2020-04-01 Orthodontic Update

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April 2020 . Volume 13 . Number 2
Orthodontic Pain
Orthodontic Bonding to Atypical Tooth Surfaces
Treatment with Invisalign® in Specialist Practice
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Orthodontic Update 47
INSIDE THIS ISSUE
49 COMMENT Anecdotal Review Part 1

AMC Flett
Objective: To highlight considerations when taking up a
50 ORTHODONTICS new post and creating an ideal unit.
Orthodontic Pain
S Grewal, LMJ Harris, S Ponduri, H Naish, P Ellis, JR Sandy and AJ
Ireland 78 ORTHODONTICS
Objective: To explain the cause of orthodontic pain, how Tooth Autotransplantation Part 4: Alternative Treatment
the perception of pain is transmitted along well-defined pain
Options
pathways and the possible methods of orthodontic pain
S Barber, A Al-Khayatt and N Houghton
management.
Objective: To discuss the alternative treatment options
to tooth transplantation for managing missing or failing
57 ORTHODONTICS
teeth.
Orthodontic Bonding to Atypical Tooth Surfaces
N Prado, S Caldwell and M Ashley
Objective: To understand the current optimum bonding 89 ORTHODONTICS
techniques for atypical tooth surfaces and appreciate the recent A Novel Way to Identify Individual Eruption Chains
research around the subject. A Bronkhorst, V Santhanam and HG Jeremiah
Objective: To explain an alternative method of identifying
64 ORTHODONTICS eruption chains when multiple teeth are impacted.
Treatment with Invisalign® in Specialist Practice
T Henrikson
Objective: To evaluate Invisalign® treatment against fixed 93 Tricks of the Trade
Tissue Control for Bonding to Impacted Canines
appliance treatment.
JA Vesey
72 ORTHODONTICS
The Pleasures and Pitfalls of Life as a New Consultant – an 94 CPD
EDITORIAL DIRECTOR
Professor Jonathan Sandler Nerina Hendrickse Alison Murray
Consultant Orthodontist GDP Consultant Orthodontist
Chesterfield and Winchester Royal Derby Hospital
North Derbyshire Royal Hospital Hants Derby DE22 3NE
Calow, Chesterfield
Derbyshire S44 5BL Professor Anthony J Ireland Andrew Shelton
Consultant Orthodontist Consultant Orthodontist
EXECUTIVE EDITOR Division of Child Dental Health Orthodontic Department
Angela Stroud Bristol Dental Hospital and School Montagu Hospital
Lower Maudlin Street Mexborough S64 OAZ
EDITORIAL BOARD Bristol BS1 2LY
Professor F J Trevor Burke
Birmingham Dental Hospital and Lynda Kirk
School of Dentistry Orthodontic Therapist
5 Mill Pool Way Royal Derby Hospital
Edgbaston Uttoxeter New Road
Birmingham B5 7EG Derby DE22 3NE
Cover Picture: Cover Picture: Elastomeric
CPD in Orthodontic Update in partnership with orthodontic separator stretched and held in
separator pliers. (Courtesy of Naeem Adam,
MaxFac DCT2, Leeds Dental Hospital).
OU ISSN 1756-6401
GUIDED BIOFILM
THERAPY
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E.M.S. Electro Medical Systems United Kingdom

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https://t.me/WorldAndNews 07.01.2020 15:26:14

April 2020 Orthodontic Update 49
Comment
Authors' Information
Orthodontic Update invites submission of articles

pertinent to the practice of orthodontics. Articles
should be well-written, authoritative and fully
illustrated. Manuscripts should be prepared following
the Guidelines for Authors available from the Editor Primum non nocere
on request. Authors are advised to submit a synopsis Jonathan Sandler
before writing an article. The opinions expressed in
this publication are those of the authors and are not
necessarily those of the editorial staff or the members Today (2 March 2020), the Oral Health Foundation has teamed up with the British
of the Editorial Board.
Orthodontic Society to launch the ‘Safe Brace Campaign’ to help protect the great
Subscription Information British public against the onslaught of ‘Do It Yourself’ braces. This excellent website,
Print & Online UK £65

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Print & Online NON UK £81 view as to how they can stay safe when considering orthodontic options.
Print & Online DU Subscriber UK £58 Advice is offered to all patients considering a course of orthodontics
4 issues per year
and information provided as to what they might expect from a course of treatment.
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Subscriptions cannot be refunded. A reasoned argument is put forward as to why it would be wise to have an
For all changes of address and subscription appropriately qualified clinician fully assess their oral health prior to prescription of
enquiries please contact: any appliances. This comprehensive examination could very well involve radiographs
and, particularly in the case of Adult patients, BPE scores and 6 point periodontal
Orthodontic Update Subscriptions
Mark Allen Group, Unit A 1-5, Dinton Business Park, charting. Clearly, a simple intra-oral scan or a bunch of selfies and a home-made
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If found to be dentally healthy, their suitability for various types of
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fully informed patient consent, which requires the pros and cons of all the available
Head of Creative Media: Lisa Dunbar treatment methods to be fully discussed.
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these should be directed towards a clinician before the important treatment decisions
Orthodontic Update is published by: George Warman
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Publications (UK) Ltd, which is part of the
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Orthodontic Society are provided.
A week ago, the General Dental Council issued a statement on DIY
orthodontics, confirming that, in their view, it was ‘the practice of dentistry’ and all
people delivering this treatment have a requirement to be registered with the GDC.
www.markallengroup.com
They reiterated the importance of direct contact between a registrant and a potential
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Tel: 01483 304944, Fax: 01483 303191 are continuing to gather evidence about patient harm from DIY orthodontics and
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welcome information on this from all dental professionals.
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© GEORGE WARMAN PUBLICATIONS (UK) LTD Page 4 of The Times today (2 March 2020) featured a piece on ‘Dentists
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All articles published in Orthodontic Update are subject to review by specialist referees in the appropriate dental disciplines.
50 Orthodontics April 2020
Enhanced CPD DO C
Sukhraj Grewal Lydia MJ Harris, Sirisha Ponduri, Hywel Naish, Pamela Ellis, Jonathan R Sandy and Anthony J Ireland
Orthodontic Pain
Abstract: Pain is a common side-effect of orthodontic treatment. The aetiology of orthodontic pain, pain pathways and pain management
will be described.
CPD/Clinical Relevance: An understanding of the cause and subsequent management of orthodontic pain is essential for any orthodontist
in order to improve patient co-operation and satisfaction with treatment.
Ortho Update 2020; 13: 50–56
Pain and discomfort have been reported including histamine, bradykinin, substance reverses the polarity in that segment of the
to be experienced by up to 95% of P, prostaglandins and serotonin. These axon. The polarity is then reinstated by the
orthodontic patients1,2 and can be felt at mediators are released as a result of tissue sodium channels entering an inactive state,
all stages of treatment. This includes early injury. Once stimulated, nociceptive halting further ion flow, and the opening
interceptive extractions,3 the placement fibres undergo depolarization and, in the of voltage-gated potassium channels
of separators,2,4 bands,2 archwires2,5-9 and, case of orthodontics, the sensation of that allow positively charged potassium
finally, at debond and retainer fit.10,11 This pain is transmitted from the pulp and/or ions to flow out of the axon down their
pain can affect a patient’s quality of life in a periodontium to the central nervous system concentration gradient. Each segment
variety of ways and has been suggested as via nociceptive afferent fibres. These are depolarizing triggers further voltage-gated
one of the principal barriers to orthodontic mainly lightly myelinated primary afferent sodium channels to activate downstream
treatment.12 A survey of the pain Aδ fibres, which respond to mechanical and the action potential cascades along
experienced by 116 adolescent patients or thermal stimulae and are associated the axon. In myelinated Aδ fibres, the
during orthodontic treatment13 found that with acute pain. The slower primary axon is surrounded by a series of Schwann
orthodontists routinely underestimate the afferent unmyelinated C fibres respond to cells that electrically insulate the axon.
level of pain caused by their treatments. mechanical, thermal or chemical stimulant There are spaces between the Schwann
Indeed, the pain experienced following and are associated with a slower, persistant cells called nodes of Ranvier. The action
pain. These primary afferent nociceptive
archwire placement is believed to be potential jumps from node to node down
fibres are those of the trigeminal nerve,
greater than that experienced following the axon length significantly speeding up
whose cell bodies lie within the Gasserian
extractions.6 It is therefore important that conduction (Figure 2).14
or trigeminal ganglion (Figure 1).
orthodontists understand orthodontic pain
Once initiated, the pain stimulus
in order to improve pain management,
is transmitted along the neuron axon by Factors affecting the
patient acceptance, compliance and overall
propagation of an action potential. At perception of pain
satisfaction with orthodontic treatment. rest a neuron axon is negatively charged The degree of pain experienced by
intracellularly (-70 mV) relative to the area individuals in response to an identical
Pain pathways surrounding the neuron. Action potential noxious stimulus can vary greatly from
The sensation of pain is initiated in one of propagation is caused by the activation of person to person.15 The perception of pain
two ways, either by the direct stimulation voltage-gated sodium channels in response may be influenced by a number of different
of nociceptive nerve fibres by a mechanical, to depolarization of the neighbouring factors. Anxiety has been shown to be
chemical or thermal stimulus; or indirect axon segment. This leads to a rapid influx a factor affecting dental pain, lowering
stimulation following the release of any one of positively charged sodium ions into the the reported threshold9 and increasing
of a number of inflammatory mediators, cell along a concentration gradient. This the likelihood of the avoidance of dental
Sukhraj Grewal, BDS(Hons), DDS, MOrth RCS, FDS RCS, Locum Consultant Orthodontist, King’s College Hospital NHS Foundation Trust,
Lydia MJ Harris, BDS, MJD FRCS, Orthodontic Specialty Registrar, Eastman Dental Institute, University College London, Sirisha Ponduri,
BDS, DDS, MOrth RCS, FDS RCS, Consultant Orthodontist, Portsmouth Hospital NHS Foundation Trust, Portsmouth, Hywel Naish, BSc,
BDS, MFDS RCS(Ed), MOrth RCS(Ed), Specialist Practitioner, Cathedral Orthodontics, Cardiff, Pamela Ellis, BDS, MSc, MOrth RCS, FDS RCS,
Consultant Orthodontist, Dorchester Hospital NHS Foundation Trust, Dorchester, Jonathan R Sandy, BDS, MSc, PhD(Lond), MOrth RCS, FDS
RCS, FDS RCS(Ed), FFD RCS, Professor of Orthodontics and Dean of Health Sciences, University of Bristol and Anthony J Ireland, BDS, MSc,
PhD(Lond), MOrth RCS, FDS RCS, Professor of Orthodontics, Bristol Dental School , University of Bristol, Bristol, UK.
April 2020 Orthodontics 51
pain reported by adolescents to be greater

than in other age groups.2,16 Similarly,
the evidence for the effect of gender on
pain perception is mixed. At the time of
appliance or separator placement, two
studies have reported pain experience to
be greater in girls than in boys,4,16 whilst
others have concluded that gender has
no effect on pain perception following the
placement of initial archwires.5,8,9
When does orthodontic pain

occur?
It is generally considered that orthodontic
pain starts at around 2 hours after
Trigeminal appliance placement, with some studies
reporting that this is the case for between
91% and 97% of orthodontic patients.4,16
It then usually peaks at 24 hours5 before
gradually subsiding over the next 5 to 7
days.7,8 Interestingly, it would seem that
up to 25% of orthodontic patients report
experiencing pain for longer than 7 days.16
Figure 1. Pathways involved in orthodontic pain.
Location of orthodontic pain
A number of investigations have been
carried out to determine which sites within
the dental arch experience the most pain
during orthodontic treatment. In almost
all cases, the teeth which experience the
most significant pain are the incisors, in
particular the lower incisors, and this is the
case during both initial alignment and at
debond.5,10,11,16,17
Does bracket or wire type

have an effect on the pain
experienced?
In recent years a number of studies have
considered the possible effect of both
bracket and wire type on reported pain. In
particular, comparing self-ligating brackets
with conventional brackets, which utilize
elastomeric ligation (Figure 3). Perhaps
due to the complex and also subjective
nature of pain, the effect of bracket type
is not conclusive. Some studies report less
pain when using self-ligating brackets,9
Figure 2. Transmission of an action potential within the axon: 1. Axon membrane at rest, concentration others report greater pain with self-
gradients of sodium and potassium ions maintained by ion pumps. 2. Voltage-gated sodium channel ligating brackets, but only during insertion
open in response to depolarization in neighbouring axon segment. Membrane polarization inverts. or removal of the archwire,7 and others
3. Sodium channels enter an inactive state. Voltage-gated potassium channels open. Membrane report no difference at all between the two
potential re-established.
bracket types.8
There have also been a number
of investigations into the pain experienced
with lingual versus labial fixed appliances.
treatment.15 It is therefore important that both age and gender might have an It would seem that the pain related to
that the level of anxiety associated with effect on perceived orthodontic pain, but the teeth and the periodontium is most
orthodontic treatment is minimized the results of studies investigating these probably the same, but what is different
in order to optimize the patient care factors are somewhat equivocal. While is the site of any soft tissue-related
experience. some studies have demonstrated age has discomfort, which unsurprisingly is usually
It has also been suggested no effect,8,9 others have found the level of greater in the tongue in the case of lingual
the bonding material, or at its interface acute pain, which may not translate well to
with the bracket base or enamel surface. pain in orthodontic patients.
With both metal and ceramic brackets,
pain may be experienced if forces are Management of orthodontic
transmitted to the teeth, particularly pain
rotational or torqueing forces. 1. Pharmacological management of
Alternative methods of debonding, orthodontic pain
such as the use of thermal and laser The management of pain during
instruments, have been investigated, orthodontic treatment has been an
but to date there is little evidence to important area of research and numerous
indicate whether their use is associated studies have looked at the use of analgesics
with any more or less pain at debond. during procedures, such as separator22-30
Figure 3. Self-ligating brackets with initial
Although there are a and archwire placement.31-33 Although
aligning wires in place.
considerable number of studies most studies have focused on the use
centred on the pain associated with of ibuprofen or paracetamol to relieve
orthodontic procedures, such as orthodontic pain, other studies have
separator placement and archwire looked at alternative analgesics. These have
placement, there is limited research on included naproxen,32,33 piroxicam22 and
the pain associated with debonding. aspirin.28,33
A study in Iowa, USA, assessed patient In addition to the type of
discomfort levels at debond and found analgesic, there has also been some
that a threshold force existed above debate as to the timing of providing
which discomfort and pain was felt.10 analgesia in order to reduce orthodontic
The level of this threshold was not pain and discomfort. Although post-
uniform throughout the mouth and operative analgesia would be expected
Figure 4. Bracket debond using debonding was significantly influenced by tooth to reduce pain, it has been suggested
pliers. mobility and the direction of any force that pre-emptive analgesia may also
applied. Intrusive forces were the best be beneficial. When Non-Steroidal Anti-
tolerated by patients and with the rather Inflammatory Drugs (NSAIDs), such as
surprisingly high mean threshold being ibuprofen, are given pre-operatively, it
brackets, and greater in the lips and cheeks 934 g. This study also reported that pain has been suggested that it can reduce
in the case of labial brackets.18 A recent varied according to the teeth being the inflammatory response as the body
systematic review and meta-analysis debonded. The mandibular incisors has a chance to absorb and distribute the
concluded that, overall, there is more were found to display the greatest pain medicament before the onset of any tissue
oral discomfort experienced with lingual at debond, with a mean discomfort damage and prostaglandin production.34
appliances.19 threshold of below 830 g. However, it One study into pre-emptive analgesia24
With respect to archwire choice should be noted that this study only assessed the effectiveness of pre- and
and pain, a recent Cochrane review has involved 15 patients and pain was post-operative ibuprofen in 51 subjects
found no evidence that the use of any assessed in 16 teeth per patient (first and found that pre-emptive ibuprofen,
particular type of wire for initial alignment premolar to first premolar). No data given an hour before separator placement,
has any effect on perceived pain.20 were provided for pain experienced in significantly reduced the level of pain
the molar regions. reported 6 hours post-operatively and later
Pain at debond A larger randomized at bedtime. Interestingly, no significant
Debonding requires the removal of the controlled trial11 assessed pain at difference in pain was found between those
brackets and bands at the completion of debond in 90 subjects, half of which in the placebo group and those that only
treatment, along with residual adhesive were biting on a soft acrylic wafer had post-operative ibuprofen. However,
from the enamel surfaces of the teeth. The during debond. It showed similar results this may have been due to the fact that the
most commonly used method of bracket to the Iowa study, in that the lower post separator ibuprofen was administered
removal is to use debonding pliers (Figure anterior teeth were deemed to be the at 3 and 7 hours after separator placement,
4).2 In the case of metal brackets, this most painful by patients. This study also rather than immediately after placement.
works by the pliers distorting the bracket reported that subjects who bit on an Other studies investigating pre-emptive
base, leading to crack propagation and acrylic wafer during the debond process administration of ibuprofen at separator
either cohesive failure within the bonding reported reduced pain levels in the placement26,27 support these findings, and
material, or adhesive failure at the interface posterior dentition. This may have been it has been suggested that the decrease
between the bonding material and the due to the intrusive forces applied to the in observed pain is as a result of the
bracket base or enamel surface. Care needs teeth during biting. From the raw data pre-emptive anti-inflammatory effect of
to be taken to make this process as pain it would seem that 93% of the patients ibuprofen, rather than its analgesic action.
free and efficient as possible. The risk of experienced some degree of pain during A number of studies have
damage to the enamel is greater in the debond. Although the sample size was compared ibuprofen and paracetamol in
case of the removal of ceramic brackets reasonably large, the power calculation orthodontic pain management.23,25,28,30,31,33
because both the bracket material and was based on research around clinically Bradley et al compared paracetamol to
enamel are relatively brittle. The pliers must significant pain reduction within an ibuprofen in a non-inferiority randomized
therefore initiate crack propagation within accident and emergency setting21 for trial of 159 patients and found that
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ibuprofen was superior in providing pain an interest in the use of bite wafers or that they have no conflict of interest.
relief.30 The ibuprofen group reported chewing gum for pain relief. It has been Informed Consent: Informed consent was
less pain at most intervals from day 1 postulated that chewing on something obtained from all individual participants
onwards. Whilst other studies on separator hard, immediately after adjustment of included in the article.
placement have supported these findings an orthodontic appliance, helps loosen
of the superiority of ibuprofen over tightly grouped periodontal fibres,
paracetamol,23,28 others have shown which in turn reduces oedema and References
no significant difference between the inflammation by restoring the lymphatic 1. Oliver R, Knapman Y. Attitudes to
two.25,31 However, these results need to be and vascular circulation.43 orthodontic treatment. J Orthod 1985;
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of paracetamol rather than the more usual management would seem to be pain experience and psychological
clinical dose of 1000 mg. somewhat equivocal. In a study of adjustment to orthodontic treatment
It has been suggested 49 patients,42 the participants were of preadolescents, adolescents, and
that the use of NSAIDs might slow given either a bite wafer or told to take adults. Am J Orthod Dentofacial Orthop
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inhibition of Cyclooxygenases37 involved advise their patients to avoid chewing fixed appliances. Eur J Orthod 2004; 26:
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NSAID use on orthodontic tooth movement trial involving 1000, 11−17 year-old orthodontic treatment: a randomized
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orthodontic pain
a small reduction in the amount of with a self-ligating and a conventional
A number of non-pharmacological
ibuprofen used following both the initial fixed orthodontic appliance system:
methods have been suggested to control
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stimulation (Transcutaneous Electrical Angle Orthod 2009; 79: 46−50.
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follow-up.44 Some of these methods are treatment with fixed appliances, with using a self-ligating or conventional
more practical for clinical use than others. up to 95% of patients being impacted. bracket system: a randomized clinical
A randomized controlled trial,45 Pain is very subjective in nature and trial. Eur J Orthod 2008; 30: 227−232.
which assessed pain control after initial the experience of pain can differ 9. Pringle AM, Petrie A, Cunningham SJ,
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behavioural therapy and a group who emptive analgesics, such as ibuprofen associated with 2 orthodontic
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shown to be most effective24,26,27 in terms of orthodontic fixed appliances. J Orthod
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1992; 19: 47−54. 510−517. 36. Walker JB, Buring SM. NSAID
13. Krukemeyer AM, Arruda AO, Inglehart 25. Bird SE, Williams K, Kula K. Preoperative impairment of orthodontic tooth
MR. Pain and orthodontic treatment: acetaminophen vs ibuprofen for control movement. Ann Pharmacother 2001; 35:
patient experiences and provider of pain after orthodontic separator 113−115.
assessments. Angle Orthod 2009; 79: placement. Am J Orthod Dentofacial 37. Lahoti SK, Lahoti KB, Mute B, Peter
1175−1181. Orthop 2007; 132: 504−510.
K. Drug effect on orthodontic tooth
14. Lodish HF, Berk A, Kaiser C, Krieger M, 26. Bernhardt MK, Southard KA, Batterson
movement. Int J Curr Pharm Res 2014;
Bretscher A, Ploegh HL et al. Molecular KD, Logan HL, Baker KA, Jakobsen
6: 1−3.
Cell Biology. New York: Freeman- JR. The effect of preemptive and/
Macmillan Learning, 2016. or postoperative ibuprofen therapy 38. Roth PM, Thrash WJ. Effect of
15. Jerjes W, Hopper C, Kumar M, Upile for orthodontic pain. Am J Orthod transcutaneous electrical nerve
T, Madland G, Newman S et al. Dentofacial Orthop 2001; 120: 20−27. stimulation for controlling pain
Psychological intervention in acute 27. Steen Law SL, Southard KA, Law AS, associated with orthodontic tooth
dental pain: review. Br Dent J 2007; 202: Logan HL, Jakobsen JR. An evaluation movement. Am J Orthod Dentofacial
337−343. of preoperative ibuprofen for treatment Orthop 1986; 90: 132−138.
16. Scheurer PA, Firestone AR, Bürgin of pain associated with orthodontic 39. Weiss DD, Carver DM. Transcutaneous
WB. Perception of pain as a result separator placement. Am J Orthod electrical neural stimulation for
of orthodontic treatment with fixed Dentofacial Orthop 2000; 118: 629−635. pain control. J Clin Orthod 1994; 28:
appliances. Eur J Orthod 1996; 18: 28. Sudhakar V, Vinodhini T, Mohan AM, 670−671.
349−357. Srinivasan B, Rajkumar B. The efficacy 40. Marie SS, Powers M, Sheridan JJ.
17. Feldmann I, List T, Bondemark L. of different pre- and post-operative Vibratory stimulation as a method
Orthodontic anchoring techniques and analgesics in the management of pain
of reducing pain after orthodontic
its influence on pain, discomfort, and after orthodontic separator placement:
appliance adjustment. J Clin Orthod
jaw function − a randomized controlled a randomized clinical trial. J Pharm
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trial. Eur J Orthod 2012; 34: 102−108. Bioall Sci 2014; 6: S80.
18. Wu AK, McGrath C, Wong RW, 29. Yassaei S, Vahidi A, Farahat F. 41. Wang J, Jian F, Chen J, Ye NS, Huang
Wiechmann D, Rabie AB. A comparison Comparison of the efficacy of calcium YH, Wang S et al. Cognitive behavioral
of pain experienced by patients treated versus acetaminophen on reduction of therapy for orthodontic pain control: a
with labial and lingual orthodontic orthodontic pain. Ind J Dent Res 2012; randomized trial. J Dent Res 2012; 91:
appliances. Eur J Orthod 2010; 32: 23: 608−612. 580−585.
403−407. 30. Bradley RL, Ellis PE, Thomas P, Bellis H, 42. Hwang JY, Tee CH, Huang AT, Taft L.
19. Papageorgiou SN, Golz L, Jager A, Ireland AJ, Sandy JR. A randomized Effectiveness of thera-bite wafers in
Eliades T, Bourauel C. Lingual vs. clinical trial comparing the efficacy reducing pain. J Clin Orthod 1994; 28:
labial fixed orthodontic appliances: of ibuprofen and paracetamol in the 291−292.
systematic review and meta-analysis of control of orthodontic pain. Am J 43. Otasevic M, Naini FB, Gill DS, Lee RT.
treatment effects. Eur J Oral Sci 2016; Orthod Dentofacial Orthop 2007; 132: Prospective randomized clinical trial
124: 105−118. 511−517.
comparing the effects of a masticatory
20. Jian F, Lai W, Furness S, McIntyre GT, 31. Salmassian R, Oesterle LJ, Shellhart
bite wafer and avoidance of hard
Millett DT, Hickman J et al. Initial arch WC, Newman SM. Comparison
food on pain associated with initial
wires for tooth alignment during of the efficacy of ibuprofen and
orthodontic treatment with fixed acetaminophen in controlling pain after orthodontic tooth movement. Am J
appliances. Cochrane Database Syst Revs orthodontic tooth movement. Am J Orthod Dentofacial Orthop 2006; 130:
2013(4): CD007859. Orthod Dentofacial Orthop 2009; 135: 6.e9−15.
21. Powell C V, Kelly A-M, Williams A. 516−521. 44. Keith DJ, Rinchuse DJ, Kennedy M, Zullo
Determining the minimum clinically 32. Polat O, Karaman AI, Durmus E. T. Effect of text message follow-up on
significant difference in visual analog Effects of preoperative ibuprofen and patient’s self-reported level of pain
pain score for children. Ann Emerg Med naproxen sodium on orthodontic pain. and anxiety. Angle Orthod 2013; 83:
2001; 37: 28−31. Angle Orthod 2005; 75: 791−796. 605−610.
22. Kohli SS, Kohli VS. Effectiveness of 33. Polat O, Karaman AI. Pain control during 45. Wang J, Jian F, Chen J, Ye N, Huang
piroxicam and ibuprofen premedication fixed orthodontic appliance therapy. Y, Wang S et al. Cognitive behavioral
on orthodontic patients’ pain Angle Orthod 2005; 75: 214−219. therapy for orthodontic pain control: a
experiences: a randomized control trial. 34. Jackson D, Moore P, Hargreaves randomized trial. J Dent Res 2012; 91:
Angle Orthod 2011; 81: 1097−1102. K. Preoperative nonsteroidal anti-
580−585.
23. Patel S, McGorray SP, Yezierski R, inflammatory medication for the
46. Ireland AJ, Ellis P, Jordan A, Bradley R,
Fillingim R, Logan H, Wheeler TT. Effects prevention of postoperative dental
of analgesics on orthodontic pain. pain. J Am Dent Assoc 1989; 119: Ewings P, Atack NE et al. Comparative
Am J Orthod Dentofacial Orthop 2011; 641−647. assessment of chewing gum and
139: e53−e58. 35. Iwasaki L, Chandler J, Marx D, Pandey ibuprofen in the management of
24. Minor V, Marris CK, McGorray SP, J, Nickel J. IL‐1 gene polymorphisms, orthodontic pain with fixed appliances:
Yezierski R, Fillingim R, Logan H et al. secretion in gingival crevicular fluid, a pragmatic multicenter randomized
Effects of preoperative ibuprofen on and speed of human orthodontic tooth controlled trial. Am J Orthod Dentofacial
pain after separator placement. Am J movement. Orthod Craniofacial Res Orthop 2016; 150: 220−227.
Enhanced CPD DO C
Naomi Prado Susi Caldwell and Martin Ashley
Orthodontic Bonding to
Atypical Tooth Surfaces
Abstract: Orthodontic bonding techniques continue to evolve with the ever-changing population. With the demand for orthodontic
treatment increasing, the specialty is regularly presented with restored dentitions, anterior crowns, bleached teeth, as well as those
presenting with developmental conditions, such as fluorosis and amelogenesis imperfecta. Reduced orthodontic bond strength can lead
to failure of the appliance and in turn lead to prolonged treatment times and patient dissatisfaction. This article aims to summarize the
recommended methods for bonding and give an updated review of optimizing techniques.
CPD/Clinical Relevance: Adequate bracket bond strength is an essential part of orthodontic treatment, to prevent breakages and reduce
treatment time and risk factors.
Ortho Update 2020; 13: 57–62
The invention of direct bonding of brackets challenges. Many patients now present with (Camphorquinone);
to enamel surfaces of teeth has dramatically teeth restored with a variety of materials, Pigment for colour (usually metal oxides
changed orthodontic treatment. The acid- such as composite or amalgam fillings, such as titanium or aluminium oxides).
etch bonding technique was introduced by porcelain veneers and ceramic or metal Enamel is a highly mineralized
Buonocore in 19551 and later adopted by crowns. In an unrestored dentition, patients tissue, made up of hydroxyapatite crystals
Newman for the attachment of orthodontic may also present with previously bleached (86%) with water and inorganic content.5
brackets.2 This led to the progression from teeth and both adult and adolescent patients The hydroxyapatite crystals are arranged in
the traditional banding of individual teeth, may present with other atypical tooth rods with a smooth surface.
to the direct bonding technique that is now surfaces, including developmental conditions Bonding of composite resin
ubiquitous. such as fluorosis and amelogenesis to enamel is micromechanical in nature.6
This ability to bond orthodontic imperfecta. The enamel surface is etched with 37%
brackets directly has offered numerous Many studies have reported phosphoric acid, allowing selective
clinical advantages including: reduced different methods for optimizing bonding to dissolution of enamel rods and the creation
patient chair-time; increased patient comfort; these atypical surfaces and this article aims of microporosities of around
improved aesthetics; reduced plaque to discuss and summarize the most popular 30 micrometres in depth. A low viscosity
retention; and the possibility of placing techniques. resin (bond) is then applied, which
attachments on partially erupted teeth. penetrates into the microporosities and
Although a number of bonding Traditional acid-etch technique leads to the formation of resin tags.5 The
materials have been trialled, composite has Orthodontic bonding to enamel and dentine resin tags allow micromechanical retention
been found to be the most effective for surfaces is done via the acid-etch technique, to the composite, which is light-cured
orthodontic bonding, exhibiting adequate with composite resin. (using blue light of 470 nm) to initiate
bond strength to withstand intra-oral and Modern composite is composed of:5 free radical polymerization; thus changing
orthodontic forces (6−8 MPa at 24 hours,3 An organic resin matrix (Bis-GMA, with a the composite resin from a fluid to a solid
with acceptable bond failure rate of 1−5%4). TEGDMA diluent to reduce viscosity); state.5
With the demand for orthodontic treatment Inorganic filler particles (commonly silica In recent years, there has
increasing, particularly amongst the adult or glass-containing aluminium); been a move towards simplifying the
population, the specialty is facing new Initiators and accelerators acid-etch technique, such as with the use
Naomi Prado, BSc(Hons), BDS, MFDS RCPS(Glasg), Orthodontic Registrar, University Dental Hospital Manchester, Susi Caldwell, BDS,
MDent Sci, FDS, MOrth, FDS(Orth), RCS(Eng), Consultant Orthodontist, Wythenshawe Hospital and Martin Ashley, BDS(Hons), FDS
RCS(Eng), FDS(Rest Dent) RCSEng, MPhil, Consultant and Honorary Senior Clinical Lecturer in Restorative Dentistry, Manchester University
Foundation NHS Trust, Manchester, UK.
a contamination.7 The active ingredient in follows:

these products is methacrylated phosphoric Diamond bur − the most widely available
acid ester, which dissolves calcium from and easiest chair-side method is simple
the hydroxyapatite crystals in enamel. The roughening of the porcelain by using a
calcium then attaches to the phosphate high-speed diamond bur to remove the
group of the ester and forms a complex, glazed surface.
which is polymerized when the resin is set.8 Sandblasting − chairside sandblasting
b A meta-analysis was conducted with aluminium oxide particles to create
by Fleming et al in 2012, to review the irregularities in the porcelain surface.
evidence comparing bonding with traditional Prior to any preparation of
acid-etch technique, compared to using self- porcelain/ceramic surfaces for orthodontic
etching primers. The analysis concluded that bonding, patients should be informed and
there was no significant evidence to favour consented for the common risk that the
one system over the other, in terms of bond restored surface will not be aesthetically
failure and reducing clinical chair-time.9 uniform following debond. Even without
c Therefore, the choice of methods for bonding additional surface conditioning (diamond
to enamel is very much at the discretion of bur or sandblasting) studies have shown
the operator. that the restorations are often irreversibly
damaged.16 Therefore, replacement of the
Bonding to porcelain and restorations affected may be required, after
ceramic surfaces the orthodontic appliances are removed.
Bonding of orthodontic brackets to porcelain Fully informed consent for this stage must
d or ceramic surfaces exhibits a higher degree be obtained at the start of treatment.
of failure, when compared to enamel.10
Dental porcelain/ceramics are glass materials Bonding to amalgam and
with an amorphous structure containing metals
metal oxides (silica/alumina).11 The most A study by Keim et al concluded that there
well recognized technique for bonding to had been a significant reduction in the
porcelain is via the use of hydrofluoric acid number of orthodontists banding posterior
e and a silane coupling agent (Figure 1). teeth and, due to the advances in bonding,
Hydrofluoric acid (9.6%) has been more clinicians were favouring bonding
shown to react with the silica phase within tubes onto molars.17 However, with the
the porcelain, creating microchannels and corresponding increase in numbers of the
so facilitating micromechanical retention.10 adult population undergoing orthodontic
It has been found that longer etching time treatment, patients may present for
results in further dissolution of the glassy treatment with extremely large amalgam
matrix and subsequent increase in overall restorations, often extending onto the
f surface area, by increased formation of buccal surfaces of their posterior teeth.
the microchannels. For this reason, it is If the size of amalgam
suggested that the etching phase of bonding restoration is such that there is still
is extended to 60 seconds.12 It is important significant adjacent tooth structure, then
to note that hydrofluoric acid is highly bonding via the conventional acid-etch
irritant to soft tissues and so extreme care technique, to the surrounding enamel,
and effective isolation should be exercised is likely to be sufficient to prevent bond
in clinical practice, to avoid acid burn of failure.18 However, in such cases that the
the surrounding tissues. High volume restoration is large enough to leave little
Figure 1. (a−f) Steps for bonding to porcelain suction throughout the procedure is often surrounding tooth structure, successful
surfaces. (a) Patient presenting for bond-up with recommended. orthodontic bonding is a challenge
porcelain crown UL1. (b) Surface conditioning Multiple studies have found that (Figure 2).
using simple diamond bur preparation and the bond strength of orthodontic brackets to Multiple studies have
etch stage (for 60 seconds): note the soft tissue porcelain surfaces is significantly improved investigated different procedures for
protection. (c) Application of a saline coupling by the application of a silane coupling improved amalgam bonding.19,20,21,22 It is
agent. (d) Application of bond. (e) Placement agent.13,14,15 Silane works by forming weak generally accepted that adequate bond
of orthodontic bracket and light curing for chemical bonds with both organic and strength can be achieved by a combination
polymerization. (f) Porcelain bonding kit (other inorganic surfaces, therefore bonding with of:
manufacturers available). both the porcelain surface and the composite Micromechanical retention via surface
resin. conditioning (diamond bur or sandblasting,
In addition to the above steps, as outlined above);
bond strengths can be further increased by Chemical retention via a 4-META
of self-etching primers. These combine mechanical surface conditioning procedures. coupling agent.
the conditioning (etch) and priming The purpose of these techniques is to 4-META (4-methacryloxyethyl
(bond) steps, therefore reducing clinical increase the surface area available for the trimellitate anhydride) is an agent that
chair-time and the possibility of moisture bonding techniques to be successful as increases adhesion to a number of
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a a than the self-etch systems.29,30 A postulated

reason for this is that the hydrogen-
peroxide agents may significantly decrease
the enamel calcium and phosphate
content.28 As previously discussed, self-etch
primers work by dissolving the calcium
from hydroxyapatite crystals, therefore
bleached enamel with decreased calcium
content will cause the self-etch primer to
be less effective.
b Bonding to enamel defects

b
Orthodontic bonding to a compromised
enamel surface continues to pose a
clinical challenge. Dental fluorosis is a
developmental defect caused by increased
exposure to fluoride during dental
development. Fluorosed enamel has an
outer hypermineralized and acid-resistant
layer, followed by hypomineralized defects
Figure 2. (a) Amalgam bonding vs (b) banding in the subsurface layer.31 These defects can
on molar teeth. present as discoloration (white or brown),
Figure 3. (a) Severe AI with widespread enamel
hypoplasia. (b) Mild AI with generalized mild
pitting or striations. Studies using scanning
pitting of the tooth surface. In these cases, it is electron microscopes have found that the
surfaces, including metals. It contains two important to remember that the altered tooth hypermineralized enamel layer is unable to
functional groups, a hydrophilic group surface can cause differential expression of the be effectively etched with 37% phosphoric
and a hydrophobic group, both having an prescription in the orthodontic bracket, due to acid, leading to irregularities in the etching
affinity for the metal oxides on the surface of the bracket base not sitting uniformly against pattern and therefore a decreased bond
amalgam and the composite resin used for the tooth surface. Therefore, it may be prudent strength.32,33,34
bonding. This increases the surface energy to consider pre-orthodontic composite veneers There is paucity of evidence to
of amalgam and so increases the wettability, on the worst affected teeth. This will serve to identify the optimum bonding technique
improve aesthetics for the patient and also allow for enamel exhibiting moderate-severe
thus leading to the ability to chemically bond
more controlled expression of the prescription. fluorosis. Microabrasion with acid etch has
to the resin.23
The combination of 4-META been trialled and found to be effective,
with surface conditioning has also been however, this is associated with poorer
for several days. Oxygen is an inhibitor of the compliance with patients (due to the
found to be suitable for bonding to other composite polymerization process. Therefore, microabrasion process), increased chair-
metal surfaces, including gold and stainless during this time, bonding with composite time, increased costs and irreversible
steel. However, in these instances, the bond may be impaired due to the potential damage to the enamel surface.34,35
strength is significantly weaker in comparison interference in the polymerization stage.24
Multiple studies have discussed
to amalgam18 and, therefore, orthodontic Studies have also shown that the resin tags the fact that the severity of fluorosis differs
bonding to these materials remains a produced when etching bleached teeth, are not only from tooth-to-tooth, but also from
challenge. smaller, more fragmented and penetrate to a site-to-site on a single tooth surface.36 Due
shallower depth than in untreated enamel,26,27 to this, it is difficult to conduct a reliable
Bonding to whitened teeth again leading to a weakened bond strength. study and recommend a reliable treatment
Tooth whitening is an aesthetic procedure Many studies have found the in modality. Each case should be assessed on
that is becoming more widely practised, as vitro bond strength of composite to enamel its own merit, but it is generally accepted
both in-clinic and at-home treatments. Dental is significantly reduced when placed within that increased etching time will penetrate
bleach consists of either hydrogen peroxide 24 hours of bleaching, however, a few studies the hypermineralized enamel layer and
or carbamide peroxide, along with stabilizing in comparison have found the opposite.28 In potentially elicit higher bond strengths.
agents. Whitening is an oxidative bleaching vitro studies have suggested the optimum Amelogenesis imperfecta (AI)
process by which the peroxide molecules time for bonding following bleaching to be is a developmental abnormality of tooth
diffuse into the tooth surface and produce 1−3 weeks, however, in vivo studies have enamel, resulting in poor development or
oxygen–free radicals and hydrogen peroxide given conflicting evidence, with no consistent complete absence of enamel due to the
anions.24 These molecules then travel through suitable time frame.28 It is generally accepted improper differentiation of ameloblasts.37 AI
the enamel rods and into dentine, where that it is prudent to wait 7 days before can affect both the primary and permanent
they break down extrinsic and intrinsic composite bonding to whitened teeth and dentition and has been shown to have
coloured pigments, transforming them to this is something that should be considered a variable prevalence of approximately
colourless materials and therefore resulting in when planning orthodontic treatment. 1:4,000 to 1:14,000 in Western populations38
25
a lightened appearance. With regards to traditional acid- (Figure 3).
Following this process, the etch technique vs self-etching primers, When treatment planning AI
elimination of oxygen–free radicals from the studies have shown that traditional etch and patients, it is important to complete a
enamel is not immediate and may remain rinse systems give a higher bond strength thorough examination of the weakened
enamel surface. It is essential that the delicate obtained from all individual participants bonding to gold, amalgam and porcelain.
enamel is deemed suitable to withstand not included in the article. J Clin Orthod 1993; 27: 661−675.
only orthodontic forces, but also the debond 22. Zachrisson BU, Buyukyilmaz T, Zachrisson
YO. Improving orthodontic bonding to silver
procedure. Conventional fixed appliance References amalgam. Angle Orthod 1995; 65: 35−42.
therapy can be used, but bond strengths 1. Buonocore MG. A simple method of increasing
23. Setcos JC, Staninec M, Wilson NHF. The
have been shown to be less reliable.39 the adhesion of acrylic filling materials to enamel
development of resin bonding for amalgam
This can lead to multiple bracket failures, surfaces. J Dent Res 1955; 34: 849−853.
restorations. Br Dent J 1999; 186: 328−332.
increasing treatment time and ‘burning 2. Newman GV. Epoxy adhesives for orthodontic
24. Pimentel AH, Valente LL, Isolan CP et al. Effect
out’ the compliance of patients who are attachments: progress report. Am J Orthod 1965;
of waiting time for placing resin composite
likely to have already undergone extensive 51: 901−912.
restorations after bleaching on enamel bond
3. Reynolds IR. A review of direct orthodontic bonding.
dental treatment. In order to overcome this, strength. Appl Adhes Sci 2015; 3(23). Open Access
Br J Orthod 1975; 2: 171−178.
the use of resin-modified glass ionomer 4652.
4. Bishara SE, Fehr DE. Ceramic brackets: something
cement has been suggested. This adhesive old, something new, a review. Semin Orthod 1997;
25. McEvoy SA. Chemical agents for removing
system is less reliant on resin tag formation 3: 178−188.
intrinsic stains from vital teeth. Part II. Current
and will potentially also reduce further techniques and their clinical application.
5. Mount GJ, Hume WR. Preservation and Restoration
demineralization of the enamel surface, due of Tooth Structure 2nd edn. Brighton, Australia: Quintessence Int 1989; 20: 379−384.
to its fluoride properties.39 The use of ceramic Knowledge Books & Software, 2005; pp200−214. 26. Titley KC, Torneck CD, Smith DC, Adibfar A.
Adhesion of composite resin to bleached and
brackets has been recommended for AI 6. Van Meerbeek B, Inoue S, Perdiago J, Lambrechts
P, Vanherle G. Enamel in dentine adhesion. In: unbleached bovine enamel. J Dent Res 1988; 67:
cases, as they are able to be removed with a
Fundamentals of Operative Dentistry 2nd edn. 1523−1528.
high-speed handpiece. This avoids the use
London: Quintessence Publishing, 2001: pp236−259. 27. Nour El-din AK, Miller BH, Griggs JA, Wakeld C.
of traditional debonding pliers, which exert Immediate bonding to bleached enamel.
7. Miller RA. Laboratory and clinical evaluation of a
a high force on the tooth, and thus helps Oper Dent 2006; 31: 106−114.
self-etching primer. J Clin Orthod 2001; 35: 42−45.
to preserve the delicate enamel surface. 8. Chu CH, Ou KL, Dong de R et al. Orthodontic 28. Greenwall L, ed. Tooth Whitening Techniques 2nd
However, again, each case needs to be fully bonding with self-etching primer and self-adhesive edn. Oxford: CRC Press, 2017: 247−258.
assessed and the method most suitable for systems. Eur J Orthod 2011; 33: 276−281. 29. Gurgan S, Alpaslan T, Kiremitci A, Cakir FY. Effect of
the patient should be discussed with all 9. Fleming PS, Johal A, Pandis N. Self-etch primers and different adhesive systems and laser treatment on
involved. conventional acid-etch technique for orthodontic the shear bond strength of bleached enamel.
bonding: a systematic review and meta-analysis. J Dent 2009; 37: 527−534.
Am J Orthod Dentofacial Orthop 2012; 142: 83−94. 30. Moule CA, Angelis F, Kim GH, Le S. Resin bonding
Conclusion 10. Grewal Bach GK, Torrealba Y, Lagravère MO. using an all-etch or self-etch adhesive to enamel
Overall, the bonding of orthodontic Orthodontic bonding to porcelain: a systematic after carbamide peroxide and/or CPP-ACP
brackets to atypical tooth surfaces poses a review. Angle Orthod 2014; 84: 555−560. treatment. Aust Dent J 2007; 52: 133−137.
significant challenge to the clinician. Multiple 11. Shenoy A, Shenoy N. Dental ceramics: an update. 31. Noble J, Karaiskos NE, Wiltshire WA. In vivo
methods for varying tooth surfaces have J Conserv Dent 2010; 13: 195−203. bonding of orthodontic brackets to fluorosed
been described, each with their own merits 12. Karan S, Toroglu MS. Porcelain refinishing with enamel using an adhesion promotor.
and downfalls. Careful examination of the two different polishing systems after orthodontic Angle Orthod 2008; 78: 357−360.
dentition is essential in order to allow the debonding. Angle Orthod 2008; 78: 947−953. 32. Hoffman S, Royelstad R, McEwan WS, Drew CM.
13. Costa AR, Correr AB, Puppin-Rontani RM et al. Effect
clinician to ascertain the best process for Demineralisation studies of fluoride treated
of bonding material, etching time and silane on the enamel using scanning electron microscopy.
optimizing bonding to each individual tooth.
bond strength of metallic orthodontic brackets to J Dent Res 1969: 48: 1296−1302.
As part of the consent process, ceramic. Braz Dent J 2012; 23: 223−227.
33. Kochavi D, Gedalia I, Anaise J. Effects of
each patient should be specifically informed 14. Barceló Santana HF et al. Evaluation of bond
conditioning with fluoride and phosphoric acid
if he/she has a tooth structure that may strength of metal brackets by a resin to ceramic
on enamel surfaces as evaluated by scanning
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electron microscopy and fluoride incorporation.
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J Dent Res 1975; 54: 304−309.
Multidisciplinary work with Restorative M. Should silane coupling agents be used when
34. Opinya GN, Pameijer CH. Tensile bond strength
Dentistry colleagues can facilitate treatment bonding brackets to composite restorations? An in
of fluorosed Kenyan teeth using the acid etch
for patients with dentitions that are already vitro study. Eur J Orthod 2009; 232: 274−280.
technique. Int Dental J 1986; 336: 225−229.
16. Pannes DD, Bailey DK, Thompson JY, Pietz DM.
restored or will need further restoration. Use 35. Miller RA. Bonding fluorosed teeth: new materials
Orthodontic bonding to porcelain: a comparison of
of indirect composite provisional crowns, for for old problems. J Clin Orthod 1995; 29: 424−427.
bonding systems. J Pros Dent 2003; 89: 66−69.
instance, can allow the placement of brackets 17. Keim RG, Gottlieb EL, Nelson AH, Vogels DS. JCO
36. Ng’ang’a PM, Ogaard B, Cruz R et al. Tensile
more reliably in patients with significantly Study of orthodontic diagnosis and treatment
strength of orthodontic brackets bonded to
compromised tooth surfaces. procedures, part 1. Results and trends. J Clin Orthod fluorotic and nonfluorotic teeth: an in vitro
With the changing population 2002; 36: 553−568. comparative study. Am J Orthod Dentofacial
undergoing orthodontic treatment, it is 18. Zachrisson BU. Orthodontic bonding to artificial Orthop 1992; 102: 244−250.
tooth surfaces: clincial versus laboratory findings. 37. Seymen F, Kiziltan B. Amelogenesis imperfecta:
important that the specialty recognizes the
Am J Orthod Dentofacial Orthop 2000; 117: 592−594. a scanning electron microscopic and
associated difficulties in bonding and is
19. Buyukyilmaz T, Zachrisson B. Improved orthodontic histopathalogic study. J Clin Pediatr Dent 2002; 26:
aware of the techniques available to ensure
bonding to silver amalgam. Part 2. Lathe-cut, 327−335.
that all patients are receiving the best 38. Arkutu N, Gadhia K, McDonald S, Malik K, Currie
admixed, and spherical amalgams with different
possible care. intermediate resins. Angle Orthod 1998; 68: 337−344. L. Amelogenesis imperfecta: the orthodontic
20. Jost-Brinkmann PG, Bohme A. Shear bond strengths perspective. Br Dent J 2012; 212: 485−489.
Compliance with Ethical Standards attained in vitro with light-cured glass ionomers vs 39. Seow W, Amaratunge A. The effects of acid
Conflict of Interest: The authors declare that composite adhesives in bonding ceramic brackets to etching on enamel from different clinical variants
they have no conflict of interest. metal or porcelain. J Adhes Dent 1999; 1: 243−253. of amelogenesis imperfecta: an SEM study. Pediatr
Informed Consent: Informed consent was 21. Zachrisson BU, Buyukyilmaz T. Recent advances in Dent 1998; 20: 37−42.
Wishing all our

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This once in a lifetime event
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Enhanced CPD DO C
Thor Henrikson
Treatment with Invisalign®

in Specialist Practice
Abstract: Orthodontic treatment with Invisalign® can produce a high quality treatment outcome. As in all orthodontic methods, however,
there is a steep learning curve. The most important factor is for the clinician responsible for the case to take full control when planning
and working with the case using the ClinCheck software. Since aligners are removable, another important factor for treatment success
is, of course, patient compliance. In moderate open bite cases, when vertical control is extremely important, in the opinion of the author,
Invisalign® is now the preferred treatment choice over fixed appliance treatment.
CPD/Clinical Relevance: To understand that it is possible to perform high-quality orthodontics with Invisalign®. However, to achieve good
results, it is important to take full control in the ClinCheck process when planning the treatment.
Ortho Update 2020; 13: 64–70
The Invisalign® system uses a series of Important factors for a selected and placed by the clinician. It
computer-generated, clear, removable successful treatment outcome are: is possible for the clinician to decide
aligners to move the dentition. Each Treatment sequencing; which teeth need attachments to
aligner should be worn for 20−22 Treatment velocity; achieve the desired tooth movement
hours per day and is designed to The use of appropriate and this decision is placed by the
move a tooth, or groups of teeth, attachments; clinician on the prescription form.
by about 0.15−0.3 mm. The aligners Overcorrections. In the author’s practice, for
should be changed, and movement reasons of aesthetics, it is attempted
advanced, every 1−2 weeks to allow Aligner material and to avoid attachments 3−3 in the upper
satisfactory progress towards the end attachments jaw, during the initial set of aligners.
result. The aligners are currently made After a discussion with the patient, the
The final treatment goal in SmartTrack® material, which required attachments are often added
is decided by the clinician within the is claimed to deliver both high during the second set of aligners.
software program ClinCheck® Pro, elasticity and a relatively constant In premolar extraction
which is now completely interactive. force. Attachments are a vital part treatments, standard horizontal 4−5
ClinCheck® Pro was introduced in when treating patients with the mm x 1 mm thickness attachments
2014 and consists of a toolbar with Invisalign® system. Placement of are recommended instead of the
3D controls to be able to adjust each these attachments helps ensure that optimized attachments, and this
tooth directly, in all three planes the tooth movements occur similarly modification has proved effective, in
of space on the 3D model. Before to those shown in the CC treatment the author’s practice, to avoid tipping
ClinCheck® Pro was introduced, all plan, and is an essential step to during space closure.
communication with Invisalign® to achieve the patient outcomes that According to the author’s
determine the final tooth position have been promised. There are two clinical experience, to be able to
was made in writing. This meant that, types of attachments that could be achieve a high quality treatment
before 2014, the clinicians did not used during an Invisalign® treatment: outcome, almost all Invisalign®
have true control of the ClinCheck 1. Optimized attachments: These are treatments require a second set of
(CC) process, which resulted in much the ones that are suggested and aligners to reach the treatment goal.
less real control of the treatment placed by the Invisalign® software, In some more challenging treatments,
aim and certainly of the treatment during the automated CC process; a third set of aligners may even be
outcome. 2. Standard attachments: These are required. Gu et al evaluated the
Thor Henrikson, DDS, PhD, Associate Professor at University of Malmo, Private Practice, Radmansgatan 10, 211 46 Malmo, Sweden.
a f Cases
Three Invisalign® cases are going to be
presented to give an overview of the
treatment possibilities:
Case 1: (Figure 1) Class I (Cl II tendency)

crowding. Non-extraction treatment
In this case, after the treatment plan
was completed, a pre-scanning IPR was
performed. The reason for performing
b g pre-scanning IPR is to avoid ‘round
tripping’ when aligning the teeth. In
total for this case, 71 aligners were used.
The first treatment sequence involved 38
aligners, and the second set (Additional
Aligners) involved another 33 aligners.
The total treatment time was 17 months
h and the achieved result was retained
by bonded Memotain® retainers 3−3 in
c
both jaws and, in addition, a vacuum-
formed retainer in the upper jaw at
night.
As previously described, no
attachments were used UR3−UL3 in the
first set of aligners for aesthetic reasons.
During the second set of aligners, an
i optimized attachment was added to UL2
to achieve derotation and extrusion. On
d UR2, a standard epsiloid attachment was
added.
Post-treatment evaluation
The arches were well aligned, and
the sagittal and transversal relations
improved on the left side. Since the
patient had significant gingival recession
before the treatment, efforts were made,
during the CC process, to add palatal
root torque when expanding the arches,
j hopefully to avoid further gingival
e recession.
Case 2: (Figure 2) Class I, large overjet,

crowding. Lower incisor extraction
treatment
In this case, it was decided to extract
one lower incisor due to the severe
crowding in the lower front. To be
able to correct the 7 mm overjet and
to create space in the upper jaw, pre-
scanning IPR was performed. In addition,
transversal expansion in the molar-
premolar area (2 mm at each side) were
added to the CC. The first set of aligners
Figure 1. Case 1: (a−e) Pre-treatment views. (f−j) Post-treatment views. included 25 aligners, followed by a set of
additional aligners, including 22 aligners.
Power ridges were added at UR1 and
treatment outcome, the duration and treatment takes less time than fixed UL1 at the second set of aligners stage
to improve the palatal root torque on
the improvement in two groups of appliance therapy seems to be inaccurate.
the upper incisors. Overcorrected lingual
patients in a retrospective study.1 One In the author’s experience, Invisalign® root torque was added cuspid-to-cuspid
group was treated with a conventional treatment takes just as long as fixed in the lower jaw to avoid lingual tipping
fixed appliance and one with Invisalign®. appliance treatments to be able to achieve of these teeth during the space closure.
However, Gu et al’s claim that Invisalign® an excellent result. The total treatment time was
a f challenges. The patient had an open

bite forward of the molars, UL7
needed to be extracted due to a
vertical fracture, and the patient also
had a severe gingival recession on LR1,
possibly due to earlier orthodontic
treatment.
The treatment plan
included intrusion of posterior teeth
b to correct the open bite. In this
g
case, extrusion of incisors should be
avoided as the patient already showed
the ideal amount of tooth display
of the upper incisors. In order to
intrude posterior teeth, the following
instruction was added during the
CC process: ‘Intrude posterior teeth
c tooth by tooth to correct the open
h
bite’. With this explicit instruction,
the most posterior right and left
molars in both jaws are intruded
simultaneously as all of the other teeth
are used as anchorage. Then, once this
intrusion is achieved, the next tooth
pair is intruded using the remaining
teeth again as anchorage. To be able
to control the intrusion, standard
d i rectangular 4 x 1 mm attachments are
added on all molars and premolars.
Another important consideration is
to add palatal crown torque on the
molars to avoid buccal flaring of these
teeth.
The next challenge was
to add lingual root torque on LR1 to
torque the root back into the alveolus.
A power ridge was added at LR1 to
help to achieve the lingual root torque.
The last challenge was to close the
e j space created after extracting UL7
effectively. Substantial overcorrection
of the tip was added to UL8 to
counteract the mesial tipping which
would otherwise occur during space
closure.
Post-treatment evaluation
All treatment goals were achieved
using three sets of aligners and the
total treatment time was 20 months.
The result was retained with bonded
Figure 2. Case 2: (a−e) Pre-treatment views. (f−j) Post-treatment views. retainers 3−3 in both jaws and a
vacuum-formed retainer at night in the
upper jaw. Parallel roots at UL6 and
12 months and the treatment result was present in the front, despite extracting UL8 were successfully achieved despite
retained by bonded retainers 3−3 in both in only the lower jaw. This was probably the extraction of UL7. The root of LR1
jaws. achievable because of the large size of the was torqued into the bone and the
lower incisors and the slightly diminutive amount of gingival recession reduced
Post-treatment evaluation upper lateral incisors. substantially.
The arches were well aligned, and the
overjet was normalized. The Class I Case 3: (Figure 3) Class I, open bite, gingival Discussion
intercuspation was maintained and, in recession at LR1 and extraction of UL7 Working hard on the CC is vitally
addition, occlusal contacts were also This case included several clinical important to reach excellent treatment
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Nobody expects
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Last week Helen enjoyed an evening
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clinical course. She never expected to or injury can have, not just on your health and wellbeing
be calling him this morning saying she but on your work and lifestyle as well. An illness or injury
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or call our member services consultants on 020 7400 5710
Dentists’ Provident is the trading name of Dentists’ Provident Society Limited which is incorporated in the United Kingdom under the Friendly Societies Act 1992 (Registration
Number 407F). Authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority in the United
Kingdom (Firm Reference Number 110015) and regulated in the Republic of Ireland by the Central Bank of Ireland for conduct of business rules (Firm Reference Number C33946).
Calls are recorded for our mutual security, training and monitoring purposes. These case studies are for illustration purposes only and not based on real individuals. They are not
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a f i
b
g
c h
e
l
Figure 3. Case 3: (a−e) Pre-treatment views. (f−l) Post-treatment views.
results with Invisalign®. When attempting when treating with Invisalign®. This treatment outcome, duration and
difficult tooth movements, it is often specific and explicit instruction needs improvement in two groups of
necessary to add overcorrections to be to be given to the CC technicians orthodontic patients:1 one treated
able to achieve the desired treatment and a check done on the revised CC with a fixed appliance and one with
result. In a review by Rossini et al, extrusion to see that instructions have been Invisalign®. They found that Invisalign®
and rotation were claimed to be the least followed to the letter. In addition, it is is not as effective as a fixed appliance
predictable movements with Invisalign®.2 often necessary to use attachments in achieving great improvement and
Consequently, it is often necessary also to when performing unpredictable tooth that Invisalign® treatment was faster
slow down the movement velocity during movements. than fixed appliance treatment. The
difficult and less predictable movements Gu et al evaluated the reason for this difference in quality
of the outcome reported could be mainly due to extrusion of incisors, which Compliance with Ethical Standards
the shorter treatment time with was in accordance with their planning in Conflict of Interest: The authors declare
Invisalign®. In the author’s experience, the CC. In the author’s practice, planning that they have no conflict of interest.
Invisalign® treatments take just as for less extrusion of incisors and more Informed Consent: Informed consent was
long as fixed appliance treatments intrusion of molars and premolars is often obtained from all individual participants
to achieve the same standard of performed. By doing a stepwise, tooth by included in the article.
outcome. As mentioned previously, to tooth intrusion, this procedure to intrude
achieve a high quality result almost two pairs of teeth (upper and lower jaw) is
all Invisalign® treatments require two possible using the anchorage potential of References
sets of aligners. Gu et al, in their study all the other teeth. 1. Gu J, Tang JS, Skulski B et al.
only used one set and this could be Evaluation of Invisalign treatment
the main reason for the difference in
quality between the fixed appliance
Conclusions effectiveness and efficiency compared
Orthodontic treatment with Invisalign® to conventional fixed appliances using
and the Invisalign® group results.1
In fixed appliance can be performed to a high standard the Peer Assessment Rating index.
treatments, it is frequently necessary but, as with all orthodontic techniques, Am J Orthod Dentofacial Orthop 2017;
to replace brackets and to bend developing expertise requires time and 151: 259−266.
the archwires to get a well finished effort. 2. Rossini G, Parrini S, Castroflorio T et al.
treatment result. In an Invisalign® case, The most important factor is Efficacy of clear aligners in controlling
a second or even a third set of aligners for the clinician to take full control when tooth movements. a systematic
should be considered as the necessary planning and working with the case using
review. Angle Orthod 2015; 85:
finishing required to achieve a quality the ClinCheck software.
881−889.
result. In moderate open bite cases,
in experienced hands, Invisalign® can 3. Khosvari R, Cohanim B, Hujoel P
Khosvari et al evaluated
treatment effects when treating deep be superior to fixed appliance due to et al. Management of overbite with
and open bites with the Invisalign® the possibility to intrude posterior teeth the Invisalign appliance. Am J Orthod
appliance.3 In open bites, the median sequentially, thus enabling good vertical Dentofacial Orthop (AJO-DO) 2017;
deepening was 1.5 mm and this was control of the case. 151: 691−699.
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COVID-19
Update from George Warman Publications
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Andrew MC Flett
The Pleasures and Pitfalls

of Life as a New Consultant
– an Anecdotal Review
Part 1
Abstract: This first of a two-part article aims to provide a road map to the budding clinician wishing to take on the role of a Consultant
Orthodontist. Part 1 suggests what to consider when taking up a new post and how to create an ideal unit. Part 2 will provide the author’s
personal insight into the first 18 months of a consultant post. Hints and tips from other newly qualified consultants are also provided, to
enable future consultants to avoid the pitfalls and enjoy the pleasures of an immensely rewarding job.
CPD/Clinical Relevance: To provide first-hand, real world knowledge of life as a new consultant orthodontist in the 21st century NHS.
Ortho Update 2020; 13: 72–77
Woo hoo! You have now passed the ISFE. ‘Exciting opportunity at fantastic unit… end of the day.
No more compulsory exams . . . ever! ‘State of the art facilities, stimulating You may also want to consider
For me, and I suspect all my colleagues place to work with a committed team of the location, surrounding geography and
who pass their ISFE, the feeling is one colleagues’ possible places to live. For others, schooling
of immense relief coupled with utter ‘A fabulous place to live with amazing may be a major consideration, so you
exhaustion. Many of us have spent at recreation opportunities, great transport should also look carefully into this aspect
least 10 years of our lives getting to the lnks and fantastic schools and housing . . . of your future life before committing. Being
finish line . . . so what next? so what’s not to like?’ close to family and friends could also be a
In the current climate there is ‘deal breaker’. Hopefully, you should also be
of course a wealth of possibilities open able to look forward to far more completely
to you. There are currently a healthy There are many considerations free weekends in the near future, so finding
number of consultancy vacancies when deciding where to become a a place that meets all the requirements to
throughout the country, unlike in recent Consultant. The best place to start is to fill your leisure time is extremely important.
times. If you decide to follow a hospital think about exactly what motivates you In terms of applying and
career, all you have to decide is in which to go to work in the morning. Is it purely securing a consultant job, I would
part of the country you would like to the clinical work? Or perhaps you are wholeheartedly recommend reading about
live and where in particular you wish to attracted by the opportunity for teaching, the experiences and advice that can be
‘hang your hat’ and hopefully make your or possibly research? The two main gleaned from this paper before completing
mark (Figure 1). environments you can choose between an online job application.1 To summarize,
to work as a Consultant are a District this article provides you with all you need
Where to go. . . what to do. . General Hospital or, alternatively, a Dental to know about applying and securing that
.? Hospital. Each has its own merits and you dream job. Don’t be fooled into thinking
The typical job description often goes have to decide which place may provide that a post is won at the interview. All
like this: the most professional fulfilment at the interview processes are transparent
Andrew MC Flett, Consultant Orthodontist, Queen’s Medical Centre, Derby Road, Nottingham, NG7 2UH; King’s Mill Hospital, Mansfield
Road, Sutton-in-Ashfield, NG17 4JL, UK.
What to consider? help you progress further on in your

Here are some general points to consider career.
when visiting your prospective place
Office space
of work which could possibly be your
professional home for the next 30 years. Having your own private space for
administration, study, research, diagnosis
Staff and treatment planning is sadly
Irrespective of how you may feel after the becoming a luxury in the NHS. You may
exam, you will still be relatively ‘green’ to not have an issue with ‘hot-desking’
the nuances and wider working practices or working in a shared office, and for
of the NHS. In order to drive your ‘vision’ many medical specialties in the NHS, like
forward you need to find a group of anaesthetics, this is the norm. It should
people with whom you can work well. definitely be something you ask about
In the NHS, each member of ‘your team’ pre-interview. You may have a personality
will have his/her own line-manager and type that allows you to be completely
appraiser. This makes complete control tolerant of others’ noisy dispositions and
of any member of staff by you virtually unusual habits and, of course, you may
impossible. have some of your own. If you do need
I suggest you visit your your own space, bearing in mind that
preferred unit at least 2 or 3 times to get this could be your working environment
Figure 1. You ‘have arrived’ when your name is the feel for ‘the politics’ working in each for over a quarter of a century, this can
finally on a door! department. It is also worth ‘sitting in’ on a be a point of negotiation. If your ‘new
clinical session or two to see the dynamics office’ is completely dilapidated, you
of the clinic. You would expect all future may want to consider ‘a lick of paint’ and
colleagues to be showing you their best some updated office equipment in your
side when you arrive, but you may be bargaining as part of the deal to take up
sorely disappointed. What you experience, a post (Figure 2).
in these few short preliminary visits could
well sway your decision one way or the Secretarial support
other. Despite being the consultant you will not
Gaining an insight into the be omnipresent; nor should you try to
staff turnover rate may help you decide be! Attempting to do everything, and to
if the unit is a stable and happy place please everyone, will likely burn you out
to be, or more likened to the proverbial within a couple of years.
‘lunatic asylum’! Try and identify the key Some of the best clinicians
members of the team that you will be and consultants I have worked with
working alongside. We have all witnessed, have learnt the art of delegation. By
during our training, many a personality learning this skill, you can focus your
clash, which gets in the way of a team time and effort on the really important
working effectively and efficiently. There areas of your practice, whilst others assist
are, of course, no hard and fast rules and it you with general duties. At my unit, I
is impossible to offer any science to help share a secretary with my Consultant
with this potential dilemma. Ask yourself colleagues. This allows her to be fully
‘does it feel right?’ and ‘do your potential informed about others’ workloads and
Figure 2. DIY consultant moving (circa 2016). pressures. My secretary is absolutely
colleagues seem honest and genuine?’.
Your future consultant invaluable when patients or dentists ring
colleagues are also another extremely up with problems, or for advice. Having
important aspect to consider. Their a secretary who can competently field
and robust. If you put in an abysmal these issues whilst you are otherwise
reputation in the region can only take
performance, against other highflyers, your engaged is fundamental for effective
you so far; it is sometimes conjecture and
name is unlikely to make it above the unit often opinions that are misguided and ill- working. Using her experience, she can
entrance. However, this paper suggests informed. Identify the consultants you will deal with most problems over the phone.
the key people you should identify and be working alongside for the foreseeable If the issue is outside her comfort zone,
meet before the ‘big day’ to facilitate a future. Ask them how they see you fitting our ‘open-door policy’ ensures that, in
favourable opinion of you being created. into the team and what particular plans most cases, a response is given by the
The interview process itself is focused on, they have for the future of the unit and end of the week.
as this is unlike the now universal national service. Every consultant will certainly have Once you take up your
recruitment process that most trainees his/her own pressures and personal goals post, it is worth setting aside some
have endured. When you are successful in to achieve. Ask yourself if your areas of time with your new secretary to gain
your application, insight is given into job interest align with his/hers, fuelling future an understanding of his/her level of
planning, standard consultant contract collaborations, publications and research experience in relation to orthodontics.
arrangements and orientation into your projects. Collaborative work will raise the It is also useful to establish how you
new role. profile of your unit generally, and will also would like things to operate and when
decide to centralize services regionally. is this altruistic behaviour that really does
Each person will have an area provide added value to training courses
of orthodontics that interests him/her across the country. I hope to be able to
and so, ideally, find a unit that aligns with emulate this attitude in the coming years
your area of interest and expertise. Larger and continue to help provide excellent
units with a plethora of trainees will allow training across the region. I urge you to
you to have exposure from the relatively consider the same thoughts.
mundane to the complex orthodontic case.
The drawback of this is that your unit may Honeymoon period
be the ‘catch all’ when it comes to referrals. Before and shortly after you start, expect
This could mean that you will be constantly to be gently eased into your new role.
fighting your 18-week target. Whilst this You should have taken the time to visit
Figure 3. Before buying new kit, ensure that it isn’t essential for all orthodontic cases, or the unit on at least one occasion before
complies with trust cleaning procedures and as Simon Stevens recently commented,2 deciding this is the place to forge your
medical devices directives. most trusts still have to report any 18-week career. Recognize this small window of
breach. This can get management into opportunity as your ‘honeymoon period’.
panic mode, requiring an ‘action plan’ to During this time, and possibly before
reduce the wait. The threat of fines and signing your contract, consider a ‘wish-list’
he/she should come to you for advice. Do loss of money for the unit development of what things you would like in place
not assume people completely understand is something to consider. If you want to before you start serious clinical work. For
your specialist field and be willing to spend provide higher quality care by investing in me the ‘deal-breaker’ was a new dental
time explaining processes to all your future newer techniques and equipment, there is chair and some software to store photos
colleagues and staff. little argument if you are ‘in the black’ with and review and trace radiographs. Review
no management worries. the instrument kits and decide if there is
Practice profile enough there to make things work. You
Personally, I chose a unit where
When considering the merits of each may have some unique pieces of kit that
there was one other Consultant, who I
potential unit, you should assess the variety you just can’t do without. Now is the time
felt I could get on with for many years. He
of cases you will be expected to treat and the to order them!! Once you are firmly in post
has 11 years experience as a Consultant
profile of the unit. There are some units in the you will be subject to the current cash
at the trust and also works in specialist
UK where there are up to eight orthodontic constraints that all departments are under.
practice. This gives us immense insight
consultants working for the same trust. Acquiring additional expensive items later
about orthodontics inside and outside
The advantage of this is the obvious ‘safety will be problematic.
the trust. Before I applied to the trust,
in numbers’, which can be put to good
Steven and I had many conversations
use when applying for additional trainees, Systems in place
about what we would like to achieve
equipment and contracts. Any problems I think it appropriate to establish your
together to ensure that we were on the
that arise, especially of a clinical nature, can working pattern and work ethic early. You
same page. We liaise about leave and have
be shared if you have the right team around are now the leader of a team, and when
managed to collaborate on some projects
you for support. Setting up and completing problems arise, people will turn to you to
already, utilizing our complementary but
larger research projects may be easier as put things right. I wholeheartedly embrace
different views and skill sets when tackling
many hands will make light work, especially if the notion of leading by example. The
problems.
the skill set is varied. However, in a relatively standards by which you measure yourself
democratic set-up, your individual voice should be the standards that you expect
within a large unit may be diminished. This Future plans for you and the of other staff members. Whilst not every
could make achieving your individual wants NHS member of staff will arrive one hour before
and desires less likely. Annual leave rotas will the start of a clinic or stay late working on a
be needed to be negotiated in the pursuit of The job crucial patient, by showing your dedication
fairness, and your patients should always be First and foremost, I enjoy the clinical to the cause, you will hopefully win some
covered in the event of you being away. aspect of the job. For that reason, I decided hearts and minds for another day.
Conversely, other units exist to work at a District General Hospital. I still Kits and essential equipment
where there are only one or two, all powerful, try to contribute, where possible, to the is something you should establish early
consultants. Obviously, if you want it all your training programme at the local Dental as well. If you are working at the unit with
own way, and want to be responsible for all Hospital in Sheffield. This keeps your fellow consultant(s), like me, you should get
the decision-making, then this type of unit thoughts fresh on topics as you prepare together to discuss kit collectively. Again,
may be the place for you. No one is going lectures, preventing you from just switching having a new consultant on the block does
to ‘divide and conquer you’ if you call all the into autopilot. From a personal point of give you some latitude for ordering some
shots. It requires a special type of individual view, I can still remember being a trainee, new equipment. Try to buy the highest
to run a unit single-handedly. Every decision and recall all the hours other consultants quality you can, so that you won’t be
you make is yours and the buck stops with put into me, when I was training. All of replacing your ‘new’ kit regularly due to the
you. A unit like this is usually smaller than them have lives outside work, be it family purchase of a substandard product.
others and so, in an era of NHS efficiency commitments or hobbies to pursue. If you are ordering any new
targets (read: cuts to funding), a unit such Nevertheless, all the consultants I have equipment, ensure that all checks and
as this may have to amalgamate with larger come to respect, go way beyond their 9−5 balances are satisfied before pressing
ones nearby or cease to exist if the NHS job plan to deliver a fantastic training. It the order button (Figure 3). Trusts have
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a multitude of paperwork to complete on symbiotic relationship between you and your far are the non-clinical aspects of the job.
new equipment. Make sure that you know surgeon. As with most surgical units, there is By the time you secure your consultancy
the local sterilization guidelines in your usually a plethora of various trainees wanting job you should be able to deal with most
hospital and that any new equipment has help, advice or a work-based assessment of the clinical cases that are referred to
a transparent guide on how to achieve this. completing. As with all things when you start you. That is not to say that you shouldn’t
A CE mark is paramount for most reusable as a new consultant, learn the word ‘no’, and expect some head-scratching, researching
instruments.3,4 do not take too much on in the early days. and wondering about those cases that you
Establish your own working patterns before have never seen before. That is part of the
Capacity and waiting lists diving in to save others. challenge of being a consultant!
Transfers Our unit has a range of trainees Managers, clinical leads and
These are a necessary part of starting new from post-CCST orthodontists, orthodontic fellow consultants all have different
as an orthodontist. In my experience, the trainees, StRs in maxillofacial surgery and motivators and drivers. The skill to people
transfer case is rarely a good thing, unlike dental core trainees (DCTs). Senior trainees management is to determine for yourself
the excitement some seem to get when the will want viva practice or WBAs completing what you think these are. Staff room politics
football transfer window opens. The other and so accommodate them if you can make is rarely of use here. In order to move
complication is that, as a trainee, you may the time. They may be your fellow colleagues forwards with your grand plans, it is first
have had limited exposure to transfers, in the future! worth spending some time understanding
especially ones that aren’t going according to DCTs are an unusual set of the lay of the land. Where are the pressures
plan. I have known some colleagues get into trainees in that they carry out a junior on management coming from? What is the
difficulty with transfers and not feel confident doctor’s role, albeit only trained in dentistry. current focus of your clinical lead? Would
enough to continue treatment. There has been a realization, at deanery your consultant colleague be supportive, or
The first port of call is to treat level, that these dentists should not solely be at the very least, not be obstructive to your
any transfer as a ‘new patient’ as that is what learning from maxillofacial surgeons as many plan to modernize or change practice?
they are to you! Take a new medical history, will not progress down that career pathway. As a general rule of thumb,
reassess that case and ascertain how long So, gone are the days of being called a senior your supervising managers are happiest
they have been in treatment. Review the house officer (SHO) and welcome to the when your activity is high, your new patient
motivation of the patient. This is usually world of DCTs! Deaneries now expect these waiting list is low, compliments are high and
closely linked to the level of oral hygiene trainees to get rounded training during their complaints are low. If you can prove you are
exhibited intra-orally. Rule out any pathology rotation. Whilst the majority of their time will providing a high-quality service then your
that may make continuing treatment still be spent doing MFU tasks, there is now life should be a little easier. PAR scoring and
impossible, justifying any radiographs an understanding that experience elsewhere patient satisfaction questionnaires or quality
you take. Obtaining the start records with is beneficial. I would advise that you try and of life outcomes are things you should
complete notes is essential to understand get involved with providing some training incorporate into your daily practice.
the progression of the case, as well as best for the DCTs. They are year 2 or 3 dentists, In the second part of this
practice. If unsure about transferring patients keen to learn, and rarely set in their ways. article, fellow consultants and I will provide
yourself, as some trusts seem to be, refer It has been great to get back to basics and the reader with personal insight into the
to the British Orthodontic Society’s general teach them how to diagnose patients from reality of becoming the new consultant
guidance. 5 an orthodontic perspective via new patient orthodontist.
In the event that you really do not clinics or seminars. Some are keen to do
think that the treatment goals originally set orthodontics and should be helped in their
out are achievable, you should discuss this career by completing audits or case reports References
with the patient honestly and openly. Get for you and your department. This will help 1. Patel A. Beginner’s guide to becoming a successful
advice from colleagues if you are not sure them to progress and you to fulfil your job consultant− a personal experience of the first year.
and consult your protection society if you plan on an annual basis. Ortho Update 2015; 8: 126−130.
have any concerns about any cases. If you 2. Triggle N. NHS operations: waiting times to rise in
think that the case is lost and it is not safe to Research ‘trade off’, boss says. 31 March 2017. http://www.
continue, consider cessation of treatment as I do believe that, as consultants, we should bbc.co.uk/news/health-39420662 (Accessed
soon as possible. You can’t be accountable be close to the cutting edge of new August 2017).
for previous decisions made, but you could techniques and thinking. Staying research 3. Department of Health. https://www.gov.uk/
be called to account continuing treatment active during your career will achieve this topic/medicines-medical-devices-blood/
where further harm can arise. Be tactful and replenish your enthusiasm when the medical-devices-regulation-safety (Accessed
during these communications and do not monotony of work or a stressful event puts August 2017).
point fingers or lay blame. Only report factual you at a low ebb. Rarely can you produce 4. British Orthodontic Society advice sheet 13.
information and steer away from opinion and high quality research single-handedly. Realize https://www.bos.org.uk/Portals/0/Public/docs/
supposition. It will be for others to investigate your limitations and find others who have Advice%20Sheets/13orthodontictransfercases.
if systemic failure is suspected. Your role in different skill sets from you and with whom pdf (Accessed August 2017).
this event is to escalate to higher powers you can work. Aim to have at least one 5. Hospital decontamination HTM 01-01. https://
where necessary and let them take on the project active at all times and another one in www.gov.uk/government/uploads/system/
decision-making. 6 the pipeline to follow through with when the uploads/attachment_data/file/536144/
current one is completed. HTM0101PartA.pdf (Accessed August 2017).
Training 6. NHS England guidance. https://www.england.
Most orthodontic departments are affiliated This wasn’t in the curriculum? nhs.uk/ourwork/whistleblowing/ (Accessed
with a maxillofacial unit which creates a The biggest challenges I have faced thus August 2017).
Enhanced CPD DO C
Sophy Barber Ahmed Al-Khayatt and Nadine Houghton
Tooth Autotransplantation
Part 4: Alternative
Treatment Options
Abstract: Tooth autotransplantation is a versatile and successful technique if used in suitable cases; however, it is not always the optimal
treatment choice. This article will explore alternative treatment strategies for managing failing or missing teeth, including methods for
managing the bone, orthodontic options and techniques for tooth replacement. These methods may be considered as an adjunct to tooth
transplantation, or an alternative, if transplantation is not deemed appropriate. Indications for alternative treatments are discussed with
illustrations from treated cases.
CPD/Clinical Relevance: A number of approaches are available for managing failing or missing teeth and are dependent on the clinical
situation. It is important for dental specialists to understand these options and to work collaboratively to determine the best option for
patients on an individual basis.
Ortho Update 2020; 13: 78–86
The advantages of tooth for tooth replacement,2 and the associated the anterior maxilla region. Decoronation
autotransplantation and the broad gingival recession can cause additional involves a coronectomy to remove the
applications for which the technique problems for prosthodontic rehabilitation crown of the ankylosed tooth. This needs
can be used have been outlined in the in the aesthetic zone.3 One of the greatest to be extended below the level of the
previous reports in this series. While tooth advantages of tooth autotransplantation is cemento-enamel junction and 1 mm
autotransplantation is a highly versatile the ability of the donor tooth to preserve under the crestal bone margin. Previous
and successful technique, it is not suitable the height and volume of the alveolar endodontic materials are removed through
for all cases with failing or missing teeth, bone in the recipient site.4 However, in instrumentation of the pulp canal and
and other management strategies may cases where tooth transplantation is not a saline is used for thorough irrigation.
be preferable (Table 1). These alternative suitable treatment option, other methods The aim is to induce bleeding and clot
treatment options are described with of bone management may be considered. formation in the canal, providing cells
an explanation of the purpose of the These methods include decoronation, for replacement resorption.5 The root of
treatment and indications for use, with dento-osseous osteotomy and alveolar the ankylosed tooth is left in the bone
illustrations from clinical cases. ridge preservation techniques. with primary closure of the mucosa to
encourage soft tissue healing and bone
Preservation of alveolar bone Decoronation apposition.6 Replacement resorption
Decoronation is a popular method for of the root is expected to continue but
Reduction in alveolar bone volume
preventing bone defects associated with with simultaneous bone deposition,
has been recognized as an undesirable
infraocclusion that occurs secondary to resulting in minimal loss of alveolar bone.
sequelae to tooth loss for more than
ankylosis in growing patients. It is most Reorganization of the transeptal fibres
four decades.1 A lack of alveolar bone is
commonly used for growing children who encourages bone growth in line with
problematic as it limits the options available
have undergone severe dental trauma in vertical alveolar development of adjacent
Sophy Barber, BDS, MJDF(RCS Eng), MSc, MOrth(RCS Ed), Post-CCST Registrar in Orthodontics, Leeds Dental Institute, Ahmed Al-Khayatt,
BChD, MFDS(RCS Ed), FDS(Rest Dent) RCPS(Glasgow), FDS RCS(Rest Dent), Consultant in Restorative Dentistry and Oral/Facial Rehabilitation
and Nadine Houghton, BDS, MFDS, MDSci, MOrth(RCS Eng), FDS Orth(RCS Eng), Consultant Orthodontist, Bradford Teaching Hospitals
Foundation Trust, UK.
Purpose of Treatment modality Indication for use

treatment
Preservation of Decoronation Management of an ankylosed tooth in a growing patient to prevent bony deficits
alveolar bone developing.
Used to preserve alveolar bone during dental development prior to definitive tooth
replacement with tooth transplantation or prosthetic tooth.
Dento-alveolar Repositioning of an ankylosed tooth in a non-growing patient, usually undertaken as part

osteotomy of a comprehensive orthodontic treatment. Ankylosed tooth may eventually be lost and
require replacement.
Alveolar ridge Techniques used to preserve bone, usually for future placement of a dental implant.
preservation Methods include hard and soft tissue grafting with concomitant use of barrier
techniques membranes, usually as an adjunct to atraumatic tooth extraction.
Orthodontic tooth Movement of tooth through edentulous site to encourage bone deposition to aid tooth
movement in replacement with tooth transplantation or prosthetic tooth.
edentulous site
Space elimination Orthodontic Movement of adjacent teeth into edentulous site to eliminate the need for tooth
space closure with replacement. The substitute tooth and adjacent teeth can be camouflaged using
camouflage restorative techniques to improve aesthetics.
Orthodontic space Movement of adjacent teeth to change site requiring tooth replacement.
redistribution
Tooth replacement Removable prostheses Interim treatment for temporary tooth replacement.
Definitive treatment in cases where other treatment methods contra-indicated.
Tooth-supported Temporary or permanent method of tooth replacement in growing or non-growing

prostheses patients.
Implant-supported Permanent method of tooth replacement in non-growing patients in sites with adequate
prostheses space and bony volume.
Table 1. Treatment methods that may be used as an adjunct or alternative to tooth autotransplantation
teeth. Placing an interim removable or ankylosed, infraoccluded teeth involves within four to six weeks and orthodontic
fixed tooth replacement into the coronal repositioning a tooth or blocks of teeth post-surgical mobilization of the segment
space following mucosal healing helps within the surrounding bone using a should therefore be completed within two
to maintain the space in the arch and dento-osseous osteotomy. This technique to four weeks.10 Figure 2 illustrates the use
restore aesthetics. Observational studies is most commonly used for a single tooth of single-tooth osteotomy to reposition an
demonstrate that decoronation successfully and subsequently is referred to as a single ankylosed incisor in a non-growing patient
maintains the alveolar bone and can tooth osteotomy. The tooth is separated following dental trauma.
even lead to a small gain in ridge height, within a segment of bone, usually using Dento-osseous osteotomies are
although success depends on timing the a piezoelectric instrument to minimize not without risks and the main concerns
procedure correctly.7 Decoronation is damage to adjacent tooth roots. The are loss of tooth vitality, avascular necrosis
used as an interim treatment to maintain fragment can then be repositioned in in the bone segment, gingival recession,
bone in growing patients whilst awaiting one of two ways. In cases where the loss of crestal bone and pocket formation,
the necessary dental development for movement is small, the segment can and a delay in movement of the segment
definitive treatment. Figure 1 illustrates be placed immediately into the correct due to bone interferences.10 Single
the decoronation procedure, which position and secured using fixed ligation.8 tooth osteotomies are only suitable for
was undertaken to manage progressive Alternatively, in cases where this is not patients where minimal further growth is
ankylosis of an incisor following trauma in feasible due to the extent of movement expected, as the underlying ankylosis is not
a young patient. The bone was maintained required, an orthodontic appliance can be addressed, so the tooth will remain static
in the site until the patient was ready for used to move the segment into the correct following the cessation of orthodontic
tooth autotransplantation. position gradually using a distraction treatment. In addition, the process of
osteogenesis type technique with the replacement resorption will progress
Dento-osseous osteotomy ankylosed tooth as the point of force more rapidly in growing patients, leading
An alternative method for managing application.9 Bone healing is completed to earlier loss of the ankylosed tooth and
a e implant-supported tooth replacement,

but it is less likely to have a role in
tooth transplantation as the donor
tooth is usually transplanted at the
same time as the failing tooth is
extracted, eliminating the risk of
alveolar resorption. A Cochrane review
of eight RCTs evaluating alveolar ridge
preservation techniques in adults
found limited evidence to demonstrate
b their effectiveness in minimizing ridge
changes,2 and no evidence could be
f found for growing patients.
Orthodontic tooth movement to develop

bone
The alveolus is functional bone and
therefore bone only develops and
persists in the presence of teeth.
Underdevelopment causing atrophic
alveolar ridges or local bony deficits
c is most often reported in people
with hypodontia11 and management
through orthodontic movement of
adjacent teeth through agenesis sites
has been advocated as a method to
increase bone volume prior to tooth
replacement.12 This technique can
theoretically be applied to any site
with inadequate bone. However,
the results from this are variable
d and bone resorption can occur if
bone-maintaining methods of tooth
replacement are not considered prior
to orthodontic movement.13-15
Orthodontic management
Orthodontic space closure
All methods of tooth replacement,
including tooth transplantation,
carry a risk of failure that obligates
Figure 1. Decoronation procedure for an ankylosed maxillary right central incisor with infraocclusion patients to future dental treatment.
in a growing patient. (a) A buccal flap is raised to enable visualization of the tooth and supporting For some people with existing or
bone. (b) Coronectomy extending 1 mm under the crestal bone. (c) Pulp extirpation from the root potential tooth loss, this commitment
canal in the remaining root and induction of intracanal bleeding. (d) Primary closure of the mucosal to long-term dental treatment may
flap. (e) Post-operative healing. (f) The remaining root left in situ to maintain bone and maximize future be insurmountable and, instead,
options for tooth replacement.
they may wish to consider treatment
planning options that obviate the
need for tooth replacement. Most
commonly this involves orthodontic
therefore less treatment benefit. Single also called socket preservation or alveolar space closure, where fixed appliances
tooth osteotomy technique provides a ridge grafting. This is an umbrella term are used to move the adjacent teeth
method for moving an ankylosed tooth for techniques that aim to maintain either to eliminate the need for
within an orthodontic treatment plan. It favourable alveolar ridge architecture tooth replacement completely or
allows other aspects of malocclusion to be for future tooth replacement. Alveolar to relocate the edentulous space
resolved but it is not a definitive treatment. ridge preservation techniques involve into a site that is more amenable to
The eventual loss of the ankylosed tooth placement of a graft material alone, tooth replacement. The suitability of
should be considered and the long-term or in combination with a barrier orthodontic space closure depends
plan is likely to involve tooth replacement. membrane, at the time of tooth on the site of the missing tooth, the
extraction, theoretically to encourage morphology of adjacent teeth and
Alveolar ridge preservation osteoconduction and osteoinduction. other aspects of malocclusion (Table
Another suggested approach to bone Alveolar ridge preservation has been 2). Elimination of maxillary lateral
management is alveolar ridge preservation, widely reported in conjunction with incisor, mandibular incisor and second
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a d 1. Removable mucosal or tooth-borne

prostheses;
2. Tooth-supported fixed prostheses; and
3. Implant-supported fixed prostheses.
1. Removable prostheses
Removable prostheses are usually
b considered in the interim, rather than as
a definitive method of tooth replacement
in young people where only one or
two teeth are missing. The prostheses
e rely on the soft tissues or the dentition
for support and retention. However, in
certain cases, removable prostheses may
be the definitive treatment option if
other methods of tooth replacement are
contra-indicated; for example, in those
with complicated risk factors or medical
health issues, long edentulous spans
and poorly strategic adjacent teeth. The
prosthesis of choice is most commonly an
c f acrylic denture, although cobalt chrome
dentures and orthodontic retainer
type designs may also be considered.
Removable prostheses have a number
of advantages: replacement of hard and
soft tissue defects,11 appliance removal to
facilitate effective oral hygiene, relatively
cheap and easy to manufacture, capacity
for adjustments and incorporation
Figure 2. A single tooth dento-osseous osteotomy of a maxillary right lateral incisor. (a) Infraocclusion of additional features. Removable
of the tooth secondary to ankylosis following trauma. (b) Periapical radiograph illustrating the prostheses can take some time to adjust
ankylosed position of the maxillary lateral incisor and associated vertical defect in the alveolar bone. to and compliance in young children is
The canal obliteration of this tooth and endodontic treatment of the adjacent canine are further variable.
evidence of the trauma history. (c) The lateral incisor position at the time of surgery following fixed
appliance treatment to align the maxillary arch. (d) Separation of the bone segment containing the 2. Tooth-supported fixed prostheses
lateral incisor. (e) Repositioning of the segment using an orthodontic bracket on the tooth and the The two main types of tooth-supported
archwire. (f) The tooth is secured to the archwire and the mucosa is sutured closed around the tooth. fixed prostheses commonly considered
for replacing one or two missing tooth
units are resin-bonded bridges and
conventional bridges.17 Resin-bonded
premolar agenesis sites are the most provide a good occlusal, restorative,
bridges (RBB) with either a single wing
common application for orthodontic aesthetic and functional result. For
cantilever design or a double wing fixed-
space closure. Camouflage of maxillary example, in a case where canines and
fixed design are the most popular type of
lateral incisors in the central incisor second premolars are missing, the first tooth-supported fixed prostheses. Single
position is challenging due to the premolar can potentially be mesialized wing cantilever designs are preferred
discrepancy in crown and root widths into the canine position. Restoration by many restorative dentists as there is
and the subsequent difficulties in of the canine region is highly concern that bond failure of one wing
achieving a satisfactory functional and unpredictable with limited availability in a fixed-fixed design may result in
aesthetic restoration. Modifications of successful options, compared to undetected caries under the debonded
in tooth positioning aid restoration the premolar sites, which have lower wing. In the RBB design, a ceramic pontic
and reduce the occlusal forces on the aesthetic and occlusal demands and is attached to adjacent teeth via a non-
substitute tooth.16 Figure 3 shows a more treatment options from adjacent precious wing or wings, using enamel
patient who lost both central incisors strategic teeth. bonding adhesives. The main advantage
through dental trauma. The treatment of RBBs is that no or minimal preparation
plan involved orthodontic space closure Methods of tooth is required to facilitate placement.
with the lateral incisors camouflaged replacement Estimated 10-year survival rates are 80.4%
as central incisors and the canines Tooth transplantation is one method (95% confidence interval 77.6–83.2%).18
replacing the lateral incisors. of tooth replacement, but in cases Clinical variables influencing survival
where a donor tooth is not available, revealed that design of the restoration,
Orthodontic space redistribution other methods of tooth replacement consideration of the occlusion,
Space redistribution can be used to may be considered. For replacement cementation technique and experience
move sound teeth with good root of one or two teeth, these treatment of the operator were significant factors.
length and morphology into sites which options fall into three categories: Minimal tooth preparation was shown to
Considerations Patient wishes Presenting complaint

for all treatment Desired outcome
methods Commitment to long-term maintenance
Ability to accept treatment
Dental health Current health of teeth

Periodontal condition
Oral hygiene
History of dental disease
Relevant medical history Any medical factor that may impact on ability to accept treatment
Patient’s age and maturity Growing or non-growing
Understanding of treatment options
Occlusion Crowding or spacing
Other missing teeth
Inter-arch relationship
Considerations Size of edentulous space Suitability for restoration

specifically for tooth Scope for optimizing space
replacement
Health and position of Suitability to act as abutments
adjacent teeth
Recipient site factors Space in arch
Alveolar bone volume and quality
Position of adjacent tooth roots
Gingival architecture Impact on potential restoration

Functional occlusion Potential interferences
Occlusal loading
Considerations Amount of space closure Impact of closing space on occlusion
specifically for space required Feasibility of space closure
closure Need for anchorage support
Morphology of substitute Crown size and shape

tooth Emergence profile
Morphology of adjacent Ability to achieve harmony and symmetry with or without camouflage techniques
teeth
Gingival architecture Impact on potential restoration
Table 2. Factors to consider during treatment planning for missing or failing teeth.
be superior for longevity compared a result of shine-through from would not be deemed to be destructive
with other types of preparation. the metal wing.17 Figures 4 and and a full coverage restoration would
Patient satisfaction has been shown 5 show patients who underwent be beneficial.
to be high for this type of treatment. tooth replacement with a RBB, as
This makes treatment simple and autotransplantation was contra- 3. Implant-supported tooth replacement
predictable to deliver, with or without indicated due to the lack of a suitable Implant-supported tooth replacement
anaesthetic, and with no biological donor tooth. has gained widespread popularity over
cost to the patient. For young Conventional bridges are the last 40 years. The survival rate of
patients, RBBs can be attached with less commonly used due to the need implants in adults has been shown to
provisional cement, allowing removal for extensive tooth preparation of the be as high as 96.5% over 10 years,19
at a later date, if necessary, making abutment teeth to provide sufficient although success is more difficult to
them a suitable temporary measure coronal reduction for placement of a estimate due to wide variation in the
for tooth replacement. The pontic is full-coverage abutment. Conventional criteria used to evaluate success20
able to deliver excellent aesthetics, bridges are indicated for patients and heterogeneity in treatment
and improvements in opaque luting who have existing coronal coverage protocols. Patient-reported outcomes
cements have reduced the problems restorations in suitable abutment from implants, such as satisfaction
caused by grey discoloration as teeth, where further preparation with appearance and function, have
a b c
Figure 3. Orthodontic space closure with substitution of the maxillary lateral incisors into the position of the avulsed central incisors. (a) The patient
presented for orthodontic assessment prior to suffering the dental trauma, in which both central incisors were avulsed. Initially the treatment plan involved
extraction of maxillary premolars to create space for alignment. (b) Following avulsion of the central incisors, the plan was modified. It was agreed that
the lateral incisors would be used to replace the central incisors, accepting the canines as substitxsutes for the lateral incisors and premolars in the canine
position. (c) Removal of the fixed appliance and chairside restoration of the lateral incisors by the treating orthodontist. This was an interim measure to allow
the gingival inflammation to resolve prior to gingival recontouring and definitive restorative treatment to camouflage the anterior four teeth.
b Figure 6. A single screw-retained implant crown

replacing the left maxillary central incisor in
an adult patient. This tooth was lost following
trauma and the resulting buccal bone concavity
required simultaneous bone augmentation at
the time of implant placement.
the recipient site need to be assessed

Figure 4. (a, b) Placement of a resin-bonded to determine the feasibility of implant
bridge for a patient with a poor prognosis right Figure 5. (a, b) Placement of a resin-bonded treatment. Implants require adequate
maxillary central incisor following dental trauma. bridge by the patient’s general dentist to bone volume for placement to allow for
The crown of the failing tooth was used to create replace the maxillary left central incisor in a a functional and aesthetic result. Ideally,
the pontic by connecting the extracted crown to patient who did not want to undergo tooth a distance of 1.5–2.0 mm of interseptal
the adjacent tooth via butterfly metal wings. This autotransplantation.
provides an ideal match in terms of morphology
bone is required between the implant
and shade. and adjacent roots to encourage papilla
regeneration.24 Augmentation procedures
surrounding teeth. As such, implants may be possible to manage horizontal
been demonstrated to be high in well are not advocated for use in growing and some vertical and bucco-lingual
planned cases with good bone quantity patients.22 Evidence of infraocclusion deficits; however, inadequate mesio-
and favourable clinical factors.21 Implant of up to 1.6 mm over 3 years has distal space between the adjacent tooth
success is dependent on osseointegration been demonstrated in anterior crown and roots may prevent their use.
to gain stability and this fusion to the implants placed in adolescents.23 In Sufficient coronal space is required
bone prevents the implant-supported those where growth is complete, to allow a restoration that mimics the
structure adapting and erupting with the additional factors associated with natural contours and is in harmony
with the surrounding teeth.25 The Br J Orthod 1998; 25: 275−282. 16. McDowall RJ, Yar R, Waring DT. 2 ‘2’ 1:
distance between the contact point 5. Malmgren B. Decoronation: how, Orthodontic repositioning of lateral
and alveolar crest has been shown why, and when? J Calif Dent Assoc incisors into central incisors. Br Dent J
to be highly important to papilla 2000; 28: 846−854. 2012; 212: 417−423.
presence.26 Lack of mesio-distal space 6. Sapir S, Shapira J. Decoronation for 17. Hemmings K, Harrington Z. Replacement
and bone quality are the most common the management of an ankylosed of missing teeth with fixed prostheses.
contra-indications to implant use in young permanent tooth. Dent Dent Update 2004; 31: 137−141.
maxillary lateral incisor and mandibular Traumatol 2008; 24: 131−135. 18. King PA, Foster LV, Yates RJ, Newcombe
incisor sites. Figure 6 shows implant- 7. Mohadeb JV, Somar M, He H. RG, Garrett MJ. Survival characteristics of
supported tooth replacement in an adult Effectiveness of decoronation 771 resin-retained bridges provided at
who did not wish to undergo tooth technique in the treatment of a UK dental teaching hospital. Br Dent J
autotransplantation. ankylosis: a systematic review. Dent 2015; 218: 423−428; discussion 428.
Traumatol 2016; 32: 255−263. 19. Karoussis IK, et al. Long-term implant
Conclusions 8. Chae JM, Paeng JY. Orthodontic prognosis in patients with and without a
Tooth transplantation is a highly treatment of an ankylosed history of chronic periodontitis: a 10-year
successful and biological method of maxillary central incisor through prospective cohort study of the ITI Dental
tooth replacement. The outcome may single-tooth osteotomy by using Implant System. Clin Oral Implants Res.
be improved by the use of adjunctive interdental space regained from 2003; 14: 329−339.
treatments, such as decoronation and microimplant anchorage. Am J 20. Papaspyridakos P, Chen CJ, Singh M,
temporary tooth replacement, to allow Orthod Dentofacial Orthop 2012; Weber HP, Gallucci GO. Success criteria in
transplantation to be delayed until the 141: e39−e51. implant dentistry: a systematic review.
optimum time. This paper highlights the 9. Kofod T, Wurtz V, Melsen B. J Dent Res 2012; 91: 242−248.
importance of understanding alternative Treatment of an ankylosed central 21. Derks J, Hakansson J, Wennstrom JL,
treatment options of tooth replacement incisor by single tooth dento- Klinge B, Berglundh T. Patient-reported
and the advantages and disadvantages osseous osteotomy and a simple outcomes of dental implant therapy in a
of each. distraction device. Am J Orthod large randomly selected sample. Clin Oral
Dentofacial Orthop 2005; 127: Implants Res 2015; 26: 586−591.
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The orthodontic and restorative 10. Uzuner FD, Darendeliler N. osseointegrated implants in orthodontic
treatment was undertaken by numerous patients: I. Implants and their use in
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Dental Institute and Bradford Teaching 23. Thilander B, Odman J, Lekholm U.
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11. Morgan C, Howe L. The restorative
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12. Managing congenitally missing
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3. D
Evidence-based knowledge on the
biology and treatment of extraction 15. Beyer A, Tausche E, Boening K, 4. B
sockets. Clin Oral Implants Res 2012; Harzer W. Orthodontic space
23(Suppl 5): 80−82. opening in patients with
5. D
4. Thomas S, Turner SR, Sandy JR. congenitally missing lateral 6. C
Autotransplantation of teeth: is there incisors. Angle Orthod. 2007; 77:
a role? 404−409.
7. A
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Adele Bronkhorst Vijay Santhanam and Huw G Jeremiah
A Novel Way to Identify

Individual Eruption Chains
Abstract: A common way of treating impacted teeth is by orthodontic extrusion. When the teeth are deeply buried in the alveolar bone
a closed eruption technique is often indicated. When multiple teeth are impacted and need to be extruded in a particular sequence, it
may be difficult to be sure which eruption chain is attached to a particular tooth. This case report demonstrates a novel way of identifying
individual eruption chains.
CPD/Clinical Relevance: This case report demonstrates a novel way of identifying individual eruption chains attached to multiple impacted
teeth.
Ortho Update 2020; 13: 88–90
Dental impaction can be defined as a tooth that is to transfer the extrusive force onto the teeth via the
prevented from erupting into position because of
History, diagnosis and initial
treatment plan eruption chains.
a malposition, lack of space or other impediments.1 Prior to surgery, the gold chains were
A healthy, non-syndromic 9-year-old female patient was
Although it has been reported to affect as many as colour coded by attaching two similarly coloured
referred regarding ‘delayed eruption of the maxillary
25% to 50% of the population, multiple impactions are elastic modules (3M Unitek) to each gold chain with
incisors and the presence of a maxillary midline
less commonly seen.2 0.010” SS ligature wire (Figure 3). Once visualized
supernumerary tooth’. A DPT radiograph confirmed the
According to a review by Bishara, the following adequate bone removal, a predetermined
presence of a mesiodens and delayed root maturation of
causes of tooth impaction can be divided into colour coded gold chain was attached to each
the maxillary incisors (Figure 1). As per the Royal College
generalized and localized factors.3 The more common exposed tooth. Prior to flap closure, bond strength was
of Surgeons Guidelines for Management of Unerupted
localized and generalized factors are summarized in tested. The gold chains were passed transmucosally
Maxillary Incisors (2010), treatment was provided to
Table 1. remove the primary central incisors and the mesiodens and the flaps were sutured into position. The chains
The impaction of multiple permanent and then monitor permanent incisor eruption. were ligated with 3/0 prolene sutures to the gingival
teeth occurs less frequently than that of single teeth. tissues. No eruptive force was placed on the day of
Multiple impactions add significant complexity to exposure (Figure 4). Three weeks later a modified
treatment, often resulting in lengthened overall
Treatment progress and Nance transpalatal arch was placed (Figures 5a and b)
treatment time.
treatment plan review and extrusive force applied.
Factors reported to increase treatment Eruption was monitored following the extractions.
The patient was again clinically reviewed by both the
complexity and time include:
orthodontist and the surgeon at age 11 years. Her Discussion
Age at the start of treatment; Patients with multiple impactions need co-ordinated,
overall dental development was still delayed. The UL1
Degree of root formation; multidisciplinary management to guide eruption of as
had partially erupted into the dental arch. However, the
Position and distance of the tooth from the occlusal many teeth as possible. It is important to set realistic
UR4, UR3, UR2, UR1, UL2, UL3 were still unerupted and in
plane; treatment goals and teeth that cannot successfully be
unfavourable positions (Figure 2).
Degree of dilacerations. brought into the arch may require extraction followed
Due to the position of the unerupted
During treatment there is a further risk by either space closure or prosthetic replacement.
permanent incisors and canines and lack of
of failure due to ankylosis, external root resorption, The timing of orthodontic treatment,
improvement, it seemed unclear if these teeth were
and/or root exposure during or after orthodontic tooth type of surgery to uncover the impacted tooth,
likely to improve spontaneously. The patient’s family
movement. were keen to try to align the teeth without extraction of orthodontic mechanics necessary and potential
When faced with multiple impacted adult teeth. problems vary according to which tooth/teeth are
teeth in ectopic positions, it may not be easy to After careful consideration, active impacted.
identify which eruption chain is attached to a intervention was proposed including extraction of URC, The aim of surgical uncovering is:
particular tooth. When a complex case presented with URB, ULB and ULC. The closed eruption technique with To eliminate any hard or soft tissue pathology/
multiple impacted teeth, the team came up with a gold chain bonded on the UR4, UR3, UR2, UR1, UL1, UL2, obstructive entities;
novel way to identify the chains and which teeth they UL3 was planned to aid orthodontic extrusion of these To provide the orthodontist with access to the
were connected to. teeth. A modified Nance transpalatal arch was proposed impacted tooth usually by creating a suitable area to
Adele Bronkhorst, BChD, MDent(Ortho), FDS(Ortho) RCS, PGCME, Post-CCST Registrar in Orthodontics, Vijay Santhanam, BDS, MBChB,
MRCS, FDS RCS, FRCS(OMFS), PGCME, Consultant Oral and Maxillofacial Surgeon and Huw G Jeremiah, BDS, BSc, MFDS(RCS), MSc,
MOrth(RCS), FDS(Orth) RCS, GCAP AHEA, Consultant Orthodontist, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2
2QQ, UK.
Local Factors Generalized Factors

Crowding Past irradiation of the area
The presence of supernumerary teeth A history of febrile diseases
Prolonged retention or early loss of primary Certain syndromes, eg cleidocranial dysplasia,
teeth Gardner and Down syndromes
Abnormal position of the tooth bud Metabolic disorders: Figure 4. Chains sutured onto the gingival
Endocrinal disorder, eg hypopituitarism, tissues following exposure.
The presence of an alveolar cleft
hypothyroidism
Ankylosis, cystic or neoplastic formation
Mucosal disorders, eg gingival fibromatosis
a
Trauma – dental Bone disorders, eg cherubism, osteopetrosis
Trauma – alveolar
Dilaceration of the root
Table 1. General and local factors which could cause tooth impaction.
Figure 5. (a) Modified Nance transpalatal bar. (b)

Intra-oral view of Nance transpalatal bar in situ
Figure 1. DPT radiograph exposed (aged 9 years) demonstrating delayed dental age, presence of with chains attached.
midline supernumerary tooth and unerupted maxillary central incisors.
to identify different eruption chains, allowing the

orthodontist to apply force vectors confidently, as
required in complicated cases with multiple impacted
teeth. This technique can be easily adapted into
clinical practice to deliver targeted, predictable
traction to unerupted teeth.
Compliance with Ethical Standards

Conflict of Interest: The authors declare that they have
Figure 2. DPT radiograph exposed (aged 11 years) following extraction of the supernumerary tooth
no conflict of interest.
demonstrating delayed dental age, presence of unerupted maxillary incisors.
Informed Consent: Informed consent was obtained
from all individual participants included in the article.
teeth needed to be extruded in a particular sequence,

References
with particular force vectors. Therefore it was vital to 1. Mead SV. Oral Surgery 4th edn. St Louis: CM Mosby Co,
1954: pp507–510.
be able to identify which chain is attached to a specific
2. Andreasen JO, Pindborg JJ, Hjorting-Hansen E, Axell
tooth to enable predictable eruptive mechanics.
T. Oral health care: more than caries and periodontal
The crowns of UL2 and UL3 were
disease. A survey of epidemiological studies on oral
positioned in a similar AP plane and the chains
Figure 3. Colour coding of chains according to disease. Int Dent J 1986; 36: 207–214.
entered the oral cavity in virtually the same position.
tooth number. 3. Bishara SE. Impacted maxillary canines: a review. Am J
This could have led to confusion as to which chain to
Orthod Dentofacial Orthop 1992; 101: 159–171.
apply traction. By identifying the dark blue marked
4. Becker A, Zogakis I, Luchian I, Chaushu S. Surgical
chain, it was possible to apply extrusive force to the exposure of impacted canines: open or closed surgery?
UL2 with confidence. When attaching the light blue Semin Orthod 2016; 22: 27–33.
bond an attachment to; chain of the UL3 to the modified Nance appliance, it
Minimal tissue damage to adjacent structures was easy to identify that this is the chain that required
and the cemento-enamel junction and root of the a distal component of force. As the teeth erupt, the
Further reading
impacted tooth/teeth to be exposed.4 force vectors and eruption sequence may need to 1. Kokich VG, Mathews DA. Orthodontics and Dentofacial
The wide mucosal flap employed in the Orthopedics. Ann Arbor: Needham Press, 2001:
be adapted and it will remain a predictable task to
closed eruption technique allows for better vision and pp395–422.
identify which chain is attached to which impacted
haemostasis (thus implied improved bonding) and 2. Yaqood O, O’Neill J, Gregg T et al. Management of
tooth.
increases the range of impacted teeth that can be unerupted maxillary incisors. Royal College of Surgeons,
salvaged. Faculty of Dentistry. 2010. https://www.rcseng.ac.uk/
This case presented with impacted teeth Conclusion dental-faculties/fds/publications-guidelines/clinical-
and crowns in close proximity to one another. These The technique devised is a novel, cost-effective way guidelines (Updated 2016)
Tricks of the Trade: Tissue

Control for Bonding to
Impacted Canines
Open exposure for palatally impacted A method which greatly irrigated with water and air dried before
canines is an effective and well increases bonding success in situations application of the usual etchant, bonding
documented technique, with the tooth where blood and gingival fluid are agents and placement of an attachment
erupting into the palate relatively quickly, present is the placement of retraction (Figure 3).
and usually without complication.1 On cord soaked in styptic around the margin This method is demonstrated
occasion, it may be necessary to bond an of the tooth. This provides simultaneous in a 13-year-old female who underwent
attachment soon after surgery, either to haemostasis and retraction of the soft open exposure of both maxillary canines
prevent the mucosa re-covering the tooth tissues, increasing the surface area and inflammation of the surrounding
or to commence alignment. Typically, the available for bonding and reducing mucosa. If cord is not available, retraction
ideal position for bonding the attachment contamination. paste dispensed from a campule may be
is close to the gingival margin due to partial The tooth to be bonded used.
eruption and rotation of the canine. should be cleaned and dried as much as
Difficulty in maintaining good possible and wide-diameter retraction References
oral hygiene in the immediate post- cord, soaked in 15.5% ferric sulfate 1. Kokich VG. Preorthodontic uncovering
surgical period means that the mucosa and solution, gently packed into the sulcus and autonomous eruption of palatally
gingivae are often inflamed and prone to (Figure 2). The retraction cord should be impacted maxillary canines.
bleeding (Figure 1). removed after 60 seconds and the tooth Sem Orthod 2010; 16: 205–211.
Figure 2. Wide-diameter retraction cord, soaked

Figure 1. Mucosa and gingivae are inflamed and in 15.5% ferric sulfate solution, gently packed into Figure 3. Application of the usual etchant, bonding
prone to bleeding. the sulcus. agents and placement of an attachment.
Jennifer A Vesey, BSc, BDS(Hons), DDSc, MJDF RCS(Eng), MOrth RCSEd, MRACDS(Orth), ST3 Orthodontics, Liverpool University Dental
Hospital and The Countess of Chester Hospital, Liverpool Road, Chester CH2 1UL, UK.
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94 Orthodontic Update April 2020
CPD
A.continuing education
Test your knowledge on the content of the articles published.

The following 7 questions relate to some of the articles carried this month. Only one answer is correct.
To receive CPD credit, answer the questions online at www.orthodontic-update.co.uk
Q1 GREWAL ET AL 13: 50–56 Q5 HENRIKSON 13: 64–70
In pain pathways the smaller primary unmyelinated fibres are When treating with Invisalign®, what is the most important factor,
called: for the clinician responsible, to produce a high quality treatment
A. A fibres. outcome?:
B. B fibres. A. To increase the movement velocity.
C. C fibres. B. To use every aligner for two weeks.
D. D fibres. C. To take full control when planning and working with the case using the
ClinCheck software.
D. To use attachment at every tooth.
Q2 GREWAL ET AL 13: 50–56
How many hours after appliance placement does orthodontic pain Q6 BARBER ET AL 13: 78–86
peak?:
A. 10 minutes. Decoronation can be used for which of the following?:
B. 1 hour. A. To restore aesthetics.
C. 24 hours. B. To prevent infraocclusion and preserve alveolar bone.
D. 48 hours. C. To avoid the need for endodontic treatment.
D. To reposition an ankylosed tooth.
Q3 PRADO, CALDWELL AND ASHLEY 13: 57–62
The most well recognized technique for orthodontic bonding to

Q7 BARBER ET AL 13: 78–86
porcelain surfaces is: Which of the following is not a direct risk of single tooth osteotomy?:
A. Traditional acid-etch technique with phosphoric acid. A. Loss of tooth vitality.
B. Chemical retention using 4-META coupling agent. B. Gingival recession.
C. Chemical and micro-mechanical retention using hydrofluoric acid and C. Loss of crestal bone.
a saline coupling agent. D. Increased risk of caries.
D. Chemical retention using hydrofluoric acid only.
Q4 PRADO, CALDWELL AND ASHLEY 13: 57–62
When bonding to enamel defects, which of the following

statements is true?:
A. Each case should be assessed on its own merit.
B. Longer etching time may be need.
C. Careful examination of the dentition is essential.
D. All of the above.
DEADLINE FOR SUBMISSION: 12 JULY 2020

CPD in Orthodontic Update in partnership with
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