comment on the patient in Figure 7 (whose poor
oral hygiene resulted in inflamed gingival margins with
swelling and fibrotic interdental papillae) also presents a
technical vs a practical issue. As any orthodontist in
practice for more than 6 months can testify, many adoles-
cents do not practice excellent, or even good, oral hygiene,
despite our efforts to encourage it. This results in swelling
and hypertrophy of the gingiva close to the bracket, which
in turn complicates effective plaque removal. We would
really like all patients to respond to our entreaties for ideal
oral hygiene, but this patient, in spite of 2 years of our
encouraging good oral hygiene, had shown no particular
interest in it. Jarjoura thought that the proper treatment
would have been to reduce gingival inflammation after
appliance removal. Although this is certainly a valid
treatment option, this patient had not shown any compli-
ance with oral hygiene. Our clinical judgment was made to
immediately remove the pseudopockets, thus increasing
the possibility and effectiveness of good oral hygiene. This
boils down to a practical versus a technical debate. Did we
harm the patient? No. We believe that this is not overtreat-
American Journal of Orthodontics and Dentofacial Orthopedics
ment but, instead, is an enhancement of the patient’s oral
health and appearance.
The technology presented in this series of articles was for
minor esthetic finishing and enhancement of efficient orth-
odontic treatment. None of the cases presented involved
restorative dentistry where margins would have been placed
in violation of the biologic width. We do not charge for this
treatment as a separate procedure; instead, we consider it part
of case finishing not dissimilar to the routine manicuring of
incisal edges at the end of orthodontic treatment. The state-
ment that the laser is “a tool looking for a purpose” is refuted
by these articles in which its numerous applications in
orthodontic practice are described.
David Sarver
Mark Yanosky
Vestavia Hills, Ala
Am J Orthod Dentofacial Orthop 2005;127:528
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Copyright © 2005 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2005.03.008
Buccal smile corridors
The recent article on smile esthetics (Moore T, Southard
KA, Casko JS, Qian F, Southard TE. Buccal corridors and
smile esthetics. Am J Orthod Dentofacial Orthop 2005;127:
208-13) would be enhanced if the authors would describe the
facial types of the 10 subjects (5 men, 5 women) in their study
and how this morphologic feature might influence the effect
of buccal corridor change on smile macroesthetics.
Empirically, I argue that facial types near the 2 ends of
the spectrum— dolichocephaly and brachycephaly—are
greatly affected by a positional change in tooth mass in the
buccal corridor. The subject shown in Figure 2 appears to
have a mesocephalic facial type based on vertical facial thirds
and transverse facial fifths. She is neutral for any vertical or
horizontal facial esthetic imbalance. Hence, one can increase
the position of tooth mass transversely from narrow to broad
without adversely affecting her macroesthetic smile. This
subject has a flat smile arc that becomes further accentuated
by the increase in tooth mass transversely. Overall, the flat
smile arc does not terribly compromise the overall esthetic
balance because of the mesocephalic face’s ability to tolerate
increased transverse or vertical change in mini- and microes-
thetic features. However, excess tooth mass in the buccal
corridor in the brachycephalic face could exaggerate the
transverse facial imbalance, give the illusion of a flatter smile
arc, and diminish the macroesthetic smile. Conversely, exag-
geration of a consonant smile arc and inadequate tooth mass
transversely positioned in the buccal corridor could accentu-
ate the vertical facial imbalance and diminish the macroes-
thetic smile in the dolichocephalic face.
If one “extracts” a single smile characteristic from the
orthodontic problem list and examines that feature detached
from the total face, it can lose its spatial relevance in the
macro-, mini-, and even microesthetic assembly of facial
elements. Buccal corridor has been classified as a miniesthetic
feature of the smile, which is influenced by the macroesthetic
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 127, Number 5
feature of facial type.1 There is a definite interplay between
the miniesthetic features of smile arc and buccal corridor, and
the common denominators between the 2 are tooth mass and
position. Any modification of the transverse position of the
buccal segments will have a potential effect on the vertical
position of the anterior sweep of the dentition. The general
conclusion that the public prefers “minimal buccal corridors”
in the smile should be open to continued debate. This esthetic
preference should be further examined in light of the mac-
roesthetic feature of facial type and the miniesthetic feature of
smile arc.
Marc B. Ackerman
Bryn Mawr, Pa
Am J Orthod Dentofacial Orthop 2005;127:528-9
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Copyright © 2005 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2005.03.009
REFERENCE
1. Ackerman MB, Sarver DM. Database acquisition and treatment
planning. In: Miloro M, editor. Peterson’s principles of oral and
maxillofacial surgery. Vol. 2. Hamilton, Ontario, Canada: B. C.
Decker; 2004.
Author’s response
I thank Dr Ackerman for his insights and look forward to
pursuing further research in this area.
Thomas Southard
Iowa City, Iowa
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Copyright © 2005 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2005.03.010
Author’s response to “Effect of
cervical headgear”
Regarding Dr Arthur L. Kapit’s remarks in his recent
letter to the editor (Effect of cervical headgear. Am J Orthod
Dentofacial Orthop 2005;127:2) in response to our article,
“The effect of cervical headgear on patients with high or low
mandibular plane angles and the ‘myth’ of posterior mandib-
ular rotation” (Haralabakis NB, Sifakakis IB. Am J Orthod
Dentofacial Orthop 2004;126:310-7), I would like to offer the
following counterarguments.
A steep mandibular plane angle is the main characteristic
of the hyperdivergent facial pattern; it appears in all reliable
and established sources of orthodontic terminology. A
hyperdivergent facial pattern is characterized by a steep
mandibular plane angle, a long anterior lower facial height,
an open bite tendency, a retrognathic mandible with an
associated Class II malocclusion, and lip incompetence.1
“High angle” is a general term applied to a craniofacial
pattern of growth that is more vertical than normal; a
high-angle patient has an unfavorable angle of the lower
border of the mandible.2
Although it was not our intention to evaluate dimorphic
Readers’ forum 529
growth, the distribution of the sexes was even in the 2 groups.
Boys and girls were pooled because headgear therapy affects
them in the same direction, regardless of the magnitude of the
effect.
Our sample was not a half-step Class II sample but
consisted of patients who had at least a half-step bilateral
Class II Division 1 malocclusion. This type of argument is
based on the concept of the equation of the stomatognathic
system with an articulator, which is not based on scientific
evidence.
Regarding Dr Kapit’s comments about the annihilation of
cephalometrics, we think that, regardless of our findings,
there is still much to learn and investigate from cephalometric
analysis, especially on a comparative basis, and that such a
conclusion is at least inappropriate.
Nikos B. Haralabakis
Athens, Greece
Am J Orthod Dentofacial Orthop 2005;127:529
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Copyright © 2005 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2005.03.011
REFERENCES
1. Daskalogiannakis J. Glossary of orthodontic terms. Berlin: Quin-
tessence; 2000.
2. Hering K, Ruf S, Pancherz H. Orthodontic treatment of openbite
and deepbite high-angle malocclusions. Angle Orthod 1999;69:
470-7.
3. http://drsteveappel.com/glossary/h.html.
Functional matrix theory
Having read Dr John Mew’s article, “The postural basis
of malocclusion: a philosophical overview” (Am J Orthod
Dentofacial Orthop 2004;126:729-38), I conclude in part that
Dr Mew dismisses Dr Moss’s hypothesis of the functional
matrix too quickly. Says Dr Mew, “It has little favor with
embryologists who point out that the long bones from chick
embryos will develop normally without soft tissues.”
In 1956, Fell1 wrote that “Environmental factors are
responsible for preserving the characteristic shape of the
skeletal rudiment. This is shown by the fact that explanted
primordia which develop a comparatively normal form during
the first few days in vitro, lose much of the characteristic
shape on more prolonged cultivation and become increasingly
distorted.”
Marc Ausubel
West Hills, Calif
Am J Orthod Dentofacial Orthop 2005;127:529
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Copyright © 2005 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2005.03.012
REFERENCE
1. Fell HB. Skeletal development in tissue culture. In: Bourne GH,
editor. The biochemistry and physiology of bone. New York:
Academic Press; 1956. p. 418.