Australian

Orthodontic Journal
Volume 29 Number 2, November 2013

Contents
Guest Editorial
137 The challenges for Orthodontics
Fraser McDonald

Original articles
139 Evaluation of the cytotoxicity of elastomeric ligatures after sterilisation with 0.25% peracetic acid
Matheus Melo Pithon, Rogério Lacerda dos Santos, Renata Lima Pasini Judice, Paulo Sérgio de Assunção and Luciana Restle
145 The impact of spur therapy in dentoalveolar open bite
Philipp Meyer-Marcotty, Janka Kochel and Angelika Stellzig-Eisenhauer
153 Mesiodistal tooth dimensions and anterior and overall Bolton ratios evaluated by cone beam computed tomography
Mevlut Celikoglu, Metin Nur, Dogan Kilkis, Omer Said Sezgin and Mehmet Bayram
159 The evidence supporting methods of tooth width measurement: Part I. Vernier calipers to stereophotogrammetry
Devan Naidu and Terrence J. Freer
164 The evidence supporting methods of tooth width measurement: Part II. Digital models and intra-oral scanners
Devan Naidu and Terrence J. Freer
170 2013 Survey of Australian Orthodontists' procedures
Peter Miles
176 Effects of four premolar extractions on vermilion height and lip area during a posed smile in patients with bimaxillary
protrusion
Nety Trisnawaty, Hideki Ioi, Toru Kitahara, Akira Suzuki and Ichiro Takahashi

Review
184 Paediatric sleep-disordered breathing due to upper airway obstruction in the orthodontic setting: a review
Vandana Katyal, Declan Kennedy, James Martin, Craig Dreyer and Wayne Sampson

Case reports
193 Bilateral missing lower permanent incisors: a case report
Mohamed I. Masoud
200 Long term stability of intra-oral maxillary distraction in unilateral cleft lip and palate: a case report
Şirin Nevzatoğlu, Nazan Küçükkeleş and Zeki Güzel
209 Management of unilaterally impacted multiple posterior teeth: a case report
Pawanjit Singh Walia, Sushil Kumar, Anu Singla and Varun Grover

Opinion piece
217 The fallacy of serial extractions
K. Paul Lee

Letter
222 Occlusal variation in the Zuni: a pre-contact North American population
Colin Twelftree

General
223 Book reviews 233 In appreciation 236 Calendar
226 Literature reviews 234 New products 237 Index

Australian Orthodontic Journal Volume 29 No. 2 November 2013

Australian
Orthodontic Journal
The Australian Orthodontic Journal is published twice a year
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EDITOR
Associate Professor Craig Dreyer
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EDITORIAL BOARD
Emeritus Professor T. J. Freer (Queensland)
Professor A. Darendeliler (New South Wales)
Professor O. Kharbanda (India)
Professor F. McDonald (United Kingdom)
Professor W. Sampson (South Australia)
Professor K. Takada (Japan)
Associate Professor M. Goonewardene (Western Australia)
Associate Professor C. Ho (Queensland)
Dr T. Collett (Victoria)
Dr J. Fricker (Australian Capital Territory)
Dr D. Fuller (Victoria), Book reviewer/editor
Dr W. Weekes (New South Wales)
Dr A. Weir (Queensland)
Australian Orthodontic Journal Volume 29 No. 2 November 2013
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Guest Editorial
The challenges for Orthodontics
‘On reflection’ is always an over-clichéd phrase, yet,
how appropriate it is. Since its inception, the specialty
of orthodontics has developed enormously and
attracted some of the most charismatic and intelligent
individuals in the dental profession. Yet, after
significant numbers of students have been trained
throughout the world, especially on a formalised
3-year, full-time program,1 the profession is no
closer to understanding the ‘need’ for orthodontics.
The nature and outcome of treatment is known in
the most detailed of ways, especially following the
development of randomised clinical trials, which
corroborate that which is diagnostically suspected.
However, there is very little data to suggest that
orthodontic treatment positively alters susceptibility
to dental disease, yet patients still attend specialist
surgeries and supportive dental practitioners continue
to refer. More importantly, third party schemes exist
to fund this care.
The main reason for public attendance is to obtain
straight teeth and orthodontics temporarily provides
a solution and fulfils a perceived need, but are
practitioners merely reorganisers of structural protein
and the hairdressers of teeth?
In a recent national orthodontic ‘research day’ to
focus and develop future strategies, it was highly
noticeable that the concept of traditional orthodontic
research (cephalograms, study models, materials
etc), was unanimously ignored in favour of the
‘worth’ to patients of orthodontic care. This clearly
is in recognition and a change in what is considered
important.
Despite all luminaries present, no existing study
was mentioned which demonstrated an orthodontic
health gain.
In the meantime, alternative educational providers
attract registrants who attend, are influenced and
1
Currently, whilst Orthodontics is identified as a unique specialty, coordinating four dimensions, there is incomplete acceptance for the recognition and
funding of training as certain countries are still unable to accept a specialist list.
subsequently practise in the haze of commercial lust.
Astute professionals, often by their nature as under-
spoken individuals representing a silent majority,
identify the defective commercial claims as clearly
having little scientific basis and, when investigated,
having little basis in reality.
Advertisements are very persuasive. A complete
industry has developed, including and detailing the
psychological basis related to the manipulation of
thought processes. Parallels are seen with the publicity
campaigns of politicians. How slick and manipulative
are these strategies and it is easy to see how the skills
of promoting candidates in elections can be used to
promote goods and orthodontic services.
Equally, orthodontics is being driven by the perceived
need and the public is demanding quicker and more
‘invisible’ braces. When does a patient’s request
become ridiculous or not in their best interest? Who
is driving the patient’s care, the patient, the clinician
or the internet?
Perhaps consideration should be given to 6-month
wonder treatments often funded by third party
schemes. Do serious orthodontists and dentists believe
that significant changes can occur in the dentition and
investing structures over this time frame? Do they also
believe that the types of change are actually stable and
in the best interests of the patient? How long should
it be before treatment ‘success’ is declared; should it
be at the end of treatment, or possibly at 6 months,
or even at 6 years after appliances have been removed?
The speciality has so many unanswered questions
related to its value as a profession. Do most patients
really appreciate their results and the effort expended
in that achievement?
The answer has to be yes, but the speciality must also
remember its luxury and exulted status. The people
Australian Orthodontic Journal Volume 29 No. 2 November 2013 137
 GUEST EDITORIAL

in Third World countries without clean water, are what the conscientious objectors need to do is be
hardly rushing to orthodontic practices which offer patient and hope that the ‘God’ hypothesis is valid.
the latest, quickest and most efficient appliance
Professor Fraser McDonald
system. The medical, dental and social needs of
these people far surpass the need for straight teeth. Chair in Orthodontics
King's College London
So ‘on reflection’, orthodontics is still in a health
Strand
environment in which those who can move teeth into
London WC2R2LS
healthy, appropriate and relatively stable positions will
United Kingdom
continue to earn a steady living. Those who live by
short term gains will ultimately reap their rewards; Email: fraser.mcdonald@kcl.ac.uk

138 Australian Orthodontic Journal Volume 29 No. 2 November 2013

Evaluation of the cytotoxicity of elastomeric
ligatures after sterilisation with 0.25% peracetic
acid
Matheus Melo Pithon,* Rogerio Lacerda dos Santos,† Renata Lima Pasini Judice,±
Paulo Sergio de Assuncao± and Luciana Restle±
State University of Sudoeste da Bahia, UESB,* Federal University of Campina Grande, UFCG† and Central Navy Dental
Clinic, Rio de Janeiro,± Brazil

Introduction: Sterilisation using peracetic acid (PAA) has been advocated for orthodontic elastic bands. However, cane-loaded
elastomeric ligatures can also become contaminated during processing, packaging, and manipulation before placement in the
oral cavity and are therefore susceptible, and possible causes, of cross-contamination.
Aim: To test the hypothesis that 0.25% peracetic acid (PAA), following the sterilisation of elastomers, influences the cytotoxicity of
elastomeric ligatures on L929 cell lines.
Materials and methods: Four hundred and eighty silver elastomeric ligatures were divided into 4 groups of 120 ligatures to
produce, Group TP (latex natural, bulk pack, TP Orthodontics), Group M1 (Polyurethane, bulk pack, Morelli), Group M2
(Polyurethane, cane-loaded, Morelli) and Group U (Polyurethane, cane-loaded, Uniden). Of the 120 ligatures in each group,
100 were sterilised in 0.25% PAA at time intervals (N = 20) of 1 hour, 2 hours, 3 hours, 4 hours and 5 hours. The 20 remaining
elastomeric ligatures in each group were not sterilised and served as controls. Cytotoxicity was assessed using L929 cell lines
and a dye-uptake method. Analysis of variance (ANOVA), followed by the Tukey post hoc test (p < 0.05) determined statistical
relevance.
Results: There was a significant difference between TP, Morelli and Uniden elastomerics (p < 0.05), but no difference between
the two types of Morelli elastomerics at the 1 hour time interval. In addition, there was a significant difference between Group
CC and the other groups assessed, except between Groups CC and TP at the 1 hour time interval. The non-sterilised elastomeric
ligatures showed similar cell viability to that observed after 1 hour of standard sterilisation.
Conclusion: PAA did not significantly influence the cytotoxicity of elastomeric ligatures after a sterilisation time of 1 hour and is
therefore recommended for clinical use.
(Aust Orthod J 2013; 29: 139-144)

Received for publication: January 2012

Accepted: May 2013

Renata Lima Pasini Judice: renatajudice@gmail.com; Rogério Lacerda dos Santos: lacerdaorto@hotmail.com OR lacerdaorto@bol.com.br
Matheus Melo Pithon: mateuspithon@gmail.com OR matheuspithon@hotmail.com; Paulo Sérgio de Assunção: passuncao@superig.com.br
Luciana Restle: lurestle@ig.com.br

Introduction physical, biological and chemical properties of dental

The rise in blood-borne diseases caused by viruses such
as hepatitis C and HIV has generated an extensive
review of infection control in dentistry.1 There has
been significant advancement and increasing use
of sterilisation and disinfection techniques since
the early 1990s. As a result, problems regarding the
deterioration of instruments and an alteration of the
materials have appeared.1-2 Furthermore, studies have
shown that sterilised orthodontic materials may be
cytotoxic3 and cause harm.4
Cane-loaded elastomeric ligatures are orthodontic
materials which are highly susceptible to cross-
contamination1 during processing, packaging, and
manipulation by the dental assistant or orthodontist

© Australian Society of Orthodontists Inc. 2013 Australian Orthodontic Journal Volume 29 No. 2 November 2013 139
 PITHON ET AL
Table I. Experimental groups used for the cytotoxicity test.
Group Commercial brand
TP TP Orthodontics
M1 Morelli
M2 Morelli
U Uniden
before being placed in the oral cavity. Elastomeric
ligature placement usually occurs without prior
disinfection or sterilisation. With the advent of
tougher biohazard measures, this clinical conduct has
been questioned.5-6
In an assessment of different elastomeric sterilisation
methods, Pithon et al.7 determined that the use of
ethylene oxide, ultraviolet radiation and gamma
rays did not affect elastomeric cytotoxicity but
70% alcohol, 2% glutaraldehyde, autoclaving or
microwaving increased cytotoxicity.
A clinical need has been established for elastomerics to
be inert in the oral environment and capable of being
sterilised whilst maintaining their elastic characteristics
and pigmentation. Sterilisation with peracetic acid
or peroxyacetic acid (PAA) has been suggested for
orthodontic elastics and other dental materials due to
minimal product deterioration and shorter sterilisation
time compared with the use of glutaraldehyde.7 It has
been reported that PAA does not produce toxic or
mutagenic by-products after reaction with materials,8
as the PAA decomposition products are acetic acid,
hydrogen peroxide, oxygen and water.9
The aim of the present study was to test the hypothesis
that PAA does not influence the cytotoxicity of
orthodontic elastomeric ligatures, which therefore
remain safe for clinical use.
Material and methods
Four hundred and eighty silver elastomeric ligatures
from various manufacturers were obtained and divided
into 4 groups of 120 ligatures. Groups were identified as
Group TP (latex natural, bulk pack, TP Orthodontics,
La Porte, IN, USA), Group M1 (Polyurethane, bulk
pack, Morelli, Sorocaba, SP, Brazil), Group M2
(Polyurethane, cane-loaded, Morelli, Sorocaba, SP,
Brazil) and Group U (Polyurethane, cane-loaded,
Uniden, Sorocaba, SP, Brazil) (Table I). The elastic
140 Australian Orthodontic Journal Volume 29 No. 2 November 2013
Presentation Lot Reference number
bulk pack 0429010 361083
bulk pack 1132651 6003417
cane-loaded 1435294 6003317
cane-loaded 071009-E1-4 000-1222
ligatures from TP Orthodontics and Morelli (Group
M1) were converted into a cane-loaded system by
using sterile straight Halsted mosquito forceps to
standardise the groups (Quinelato, Rio Claro, São
Paulo, Brazil).
Of the 120 ligatures in each group, 100 were further
subdivided and sterilised in 100 ml of 0.25% peracetic
acid (Proxitane®, Alfa, Curitiba, PR, Brazil) over five
different time intervals (N = 20) of 1 hour (T1), 2
hours (T2), 3 hours (T3), 4 hours (T4) and 5 hours
(T5). Subsequently, all ligatures were washed for
15 minutes in de-ionized water using the Milli-Q®
purification system (Millipore, Bedford, MA, USA)
to remove excess peracetic acid. The 20 remaining
elastic ligatures in each group remained unsterilised
and served as controls. The cytotoxicity of materials
was determined in accordance with the evaluation and
standardisation norms of ISO 10993-59.
Cell line, L929, was obtained from the American
Type Culture Collection (ATCC, Rockville, MD,
USA) (rat fibroblasts). The cells were cultivated in
Eagle’s minimal essential medium (MEM) (Cultilab,
Campinas, São Paulo, Brazil) and supplemented
with 2 mM of L-glutamine (Sigma, St. Louis, MO,
USA), 50 mg/ml of gentamycin (Schering Plough,
Kenilworth, NJ, USA), 2.5 mg/ml of fungizone
(Bristol-Myers-Squibb, NY, USA), 0.25 ml of sodium
bicarbonate solution (Merck, Darmstadt, Germany),
10 mM of HEPES (Sigma, St. Louis, MO, USA) and
10% of fetal calf serum (FCS) (Cultilab, Campinas,
São Paulo, Brazil), and kept at 37ºC in a 5% CO2
environment.
Three additional cell groups were assessed in order
to characterise and differentiate the cellular response.
These comprised Group CC (cell control) in which
the cells were not exposed to any material, Group C+
(positive control) in Tween 80® (polyoxyethylene-20-
sorbitan) and C- (negative control) in PBS (phosphate-
buffered saline) solution.

Figure 1. Percentage difference of the cell viability decrease of elastics in different time intervals (T1-T5).
Following sterilisation of the elastomeric ligatures,
samples of ligatures were placed in 24-well plates
containing a culture medium (MEM) (Cultilab,
Campinas, São Paulo, Brazil). The culture medium
was replaced every 24 hours, the supernatants
collected and the effect on the L929 cells was assessed.
The supernatants were placed, in triplicate, in a 96-
well plate containing a confluent monolayer of L929
cells and incubated for 24 hours at 37o C in a 5% CO2
environment.
After the incubation period, cell viability was
determined by a dye uptake technique10 which
involved the addition of 100 ml of 0.01% neutral red
(Sigma, St. Louis, MO, USA) to the culture medium
in each microplate well. A further 3 hour incubation
at 37o C allowed the dye to penetrate into the live cells
following which 100 ml of 4% formaldehyde solution
(Reagen, Rio de Janeiro, Brazil) was added to the PBS
(NaCl 130 mM; KCl 2 mM; Na2HPO4 2H2O 6 mM;
K2HPO4 1mM, pH 7.2) for five minutes to promote
fixation of the cells to the plates.
Dye extraction was performed by the use of 100 ml of
1% acetic acid solution (Vetec, Rio de Janeiro, Brazil)
in 50% methanol (Reagen, Rio de Janeiro, Brazil).
Readings were performed in a spectrophotometer
STERILISATION OF ELASTOMERS WITH PERACETIC ACID
(BioTek, Winooski, VT, USA) at a wavelength of
492 nm (l = 492 nm) over 20 minutes.
A post hoc comparison was performed to determine
cytoxicity ranking.11-12 Statistical calculations were
undertaken by a one-way analysis of variance
(ANOVA) followed by a Tukey post hoc test (SPSS
13.0®, SPSS Inc., Chicago, lL, USA). P values less than
.05 (p ˂ 0.05) were accepted to indicate significant
differences. Each culture well was considered as an
individual sample.
Results
The results indicated that Group TP (TP
Orthodontics) maintained greater cell viability at all
time periods assessed. Groups M1 and M2 (Morelli,
bulk pack and cane-loaded, respectively) showed
similar cell viability throughout the experiment.
Group U (Uniden) showed low cell viability at a time
interval of 1 hour and beyond. There was a statistically
significant difference between the TP, Morelli and
Uniden brands (p < 0.05) but there was no statistically
significant difference (p < 0.05) between the two types
of Morelli brand at the 1 hour time interval (Table II).
At time intervals of 2, 3, 4 and 5 hours, there was
a statistically significant difference between Group
Australian Orthodontic Journal Volume 29 No. 2 November 2013 141
 PITHON ET AL

Table II. Number of cells (Mean), standard deviation and statistical analysis of groups of elastic bands tested.

Non sterilised T1 T2 T3 T4 T5
Mean (SD) Stat. Mean (SD) Stat. Mean (SD) Stat. Mean (SD) Stat. Mean (SD) Stat. Mean (SD) Stat.
TP 689.4 (22.2) A 651.1 (42.2) A 592.2 (13.4) A 574.1 (35.5) A 535.5 (28.9) A 522.2 (56.2) A
M1 589.4 (17.3) B 575.6 (76.2) B 570.1 (28.2) A 562.2 (87.1) A 512.7 (45.8) A 509.2 (24.5) A
M2 573.1 (28.2) B 571.2 (27.8) B 568.2 (45.2) A 556.2 (59.1) A 533.6 (76.2) A 514.5 (55.2) A
U 104.1 (14.5) C 100.6 (34.5) C 99.1 (45.3) B 96.3 (11.3) B 90.2 (18.2) B 88.3 (45.6) B
CC 714.6 (55.2) A 714.6 (55.2) A 714.6 (55.2) C 714.6 (55.2) C 714.6 (55.2) C 714.6 (55.2) C
C+ 102.1 (12.3) C 102.1 (12.3) C 102.1 (12.3) B 102.1 (12.3) B 102.1 (12.3) B 102.1 (12.3) D
C- 704.6 (34.1) A 704.6 (34.1) A 704.6 (34.1) C 704.6 (34.1) C 704.6 (34.1) C 704.6 (34.1) C
Stat. = statistical analysis: Equal letters correspond to the absence of statistical differences (p > 0.05)
SD = standard deviation

Uniden and the other groups (p < 0.05). However,
there was no statistically significant difference between
Groups TP and Morelli (bulk pack and cane-loaded).
Statistically significant differences were observed
between Group CC and all other groups assessed,
except between Groups CC and TP at the 1 hour time
interval.
For the non-sterilised elastomerics, cell viability was
evident and considered as 100%. The non-sterilised
groups of elastomerics showed similar cell viability to
that observed after a standard sterilisation protocol of
1 hour. As the sterilisation time increased, a gradual
decrease in cell viability occurred (Figure 1).
Group TP showed the highest percentage difference
of viable cells between the time intervals. The Groups
M1 and M2 showed similar percentage differences,
while Group U maintained this variable more subtly
(Figure 1).
Discussion
So that patients and professionals can be protected,
infection control authorities have recommended that
disinfection must be performed if the sterilisation
of materials which come into contact with the oral
environment is not possible.13 Because of the large
number of bacterial species in the oral cavity,1 diseases
such as influenza, tuberculosis, herpes and hepatitis B,
may be transmitted during dental operative procedures.
However, effective sterilisation or disinfection usually
prevents the dissemination of pathogens.14
A concentration of 0.25% peracetic acid (PAA) has
been identified as a chemical alternative to sterilise
critical and semi-critical devices to prevent cross-
contamination.5 Its odour is less pungent than
glutaraldehyde and it is not affected by glass and by
most plastics.6 The aim of this study was to determine
whether PAA could be successfully used to sterilise
elastomers without producing adverse effects.
Cellular alterations may be observed by different
methods,15-17 but in the present study, the cellular
incorporation of neutral red was measured.3,13,18-20
This method has previously been widely used for
orthodontic materials.3,19-21 The cytotoxicity of
materials is determined by spectrophotometry, which
records the amount of dye incorporated into the cells
and which directly relates to the number of viable
cells. The cells used were derived from the L929 line
of mouse fibroblasts which are comparable to human
gingival fibroblasts22-23 and therefore provide an
appropriate model for cytotoxicity tests of materials
and cells related to the oral cavity.
As the end-product of the reaction of hydrogen
peroxide with acetic acid, PAA is considered
an efficient sterilisation method against a wide
range of microorganisms when used at low active
concentrations.22,24-26 However, it is imperative
to know if the method of sterilisation alters the
properties of dental materials, in this case orthodontic
elastomers.
PAA is commonly used for a sterilisation period of 1
hour at a concentration of 0.25%.22,24-26 The present
study found that the elastic ligatures manufactured by
TP Orthodontics and Morelli showed cell viability
higher than 80% after a 1 hour sterilisation period.
These values were found to be similar to the non-
sterilised control elastic ligatures. It was concluded
that a sterilisation process of 1 hour was sufficient

142 Australian Orthodontic Journal Volume 29 No. 2 November 2013


and did not result in noticeable adverse effects on cell
viability.
However, a sterilisation period longer than 1 hour
produced a higher cell cytotoxic effect. This suggested
that the use of PAA for a prolonged sterilisation
period or the re-sterilisation of elastic ligatures which
had previously been exposed to PAA, may lead to a
higher release of bioactive components which affect
the viability of the fibroblast.
The elastic ligatures manufactured by Uniden
produced low cell viability over all experimental time
periods. It is possible that a different manufacturing
process and/or the presence of stabilising substances in
the composition of these ligatures may be responsible
for the performance differences, since all tested
ligatures were made of the same raw material.
Studies21,27 which have analysed the possible cytotoxic
effects of dyes used in the fabrication of intra-oral
elastic ligatures revealed that the colourless and
coloured elastomerics caused cytotoxic effects in in
vitro experimental conditions. The conclusion drawn
was that pigmentation was unlikely to influence the
cytotoxicity of elastics.
Santos et al.3 compared the cytotoxicity of latex-
free elastomeric ligatures (American Orthodontics
and Unitek) with those of polyurethane (Morelli,
GAC, Tecnident) and those that contained latex (TP
Orthodontics). Latex-free elastomeric ligatures were
found to cause less cell lysis than latex or polyurethane
ligatures, the latter being more cytotoxic. The elastic
ligatures made by TP Orthodontics maintained
greater cell viability while the Uniden brand produced
the least cell viability among the groups assessed.
However, cell viability was still higher than 50%,3
in support of the findings of the present study. In
an examination of the degradation in strength of
elastomeric ligatures, Simões28 assessed different
brands and types (cane-loaded and modular) after
sterilisation in 0.25% peracetic acid and found that all
assessed brands suffered minimal degradation without
exhibiting any statistically significant differences.
According to Ceretta,29 a cytotoxic chemical product
must be considered when cell population reduction is
higher than 10%. In the present study, cell reduction
was 5.5% after 1 hour, which was much less than
other reported methods of sterilisation.5 In addition,
PAA was considered a viable alternative method of
sterilisation, compared with ethylene oxide, UV
radiation and gamma rays, because it required shorter
STERILISATION OF ELASTOMERS WITH PERACETIC ACID
sterilisation time,5 and was an acceptable method for
clinical or public health application. This does not
apply for UV radiation and gamma rays, which are
mainly for industrial use.
The comparison of 0.25% peracetic acid on the
cytotoxicity of test samples against an unsterilised
control sample, revealed that the TP Orthodontics
ligatures were affected by PAA, even though greater
cell viability existed over all assessed time intervals.
The Uniden brand was least affected by PAA, but
produced the lowest cell viability of the groups. A
possible reason why PAA had a greater influence on
elastic ligatures made by TP Orthodontics is perhaps
because they are made ​​from natural latex compared
with Morelli and Uniden ligatures, which are made of
polyurethane. PAA has been shown to react with types
of vinyl, synthetic and natural rubbers, depending on
contact time.8,28
As elastic ligatures are in close contact with the gingiva
and oral mucosa, care regarding their potential
cytotoxic effects is recommended. However, the results
found in in vitro tests must not be over-estimated
and further clinical studies are needed to confirm the
present findings.
Conclusion
It is concluded that PAA did not significantly
influence the cytotoxicity of elastomeric ligatures at
the recommended sterilisation time of 1 hour. The
TP Orthodontics brand showed greater cell viability,
but was more susceptible to the influence of PAA
compared with the other brands. However, while
clinical testing is required, PAA is recommended
for routine use for the disinfection of elastomeric
ligatures.
Corresponding author
Dr Matheus Melo Pithon
Av. Otávio Santos, 395, sala 705
Centro Odontomédico Dr. Altamirando da Costa
Lima
Recreio, CEP 45020-750 – Vitória da Conquista-BA
Brazil
Email: matheuspithon@gmail.com
References
1. Gordon BL, Burke FJ, Bagg J, Marlborough HS, McHugh ES.
Systematic review of adherence to infection control guidelines in
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dentistry. J Dent 2001;29:509-16.
2. McCarthy GM, Mamandras AH, MacDonald JK. Infection control
in the orthodontic office in Canada. Am J Orthod Dentofacial
Orthop 1997;112:275-81.
3. Santos RL, Pithon MM, Martins FO, Romanos MT, Ruellas AC.
Cytotoxicity of latex and non-latex orthodontic elastomeric ligatures
on L929 mouse fibroblasts. Braz Dent J 2010;21:205-10.
4. Schmalz G. Use of cell cultures for toxicity testing of dental materials:
advantages and limitations. J Dent 1994;22 Suppl 2:S6-11.
5. Davies C. Orthodontic products update. Cross infection control and
elastomeric module delivery systems. Br J Orthod 1998;25:301-3.
6. Schneeweiss DM. Avoiding cross-contamination of elastomeric
ligatures. J Clin Orthod 1993;27:538.
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sewage sludge disposal to pasture. Water Sci. Technol 1984;17:451-
66.
8. Gehr R, Cochrane D, French M. Peracetic acid as a disinfectant
for municipal wastewaters: encouraging performance results from
physicochemical as well as biological effluents.Proceedings of the
Disinfection Conference. St. Petersburg, February 2002. 2002.
9. Monarca S, Richardson SD, Feretti D, Grottolo M, Thruston
AD, Jr., Zani C et al. Mutagenicity and disinfection by-products
in surface drinking water disinfected with peracetic acid. Environ
Toxicol Chem. 2002;21:309-18.
10. Neyndorff HC, Bartel DL, Tufaro F, Levy JG. Development of a
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12. Welsch R E. Stepwise multiple comparison procedures. J Am Stat
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13. Pithon MM, Santos RL, Martins FO, Romanos MT, Araújo MT.
Cytotoxicity of orthodontic elastic chain bands after sterilization by
different methods. Orthod Waves. 2010;69:151-5.
14. Miller CH. Cleaning, sterilization and disinfection: basics
of microbial killing for infection control. J Am Dent Assoc
1993;124:48-56.
15. Santos RL, Pithon MM, Oliveira MV, Mendes GS, Romanos MTV,
Ruellas ACO. Cytotoxicity of intraoral orthodontic elastics. Braz J
Oral Sci 2008;24:1520-5.
16. Hafez HS, Selim EM, Kamel Eid FH, Tawfik WA, Al-Ashkar EA,
Mostafa YA. Cytotoxicity, genotoxicity, and metal release in patients
with fixed orthodontic appliances: A longitudinal in-vivo study. Am
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J Orthod Dentofacial Orthop 2011;140:298-308.
17. Limberger KM, Westphalen GH, Menezes LM, Medina-Silva R.
Cytotoxicity of orthodontic materials assessed by survival tests in
Saccharomyces cerevisiae. Dent Mater 2011;27:e81-6.
18. Dos Santos RL, Pithon MM, Romanos MTV. The influence of pH
levels on mechanical and biological properties of nonlatex and latex
elastics. Angle Orthod 2012; 82:709-14.
19. Pithon MM, dos Santos RL, Martins FO, Romanos MT, Araujo
MT. Cytotoxicity of orthodontic separating elastics. Aust Orthod J
2010;26:16-20.
20. dos Santos RL, Pithon MM, Martins FO, Romanos MT, de Oliveira
Ruellas AC. Evaluation of the cytotoxicity of latex and non-latex
orthodontic separating elastics. Orthod Craniofac Res 2010;13:28-
33.
21. Santos RL, Pithon MM, Mendes GS, Romanos MTV, Ruellas ACO.
Cytotoxicity of intermaxillary orthodontic elastics of different colors:
An in vitro study. J Appl Oral Sci 2009;4:326-9.
22. Schedle A, Samorapoompichit P, Rausch-Fan XH, Franz A, Fureder
W, Sperr WR et al. Response of L-929 fibroblasts, human gingival
fibroblasts, and human tissue mast cells to various metal cations. J
Dent Res 1995;74:1513-20.
23. Franz A, Konig F, Skolka A, Sperr W, Bauer P, Lucas T et al.
Cytotoxicity of resin composites as a function of interface area. Dent
Mater 2007;23:1438-46.
24. Greenspan DG, Mackellar FP. The application of peracetic acid
germicidal washes to mold control of tomatoes. Food Technol
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25. Vizcaino-Alcaide MJ, Herruzo-Cabrera R, Fernandez-Acenero
MJ. Comparison of the disinfectant efficacy of Perasafe and 2%
glutaraldehyde in in vitro tests. J Hosp Infect 2003;53:124-8.
26. Montebugnoli L, Chersoni S, Prati C, Dolci G. A between-patient
disinfection method to control water line contamination and biofilm
inside dental units. J Hosp Infect 2004;56:297-304.
27. Holmes J, Barker MK, Walley EK, Tuncay OC. Cytotoxicity
of orthodontic elastics. Am J Orthod Dentofacial Orthop
1993;104:188-91.
28. Simões AS. Degradation assessment strength elastics ligature after
sterilization by acid peracetic 0.25%. Monograph to obtain the title
of specialist in orthodontics presented to Odontoclínica Central
Navy, Rio de Janeiro, 2010. 2010.
29. Ceretta RA. Evaluating the effectiveness of peracetic acid sterilization
of dental equipment. Master’s thesis.Universidade do Extremo Sul
Catarinense, Criciúma. 2008.
The impact of spur therapy in dentoalveolar
open bite
Philipp Meyer-Marcotty, Janka Kochel and Angelika Stellzig-Eisenhauer
Department of Orthodontics, Dental Clinic of the Medical Faculty, University of Wuerzburg, Germany

Aim: A longitudinal case-control study, designed to analyse the isolated effect of attached palatal spurs in patients displaying a
dentoalveolar anterior open bite, is presented.
Methods: Thirty-one patients (mean age of 13.3 years ± 3.17 years) underwent a standardised treatment protocol with fixed
anterior spurs for 8.3 months. Lateral cephalograms and plaster casts were analysed before (T1) and after spur therapy (T2). The
data were tested using paired t-tests with a significance level of p < 0.05.
Results: The cephalometric analysis showed significant elongation of the height of the maxillary (mean +1.22 mm) and the
mandibular (mean +1.39 mm) alveolar processes, as well as uprighting of the lower anterior teeth. The plaster cast analysis
showed an increase in maxillary intermolar width (mean +0.98 mm) and a decrease in intercanine distance (mean -0.96 mm).
The mandibular anterior width and dental arch length reduced. Overall, spur therapy resulted in a significant increase in overjet
and overbite.
Conclusion: The use of spurs produced a resolution of the open bite in all patients. Therefore, spurs could be considered an
effective mechanism for the management of anterior open bite in selected adolescent patients.
(Aust Orthod J 2013; 29: 145-152)

Received for publication: June 2012

Accepted: July 2013

Philipp Meyer-Marcotty: Meyer_P1@klinik.uni-wuerzburg.de; Janka Kochel: Kochel_J@klinik.uni-wuerzburg.de; Angelika Stellzig-Eizenbauer:

stellzig_A@klinik.uni-wuerzburg.de

Introduction Furthermore, a digit-sucking or lip habit can produce

An open bite is defined as a lack of vertical overlap
or contact of the upper and lower incisors in any
sagittal relationship.1 The prevalence of an open bite
in the mixed dentition ranges from 17% to 36.3%.1,2
A tendency for vertical self-correction seen as a
spontaneous increase in overbite has been reported in
patients from 7 to 12 years of age.3
However, the treatment of patients with a persistent
open bite remains an orthodontic challenge. The
aetiology is frequently multifactorial but three possible
causal factors have been identified: (1) dyskinesia,
(2) the function and size of the tongue and (3) a
vertical growth pattern with or without an anterior
inclination of the maxilla.4 A correlation has been
reported between the orofacial musculature and facial
structure which suggests a causal relationship between
incorrect tongue position and an anterior open bite.6
a malocclusion characterised by an anterior open bite.
If a sucking habit persists beyond the time that the
anterior permanent teeth erupt, an open bite with
proclined incisors may result.5 Due to the many
aetiological factors, multiple treatment strategies have
been directed at eliminating the cause or correcting the
dentofacial effects in order to improve the occlusion
and masticatory function.7-9
An anterior resting tongue posture has been identified
as a leading factor related to an anterior open
bite and relapse after orthodontic or combined
surgical-orthodontic therapy.5,10,11 The management
of tongue position is considered essential for successful
treatment and various treatment approaches have
been reported. Functional orthodontic appliances,
vestibular shields, tongue cribs or myofunctional
therapy have been applied with varying success.10,12-16

© Australian Society of Orthodontists Inc. 2013 Australian Orthodontic Journal Volume 29 No. 2 November 2013 145
 MEYER-MARCOTTY ET AL
Rogers first described therapy of incorrect tongue
posture by employing palatal spurs.17 Spur use was
based on the premise that incorrect tongue posture
could not been consciously and continuously
controlled by the patient. Therefore, the modification
of tongue posture could only be successful with
considerable effort which was made more difficult by
the duration of the dysfunction. By the application
of palatal spurs, a nociceptive reflex is reportedly
triggered, in order to avoid the cause of induced
discomfort.15 The avoidance act sets in motion a
learning process and the neuromuscular establishment
of a changed resting tongue posture.
Despite previous reports of spur therapy, few studies
have examined their effectiveness in managing
anterior tongue posture and improving an anterior
open bite.10,14,18 In addition, published papers are case
studies or individual reports which do not permit
scientifically-grounded conclusions.10 Therefore, the
aim of this prospective, longitudinal study was to
determine, in patients presenting with an anterior
open bite, the effect of palatal spurs on the craniofacial
and dentoalveolar complexes.
Materials and methods
Thirty-one patients (16 female and 15 male) were
recruited. All patients were of Caucasian origin with a
mean age of 13.3 years ± 3.17 years (Table I) and were
treated in the Department of Orthodontics of the
Dental Clinic, University of Wuerzburg, Germany.
The Declaration of Helsinki and the ethical standards
established by the Institutional Review Board were
followed and maintained during treatment. The study
was conducted after informed and written consent
from each participant.
The inclusion criteria identified an anterior open bite,
or a relatively small overbite (< 2 mm), in combination
with an anterior resting tongue posture, a visceral
(infantile) swallowing pattern or a tongue thrust.
Exclusion criteria were a lateral or anterior crossbite,
a persistent digit habit, previous orthodontic or
myofunctional therapy, and patients with a cleft lip
and palate or with a craniofacial syndrome.
Treatment protocol
All patients underwent palatal spur therapy using
a fixed appliance for a mean duration of 8 months
146 Australian Orthodontic Journal Volume 29 No. 2 November 2013
Table I. Mean age in years (Y) and standard deviation (SD) of the study
group.
Study group N Y SD
All 31 13.33 3.17
Female 16 12.75 2.92
Male 15 13.58 3.16
± 3 months (Figures 1a-f ). The length of therapy was
determined by the criteria described by Haung et al.14
and Meyer-Marcotty et al.18 who recommended that
spurs be placed for at least 6 months or until a positive
anterior overbite was achieved. No other appliance was
used during the observation and treatment period.
The spur appliance consisted of a 0.9 mm palatal
arch, fixed to the upper first molars. Pointed spurs,
approximately 3 mm long, were soldered to the
anterior and/or lateral tooth area, at a 45° downward
angle and inclined towards the occlusal plane. As
therapy progressed, the position and angulation of
the spurs were varied according to individual postural
tongue changes and to establish new sensory stimuli.
Method
In order to analyse dentoalveolar spur effects, plaster
casts of the 31 patients were taken prior to treatment
(T1) and immediately after therapy (T2). Craniofacial
effects were assessed via lateral cephalograms but,
because 5 patients had no film after treatment,
they were excluded from the study, which left 26
cephalograms for assessment. The cephalograms
were taken on the same machine (Orthopos DS
Ceph®, Siemens, Erlangen, Germany) according to
a standardised procedure, which assured consistency
of imaging. The cephalometric analysis comprised
13 measurements (7 angular and 6 linear) related
to 20 landmarks according to Rakosi (Figures 2a-
b).19 Additionally, measurements of the alveolar and
basal height of the maxilla and mandible according
to Beckmann et al. were used to analyse changes in
the anterior dentoalveolar regions (Figure 2c).20 The
radiographic analysis was performed by the same
investigator using the fr-win® software (Computer
konkret AG, Dental Software, Falkenstein) to
minimise variability.
Manual measurements of the plaster casts using a
caliper with an accuracy of 0.1 mm were performed by

(a)
(b) (c)
(e) (f)
Figure 1. Patient treated exclusively with the Spur appliance.
(a) Spur appliance in situ; (b) Pretreatment (intra-oral frontal); (c) Pretreatment with tongue dysfunction; (d) Post-treatment (intra-oral frontal); (e) Pretreatment
(Lateral cephalogram); (f) Post-treatment (Lateral cephalogram)
the same investigator. In total, 8 measurements were
included in the cast analysis (Figures 3a-b). Intra-arch
measurements comprised the anterior and posterior
width of the dental arches, the length of the dental
arch, and the maxillary and mandibular intercanine
distances.
Statistical data analysis
Statistical analysis was conducted using SPSS software,
Version 14.0 for Windows (SPSS Inc. Chicago, IL,
IMPACT OF SPUR THERAPY IN DENTOALVEOLAR OPEN BITE
(d)
USA). The distribution of the data was tested using
the Kolmogorov-Smirnov test, which indicated a
normal distribution. The collected data were analysed
using paired t-tests to reveal differences between T1
and T2. The significance level was set at p < 0.05.
Method error
The same investigator retraced 10 randomly-selected
cephalograms and remeasured 10 plaster casts after a
period of 6 weeks. The method error was calculated
Australian Orthodontic Journal Volume 29 No. 2 November 2013 147
 MEYER-MARCOTTY ET AL

(a) (b) (c)

Figure 2. (a) Craniofacial complex: 1 = NSL-NL (°); 2 = NSL-ML (°); 3 = NL-ML (°); 4 = U1_NSL (°); 5 = U1_NL (°); 6 = L1_ML (°); 7 = Interincisal angle
(°); 8 = U1_NPog (mm); 9 = L1_NPog (mm)
(b) Occlusion: 10 = Overjet (mm); 11 = Overbite (mm)
(c) Alveolar and basal height of the maxilla and the mandible. Measurement of maxillary (MxH) and mandible (MdH) alveolar height according to Beckman
et al.20 12 = MxH (mm); 13 = MdH (mm)

(a) (b)
Figure 3. Plaster cast analysis.
(a) Maxilla: 1 = Anterior width of dental arch (mm); 2 = Posterior width of dental arch (mm); 3 = Anterior length of dental
arch (mm); 4 = Intercanine distance (mm)
(b) Mandible: 5 = Anterior width of dental arch (mm); 6 = Posterior width of dental arch (mm); 7 = Anterior length of
dental arch (mm); 8 = Intercanine distance (mm)

according to Dahlberg.21 No significant difference was
found between the first and second measurements on
the radiographs. The method error was 0.38 – 0.68 mm
in the plaster cast analysis and 0.45 – 0.97° and 0.18
– 0.89 mm respectively, in the cephalometric analysis
(Table II and III). Therefore, good reproducibility was
established and accepted for each parameter.
Results
Cephalometric analysis
The results of the cephalometric analysis are shown
in Table IV. Spur therapy caused no statistically
significant influence on the maxilla or on the mandible
in the vertical dimension (inclination of the jaws).
The maxillary (NSL-NL) and the mandibular (NSL-
ML) measurements were almost normal at T1 and
T2 according to the Rakosi analysis. The inter-basal
angle (NL-ML) slightly increased at T2, but without
statistical significance.
The sagittal position of the upper anterior teeth
did not significantly alter following spur therapy
(U1_NSL/ U1_NL). In contrast, the lower anterior
teeth uprighted at T2. The angulation of the lower
incisors to the mandibular plane (L1-ML) decreased
significantly (p < 0.001) as did the distance between

148 Australian Orthodontic Journal Volume 29 No. 2 November 2013

 IMPACT OF SPUR THERAPY IN DENTOALVEOLAR OPEN BITE

Table II. Cephalometric analysis: method error of measurements Table III. Plaster cast analysis: method error of measurements according
according to Dahlberg.21 to Dahlberg.21

Variable Method error of Variable Method error of

measurements
Inclination of the jaw bases
1 NSL-NL (°)
2 NSL-ML (°)
3 NL-ML (°)
Dental analysis
4 U1_NSL (°)
5 U1_NL (°)
6 L1-ML (°)
7 U1-NPog (mm)
8 L1-NPog (mm)
9 Interincisal angle (°)
Occlusion
10 Overjet (mm)
11 Overbite (mm)
Height of the alveolar processes
12 MdHab (mm)
13 MxHab (mm)
the lower incisor to NPog (L1-NPog: p = 0.012).
Additionally, a significant increase in the interincisal
angle was observed (p = 0.005).
Overjet, as well as overbite, increased significantly
during therapy (overjet: p = 0.009; overbite:
p = 0.014). In contrast with the insignificant changes
in the inclination of the jaws, the cephalometric
evaluation of maxillary and mandibular anterior
alveolar height (according to Beckmann20) showed
significant vertical development (alveolar height of
the mandible MdH: p = 0.001; alveolar height of the
maxilla MxH: p = 0.005).
Plaster cast analysis
The results of the plaster cast analysis are shown in
Table V. The maxillary intermolar width increased
significantly (p = 0.013), whereas intercanine distance
significantly decreased during the study (p = 0.024).
Anterior mandibular width and the length of the
dental arch significantly decreased (anterior width:
p = 0.024; length of the dental arch: p = 0.003).
measurements
Maxilla
0.81 1 Anterior width (mm) 0.38
0.46 2 Posterior width (mm) 0.57
0.92 3 Anterior length (mm) 0.66
4 Intercanine distance (mm) 0.41
0.45 Mandible
0.89 5 Anterior width (mm) 0.68
0.97 6 Posterior width (mm) 0.48
0.18 7 Anterior length (mm) 0.57
0.28 8 Intercanine distance (mm) 0.42
0.9 Occlusion
9 Overjet (mm) 0.36
0.24 10 Overbite (mm) 0.20
0.20
0.73
Discussion
0.89
The impact of palatal spur therapy was longitudinally
analysed in a group of Caucasian subjects possessing
an anterior open bite. The effects on the dentofacial
complex and the alveolar and basal heights of the
maxilla and the mandible were assessed on pre- and
post-treatment lateral cephalograms. Furthermore,
the morphological changes in the dental arches were
measured on plaster casts. Overall, an increase of
overjet and overbite was found during spur therapy.
No other appliance was used which allowed an isolated
determination of the impact of treatment. Meyer-
Marcotty et al. previously described a standardised
spur therapy protocol which was adopted in the
present study.18 The analysis of the pretreatment lateral
cephalograms showed a tendency towards a skeletal
open bite in all patients. In addition, the underlying
skeletal growth pattern appeared consistent with
patients characterised by an anterior open bite.22 The
cephalometric analysis conducted during the present
study showed a clinically insignificant increase in
the vertical position of the maxilla and mandible.
A slightly increased inter-basal angle was without
statistical significance and so, no clinically significant
vertical effect on the maxilla and the mandible could
be ascribed to the spur therapy.

Australian Orthodontic Journal Volume 29 No. 2 November 2013 149

 MEYER-MARCOTTY ET AL

Table IV. Cephalometric analysis; mean value (M) and standard deviation (SD) at the study times T1 and T2; difference (∆) between T1 and T2;
significance (S) for p < 0.05; results after the t-tests for paired random samples for normal distribution of the variables (n.s. not significant, *significant,
** highly significant, *** most highly significant.

Variable T1 T2 Δ(T2-T1) S
M SD M SD M SD p
Inclination of the jaws
1 NSL-NL (°) 5.84 2.90 6.04 3.14 0.20 2.05 0.623 n.s.
2 NSL-ML (°) 35.73 5.87 36.36 6.13 0.63 2.33 0.181 n.s.
3 NL-ML (°) 29.89 5.30 30.31 5.59 0.42 2.23 0.342 n.s.
Dental analysis
4 U1_NSL (°) 104.85 6.77 104.07 8.05 -0.78 5.03 0.439 n.s.
5 U1_NL (°) 69.31 6.63 69.90 7.98 0.59 4.89 0.543 n.s.
6 L1-ML (°) 90.59 7.16 86.73 7.40 -3.87 4.57 0.000 ***
7 U1-NPog (mm) 7.22 3.14 7.44 3.56 0.22 2.01 0.583 n.s.
8 L1-NPog (mm) 4.04 2.44 3.12 3.16 -0.92 1.74 0.012 *
9 Interincisal angle (°) 128.83 7.31 132.87 9.86 4.03 6.67 0.005 **
Occlusion
10 Overjet (mm) 3.16 1.98 4.31 2.29 1.15 2.07 0.009 **
11 Overbite (mm) -0.35 1.88 0.64 1.98 0.99 1.91 0.014 *
Height of the alveolar processes
12 MdH (mm) 31.97 4.31 33.36 4.43 1.39 1.92 0.001 ***
13 MxH (mm) 20.54 3.93 21.66 2.95 1.12 1.84 0.005 **
paired t-tests

Table V. Plaster cast analysis; mean value (M) and standard deviation (SD) at the study times T1 and T2; difference (∆) between T1 and T2; significance
(S) for p < 0.05; results after the t-tests for paired random samples for normal distribution of the variables (n.s. not significant, * significant, ** highly
significant, *** most highly significant).

Variable T1 T2 Δ(T2-T1) S
M SD M SD M SD p
Maxilla
1 Anterior width (mm) 36.48 3.01 36.20 2.99 -0.27 1.14 0.206 n.s.
2 Posterior width (mm) 47.07 3.47 48.05 3.36 0.98 1.99 0.013 *
3 Anterior length (mm) 18.20 2.02 18.38 2.18 0.19 1.24 0.423 n.s.
4 Intercanine distance (mm) 34.11 1.97 33.15 2.99 -0.96 1.99 0.024 *
Mandible
5 Anterior width (mm) 35.66 2.69 35.15 2.36 -0.51 1.15 0.024 *
6 Posterior width (mm) 48.75 2.78 49.01 2.69 0.26 1.22 0.262 n.s.
7 Anterior length (mm) 15.50 2.37 15.00 2.09 -0.51 0.83 0.003 **
8 Intercanine distance (mm) 27.16 2.04 26.67 1.88 -0.49 1.53 0.111 n.s.
Occlusion
10 Overjet (mm) 3.41 1.99 4.13 2.08 0.73 1.70 0.029 *
11 Overbite (mm) 0.48 1.94 1.77 1.54 1.30 2.11 0.003 **
paired t-tests

150 Australian Orthodontic Journal Volume 29 No. 2 November 2013


Several dental parameters were significantly altered
by therapy. Treatment resulted in uprighting of the
lower incisors and a significant, concomitant increase
in the inter-incisal angle. Furthermore, an increase in
overjet and overbite was found. These measurements
suggested an adaptation of the tongue and a reduction
of its influence on the anterior teeth due to induced
positional changes. Previous literature has described
the tongue of patients wearing a palatal crib as
occupying a more posterior and higher position in the
mouth.23 Moreover, the findings of a recent Magnetic-
Resonance-Imaging-Study revealed that the tongue
tip became positioned more posteriorly when a crib
was placed.24 Therefore, the spur-induced changes
in tongue position likely produced adaptive dental
changes, resulting in the uprighting of the lower
incisors and the increase in inter-incisal angle and
overjet. All patients showed a significant increase in
anterior maxillary and mandibular alveolar height,
leading to an improvement in overbite. By using
Beckmann’s20 differentiated analysis, an elongation
of the anterior dentoalveolar processes (increase in
alveolar height) was shown. This could be interpreted
as an alveolar adaptation independent of skeletal
basal changes (inclination of the upper/lower jaws).
Moreover, the increase in alveolar height, as previously
demonstrated in skeletal open bite patients, is
suggestive of a level of dentoalveolar compensation25,26
in the production of a positive overbite.
The transverse analysis of the plaster casts showed
a significant increase in maxillary intermolar width
and a decrease in intercanine distance. Concurrently,
mandibular anterior width and the length of the dental
arch decreased. The arch changes may be explained by
an induced alteration in resting tongue position and
a resulting change in tongue pressure on the teeth.
In a study by Taslan et al., resting tongue pressure
was shown to increase significantly on the upper first
molar and decrease on the lower incisors after the
insertion of a crib appliance.27 The effectiveness of
crib therapy was described as the ability to redirect
the resting posture of the tongue into a less influential
position, resulting in a decrease in lingual pressure
on the anterior teeth.28 The results of Taslan et al.
supported the hypothesis that the adaptive capacity
of the tongue appeared responsible for the changes
evident in the present plaster cast analysis. Therefore,
spurs may be effective in adolescent patients with an
anterior open bite or open bite tendency caused by
tongue dysfunction.
IMPACT OF SPUR THERAPY IN DENTOALVEOLAR OPEN BITE
Parker confirmed the successful use of spurs in open
bite treatment but reported a traumatising effect
on patients.29 However, this unfavourable effect
was contested by Haryett et al., who examined
the psychological impact of various orthodontic
appliances designed to discourage habits.30,31 No
orthodontic appliance, including spurs, caused
psychological problems related to the management of
habits. Moreover, spur therapy was shown to be the
most effective treatment protocol. Clinical experience
has confirmed that no patient treated with palatal
spurs had the appliance removed early, nor were
injuries to the tongue or the oral mucosa encountered.
Justus explained the lack of deleterious effect by the
adoption by the tongue, of a new resting posture
dictated by a nociceptive or proprioceptive reflex.15
This process began immediately upon placement of
the spurs so that, despite the spurs’ sharp ends, no soft
tissue injuries occurred.
One limitation of the present study was the absence
of a comparative control group. However, it is not
unusual to commence research with a well-controlled
prospective clinical trial (using no other appliance in a
defined group of patients). Moreover, there are ethical
considerations in the denial of therapy in a defined
control group.
Conclusion
The treatment of open bite patients with fixed palatal
spurs produced distinctive morphological changes in
the dental arches. The main findings were:
1. An increase of overjet and overbite,
2. Uprighting of the lower incisors,
3. Elongation of maxillary and mandibular alveolar
heights.
In summary, the use of palatal spurs created an
increase in overbite in all patients. Therefore, it is
concluded that spurs are effective in the management
of a tongue-induced anterior open bite in carefully-
selected adolescent patients.
Conflict of Interest
The corresponding author states that there is no
conflict of interest.
Corresponding author
Priv. Doz. Dr Philipp Meyer-Marcotty
Department of Orthodontics
Australian Orthodontic Journal Volume 29 No. 2 November 2013 151
 MEYER-MARCOTTY ET AL
Dental Clinic of the Medical Faculty
University of Wuerzburg
Pleicherwall 2,
97070 Würzburg
Germany
Email: Meyer_P1@klinik.uni-wuerzburg.de
References
1. Cozza P, Baccetti T, Franchi L, Mucedero M, Polimeni A. Sucking
habits and facial hyperdivergency as risk factors for anterior open
bite in the mixed dentition. Am J Orthod Dentofacial Orthop
2005;128:517-9.
2. Tausche E, Luck O, Harzer W. Prevalence of malocclusions in the
early mixed dentition and orthodontic treatment need. Eur J Orthod
2004;26:237-44.
3. Worms FW, Meskin LH, Isaacson RJ. Open-bite. Am J Orthod
1971;59:589-95.
4. Beane RA, Jr. Nonsurgical management of the anterior open bite: a
review of the options. Semin Orthod 1999;5:275-83.
5. Proffit WR. Contemporary Orthodontics. St. Louis: Mosby;
2000:134-6.
6. Proffit WR, Fields HW, Nixon WL. Occlusal forces in normal- and
long-face adults. J Dent Res 1983;62:566-70.
7. Erbay E, Ugur T, Ulgen M. The effects of Frankel’s function
regulator (FR-4) therapy on the treatment of Angle Class I skeletal
anterior open bite malocclusion. Am J Orthod Dentofacial Orthop
1995;108:9-21.
8. Frankel R, Frankel C. A functional approach to treatment of skeletal
open bite. Am J Orthod 1983;84:54-68.
9. Kuster R, Ingervall B. The effect of treatment of skeletal open bite
with two types of bite-blocks. Eur J Orthod 1992;14:489-99.
10. Shapiro PA. Stability of open bite treatment. Am J Orthod
Dentofacial Orthop 2002;121:566-8.
11. Subtelny JD. Oral habits - studies in form, function, and therapy.
Angle Orthod 1973;43:349-83.
12. Cozza P, Baccetti T, Franchi L, McNamara JA, Jr. Treatment effects
of a modified quad-helix in patients with dentoskeletal open bites.
Am J Orthod Dentofacial Orthop 2006;129:734-9.
13. Fadel B, Miethke RR. The orthodontic treatment of open bite with
dysfunctions and habits. Orthodontics 1994;8:23-34.
14. Huang GJ, Justus R, Kennedy DB, Kokich VG. Stability of anterior
openbite treated with crib therapy. Angle Orthod 1990;60:17-24;
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15. Justus R. Correction of anterior open bite with spurs: long-term
stability. World J Orthod 2001;2:219-31.
16. Klocke A, Korbmacher H, Kahl-Nieke B. Influence of orthodontic
appliances on myofunctional therapy. J Orofac Orthop 2000;61:414-
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17. Rogers A. Open bite cases involving tongue habits. Int J Orthod
1927;13:837.
18. Meyer-Marcotty P, Hartmann J, Stellzig-Eisenhauer A. Dentoalveolar
open bite treatment with spur appliances. J Orofac Orthop
2007;68:510-21.
19. Rakosi T. Bedeutung der angulären und linearen Messungen in der
dento-skelettalen Analyse. In: Rakosi T, editor. Atlas und Anleitung
zur praktischen Fernröntgenanalyse. München: Hanser; 1988;58-98.
20. Beckmann SH, Kuitert RB, Prahl-Andersen B, Segner D, The RP,
Tuinzing DS. Alveolar and skeletal dimensions associated with lower
face height. Am J Orthod Dentofacial Orthop 1998;113:498-506.
21. Dahlberg G. Statistical methods for medical and biological students.
New York: Interscience publications; 1940.
22. Klocke A, Nanda RS, Kahl-Nieke B. Anterior open bite in the
deciduous dentition: longitudinal follow-up and craniofacial growth
considerations. Am J Orthod Dentofacial Orthop 2002;122:353-8.
23. Cleall JF. Deglutition: A study of form and function. Am J Orthod
1965;51:566-94.
24. Sayin MO, Akin E, Karacay S, Bulakbasi N. Initial effects of the
tongue crib on tongue movements during deglutition: a Cine-
Magnetic resonance imaging study. Angle Orthod 2006;76:400-5.
25. Schendel SA, Eisenfeld J, Bell WH, Epker BN, Mishelevich DJ.
The long face syndrome: vertical maxillary excess. Am J Orthod
1976;70:398-408.
26. Betzenberger D, Ruf S, Pancherz H. The compensatory mechanism
in high-angle malocclusions: a comparison of subjects in the mixed
and permanent dentition. Angle Orthod 1999;69:27-32.
27. Taslan S, Biren S, Ceylanoglu C. Tongue pressure changes before,
during and after crib appliance therapy. Angle Orthod 2010;80:533-9.
28. Fink FS. Resting position of tongue important. Angle Orthod
1990;60:244.
29. Parker JH. The interception of the open bite in the early growth
period. Angle Orthod 1971;41:24-44.
30. Haryett RD, Hansen FC, Davidson PO, Sandilands ML. Chronic
thumb-sucking: the psychologic effects and the relative effectiveness
of various methods of treatment. Am J Orthod 1967;53:569-85.
31. Haryett RD, Hansen FC, Davidson PO. Chronic thumb-sucking.
A second report on treatment and its psychological effects. Am J
Orthod 1970;57:164-78.
Mesiodistal tooth dimensions and anterior and
overall Bolton ratios evaluated by cone beam
computed tomography
Mevlut Celikoglu,* Metin Nur,† Dogan Kilkis,± Omer Said Sezgin+ and Mehmet
Bayram*
Department of Orthodontics, Faculty of Dentistry, Karadeniz Technical University, Trabzon,* Department of Orthodontics,
Faculty of Dentistry, Sifa University, Izmir,† Private Practice, Trabzon± and Department of Oral Diagnosis and Radiology,
Faculty of Dentistry, Karadeniz Technical University, Trabzon,+ Turkey

Aim: The mesiodistal widths of the maxillary and mandibular teeth and anterior and overall tooth size ratios were measured by
CBCT and conventional orthodontic plaster methods, compared, and correlation coefficients for both methods determined.
Material and methods: The records of 26 patients (14 males and 12 females) between the ages of 18 and 28 years were
randomly selected from the archives of the Oral Diagnosis, Radiology and Orthodontic Departments at the Karadeniz Technical
University. The mesiodistal diameters of the maxillary and mandibular permanent teeth from first molar to first molar were
measured on the patient’s plaster models and also on CBCT arch renditions. Anterior and overall Bolton ratios were calculated for
each method. Comparisons were performed using Pearson’s correlation coefficient (PCC).
Results: The measurements of the mesiodistal widths of most maxillary and mandibular teeth were similar and consistent between
the conventional and CBCT methods. PCC values ranged from 0.637 (mandibular right second premolar) to 0.916 (maxillary
right canine). PCC values for anterior and overall ratios were 0.756 and 0.781, respectively, indicating that correlations
between conventional and CBCT methods were acceptable.
Conclusion: Dental measurements and anterior and overall Bolton ratios calculated on CBCT showed acceptable PCC values
indicating that CBCT measurements could be used instead of those obtained from conventional plaster models.
(Aust Orthod J 2013; 29: 153-158)

Received for publication: September 2012

Accepted: July 2013

Mevlut Celikoglu: mevlutcelikoglu@hotmail.com; Metin Nur: Nurmetin@yahoo.com; Dogan Kilkis: dt.dogan@gmail.com; Omer Said Sezgin:
omersaidsezgin@gmail.com; Mehmet Bayram: dtmehmetbayram@yahoo.com

Introduction results may be used for case presentation and record

Successful orthodontic treatment is based on
comprehensive diagnosis and treatment planning.1
The fundamental requirements assisting in diagnosis
are orthodontic models, photographs, radiographs,
and a thorough clinical examination.2
An orthodontic model is a precise three-dimensional
replica of a patient’s dentition on which measurements
may be performed more easily and accurately than in
the patient’s mouth.3 In addition to the facilitation
of diagnosis and treatment planning, model analysis
allows an evaluation of treatment progress and
keeping.2,4,5 However, the process of model generation
is time-consuming and physical storage space is
required, both of which add financial and logistic
burdens.1
The use of computer technology in dentistry has
become an integral part of practice management. The
electronic capture of patient information eliminates the
problems of physical storage, retrieval, maintenance
and improves office management.2,6,7 A contemporary
focus has been on the generation of digital models,
either by intra-oral laser scanning,8 laser scanning of
the orthodontic model,9 non-destructive scanning

© Australian Society of Orthodontists Inc. 2013 Australian Orthodontic Journal Volume 29 No. 2 November 2013 153
 CELIKOGLU ET AL
of the model or impressions with micro-computed
tomography or destructive imaging of the model with
incremental image captures.10
Several reports have compared the reliability
and accuracy of dental casts with digital scans
of corresponding impressions. The reliability of
measurements conducted on digital models produced
from impressions has been proven to be as good,
if not better, than measurements obtained from
plaster casts.11 El-Zanaty et al.2 confirmed excellent
agreement between dental measurements including
mesiodistal widths of the teeth, arch widths, arch
lengths, arch perimeters and palatal depths determined
by conventional and computerised tomographic
(CT) methods. Although the use of digital models
is increasing, their generation still involves the
taking of impressions and their subsequent scanning
which requires time to complete.12 According to
Kau et al.,13 current imaging techniques involving
cone beam computed tomography (CBCT) could
potentially eliminate the time-consuming and often
uncomfortable process of obtaining impressions. It
was determined that CBCT digital models were as
accurate as OrthoCAD digital models in providing
linear measurements for overjet, overbite, and
crowding values.13 To date, however, no study has
compared the anterior and overall Bolton ratios and
tooth widths generated from CBCT and conventional
orthodontic plaster model methods. Therefore, the
aim of the present study was to determine correlation
coefficients by the measurement of the mesiodistal
widths of the maxillary and mandibular teeth and
to calculate anterior and overall tooth size ratios via
CBCT and conventional study cast methods.
Material and methods
The present sample size was based on a significance
level of 0.05 and a power of 85% to detect a clinically
meaningful difference of 0.15 mm (± 0.17 mm) for
the mesiodistal width of a tooth. The power analysis
indicated that 24 patients were required. In order
to increase the power of the study, the records of 26
patients (14 males and 12 females) were enrolled.
The patients were aged between 18 and 28 years and
were randomly selected from the archives of the Oral
Diagnosis, Radiology and Orthodontics departments
at the Karadeniz Technical University.
The selection criteria included the presence of erupted
mandibular and maxillary permanent dentitions
154 Australian Orthodontic Journal Volume 29 No. 2 November 2013
from the first molar to first molar, the presence of a
reproducible, stable occlusion and the existence of
plaster orthodontic models (taken with alginate) and
a CBCT scan (Kodak 9500 Cone Beam 3D System,
Kodak Dental Systems, Carestream Health, Rochester,
NY, USA) of the dentofacial region. All patients had
skeletal and dental Class I relationships without tooth
agenesis. Minimal crowding of less than 3 mm in both
arches was a required criterion. Approval for the study
was previously granted by the Ethics Committee of
the Karadeniz Technical University.14 The patients
were not subjected to any additional radiation for this
retrospective study and so, no further ethics approval
was required.
CBCT scans were performed according to the
following settings: a field of view (FOV) of 18.4
x 20.6 cm, a voxel size of 0.3 mm, a scan time of
10.8 seconds at 90 kV and 10 mA. Each person was
positioned through adjustment of the chin support
until the Frankfurt plane coincided with a horizontal
laser reference. Following the scan, 3D virtual models
were reconstructed and tooth widths were measured
by Invivo5 imaging software (Anatomage, San Jose,
CA, USA) (Figures 1 and 2). Mesiodistal diameters of
the permanent teeth from the first molar to first molar
in the maxillary and mandibular arches were measured
on conventional plaster casts and by CBCT methods
by the same examiner using a method previously
described by Hunter and Priest.15 Cast measurements
were obtained using a digital caliper accurate to 0.01
mm (Mitutoyo, Tokyo, Japan).
Anterior and overall Bolton ratios were calculated
from the tooth width measurements and based on the
following formulae:
Anterior ratio = Sum of the mandibular 6 anterior
teeth/Sum of the maxillary 6 anterior teeth
Overall ratio = Sum of the mandibular 12 teeth/Sum
of the maxillary 12 teeth
Statistical analysis
A Kolmogorov-Smirnov test showed normal
distribution and so parametric tests were applied for
data analysis. Mean and standard deviations of the
mesiodistal width of each tooth were determined using
both measurement methods. Pearson’s correlation
coefficients (PCC) were calculated to assess the inter-
method variation. In order to determine measurement
error, plaster and CBCT models of 15 patients were

Figure 1. An example of a 3D virtual model of the maxillary arch used
in the present study.
randomly selected and re-measured by the same
examiner, one month after the first measurements.
Intra-class correlation coefficients were performed to
assess the reliability of the measurements as described
by Houston.16 All statistical analyses were performed
using the SPSS software package program (SPSS for
Windows 98, version 10.0, SPSS Inc, Chicago, IL,
USA). A p value of < 0.05 was considered statistically
significant.
Results
The coefficients of reliability (Houston method)
for all measurements ranged from 0.92 to 0.97 for
the conventional method and from 0.94 to 0.99
for CBCT method, confirming the reliability of
the measurements by either method. The mean
and standard deviation of the mesiodistal widths of
the teeth and the difference in values between the
methods are shown in Table I. The mean difference
of mesiodistal tooth width measurements between
the methods (CBCT-conventional) ranged from
-0.34 mm (mandibular left first premolar) to 0.24
mm (maxillary right first molar). The total mean
differences between the methods in the maxillary and
mandibular arches were -0.01 mm and -0.03 mm,
respectively. Measurements of the mesiodistal widths
of most maxillary and mandibular teeth showed strong
correlations between the conventional and CBCT
methods. PCC values ranged from 0.637 (mandibular
BOLTON RATIOS FROM CONE BEAM COMPUTED TOMOGRAPHY
Figure 2. An example of a 3D virtual model of the mandibular arch
used in the present study.
right second premolar) to 0.916 (maxillary right
canine).
The mean and standard deviation values of the
anterior and overall Bolton ratios calculated by means
of conventional and CBCT methods are shown in
Table II. PCC values for anterior and overall ratios
were 0.756 and 0.781, respectively, which indicated
that conventional and CBCT methods showed high
correlations. The results of the paired t-test revealed that
the difference between the methods was insignificant
in regard to the overall ratio (a difference of 0.58%,
p = 0.184), while it was statistically significant for the
anterior ratio (a difference of 1.11%, p = 0.018).
Discussion
The digitisation of orthodontic records and the use
of computer technology is becoming commonplace
and welcome in orthodontic diagnosis and treatment
planning.17 According to Proffit and Ackerman,18
an advantage of digitising tooth dimensions for
space analysis was the provision of a quick patient
assessment. In agreement, Tomasetti et al.17 compared
three computerised Bolton tooth size analyses
(QuickCeph, OrthoCad, and Hamilton Arch
Tooth System (HATS)) with a conventional manual
measurement method and found that QuickCeph
was the fastest (1.85 minutes) in the time required
to complete a Bolton analysis, followed by HATS
Australian Orthodontic Journal Volume 29 No. 2 November 2013 155
 CELIKOGLU ET AL

Table I. Correlation of the mesiodistal tooth widths measured conventionally and digitally.

Mesiodistal tooth Conventional CBCT Difference

width (mm) PCC
Mean SD Mean SD Mean SD
Maxillary right
Central incisor 8.87 0.61 9.04 0.65 0.17 0.37 0.834
Lateral incisor 6.96 0.69 6.83 0.61 -0.16 0.31 0.891
Canine 7.77 0.47 7.92 0.51 0.15 0.20 0.916
First premolar 7.08 0.46 6.77 0.50 -0.31 0.28 0.838
Second premolar 6.77 0.49 6.56 0.40 -0.21 0.32 0.767
First molar 10.31 0.63 10.55 0.80 0.24 0.46 0.811
Maxillary left
Central incisor 8.95 0.59 9.01 0.57 0.06 0.38 0.789
Lateral incisor 6.83 0.69 6.78 0.62 -0.05 0.31 0.893
Canine 7.68 0.45 7.90 0.55 0.22 0.23 0.911
First premolar 7.05 0.40 6.77 0.51 -0.28 0.32 0.773
Second premolar 6.70 0.48 6.59 0.47 -0.11 0.26 0.850
First molar 10.39 0.61 10.56 0.78 0.17 0.48 0.791
Mandibular right
Central incisor 5.63 0.40 5.66 0.37 0.03 0.24 0.792
Lateral incisor 6.05 0.36 5.89 0.42 -0.16 0.17 0.814
Canine 6.79 0.38 6.84 0.44 0.05 0.29 0.757
First premolar 7.10 0.49 6.80 0.59 -0.30 0.38 0.774
Second premolar 6.99 0.42 7.03 0.65 0.04 0.50 0.637
First molar 10.81 0.74 11.13 0.78 0.32 0.48 0.804
Mandibular left
Central incisor 5.61 0.36 5.54 0.33 -0.07 0.25 0.885
Lateral incisor 6.01 0.39 5.93 0.41 -0.08 0.26 0.782
Canine 6.81 0.38 6.84 0.44 0.03 0.24 0.833
First premolar 7.09 0.50 6.75 0.59 -0.34 0.33 0.832
Second premolar 7.10 0.47 6.96 0.59 -0.14 0.33 0.829
First molar 10.76 0.73 10.95 0.80 0.19 0.49 0.798
PCC > 0.750 shows acceptable correlation

Table II. Anterior and overall tooth size ratios measured conventionally and digitally.

Tooth size ratios Conventional CBCT PCC Paired t-test

Mean and SD Mean and SD
Anterior ratio 78.69 ± 3.34 77.58 ± 2.71 0.756 0.018
Overall ratio 91.27 ± 3.10 90.69 ± 2.21 0.781 0.184
PCC > 0.750 shows acceptable correlation

156 Australian Orthodontic Journal Volume 29 No. 2 November 2013


(3.40 minutes), OrthoCad (5.37 minutes), and the
conventional method (Vernier caliper) (8.06 minutes).
Although QuickCeph was the fastest to produce a
result, it offered the lowest correlation with manual
measurement (PCC value for anterior and overall
discrepancies were 0.439 and 0.432, respectively) and
was therefore considered the most inaccurate.
The beneficial use of CBCT in dentistry is
increasingly being documented.19,20 Although several
reports3,13,14,21,22 have substantiated the reliability and
accuracy of angular and linear measurements, few
have focused on dental measurements.3,13,22 Nguyen et
al.22 tested the accuracy and reproducibility of CBCT
in predicting the mesiodistal diameter of unerupted
teeth and found that CBCT could be used with
confidence as an accurate measurement tool. Kau
et al.13 indicated that CBCT digital models were as
accurate as OrthoCad digital models in performing
measurements of overjet, overbite, and Little’s
irregularity index. The present study was based on
the knowledge that no previous investigation had
compared tooth widths and calculated Bolton ratios
using CBCT and conventional manual plaster cast
methods.
The present study revealed that PCC values for
anterior and overall Bolton ratios generated by CBCT
and conventional methods were 0.756 and 0.751,
respectively. Because few studies have investigated a
Bolton analysis performed and produced by CBCT,
comparison was difficult. However, Bolton’s ratios
have been assessed in different populations and
malocclusion groups.23-26 Tomasseti et al.17 compared
the computerised Bolton analyses performed using
conventional and CT methods and found that the
PCC values were the highest when the HATS method
was used (anterior: 0.825; overall: 0.885) and the
least for QuickCeph (anterior: 0.439; overall: 0.432).
The CBCT method showed a high correlation
(anterior: 0.756; overall: 0.751) as did the HATS
method. Tarazona et al.27 evaluated the reliability
and reproducibility of calculating the Bolton index
using CBCT and a two-dimensional digital method
and showed that the Bolton ratio calculated from 3D
models obtained from the CBCT was as accurate and
reproducible as the ratio calculated on digital models
obtained from plaster casts.
The high correlation coefficients for the Bolton ratios
found in the present study were also compared with
CBCT and conventional methods by means of a
BOLTON RATIOS FROM CONE BEAM COMPUTED TOMOGRAPHY
paired t-test. The statistical results indicated that the
difference in the overall ratio was insignificant (p =
0.184), but was found to be significant for the anterior
ratio (p = 0.018). However, as the difference in the
anterior ratio between the groups was only 1.1%, it
was unlikely to be of clinical significance.28
An additional significant finding of the present
study was the high correlation in the measured
mesiodistal diameter of respective teeth, except for
the mandibular right second premolar. While few
studies have compared tooth widths measured on
CBCT and plaster models, El-Zanaty et al.2 assessed
the accuracy of dental measurements performed on
CT and plaster models. It was considered that a three-
dimensional dental measurement method was a viable
alternative to caliper measurements on a conventional
plaster model, as fair agreement (PCC < 0.75) was
established for several teeth (maxillary right and left
second premolar, right first molar, left central incisor,
and the mandibular left and right central incisors,
right canine and left first premolar). The present
study found high intra-class correlation coefficients
using the Houston method,16 which confirmed the
reliability of the measurements determined by both
methods (0.92 - 0.97 for the conventional method
and 0.94 - 0.99 for CBCT method). El-Zanaty et al.2
also found higher intra-class correlation coefficients,
using 3D virtual models generated from CT scans
(0.954- 0.999 for the CT method and 0.913 - 0.999
for the conventional plaster model).
The operator’s familiarity and skill in sensitively
using a computer mouse are possible contributing
factors affecting the accuracy of all computer-based
measurements of digital casts.2 In the present study,
all measurements were conducted by an experienced
radiologist and PCC scores were found to be high.
Measurement results may be additionally affected
by a systematic error associated with the CBCT
method.3 However, CBCT has been used to measure
the diameter of unerupted teeth in orthodontic
patients more accurately than other methods to date.22
Although the correlation coefficient for the widths of
almost all teeth was high, it was low and unexplained
for several measurements including the width of the
mandibular right second premolar (0.637).
It has been suggested that the conventional plaster
cast recording method could be eliminated by
CBCT measurements and therefore provide a saving
in physical storage space. Although CBCT has an
Australian Orthodontic Journal Volume 29 No. 2 November 2013 157
 CELIKOGLU ET AL
obvious advantage over conventional radiography as it
provides three-dimensional scans,14,29 the higher dose
of radiation is a significant consideration.30 In addition,
the advantages of the CBCT come at an additional
cost compared with traditional radiographs.27
Conclusion
According to the results of the present study, dental
measurements, anterior and overall Bolton ratios
calculated on CBCT showed acceptable PCC values,
indicating that CBCT could be used for dental
measurement and analysis in place of conventional
plaster models.
Corresponding author
Dr Mevlut Celikoglu
Department of Orthodontics
Faculty of Dentistry
Karadeniz Technical University
Trabzon
Turkey
Email address: mevlutcelikoglu@hotmail.com
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Thresholds for clinically significant tooth-size discrepancy. Angle
Orthod 2009;79:740-6.
29. Tarazona B, Llamas JM, Cibrian R, Gandia JL, Paredes V. A
comparison between dental measurements taken from CBCT models
and those taken from a digital method. Eur J Orthod 2013;35:1-6.
30. Lorenzoni DC, Bolognese AM, Garib DG, Guedes FR, Sant’anna
EF. Cone-beam computed tomography and radiographs
in dentistry: aspects related to radiation dose. Int J Dent
doi:10.1155/2012/813768.
The evidence supporting methods of tooth
width measurement: Part I. Vernier calipers to
stereophotogrammetry
Devan Naidu and Terrence J. Freer
School of Dentistry, The University of Queensland, Brisbane, Australia

Measuring tooth widths is a key component of orthodontic treatment planning. Over recent decades, many methods have been
proposed to achieve this purpose. The current review highlights and describes the initial techniques. The evidence behind their
use is presented along with a brief discussion of their benefits and shortfalls. With knowledge and understanding of the accuracy
and limitations of the various measurement methods, the clinician may be better informed and therefore able to select the most
appropriate method for clinical practice.
(Aust Orthod J 2013; 29: 159-163)

Received for publication: June 2013

Accepted: August 2013

Devan Naidu: devannaidu1@gmail.com; Terrence Freer: t.freer@uq.edu.au

Introduction derived from plaster casts with those obtained by

Measuring tooth widths and performing a Bolton
tooth-size analysis is a common task in orthodontic
diagnosis and treatment planning. It is desirable to
detect any disproportionately-sized teeth early so that
they can be appropriately considered in a treatment
plan. Various methods have been proposed to provide
tooth measurements. However, with the many choices
available, confusion exists over the most suitable
method to employ. Therefore, the aim of the present
paper is to provide an overview of the initial techniques
and highlight their accuracy and usefulness.
Vernier calipers
Traditionally, tooth-size analyses have been performed
manually on plaster study casts.1 Mesio-distal tooth
widths have been measured using Vernier calipers
(Boley gauge) or needlepoint dividers2,3 which Bolton
used in his original article.4 Shellhart et al. assessed
the reliability of a Bolton analysis conducted using
these two instruments and found that the Boley gauge
was slightly more reliable than needlepoint dividers.5
Zilberman et al. compared caliper measurements
removing and measuring artificial teeth from a
master setup.6 The results showed that tooth width
readings were highly correlated (R = 0.929 - 0.988)
from which the authors concluded that measurements
made on study models with calipers were accurate
and repeatable.6 Quimby et al. demonstrated that
there was no significant difference (p > 0.05) between
measurements made manually on plaster casts
and those made on an original dentoform setup.7
The mean discrepancies were within 0.18 mm.7
Therefore, Vernier calipers are currently regarded
as the ‘gold standard’ for performing tooth width
measurements.2, 8-13
Holography
Holography uses a laser light to reproduce a 3D image
of a dental cast. In 1990, Buschang et al. assessed the
accuracy of holograms by comparing tooth width
measurements carried out on study casts using calipers,
with those carried out on holographic images using a
viewer.14 The results showed that the random errors of
measurement on a hologram can be twice as great.14

© Australian Society of Orthodontists Inc. 2013 Australian Orthodontic Journal Volume 29 No. 2 November 2013 159
 NAIDU AND FREER
However, differences in tooth size were not statistically
significant.14 The authors concluded that, when used
for quantitative measurements, holograms should be
at least as accurate as photocopies and photographs.14
In 1991, Rossouw et al. used a reflex metrograph to
perform measurements on holographic images.15 A
hologram was first constructed using a 25 mW Helium
Neon Laser directed at a holographic plate.15 A reflex
metrograph, as described by Takada et al.,16 was then
used to measure 3D co-ordinates on the hologram.15
Rossouw et al. found that measurements made using
this method were comparable with those made with
Vernier calipers.15 Mean measurement differences did
not exceed 0.5 mm and the authors concluded that, in
principle, holography is a satisfactory and efficient way
to record and preserve orthodontic study models.15
In 1995, Romeo further discussed the technique of
holography and alluded to the storage dilemma faced
by orthodontists who have the long-term medico-legal
requirement to retain patient records.17 Holographic
films may be the solution to the problem but have
limitations. 17 Keating et al. stated that the images were
difficult to produce and could not be manipulated as
easily as plaster models.18 In addition, Rossouw et al.
acknowledged that the processing and measurement
of holograms was intricate and expensive, which may
hinder effective clinical use.15
Digitised photocopies and scanners
Studies evaluating digitised photocopies and scanned
images have yielded mixed results. Yen was the
first to introduce a method in which study casts
were photocopied and key landmarks digitised.19
A computer program was subsequently run which
displayed tooth-size values and Bolton ratios.19 Yen
stated that, because the direct measurements of a 3D
object had the high potential for error and variability,
measurements on a 2D transfer were easier and could
provide more consistent results.19 However, following
Yen’s publication, Champagne determined that
photocopies were an unreliable method for arch length
measurement and space analysis.20 In 1997, Schirmer
and Wiltshire also evaluated computer-aided space
analysis in which models were photocopied using a
photostat machine (Xerox, Japan). Mesio-distal tooth
sizes were digitised and the results processed with a
dedicated computer program.21 It was found that,
when compared with measurements obtained using
Vernier calipers, the digitised measurements differed
160 Australian Orthodontic Journal Volume 29 No. 2 November 2013
significantly (p < 0.001) as 19 of the 24 teeth were
recorded as smaller.21 Hence, it was affirmed that
accurate measurements could not be made from
photocopies of dental casts.21 However, in 2006,
Paredes et al. re-evaluated digitisation and scanned
100 dental casts.1 The scanner (Hewlett Packard
Scan Jet µc*/T, Houston, TX, USA) was calibrated
and tooth sizes measured using a computer mouse.1
A software program then determined dental sizes in
millimetres and automatically calculated the Anterior
Bolton Index (ABI) and Overall Bolton Index
(OBI).1 A comparison of tooth widths yielded very
low coefficients of variation which indicated that
the digital and traditional methods produced similar
results.1 In addition, there was concordance in 90
cases for the ABI, and for the OBI, concordance was
found in 97 cases.1 The discordances were small, and
maximum discrepancies of 1.5% for the ABI and 1%
for the OBI were judged to be clinically insignificant.1
Hence, the authors suggested that the proposed digital
method was as sensitive and accurate as calipers for
calculating Bolton indices.1
Digitised photocopies and scanned images offer many
advantages. Yen believed that a competent assistant
could be trained to digitise the landmarks and generate
a space analysis, which saves the orthodontist valuable
time.19 Paredes et al. stated that the use of scanned
images to calculate Bolton ratios was faster and easier
to perform.1 The main disadvantage of photocopies
and scanned images was their 2D representation of
a 3D object.20 Schirmer and Wiltshire stated that
measurement errors may arise from several sources
including the convex structure of teeth, the curve of
Spee, differences in tooth inclinations, deviations of
tooth axes from the perpendicular, and crowded tooth
positions.21
Digital calipers
Digital calipers have been recently introduced
(Figure 1) and these may be linked to a computer
for efficient data transfer.2 Ho and Freer advocated
their use to perform tooth width measurements.22 It
was stated that the use of digital calipers with direct
input into a computer program can virtually eliminate
measurement transfer and calculation errors,
compared with analyses which require dividers, rulers
and calculators.22

Figure 1. Measurement with digital calipers.33 Figure 2. Digitisation on the DigiGraph™
Workstation.23
Figure 4. (a) Laser scanning and (b) the generated 3D graphic of the dental model.25,26
Sonic digitisation
Mok and Cooke in 1998, evaluated the use of sonic
digitisation as a method of measuring tooth widths.23
Dental casts were placed on a DigiGraph Workstation
(DigiGraph, Dolphin Imaging Systems, CA, USA)
and digitised.23 The measurements were taken by
positioning the tip of a digitising handpiece on a
chosen landmark and pressing a trigger (Figure 2).23
The results showed that the system consistently over-
estimated mesio-distal tooth widths by 1 mm in the
mandible and 0.5 mm in the maxilla.23 Therefore,
caution was recommended when using sonic
digitisation for space analysis.23
Digital photographs
Lowey in 1993, evaluated the IMSCAN method
which used a video camera linked to a computer to
acquire digital images of study casts.11 The captured
images were displayed on a monitor and arch segments
and tooth widths subsequently measured.11 The
results revealed that the IMSCAN method tended to
‘over-measure’ teeth.11 Although this was statistically
METHODS OF MEASURING TOOTH WIDTH: PART I
Figure 3. Occlusal photograph with a modified lip
retractor.24
significant, the measurements were clinically
comparable with those obtained using calipers.11
In 2009, Naidu et al. re-evaluated the use of digital
photographs of plaster models taken and transferred to
a computer for measurement.8 The results supported
those of Lowey8,11 who indicated that tooth widths
tended to be over-estimated (mean - 0.07 mm larger).
The difference was statistically significant but the
accuracy of digital photographs was still considered
to be clinically acceptable.8 Normando et al. acquired
photographs of the dentition with occlusal rulers
attached to acrylic retractors (Figure 3).24 It was found
that the photographic measurements had acceptable
accuracy for clinical purposes.24 Eighteen of the 24
tooth width measurements were not statistically
different to the caliper recordings.24 Of the 6 that
were, the discrepancy was deemed to be minor (range:
0.13 – 0.33 mm).24
Naidu et al. stated that digital photographs offer
an advantage as the technology is accepted, readily
available, and practitioners are familiar with the
basic equipment.8 Photography is advantageous in
situations in which clinicians are assessing isolated
Australian Orthodontic Journal Volume 29 No. 2 November 2013 161
 NAIDU AND FREER
populations or patients with orthodontic appliances.24
However, Lowey identified the curve of Spee as a
potential source of error in photographs.11 It was
determined that an exaggerated curve of Spee would
under- or over-score tooth width measurements when
teeth were below or above the level of calibration,
respectively.11 Two-dimensional images also have
inherent visualization limitations as landmarks in
crowded arches are easily obscured when viewing a
study cast from above.11 As an example, the inaccurate
measurement of a mesially-inclined maxillary canine
whose mesial margin is likely obscured to any system
which viewed the canine from above (occlusally).11
Laser scanning
In 1996, Kuroda et al. introduced a newly-developed
3D dental cast analysing system which used laser
scanning.25 The unit was comprised of a measuring
device with a slit-ray laser projector, two sets of video
cameras and a personal computer as a controller.25
The dental cast was scanned with a laser beam and
converted into a 3D graphic (Figure 4).25 Conventional
linear and angular measurements were conducted on
the model and the measurement error was found to
be less than 0.05 mm.25 In 1999, Motohashi and
Kuroda proposed an improved laser scanning method
which aimed to eliminate blind sectors. The model
was scanned from two different directions by rotating
a mounted cast.26 Lu et al. introduced the inclusion of
a semi-conductor laser by which two pulsate motors
made movements of the dental cast and allowed 3D
data capture anywhere on its surface.27 The advantages
of the system were its precision, simplicity, high
efficiency, and the ability to supply new information
which could not be generated by other methods.27 To
assess the accuracy of laser scanned casts, Hirogaki et
al. in 2001 compared measurements on computer-
reconstructed models with those on actual casts.28
The differences were within 0.3 mm and hence,
the laser scanning method was considered to be
satisfactory for the purpose of tooth-size analysis.28
Abizadeh et al. in 2012 evaluated the accuracy of the
R250 Scanner (3-Shape, Copenhagen, Denmark) in
making measurements of occlusal relationships and
arch dimensions.29 The results showed that the digital
recordings tended to be slightly smaller for 11 of the
16 parameters assessed; however, these differences
were not clinically relevant.29
162 Australian Orthodontic Journal Volume 29 No. 2 November 2013
Stereophotogrammetry
Ayoub et al. in 1997, introduced the technique of
stereophotogrammetry.30 The system involved the
use of stereo pairs of video cameras connected to a
computer and special coloured illumination to record
dental study models in a digital format.30 In 2003, Bell
et al. conducted a study to evaluate the accuracy of this
method in measuring dental casts.31 Measurements of
the 3D images were obtained to a precision of 0.27
mm.31 This difference was within the operator error
range of 0.1 - 0.48 mm and was not statistically
significant (p < 0.05).31 Therefore, the authors
concluded that the photostereometric technique was
an accurate and reproducible way of measuring dental
study casts. Al-Khatib et al. in 2012, produced similar
findings with mean tooth-size differences between
direct and 3D stereophotogrammetric measurements
ranging from 0.07 – 0.21 mm.32 Although several
statistically significant differences were found, they
were considered to be clinically insignificant.32
Conclusion
Considerable research has been conducted into
different methods of measuring tooth widths and
performing Bolton analyses. The traditional method
of using Vernier calipers on plaster models is still
regarded as the ‘gold standard.’ Earlier techniques
such as holography, digitising photocopies, and
sonic digitisation have demonstrated measurement
errors. However, more contemporary methods such
as the use of digital photographs, laser scanning, and
stereophotogrammetry have been shown to be more
clinically accurate.
Corresponding author
Dr Devan Naidu
School of Dentistry
The University of Queensland
200 Turbot Street
Brisbane Queensland 4000
Australia
Email: devannaidu1@gmail.com
References
1. Paredes V, Gandia JL, Cibrian R. Determination of Bolton tooth-size
ratios by digitization, and comparison with the traditional method.
Eur J Orthod 2006;28:120-5.

2. Othman SA, Harradine NW. Tooth-size discrepancy and Bolton’s
ratios: a literature review. J Orthod 2006;33:45-51; discussion 29.
3. Tomassetti JJ, Taloumis LJ, Denny JM, Fischer JR, Jr. A comparison
of 3 computerized Bolton tooth-size analyses with a commonly used
method. Angle Orthod 2001;71:351-7.
4. Bolton WA. Disharmony in tooth size and its relation to the analysis
and treatment of malocclusion. Am J Orthod 1958;28:113-30.
5. Shellhart WC, Lange DW, Kluemper GT, Hicks EP, Kaplan AL.
Reliability of the Bolton tooth-size analysis when applied to crowded
dentitions. Angle Orthod 1995;65:327-34.
6. Zilberman O, Huggare JA, Parikakis KA. Evaluation of the validity
of tooth size and arch width measurements using conventional
and three-dimensional virtual orthodontic models. Angle Orthod
2003;73:301-6.
7. Quimby ML, Vig KW, Rashid RG, Firestone AR. The accuracy and
reliability of measurements made on computer-based digital models.
Angle Orthod 2004;74:298-303.
8. Naidu D, Scott J, Ong D, Ho CT. Validity, reliability and
reproducibility of three methods used to measure tooth widths for
Bolton analyses. Aust Orthod J 2009;25:97-103.
9. Stevens DR, Flores-Mir C, Nebbe B, Raboud DW, Heo G, Major
PW. Validity, reliability, and reproducibility of plaster vs digital study
models: comparison of peer assessment rating and Bolton analysis
and their constituent measurements. Am J Orthod Dentofacial
Orthop 2006;129:794-803.
10. Santoro M, Galkin S, Teredesai M, Nicolay OF, Cangialosi TJ.
Comparison of measurements made on digital and plaster models.
Am J Orthod Dentofacial Orthop 2003;124:101-5.
11. Lowey MN. The development of a new method of cephalometric
and study cast mensuration with a computer controlled, video image
capture system: Part I. Br J Orthod 1993;20:203-14.
12. Santoro M, Ayoub ME, Pardi VA, Cangialosi TJ. Mesiodistal crown
dimensions and tooth size discrepancy of the permanent dentition of
Dominican Americans. Angle Orthod 2000;70:303-7.
13. Horton HM, Miller JR, Gaillard PR, Larson BE. Technique
comparison for efficient orthodontic tooth measurements using
digital models. Angle Orthod 2010;80:254-61.
14. Buschang PH, Ceen RF, Schroeder JN. Holographic storage of
dental casts. J Clin Orthod 1990;24:308-11.
15. Rossouw PE, Benatar M, Stander I, Wynchank S. A critical
comparison of three methods for measuring dental models. J Dent
Assoc S Afr 1991;46:223-6.
16. Takada K, Lowe AA, DeCou R. Operational performance of the
Reflex Metrograph and its applicability to the three-dimensional
analysis of dental casts. Am J Orthod 1983;83:195-9.
17. Romeo A, Canal F, Roma M, de la Higuera B, Ustrell JM, von
Arx JD. Holograms in orthodontics: a universal system for the
METHODS OF MEASURING TOOTH WIDTH: PART I
production, development, and illumination of holograms for the
storage and analysis of dental casts. Am J Orthod Dentofacial
Orthop 1995;108:443-7.
18. Keating PJ, Parker RA, Keane D, Wright L. The holographic storage
of study models. Br J Orthod 1984;11:119-25.
19. Yen CH. Computer-aided space analysis. J Clin Orthod 1991;25:236-8.
20. Champagne M. Reliability of measurements from photocopies of
study models. J Clin Orthod 1992;26:648-50.
21. Schirmer UR, Wiltshire WA. Manual and computer-aided space
analysis: a comparative study. Am J Orthod Dentofacial Orthop
1997;112:676-80.
22. Ho CT, Freer TJ. The graphical analysis of tooth width discrepancy.
Aust Orthod J 1994;13:64-70.
23. Mok KH, Cooke MS. Space analysis: a comparison between sonic
digitization (DigiGraph Workstation) and the digital caliper. Eur J
Orthod 1998;20:653-61.
24. Normando D, da Silva PL, Mendes AM. A clinical photogrammetric
method to measure dental arch dimensions and mesio-distal tooth
size. Eur J Orthod 2011;33:721-6.
25. Kuroda T, Motohashi N, Tominaga R, Iwata K. Three-dimensional
dental cast analyzing system using laser scanning. Am J Orthod
Dentofacial Orthop 1996;110:365-9.
26. Motohashi N, Kuroda T. A 3D computer-aided design system
applied to diagnosis and treatment planning in orthodontics and
orthognathic surgery. Eur J Orthod 1999;21:263-74.
27. Lu P, Li Z, Wang Y, Chen J, Zhao J. The research and development
of noncontact 3-D laser dental model measuring and analyzing
system. Chin J Dent Res 2000;3:7-14.
28. Hirogaki Y, Sohmura T, Satoh H, Takahashi J, Takada K. Complete
3-D reconstruction of dental cast shape using perceptual grouping.
IEEE Trans Med Imaging 2001;20:1093-101.
29. Abizadeh N, Moles DR, O’Neill J, Noar JH. Digital versus plaster
study models: how accurate and reproducible are they? J Orthod
2012;39:151-9.
30. Ayoub AF, Wray D, Moos KF, Jin JR, Niblett TB, Urquhart C et
al. A three-dimensional imaging system for archiving dental study
casts: a preliminary report. Int J Adult Orthodon Orthognath Surg
1997;12:79-84.
31. Bell A, Ayoub AF, Siebert P. Assessment of the accuracy of a three-
dimensional imaging system for archiving dental study models. J
Orthod 2003;30:219-23.
32. Al-Khatib AR, Rajion ZA, Masudi SM, Hassan R, Townsend GC.
Validity and reliability of tooth size and dental arch measurements: a
stereo photogrammetric study. Aust Orthod J 2012;28:22-9.
33. Mullen SR, Martin CA, Ngan P, Gladwin M. Accuracy of space
analysis with emodels and plaster models. Am J Orthod Dentofacial
Orthop 2007;132:346-52.
Australian Orthodontic Journal Volume 29 No. 2 November 2013 163
 The evidence supporting methods of tooth
width measurement: Part II. Digital models and
intra-oral scanners
Devan Naidu and Terrence J. Freer
School of Dentistry, The University of Queensland, Brisbane, Australia
Digital models and intra-oral scanners are gaining increasing popularity in orthodontic diagnosis and treatment planning by
allowing clinicians to store and ‘virtually’ analyse dental casts. The present paper reviews the various digital model programs and
available intra-oral scanners and presents the research which has tested their accuracy. With this information, clinicians may be
better informed to adopt the most appropriate system.
(Aust Orthod J 2013; 29: 164-169)
Received for publication: June 2013
Accepted: August 2013
Devan Naidu: devannaidu1@gmail.com; Terrence Freer: t.freer@uq.edu.au
Introduction
Recently, digital models and intra-oral scanners have
been introduced to the discipline of orthodontics.
Both offer advantages which can significantly improve
practice efficiency. The aim of this paper is to explore
the evidence supporting the use of digital models and
intra-oral scanners for performing tooth-size analyses.
In addition, the advantages and disadvantages of each
system will be discussed.
3D digital models
Digital study models were first introduced in 1999
by OrthoCAD (Cadent, Carlstadt, NJ, USA) (Figure
1), and were followed in early 2001 by the emodel
system (GeoDigm, Chanhassen, MN, USA).1,2 More
recently, DigiModel (Orthoproof, Nieuwegein, The
Netherlands) (Figure 2) and Lava Digital Models (3M
Unitek, Monrovia, CA, USA) have been released.3-5
Generally, alginate impressions of the patient’s
dentition and a wax registration bite are required in
order to generate the models.2,4,6,7 OrthoCAD and the
emodel system require the impressions to be poured in
plaster to produce study casts which are subsequently
scanned to create a virtual model.2,8 DigiModel
164 Australian Orthodontic Journal Volume 29 No. 2 November 2013
and Lava Digital Models perform direct scanning
of the alginate impression.4,5 Flash computerised
tomography (CT) is used to record the impression
details which removes the need for plaster casts.4,5
Once the digital models have been generated, they are
made available to the practitioner for downloading
from the company’s web site2,7,8 or data files may be
electronically sent to the office.3,6 The clinician is
able to view the 3D models on provided software and
conduct routine measurements such as tooth widths,
overjet, overbite, arch length, arch width, and perform
a Bolton analysis.7
Numerous studies, particularly using the OrthoCAD
system, have evaluated the use and value of 3D
digital models in the analysis of tooth size.1 In 2001,
Tomassetti et al. assessed four methods of calculating
overall and anterior Bolton ratios using 22 sets
of models.9 The mean Vernier caliper values were
compared to values derived from 3 computerised
methods including QuickCeph (QuickCeph
Systems, CA, USA), the Hamilton Arch Tooth
System (HATS) (GAC International, NY, USA) and
OrthoCAD.9 No statistically significant differences
in Bolton ratios existed between the methods
(p < 0.05).9 However, clinically significant differences
© Australian Society of Orthodontists Inc. 2013

Figure 1. Measurement of an (a) incisor, (b) canine, (c) premolar, and (d) molar using the OrthoCAD measurement tool; (e and f)
more tooth size measurements; and (g) overjet and overbite measurements after (f) selecting an appropriate plane of section.7,10
Figure 2. Measuring the first permanent molar with DigiModel.3
(> 1.5 mm) were evident for all methods.9 QuickCeph
was the fastest in performing the analyses (1.85
minutes) followed by HATS (3.40 minutes),
OrthoCAD (5.37 minutes), and Vernier calipers (8.06
minutes).9 The authors concluded that time-efficient
computerised methods are available to perform
Bolton analyses but accuracy might be compromised.9
METHODS OF MEASURING TOOTH WIDTH: PART II
Zilberman et al. in 2003, assessed the accuracy of
measuring casts with OrthoCAD compared with
caliper measurements.10 The software measurements
were highly correlated (R = 0.763 – 0.975) with no
statistically significant differences.10 In addition,
inter- and intra-observer errors were small.10 The
OrthoCAD measurement tool therefore showed high
accuracy and reproducibility which was considered to
be clinically acceptable.10 Santoro et al. reported that
OrthoCAD’s tooth width measurements were slightly
smaller than those of manual measurements.7 The
magnitude of these differences ranged from 0.16 mm
to 0.38 mm and were considered clinically irrelevant.7
In 2004, Quimby et al. found that OrthoCAD’s
measurements differed statistically and were found to
be slightly larger.6 Furthermore, there was significantly
greater variance associated with measurements made
on the computer-based models.6 Despite this, it
was concluded that the accuracy and reliability of
OrthoCAD appeared to be clinically acceptable.6
In an assessment of the emodel system, Stevens et
al. compared plaster casts with digital models for
recording tooth widths and performing a Bolton
analysis.2 The reproducibility of digital models using
the concordance correlation coefficient was found
to be excellent in most cases.2 Mean tooth width
Australian Orthodontic Journal Volume 29 No. 2 November 2013 165
 NAIDU AND FREER
differences ranged from 0.01 to 0.21 mm between the
two methods and a half of the results were statistically
significant.2 Emodel measurements were larger and
smaller than plaster measurements in almost equal
proportions.2 Bolton anterior and overall ratios were
not statistically different (p = 0.790 and p = 0.084,
respectively).2 The authors concluded that emodels
were a clinically acceptable replacement of plaster casts
for routine orthodontic measurements.2 Mullen et al.
in 2007, assessed the accuracy and speed of performing
a Bolton analysis using emodel compared with hand-
held plaster models.11 The results showed that there
was no statistically significant difference between the
Bolton ratios calculated using the two methods.11 The
mean difference was 0.05 ± 1.87 (p = 0.86).11 It also
took less time to calculate the Bolton ratio using the
emodel system by an average of 65.6 seconds.11 Mullen
et al. determined that calculating a Bolton ratio using
the emodel system is just as accurate, and significantly
faster, than the manual method of using calipers to
measure plaster models.11 In 2010, Horton et al. found
that when used to measure mesial-distal tooth widths,
the emodel system produced a small positive bias or
over-estimation of tooth sizes.12 However, the authors
acknowledged that this bias was small and should not
restrict the clinical use of the digital technique.12
The first study evaluating DigiModel in measuring
tooth widths and performing Bolton analyses was
published by Naidu et al. in 2009.3 The results
indicated that DigiModel tended to underestimate
mesio-distal tooth widths by an average of 0.08 mm,
overestimate the overall Bolton ratio by an average of
0.18% and underestimate the anterior Bolton ratio
by an average of 0.43%.3 The Bolton discrepancies
equated to an overall tooth size discrepancy (TSD) of
0.18 mm and an anterior TSD of 0.24 mm, which
was considered to be clinically insignificant.3 The
reliability and reproducibility of DigiModel was
found to be excellent.3
Published research has indicated that the mean
discrepancy between digital model and plaster
measurements is low.1 Statistically significant
tooth-size differences between the studies has been
found to be equivocal.12 Nevertheless, all studies
have considered that the differences were clinically
insignificant.1 Computer models were also deemed
to be reliable and reproducible, which has rendered
3D digital models a clinically acceptable substitute for
traditional plaster casts.12
166 Australian Orthodontic Journal Volume 29 No. 2 November 2013
3D digital models offer a number of advantages:
1. Archiving: Storage space is negligible.13 Hundreds
of models can be stored on a portable hard drive or
a DVD.6 This will solve or alleviate the problems
associated with storing plaster casts.14
2. Integration: Joffe15 and Asquith et al.13 stated
that digital models can be easily integrated
into a patient’s electronic file along with digital
photographs, radiographs and clinical notes.
3. Instant retrieval: Retrieval is fast and efficient.
Patient records can be accessed instantly via a
computer without the need to search and retreive
plaster models.1,2
4. Viewing: Images can be viewed at multiple
locations.13 In addition, the zoom function
exaggerates features that would not normally be
noticeable on plaster casts.2 This may be helpful in
detecting extra information.2 Furthermore, virtual
models create no physical barrier in the placement
of measurement points or calipers between the
teeth.2 Therefore, provided that landmarks are
carefully selected, it is reasonable to accept that
digital measurements may be more accurate.2
5. Transfer of files: Virtual images may be sent
anywhere in the world for instant referral,
consultation, or, with permission, for use by
internet study clubs.1,2
6. Saves money: Monthly storage costs associated
with plaster models are avoided.2
7. Diagnostic setups: Accurate and simple diagnostic
setups of various extraction patterns can be
performed.2
8. Speed: Proffit et al. emphasised that an advantage
of digitising models is the ability of the computer
to quickly perform a tooth-size analysis.16 When
calculating Bolton ratios from plaster models,
it is necessary to document the measurements
and make calculations with either a calculator or
computer.11 However, using computer software,
the analysis can be done electronically which
creates a digital time advantage.11
9. Patient appeal: Zilberman et al. stated that 3D
digital models may appeal to patients as modern
dental care.10 Younger patients especially, may
relate to the technology.17
10. Durability: Durability is a disadvantageous factor
related to plaster casts.12 Through repeated use
and measurement, a plaster cast may be damaged
or broken.12 However, digital models can be

virtually manipulated and sectioned without
being permanently altered.12
3D digital models have several limitations:
1. Lack of tactile input: Digital models cannot
be held and assessed in the same way as plaster
casts.7,13
2. Learning curve: Familiarisation with the
appropriate software takes time.13 The learning
curve for the software is often steep but short-
lived.2
3. 2D viewing: Although the model is 3D, the image
can only be viewed on a 2D screen.13
4. Failure: Computer failure, software failure, or
manufacturer insolvency can possibly mean that
the models may become inaccessible.6
Intra-oral scanners
The latest introduction to dentistry has been the intra-
oral scanner. It is a chair-side unit which allows the
clinician to obtain a virtual impression of the patient’s
oral cavity. Using a handheld camera, the geometry of
the dentition can be captured to instantly produce a
3D image of the patient’s teeth and occlusion.
In September 2009, Cadent introduced an iOC intra-
oral scanner (Figure 3) which uses parallel confocal
imaging to digitally record the surfaces and contours
of the teeth and gingiva.18,19 The unit employs a
combination of laser and optical scanning to capture
information without the need for surface pre-coating
with titanium oxide powder.19
The iOC scanner offers several advantages:
1. Comfort: Taking conventional impressions can be
stressful for the practitioner and uncomfortable
for a young patient.20 Digital impressions can
Figure 3. (a) The iOC scanner; (b) during active scanning the area of interest appears on the monitor.19,21
METHODS OF MEASURING TOOTH WIDTH: PART II
overcome this problem by removing the ‘gag
factor’.19
2. Real-time display: The virtual impression is
instantly available for immediate patient and
parent consultation and efficient treatment
planning.19
3. Accuracy: Cadent claims superior accuracy with
the iOC scanner.19
4. Going green: The environmental ‘footprint’
of digital impressions is significantly smaller
than traditional impressions.20 The disposal of
a substantial volume of plastic impression trays
and impression material can be environmentally
avoided.20
5. Increased productivity: Following digital
impressions, surgery preparation is much quicker
as there is no impression debris to clean up and
no forms or packaging to arrange for laboratory
delivery.21
6. Cleft lip and palate patients: Asquith and McIntyre
stated that the development of intra-oral scanning
and 3D digital modelling may offer the potential
to eliminate the need for serial impressions
during childhood and adolescence, particularly as
compliance for impression taking in patients with
clefts is reduced.13
The iOC system also has disadvantages:
1. Cost: The initial investment cost of the machine is
significant and needs to be considered carefully.20
2. Learning curve: As with all new technology a
learning curve is present.21 However, Cadent
provides in-office training for staff.19,20 Similarly,
Figure 4. The Lythos Digital Impression
System.30
Australian Orthodontic Journal Volume 29 No. 2 November 2013 167
 NAIDU AND FREER
intuitive software and automated prompts allow
the iOC to guide the user through the scanning
sequence.22
3. Time: According to Cadent, after mastering
the technique, full arches can be scanned in 6-8
minutes.19,22 Within a minute, the system builds a
preview 3D model with the teeth articulated.23
The only published orthodontic study which has
evaluated the use of the iOC scanner was presented
by Naidu et al. in 2013. It was found that teeth
measured using the iOC/OrthoCAD system were, on
average, 0.024 mm larger than those measured with
calipers.24 Although this difference was statistically
significant (p = 0.0083), it was deemed to be clinically
insignificant.24 Most of the tooth width differences
(98.2%) were within 0.5 mm.24 Furthermore,
there was an equal number of overestimates and
underestimates of tooth widths, indicating that the
0.024 mm bias was not consistent.24 The accuracy of
the Bolton ratios produced digitally was also judged to
be clinically acceptable.24 The reliability of the system
was excellent with replicates strongly correlated (r =
0.99), and the intra-class correlation coefficient scores
for reproducibility exceeded 87%.24 The authors
concluded that the iOC/OrthoCAD system was a
reliable and effective orthodontic aid.24
The Lava Chairside Oral Scanner (C.O.S.) (3M
ESPE) was released in February 2008.25,26 The Lava
C.O.S. consists of a mobile cart containing a CPU,
a touch screen display, and a scanning wand which
has a camera at the tip containing 192 blue LED cells
and 22 lens systems.26 Powder coating of the dentition
with titanium oxide is necessary for data capture.27
Active Wavefront Sampling and ‘3D in Motion’
technology are used for recording 3D impressions.26
The user captures continuous 3D video images
to create a virtual impression in real-time on the
monitor.25,28 After scanning, the electronic files are
sent via the internet to the company for processing
into digital models.29 These can then be downloaded
and subsequently analysed by the orthodontist using
the DigiModel software.29 There is also the option
of printing the virtual models as stereolithographic
(SLA) casts.28 SLA models made from epoxy resin
can be generated and sent to the clinician if physical
copies are required.29
Recently, two studies testing the accuracy of the Lava
C.O.S. have been published. Cuperus et al. in 2012,
compared measurements obtained on digital and SLA
168 Australian Orthodontic Journal Volume 29 No. 2 November 2013
models generated from scanning with measurements
made on dry human skulls.29 It was found that of the 44
variables measured, 37 showed statistically significant
differences between the skulls and the SLA models and
15 showed statistically significant differences between
the skulls and digital models (p < 0.05).29 In general,
measurements made on casts produced by an intra-
oral scan tended to be smaller than those obtained
from skulls.29 However, the authors concluded that
these differences were clinically insignificant and
therefore the SLA and digital models were judged to
be clinically valid platforms from which to measure
dental distances and segments.29 In 2013, Wiranto
et al. found that tooth width measurements made
on DigiModels generated with the LAVA C.O.S.
were similar to manual measurements made on
plaster casts.27 Although several of the measurements
showed statistically significant differences (p < 0.05),
none of the differences exceeded 0.2 mm and were
therefore regarded as clinically acceptable.27 When
used to perform Bolton ratios, the two methods were
comparable as none of the Bolton TSDs exceeded 1.5
mm for the entire arch.27 The authors concluded that
the intra-oral scanner is a valid and reliable system for
obtaining dental measurements.27
The most recently-released scanner is the Lythos
Digital Impression System (Ormco) (Figure 4).30 It
was introduced in March 2013.30 However, there are
currently no published studies testing the accuracy of
this machine for orthodontic purposes.
Conclusion
Much research has been conducted into the evaluation
of digital models. The results of these investigations
have generally been positive and show that the
accuracy and reliability of digital models are clinically
acceptable. The latest device is the intra-oral scanner
which shows great promise. However, few studies have
been published evaluating its use in orthodontics and
so, no meaningful recommendations can currently
be made. Therefore, it is concluded that further well-
designed studies are needed in this area.
Corresponding author
Dr Devan Naidu
School of Dentistry
The University of Queensland

200 Turbot Street
Brisbane Queensland 4000
Australia
Email: devannaidu1@gmail.com
References
1. Fleming PS, Marinho V, Johal A. Orthodontic measurements on
digital study models compared with plaster models: a systematic
review. Orthod Craniofac Res 2011;14:1-16.
2. Stevens DR, Flores-Mir C, Nebbe B, Raboud DW, Heo G, Major
PW. Validity, reliability, and reproducibility of plaster vs digital study
models: comparison of peer assessment rating and Bolton analysis
and their constituent measurements. Am J Orthod Dentofacial
Orthop 2006;129:794-803.
3. Naidu D, Scott J, Ong D, Ho CT. Validity, reliability and
reproducibility of three methods used to measure tooth widths for
Bolton analyses. Aust Orthod J 2009;25:97-103.
4. 3M Unitek. Digital imaging solutions. URL: http://solutions.3m.
com/wps/portal/3M/en_US/orthodontics/Unitek Accessed Jul 4
2011.
5. Orthoproof. Orthoproof Australasia: the digital future of
orthodontics. URL: http://www.orthoproof.com.au/index.html.
6. Quimby ML, Vig KW, Rashid RG, Firestone AR. The accuracy and
reliability of measurements made on computer-based digital models.
Angle Orthod 2004;74:298-303.
7. Santoro M, Galkin S, Teredesai M, Nicolay OF, Cangialosi TJ.
Comparison of measurements made on digital and plaster models.
Am J Orthod Dentofacial Orthop 2003;124:101-5.
8. GeoDigm Corporation. Emodel: 3d digital dental models. URL:
http://www.geodigmcorp.com/emodel_services/emodel_by_
geodigm.html
9. Tomassetti JJ, Taloumis LJ, Denny JM, Fischer JR, Jr. A comparison
of 3 computerized Bolton tooth-size analyses with a commonly used
method. Angle Orthod 2001;71:351-7.
10. Zilberman O, Huggare JA, Parikakis KA. Evaluation of the validity
of tooth size and arch width measurements using conventional
and three-dimensional virtual orthodontic models. Angle Orthod
2003;73:301-6.
11. Mullen SR, Martin CA, Ngan P, Gladwin M. Accuracy of space
analysis with emodels and plaster models. Am J Orthod Dentofacial
Orthop 2007;132:346-52.
12. Horton HM, Miller JR, Gaillard PR, Larson BE. Technique
comparison for efficient orthodontic tooth measurements using
digital models. Angle Orthod 2010;80:254-61.
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13. Asquith J, McIntyre G. Dental arch relationships on three-
dimensional digital study models and conventional plaster study
models for patients with unilateral cleft lip and palate. Cleft Palate
Craniofac J 2012;49:530-4.
14. Leifert MF, Leifert MM, Efstratiadis SS, Cangialosi TJ. Comparison
of space analysis evaluations with digital models and plaster dental
casts. Am J Orthod Dentofacial Orthop 2009;136:16.e1-4.
15. Joffe L. OrthoCAD: digital models for a digital era. J Orthod
2004;31:344-7.
16. Proffit WR, Fields HW, Sarver DM. Contemporary orthodontics.
4th edn. St. Louis: Mosby: Elsevier 2007;195.
17. Peluso MJ, Josell SD, Levine SW, Lorei BJ. Digital models: An
introduction. Semin Orthod 2004;10:226-38.
18. Cadent™. Open technology: a timeline of digital innovation. Open,
2010;1:6.
19. Cadent™. iOC™ powered by iTero™: a digitally perfect
orthodontic impression. URL: http://cadent.cnpg.com/video/
flatfiles/1217/
20. Radz G. Clinical impressions of digital impressions. Dental
Economics 2009;99(3).
21. Mitchem C. Why digital impressions? Accuracy and productivity.
Dental Economics 2012;102(1).
22. Cadent™. Cadent iOC powered by iTero. URL: http://www.
cadentinc.com/ioc/ioc.html
23. Jacobson C. Taking the headache out of impressions. Dentistry
Today 2007;74-6.
24. Naidu D, Freer T. Validity, reliability, and reproducibility of the iOC
intraoral scanner: a comparison of tooth widths and Bolton ratios.
Am J Orthod Dentofacial Orthop 2013;144:304-10.
25. ESPE M. Lava™ Chairside Oral Scanner C.O.S. URL: http://
solutions.3m.com/wps/portal/3M/en_US/LavaCOS/3MESPE-
LavaCOS/
26. Birnbaum N, Aaronson H, Stevens C, Cohen B. 3D digital
scanners: a high-tech approach to more accurate dental impressions.
Inside Dentistry 2009;5(4).
27. Wiranto MG, Engelbrecht WP, Tutein Nolthenius HE, van der
Meer WJ, Ren Y. Validity, reliability, and reproducibility of linear
measurements on digital models obtained from intraoral and cone-
beam computed tomography scans of alginate impressions. Am J
Orthod Dentofacial Orthop 2013;143:140-7.
28. Pilsner D. Implementing digital impressions. Journal of Dental
Technology 2009;26-31.
29. Cuperus AM, Harms MC, Rangel FA, Bronkhorst EM, Schols JG,
Breuning KH. Dental models made with an intraoral scanner: a
validation study. Am J Orthod Dentofacial Orthop 2012;142:308-13.
30. Ormco. Lythos Digital Impression System. URL: http://ormco.com/
aao/
Australian Orthodontic Journal Volume 29 No. 2 November 2013 169
 2013 Survey of Australian Orthodontists'
procedures
Peter Miles
Private Practice, Queensland, Australia

Aim: This survey of Australian orthodontists was conducted to assess treatment preferences.
Methods: Email invitations to participate in an online survey were sent to a total of 433 Australian Society of Orthodontists (ASO)
members and 158 replies were received (36% response).
Results: For Class II treatment, most practitioners preferred to wait and treat later but when early treatment was performed, the
Twin Block was the most popular appliance. For fixed appliance treatment, the 0.022 inch slot was the most commonly used
(73%) and the median treatment time was 20 months. The median extraction rate was 23% which was similar to that reported in
a 2008 USA survey. Sequential plastic aligners were used by 73% of respondents and Temporary Skeletal Anchorage Devices
were used by 77%. The most common research question clinicians would like answered related to retention.
Conclusion: The responses were similar Australia-wide but some areas of difference were revealed and discussed.
(Aust Orthod J 201329: 170-175)

Received for publication: July 2013

Accepted: August 2013

Peter Miles: pmiles@beautifulsmiles.com.au

Introduction area and the email addresses of all listed members

The present article describes a nationwide enquiry
conducted of Australian orthodontists and their usage
of various techniques in clinical practice. A survey
regarding early orthodontic treatment was originally
conducted in Queensland to provide evidential data
for presentations to the School Dental Service, general
practitioners and dental therapists and to address
some of the myths and misconceptions regarding
early orthodontic intervention. This served as a pilot
study and a catalyst for the current national survey of
orthodontists.
Methods
The survey was based upon an investigation published
in the Journal of Clinical Orthodontics (JCO).1
There was a focus on early treatment which had the
advantages of keeping the survey short (30 questions)
and to potentially improve the response rate. The
Australian Society of Orthodontists' website (www.
aso.org.au) was accessed through the members’
were entered into the survey. This meant that some
members would not be included (as they had no listed
email address) and some practices would only receive
one survey (as two or more members shared the same
email address). However, it was considered that the
small number missed would not significantly affect
the final outcome.
The online survey tool, Survey Monkey (http://www.
surveymonkey.net) was used to send 433 emails to
ASO members requesting their participation. The
initial response was 121 and a reminder email sent
11 days later resulted in an additional 37, which
produced a total of 158 and a response rate of 36%
over the 16 days of the survey. This compared well
with the JCO response rate of 7% and was therefore
highly likely to be representative of orthodontic
procedures conducted within Australia. The response
rate from all states and territories was similar; however,
the number of responses (due to the smaller number
of orthodontists) from the Northern Territory (1),
the ACT (3) and Tasmania (4) were too small to be

170 Australian Orthodontic Journal Volume 29 No. 2 November 2013 © Australian Society of Orthodontists Inc. 2013
Figure 1. Usage of removable and fixed Class II correctors apart from elastics. SURVEY OF ORTHODONTISTS

0   20   40   60   80   100   120  

Andresen   16  

Bionator   26  

Carriere   1  

Frankel   1  

Headgear   58  

Herbst   52  

Magnaglide   1  

Nance  Anchor   17  

Forsus,  Jasper,  etc.   96  

Teuscher   4  

TSAD  Anchor   11  

Twin  Block   110  

None   3  
 
Figure 1. Usage of removable and fixed Class II correctors apart from elastics.

assessed individually due to the potential for outcome The percentage of adult cases under treatment was
bias. The median was used for all responses rather 20% nationally with little variation between states/
than the average/mean, as the median was less likely territories and consistent with the USA median of
to be affected by extremely high or low responses. 20%. The median age of the youngest child undergoing
However, when a large discrepancy was noted, it treatment was 6 years (range 1 – 9 years), which seems
invited discussion. logical as this is the age anterior crossbites and early
eruptive disorders may become evident. Of presenting
Statistical analysis children, the median percentage of cases receiving
early treatment was 15% while, of the eligible Class II
Responses are reported as percentages but when children, a median of 15% received early treatment.
examining for possible associations between variables, However, early treatment varied slightly between
the Spearman’s rank correlation coefficient for non-
states as demonstrated in Table I, with Queensland
parametric data was calculated (p < 0.05, 2 tailed).
(10%) and South Australia (9%) performing fewer
Analysis was done using Analyse-it software for Excel
early interventions compared with practitioners in
(version 2.26 Excel 12+, Analyse-it Software, Ltd.).
other states.
When asked about the nature of Class II correctors
Results and Discussion (apart from elastics), the most frequent responses
The median age of orthodontists in Australia is 53 indicated that Twin Blocks were the commonly-used
with 21-25 years in practice, which is similar to the removable appliances and spring correctors (such as
USA figure (52 years of age and 21 years in practice). Forsus, Jasper Jumper, Twin force, etc.) were common
The majority of practitioners are males (Australia additions to fixed appliances (Figure 1). This contrasts
84% vs. USA 85%).1 However, of those who had with the USA experience in which the Herbst appliance
not yet reached 10 years of practice, 33% (12 of 36) was significantly more popular than the Twin Block.
were female, which indicated a more recent increase The ‘Other’ appliance category included four
in the proportion of women training as orthodontists. Victorian respondents who used Teuscher appliances

Australian Orthodontic Journal Volume 29 No. 2 November 2013 171

 MILES

Table I. Demographics and appliance preferences (Medians reported and rounded).

National New South Queensland South Australia Victoria Western

Wales Australia

Responses vs. emails sent 158/433 39/133 44/88 10/38 41/113 16/38
Response rate 36% 29% 50% 26% 36% 42%
Age 53 yrs 54 yrs 53 yrs 58 yrs 52 yrs 50 yrs
Gender - Male 84% 90% 80% 80% 78% 94%
Gender - Female 16% 10% 20% 20% 22% 6%
Years in practice 21-25yrs 21-25yrs 21-25yrs >25yrs 21-25yrs 16-20yrs
Orthodontic training
Australia 78% 69% 82% 90% 83% 69%
Canada 1% 3% 0% 10% 0% 0%
India <1% 3% 0% 0% 0% 0%
New Zealand 2% 3% 2% 0% 2% 0%
Singapore <1% 0% 0% 0% 2% 0%
South Africa 2% 5% 0% 0% 0% 6%
UK 9% 10% 14% 0% 7% 13%
USA 6% 8% 2% 0% 5% 13%
Adult cases 20% 20% 20% 15% 15% 20%
Youngest patient seen 6 yrs 6 yrs 6 yrs 6 yrs 6 yrs 6 yrs
% children receiving early Tx 15% 20% 10% 9% 20% 23%
% Class II children receiving Tx 15% 20% 10% 13% 20% 20%
Alignment system (routine)
Pre-adjusted edgewise 90% 95% 98% 40% 92% 94%
Tip-Edge 6% 0% 2% 50% 2% 0%
Edgewise (no prescription) 3% 5% 0% 0% 2% 6%
Sequential Plastic Aligners 1% 0% 0% 10% 2% 0%
Preadjusted prescription
0.022 inch 73% 79% 59% 90% 63% 94%
0.018 inch 24% 21% 34% 10% 38% 0%
Bidimensional or variant 3% 0% 7% 0% 0% 6%
Preferred prescription
Alexander 3% 8% 2% 0% 0% 0%
Andrews 1% 5% 0% 0% 0% 0%
Damon 5% 5% 7% 0% 5% 6%
Hilgers 3% 3% 2% 0% 5% 0%
MBT 45% 45% 60% 50% 30% 50%
Orthos 5% 3% 7% 0% 5% 0%
Roth 34% 26% 16% 50% 53% 38%
Other 4% 5% 5% 0% 3% 6%
Bracket material/type
Stainless steel 94% 97% 95% 100% 88% 88%
Ceramic 83% 87% 86% 90% 73% 81%
Plastic 7% 8% 9% 0% 10% 0%
Gold 8% 8% 16% 0% 0% 6%
Titanium 3% 3% 2% 0% 5% 0%
Self-ligating 47% 54% 27% 10% 58% 81%
Direct bonding 83% 87% 73% 100% 88% 69%
Indirect bonding 17% 13% 27% 0% 12% 31%
Bond failure rate 5% 5% 5% 4% 5% 5%

172 Australian Orthodontic Journal Volume 29 No. 2 November 2013


(or a variation). Nance-anchored appliances (which
could include the Pendulum appliance or the Jones
Jig although not specified) were more commonly used
in Western Australia, South Australia, Tasmania and
Victoria.
When asked about alignment systems, respondents
indicated that Begg and lingual systems were not
routinely used. Pre-adjusted edgewise was the most
popular appliance (89%) followed by Tip-Edge (6%),
non-prescription edgewise (3%) and sequential plastic
aligners (1%). The slot size used by clinicians was
0.022 inch (73%) in preference to an 0.018 inch slot
(24%) while 3% used bi-dimensional attachments
(in Queensland and Western Australia) or a variant
using an 0.022 inch attachment on the molars only.
This varied by state as an 0.018 inch slot was used
by respondents in Queensland, New South Wales and
Victoria. The preferred prescription was dominated
by MBT (45%) and Roth (34%). Less frequently used
were Orthos and Damon prescriptions (both 5%)
and other prescriptions comprising the remainder.
It is interesting to note the longevity of the Roth
prescription compared with the Andrews prescription
in Australia and the USA. The preference for the
0.022 inch slot over the 0.018 inch slot may also
be influenced by prescription and bracket type. For
example, the use of MBT prescription and Damon
brackets in the USA (which both prescribe 0.022 inch
slot brackets) increased from the 2002 JCO survey to
2008 with a subsequent increase in 0.022 inch and
decrease in 0.018 inch by approximately 8% each.
The survey replies indicated that the preferred bracket
materials were either stainless steel (94%) or ceramic
(83%) with only small numbers of plastic, gold and
titanium brackets making up the remainder. Self-
ligating brackets were used by 47% of practitioners.
Most preferred the direct bonding of attachments
(83%) while the remaining 17% preferred indirect
bonding which is slightly higher than the USA
average of 13% reported in 2008.1 However, there
were regional variations as Western Australia (31%)
and Queensland (27%) respondents indicated a
higher proportion of orthodontists used indirect
bonding while 100% of respondents in South
Australia preferred direct bonding. Similar to the JCO
survey,1 the median bond failure rate was 5% which
was independent of the bonding technique employed.
The treatment time in fixed appliances was similar
in all states, with the national median being 20
SURVEY OF ORTHODONTISTS
months (Table II). The most common and median
appointment interval was 6 weeks (57%) and the
next most common was 8 weeks (25%) although
this ranged from 4 to 12 weeks. When asked details
regarding extraction rates of adult teeth (not including
third permanent molars), the median response was
23%, with a large range between individuals of 4%
to 80%. The median extraction rate varied by state
with South Australia and Western Australia revealing
the highest median extraction rate of 30%. It could be
surmised that a bias towards the higher use of Tip-Edge
(which was only used by practitioners who had been
in practice for 21 or more years) in South Australia
may be a factor, but this was not the case as the
extraction rate for Tip-Edge users was slightly lower in
South Australia (28%) and nationally (26%). Age was
also not a factor (Spearman’s correlation rs = -0.04,
95% confidence interval = -0.20 to 0.11, p = 0.5973).
Despite South Australia and Western Australia having
the highest median extraction rates (30%) and lowest
median treatment times (18 months), there was a
weak association between a higher extraction rate and
an increased median treatment time which would
be expected (Spearman’s correlation rs = 0.23, 95%
confidence interval = 0.08 to 0.38, p = 0.0035).
The use of Sequential Plastic Aligners (SPA) was
relatively common as 73% of respondents indicated
their use in treating a median number of 8 cases (range
0 to 300) in the past 12 months. This varied by state
as South Australia had the lowest median usage rate
by practitioners (50%) compared with New South
Wales (82%) and Queensland (80%) indicating the
highest uptake. Victoria (5) and New South Wales
(5.5) had the lowest median number of SPA cases
per practitioner while Western Australia (13) and
Queensland (10) treated the highest number of cases
per practitioner during the preceding 12 months.
The results regarding the use of SPAs is an excellent
example of misleading statistics as the average number
of cases treated by New South Wales (21), Western
Australia (39) and South Australia (65) practitioners
was significantly higher than the median (6, 13 and 8
respectively). This was likely due to higher usage by
individual practices. The median treatment time for
SPA was 18 months. The slightly shorter treatment
time compared with fixed appliances may suggest
that SPAs are used on simpler cases involving fewer
extractions. This is supported by a weak negative
correlation between extraction rate and the use of
Australian Orthodontic Journal Volume 29 No. 2 November 2013 173
 MILES

Table II. Treatment, scheduling and retention (Medians reported and rounded).

National New South Queensland South Australia Victoria Western

Wales Australia

Median treatment time - fixed 20 mths 20 mths 19 mths 18 mths 21 mths 18 mths
Normal appointment interval 6 wks 6wks 6wks 6wks 6wks 6wks
4 weeks 7% 13% 9% 0% 2% 6%
5 weeks 7% 3% 7% 0% 12% 13%
6 weeks 57% 64% 64% 80% 44% 38%
8 weeks 25% 18% 20% 10% 34% 38%
10 weeks 3% 3% 0% 0% 5% 6%
12 weeks 1% 0% 0% 10% 0% 0%
Extraction rate (not 8s) 23% 20% 20% 30% 25% 30%
Sequential Plastic Aligner users 73% 82% 80% 50% 66% 63%
Median SPA cases last 12 months 8 6 10 8 5 13
Median treatment time – SPA 18 mths 17 mths 18 mths 15 mths 18 mths 18 mths
Usage of TSADs 77% 82% 80% 60% 73% 88%
Median TSAD cases last 12 months 5 5 5 2 3 10
Placement of TSADs
Orthodontists 61% 81% 66% 50% 50% 43%
Oral Surgeons 29% 9% 34% 50% 40% 36%
Periodontists 7% 3% 0% 0% 10% 14%
Dentist/Prosthodontist 2% 6% 0% 0% 0% 7%
Median TSAD failure rate 20% 18% 25% 23% 20% 20%
Maxillary retainers
Hawley/Plate 47% 41% 34% 30% 78% 31%
Clear plastic/Invisible 80% 82% 89% 100% 56% 100%
Bonded 53% 67% 60% 80% 39% 25%
Mandibular retainers
Plate/spring aligner 27% 18% 11% 30% 44% 31%
Clear plastic/Invisible 47% 54% 48% 90% 22% 81%
Bonded 3-3 or similar 81% 95% 86% 80% 63% 75%
Banded 3-3 or similar 2% 5% 5% 0% 0% 0%
None 1% 0% 0% 0% 2% 0%
Other retention strategies
Fibreotomy/CSF 27% 15% 32% 20% 31% 29%
Stripping 83% 96% 76% 70% 81% 86%
Over-correction 41% 33% 42% 50% 50% 21%
Retention period
1-2 years 4% 10% 2% 0% 5% 0%
3-5 years 22% 10% 25% 50% 20% 19%
6-10 years 3% 3% 2% 0% 2% 0%
11+ years 3% 5% 5% 0% 0% 0%
Lifetime 68% 72% 66% 50% 73% 81%

174 Australian Orthodontic Journal Volume 29 No. 2 November 2013


SPAs (Spearman’s correlation [rho] = -0.31, 95%
confidence interval = -0.44 to -0.16, p < 0.001). It is
also reflected in the JCO study which found that the
majority of patients treated with a SPA in the USA
were Class I crowded or spaced cases.1
Temporary Skeletal Anchorage Devices (TSADs) were
used by 77% of practitioners who indicated a median
usage rate of five per year. This varied by state with
88% of the Western Australian practitioners but only
60% of respondents in South Australia indicating their
use. This compares favourably with the JCO survey in
2008 in which 61% of practitioners in the USA used
TSADs on a median of three cases in the previous
year. Sixty-one per cent of the TSADs were placed by
the treating orthodontist (43% in 2008 JCO), 29%
by oral surgeons, and the remainder by periodontists
(7%) and dentists/prosthodontists (2%). The median
reported failure rate was 20%, which is similar to that
reported in the current literature2 but higher than the
results of the JCO survey1 of 5% (2% failures, 3%
loose).
Clear plastic/invisible retainers were the most
frequently used maxillary retainer (80%) ahead of
bonded palatal wires (53%) and Hawley appliances
or their variations (47%). A bonded lingual wire was
the most popular form of retention in the lower arch
(81%) followed by clear plastic/invisible retainers
(47%) and lower Hawley or spring aligner appliances
(27%). Lower banded canine-to-canine retainers
were used by 2% of respondents and 1% reported
occasionally using no retention. Other strategies
that were sometimes employed to improve stability
included interproximal stripping (83%), over-
correction (41%), and fibreotomy/circumferential
supracrestal fibreotomy(CSF)/pericision (27%).
Fraenectomy for diastemata was mentioned in the
‘Other’ category by one respondent. The majority of
orthodontists recommended lifetime retention (68%)
while the next most common recommendation was
3-5 years (22%).
When respondents were asked to suggest research
questions for consideration, the responses varied but
could be grouped into several basic categories. By far
the most common concerns were topics related to
retention and stability (22 of 88 or 25%). Themes
related to oral hygiene and risks associated with long
term fixed retainers and the most effective retention
strategies were frequent questions. In addition,
the relative stability of expansion versus extraction
treatment required clarification.
SURVEY OF ORTHODONTISTS
The efficacy of new technologies and their claims
regarding accelerating treatment (10%) were issues
of practitioner concern. The technologies included
robotically bent wires, vibrational appliances and
self-ligating brackets which were topics of interest, as
claims are made regarding accelerated treatment but
usually based upon low levels of evidence from poorly
designed studies. Less commonly-asked questions
related to the quality and predictability of outcomes
with sequential plastic aligner treatment (7%), Class
II treatment (6%) and the efficacy of myofunctional
appliances (5%). All unanswered questions regarding
myofunctional appliances related to their efficiency
and efficacy of treatment.
Conclusion
This is the first published survey of the Australian
orthodontic workforce and associated treatment
preferences. The demonstrated responses were similar
to trends reported in the USA. However, there was
a preference for Twin Block use rather than Herbst
appliance treatment for early Class II correction. A
comparison of the Australian results with the next
JCO study, currently being conducted online (2013),
will be revealing.
Corresponding author
Dr Peter Miles
10 Mayes Avenue
Caloundra, Queensland 4551
Australia
Email: pmiles@beautifulsmiles.com.au
References
1. Keim RG, Gottlieb EL, Nelson AH, Vogels III DS. 2008 JCO Study
of orthodontic diagnosis and treatment procedures. Part 1: Results
and trends. J Clin Orth 2008;42:625-40.
2. Manni A, Cozzani M, Tamborrino F, De Rinalds S, Menini A.
Factors influencing the stability of miniscrews. A retrospective study
on 300 miniscrews. Eur J Orth 2011;33:388-95.
Australian Orthodontic Journal Volume 29 No. 2 November 2013 175
 Effects of four premolar extractions on vermilion
height and lip area during a posed smile in
patients with bimaxillary protrusion
Nety Trisnawaty, Hideki Ioi, Toru Kitahara, Akira Suzuki and Ichiro Takahashi
Section of Orthodontics, Faculty of Dental Science, Kyushu University, Fukuoka, Japan

Objective: The purpose of this study was to evaluate the effects of four premolar extractions and orthodontic treatment on changes
to the lips and vermilion height during a posed smile.
Methods: Fifteen female patients who were diagnosed with bimaxillary protrusion and treated with four premolar extractions
were selected. The control group consisted of 25 female volunteers with a normal occlusion. Frontal photographs of the patients
during a posed smile were taken before and after orthodontic treatment. Thirty-five landmarks on the upper and lower lips were
identified and used to generate measurements of lip area and vermilion height. Linear and angular cephalometric measurements
were also obtained.
Results: The mean values for vermilion height and lip form before orthodontic treatment were significantly larger in the treatment
group compared with those of the control group. Following treatment, values significantly decreased to the extent that there was
no significant difference in the vermilion height and lip form between the post-treatment and control groups. Only three and four
significant correlations were found between the changes in incisor position and changes in vermilion height and lip area for the
upper and lower lips, respectively.
Conclusions: The vermilion height and lip area in patients with bimaxillary protrusion approached comparative and normal values
as a result of four premolar extractions and orthodontic retraction.
(Aust Orthod J 2013; 29: 176-183)

Received for publication: January 2013

Accepted: August 2013

Nety Trisnawaty: netytrisnawaty@yahoo.com; Hideki Ioi: ioi@dent.kyushu-u.ac.jp; Toru Kitahara: kitahara@dent.kyushu-u.ac.jp;

Akira Suzuki: suzuki@dent.kyushu-u.ac.jp; Ichiro Takahashi: takahashi@dent.kyushu-u.ac.jp

Introduction that vertical lip thickness is an important factor in the

The face plays a key role in communication and
interaction in the context of human social behaviour.1-3
The mouth and teeth are considered fundamental
in the appreciation of facial aesthetics.4,5 A smile
influences perceived attractiveness and is pivotal in
social interaction which mainly focuses on the eyes
and mouth.6 Recent research has demonstrated that
vermilion height plays an important role in determining
smile aesthetics.7 It has been stated7 that the vertical
thickness of the upper lip is an aesthetic determinant
for orthodontists and laypersons, while the vertical
thickness of the lower lip is an aesthetic determinant
only for laypersons. The reported conclusion suggested
determination of smile attractiveness.
Patients with a malocclusion characterised by a
bimaxillary protrusion exhibit dentofacial features
related to a protruded lower facial profile, difficulty
in establishing a lip seal, and an increased vermilion
height due to labially inclined anterior teeth. Dentally
protrusive patients have long been treated via premolar
extractions to straighten their profile and to facilitate
a lip seal.7 However, this treatment modality has the
potential to decrease vermilion height which has been
reported to be aesthetically detrimental. Contemporary
attractive faces have been shown to have relatively large
mouths, with a full vermilion dominating the orolabial

176 Australian Orthodontic Journal Volume 29 No. 2 November 2013 © Australian Society of Orthodontists Inc. 2013

area.8 Although numerous studies have examined the
relationship between anterior tooth retraction and
changes in facial profile,9-15 to date, none have reported
on the effects of premolar extractions on vermilion
height in a smiling face.
As the relationship between incisor protrusion and
lip thickness is an important consideration when
planning orthodontic treatment, the purpose of the
present study was to evaluate the effects of orthodontic
treatment involving the extraction of four premolars
on changes to vermilion height and lip area during
smiling. The hypotheses to be examined were: (1)
the vermilion height and lip form in patients with
bimaxillary protrusion would be larger compared with
patients with a normal occlusion, (2) the orthodontic
retraction of anterior teeth would decrease the
vermilion height and the surface areas of the upper and
lower lips, and (3) the amount of anterior retraction
would correlate with a decrease in vermilion height
and the area of the lips.
Material and methods
Samples
The examination group was selected from the patient
files of the Section of Orthodontics, Faculty of Dental
Science, Kyushu University, Fukuoka, Japan. Case
records contained pre- and post-treatment frontal
facial photographs of a posed smile, cephalograms,
dental photographs, panoramic radiographs, dental
casts and accompanying descriptions of diagnoses,
treatment plans, and summaries of treatment. The
selection criteria for the patient group included:
1. Japanese female adults, whose minimum ages at the
beginning of treatment were at least 18 years old.
2. Orthodontic treatment consisting of the extraction
of four premolars, with subsequent retraction of
the anterior teeth.
3. Pre- and post-treatment cephalometric radiographs
of adequate diagnostic quality.
4. A skeletal Class I pattern and an Angle Class I
molar relationship.
5. Pretreatment upper incisor protrusion (U1-
point A vertical line to the occlusal plane) more
than 6.0 mm.
6. Pretreatment lower incisor protrusion (L1-APog)
more than 4.9 mm.
7. A pretreatment overjet less than 4.0 mm.
8. An absence of craniofacial anomalies.
EFFECTS OF EXTRACTIONS ON VERMILION
The present study identified fifteen female patients
(age range: 18 to 31 years, mean age ± standard
deviation (SD): 23.1 ± 4.1 years), all of whom were
treated with edgewise appliances.
A control group was selected from dental students
and staff members at Kyushu University. Twenty-five
female volunteers (age range: 20 to 30 years, mean
age ± SD: 23.5 ± 3.0 years) with a normal occlusion
were recruited. Further inclusion criteria were an
Angle Class I occlusion with minor or no crowding,
the presence of all teeth except third molars and no
previous orthodontic treatment. All volunteers in the
control group were healthy and free from any oral,
dental and craniofacial anomalies.
The research protocol was approved by the Kyushu
University Institutional Review Board for Clinical
Research.
Facial photograph analysis
The frontal photographs of the sample group were
taken with a posed smile in a seated position with the
head orientated and fixed by ear rods at a distance of
1.5 metres from the camera. The subject’s head was
positioned so that Frankfort horizontal (FH) was
parallel to the floor, while the mid-sagittal plane was
aligned with the centre of the camera lens. The posed
smile was taken in a relaxed, but smiling lip position.
The smiling frontal photographs were taken before
and immediately after orthodontic treatment. All
were scanned at a resolution of 300 dpi, printed on
A4 size paper, hand traced and 35 facial landmarks
identified and marked (Figure 1).
An X-axis was drawn parallel to the line connecting
the right and left irises through the subnasal point
(Sn). A Y-axis was drawn perpendicular to the X-axis
through the Sn point following which, two vertical
lines were drawn through the right and left superior
vermilion points (9, 11). The distance from the
superior vermilion point to the right (6) and left
(14) corners of the mouth was divided into three
equal parts. Four additional vertical lines were drawn
through points 7, 8, 12 and 13. Landmarks numbered
6 to 21 (Figure 1) were allocated to the upper lip,
whereas the corresponding landmarks numbered 22
to 35 were allocated to the lower lip. Vermilion height
was defined as the distance between the superior and
inferior vermilion borders. Upper lip area was defined
as the area bounded by the landmarks numbered
Australian Orthodontic Journal Volume 29 No. 2 November 2013 177
 TRISNAWATY ET AL

6–21. The lower lip area was defined as the area

bounded by the landmarks numbered 22–35. The
vermilion heights (points 7-15, 8-16, 9-17, 10-18,
11-19, 12-20, 13-21, 22-29, 23-30, 24-31, 25-32,
26-33, 27-34, 28-35) were measured and the areas of
both lips calculated using software programs Winceph
5.5 (Rise, Sendai, Japan) and Adobe Photoshop 7.0
(Adobe systems, San Jose, CA, USA). All landmarks
were digitised into X and Y coordinates, and statistical
analysis was performed on these values. Facial size
differences were evaluated between the treatment
group and the control group by the Mann-Whitney
U test which indicated that there was no significant
difference in the facial size between groups. Therefore,
the two groups could be confidently compared.
Figure 1. Facial photograph analysis:
Upper vermilion height 7-15, 8-16, 9-17, 10-18, 11-19, 12-20, 13-21.
Cephalometric analysis Lower vermilion height 22-29, 23-30, 24-31, 25-32, 26-33, 27-34,
28-35.
Lateral cephalograms before and after orthodontic
treatment were taken with the lips in a relaxed position
and teeth in occlusion.16,17 The radiographs were taken
with a DR-155-23HC (SSR-2B, Hitachi Medical
Corporation, Tokyo, Japan) and exposed at 100 kV,
200 mA at the Dental Radiology Clinic of Kyushu
University Hospital. All cephalometric radiographs
were traced by hand on matte acetate sheets by one
author (NT) to avoid inter-investigator variability.
A reference X axis was constructed parallel to the
occlusal plane through sella, while a reference Y axis
was drawn through sella and perpendicular to the X
axis on the pretreatment tracings (Figure 2). The X
and Y axes were transferred to post-treatment tracings
by superimposing on sella-nasion lines registering
at sella. Six linear measurements and three angular
measurements were used to evaluate horizontal dental
changes (Figure 2).

Statistical analysis
The Kolmogorov-Smirnov test indicated that the
measurements used in this study were not normally
distributed and so the pretreatment and post-
treatment values were compared using the Wilcoxon
signed-rank test. The Mann-Whitney U test was used
to indicate the differences between the treatment
group and the control group. Spearman correlation
coefficients were calculated to assess the association
between changes in incisor position compared with
vermilion height or lip area. The minimum level of
statistical significance was set at p < 0.05.
Figure 2. Horizontal dental and angular measurements:
1. H-tU1 (distance from the tip of the maxillary incisor to the Y-axis) (mm)
2. H-cU1 (distance from the cervical point of the maxillary incisor to the
Y-axis)
3. H-tL1 (distance from the tip of the mandibular incisor to the Y-axis)
4. H-cL1 (distance from the cervical point of the mandibular incisor to
the Y-axis)
5. tU1-Mo (distance between the tip of the maxillary incisor and the
centre of the maxillary first molar)
6. tL1-Mi (distance between the tip of the mandibular incisor and the
centre of the mandibular first molar)
7. U1 to SN (angle between the maxillary incisor long axis and the
sella-nasion line)
8. U1 to FH (angle between the maxillary incisor long axis and the
Frankfort horizontal plane)
9. L1 to Md (angle between the mandibular incisor long axis and the
mandibular plane).

178 Australian Orthodontic Journal Volume 29 No. 2 November 2013

 EFFECTS OF EXTRACTIONS ON VERMILION

Sample size
A sample size calculation was undertaken using the
nQuery Adviser software package (Version 6.01,
Statistical Solutions, Cork, Ireland). The pilot study
estimated that the effect size was 1.245. On the basis
of a significance level of alpha = 0.050, the sample size
was calculated to achieve 90% power. The sample size
calculation showed that 15 subjects were necessary to
detect a significant difference.

Reliability
All facial photographs were traced and digitised on
two separate occasions and intra-class correlation
coefficients (ICC) for vermilion height and lip area
measurements were used to detect intra-observer error.
Because all ICC were greater than or equal to 0.94,
the method error was considered to be negligible.
Facial photographs of 10 female volunteers were
taken three times at one-week intervals to assess test-
retest consistency. The photographs were traced and
digitised by one observer (NT) and the Friedman test, Figure 3. Actual photographs of the vermilion in the patient group
followed by the Dunn test, were applied to evaluate the before (A) and after treatment (B).

reliability of the method. There were no statistically
significant differences in the vermilion height and lip
area between the three facial photographs.
Results
Lip morphological changes
The photographs of the vermilion area in the patient
group before and after treatment are shown in Figure
3. The upper vermilion height change during a
posed smile in the patients who received orthodontic
treatment are shown in Figure 4. The height of the
pretreatment upper vermilion was significantly
larger than those of the post-treatment and control
groups. Moreover, there was no significant difference
between the post-treatment and control groups. On
average, every 1 mm of maxillary incisor tip retraction
produced a 0.18 mm decrease in upper vermilion
height (Up 10-18). The changes in lower vermilion
height in patients who received orthodontic treatment
are shown in Figure 5. The values of pretreatment
lower vermilion height were significantly larger than
those of the post-treatment and control groups.
There was no significant difference between the
post-treatment and control groups. Every 1 mm of
mandibular incisor tip retraction produced a 0.24
mm decrease in lower vermilion height (Lo 25-32).
The individual change variations in vermilion height
due to orthodontic treatment are shown in Figure 6.
On average, similar decreasing tendencies in the upper
and lower vermilion heights were found but individual
variations were evident. The lip area changes in
orthodontic treatment are shown in Figure 7. The
values of the pretreatment lip area were significantly
larger than those of the post-treatment and control
groups for the upper and lower lips, except between
the pretreatment and control groups for the lower lip.
Moreover, there was no significant difference between
the post-treatment and control groups for the upper
and lower lip areas. Every 1 mm of maxillary incisor
tip retraction produced a 6.39 mm2 decrease in upper
lip area. In addition, every 1 mm of mandibular incisor
tip retraction produced an 8.16 mm2 decrease in lower
lip area. The individual changes in lip area due to
orthodontic treatment are shown in Figure 8. Similar
decreasing tendencies in the upper and lower lip areas
were found, with noted individual variations.
Cephalometric analysis
The cephalometric analysis revealed that the upper
and lower incisors moved significantly posteriorly

Australian Orthodontic Journal Volume 29 No. 2 November 2013 179

 TRISNAWATY ET AL

Figure 4. Upper vermilion height changes in the orthodontic treatment:
Up 7-15, the upper vermilion height 7-15; Up 8-16, the upper vermilion
height 8-16; Up 9-17, the upper vermilion height 9-17; Up 10-18, the
upper vermilion height 10-18; Up 11-19, the upper vermilion height 11-
19; Up 12-20, the upper vermilion height 12-20; Up 13-21, the upper
vermilion height 13-21
Figure 5. Lower vermilion height changes in the orthodontic treatment:
Lo 22-29, the lower vermilion height 22-29; Lo 23-30, the lower vermilion
height 23-30; Lo 24-31, the lower vermilion height 24-31; Lo 25-32, the
lower vermilion height 25-32; Lo 26-33, the lower vermilion height 26-33;
Lo 27-34, the lower vermilion height 27-34; Lo 28-35, the lower vermilion
height 28-35.

and lingually based on measurements found in Table

I (H-tU1, H-cU1, H-tL1, H-cL1, U1-SN, U1-FH,
L1-Md, tU1-Mo, and tL1-Mi).

Relationship between incisor position and

lip morphology
The changes in incisor position and changes in
vermilion height or lip area for the upper lip revealed Figure 6. Individual variations in the changes of vermilion height due
to the orthodontic treatment. A, Upper vermilion height (Up 10-18); B,
three significant correlations (Table II). The changes Lower vermilion height (Lo 25-32).
in vermilion height at Up9-17 and Up11-19 were
significantly correlated with the changes of L1-
Md plane angle. The change in vermilion height at
Up11-19 was also significantly correlated with the
changes at tL1-Mi. The changes in incisor position
and changes in vermilion height or lip area for the
lower lip revealed four significant correlations (Table
III). The change of vermilion height at Lo28-35 was
significantly correlated with the changes of H-tL1 or
L1-Md plane angle. Lower lip area was significantly
correlated with changes of H-tU1 or H-cU1.

Figure 7. Lip area changes in the orthodontic treatment.

Discussion
The present report is the first study to evaluate
the effects of orthodontic treatment involving the
extraction of four premolars and accompanying
changes in vermilion height and lip area during a
posed smile.
The values of the pretreatment vermilion height and
lip area for the upper and lower lips were significantly
larger than those of the control group. The extraction Figure 8. The individual variations in the changes of lip area due to the
of four premolars resulted in significant decreases orthodontic treatment. A, Upper lip area; B, Lower lip area.

180 Australian Orthodontic Journal Volume 29 No. 2 November 2013

 EFFECTS OF EXTRACTIONS ON VERMILION

Table I. Incisor position changes in the orthodontic treatment.

Pretreatment Post-treatment
p value
Mean ± SD Mean ± SD
H-tU1 (mm) 89.4 ± 4.1 84.3 ± 3.1 < 0.001
H-cU1 (mm) 85.2 ± 3.6 82.3 ± 2.9 < 0.001
H-tL1 (mm) 85.7 ± 4.2 80.9 ± 3.2 < 0.001
H-cL1 (mm) 83.4 ± 3.4 80.1 ± 3.3 < 0.001
U1-SN (°) 112.0 ± 6.2 99.6 ± 8.2 < 0.001
U1-FH (°) 119.4 ± 4.6 107.6 ± 7.4 < 0.001
L1-Md (°) 100.8 ± 9.5 93.5 ± 9.7 < 0.01
tU1-Mo (mm) 36.7 ± 2.1 29.9 ± 1.6 < 0.001
tL1-Mi (mm) 31.2 ± 2.4 25.1 ± 1.5 < 0.001

Table II. Spearman correlation coefficients between changes of incisor position and vermilion height or lip area in upper lip.

Up7-15 Up8-16 Up9-17 Up10-18 Up11-19 Up12-20 Up13-21 Upper lip

area
H-tU1 (mm) -0.216 -0.241 -0.254 -0.242 -0.171 -0.198 -0.480 -0.064
H-cU1 (mm) -0.324 -0.075 0.121 0.062 0.172 0.007 -0.436 0.018
H-tL1 (mm) -0.041 -0.136 -0.122 -0.091 0.002 -0.032 -0.158 -0.013
H-cL1 (mm) -0.278 -0.320 -0.348 -0.264 -0.343 -0.499 -0.428 -0.306
U1 to SN (°) 0.072 -0.084 -0.257 0.042 -0.287 -0.345 -0.238 -0.096
U1 to FH (°) -0.019 -0.263 -0.342 -0.052 -0.313 -0.381 -0.279 0.014
L1 to Md plane (°) -0.101 0.385 0.541* 0.326 0.616* 0.451 0.127 0.066
tU1-Mo (mm) -0.208 0.034 0.109 -0.065 0.198 0.198 -0.432 0.086
tL1-Mi (mm) 0.278 0.258 0.428 0.186 0.564* 0.471 0.368 0.375
*p < 0.05

Table III. Spearman correlation coefficients between changes of incisor position and vermilion height or lip area in lower lip.

Lo22-29 Lo23-30 Lo24-31 Lo25-32 Lo26-33 Lo27-34 Lo28-35 Lower lip

area
H-tU1 (mm) 0.477 0.134 0.070 0.025 0.083 0.196 0.491 0.668**
H-cU1 (mm) 0.492 0.082 0.205 0.305 0.264 0.063 0.498 0.564*
H-tL1 (mm) 0.481 0.296 0.098 -0.203 0.057 0.280 0.679** 0.411
H-cL1 (mm) 0.095 0.321 0.094 -0.071 0.071 0.333 0.322 0.356
U1 to SN (°) 0.055 0.085 -0.016 0.056 -0.038 0.147 0.246 0.364
U1 to FH (°) 0.108 0.036 -0.105 -0.164 -0.128 0.101 0.234 0.507
L1 to Md plane (°) 0.454 0.382 0.453 0.222 0.416 0.293 0.607* 0.186
tU1-Mo (mm) 0.504 -0.064 0.002 0.033 0.029 -0.011 0.451 0.407
tL1-Mi (mm) 0.356 0.200 0.280 -0.109 0.227 0.176 0.468 0.104
*p < 0.05, **p < 0.01

Australian Orthodontic Journal Volume 29 No. 2 November 2013 181

 TRISNAWATY ET AL
in vermilion height and lip area which approached
control group values. However, post-treatment values
were not less than those of the control group. The
success of orthodontic treatment is often measured
by smile aesthetics and the orthodontic literature has
identified factors which contribute to an aesthetic
smile. These include the display and condition of
the teeth and gingiva, as well as arch size and shape,
symmetry and width, skeletal base relationship, and
smile arc.18-22 However, little attention has been paid
to the lips and their relation to smile aesthetics. Scott
et al. assessed smiling lip attractiveness and reported
that thick and medium upper and lower lip vermilions
were rated as significantly more attractive than thin
vermilions for both lips. This finding is in agreement
with McNamara et al.,7 who speculated that a great
deal of current advertising in the mass media is
aimed at self-improvement. This included a focus
on fuller lips and presented plastic surgery and other
cosmetic treatments to enhance lip size. It therefore
seems reasonable to recommend that clinicians pay
close attention to changes in the vermilion height
and lip area in the frontal view, especially when
treatment planning involves posterior movements of
the anterior teeth. Treatment involving extractions
of four premolars can be beneficial in patients with
bimaxillary protrusion who want to straighten their
profiles.23 The current results suggest that clinicians
could decrease vermilion height toward normal values
while simultaneously improving the patients’ facial
appearance.
Three and four significant correlations were found
between the horizontal changes in incisor position
and changes in vermilion height and lip area for the
upper and lower lips, respectively. McNamara et al.7
stated that the vertical thickness of the upper lip was
significantly related to maxillary incisor protrusion,
while the vertical thickness of the lower lip was related
to lower anterior facial height. The results of the
present study revealed changes in upper vermilion
height were weakly related to the horizontal position
of the incisors. The poor correlations might be
individual response variations in vermilion height or
lip area relative to the positional changes of incisors.
Further studies considering additional variables which
might affect vermilion height would be necessary.
The possibility of a standardised, repeatable, and
reproducible method in analysing lip morphology was
evaluated. The reliability test showed that on separate
182 Australian Orthodontic Journal Volume 29 No. 2 November 2013
occasions, ICC values were greater than or equal to
0.94 for vermilion height and lip area measurements.
Moreover, morphological differences were minimal
over the three separate examinations. Therefore, the
measuring system utilised in this research protocol
proved to be reliable, and the vermilion height and
lip area appeared to be consistent variables in the
evaluation of lip morphology.
The present study demonstrated that post-treatment
vermilion height and lip area displayed during a
posed smile decreased and approximated control
group values after treatment which involved the
extraction of four premolars. However, no evidence
exists regarding specific vermilion height values
preferred by orthodontists and their patients.
Generally, orthodontic treatment is planned so that
post-treatment cephalometric values lie within the
average range provided that physiological function
is not impaired. Using cognitive averaging theory,
Principe and Langlois24 speculated that an average face
is preferred because it is closer to a central tendency
and is more prototypical than a less attractive face.
Therefore, an average vermilion height would be
desirable as an objective of orthodontic treatment.
Additional research which evaluates perceptions and
desirable values of vermilion height and lip area is
therefore warranted.
Conclusions
1. Pretreatment vermilion height and lip area for the
upper and lower lips were significantly larger than
those of a control group.
2. Vermilion height and lip area showed significant
decreases toward control group values as a result of
orthodontic treatment.
3. Few significant correlations were established
between the observed horizontal changes in incisor
position and the changes in vermilion height or lip
area for the upper and lower lips.
4. The present study suggests that a clinical decrease in
vermilion height and a simultaneous improvement
in facial profile are beneficial in patients with
pretreatment bimaxillary protrusion.
Acknowledgment
We thank Dr Ze’ev Davidovitch for his valuable help
with this manuscript.

Corresponding author
Dr Hideki Ioi
Section of Orthodontics
Graduate School of Dental Science
Kyushu University
3-1-1 Maidashi, Higashi-ku
Fukuoka 812-8582
Japan
Email: ioi@dent.kyushu-u.ac.jp
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8. Scott CR, Goonewardene MS, Murray K. Influence of lips on the
perception of malocclusion. Am J Orthod Dentofacial Orthop
2006;130:152-62.
9. Oliver BM. The Influence of lip thickness and strain on upper lip
response retraction. Am J Orthod 1982;82:141-9.
EFFECTS OF EXTRACTIONS ON VERMILION
10. Rains MD, Nanda R. Soft-tissue changes associated with maxillary
incisor retraction. Am J Orthod 1982;81:481-8.
11. Drobocky OB, Smith RJ. Changes in facial profile during
orthodontic treatment with extraction of four first premolars. Am J
Orthod Dentofacial Orthop 1989;95:220-30.
12. Bravo LA. Soft tissue facial profile changes after orthodontic treatment
with four premolars extracted. Angle Orthod 1994;64:31-42.
13. Kusnoto J, Kusnoto H. The effect of anterior tooth retraction on lip
position of orthodontically treated adult Indonesians. Am J Orthod
Dentofacial Orthop 2001;120:304-7.
14. Yasutomi H, Ioi H, Nakata S, Nakashima A, Counts AL. Effects of
retraction of anterior teeth on horizontal and vertical lip positions
in Japanese adults with the bimaxillary dentoalveolar protrusion.
Orthod Waves 2006;65:141-7.
15. Hayashida H, Ioi H, Nakata S, Takahashi I, Counts AL. Effects of
retraction of anterior teeth and initial soft tissue variables on lip
changes in Japanese adults. Eur J Orthod 2010;33:419-26.
16. Ricketts RM. A foundation for cephalometric communication. Am J
Orthod 1960;46:330-57.
17. Burstone CJ. Lip posture and its significance in treatment planning.
Am J Orthod 1967;53:262-84.
18. Betts NJ, Vanarsdall RL, Barber HD, Higgins-Barber K, Fonseca
RJ. Diagnosis and treatment of transverse maxillary deficiency. Int J
Adult Orthodon Orthognath Surg 1995;10:75-96.
19. Kokich VG. Esthetics and vertical tooth position: orthodontic
possibilities. Compend Contin Educ Dent 1997;18:1225-31.
20. Kokich VO Jr, Kiyak HA, Shapiro PA. Comparing the perception
of dentists and lay people to altered dental esthetics. J Esthet Dent
1999;11:311-24.
21. Padwa BL, Kaiser MO, Kaban LB. Occlusal cant in the frontal
plane as a reflection of facial asymmetry. J Oral Maxillofac Surg
1997;55:811-6.
22. Sarver DM. The importance of incisor positioning in the esthetic
smile: the smile arc. Am J Orthod Dentofacial Orthop 2001;120:98-
111.
23. Bills DA, Handelman CS, BeGole EA. Bimaxillary dentoalveolar
protrusion: Traits and Orthodontic Correction. Angle Orthod
2005;75:333-9.
24. Principe CP, Langlois JH. Faces differing in attractiveness elicit
corresponding affective responses. Cogn Emot 2011;25:140-8.
Australian Orthodontic Journal Volume 29 No. 2 November 2013 183
 Paediatric sleep-disordered breathing due to
upper airway obstruction in the orthodontic
setting: a review
Vandana Katyal,* Declan Kennedy,† James Martin,+ Craig Dreyer* and Wayne
Sampson*
Orthodontic Unit, School of Dentistry, The University of Adelaide,* Discipline of Paediatrics, The University of Adelaide†
and Sleep Disorders Unit, Womens and Childrens Hospital,+ Adelaide, Australia

The essential feature of paediatric sleep-disordered breathing (SDB) is increased upper airway resistance during sleep presenting
clinically as snoring. Paediatric SDB is a continuum ranging from primary snoring (PS), which is not associated with gas
exchange abnormalities or significant sleep fragmentation, to obstructive sleep apnoea (OSA) with complete upper airway
obstruction, hypoxaemia, and obstructive hypoventilation. Adenotonsillar hypertrophy, obesity and craniofacial disharmonies
are important predisposing factors in the development and progression of paediatric SDB. Clinical symptoms are significant and
domains affected include behaviour, neurocognition, cardiovascular morbidity and quality of life. Overnight polysomnography
is the current diagnostic gold standard method to assess SDB severity while adenotonsillectomy is the recommended first line of
treatment. Other treatments for managing paediatric SDB include nasal continuous airway pressure, the administration of nasal
steroids, dentofacial orthopaedic treatment and surgery. However, there are insufficient long-term efficacy data using dentofacial
orthopaedics to treat paediatric SDB. Further studies are warranted to define the characteristics of patients who may benefit most
from orthodontic treatment.
(Aust Orthod J 2013; 29: 184-192)

Received for publication: July 2013

Accepted: August 2013

Vandana Katyal: vandykatyal@gmail.com; Declan Kennedy: declan.kennedy@adelaide.edu.au; James Martin: james.martin@adelaide.edu.au

Craig Dreyer: craig.dreyer@adelaide.edu.au; Wayne Sampson: wayne.sampson@adelaide.edu.au

Introduction Sleep-disordered breathing (SDB) in children

The oral cavity, pharynx, and larynx constitute the
components of the anatomic upper airway structures
that underlie respiration, swallowing, and phonation
in humans. In children, the upper airway is greatly
influenced by the growth and development of the
head and neck structures along a temporal continuum
spanning from the neonatal period through to the end
of adolescence.1 Patency of the upper airway during
sleep is controlled by complex interactions between
upper airway resistance, pharyngeal collapsibility, the
tone of the pharyngeal dilator muscles, and negative
intra-lumenal pressure generated by the muscles of
respiration.2
is clinically characterised by snoring, an altered
respiratory pattern during sleep and physiologically,
by increased upper airway resistance, partial upper
airway obstruction, or complete obstruction which
disrupts ventilation, oxygenation, and sleep quality.3
In this review, a focus has been placed on paediatric
SDB due to upper airway obstruction. Paediatric SDB
is a continuum which ranges from primary snoring
(PS) which is not associated with gas exchange
abnormalities or significant sleep fragmentation,
through to upper airway resistance syndrome,
characterised by repeated arousals and sleep
fragmentation to obstructive sleep apnoea (OSA)
with complete upper airway obstruction, hypoxaemia,

184 Australian Orthodontic Journal Volume 29 No. 2 November 2013 © Australian Society of Orthodontists Inc. 2013
 Paediatric sleep-disordered breathing due to upper airway obstruction in the orthodontic setting
and obstructive hypoventilation. PS is currently
defined by the observation of audible sonorous noises
occurring more than three times per week without
evidence of apnoea, hypoventilation or significant
sleep fragmentation.4 The prevalence of snoring
ranges from 3.2 - 35% with most authors reporting
a prevalence of 10% for PS, while the prevalence of
paediatric OSA ranges from 1% - 5%.5-12 Paediatric
SDB is most frequently encountered between 2 - 8
years of age which corresponds with the age range of
greatest enlargement of upper airway lymphoid tissue
relative to craniofacial size.3,7,10,13-15 Paediatric OSA is
more prevalent in some races as an increased incidence
is found in African-American and Asian children, as
well as children with respiratory disease such as allergic
rhinitis and asthma, obese children and children with
a family history of OSA.1,15
The spectrum of SDB in children is gaining increased
recognition as all levels of severity have been
associated with deleterious health implications if not
recognised and treated.3,16,17 The domains affected
include quality of life,18 behaviour,10 neurocognition19
and cardiovascular changes.20 Despite the significant
morbidity associated with SDB in children, it is often
not recognised in clinical practice. A previous study
reported that approximately 80% of symptomatic
habitual snorers are not reported to their general
medical practitioners.21 In addition, there is a 226%
(2.3 fold) increase in health care utilisation among
children with OSA when compared with unaffected
individuals.22 Hence, early diagnosis and intervention
would be beneficial and cost-effective.
Predisposing factors for paediatric OSA
Similar to adults, there is no single cause of paediatric
SDB and it is believed to be due to a complex
interaction of neuromuscular, inflammatory and
anatomic factors.23-25
Adenotonsillar hypertrophy
Paediatric SDB is most commonly associated
with tonsillar and adenoidal hypertrophy.26 While
lymphatic tissue normally shrinks in volume after the
age of ten,27 the hypertrophic tonsillar and adenoid
tissue might be so large that normal tissue reduction
is insufficient to remove an obstruction.25 The relative
enlargement of lymphoid tissue can create a narrower
airway which increases the likelihood of breathing
resistance and the chance of airway collapse. The
critical relationship is the size of the hypertrophied
tonsils and adenoids relative to the size of the upper
airway.1 On careful inspection, two children with
the same size tonsils may have different levels of
obstruction depending on upper airway size during
sleep.
Obesity
The prevalence of childhood obesity has tripled in the
last 25 years and is presently estimated to be 18%.28
Redline et al.15 have found obesity to be a significant
risk factor for OSA in children and adolescents (odds
ratio = 4.59; 95%, confidence interval 1.58 to 13.33).
This factor is important as it is now recognised that,
even after SDB has been treated by adenotonsillectomy,
there is a significant risk of ongoing obstruction.
Craniofacial anomalies
Craniofacial anomalies result from altered genetic
expression, or from environmental insults or both.29
Children and adolescents seeking orthodontic
treatment might present with variable craniofacial
disharmony. Children with long faces and retrognathic
mandibles have been shown to have increased SDB
and OSA symptoms.17,30,31 In the transverse plane,
maxillary constriction is a sign of reduced transverse
dimension of the upper airways and an indirect
measure of increased nasal resistance.32
A screening facial and dental examination in the
general paediatric orthodontic population can reveal
highly positive associations between parentally-
reported paediatric SDB symptoms and long-face
characteristics, a narrow palate and severe maxillary
crowding.31 However, antero-posterior deficiency,
overjet and retrognathia as recorded by clinical
examination is not highly associated with many
reported SDB symptoms.31
Two recent meta-analyses suggest that sagittal and
vertical craniofacial associations measured on a lateral
cephalogram, might have low clinical significance in
predicting childhood SDB, due to small differences
between subjects and a control group.33,34 Despite
the limitations and inherent projection errors, the
cephalometric radiograph remains a valid method
for measuring dimensions of nasopharyngeal and
retropalatal regions, which correlates well with
Australian Orthodontic Journal Volume 29 No. 2 November 2013 185
 KATYAL ET AL
three-dimensional magnetic resonance imaging.35
In addition, volumetric analyses of the lower facial
skeleton measured by magnetic resonance imaging
show no skeletal difference between non-syndromic
children diagnosed with OSA and controls, although
the soft palate is larger in children with OSA.36,37
A comprehensive analysis of the facial skeleton and
occlusion requires an understanding of the upper
airway. The three-dimensional airway has been shown
to have a relationship with facial morphology and
skeletal malocclusions. Grauer et al. have reported
that skeletal Class II malocclusions show a smaller
inferior compartment airway volume compared
with Class I or Class III patients, but no correlation
of airway volume with vertical facial types has been
identified.38 Additional studies have found no volume
difference at various sites in the airway but found
total airway volume in Class II malocclusion patients
is smaller than in Class I patients.39,40 Children with
a Class III malocclusion show a larger and flatter
oropharyngeal airway when compared with Class I
children.41 Whether these differences in airway shape
and volume predispose an individual to SDB is not
well understood.
Other factors
Any syndrome or disorder which affects upper airway
structure, airway muscle tone, upper airway muscle
control or sleep may predispose syndromic children
to OSA.1
Clinical symptoms
Daytime symptoms of SDB might be associated with
a wide variety of symptoms.19,42-48 Affected children
can present with behavioural and discipline problems,
neurocognitive deficits such as poor learning, impaired
cognitive performance, memory and attention deficits
and are more likely to be diagnosed with attention
deficit hyperactivity disorder (ADHD).19,46,47,49 Other
symptoms might manifest as morning headaches and
mouth breathing.50 Severe paediatric OSA has been
associated with a failure to thrive, hypertension,
insulin resistance and lipid dysregulation.4
Snoring is the most common night-time symptom of
SDB in children.3 Other night-time symptoms that
might be noted are restless sleep, frequent arousals,
snorting, gasping, unusual sleeping positions, sweating
during sleep and nocturnal enuresis.11,51
186 Australian Orthodontic Journal Volume 29 No. 2 November 2013
Complications of paediatric SDB
Behavioural and neurocognitive deficits
Children with SDB show reduced attention
capability, hyperactivity, increased aggression,
irritability, emotional and peer problems and somatic
complaints.10,43,47,49,50 Neurocognitive deficits include
a reduction in memory and intelligence.46,50 A current
challenge in this field is the determination of the
severity of upper airway obstruction that results in
neurocognitive sequelae. In addition, the recognition
of more vulnerable periods in a young child’s
development when SDB may have a more injurious
effect, would be beneficial. Gozal and Pope52 have
shown that 13-year-old children with low academic
performance are more likely to snore during early
childhood and have surgery for SDB compared with
children with high academic performance, thereby
suggesting that snoring in early childhood may have
long term deleterious effects. Whether this restricts
the affected children’s future academic or occupational
success is unknown.
Cardiovascular complications
Children with PS and OSA have been shown to have
higher diastolic blood pressure compared with non-
snoring children.1,53 Increased blood pressure in
childhood is predictive of hypertension in adulthood.23
However, it is uncertain whether pressure changes
are a precursor to cardiovascular disease. Potential
mechanisms of OSA-mediated cardiovascular morb-
idity are similar in children and adults.20 Factors such
as hypoxia, oxidative stress, inflammation, endothelial
dysfunction and sympathetic activation have been
implicated in paediatric OSA.20
Growth
Severe OSA might result in failure to thrive although
this is now not as common due to rising prevalence
of obesity.54 This is thought to reflect disruption of
the normal growth hormone regulation during sleep
and increased energy requirements of obstructed
breathing. Not surprisingly, some children with
SDB demonstrate increased growth velocity after
adenotonsillectomy.54,55 It is currently controversial
whether craniofacial growth normalises post
adenotonsillectomy.56,57
 Paediatric sleep-disordered breathing due to upper airway obstruction in the orthodontic setting
Quality of Life (QOL)
QOL is increasingly recognised as an important
health outcome in medicine and dentistry. It reflects
the World Health Organisation’s definition of health
as ‘the state of complete physical, mental, and social
well-being and not merely the absence of disease or
infirmity.’ The impact of paediatric SDB extends
beyond sleep parameters to affect children’s behaviour,
functioning and family life.58 A complex relationship
exists between paediatric OSA, behaviour and QOL,
which highlights that children with OSA have poorer
health status than unaffected children.18
Mortality
Death during sleep in children suffering from SDB
is considered rare, and most deaths are believed
to be peri-operative after adenotonsillectomy.3
Children with unrecognised OSA and a compromised
cardiovascular system might decompensate during
general anaesthesia.59,60
Diagnosis of paediatric SDB
Since snoring is the cardinal symptom of paediatric
SDB, screening for snoring has been recommended
as part of routine health-care visits by the American
Academy of Pediatrics (AAP).61 However, history and
clinical examination can be poor predictors of OSA
with an overall predictive value of 55.8%.62
Role of polysomnography (PSG)
The 2012 AAP technical report for Diagnosis and
Management of Childhood Obstructive Sleep Apnoea
states that nocturnal, attended, laboratory PSG is
considered the gold standard for the diagnosis of
OSA because it provides an objective, quantitative
evaluation of disturbances in respiratory and sleep
patterns.12 It allows an estimation of the severity of the
disease and, therefore, provides a prediction for the risk
of postoperative complications in children undergoing
adenotonsillectomy.1 Paradoxically, less than 10%
of snoring children referred for adenotonsillectomy
undergo an overnight PSG.63 This could be due to its
expense, the time required and reduced availability in
some health care settings.
PSG measures the Apnoea-Hypopnoea Index (AHI)
as well as other sleep-breathing parameters. AHI is the
number of apnoeic events (obstructive, central and
mixed) plus hypopnoeas per hour of sleep. This is also
referred to as the Respiratory Distress Index (RDI).
An AHI greater than 1 event per hour is considered to
be abnormal in children while 5 events per hour is the
current level for considering operative intervention
with adenotonsillectomy.64 The correlation of PSG
indices with daytime sleepiness, hyperactivity, and
neurocognitive function measured objectively, is
generally poor,65 however, it does give clear indications
of the child’s respiratory status.
Role of questionnaires
Questionnaires have been developed to aid in
the identification of children with SDB.66 The
questionnaires help standardise history taking and
are a valuable tool in epidemiologic research but they
ultimately rely on parental recording. The commonly
used and validated 22-item Paediatric Sleep
Questionnaire (PSQ) used in screening children has
reasonable sensitivity (0.85) and specificity (0.87)67 to
predict the risk of SDB when compared to a PSG.66
A health-related quality of life (QOL) survey focuses
on the physical problems, functional limitations and
emotional consequences of a disease. Several disease-
specific QOL instruments such as the validated OSA-
1868 have been developed for children with OSA. The
OSA-18 is the most widely used QOL questionnaire
for paediatric OSA and has been validated as a
discriminative and worthy evaluative instrument. The
correlation between OSA-18 scores and RDI is fair
(r = 0.43).68,69 The fair correlation may be explained by
the reliance of PSG on physiological sleep parameters
whereas the OSA-18 relies on caregiver concerns.
Role of lateral cephalometric radiographs
The lateral cephalogram is recommended as a screening
radiograph and is a valid method for measuring
dimensions of the nasopharyngeal and retropalatal
region. The cephalogram correlates well with three-
dimensional magnetic resonance imaging.35 It has the
added advantage of providing a means of evaluating
craniofacial morphology in the sagittal and vertical
plane.
Treatment modalities for paediatric SDB
Adenotonsillectomy
As adenotonsillar hypertrophy is commonly associated
Australian Orthodontic Journal Volume 29 No. 2 November 2013 187
 KATYAL ET AL
with SDB in children, adenotonsillectomy is the
recommended first line of treatment.61 The correlation
between the severity of apnoea and adenotonsillar size
is variable but not surprising given the size of the upper
airway is the other determinant.37,70 However, the use
of this surgical treatment option for those with PS,
remains controversial.71 A meta-analysis of published
research72 suggests that the procedure is effective
in curing 75% of paediatric OSA cases. However,
several large and more recent meta-analyses have
reported that complete normalisation of PSG results
might occur in only 25 - 60% of treated children.73-76
Cephalometric abnormalities and obesity account for
persistent snoring and upper airway obstruction in
adolescents who have undergone adenotonsillectomy
for upper airway obstruction.75,77
It should be noted that the prevalence of paediatric
SDB may change with time. Marcus et al.78 (CHAT
study) reported the normalisation of PSG scores in
nearly 47% of OSA-affected children randomised to
watchful waiting for 7 months, in comparison with
an adenotonsillectomy-surgery group. This might
have been due to growth enlargement of the airway,
regression of lymphoid tissue or routine medical care,
and highlights the change in the disease symptoms over
time. However, there are few long-term studies. Even
though complete resolution is not always achieved,
adenotonsillectomy has been found to improve
several other sequelae of SDB such as quality of life,18
behaviour19 and neurocognition.19 Nevertheless,
adenotonsillectomy as a surgical procedure carries risks
such as haemorrhage, respiratory decompensation,
anaesthetic complications and in rare cases, death.71
Nasal Continuous Positive Airway Pressure
(CPAP)
Nasal CPAP is second-line therapy for paediatric OSA
if adenotonsillectomy cannot be performed or if there
is residual OSA post-surgery.61 The distinct advantage
of CPAP is its non-surgical nature. The disadvantages
of CPAP treatment relate to the patient’s inability to
acclimatise and accept the device. Additionally, there
is emerging evidence of mid-face hypoplasia and other
craniofacial side effects in children using CPAP.79,80
Supplemental medical treatment
Additional treatments include the use of oral
leukotriene-receptor antagonists, anti-inflammatory
188 Australian Orthodontic Journal Volume 29 No. 2 November 2013
drugs and the application of nasal corticosteroids.3
These treatments can be effective in mild or residual
cases.
Surgery
Surgical treatment options in complicated OSA
can include uvulopaltopharygoplasty (UPPP),
distraction osteogenesis, and mandibular or maxillary
advancement procedures.25,45 These are utilised in
specific circumstances, particularly in syndromal
children.
Dentofacial orthopaedics and orthodontic
treatment
A variety of oral appliances provide potential
additional treatment alternatives for paediatric SDB.
Oral appliances might help improve upper airway
patency during sleep by enlarging the upper airway
and/or decreasing upper airway collapsibility, thereby
enhancing upper airway muscle tone.81 Rapid maxillary
expansion (RME), mandibular advancement to
attempt growth modification in patients with a Class
II dentofacial relationship and maxillary advancement
in Class III SDB patients, could be effective.82,83
Several publications provide direct evidence of the
positive effects of RME in children diagnosed with
OSA.84-87 Palmisano et al.87 have reported on 10
‘young’ patients (range 14–37 years) in which 9
patients improved, and 7 were brought into the
normal range. One patient showed no improvement.
Obvious weaknesses of the study include the small
sample size (N = 10), a variation in the expansion
techniques applied (six surgical expansions, four
non-surgical), affected patients had only mild to
moderate sleep apnoea and the study included
adolescent and adult patients. Pirelli et al.84 have
addressed several of the limitations by investigating
maxillary expansion in 31 children with a mean
age of 8.7 years and a mean pretreatment AHI of
12.2. The experimental group was stratified into
three categories; AHI of 5–10, 10–15 and 15+ with
the largest group in the 10–15 range. Immediately
following expansion (mean expansion was 4.32 mm),
29 of the 31 patients had an AHI of less than 5. At
review (6–12 months post-expansion), all patients
had an AHI less than 1 and were therefore considered
within the normal range. The final improvement
might have been a result of expansion appliance
removal, which allowed the tongue additional space.
 Paediatric sleep-disordered breathing due to upper airway obstruction in the orthodontic setting
Villa et al.86 have conducted a prospective examination
of 16 patients (mean age 6.9 years; range 4.5–10.5) a
year following the RME. The study aimed to examine
the effect of expansion and also correlate the size of
the tonsils. While 2 patients were lost at follow-up,
AHI improved from a mean of 5.8 at the start to a
mean of 2.7 after 6 months. The final AHI was 1.5
at 12-month follow-up, even with the presence of
enlarged tonsils in 11 of the 14 patients. The result has
demonstrated that maxillary expansion can produce
significant improvement in OSA. For the small group
of patients who did not reach an acceptable AHI level,
the residual OSA may have been better treated by
adenotonsillectomy following expansion. It remains
to be determined whether children with PS benefit as
well as children with OSA following RME treatment.
Biobloc therapy, to enhance maxilla-mandibular
horizontal projection and posterior airway space,
has been reported to produce a 31% increase
in the nasopharyngeal area, a 23% increase in
the oropharyngeal area and a 9% increase in the
hypopharyngeal area.88 However, the participants were
not assessed for SDB and the study failed to recruit
control subjects. To date, only one randomised trial
assessing sagittal growth modification in a paediatric
OSA population has been published.89 The treated
adolescent patients wore the mandibular advancement
appliance full time (except when eating) in an attempt
to treat the OSA and the deficient mandibular growth.
All patients improved and the mean AHI reduced
from a pretreatment value of 7.1 to a post-treatment
level of 2.6. Using the low threshold for success of a
50% decrease in AHI, the majority of patients (64%)
were successfully treated. Using the more stringent
level of success of normalising the AHI, only 50% of
patients were successfully treated. However, the effect
of relapse was not explored.
Evidence for Class III growth modification by maxillary
advancement is indirect, weak and some benefits
may be due to the RME phase of the treatment.24
Encouraging reports of enhanced protraction with
skeletal anchorage have been published, which may
see benefits greater than those previously reported.90
A recent randomised clinical trial, with 3 years follow-
up, has shown that 70% of children treated with a
protraction face mask retain favourable changes to
their maxillary and mandibular bases, which suggests
that changes may be retained in the longer-term.91
Further studies are required to evaluate the effects of
maxillary advancement upon the upper airway.
A Cochrane database systematic review of data in
the literature until 2005 has found that evidence
is not sufficient to declare that oral appliances or
functional orthopaedic appliances are effective in
the treatment of OSA in children.92 However, the
authors have concluded that oral appliances or
functional orthopaedic appliances may be helpful in
the treatment of children with craniofacial anomalies
that represent risk factors for apnoea.
Oropharyngeal exercises (Myofunctional
therapy)
Derived from speech therapy, the role of myofunctional
training in treating paediatric SDB is unclear. It may
be an effective treatment option in promoting correct
oral breathing patterns,82 however, its efficacy and
cost-effectiveness is yet to be proven in controlled
studies.
Multi-therapies in paediatric SDB
Multi-therapies might act synergistically in treating
paediatric SDB. In snoring and mild OSA cases
without obesity (AHI > 1 < 5), Villa et al.82 have
proposed orthodontic treatment in conjunction
with medical and myofunctional therapy. In non-
obese OSA cases with AHI > 5, adenotonsillectomy,
along with orthodontic treatment with or without
myofunctional therapy, should be considered.82
Kaditis et al.93 have proposed a stepwise treatment
approach which starts with weight control and is
followed by nasal corticosteroids, adenotonsillectomy
surgery, orthodontic devices, CPAP and, finally,
craniofacial surgery or tracheostomy in severe cases.
Conclusions
1. All children should be screened for snoring
and signs of upper airway obstruction at a first
consultation.
2. Craniofacial disharmony might be an important
predisposing factor in the development and
progression of paediatric SDB but remains poorly
understood and controversial.
3. Adenotonsillectomy is the recommended first line
treatment of OSA in children.
4. Although dentofacial orthopaedics is one
therapeutic option in the management of paediatric
SDB, there are insufficient long-term data on its
Australian Orthodontic Journal Volume 29 No. 2 November 2013 189
 KATYAL ET AL
efficacy. Further studies are indicated to define the
patients who might benefit most from orthodontic
intervention.
5. A greater degree of collaboration between sleep
medicine, ear, nose and throat specialists and
orthodontists is required to establish individualised
approaches for successful treatment.
6. There is currently no consensus on the best method
of multi-therapy management for paediatric SDB.
Therefore, there is an urgent need to research
and establish effective protocols and delineate the
relative contributions of each therapy.
Acknowledgments
We express our gratitude to Dr Yvonne Pamula
for her wise counsel and the Australian Society
of Orthodontists Foundation for Research and
Education (ASOFRE) for supporting this project.
Corresponding author
Dr Vandana Katyal
Level 5, Adelaide Dental Hospital
Frome Road
Adelaide South Australia 5005
Australia
Email: vandykatyal@gmail.com
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Bilateral missing lower permanent incisors:
a case report
Mohamed I. Masoud
Department of Developmental Biology, Harvard School of Dental Medicine, Boston, MA, USA and Department of
Preventive Dental Sciences, King Abdulaziz University, Jeddah, Saudi Arabia

Aim: This case report describes the treatment of a patient of African descent with bilateral congenitally missing mandibular
incisors and a 10 mm overjet.
Methods: The article discusses the incidence of tooth agenesis and the different approaches to treating patients with bilateral
congenitally missing lower incisors. The current treatment involved lower canine substitution for the lower lateral incisors and
upper premolar extractions because of malformation. Temporary micro-implants were placed to augment anchorage and to
resolve the excessive overjet by the retraction of the upper anterior teeth while preserving a Class I molar relationship.
Results: The Bolton disharmony created by the incisor agenesis and the extraction pattern proved to be a challenge and although
an acceptable result was achieved, it was expectedly less than ideal.
(Aust Orthod J 2013; 29: 193-199)

Received for publication: October 2012

Accepted: May 2013

Mohamed I. Masoud: mohamed_masoud@hsdm.harvard.edu OR masoudortho@gmail.com

Introduction The possible treatment approaches to manage lower

The prevalence of hypodontia, excluding third molars,
in European populations is 8.5% in females and 6.5%
in males.1 The most frequently occurring congenitally
missing teeth are the mandibular second premolars
(3.4%) and the maxillary lateral incisors (2.2%).1 Arab
and African populations have commonly agenic teeth
similar to Europeans but have been shown to have a
lower incidence of hypodontia.2-4 The prevalence of
hypodontia in Asian and European populations is
comparable but the most frequently agenic tooth is
the mandibular incisor with a prevalence of 58.7%
in Asian children exhibiting hypodontia.5,6 Evidence
suggests that hypodontia, together with malformed
teeth, are inherited as an autosomal dominant trait.7
Bilateral agenesis of the mandibular incisors has been
rarely reported in the literature and case descriptions
of the orthodontic treatment of lower incisor agenesis
are lacking. Four cases exhibiting bilateral agenesis
of permanent mandibular central incisors have been
reported in India, of which 3 had retained primary
central incisors. The cases were unrelated and none
received orthodontic treatment.8
incisor agenesis include prosthetic replacement of
the missing teeth, or orthodontic therapy requiring
the extraction of maxillary premolars to balance
the dentition, and mesialisation of the lower
buccal segments to close the lower anterior space.
Schwarz reported a Class II division II patient with
congenitally missing lower incisors who was treated
with mesialisation of the lower teeth and surgical
advancement of the mandible.9 Newman described
two unrelated cases with bilateral congenitally missing
lower incisors treated by mesialising the mandibular
teeth and the substitution of the lower canines for
the lower lateral incisors. Both cases finished in
a partial Class III molar relationship and upper
canines displaying less than ideal interdigitation.10
In addition, Newman reported a family including a
mother and three daughters with congenitally missing
lower teeth. The mother and two daughters had a
unilateral missing incisor while the third daughter
had bilaterally missing lower incisors and a Class II
molar relationship. The latter case was treated with
Class II elastics and space closure in the lower arch,

© Australian Society of Orthodontists Inc. 2013 Australian Orthodontic Journal Volume 29 No. 2 November 2013 193
 MASOUD

Table I. Pretreatment, progress and post-treatment cephalometric values.

Measurement Pretreatment value Progress value Post-treatment value

SNA angle (º) 78.0 77.5 79.5
SNB angle (º) 75.4 75.6 77.5
ANB angle (º) 3.0 1.9 2.0
Witts appraisal (mm) 1.9 -1.3 -1.7
Cond-A (mm) 71.0 70.0 73.0
Cond-Gn (mm) 93.0 93 .0 100.0
Max-Mand (mm) 21.0 23.0 28.0
SN to MP (º) 37.5 36.3 37.0
FH to MP (º) 26.5 26.1 27.2
U1 to NA (º) 50.5 26.5 34.0
U1 to NA (mm) 1.0 5.0 6.0
L1 to NB (º) 42.0 28.5 25.2
L1 to NB (mm) 7.0 6.0 7.0
L1 to MP (º) 109.3 96.6 90.7

which resulted in a Class I relationship on the left, a
partial Class III relationship on the right, and a lower
midline that significantly deviated to the left of the
upper midline.11 An adult with bilaterally missing
lower incisors treated with upper first premolar
extractions has been described, along with a 10 year
post-treatment review.12 The case was treated to a
Class I molar relationship and a full unit Class III
canine relationship. Upper posterior anchorage was
achieved using universal T-loop mechanics supported
by high pull headgear. The treatment of lower incisor
agenesis is therefore case dependent and so the purpose
of the present article is to report the orthodontic
management of a patient with bilaterally congenitally
missing mandibular incisors and a markedly increased
overjet treated with upper premolar extractions, and
lower canine to lateral incisor substitutions.
Diagnosis and aetiology
The patient was a 13-year-old female of Eritrean
descent with a chief complaint of excessive overjet
(Figures 1-3). Her medical history was unremarkable
and her history demonstrated regular dental care
and good oral hygiene. There was no family history
of trauma or dental anomalies. Extra-oral evaluation
revealed a convex profile, prominent lips, a deep
mentolabial sulcus, and mentalis strain on closure.
Intra-oral and radiographic examinations revealed
bilaterally congenitally missing lower incisors,
abnormal anatomy of the upper right second
premolar, 2 mm of crowding in the maxillary arch
and 3 mm of spacing in the mandibular arch (if the
missing incisors were not taken into consideration).
The upper midline was coincident with the facial
midline and the lower midline was 1.5 mm to the
left. The upper and lower arches were co-ordinated
and the occlusion displayed no crossbites. The molars
and canines were in a Class I relationship bilaterally.
However, the overjet was measured at 10 mm and the
increased overbite was causing traumatic occlusion
on to the palatal mucosa. A cephalometric analysis
(Table I) revealed a hyperdivergent Class I skeletal
relationship with extremely proclined and protrusive
upper and lower incisors.
Treatment objectives
The treatment objectives for this patient were to reduce
the overjet, upright the upper and lower incisors,
relieve the upper crowding, close the lower spaces,
maintain the Class I molar relationship, perform
bilateral lower canine substitutions, and achieve a full
unit Class III canine relationship.

194 Australian Orthodontic Journal Volume 29 No. 2 November 2013


Figure 1. Pretreatment extra-oral and intra-oral photographs.
Figure 3. Pretreatment panoramic radiograph.
Figure 2. Pretreatment cephalometric
radiograph.
Treatment alternatives
The opening of space for prosthetic replacement of
the missing lower teeth was considered but discarded
since the patient had lip strain on closure and
requested orthodontic treatment which would result
in retraction of her upper and lower lips. An alternative
BILATERAL MISSING LOWER PERMANENT INCISORS: A CASE REPORT
treatment approach would be the distalisation of the
upper posterior segments into a full unit Class III
relationship (with or without upper second molar
extractions) and perform bilateral canine to incisor
substitutions in the lower arch. In addition to the
challenges posed by distalising the maxillary buccal
Australian Orthodontic Journal Volume 29 No. 2 November 2013 195
 MASOUD

Figure 5. Initial, progress, and post-treatment overall superimposition.

Figure 4. Progress periapical radiographs showing the position of the

micro-implants for the retraction of the maxillary anterior teeth.

segments by 6 mm, considerable bite opening would

likely result and a worsening of the hyperdivergent
facial pattern. Upper first premolar extractions
would be beneficial for controlling upper posterior
anchorage, however, the patient’s upper right second
premolar was dysmorphic and a decision was made to
extract both upper second premolars.

Treatment plan
The chosen treatment plan involved bilateral lower
canine substitution and the extraction of the upper
second premolars. The goal was to finish the occlusion
in a full unit Class III canine relationship and Class I
molar relationship. To significantly retract the upper
canines and first premolars, absolute anchorage in the
upper arch and minimal anchorage in the lower arch
was planned with the aid of micro-implants placed
mesial to the upper first molars. The retention plan
included upper and lower fixed retainers from canine
to canine and removable Hawley retainers with labial
acrylic to be worn at night.
Figure 6. Initial, progress, and post-treatment segmental
superimpositions.
Treatment progress
Pre-adjusted stainless steel brackets with an 0.018 inch
slot were attached. The facial contour and cusp tips of
the lower canines were preliminarily reshaped before
placement of lower incisor brackets. Levelling and
alignment was achieved on 0.016 inch nickel titanium
(NiTi) wires. Two micro-implants (8 mm in length
and 1.4 mm in diameter) were inserted mesially to the

196 Australian Orthodontic Journal Volume 29 No. 2 November 2013


upper first molars (Figure 4). NiTi closed coil springs
attached to the micro-implants were used to retract
the upper teeth en masse on 0.016 x 0.022 inch TMA
wires. The line of action of the force was kept below the
centre of resistance of the anterior teeth to retrocline the
upper incisors. The lower spaces were closed with the
aid of power chain and Class II elastics. Bite opening
was achieved using sweeps in the upper and lower
working archwires. Following a year of treatment, the
upper canines were retracted to a full unit Class III
relationship but were in a Class I relationship relative
to the lower first premolars. The micro-implants were
removed to allow the molars to close the remaining
upper spaces. The lower incisor roots were torqued
labially while the incisal edge position was maintained.
The tooth size discrepancy, which resulted from the
lower canine substitution, contributed to an edge-
to-edge incisal relationship evident in the progress
cephalometric radiographic evaluation (Figures 5 and
6). Significant interproximal reduction of the lower
canines and incisors was necessary to achieve a positive
overjet. A progress panoramic radiograph allowed
evaluation of root positions and the need to rebond
selected teeth for occlusal detailing. Final records were
taken 28 months after the start of treatment (Figures
7-9). More than 12 months was devoted to finishing
and detailing since the patient had a significant amount
of mandibular growth during that period (Figures 5,
6 and 9). Despite the interproximal reduction and
reported compliance with the elastic wear, there was
extreme difficulty in achieving a positive overjet and
overbite. The patient was finally debonded with an
overjet and overbite of 1-1.5 mm, which was less than
ideal.
Discussion
Absolute anchorage using micro-implants was initially
planned to overcome the difficulty of retracting the
upper incisors, canines, and first premolars one full
unit into the upper second premolar extraction spaces.
The amount of mandibular growth which occurred
was not anticipated. The patient’s compliance with
elastic wear during the finishing stages was repeatedly
questioned but she was adamant that the elastics were
worn consistently as instructed. The superimposition
of the final and progress tracings confirmed her
compliance since mandibular growth was significantly
compensated for by the Class III elastics (Figure 6).
In addition to the unexpected growth challenges,
BILATERAL MISSING LOWER PERMANENT INCISORS: A CASE REPORT
finishing of the case was difficult and hampered by
the retroclination of the upper incisors during their
retraction and the tooth-size discrepancy which
resulted from the lower canine substitutions. A
significant portion of the finishing effort was directed
towards addressing those problems. Because of the
canine substitutions, a Bolton analysis revealed 3.5
mm of mandibular anterior excess. Only 2.5 mm
of interproximal reduction was achieved and in
retrospect, it would have been preferable to correct
the remaining discrepancy by building up the upper
lateral incisors.
Most previously reported cases of incisor agenesis have
involved a non-extraction approach along with Class
II elastics, in an effort to finish the canines and molars
in a full unit Class III relationship. However, that goal
was seldom achieved in published records.10,11 Choi
et al. reported an adult case with bilaterally missing
lower incisors and a Class I molar relationship treated
with upper first premolar extractions and lower canine
substitution. Since the goal was to finish with Class
III canine and Class I molar relationships, absolute
anchorage was necessary, especially in the absence of
growth. This was achieved with the aid of high pull
headgear, and differential force moments generated by
an A-type segmented Burstone universal T-loop. Ten-
year post-retention records demonstrated excellent
long-term stability.12 Although presenting with similar
problems, the current patient had less overbite and was
approaching puberty at the beginning of treatment.
There was also a dysmorphic upper right second
premolar and low gingival margins on both upper
second premolars, which favoured their extraction.
Micro-implants were used to overcome the anchorage
challenges dictated by the upper extraction pattern.
Unlike maxillary canine substitutions, mandibular
canine substitutions are performed in a region of the
mouth usually minimally visible. Both substitutions
impede the orthodontic ability to establish canine
guidance and a Class I canine relationship. Long-
term studies have evaluated the risks and benefits of
canine substitutions and brought into question the
importance of a Class I canine relationship.13,14 When
compared with patients with spaces regained for
maxillary lateral incisors, patients with maxillary canine
substitutions are periodontally healthier, generally
more satisfied with their treatment results, and are at
minimal risk of developing temporomandibular joint
dysfunction. 13,14
Australian Orthodontic Journal Volume 29 No. 2 November 2013 197
 MASOUD

Figure 7. Post-treatment extra-oral and intra-oral photographs.

Figure 9. Post-treatment cephalometric radiograph.

Figure 8. Post-treatment panoramic radiograph.

Had the current patient’s lips been less protrusive,
opening spaces for two lower implants would have
been a possible treatment alternative. To avoid the
difficulty of placing implants in the mandibular
anterior region, spaces could have been opened in the
canine or premolar areas. This treatment approach is
reasonable if the molars are in a Class I relationship
at the outset. If the molars presented in a Class II
relationship, a further treatment option may have
involved upper premolar extractions with implant
replacements in the lower arch. Alternatively, canine
substitution may have been possible in the lower

198 Australian Orthodontic Journal Volume 29 No. 2 November 2013


arch, coupled with upper premolar extractions and
distalisation in the upper arch.
If the molars presented in a Class III relationship,
lower canine substitutions could have been possible
without upper extractions. A partial Class III
relationship would make distalisation or upper
premolar extractions necessary to achieve ideal
interdigitation. The existence of an underlying Class
III or Class II skeletal discrepancy which required
growth modification or orthognathic surgery would
suggest that the decision to extract in the upper arch
and close space in the lower arch would be dictated by
the degree of crowding and the initial incisor position.
Conclusion
A patient with bilaterally missing lower incisors,
severe overjet, Class I molars, and incompetent
lips was treated with lower canine to lateral incisor
substitutions, upper second premolar extractions
and temporary micro-implants for upper posterior
anchorage. Achieving ideal overjet and overbite was
hindered by the patient’s unexpected mandibular
growth and the Bolton discrepancy that was a result
of the canine substitutions.
Corresponding author
Dr Mohamed I. Masoud
Director of Orthodontics
Harvard School of Dental Medicine
188 Longwood Ave
Boston MA 02115
U.S.A.
Email: mohamed_masoud@hsdm.harvard.edu OR
masoudortho@gmail.com
BILATERAL MISSING LOWER PERMANENT INCISORS: A CASE REPORT
References
1. Bäckman B, Wahlin YB. Variations in number and morphology of
permanent teeth in 7-year-old Swedish children. Int J Paediatr Dent
2001;11:11-17.
2. Al-Emran S. Prevalence of hypodontia and developmental
malformation of permanent teeth in Saudi Arabian schoolchildren.
Br J Orthod 199;17:115-18.
3. Albashaireh ZS, Khader YS. The prevalence and pattern of
hypodontia of the permanent teeth and crown size and shape
deformity affecting upper lateral incisors in a sample of Jordanian
dental patients. Community Dent Health 2006;23:239-43.
4. Harris EF, Clark LL. Hypodontia: an epidemiologic study of
American black and white people. Am J Orthod Dentofacial Orthop
2008;134:761-7.
5. Niswander JD, Sujaku C. Congenital anomalies of teeth in Japanese
children. Am J Phys Anthropol 1963;21:569-74.
6. Davis PJ. Hypodontia and hyperdontia of permanent teeth in
Hong Kong schoolchildren. Community Dent Oral Epidemiol
1987;15:218-20.
7. Svinhufvud E, Myllärniemi S, Norio R. Dominant inheritance of
tooth malpositions and their association to hypodontia.Clin Genet
1988;34:373-81.
8. Nagaveni NB, Umashankara KV. Congenital bilateral agenesis of
permanent mandibular incisors: case reports and literature review.
Archives of Orofacial Sciences 2009;4:41-6.
9. Schwarz L. Post-treatment appraisal of orthodontic results. Trans Eur
Orthod Soc 1966;87-9.
10. Newman GV. Congenitally missing mandibular incisors: treatment
procedures. Am J Orthod 1967;53:482-91.
11. Newman GV, Newman RA. Report of four familial cases with
congenitally missing mandibular incisors. Am J Orthod Dentofacial
Orthop 1998;114:195-207.
12. Choi YJ, Chung CJ, Choy K, Kim KH. Absolute anchorage with
universal T-loop mechanics for severe deepbite and maxillary anterior
protrusion and its 10-year stability. Angle Orthod 2010;80:771-83.
13. Nordquist GG, McNeill RW. Orthodontic vs. restorative treatment
of the congenitally absent lateral incisor: long-term periodontal and
occlusal evaluation. J Periodontol 1975;46:139-43.
14. Robertsson S, Mohlin B. The congenitally missing upper lateral
incisor. A retrospective study of orthodontic space closure versus
restorative treatment. Eur J Orthod 2000;22:697- 710.
Australian Orthodontic Journal Volume 29 No. 2 November 2013 199
 Long term stability of intra-oral maxillary
distraction in unilateral cleft lip and palate: a
case report
Şirin Nevzatoğlu,* Nazan Küçükkeleş* and Zeki Güzel†
Department of Orthodontics, School of Dentistry, Marmara University, Istanbul,* Plastic and Reconstructive Surgeon,
Private Practice, Istanbul,† Turkey

Objective: This case report presents short and long term treatment results of a unilateral cleft lip and palate patient treated with a
modified intra-oral tooth-bone borne distraction appliance.
Materials and methods: The chief complaints of a 16-year-old, unilateral cleft lip and palate patient were poor facial aesthetics,
crowding and a fistula. Severe maxillary retrognathism was treated via distraction osteogenesis of the maxilla and performed
using an intra-oral tooth-bone borne appliance. Treatment continued to completion with a multibracket system. At an eight-year
review following the distraction procedure, the short and long term results were determined cephalometrically.
Results: Following the distraction, A-point advanced 7 mm, 2 mm of which relapsed during fixed appliance treatment. At the end
of the active treatment, the patient’s skeletal and dental Class III relationship improved to Class I, which was preserved at the
long-term review. The profile was markedly improved by the distraction osteogenesis.
Conclusion: In cases of severe maxillary retrognathism as a result of a cleft lip and palate, maxillary distraction osteogenesis
provides a viable alternative to orthognathic surgery.
(Aust Orthod J 2013; 29: 200-208)

Received for publication: August 2012

Accepted: July 2013

Şirin Nevzatoğlu: sirin2288@hotmail.com OR sirin.nevzatoglu@marmara.edu.tr; Nazan Küçükkeleş: nazles@tnn.net;

Zeki Güzel: mzekiguzel@gmail.com

Introduction timing and an optimal progression of the different

Cleft lip and/or palate anomalies are common
craniofacial malformations, and patients may
present with multiple functionally and aesthetically
challenging problems. Maxillary hypoplasia secondary
to a repaired cleft lip and palate is an unfortunate
sequela, the extent of which depends on several
factors, including the degree of the cleft deformity and
the extent of scar tissue formed as a result of surgical
repair.1
Orthodontic treatment plays a significant role in the
multidisciplinary approach to the treatment of cleft
patients.2 Treatment is governed by physiological and
functional parameters, including the severity of the
maxillomandibular discrepancy, the expected relapse
tendency and the expected aesthetic result. Successful
treatment outcomes also depend upon appropriate
treatment processes.2
Current protocols for the management of cleft patients
may include conventional orthodontic treatment
alone,3 orthognathic surgery in conjunction with
orthodontic treatment4 and orthodontic treatment
combined with distraction osteogenesis.5,6 Separation
of the pterygomaxillary buttress is generally difficult
in cleft patients, and so mobilisation of the maxilla
is correspondingly difficult. Often lip scarring is
a consequence of previous operations, which may
increase lip tension and therefore, enhance the relapse
tendency. Despite improvements in surgical fixation,
the likelihood of postsurgical relapse in cleft patients
is greater compared with non-cleft patients presenting
with maxillary hypoplasia.7 The extreme discrepancies
and displacement of bony segments may make

200 Australian Orthodontic Journal Volume 29 No. 2 November 2013 © Australian Society of Orthodontists Inc. 2013

Figure 1. Initial extra-oral and intra-oral photographs.
stabilisation difficult and palatal and facial scarring can
increase postsurgical relapse in CLP patients treated
with a conventional Le Fort I maxillary advancement.
However, distraction osteogenesis provides a treatment
alternative to conventional surgery. A greater amount
of maxillary advancement, as well as more significant
soft tissue change, may be obtained with a distraction
osteogenesis protocol.8,9 In addition, stability and long
term results of distracted cases are also reported to be
better than cleft patients treated with conventional
orthognathic surgery. In the following case report,
the short and long term results of a unilateral cleft
lip and palate patient treated via intra-oral maxillary
distraction osteogenesis, is presented.
Diagnosis
A 16-year-old male with a unilateral cleft lip and palate
presented for treatment at the Marmara University,
Faculty of Dentistry, Department of Orthodontics.
The patient’s chief complaints were an unaesthetic
smile, an unsatisfactory occlusion and crowding. The
patient had a low smile line. His upper midline was co-
incident with the face whereas his lower midline had
shifted 1 mm towards left. He had an Angle’s Class
III molar relationship on both sides, upper and lower
crowding and an occlusion highlighted by anterior
and posterior crossbites. The upper left lateral and
LONG TERM RESULTS OF INTRA-ORAL MAXILLARY DISTRACTION
second premolar were congenitally missing while the
upper right lateral incisor, located in the cleft region,
was peg-shaped. The initial overjet was measured at -3
mm whereas the overbite was 4 mm (Figure 1). At the
initial clinical examination, no fistula was evident in
the cleft palate region.
A cephalometric analysis revealed a skeletal Class III
relationship due to severe maxillary retrognathism
(NperA: -13 mm, SNA: 69°, Max.Depth: 77°) with
accompanying retroclined upper and lower incisors.
The profile was concave with an increased nasolabial
angle but a normal, continuing, vertical growth
pattern was expected (Table I).
Treatment objectives
The treatment objectives were to correct the transverse
and sagittal discrepancy, to relieve the crowding,
normalise overjet and overbite, to provide appropriate
space for prosthetic rehabilitation and improve smile
and overall facial aesthetics.
Treatment progress
A challenging treatment plan included rapid
maxillary expansion, sagittal distraction osteogenesis
of the maxilla using a modified intra-oral tooth-
bone borne distraction appliance, levelling of the
Australian Orthodontic Journal Volume 29 No. 2 November 2013 201
 NEVZATOGLU ET AL

Table I. Skeletal, dental and soft tissue profile evaluation of the patient at pretreatment, post-treatment and recall periods.

Standard Pretreatment Post-distraction Post-treatment Recall

Skeletal evaluation
Vertical
∑ (Sum of Saddle- 396 ± 3 391 399 398 389
articular-gonial angles)
GoMe-SN (°) 32 ± 7 32 41 32 31
Maxillary height (°) 60 59 59 61 61
FMA (°) 25 23 30 26 28
R1-A (mm) 49 51 53 52
R1-B (mm) 87 95 93 92
Sagittal
SNA (°) 82 ± 2 69 76 73 73
SNB (°) 80 ± 2 73 69 70.5 71
ANB (°) 2 -4 7 2.5 2
NperA (mm) -1 - 13 -6 -8 -8
Maxillary depth (°) 90 77 85 82 82
ACB/Corpus X/X+7 75/76 75/77 75/75 75/76
R2-A (mm) 59 66 64 64
R2-B (mm) 55 49 53 52
Witts (mm) -1; 0 -4 7 5 2
SL (mm) 51 45 39.5 43 45
Dental evaluation
I-SN (°) 103 69 101 82 82
IMPA (°) 90 76 77 85 81
Holdaway 1/1 0/8 -1/7 1/9 0/9
Soft tissue profile
Nasolabial angle (°) 90-110 112 122 122 123
Upper lip-E line (mm) -4 -16 -6 -11 -10
Lower lip-E line (mm) -2 -11 -4 -8 -7

arches and finishing. At the end of orthodontic
treatment, prosthetic rehabilitation was planned for
the malformed and missing teeth. The planned rapid
maxillary expansion was achieved using an acrylic cap-
splint hyrax expander. The screw was activated twice
per day and continued for 22 days. At the completion
of expansion, a small fistula was noted in the repaired
cleft palate region.
After the completion of rapid palatal expansion, an
accurate silicone impression of the maxillary arch was
taken and a one piece, cast cap splint was fabricated
(Figure 2). Two cylinders, forming the intra-oral
attachments of the distraction device, were soldered
parallel to each other on the buccal aspects of the
intra-oral splint and the assembly cemented on the
maxillary teeth.

Description of the distraction device Surgical method

The intra-oral tooth-bone borne combined distraction A classic and complete Le Fort I osteotomy and
device consisted of three parts: a miniplate for fixation, down-fracture produced complete mobilisation of
a distraction screw, and a cast cap splint (Figure 2). the maxilla. Grafting of the cleft using iliac bone and

202 Australian Orthodontic Journal Volume 29 No. 2 November 2013


Figure 2. Intra-oral distraction appliance.
Figure 3. Post-distraction extra-oral and intra-oral photographs.
repair of the oral fistula were also performed. Before
insertion of the device, the miniplate was adjusted to
fit the zygomatic bone. The miniplate was screwed
on to the intra-oral distractor which provided vertical
adjustment of the appliance. The horizontal rod of
the distractor was inserted into the soldered tube, and
the miniplate attached to the zygomatic buttress. The
horizontal activating screw entered the mouth without
disturbing the soft tissues. Before osteotomy closure,
each screw was turned 6 times, which was equivalent
to 3.0 mm opening, and left in that position. After
successful device operation, surgery was completed
and the soft tissues were sutured.
Distraction protocol
Distractor activation started at a rate of 1 mm/day after
a latency period of 6 days. The patient was instructed
to open the screws twice a day and distraction
LONG TERM RESULTS OF INTRA-ORAL MAXILLARY DISTRACTION
continued for 12 days (Figure 3). The initial skeletal
maxillary retrusion was 13 mm. An over-correction of
2 mm was aimed for and so, at the end of distraction,
the total opening of the screws was 15 mm. Following
a retention period of 3 months, the appliances
were removed under local anesthesia and treatment
continued with 0.018 inch slot, standard edgewise
brackets. During the activation and retention periods,
the patient experienced no discomfort or irritation.
There were no intra-operative complications and the
postoperative course was uneventful. There was no
infection, no dislocation or breakage of the device and
there was no damage to the teeth or soft tissues.
Orthodontic treatment
Nickel-titanium (NiTi) arch wires were used in
both arches for initial levelling and alignment. The
orthodontic plan required the modification of the
Australian Orthodontic Journal Volume 29 No. 2 November 2013 203
 NEVZATOGLU ET AL
Figure 4. Post-treatment extra-oral and intra-oral photographs.
left central incisor (21) to the left lateral (22), the
right central (11) to the left central incisor (21), the
right canine (13) to the right lateral incisor (12), the
right first premolar (14) to the right canine (13); the
extraction of the peg-shaped lateral incisor, and the
opening of space for the right central incisor (11).
Following space opening with NiTi open coil springs,
Class II elastics were applied for the correction of the
posterior sagittal relationship. Uprighting of the roots
of the upper right central incisor (11) and canine (13)
progressed while overbite and overjet were normalised.
After finishing and detailing, the appliances were
removed and clear retainers provided for retention
(Figure 4). Comprehensive records were taken and the
patient was referred to a periodontist for the treatment
of gingival recession affecting the upper right central
incisor, and to a prosthodontist for the rehabilitation
of the upper teeth. The prosthodontic work required
a bridge between the right canine (13) and the right
central incisor (11) and a crown on the left central
incisor (21) in order to convert it to a lateral incisor
(22). The total fixed appliance treatment time was 3
years 10 months.
Four years after the completion of the active treatment
and 8 years following maxillary distraction, the patient
was recalled and reviewed. During this period, the
patient had lip and nose revision surgery. Intra-oral
and extra-oral photographs and x-rays were obtained
204 Australian Orthodontic Journal Volume 29 No. 2 November 2013
(Figures 5-7), and treatment stability, along with long
term results were evaluated.
Skeletal changes were assessed by cephalometric
radiographs which were taken before, post-distraction,
post-treatment and 4 years after active orthodontic
treatment (Figure 6). A horizontal reference plane
was drawn at an angle of 7° from SN plane through
point S in a clockwise direction (R1). A perpendicular
line was drawn through S point to this horizontal
reference plane as a vertical reference line (R2). The
horizontal (R1) and vertical (R2) reference planes, were
transferred to the post-distraction, post-treatment
and recall cephalograms in order to standardise each
measurement. Superimpositions were conducted
to reveal the skeletal, dental and soft tissue changes
(Figure 8).
Results
The maxillary sagittal measurements of SNA, ANB,
maxillary depth angle and Nper-A, R2-A and Wits
showed an increase during distraction. The anterior
movement of the maxilla was 7 mm measured at
point A, which was less than the 15 mm lengthening
of the device itself. During fixed treatment and the
recall period, a 2 mm decrease in sagittal maxillary
position was seen. Mandibular sagittal measurements
R2-B and SL decreased during distraction (6 mm and

Figure 5. Recall extra-oral and intra-oral photographs.
Figure 6. Initial (1), Post-distraction (2), Post-treatment (3), Recall (4) cephalograms.
5.5 mm, respectively), but increased during the post-
distraction period and were stable at recall (Table I).
Vertical measurements (∑, GoMe-SN and FMA) were
found to increase during the distraction process (8°,
9° and 7°, respectively), which represents extrusion
of the posterior teeth and opening of the anterior
bite. This resulted in a more posterior position of
the mandible due to a clockwise rotation. These
parameters decreased during the post-distraction and
review periods (Table I).
A dental evaluation of the patient showed that a 32°
proclination of the upper incisors (SN-UI) during
distraction and a 19° retroclination during fixed
appliance treatment occurred. The lower incisor
inclination (IMPA) increased 8° during the fixed
LONG TERM RESULTS OF INTRA-ORAL MAXILLARY DISTRACTION
treatment stage. Long term dental results were found
to be stable (Table I).
The nasolabial angle increased (10°) during distraction
and was found to be stable during fixed appliance
treatment and at the recall period. Both upper and
lower lips protruded during distraction (10 mm and
7 mm, respectively); however, recovered during fixed
treatment (5 mm and 4 mm respectively) and stayed
stable during the recall period (Table I).
At the end of fixed appliance treatment, the crowding,
posterior and anterior crossbites, as well as smile
aesthetics were corrected or improved. Ideal overjet
and overbite and good interdigitation of the posterior
teeth were achieved. These clinical changes were
found to be stable during the post-treatment period.
Australian Orthodontic Journal Volume 29 No. 2 November 2013 205
 NEVZATOGLU ET AL
Figure 7. Initial (1), Post-distraction (2), Post-treatment (3), Recall (4) OPTGs.
Figure 8. Superimposition showing skeletal, dental and soft tissue
changes of the patient.
Discussion
Instead of maxillary distraction, conventional
bimaxillary surgery was a possible alternative
treatment for this patient. However, as the patient had
a normal-sized mandible with a severely retrognathic
maxilla, significant advancement of the maxilla as well
as mandibular surgery would be needed to achieve
this treatment plan. Single jaw surgery involving
only maxillary advancement was not considered
as a treatment option because of the magnitude of
the procedure and the questionable stability of the
206 Australian Orthodontic Journal Volume 29 No. 2 November 2013
maxillary advancement. Without repositioning of the
mandible, it would have been difficult to correct the
posterior interdigitation and the soft tissue changes
would not have been acceptable. Soft tissue changes
are reported to be more significant following the
distraction protocol.8,9 This provided justification
for the maxillary distraction procedure rather than
orthognathic surgery.
The patient’s maxillary retrusion was initially of
the order of 13 mm. It was planned to advance the
maxilla by 7-9 mm to bring the canines into a Class
II relationship and allow for a slight relapse. More
advancement would have caused the patient to
become severely Class II, necessitating a consideration
of mandibular advancement surgery. It has been
reported that the activation of the screw and the
amount of generated maxillary distraction are not
equal. Pickard et al.10 reported that the mean anterior
movement of the maxilla in 19 patients using an
intra-oral maxillary distraction device was 9.6 mm
(range 4 - 17 mm) measured at point A. This differed
considerably from the lengthening of the device itself
(range 8.5 - 24 mm). Swennen et al.11 also reported a
7-8 mm advancement using a 10 - 14 day distraction
protocol, which matched half of the activation of the
screw. Therefore, the current treatment planned to
activate the screw 13 mm with an additional 2 mm

for overcorrection. At the end of the distraction, the
cephalometric assessment revealed that maxillary
advancement was 7 mm.
Another treatment option considered was an extra-oral
maxillary distraction procedure. However, patients are
at risk of external cranial trauma12,13 and many patients
find the wearing of the device uncomfortable. Adults
generally will not accept extra-oral distraction for
psychological and discomfort reasons. Alternatively,
extra-oral devices have the advantage of avoiding
fixation to the maxillary bone, which safeguards the
roots of the teeth.
The intra-oral tooth-bone borne device which was
currently used, required simplified surgery for its
initial fixation. The device had only one miniplate
attached to each zygomatic bone. The fixation of
two miniplates bilaterally requires careful parallel
orientation and positional coordination, which is
challenging. Expensive stereolithographic models
or computer graphics are usually needed.14 The
placement of a second miniplate below the osteotomy
line risks damaging the roots, and requires sufficient
bone for fixation. In addition, the removal of one
unilateral miniplate is easier than removing two and
can be done under local anesthesia.
In order to achieve good mineralisation of the newly
formed bone, the consolidation phase should be as
long as possible. Accepted practice for retention is
3 to 4 months to minimise the risk of relapse,15 but
is dependent on several factors such as blood supply,
presence of scar tissue or the thickness of the original
bone. Extra-oral devices cannot be easily maintained
for long periods because of patient acceptance which
is better with internal devices.
During fixed treatment, 28.6% (2 mm) of the obtained
sagittal advancement relapsed. Figueroa et al.16 assessed
the long-term stability of maxillary advancement
achieved by using the rigid external distraction device
in 17 young people. It was found that a 10.2° increase
of the SNA angle achieved by distraction osteogenesis
decreased by 2.4° (23.5%) in the postoperative period.
It was considered that some of the change might have
occurred because of continued growth at Nasion.
Since the study involved children, it was difficult to
separate the long-term changes of maxillary position
resulting from relapse, with those of facial growth. In
2010, Gürsoy et al.17 reported in a 5-year follow-up
study that, although the overall treatment results were
stable, the dento-skeletal treatment outcome partly
LONG TERM RESULTS OF INTRA-ORAL MAXILLARY DISTRACTION
diminished with time. However, Rachmiel et al.18
reported stable long-term results following intra-oral
distraction osteogenesis.
Conclusion
A case report demonstrating the use of distraction
osteogenesis to correct a retrognathic maxilla in a
patient with a cleft lip and palate has been presented.
The stability of the procedure was considered to be
clinically and cephalometrically acceptable. The short-
and long-term results were satisfactory for the clinician
and patient. Maxillary distraction osteogenesis offers a
viable alternative to the orthognathic surgery in cleft
lip and palate cases.
Corresponding author
Dr Sirin Nevzatoglu
Marmara University, Faculty of Dentistry
Department of Orthodontics
Tesvikiye mah. Buyukciftlik s. N:6 3rd floor 34365
Nisantasi, Sisli, Istanbul, Turkey
Email: sirin2288@hotmail.com OR sirin.
nevzatoglu@marmara.edu.tr
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Management of unilaterally impacted multiple
posterior teeth: a case report
Pawanjit Singh Walia, Sushil Kumar, Anu Singla and Varun Grover
Department of Orthodontics and Dentofacial Orthopedics, PDM Dental College and Research Institute Sarai Aurangabah,
Bahadurgarh, Haryana, India

Introduction: The impaction of permanent teeth poses a challenge to orthodontists, especially when posterior teeth are involved.
Multiple impacted posterior teeth without associated with systemic conditions/syndromes is an uncommon clinical occurrence
which leads to a posterior open bite and severely compromised function.
Aim: The present article reports the clinical management of an impacted maxillary second premolar, mandibular premolars and
mandibular first and second molars on the right side.
Method: The premolars were guided into occlusion by orthodontic traction. Disimpaction and uprighting of the mandibular first
molar were achieved using a Begg uprighting spring while a T-loop was used to correct the second molar. Absolute anchorage in
the form of miniscrews was not required as anchorage demands were minimal. The total treatment time was 24 months.
Results: Orthodontic mechanics resolved a demanding clinical problem and eliminated the need for prosthetic replacements. An
acceptable occlusion with a Class I molar relationship, normal function and a healthy periodontium were achieved.
Conclusion: The results indicated the benefits of uprighting multiple impacted teeth through orthodontic treatment.
(Aust Orthod J 2013; 29: 209-216)

Received for publication: January 2013

Accepted: August 2013

Pawanjit Singh Walia: pawanjitwalia@yahoo.in; Sushil Kumar: docshilu@yahoo.com; Anu Singla: dranusingla@gmail.com
Varun Grover: drvarun_ortho@rediffmail.com

Introduction cleidocranial dysplasia and Gardner’s Syndrome are

Impaction is an interference in the eruption of a tooth
caused by a clinically or radiographically detectable
physical barrier, or due to an abnormal position of
a tooth.1 The most frequently impacted teeth are
the maxillary and mandibular third molars, followed
by the maxillary canine and mandibular second
premolars.2 The prevalence of mandibular first molar
impaction in the population is less than 0.01% and
that of the second molar is 0.06%.3 The unilateral
impaction of multiple posterior teeth is even more rare
and has considerable clinical impact. Multiple impacted
posterior teeth usually create a severe posterior open bite
with significant functional compromise accompanying
the cessation of alveolar bone growth. The prognosis
regarding treatment time and outcome is guarded.
Dental impaction may result from systemic or
local factors. Hypothyroidism, hypopituitarism,
hypoparathyroidism, pseudohypoparathyroidism,
frequently associated with the failure of eruption of
multiple permanent teeth.4 Local factors include a lack
of arch space, the rotation of tooth buds, the infra-
occlusion of deciduous molars,5 the premature loss
of deciduous teeth and obstacles impeding eruption
which include supernumerary teeth, odontomas,
odontogenic tumors or cysts.1
The disimpaction and uprighting of posterior teeth
has functional, periodontal and restorative advantages.
Functionally, treatment provides occlusal contact for
each tooth, thereby preventing the supra-eruption of
opposing teeth and increasing masticatory efficiency.
The periodontal benefit of molar uprighting is the
elimination of a pseudo pocket, which assists in plaque
control. As proper oral hygiene around impacted teeth
is difficult and caries may easily involve adjacent teeth,
uprighting provides caries prevention and therefore
creates a restorative advantage.6

© Australian Society of Orthodontists Inc. 2013 Australian Orthodontic Journal Volume 29 No. 2 November 2013 209
 WALIA ET AL
Figure 1. Pretreatment facial and intra-oral photographs.
Five treatment approaches have been suggested to
manage impacted teeth. These include no treatment,
orthodontic treatment to disimpact, prosthetic build
up, a segmental osteotomy or extraction.7 The preferred
option to disimpact a posterior tooth is determined by
the severity of the impaction, the accessibility of the
coronal surface of the impacted tooth, a consideration
of possible undesirable side effects, as well as the ease
and expedience of intended uprighting mechanics.8
The position of a mildly tipped tooth may be
corrected by the placement of a brass wire separator
between the teeth.9 However, a more severe impaction
requires surgical repositioning10,11 or orthodontically-
assisted eruption with or without surgical exposure.
This may be followed by a corrective uprighting force
delivered by a NiTi-coil spring,12 a superelastic NiTi
wire,13 uprighting springs,6,14 an attached eruption
assisting appliance15 or a sectional arch wire.8 A
lingual approach is useful in cases providing limited
buccal access.16 Titanium miniscrews placed in the
retromolar area have also been considered a viable
additional mechanism for molar uprighting.17
There are clinical concerns regarding the alignment of
multiple impacted teeth due to the high possibility of
failure as a result of ankylosis, external root resorption
and root exposure associated with movement. There
is scant information regarding the management of
unilaterally impacted multiple posterior teeth.
210 Australian Orthodontic Journal Volume 29 No. 2 November 2013
The purpose of the present report is to discuss and
describe the orthodontic management of a rare case of
unilaterally impacted premolars and mandibular first
and second molars.
Case report
A 16-year-old female patient reported to the
Department of Orthodontics and Dentofacial
Orthopedics with the chief complaint of an inability
to chew on the right side. A review of the patient’s
medical, dental and family history revealed no
significant findings. The results of a general physical
examination revealed a healthy individual without
signs of dentofacial or syndromic anomalies.
Diagnosis
A facial analysis showed a mildly convex profile
with proportional facial thirds and no asymmetries.
An intra-oral examination revealed an Angle Class
I molar relationship on the left side, a moderate
overbite (50%), and an overjet of 4 mm. The
mandibular midline deviated to the right by 3 mm
and mild spacing was present in the anterior region
of both arches. All permanent teeth had erupted
except the maxillary second premolar, the mandibular
premolars and the mandibular first and second molars
 MANAGEMENT OF MULTIPLE IMPACTED TEETH

Table I. Cephalometric measurements.

Measurements Pretreatment Post-treatment

SNA 80° 79°
SNB 78° 77°
ANB 2° 2°
WITS 1 mm 1 mm
N ┴ A, mm 2.5 2
N ┴ Pog, mm 1 1.5
U1 – NA ( Angular/Linear) 22° / 4 mm 21° / 3 mm
L1 – NB (Angular/Linear) 28° / 4 mm 25° / 3 mm
SN – GoGn 27° 26°
U1 – SN 100° 99°
IMPA 98° 95°
Interincisal angle 121° 128°
E – Line U = -2 mm U = -2 mm
L = 0 mm L = 0 mm

on the right side, plus all third molars. This resulted

Figure 2. Pretreatment panoramic (A) and cephalometric (B) radiographs.
in a right side posterior open bite. No oral mucosal
lesions were found and soft tissue texture and tonicity
were normal (Figure 1). Panoramic and cephalometric
radiographs revealed the presence of all permanent
teeth including third molars and a deciduous maxillary
second molar, deciduous mandibular first and second
molars on the right side. These deciduous teeth were
in infra-occlusion. The maxillary second premolar
and the mandibular first and second premolars on
the right side were impacted but present beneath
the corresponding submerged deciduous teeth.
The impacted right maxillary second premolar was
upright but the impacted right mandibular first and
second premolars were angulated towards each other.
The right mandibular first molar was horizontally
impacted, facing mesially and flush with the distal
surface of the infra-occluded deciduous mandibular
second molar. The permanent right mandibular
second molar was also impacted, tipped mesially
and lying over the impacted right mandibular first
molar. The alveolar processes were severely deficient
in the region of infra-occluded and impacted teeth
(Figure 2).
A cephalometric examination revealed a Class I skeletal
pattern (ANB = 2º), an average mandibular plane
angle (SN- GoGn = 31º) with normally positioned
maxillary incisors, slightly proclined mandibular
incisors and an acceptable soft tissue profile (Table I).

Australian Orthodontic Journal Volume 29 No. 2 November 2013 211

 WALIA ET AL
Treatment objectives
The treatment aims were to:
1. Guide the impacted teeth into functional
occlusion,
2. Level and align the upper and lower arches,
3. Close the anterior spaces,
4. Match the upper and lower midline,
5. Achieve an ideal overjet and overbite.
Treatment alternatives
Several treatment options were considered and
included:
1. Orthodontically-assisted eruption with or without
surgical exposure of the impacted teeth along with
full mouth fixed mechano-therapy,
2. Orthodontic treatment accompanying surgical
repositioning of the impacted teeth,
3. Orthodontic treatment involving extraction of
the impacted teeth followed by the placement of a
prosthesis or osseo-integrated implants.
After informed consent, the patient and her parents
chose the first option. However, if orthodontically-
assisted eruption was not successful, other options
would be explored.
Treatment progress
Maxillary arch
The infra-occluded right deciduous second molar
was extracted. Fixed appliances, using a 0.022 inch
slot MBT appliance (3M Unitek, Monrovia, CA,
USA), were attached. The right second molar was also
banded to reinforce anchorage. Initial levelling and
alignment was achieved using a sequence of 0.016
inch nickel-titanium (NiTi) (3M Unitek, Monrovia,
CA, USA), 0.016 inch stainless steel (SS) and a 0.018
inch SS premium plus wires (A.J. Wilcock, Australia)
for a period of 5 months. The spaces anterior to the
extraction site were consolidated using a figure-of-
eight steel ligature wire. The right second premolar,
which had partially erupted by this time, was elevated
into occlusion using a ‘piggyback’ sectional, 0.014 inch
NiTi wire (3M Unitek, Monrovia, CA, USA). After 2
months, a 0.018 inch SS wire was tied to the right
second premolar bracket. Finally, a 0.017 x 0.025 inch
SS (3M Unitek, Monrovia, CA, USA) wire, followed
by a 0.019 x 0.025 inch SS (3M Unitek, Monrovia,
CA, USA) finishing arch wire was placed to correct
tooth inclination and refine the tooth alignment.
212 Australian Orthodontic Journal Volume 29 No. 2 November 2013
Mandibular arch
The infra-occluded right deciduous first and second
molars were extracted, along with the right third
molar. The patient was reviewed periodically and
after 4 months, the right first premolar had partially
erupted but with a distal inclination. To disimpact
and upright the second molar and first premolar,
a bracket was bonded on the first premolar and a
rectangular tube attached to the surgically-exposed
buccal surface of the second molar. A 0.017 x 0.025
inch titanium molybdenum alloy (TMA) T-loop18
(Ormco, CA, USA), with a 45º bend in both anterior
and posterior segments, was placed. Once satisfactory
uprighting of the second molar and first premolar
had been achieved in 6 months, full arch banding
and bonding was completed using a 0.022 inch slot
MBT appliance. For initial levelling and alignment, a
sequence of 0.016 inch NiTi, 0.016 inch SS and 0.018
inch SS A.J. Wilcock premium plus wires was used
for a period of 4 months and a 0.010 x 0.030 nitinol
open-coil spring (Ortho Organizers, CA, USA) was
placed between the second molar and first premolar.
Following final uprighting of the second molar (Figure
3), a lingual holding arch was inserted to preserve the
arch perimeter. In 3 months, the second premolar
partially erupted and was brought into occlusion
using a ‘piggyback’ sectional 0.014 inch NiTi wire
following which, a 0.018 inch SS wire was tied to
the second premolar bracket. Subsequently, the disto-
buccal surface of the right first molar was surgically
exposed and bonded with a Begg Light-Wire bracket
(TP Orthodontics, IN, USA). The uprighting arm of
the spring, made of 0.012 inch SS premium plus wire,
was placed in the bracket and activated by hooking
Figure 3. IOPA radiograph showing final uprighting with nitinol open-coil
spring.

Figure 4. Post-treatment facial and intra-oral photographs.
Figure 5. Post-treatment panoramic (A) and cephalometric (B) radiographs.
MANAGEMENT OF MULTIPLE IMPACTED TEETH
onto the 0.018 inch SS base arch wire. After 6 months
of molar uprighting, the tooth was banded and a
0.018 inch SS wire was passed through the molar
tube. Finally, a 0.017 x 0.025 inch SS wire, followed
by a 0.019 x 0.025 inch SS finishing arch wire were
placed to correct tooth inclination and refine levelling
and alignment.
After 24 months of active treatment, an acceptable
occlusion was achieved. Following debonding,
maxillary and mandibular canine-to-canine bonded
lingual retainers were placed.
Results
Post-treatment photographs (Figure 4) showed
overall facial balance and did not markedly change.
An acceptable occlusion, overjet and overbite were
achieved. The molar relationship was Class I on both
sides.
Post-treatment panoramic and cephalometric
radiographs (Figure 5) revealed that the impacted
teeth were repositioned at the level of the occlusal
plane. There was adequate root parallelism. The level
of alveolar bone improved considerably. The post-
treatment cephalometric evaluation and superimposed
cephalometric tracings revealed a skeletal Class I (ANB
2º), which indicated normal growth of the maxilla
and mandible during treatment. Mandibular incisor
inclination improved (Figure 6, Table I).
Australian Orthodontic Journal Volume 29 No. 2 November 2013 213
 WALIA ET AL

Biomechanical considerations
A T-Loop made of 0.0175 x 0.025 inch TMA with
a 45º bend in the anterior and posterior segments
will produce simultaneous uprighting moments at
each end. This is beneficial in cases in which teeth are
angulated towards each other (Figure 7).
An uprighting spring placed in the Begg bracket
attached to the molar produced a distal-crown a­nd
mesial-root moment, which is favourable for a
mesially-impacted molar. Equilibrium is attained by
the simultaneous generation of two vertical forces. A
favourable extrusive component of force (Fe) moved
Figure 6. Superimposed cephalometric tracing showing changes from
the impacted molar occlusally. The unfavourable pretreatment to post-treatment stages. Sella-nasion plane at sella (A),
intrusive force (Fi), acting at the loop end of the spring, palatal plane at ANS (B), mandibular plane at menton (C).
was resisted by a stiff main archwire which dissipated
the force over the entire anchor tooth segment (Figure
8). The extrusive force directed at the impacted molar
also tended to roll the molar lingually while flaring the
premolars buccally. To counteract this side effect, the
uprighting spring was curved bucco-lingually so that
placement in the molar tube caused the hook to lie
lingual to the arch wire prior to activation (Figure 9). Figure 7. Schematic diagram of T-Loop between right mandibular second
molar and first premolar.
A spring made of round wire and fitted into the Begg
bracket did not produce a force moment around
a vertical axis, which was beneficial in avoiding
unintentional rotation. If the tooth did need rotational
correction, it could be performed subsequent to the
disimpaction to considerably reduce the complexity
of the mechanics.19

Discussion
Few cases of multiple impacted teeth, unrelated to a
syndrome or systemic abnormality, have been reported
in the literature.20-23 A previous paper has discussed the
orthodontic management of unilaterally-impacted
mandibular molars24 but no reports have discussed
the orthodontic management of unilaterally impacted
premolars and mandibular first and second permanent
molars.
The infra-occlusion of deciduous molars is a relatively
common occurrence. The most frequently stated cause
is ankylosis, which has been attributed to disturbances
during expected root resorption, disturbed local
metabolism or a developmental gap in the periodontal
ligament. Other factors include genetics, trauma and
infection.25
Winter et al.5 reported that it was common to
encounter mesial tipping or ectopic eruption of
Figure 8. Schematic diagram showing mechanism of molar uprighting
spring. Fe, extrusive force on the molar; Fi, intrusive force at loop end of
the spring; M, crown distal and root mesial moment.
permanent molars which are immediately distal to an
infra-occluded deciduous molar. This could also be the
likely aetiology of horizontally-impacted mandibular
first and second molars in the present case.
Becker and Shochat26 reported that the extraction of an
ankylosed deciduous molar allowed the continuation
of the eruption process of the developing permanent
successor and the development of normal root length.
Winter et al.5 also concluded that impacted premolars
related to infra-occluded deciduous molars generally
erupted into the arch without difficulty, provided
there was sufficient space. Similarly, in the present

214 Australian Orthodontic Journal Volume 29 No. 2 November 2013


Figure 9. Schematic diagram showing bucco-lingual curve of uprighting
spring prior to activation.
case, the premolars partially erupted following the
extraction of the infra-occluded deciduous molars.
The premolars were finally brought into occlusion
using orthodontic traction.
In this clinical situation, the transplantation or
surgical repositioning of the impacted teeth was not
considered because of the depth of impaction and
the high risk of mandibular fracture or damage to the
neurovascular bundle.
The option of extracting all impacted teeth required a
deft surgical technique as well as careful management
to minimise injury to adjacent teeth. Considering
the young age of the patient and the potential for
continuing vertical growth of the facial skeleton,
placement of implant prosthesis was not a viable
option. In addition, guided bone regeneration might
be required for implant placement, which would result
in expensive and prolonged treatment. According
to Lindhe,27 there was no support for the extraction
of teeth in favour of placing implants in the young
patient. A healthy tooth has a life-long survival rate,
which has yet to be proven for a dental implant.
In the present case, as the impacted teeth were
brought into occlusion, alveolar bone was generated,
which corrected the bony deficiency. Bone generation
provides a valid reason why patients should be well
advised to retain their teeth. Unless suggested treatment
is refused, the less risky alternative of orthodontically-
MANAGEMENT OF MULTIPLE IMPACTED TEETH
assisted eruption of the impacted teeth with surgical
exposure is the preferable treatment option.
Frequently, third molar position may impede the
distal movement of an impacted molar and indicate
the need for extraction. In the presented case, to
provide adequate space for the disimpaction of the
right mandibular second molar, the removal of the
right mandibular third molar was performed before
placement of the mechanical T-loop.
If flexible and continuous wires are placed to upright
mesially-impacted molars, an undesirable distortion
in arch form would result and the premolars would
tip distally. Therefore, it is advantageous to carry out
uprighting using sectional mechanics.
A Begg uprighting spring was used to disimpact and
upright the right mandibular first molar. The spring,
made of 0.012 inch SS Australian premium plus wire,
generates light and relatively constant forces. The
highly resilient wires also resist accidental deformation.
Conclusion
The orthodontic mechanics employed in this case were
successful in bringing the multiple impacted teeth
into acceptable occlusion. The treatment procedures
used were simple, inexpensive and effective.
Corresponding author
Dr Pawanjit Singh Walia
A-102, Navrattan Apartments
Plot 7-A, Sector 23 Dwarka 110077
New Delhi
India
Email: pawanjitwalia@yahoo.in
References
1. Raghoebar GM, Boering G, Vissink A, Stegenga B. Eruption
disturbances of permanent molars: a review. J Oral Pathol Med
1991;20:159-66.
2. Aitasalo K, Lehtinen R, Oksala E. An orthopantographic study of
prevalence of impacted teeth. Int J Oral Surg 1972;1:117-20.
3. Grover PS, Lorton L. The incidence of unerupted permanent
teeth and related clinical cases. Oral Surg Oral Med Oral Pathol
1985;59:420-5.
4. Suri L, Gagari E, Vastardis H. Delayed tooth eruption: pathogenesis,
diagnosis and treatment. A literature review. Am J Orthod
Dentofacial Orthop 2004;126:432-45.
5. Winter GB, Gelbier MJ, Goodman JR. Severe infraocclusion and
failed eruption of deciduous molars associated with eruptive and
developmental disturbances in the permanent dentition: a report of
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28 selected cases. Br J Orthod 1997;24:149-57.
6. Sawicka M, Racka-Pilszak B, Rosnowsha-Mazurkiewicz A.
Uprighting partially impacted permanent second molars. Angle
Orthod 2007;77:148-54.
7. Lim WH, Kim HJ, Chun YS. Treatment of ankylosed mandibular
first permanent molar. Am J Orthod Dentofacial Orthop
2008;133:95-101.
8. Kogod M, Kogod HS. Molar uprighting with piggyback sectional
archwire. Am J Orthod Dentofacial Orthop 1991;99:276-80.
9. Moro N, Murakami T, Tanaka T, Ohto C. Uprighting of impacted
third molar using brass ligature wire. Aust Orthod J 2002;18:35-8.
10. Johnson JV, Quirk GD. Surgical repositioning of impacted second
molar teeth. Am J Orthod Dentofacial Orthop 1987;97:242-51.
11. Kang YG, Kim JY, Lee YJ, Lee BS. Segmental repositioning combined
with orthodontic fine adjustment of nonerupting permanent molars:
a case report. Quintessence Int 2010;41:449-58.
12. Aksoy A, Aras S. Use of nickel titanium coil springs for partially
impacted second molars. J Clin Orthod 1998;32:479-82.
13. Eckhart JE. Orthodontic uprighting of horizontally impacted
mandibular second molars. J Clin Orthod 1998;32:621-4.
14. Park DK. Australian uprighting spring for partially impacted second
molars. J Clin Orthod 1999;33:404-5.
15. Resch D. Clinical management of unilaterally impacted mandibular
first and second molars. J Clin Orthod 2003;37:162-4.
16. Lang R. Uprighting partially impacted molars. J Clin Orthod
1985;19:646-50.
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17. Park HS, Kyung HM, Sung JH. A simple method of uprighting with
microimplant anchorage. J Clin Orthod 2002;36:592-6.
18. Tuncay OC,  Biggerstaff RH,  Cutcliffe JC, Berkowitz J. Molar
uprighting with T-loop springs. J Am Dent Assoc 1980;100:863-6.
19. Tandur AP, Jayade CV, Jayade VP. Clinical management of
mandibular impacted second molar with an uprighting spring in
Begg bracket – Case reports. J Ind Orthod Soc 2004;37:195-203.
20. Yildrin D, Yilmaz HH, Aydin U. Multiple impacted permanent and
deciduous teeth. Dentomaxillofac Rad 2004; 33: 133-5.
21. Bayar GR, Ortakoglu K, Sencimen M. Multiple impacted teeth:
report of 3 cases. Eur J Dent 2008;2:73-8.
22. Yalcin S, Gurbuzer B. Multiple impacted teeth in the maxilla. Oral
Surg Oral Med Oral Pathol 1993;76:130.
23. Tanaka E, Kawazoe A, Nakamura S, Ito G, Hirose N, Tanne Y et al.
An adolescent patient with multiple impacted teeth. Angle Orthod
2008;78:1110-18.
24. Fu PS, Wang JC, Chen CH, Huang TK, Tseng CH, Hung CC.
Management of unilaterally deep impacted first, second, and third
mandibular molars. Angle Orthod 2012:82;565-71.
25. Kurol J, Thilander B. Infraocclusion of primary molars and the
effect on occlusal development, a longitudinal study. Eur J Orthod
1984;6:277-93.
26. Becker A, Shochat S. Submergence of a deciduous tooth:
its ramifications on the dentition and treatment of resulting
malocclusion. Am J Orthod 1982;81:240-4.
27. Lindh T. Should we extract teeth to avoid tooth-implant
combinations? J Oral Rehabil 2008;35:44-54.
Opinion piece
The fallacy of serial extractions
K. Paul Lee
Private Practice, South Perth, Western Australia, Australia
Lingually-erupting lower lateral incisors in young
children are usually viewed as a sign of crowding
and described as a malocclusion which needs
correction. Fox1 wrote ‘In any of these discrepancy
cases the removal of the temporary cuspids is
absolutely necessary, and unless the operation be
timely performed, the irregularity is, with difficulty,
remedied.’ The premature removal of the primary
cuspids is a commencement option of a serial
extraction program in the commonly-held belief
that the process will correct the crowding problem.2
The early extraction of primary cuspids will, no
doubt, allow improved alignment of the four lower
incisors but will invariably result in crowding of the
permanent cuspids. The extraction of premolars
is usually required to resolve the cuspid crowding,
followed by mechanotherapy to detail the occlusion.
Therefore, the removal of the primary cuspids has not
corrected the crowding but only shifted the problem
from the lower incisors to the buccal segments.
Introduction
The author3 has observed that lingually-erupting
lower lateral incisors in young children is extremely
common and suggests that it is the rule rather than
the exception. It is considered normal for lower lateral
incisors to erupt lingually and be lingually positioned
in the early mixed dentition. Developmentally, the
lingual position of lateral incisors is recognised and
should not be regarded as a symptom of crowding.
This raises the question of why treatment should be
necessary.
While many children in the early mixed dentition
have lower lateral incisors positioned lingually,
the irregularity is not present in most untreated
adolescents. It may be assumed that untreated
adolescents with reasonably well-aligned lower incisors,
have autonomously experienced an improvement in
incisor alignment as a result of normal growth and
development.
© Australian Society of Orthodontists Inc. 2013
The crowding of teeth is due to three factors:
1. The number of teeth,
2. The size (mesio-distal width) of the teeth,
3. The size of the dental arches.
The first two factors relate to the number and size of
the teeth which are genetically predetermined and
remain constant as the child grows. However, growth
and development of the child have a significant effect
on the size of the dental arches. The dental arches
will increase rather than decrease in dimensions,
which will affect space requirements. Differential
bone growth means an increase in some directions
more than others and at varying regional rates. The
mandible grows by a process of ‘growth remodelling’
reflected by buccal deposition and lingual resorption
which produces enlargement. This permits the arch
circumference to increase while the form of the entire
bone is maintained.16
The net result will be an improvement in an apparent
‘crowding’ situation. Unfortunately, it is not possible
to determine the amount of improvement that will
take place, because growth prediction is far from
certain. However, it appears that the rationale behind
serial extraction is based on the assumption that it
is possible to predict, at a young age, that the arch
will not develop sufficiently to accommodate all of
the permanent teeth. The interproximal reduction of
deciduous teeth instead of extractions is also based
on the same premise.4 This assumption is unjustified
since no growth prediction system has proved to be
completely accurate. When treating children in the
knowledge that growth prediction is unreliable, it is
better to be sure that you are unsure.
Prescribing a ‘tincture of time’, by monitoring and
studying the growth and development of the individual
may be more appropriate than of instituting active,
interceptive, irreversible treatment.
To prove the hypothesis that lingually-positioned
lower lateral incisors are not a symptom of crowding,
a clinical study to observe the effects of retaining the
Australian Orthodontic Journal Volume 29 No. 2 November 2013 217
 CaseCase
W.D.W.D.

CaseCase
W.D.W.D.
Opinion piece

06.12.1966
06.12.1966 16.07.1979
16.07.1979
primary cuspids was conducted. Instead of extracting or extractions. More than 12.5 years later, the lower
the primary cuspids in cases of lingually-positioned incisors were still in acceptable alignment without
lower lateral incisors, the primary cuspids were Caseretention.
B.V-H.
Case
06.12.1966B.V-H.
06.12.1966 16.07.1979
16.07.1979
allowed to exfoliate naturally.
06.12.1966
06.12.1966 16.07.1979
16.07.1979
CaseCase
B.V-H.
B.V-H.
Materials and methods
Children with ‘crowded’ lower incisors were carefully CaseCase B.V-H.
B.V-H.
examined and intra-oral photographs taken. The
space between the central incisor and the primary 23.09.1968 Case B.V-H. 24.07.1973
cuspid was measured with a divider and recorded. The 23.09.1968
23.09.1968 24.07.1973
24.07.1973
children were recalled at intervals of 18 months and Case BV-H. A 6-year 7-month-old male with a partially
were re-examined and re-photographed. As several Caseerupted G.B.
42 positioned completely lingual to the 41
Case
23.09.1968
and G.B.
23.09.1968
rotated 24.07.1973
mesio-lingually. 24.07.1973
It acceptably aligned
primary cuspids had exfoliated, measurements could
without
not be taken in several children. A 12-18 month recall 23.09.1968 any interceptive orthodontic treatment or the
23.09.1968
need to extract the primary 24.07.1973
24.07.1973
cuspids.
regimen was maintained to avoid the temptation of CaseCase G.B.G.B.
implementing interceptive treatment if no changes
were evident. Radiographs were not taken unless CaseCase G.B. G.B.
otherwise indicated, as malalignment of incisors in
young children is considered normal and therefore
not necessary to subject patients to the effects of 15.05.1979
15.05.1979 11.01.1988
11.01.1988
unjustified radiation.
15.05.1979 Case G.B. 11.01.1988
Case S.M.
Case S.M.
15.05.1979
15.05.1979 11.01.1988
11.01.1988
Results Case GB. A 9-year 5-month-old female with the 32
It was noticed there was a marked degree of 15.05.1979
15.05.1979 11.01.1988
and 42 positioned lingually.11.01.1988
These teeth spontaneously
CaseCase
S.M.
S.M.
aligned themselves without the need to extract the
improvement in the alignment of the lower incisors
over 18 months in the majority of the patients. primary cuspids.
CaseCase
S.M.S.M.
In a few cases the improvement was minimal, but
nevertheless, still noticeable. There was no case in
which the ‘crowding’ became worse. After a period
06.10.1987
06.10.1987 15.07.1999
15.07.1999
of 5 years, there was significant improvement in all
cases. However, in several, the incisor alignment was
not sufficiently improved to satisfy the patient and/or 06.10.1987
06.10.1987 15.07.1999
15.07.1999
parent. In these instances, orthodontic treatment was
06.10.1987 Case S.M. 15.07.1999
carried out as a non-extraction procedure. 06.10.1987
06.10.1987 15.07.1999
15.07.1999
Case
CaseW.D.
W.D. Case SM. An 8-year-old female with the 42 positioned
lingually. The tooth moved into position without any

orthodontic
CaseCase
A.A.A.A. intervention.

6.12.1966 Case W.D. 16.07.1979

06.12.1966
06.12.1966 16.07.1979
16.07.1979
Case WD. A 7-year 3-month-old female with the 42 07.07.1987 Case A.A. 12.02.1991
erupting lingually and the 32 unerupted but lingually 07.07.1987
Case
07.07.1987 12.02.1991
12.02.1991
CaseB.V-H.
B.V-H.
palpable. The space between the 31 and 73 was 2.5 Case AA. A 7-year-old female with the 31 positioned
mm. The 32 erupted lingually as expected and the Case adjacent
A.A.A.A.
to the 73. There was a small diastema between
‘Before’
Case ‘Before’
32 and 42 aligned without orthodontic assistance the partly erupted 31 and 41. The 72 had exfoliated

218 Australian Orthodontic Journal Volume 29 No. 2 November 2013

CaseCase
A.A.A.A.

Opinion piece

07.07.1987
07.07.1987 12.02.1991
12.02.1991
while the 82 was still present. As expected, the 32 crowding occurred more commonly in those who did
and 42 erupted lingually. The 42 aligned reasonably not receive serial extraction treatment.’
CaseCase
A.A.A.A.
well but‘Before’
‘Before’
the 32 remained displaced. Considering its
07.07.1987
07.07.1987 12.02.1991
12.02.1991 A similar investigation was not possible because the
original position, the improvement was considerable, extraction of primary cuspids in the present study
especially without orthodontic assistance. was considered unjustified in the provision of a
CaseCase
A.A.A.A. ‘Before’
‘Before’ comparative sample. The sample would have been
based on the lingual position of lower lateral incisors
and therefore an incorrect assessment of crowding.
Many authors2,6-13 have advocated serial extraction
13.09.1994
13.09.1994 13.09.1994
13.09.1994 without the benefit of a comparative study. In the
opinion of the author, to say that serial extraction
corrects crowding is the same as saying ‘thalidomide
CaseCase
A.A.A.A.
13.09.1994‘After’
‘After’ Case A.A. 'Before' 13.09.1994. cures morning sickness.’ While it has been shown that
13.09.1994
13.09.1994 13.09.1994
13.09.1994
morning sickness is managed, the story is far from
complete, as thalidomide has abhorrent side effects.
CaseCase
A.A.A.A. ‘After’
‘After’ It is the current belief that lingually-erupting and
positioned lower lateral incisors in the early mixed
dentition is not a symptom of crowding. These teeth
are developmentally positioned lingually before they
25.03.1999 Case A.A. 'After' 25.03.1999 erupt (Figure 1). Therefore, it should be considered
25.03.1999
25.03.1999 25.03.1999
25.03.1999
anatomically correct for lower lateral incisors to erupt
An Angle Class II division 2 type of occlusion was and be positioned lingually in young children.
evident when all of the permanent
25.03.1999 teeth erupted but
25.03.1999 It is important to maintain sight of the fact that
25.03.1999 25.03.1999
the 32 remained lingually positioned. Non-extraction children are not miniature adults. The skull of a
treatment with upper and lower fixed appliances was child is different from that of an adult (Figure 2).
performed. If the primary cuspids had been extracted The mandibular plane angle of a young child is more
and serial extractions undertaken, the result likely obtuse and the cranium is shaped according to brain
would not have been satisfactory. development. As it is normal for children’s and adult’s
skulls to be different, no treatment or correction is
required.
Discussion
Figure
Figure 1 1
Until recently, tonsils were routinely removed in
In this long-term observational investigation, all
children based on the diagnosis that they were large,
cases of ‘crowded’ lower incisors improved when the
even though there was no evidence of pathology.
Figure
1 1 cuspids were left in position. Even after more
primary
Figure
In the 1950s, many children were diagnosed with a
than 10 years, the results remained stable without the
supposed condition of ‘thymic hypertrophy’ and so
aid of retainers.
This challenges the commonly-held belief that the
incidence of relapse is greater if the ‘crowding’ of
incisors in young children is not corrected early. Early
extraction of primary cuspids will invariably result
in the permanent cuspids becoming crowded, likely
buccally displaced, therefore making it necessary to
extract premolars. It could be interpreted that serial
extractions promoted by the early extraction of
primary cuspids maintains the early space shortage
and results in later crowding. Powell and McEniery5
compared the result of a group of children subjected to
serial extractions with another non-extraction group. Figure 1. Lower lateral incisors are positioned lingually prior to eruption.
The study showed that ‘improvement in anterior (Courtesy of Prof. Dr Frans Van Der Linden.)14

Australian Orthodontic Journal Volume 29 No. 2 November 2013 219

 Opinion piece
Figure 2. (a) Skull of a child. (b) Skull of an adult.
Figure 3. Three children aged 4, 6 and 8 years.
were subjected to radiation in order to shrink the
thymus gland. Fortunately, such treatment is no
longer performed because it has been realised that the
tonsils and thymus glands are meant to be large in
children and that they will reduce in size with growth
and age.
The ages of the three children in Figure 3 are 4, 6
and 8 years. It is obvious that the 4-year-old child in
the centre is not able to touch his ear by stretching
his opposite hand over the top of his head. This is
perfectly normal for a child of that age. By the age of
9-10 years, most children are able to touch their ear in
this manner. The fact that the 4-year-old child cannot
touch the contra-lateral ear does not mean that his
head is too large or that the neck is too long, indicating
that treatment is needed in the form of neck removal
(neckectomy?) to allow hand-ear contact. It is normal
for most children under the age of 6 years to be unable
220 Australian Orthodontic Journal Volume 29 No. 2 November 2013
Figure 4. Typical arrangement of mandibular teeth at the age of 7 years.
to touch their ear by stretching their arm over the top
of their head.
If lingually-positioned lower lateral incisors in the
early mixed dentition are considered anatomically
correct, it follows that there has to be a mechanism
for lateral incisor improvement. It is acknowledged
that there is an inherent force causing posterior teeth
to move mesially. As the lateral incisors move labially,
the primary cuspids will be made to move laterally
(sideways).
The lateral movement of the primary cuspids is then
checked by the mesial movement of the posterior
teeth, which causes the primary cuspids to be deflected
obliquely as shown in the diagram (Figure 4). The net
result is an increase in intercanine width, which allows
the alignment of the ‘crowded’ incisors to improve. It
has been shown that there is a decrease in arch length
but an increase in arch width as the child grows. This

finding of Ricketts15 is consistent with that of Enlow,16
Bjork17 and Moore,18 who showed that lower incisors
upright themselves, indicated by the crowns of the
lower incisors autonomously moving lingually with
growth and development. This results in a decrease
in arch length. It has been noted that the diagnosis
of crowding and the need for serial extraction is
usually based on an analysis of arch length rather
than arch width (intercanine width). The alignment
of incisors depends more on intercanine width rather
than arch length. The V-shaped morphology of the
lingual surfaces of the primary cuspids and permanent
incisors is the ideal shape to allow the lateral incisors
to move labially, thereby transmitting a stimulus to
the primary cuspids and encouraging mandibular
growth in the intercanine area. This hypothesis of
mandibular bone growth is consistent with Moss’s
functional matrix concept. Extractions of primary
cuspids would deprive the functional matrix of
important proprioceptors, necessary for the normal
growth and development of the dental alveolus.
Summary
It is suggested that lingually-positioned lower lateral
incisors in young children are anatomically correct and
not a symptom of crowding. Primary canines with
intact periodontal attachments have an important role
to play as proprioceptors to encourage growth of the
alveolar arch. Extractions of primary cuspids would
deprive the alveolus of important growth stimuli.
Clinical evidence suggests that serial extraction
is counter-productive.16,19 The early extraction of
primary cuspids will invariably result in crowding
of the permanent cuspids. It is a common belief
that serial extraction corrects the crowding of lower
incisors but the procedure is not evidence based. In
reality, the problem is maintained and the ‘crowding’
shifts to involve the permanent cuspids.
Let us not forget the most basic canon of the health
profession which is ‘first do no harm, and if it is not
broken, do not try to fix it.’
Opinion piece
Corresponding author
Dr K. Paul Lee
17 Bowman Street
South Perth, 6151
Western Australia
Australia
Email: kplee@upnaway.com
References
1. Fox J. The natural history and diseases of the human teeth. Cox,
1814.
2. Kjellgren B. Serial extraction as a corrective procedure in dental
orthopaedic therapy. Trans Eur Orthod Soc 1948;134-60.
3. Lee KP. Behavior of erupting crowded lower incisors. J Clin Orthod
1980;14:24-33.
4. Rosa M. Sequential slicing of lower deciduous teeth to resolve incisor
crowding. J Clin Orthod 1994;28:596-9.
5. Powell RN, McEniery TM. A longitudinal study of isolated gingival
recession in the mandibular central incisor region of children aged
6-8 years. J Clin Periodontol 1982;9:357-64.
6. Heath J. The interception of malocclusion by planned serial
extraction. New Zealand DJ 1953;49:77-88.
7. Dewell BF. Serial extractions in orthodontics. Am J Orthod
1954;40:906-26.
8. Lloyd ZB. Serial extraction as a treatment procedure. Am J Orthod
1956;42:728-39.
9. Dale JG. Serial extraction. J Clin Orthod 1976;10:196-217.
10. Musselman JJ. Timed extractions. Dent Clin Nth Am 1978;22:711-
24.
11. Fields HW. Treatment of nonskeletal problems in preadolescent
children. Contemporary Orthodontics, Mosby, 1986:311-53.
12. Foley TF. Management of lower incisor crowding in the early mixed
dentition. ASDC Int Dent J 1996;63:169-74.
13. Yoshihara T, Matsumoto Y, Suzuki J, Sato N, Oguchi H. Effect of
serial extraction alone on crowding: relationships between tooth
width, arch length, and crowding. Am J Orthod Dentofacial Orthop
1999;116:691-6.
14. Van Der Linden FPGM, Duterloo HS. Development of the human
dentition. Harper Collins 1976:88.
15. Ricketts RM. Interview: Dr Robert M. Ricketts on growth
prediction. 1. J. Clin Orthod 1975;9:277-96.
16. Enlow DH. Handbook of facial growth. W.B. Saunders,
1975:28;130.
17. Bjork A. Variations in the growth pattern of the human mandible,
longitudinal radiographic study by the implant method. J Dent Res
1963;42;400-11.
18. Moore AW. Observations on facial growth and its clinical significance.
Am J Orthod 1959;45:399-423.
19. Solow B. Personal communication. 1995.
Australian Orthodontic Journal Volume 29 No. 2 November 2013 221
 Letter

Letters and brief communications are welcomed and need not relate to publications in the Australian Orthodontic Journal. The Journal will print experimental,
clinical and philosophical observations, reports of work in progress, educational notes and travel reports relevant to orthodontics. Right will be reserved to edit
all Letters to meet Journal requirements of space and format. All financial interests relevant to the content of a Letter must be disclosed. The views expressed in
Letters represent the personal opinions of individual writers and not those of the Australian Society of Orthodontists Inc., the Editor, or BPA Print Group Pty Ltd.

Occlusal variation in the Zuni: a pre-contact North American population

Sir, It has been regularly reported in the literature that

I am writing with reference to the article by Doctors
McKeever and Sutcliffe titled ‘Occlusal variation in
the Zuni; a pre-contact North American population’
in the May 2013 edition of the Australian Orthodontic
Journal.
I wish to commend the authors for bringing this
subject, which has largely been forgotten, to the
attention of the orthodontic community. However,
I am of the opinion their results do suggest a need
for removal of tooth structure to relieve crowding and
provide increased stability of orthodontic treatment.
This is the only real way we have of imitating pre-
contact occlusions.
As the authors mentioned, Dr Begg advocated the
removal of four first premolars to compensate for
the lack of attrition, but an overwhelming number
of studies have shown that these extractions do not
provide increased space for third molars and do not
appear to enhance lower incisor stability.
the extraction of second permanent molars not only
provides increased stability of lower incisor alignment,
but reliably provides space for the third molars.
This is why, when I am pressed, I maintain that Dr
Begg was always correct, but that he chose the wrong
teeth.
I’m also of the opinion that the extraction of second
premolars is a mid-point position providing better
lower incisor stability and more space for the third
molars than first premolar extractions.
I would hope that this somewhat provocative letter
might initiate some stimulating discussion in further
editions.
Colin Twelftree
466 Morphett Road
Warradale South Australia 5046
Australia
Email: petosa@adam.com.au

222 Australian Orthodontic Journal Volume 29 No. 2 November 2013

Book
reviews
Treatment of TMDs:
Bridging the Gap
between Advances in
Research and Clinical
Patient Management
Editors: Charles S. Greene and
Daniel M. Laskin
Publisher: Quintessence Publishing, 2013
(www.quintpub.com)
ISBN: 978-0-86715-586-0
Price: USD $108.00
Most of us would agree that the management
of temporomandibular disorders is an especially
nebulous topic. Forty years ago, as dental students, we
joked that the choice of treatment of any particular
temporomandibular disorder seemed to depend upon
which dental department saw the patient first!
At that time, it was thought that a lack of an ideal
functional occlusion predisposed the patient to
temporomandibular disorders. We realised that the
problem was multifactorial but, as a general rule, the
worse the bite, the more likely it was to have associated
joint problems. As a consequence, many patients
underwent extensive, non-reversible treatments for
little benefit.
Since then, as stated by Jeffrey Okeson in the
foreword to this book, there has been a major shift
in the management of temporomandibular disorders.
The mechanistic model first embraced by the dental
profession can no longer explain the pain our patients
experience, especially as it becomes chronic. The
evidence-based research in orofacial pain has moved
away from teeth to the vast field of understanding
human pain and suffering. In fact, most chronic
orofacial pain conditions are very similar to other
chronic pain conditions managed in the medical field.
This totally new book is focused on answering a
single broad question: What is currently happening in
various research areas that will be clinically applicable
to the management of temporomandibular disorders
in the near future?
The book is divided into five sections:
1. Understanding Regional and Widespread Pain
Phenomena
2. Assessing Susceptibility to Pain Development
and Chronicity
3. Biomechanics of TMJ Function
4. Diagnostic Technology
5. Therapeutic Advances
The book concentrates on the anatomy, biochemistry,
neurophysiology, and psychology of the common
disorders. Each chapter discusses present knowledge
in the particular field before explaining how it
might apply to the diagnosis and treatment of TMD
patients. An overview of new research in the field and
its potential for changing future patient care is also
included.
The chapters cover topics such as the relation of
abnormal joint function to joint pathology, the
prediction of treatment responsiveness, how sleep
disorders affect TMJ and facial pain, the role of co-
morbid conditions in pain response and management,
and the evolving field of pharmacotherapeutics.
As orthodontists, we are fortunate that orthodontic
treatment is not a first-line treatment of temporo-
mandibular disorders, nor is it considered to be a cause
of such problems. The issue is complex and there is no
‘silver bullet’. Okeson advises wisely to always select
the most conservative approach and to do no harm.
Some might find this book fairly ‘heavy going’
and sadly lacking in ground-breaking, clinically-
applicable information. However, the book might
be a useful addition to a dental school library, but
clinicians looking for revolutionary new solutions
to temporomandibular disorders will have to keep
waiting.
David Fuller
Australian Orthodontic Journal Volume 29 No. 2 November 2013 223
 BOOK REVIEWS
The Alexander Discipline:
Long Term Stability
Volume 2
Authors: R.G. ‘Wick’ Alexander
Publisher: Quintessence Publishing, 2011
(www.quintpub.com)
ISBN: 978-0-86715-468-9
Price: USD $152.00
Dr Alexander’s recent publication is effectively
an ‘appendix’ to Volume I of the same name, and
focuses further on the ability to maintain orthodontic
correction from the completion of comprehensive
orthodontic treatment, well into the adult dentition.
Volume I identifies his 15-keys to orthodontic stability
and Volume II aims to coordinate and apply these to
the mechanics of treatment and ‘exceptions to the
rule’.
The text is written in the first person and, as with
informal prose, is reflective of observing Dr Alexander
in a clinical setting. Each chapter begins with a
historical quote and sets the tone for the topic.
Subject chapters are very brief and are supported by
a small bibliography. Topics are reinforced by case
presentations, reflecting the principles of the chapter,
and are demonstrated with the appliances and
mechanics employed.
Thought has been applied into the mechanics of
treatment rather than using a generic approach of a
straight-wire system. However, cases are not always
shown with adequate records. The book is well
illustrated, however there are some inconsistencies in
adapting the figures to the text to illustrate the point.
Chapters 1 and 2 look at the Alexander philosophy
of treatment planning, that is, to begin with the
end result in mind. Several of his theses have been
developed by commendably and objectively reviewing
treatment results in the ‘Room of Truth’ which aims
to plan treatment while considering potential causes
of relapse from clinical and cephalometric assessment.
Chapter 3 very scantly covers additional considerations
pertaining to orthodontic treatment including
periodontal health and the temporomandibular joint.
Chapters 4-7 review applications of orthodontic
mechanics, and discuss aims and limitations of dental
and skeletal movements which allow for the best
possible long-term orthodontic alignment, occlusion
224 Australian Orthodontic Journal Volume 29 No. 2 November 2013
and stability. The Alexander discipline is scrutinised
in various parts of the text and compared with other
techniques.
The art-versus-science component of orthodontic
treatment is discussed in Chapter 8 and dental and
soft tissue considerations are mentioned in striving
to obtain the best dental and aesthetic appearance.
Other cosmetic dental procedures, in addition to
orthodontics, are also addressed.
Finally, Chapter 9 reviews other factors related to
relapse of the treated occlusion. Most notably, anterior
open bites are considered and addressed in the setting
of treatment aims. Dr Alexander also discusses ethics
and the means of retreating relapsed dentitions.
While the title suggests long-term stability is achievable,
Dr Alexander acknowledges that individual patient
variables (e.g. eruption times, skeletal function,
habits etc.) can contribute to the relapse of occlusion
and agrees some movement is acceptable in a final
occlusion.
Richard Salmon
What’s in Your
Mouth? What’s
in Your Child’s
Mouth?
Author: Douglas A Terry
Publisher: Quintessence
Publishing, 2013
(www.quintpub.com)
ISBN: 978-0-86715-618-8
Price: USD $29.50
This picture book has been produced to show children
and their parents how to look after their teeth correctly
and the consequences of neglecting to do so.
Coffee-table sized in every dimension but thickness,
this book is intended to be two in one: ‘What’s in
Your Mouth?’ when read from one end and ‘What’s
in Your Child’s Mouth’ when read from the other end.
The first half is directed at young children using large
photographs and brief accompanying text to convey

the message. When one reaches the middle of the
book, one can flip it upside down and go through
what is essentially a repeat of the same photographs
and text directed at parents.
The photographs are excellent in quality but, with
only one on most pages, they tend to be unnecessarily
large and overpowering.
The text is simple and conveys the basic principles of
1500 smiles!
Thx Give a Smile.
giveasmile.org.au
a charitable arm of the ASO
1500 smiles!
BOOK REVIEWS
oral hygiene, diet and other preventative measures. A
few pages are devoted to cleaning around orthodontic
fixed appliances.
The book might be a useful addition to a dentist’s
waiting room, although there is a risk that it could
scare the living daylights out of some children (and
some parents too!).
David Fuller
thx
Australian Orthodontic Journal Volume 29 No. 2 November 2013 225
 Recent
literature
These reviews have been prepared by the orthodontic postgraduate students from the University of Adelaide, Adelaide, Australia
Predisposing factors to severe external
root resorption associated to orthodontic
treatment
Picano GV, Freitas KMS, Cancado RH, Valarelli FP, Picano
PRB and Feijão CP
Dental Press J Orthod 2013; 18: 110-20
Aim: The aim of this retrospective study was to
determine predisposing factors among patients who
developed moderate or severe external root resorption
(Malmgren’s grade 3 and 4), on the maxillary incisors
during fixed edgewise orthodontic treatment.
Materials and methods: The sample consisted of 99
patients who had good oral and systemic health, no
tooth loss in the anterior maxillary arch, no vertical
bone loss or periodontal disease or prosthesis. Patients
had complete medical and dental records with initial
and final radiographs. Exclusion criteria included
patients with tooth agenesis, supernumerary teeth,
endodontic treatment, incomplete development of
the root apex or those who developed grade 2 (early)
resorption by the end of treatment. Patients were
divided into two groups: G1 (50 patients with a mean
initial age of 16.79 years and mean treatment time of
3.21 years) who had no root resorption or presented
only apical irregularities at the end of treatment. G2
(49 patients) consisted of those with moderate or
severe root resorption (Malmgren’s grade 3 and 4) at
the end of treatment with a mean initial age of 19.92
years and mean treatment time of 3.98 years.
Standardised initial and final periapical radiographs
were analysed for resorption based on Malmgren’s
classification: grade 0 (no resorption), grade 1
(presence of apical irregularities), grade 2 (presence of
resorption by 2 mm), grade 3 (resorption between 2
mm and a third of the original length), and grade 4
(presence of resorption greater than one third of the
original length of the root). Periapical radiographs
226 Australian Orthodontic Journal Volume 29 No. 2 November 2013
were also assessed in relation to bone crest width,
root shape, and length. Initial lateral cephalograms
were scanned, digitised and cephalometric analyses
performed.
Intra-examiner method error was evaluated by
performing measurements on 20 randomly selected
patients after a one month interval. Several appropriate
statistical tests were applied using Statistica software
and considered significant when p < 0.05.
Results: Increased age and longer treatment was
significantly related to the occurrence of severe root
resorption. Treatment involving extractions, short root
length and decreased crown/root ratio at the beginning
of treatment and thin maxillary alveolar cortical bone
(assessed from the cephalogram), increased the risk of
developing severe root resorption.
Gender, type of malocclusion, morphology of the root
and the bone crest were not found to be risk factors.
Discussion: The finding that older patients had a
higher risk of developing moderate or severe root
resorption during orthodontic treatment must
be interpreted with caution, as the age difference
between both groups was approximately 3 years and
all could be considered ‘young adults’. The average
treatment time of those exhibiting mild resorption
was 3.21 years compared with 3.98 years for moderate
or severe resorption. It can be argued that both groups
had longer than normal treatment times. Whilst some
of this study’s results supported previous findings,
others were contradictory. A more realistic result may
have been gained from randomly selecting a sample
from consecutive patients. Also, the accuracy of
periapical radiographs may be questioned. Although a
standardised paralleling technique was used, potential
exists for the misrepresentation of the image.
Conclusion: The paper showed that there are multiple
factors that can predispose a patient to moderate to

severe root resorption. However, the results should be
treated with caution due to the limited sample size,
examination method and definition of resorption.
Lisa Wong
Predicting lower third molar eruption on
panoramic radiographs after cephalometric
comparison of profile and panoramic
radiographs
Begtrup A, Grønastøð HÁ, Christensen IJ and Kjær I
European Journal of Orthodontics 2013; 35: 460-466
Introduction: Predicting the successful eruption of third
molars can be a clinical challenge. In order to assist,
several studies have described radiographic prediction
methods. With reference to profile radiographs, Bjork
(1956) stated that the absence of eruption is usually
due to a lack of space in the retromolar area and
different skeletal factors were identified as important
for describing the size of the retromolar space. These
factors included mandibular growth length, growth
direction of the condyle and the direction of tooth
eruption. Richardson (1977) also concluded that a
short narrow mandible and a low mandibular plane
angle were other associated variables.
Panoramic radiographs have also been used to predict
the eruption of lower third molars. Uthman (2007)
showed that the angle alpha (defined as the line from
gonion to the symphysis and the length of the third
molar) and the angle beta (defined as the angle formed
by the long axes of the second and third molars) along
with the gonial angle were valuable parameters in
predicting mandibular third molar eruption.
Aims: The aim of the present study was to identify
whether an association between cephalometric
measurements of profile and panoramic radiographs
exists and to subsequently determine a simple and
reliable method for predicting the eruption of the
mandibular third molar from panoramic radiographic
measurements.
Materials and methods: Radiographs were obtained
from pre-orthodontic treatment records of 53
patients (30 males and 23 females with range of age
of 18-48 years). Cephalometric measurements on
panoramic and profile radiographs were performed
and compared. Furthermore, the mesiodistal width of
the second molar was measured. Statistical methods
Recent literature
included analysis of method error and the probability
of eruption was modelled using logistic regression
analysis.
Results: Correlation was observed between all
measurements on profile and panoramic radiographs.
The skeletal variable expressing the length from the
ramus to the incisors (olr-id) showed a statistically
significant correlation. By combining this length with
the mesiodistal width of the lower second molar, the
graphical prediction of eruption of the lower third
molar was strengthened.
Discussion: In applying the formula to clinical practice,
prediction errors will be encountered if the panoramic
radiograph is distorted due to incorrect head position.
Furthermore, a study which validates the use of this
new formula with a larger sample would provide
further evidence of its useability. In addition, as the
radiographs were taken prior to orthodontic treatment,
the extraction of teeth and the consequent space effects
may affect the regression analysis. However, the graph
is easy to use and interpret and perhaps can be utilised
in practice to educate the patient as well as assess the
likelihood of the wisdom teeth erupting. Caution
should be exercised as the sample was based on a group
of patients in late teenage years and adulthood and a
prediction outcome may differ for younger patients.
Berna Kim
Impacted maxillary canines and root
resorptions of neighbouring teeth: a
radiographic analysis using cone-beam
computed tomography
Lai CS, Bornstein MM, Mock L, Heuberger BM, Dietrich T
and Katsaros C
European Journal of Orthodontics 2013; 35: 529-538
Introduction: The impaction of maxillary permanent
canines are the second most frequently impacted tooth
after third molars with a prevalence of approximately
1-3%. Some authors have hypothesised that the
aetiology of impacted canines can be related to factors
such as non-exfoliating deciduous canines, delayed
eruptive pathways and missing lateral incisors. The
aetiology of adjacent root resorption is unclear,
however, it has been postulated that enlarged dental
follicles and pressure caused by the erupting tooth
may be responsible for root resorption of nearby teeth.
Accurately locating the position of the impacted
Australian Orthodontic Journal Volume 29 No. 2 November 2013 227
 Recent literature
maxillary canine and diagnosing root resorption of
the adjacent teeth prior to commencing orthodontic
treatment is of importance, as this diagnostic
information helps to formulate and establish a
comprehensive inter-disciplinary treatment plan.
Aims: This aim of this retrospective study was to
investigate the location of impacted maxillary canines
and the factors influencing root resorption of the
neighbouring teeth using cone beam computed
tomography (CBCT).
Materials and methods: The CBCT images of 113
subjects (mean age 19.35 years, range 8.7-77.2 years,
SD ± 13.65 years) were collected and 134 impacted
maxillary canines were analysed.
Results: Unilateral impaction was present in 92 subjects
(81.4%) whilst bilateral impaction was present in 21
subjects (18.6%).
The analysis of the 3D location revealed that most
impacted canines were found in a palatal position
(51.49%), with 30.6% of canines located buccally.
Of the 134 ectopic canines, 41 adjacent incisors
exhibited signs of resorption, 34 lateral incisors
(25.4%) and 7 central incisors (5.2%). In 6 cases
with root resorption of the central incisors, the
lateral incisors also exhibited signs of resorption.
A statistically significant higher prevalence of root
resorption was found when there was complete root
development of the impacted canine. The results also
indicated a higher prevalence of resorption in adjacent
teeth when the canine was completely covered by
bone, compared with teeth with only soft tissue
coverage. Furthermore, a correlation between the
prevalence of root resorption and location of the cusp
tip in the vertical plane in relation to the long axis of
the adjacent teeth, was found. When compared with a
coronal or supra-apical location of the cusp tip, there
was a higher risk of resorption when the cusp tip was
located in the cervical, middle or apical third of the
root on the adjacent tooth.
Discussion: It appears that CBCT can provide additional
information about the location of an impacted canine
and the prevalence and degree of root resorption of
neighbouring teeth. However, despite the advantages
of CBCT in tooth localisation, it is important to
consider the increased radiation dose for the patient
and the higher cost of CBCT examinations when
compared with conventional radiography, which has
been the standard for treatment for many years.
Adam Leung
228 Australian Orthodontic Journal Volume 29 No. 2 November 2013
Occurrence of cervical invasive root
resorption in first and second molar teeth of
orthodontic patients eight years after bracket
removal
Thönen A, Peltomäki T, Patcas R and Zehnder M
J Endod 2013; 39: 27-30
Introduction: Cervical invasive root resorption (CIRR)
is an aggressively destructive form of external root
resorption that is characterised by fibrovascular tissue
and clastic resorbing cell invasion of root dentin. Often
misdiagnosed, the aetiology of this condition and its
prevalence has not been extensively investigated. A
history of orthodontic treatment has been found to
be the most common predisposing factor, followed by
trauma and intra-coronal bleaching.
The occurrence rate of CIRR in orthodontic patients
is not known; however, it has been surmised that
mandibular molars are frequently affected because
these serve as anchor teeth for many orthodontic
appliances and are therefore exposed to higher forces
compared with other teeth. Additionally, orthodontic
bands per se interfere with the resorption-protective
layer at the cervical root surface.
Aims: This study attempted to review the occurrence
of CIRR in molars in a cohort of orthodontic patients
after treatment with fixed appliances.
Materials and methods: One hundred seventy-five
patients who had been treated with fixed appliances
and who were due for final orthodontic recall during
the study period (November 2009 and March 2011)
were identified and recruited. Of these, 108 were
available to participate in the study. The average age
of the cohort (46 men and 62 women) was 25.5 years,
and the average time after bracket removal was 8.2
years. From the sample, 858 molar teeth (426 first
molars, 432 second molars) were present and were
available for investigation.
At recall, patients filled in a questionnaire regarding
their general health status. Clinically, the molar teeth
of the patients were checked by one investigator for
visual signs of CIRR, i.e., discolorations in tooth
crowns and/or localised inflammatory defects in
gingival tissues. Analogue bite-wing radiographs were
taken, unless they were already present and less than
one year old.

Two observers individually judged the bite-wing
radiographs for any possible sign of CIRR and
specifically, for the typical cloudy radiolucencies
associated with CIRR. The radiographs were judged
as ‘CIRR cannot be ruled out’ versus ‘CIRR not
present’. In patients where ‘CIRR cannot be ruled out’
limited-volume cone-beam computed tomography
(CBCT) was used to confirm the diagnosis and yield
information regarding the best possible treatment.
Results: No clinical signs of CIRR were detected in
any patient. With 96.6% agreement, 18 patients
were asked to have limited-volume CBCT because
of suspected CIRR; 13 of these (10 men/3 women)
agreed.
Apparent CIRR was identified in one patient in whom
a second maxillary molar was affected. The other three
molars had surface resorption. This tooth had been
moved mesially to replace the first molar and had
therefore been moved over a long distance.
Discussion: The protocol used by this study attempted
to identify factors which may be associated with
these lesions; however, the occurrence of CIRR was
far too low. The one identified CIRR lesion was
already clearly visible on the bite-wing radiograph
and identified by both observers independently. In
multiple cases, CBCT revealed that the conspicuous
radiographic feature was related to loss of alveolar
bone or root anatomy.
Conclusion: CIRR in molar teeth of orthodontic
patients appeared to have a low mid-term occurrence
and future prospective observational studies in
this area should take a multi-centre approach to
obtain sufficient observations of CIRR and make a
corresponding cause analysis possible.
Nida Khan
3-dimensional facial simulation in
orthognathic surgery: is it accurate?
Schendel SA, Jacobson R and Khalessi S
J Oral Maxillofac Surg 2013; 71: 1406-1414
Introduction: Treatment planning in orthognathic
surgery has traditionally relied on a visual treatment
objective created from a manual tracing of a
2-dimensional cephalometric image. More recently,
computer programs have allowed the fusion of
2-dimensional photographs, tracings and radiographs
Recent literature
to create a more realistic prediction but a review of
the literature has found that not all programs were
able to consistently predict skeletal changes after
orthognathic surgery.
Aims: The purpose of this study was to examine the
accuracy of computerised 3D soft tissue simulation in
orthognathic surgery by comparing the actual surgical
result with a computer prediction.
Materials and methods: Forty-two osteotomies were
performed in 23 consecutive patients. Prior to
surgery, patients were scanned by a photogrammetric
facial scanner and a CBCT scan was obtained. The
facial scan was then fused to the CBCT scan, creating
a patient-specific image. Surgery was simulated in
three dimensions and the resultant soft tissue face was
compared with the actual post-operative facial scan.
Soft tissue simulation was achieved using a technique
called the mass-springs model in which over 500,000
springs connect constructed hard tissue polygons to the
soft tissue polygons. This generated a 3D-deformable
tissue model which was able to account for the variable
response in different soft tissue areas.
The surgery was performed to mimic that of the
simulation. The post-operative scans were taken, on
average, 6 months after surgery so that skeletal relapse
was not a factor. To analyse the differences between
the prediction and the achieved results, the simulated
soft tissue image was superimposed on the actual
postoperative soft tissue image and the images fused.
Twenty-six points on the face were analysed which
included 9 midline points and 9 bilateral points.
Results: The authors found an average difference of
0.27 mm between the simulated and actual soft tissue
points. Midline points (e.g. forehead, nasion) showed
no difference and points around the eye, malar and
temporal region were also accurate. Pogonion and
nasal area changes showed a variation of 0.2 mm.
Points that showed up to 0.6 mm variability included
the mental points and the mental nerve, which was
judged difficult to locate and was considered not a
good reference point. The points associated with the
largest variability were those in the dynamic part of the
face – the perioral area. The authors proposed that this
was due to resting muscle forces and the recognition
of hyperfunction of the preoperative scans.
Discussion: Compared with other methods of soft
tissue modelling, the presented method required
Australian Orthodontic Journal Volume 29 No. 2 November 2013 229
 Recent literature
less computer power and was performed in real time
compared with finite element analysis. The volume
spline method is another commonly-used technique
but has been shown to have an error of up to 1.8 mm
for the entire face. The clinical rule of thumb for soft
tissue simulations to be accurate enough for clinical
use has routinely been stated as 0.5 mm or smaller for
the variables examined. This study shows variability
within this range.
The study’s limitations included the inability of the
software to account for muscle hyperfunction and the
exclusion of patients with significant facial asymmetry.
Using this spring system to predict vertical movements
was also more difficult and the authors commented
that was an area in need of further refinement.
Excellent communication between orthodontist and
oral maxillofacial surgeon is crucial in all areas of
orthognathic surgery, but particularly when using soft
tissue simulations. For the simulation to be accurate,
it is essential that the surgery performed mimics the
simulation surgery as an accurate prediction will
appear incorrect. With advances in 3D imaging
and computer modelling technology, the field of
orthognathic surgery has the ability to provide
accurate 3-dimensional predictions superior to those
previously achieved with 2-dimensional images and
tracing paper.
Conclusion: Incorporating this technology into
clinical practice will aid in treatment planning and,
importantly, provide better communication between
the patient and specialists.
Shelley Coburn (Orthod Waves-Jpn Ed 2011; 70: 7-20).
DAI score and its relation to self-perceived
dental aesthetic and orthodontic concern in
Bangladesh and Japan
Ahsan A, Yamaki M, Toshinobu H, Hossain Z and Saito I
Orthodontic Waves 2013; 72: 99-104
Introduction: The main purpose of the study was to
investigate the relationship between a patient’s self-
perceived treatment need against the severity of the
presenting malocclusion as assessed by Dental Aesthetic
Index (DAI) scores. In addition, a comparison of the
findings from a developed country (Japan) and a
developing country (Bangladesh) were undertaken.
The investigators aimed to identify factors such as
230 Australian Orthodontic Journal Volume 29 No. 2 November 2013
socio-cultural norms that may influence self-perceived
treatment need in different countries.
Subjects and method: This was a cross sectional study.
Four hundred orthodontically untreated students
were randomly selected (210 males and 190 females),
aged between 20-27 years (mean age of 22.5 years)
from a Bangladesh university. The students were
asked to respond to two self-report questionnaires
on dental appearance satisfaction and desire for
orthodontic treatment based on a 4-point Likert scale.
The questions were constructed to identify people
who were dissatisfied with their appearance and who
wanted treatment.
The dental occlusion of each participant was assessed
by one examiner according to the World Health
Organisation (WHO) guidelines. Intra-examiner
reliability was 0.90 when 40 students were re-examined
2 weeks later. Age, gender, the profession of parents
and social-economic position (high, middle-high,
middle-low and low) were recorded and correlated
with the data.
Statistical analysis: A student’s t-test was used to
compare mean DAI scores by gender. The Spearman’s
rank correlation coefficient was used to evaluate the
agreement between DAI scores and the answers to
the questionnaires. Scheffe’s post hoc test and one-
way ANOVA test were used for multiple comparisons
between DAI scores, responses to questions and social
status. Logistical regression analysis was performed
to analyse the relationships between malocclusions,
satisfaction and treatment demand. Data was
compared with a similar/identical study in Japan
Results: Results for the Bangladesh group indicated
that males had higher DAI scores compared with
females for all DAI grades. The Japanese study revealed
similar mean and severe DAI scores, but the gender
distribution was reversed. The correlation between
DAI scores, satisfaction with dental appearance and
treatment desire was weak and not significant in the
Japanese group. The correlations in the Bangladeshi
study were found moderately positive and significant.
The Spearman’s rank correlation coefficient was
0.66 when satisfaction with dental appearance was
correlated to DAI scores. The Spearman’s rank
correlation coefficient was 0.54 when treatment desire
was correlated to DAI scores. The socio-economic
status of subjects with severe malocclusion and
high DAI scores (DAI = 31-35) were shown not to
influence questionnaire responses.

Conclusions: Orthodontic treatment need measured
objectively by the Dental Aesthetic Index may correlate
differently with subjective perceived treatment need
for different population groups.
Eugene Twigge
Restoration of congenitally missing lateral
incisors after orthodontic treatment
Liu P-R and Ramp LC
Seminars in Orthodontics 2013; 19: 49-52
Introduction: The agenesis of upper lateral incisors is a
common occurrence which poses treatment planning
difficulties. Treatment options have been limited
for teenage post-orthodontic patients. Planning a
prosthetic solution creates a problem at an early age
and makes future management uncertain for both
orthodontists and prosthodontists.
Aim: The article examines the management of
congenitally missing maxillary lateral incisors in
teenage patients.
Materials and methods: Management of upper incisor
agenesis is described through a case report.
Results: The option of closing the space by mesialising
and reshaping the canine has the advantage of
providing a permanent solution. However, this plan
has the potential to adversely affect the patient’s
occlusion as well as tooth size, shape, and colour.
Alternatively, a midline shift, poor axial inclination,
and subsequent space opening may contribute to a
compromised aesthetic result.
The authors suggest that leaving or creating space
for the agenic lateral incisors can be followed by the
following prosthetic options:
• Removable prostheses: Less well accepted owing to
bulk, movement, and food entrapment.
• Metal resin-bonded bridge: Conservative but
metal could show-through and bond may fail.
• Traditional fixed partial denture (FPD): appropriate
in cases in which teeth are already heavily restored,
but is usually inappropriate in younger patients.
• Implant-supported restorations: Consideration
must be given to root position of adjacent teeth,
bone architecture and implant size.
• Intra-coronal fixed prosthetic option for
conservative restoration of the missing maxillary
Recent literature
lateral incisor uses a fibre-reinforced composite
(FRC) FPD framework supporting a composite
resin or ceramic veneer. The material consists of
glass fibres approximately 10 mμ in diameter,
manufactured and embedded within a resinous
matrix suitable for bonding with conventional
bonding materials. The operator has the option
of constructing a frame and/or pontic in the
laboratory or at chair side.
Discussion: The last option was presented in a
case report. A 16-year-old girl was referred by
her orthodontist for the restoration of bilaterally,
congenitally-missing maxillary lateral incisors. A
3-unit FPD or implant supported restoration were
rejected due to their invasiveness and the patient’s
age. Two separate FRCs FPD framework followed
by bonded porcelain veneers was presented. In
addition, two porcelain veneers were constructed
for the maxillary central incisors to improve their
anatomic form. The patient was followed for 8 years
which provided clinical evidence that fibre-reinforced
composite restorations are conservative, durable and
aesthetic in the mouths of young patients who suffer
from upper anterior agenesis.
Ahmed Abdulkarim
Effects of twin block appliance on obstructive
sleep apnea in children: a preliminary study
Zhang C, He H and Ngan P
Sleep and Breathing 2013; DOI: 10.1007/s11325-013-0840-5
Introduction: Obstructive sleep apnoea (OSA) is
disordered breathing during sleep associated with
intermittent complete or partial airway obstruction
which disrupts normal ventilation. Children who
suffer from the condition often exhibit serious daytime
symptoms. There is no general consensus regarding
optimal treatment due to the multifactorial nature of
OSA although non-surgical mandibular advancement
is a common treatment approach in adults.
Aim: The aim of this study was to investigate the
effects of a twin block (TB) appliance in children with
OSA combined with mandibular retrognathia.
Materials and methods: Forty six children (31 males,
15 females, aged 9.7 ± 1.5 years, with an average BMI
of 18.1 ± 1.04  kg/m2) diagnosed with mandibular
retrognathia and OSA by polysomnography (PSG)
Australian Orthodontic Journal Volume 29 No. 2 November 2013 231
 Recent literature
were recruited for the study. The patients were neither
obese nor showed adenotonsillar hypertrophy. The
treatment group was provided with a Twin Block
and instructed to wear the appliance full time for an
average of 10.8 months. The efficacy of treatment was
determined by monitoring via PSG and cephalometric
changes before and after appliance removal. Data were
analysed using a paired t-test.
Results: The average apnoea-hyponoea index (AHI)
decreased from 14.08 ± 4.25 to 3.39 ± 1.86 (p < 0.01).
Cephalometric measurements showed a significant
increase in the superior posterior airway space, middle
airway space, SNB angle and facial convexity, which
indicated an enhancement in mandibular growth and
a reduction in the soft palate length. This preliminary
232 Australian Orthodontic Journal Volume 29 No. 2 November 2013
study suggests that the twin block appliance may
improve a patient’s facial profile and OSA symptoms
in a group of carefully selected children presenting
with symptoms of OSA and mandibular retrognathia.
Discussion: Although AHI considerably improved,
not all children achieved complete relief of OSA
symptoms and normalisation of airway function. It is
questioned whether cephalometry was an appropriate
way of assessing airway and soft tissue changes given
that the films were taken in an upright position rather
than supine. Inherent errors with the radiographic
technique suggest that PSG was a preferable assessment
tool and that the results of this study should be viewed
with caution.
Vandana Katyal
In appreciation
Reviewers for the Australian Orthodontic Journal
Over the past year the following individuals have generously offered their time, knowledge and expertise reviewing articles for the Journal. We
sincerely thank them and acknowledge their considerable contributions which have improved the quality of the Journal.
Ross Adams, Pennant Hills, NSW
Derek Allan, Chatswood, NSW
Samar Amari, Bundoora, Vic
Chrys Antonio, Dubbo, NSW
John Armitage, Melbourne, Vic
David Armstrong, Coffs Harbour, NSW
Jonathan Ashworth, Adelaide, SA
Theo Baisi, Sydney, NSW
Steve Bajada, Rose Park, SA
Andrew Barbera, North Adelaide, SA
Matthew Barker, Wellington, New Zealand
Gosia Ewa Barley, Swanbourne, WA
Stephen Brown, Bowral, NSW
Andrew Barry, Wollongong, NSW
Anita Bonic, Pennant Hills, NSW
Karen Brook, Auckland, New Zealand
Paul Buchholz, Geelong, Vic
Tony Bunyan, Auckland, New Zealand
John Cameron, Norwood, SA
Peter Cathro, Adelaide, SA
Hong Chan, Bundoora, Vic
Kit Chan, Burwood, NSW
Jonathan Chi, Castle Hill, NSW
James Choi, Sydney, NSW
Tony Collett, Ferntree Gully, Vic
Mark Cordato, Bathurst, NSW
Michael Counsel, Menai, NSW
Rhonda Coyne, Cairns, Q
Marguerite Crooks, Christchurch, New Zealand
Linda Curl, Gawler, SA
Sheryn Deane, Gordon, NSW
Petrina DiIulio, Campbelltown, SA
Justin Fong, Gordon, NSW
Matthew Foo, Pymble, NSW
Terry Freer, Brisbane, Q
We also sincerely thank our book reviewers, who have generously donated their time and energy during the year.
Gerry Clausen, Melbourne, Vic
Lee Fox, Campbells Creek, Vic
David Fuller, Brighton, Vic
John Fricker, Manuka, ACT
Janet Fuss, Adelaide, SA
Peter Gilbert, Dunedin, New Zealand
Faye Goodyear, Toowong, Q
Koray Halicoglu, Bolu, Turkey
Paul Hanrahan, Townsville, Q
Debora Alvares Harris, Narellan, NSW
Michael Hase, Melbourne, Vic
Chris Ho, Sumner Park, Q
Henry Ho, Sydney, NSW
Kip Homewood, Berwick, Vic
Paul Ichim, Nedlands, WA
Steven Jones, London, United Kingdom
Sanj Kandasamy, Midland, WA
Heather Keall, Auckland, New Zealand
Mark Kebsch, Sydney, NSW
Brett Kerr, Ashgrove, Q
Om Kharbanda, New Delhi, India
Russell Kift, Maitland, NSW
Inger Kjaer, Copenhagen, Denmark
Yoon-Ah Kook, Seoul, Korea
Mark Kum, Christchurch, New Zealand
Sarah Lawrence, Melbourne, Vic
Igor Lavrin, Melbourne, Vic
Kerry Lester, Sydney, NSW
Andrei Locke, Melbourne, Vic
Eva Low, Liverpool, NSW
David Madsen, Manuka, ACT
Sameh Malek, Sydney, NSW
Kurien Mamootil, Moonee Ponds, Vic
Roslyn Mayne, Shepparton, Vic
Hugh McCallum, Herston, Q
Patricia Medland, Benowa, Q
Ian Meyers, Brisbane, Q
Peter Miles, Caloundra, Q
John Ladakis, Moorabbin, Vic
Andy Ong, Narre Warren, Vic
Richard Salmon, Adelaide, SA
Australian Orthodontic Journal Volume 29 No. 2 November 2013
Stephen Moate, Forestville, NSW
Kylie Moseling, Burwood East, Vic
Colin Nelson, Chermside, Q
Stephen Papas, Nundah, Q
Ashish Patal, Mandurah, WA
Timo Peltomaki, Tampere, Finland
Andrew Quick, Hamilton, New Zealand
Teriko Rex, Lane Cove, NSW
Adam Rose, Wantirna, Vic
Adam Rosenberg, Malvern East, Vic
Stevan Saicich, Elanora, Q
Paul Sambrook, Adelaide, SA
Wayne Sampson, Adelaide, SA
Andrew Sandham, Cairns, Q
Jonathan Sandy, Bristol, United Kingdom
William Scarfe, Louisville, KY, USA
Paul Schneider, Melbourne, Vic
Jonathan Skilton, Melbourne, Vic
Kieran Soma, Carlton, Vic
Liselotte Sonnesen, Copenhagen, Denmark
Jane Spark, Epping, NSW
Steve Stramotas, Chatswood, NSW
Adrian Tan, Wetherill Park, NSW
Marcus Tod, Upper Mount Gravatt, Q
Grant Townsend, Adelaide, SA
Carroll Ann Trotman, Boston, MA, USA
Martin Tyas, Melbourne, Vic
William Weekes, Gosford, NSW
Tony Weir, Greenslopes, Q
Geoffrey Wexler, Toorak, Vic
Gregory White, Hawthorn, Vic
Guy Willems, Leuven, Belgium
Matthew Williams, Wellington, New Zealand
233
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TP Orthodontic

234 Australian Orthodontic Journal Volume 29 No. 2 November 2013

 NEW PRODUCTS

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Australian Orthodontic Journal Volume 29 No. 2 November 2013 235

 Orthodontic
calendar

September 4-6
2013 Canadian Association of Orthodontists’ Annual Congress,
Montreal, Quebec, Canada.
December 7-8 Web: www.cao-aco.org/EVENTS/future.asp
Taiwan Association of Orthodontists’ Annual Meeting, KMU
Convention Centre, Kaohsuing, Taiwan. (R.O.C.) September 18-20
Web: www.tao.org.tw Czech-Slovak Orthodontic Congress, NH Olomouc Congress
Email: tao.taiwan@msa.hinet.net Hotel, Olomouc, Czech Republic.
Web: www.orthodont-cz.cz

2014 October 9-11

Societa Italiana di Ortodonzia XXVI (SIDO) International
March 4-8 Congress, Florence Fortezza da Basso, Italy.
Asociacion Mexicana de Ortodoncia, 47th Annual Session. Web: www.sido.it
Web: www.amo.org.mx Email: scientific@sido.it

March 6-8 October 17-20

Societa Italiana di Otodonzia (SIDO) Spring Meeting, Centro 9th Asian Pacific Orthodontic Congress, Kuching, Sarawak,
Congressi Lingotto, Torino, Italy. Borneo, Malaysia.
Web: www.sido.it Web: www.9apoc.com
Email: scientific@sido.it Email: chairperson@9apoc.com OR orgsec@9apoc.com

March 29-April 1 November 22-24

Australian Society of Orthodontists’ 24th Australian Orthodontic 48th Indian Orthodontic Conference, Ahmedabad, India.
Congress, Adelaide Convention Centre, Adelaide, South Web: www.48ioc.com
Australia, Australia.
Web: www.aso2014adelaide.com.au
Email: aso2014@fcconventions.com.au 2015
May 15-19
April 5-6
American Association of Orthodontists’ 115th Annual Congress,
13th International Symposium of the Greek Orthodontic Society,
San Francisco, USA.
President Hotel, Athens, Greece.
Web: www.grortho.org
June 13-18
European Orthodontic Society’s 91st Annual Congress, Venice,
April 10-12
Italy.
Societa Italiana di Ortodonzia (SIDO) Spring Meeting, Porto
Antico di Genova Centro Congressi, Italy.
September 17-19
Web: www.sido.it
CAO Annual Session, Fairmont Empress Hotel, Victoria, British
Email: scientific@sido.it
Columbia, Canada.
Web: http://cao-aco.org/EVENTS/future.asp
April 25-29
American Association of Orthodontists’ 114th Annual Session, September 27-30
New Orleans, Lousiana, USA. 8th International Orthodontic Congress and 5th Meeting of
the World Federation of Orthodontists, ExCel London, London,
June 18-21 United Kingdom.
European Orthodontic Society’s 90th Annual Congress, Warsaw, Web: www.wfo2015london.org
Poland.
October 29-30
July 5-8 Societa Italiana di Ortodonzia XXVII (SIDO) International
9th Asia Pacific Orthodontic Congress, Kuching, Sarawak, Congress, Milan, Italy.
Malaysia. Web: www.sido.it
Web: www.apoc2014.com Email: scientific@sido.it

For a list of meetings and links to websites of national and international Orthodontic Societies, visit the World Federation of
Orthodontics, www.wfo.org.

236 Australian Orthodontic Journal Volume 29 No. 2 November 2013

Index to Volume 29
The Australian Orthodontic Journal

Koong B, 86 Wang W, 96
Author index
Küçükkeleş N, 200 Wang Y, 96
Ahmad R, 58 Kumar S, 209 Yadav S, 105
Alam MK, 34 Lacerda dos Santos R, 139 Yetkiner E, 52
Araújo MV, 13 Lee KP, 1, 217 Zakaria NN, 34
Attin R, 52 Maia LH, 13 Zhou C, 96
Attin T, 52 Martin J, 184
Aykut-Yetkiner A, 52 Masoud MI, 193 Subject index
Baek S-H, 43 Nevzatoğlu S, 200
Bao B, 96 McDonald F, 137 3D camera
McKeever A, 66 Reproducibility of facial soft tissue
Bayome M, 43
landmarks on facial images captured on a
Bayram M, 153 Merican AF, 58
3D camera, 58
Becerra D, 3 Meyer-Marcotty P, 145
Miles P, 170 3D virtual models
Carrion F, 3
Evaluation of dental and basal arch forms
Celikoglu M, 153 Trisnawaty N, 176
using cone-beam CT and 3D virtual models
Cheong NW, 34 Moganadass DD, 34 of normal occlusion, 43
Cheung G, 86 Murray K, 86
Accuracy
de Assunção PS, 139 Nagaraj K, 105
The evidence supporting methods of tooth
Diaz-Zúñiga, J, 3 Naidu D, 159, 164
width measurement: Part I. Vernier calipers
Dreyer C, 184 Numabe Y, 76 to stereophotogrammetry, 159
Elias CN, 13 Nur M, 153 The evidence supporting methods of tooth
Fan M, 96 Nyssen E, 28 width measurement: Part II. Digital models
Filho HL, 13 Othman SA, 58 and intra-oral scanners, 164
Freer TJ, 159, 164 Oyonarte R, 3 Adenoids
Gamage SN, 21 Park JH, 43 Treatment of a high angle Class II
Goonewardene MS, 86 Pinho T, 115 malocclusion with severe crowding and
Pithon MM, 139
enlarged adenoids: a case report, 105
Goss AN, 21
Grover V, 209 Purmal K, 34 Aesthetic brackets
Guo C, 96 Quan C, 96 Colour stability of aesthetic brackets:
ceramic and plastic, 13
Güzel Z, 200 Restle L, 139
Han SH, 43 Rojas V, 3 Aesthetic perception
Ibel G, 28 Ruelas ACO, 13 Aesthetic perception and factors associated
with dentofacial midline awareness, 96
Ioi H, 176 Sameshima GT, 43
Islam SMS, 86 Sampson W, 184 Anthropology
Sekino S, 76
Occlusal variation in the Zuni: a pre-
Ito H, 76
contact North American population, 66
Jacquet W, 28 Sezgin OS, 153
Jamaludin M, 58 Singla A, 209 Anthropometry
The application and correlation of Pont’s
Judice RLP, 139 Stellzig-Eisenhauer A, 145
Index to the facial framework of three main
Kaji A, 76 Sutcliffe P, 66 ethnic groups in Malaysia, 34
Katyal V, 184 Suzuki A, 176
Arch
Kennedy D, 184 Takahashi H, 176
The application and correlation of Pont’s
Kilkis D, 153 Trisnawaty N, 176 Index to the facial framework of three main
Kitahara T, 176 Twelftree C, 222 ethnic groups in Malaysia, 34
Knösel M, 52 Upadhyay M, 105
Asymmetric deep bite
Kochel J, 145 Vannet BV, 28 Asymmetric deep bite with a canted
Kook Y-A, 43 Walia PS, 209 occlusal plane: a case report, 115

Australian Orthodontic Journal Volume 29 No. 2 November 2013 237

 INDEX
Attritional Occlusion
Occlusal variation in the Zuni: a pre-
contact North American population, 66
Australia
2003 Survey of Australian Orthodontists’
procedures, 170
Basal arch form
Evaluation of dental and basal arch
forms using cone-beam CT and 3D
virtual models of normal occlusion, 43
Begg uprighting spring
Management of unilaterally impacted
multiple posterior teeth: a case report,
209
Bimaxillary protrusion
Effects of four premolar extractions on
vermilion height and lip area during a
posed smile in patients with bimaxillary
protrusion, 176
Bite turbos
Asymmetric deep bite with a canted
occlusal plane: a case report, 115
Bolton ratios
Mesiodistal tooth dimensions and
anterior and overall Bolton ratios
evaluated by cone beam computed
tomography,153
Bolton tooth size analysis
The evidence supporting methods of
tooth width measurement: Part I. Vernier
calipers to stereophotogrammetry, 159
The evidence supporting methods of
tooth width measurement: Part II. Digital
models and intra-oral scanners, 164
Book reviews
Defense from Within. A guide to
Success As a Dental Malpractice
Defense Expert, 125
Evidence-Based Clinical Orthodontics,
123
The Alexander Discipine: Long Term
Stability Volume 2, 224
The Face – Pictorial Atlas of Clinical
Anatomy, 124
The Secret of the Magic Dust, 125
Treatment of TMDs: Bridging the Gap
between Advances in Research and
Clinical Patient Management, 223
What’s in Your Mouth? What’s in Your
Child’s Mouth?, 224
Canine substitution
Bilateral missing lower permanent inci-
sors: a case report, 193
238 Australian Orthodontic Journal Volume 29 No. 2 November 2013
Caries prevention
Effect of chlorhexidine varnish
application on Streptococcus mutans
colonisation in adolescents with fixed
orthodontic appliances, 52
Case reports
Asymmetric deep bite with a canted
occlusal plane: a case report, 115
Bilateral missing lower permanent
incisors: a case report, 193
Long term stability of intra-oral maxillary
distraction in unilateral cleft lip and
palate: a case report, 200
Management of unilaterally impacted
multiple posterior teeth: a case report,
209
Treatment of a high angle Class II
malocclusion with severe crowding and
enlarged adenoids: a case report, 105
Cephalometric analysis
The impact of spur therapy in
dentoalveolar open bite, 145
Cephalometry
The validity of transverse intermaxillary
analysis by traditional PA cephalometry
compared with cone-beam computed
tomography, 86
Chlorhexidine varnish
Effect of chlorhexidine varnish
application on Streptococcus mutans
colonisation in adolescents with fixed
orthodontic appliances, 52
Civilisation
Occlusal variation in the Zuni: a pre-
contact North American population, 66
Class II
Treatment of a high angle Class II
malocclusion with severe crowding and
enlarged adenoids: a case report, 105
Class III
Long term stability of intra-oral maxillary
distraction in unilateral cleft lip and
palate: a case report, 200
Cleft lip and palate (CLP)
Long term stability of intra-oral maxillary
distraction in unilateral cleft lip and
palate: a case report, 200
Colour stability
Colour stability of aesthetic brackets:
ceramic and plastic, 13
Condylar development
Morphological effects of mesenchymal
stem cells and pulsed ultrasound on
condylar growth in rats: a pilot study, 3
Cone beam computed
tomography (CBCT)
Evaluation of dental and basal arch
forms using cone-beam CT and 3D
virtual models of normal occlusion, 43
Mesiodistal tooth dimensions and
anterior and overall Bolton ratios
evaluated by cone beam computed
tomography,153
The validity of transverse intermaxillary
analysis by traditional PA cephalometry
compared with cone-beam computed
tomography, 86
Craniofacial
The application and correlation of Pont’s
Index to the facial framework of three
main ethnic groups in Malaysia, 34
Cytotoxicity
Evaluation of the cytotoxicity of elas-
tomeric ligatures after sterilisation with
0.25% peracetic acid, 139
Dental arch form
Evaluation of dental and basal arch
forms using cone-beam CT and 3D
virtual models of normal occlusion, 43
Dental cast analysis
On the augmented reproducibility in
measurements on 3D orthodontic digital
dental models and the definition of
feature points, 28
Dental midline
Aesthetic perception and factors
associated with dentofacial midline
awareness, 96
Dentofacial midline discrepancy
Aesthetic perception and factors
associated with dentofacial midline
awareness, 96
Digital calipers
The evidence supporting methods of
tooth width measurement: Part I. Vernier
calipers to stereophotogrammetry, 159
Digital models
On the augmented reproducibility in
measurements on 3D orthodontic digital
dental models and the definition of
feature points, 28
The evidence supporting methods of
tooth width measurement: Part II. Digital
models and intra-oral scanners, 164
Digitised photocopies
The evidence supporting methods of
tooth width measurement: Part I. Vernier
calipers to stereophotogrammetry, 159

Digital photographs
The evidence supporting methods of
tooth width measurement: Part I. Vernier
calipers to stereophotogrammetry, 159
Distraction osteogenesis
Long term stability of intra-oral maxillary
distraction in unilateral cleft lip and palate:
a case report, 200
Guest Editorials
The bottom line, 1
The challenges for Orthodontics, 137
Elastomers
Evaluation of the cytotoxicity of
elastomeric ligatures after sterilisation
with 0.25% peracetic acid, 139
Evidence-based orthodontics
On the augmented reproducibility in
measurements on 3D orthodontic digital
dental models and the definition of
feature points, 28
Extraction
Effects of four premolar extractions on
vermilion height and lip area during a
posed smile in patients with bimaxillary
protrusion, 176
Facial asymmetry
Aesthetic perception and factors
associated with dentofacial midline
awareness, 96
Facial soft tissue landmarks
Reproducibility of facial soft tissue
landmarks on facial images captured
on a 3D camera, 58
High angle
Treatment of a high angle Class II
malocclusion with severe crowding and
enlarged adenoids: a case report, 105
Holography
The evidence supporting methods of
tooth width measurement: Part I. Vernier
calipers to stereophotogrammetry, 159
Intra-oral distraction appliance
Long term stability of intra-oral maxillary
distraction in unilateral cleft lip and
palate: a case report, 200
Intra-oral scanners
The evidence supporting methods of
tooth width measurement: Part II. Digital
models and intra-oral scanners, 164
Laser scanning
The evidence supporting methods of
tooth width measurement: Part I. Vernier
calipers to stereophotogrammetry, 159
Le Fort 1 osteotomy
Surgically-assisted rapid maxillary
expansion of narrowed maxillae: a
case-cohort study, 21
Letters
Occlusal variation in the Zuni: a pre-
contact North American population,
222
Lip area
Effects of four premolar extractions on
vermilion height and lip area during a
posed smile in patients with bimaxillary
protrusion, 176
Lipus
Morphological effects of mesenchymal
stem cells and pulsed ultrasound on
condylar growth in rats: a pilot study, 3
Malocclusion
Occlusal variation in the Zuni: a pre-
contact North American population, 66
Mandibular fixed retainer
Influence of a mandibular fixed
orthodontic retainer on periodontal
health, 76
Mandibular growth
Morphological effects of mesenchymal
stem cells and pulsed ultrasound on
condylar growth in rats: a pilot study, 3
Maxillary retrognathism
Long term stability of intra-oral maxillary
distraction in unilateral cleft lip and
palate: a case report, 200
Measurements
On the augmented reproducibility in
measurements on 3D orthodontic digital
dental models and the definition of
feature points, 28
Mesenchymal stem cells
Morphological effects of mesenchymal
stem cells and pulsed ultrasound on
condylar growth in rats: a pilot study, 3
Molar uprighting
Management of unilaterally impacted
multiple posterior teeth: a case report,
209
Multiple impactions
Management of unilaterally impacted
multiple posterior teeth: a case report,
209
Narrow maxillae
Surgically-assisted rapid maxillary
expansion of narrowed maxillae: a
case-cohort study, 21
Occlusal plane
Asymmetric deep bite with a canted
occlusal plane: a case report, 115
Open bite
The impact of spur therapy in
dentoalveolar open bite, 145
Australian Orthodontic Journal Volume 29 No. 2 November 2013
INDEX
Opinion piece
The fallacy of serial extractions, 217
Orthodontic
The application and correlation of Pont’s
Index to the facial framework of three
main ethnic groups in Malaysia, 34
Orthodontics
The validity of transverse intermaxillary
analysis by traditional PA cephalometry
compared with cone-beam computed
tomography, 86
Orthodontic models
Mesiodistal tooth dimensions and
anterior and overall Bolton ratios
evaluated by cone beam computed
tomography,153
Orthodontic treatment
Effect of chlorhexidine varnish
application on Streptococcus mutans
colonisation in adolescents with fixed
orthodontic appliances, 52
Paediatric sleep-disordered breathing
due to upper airway obstruction in the
orthodontic setting: a review, 184
Bilateral missing lower permanent
incisors: a case report, 193
Orthodontists
2003 Survey of Australian Orthodontists’
procedures, 170
Paediatric sleep-disordered
breathing (SDB)
Paediatric sleep-disordered breathing
due to upper airway obstruction in the
orthodontic setting: a review, 184
Periodontal examination
Influence of a mandibular fixed
orthodontic retainer on periodontal
health, 76
Periodontal health
Influence of a mandibular fixed
orthodontic retainer on periodontal
health, 76
Pont’s Index
The application and correlation of Pont’s
Index to the facial framework of three
main ethnic groups in Malaysia, 34
Posterior anterior
The validity of transverse intermaxillary
analysis by traditional PA cephalometry
compared with cone-beam computed
tomography, 86
Rapid maxillary expansion
(RME)
Surgically-assisted rapid maxillary
expansion of narrowed maxillae: a
case-cohort study, 21
239
 INDEX
Relapse
Surgically-assisted rapid maxillary
expansion of narrowed maxillae: a
case-cohort study, 21
Reproducibility
Reproducibility of facial soft tissue
landmarks on facial images captured
on a 3D camera, 58
Review
Paediatric sleep-disordered breathing
due to upper airway obstruction in the
orthodontic setting: a review, 184
Scanners
The evidence supporting methods of
tooth width measurement: Part I. Vernier
calipers to stereophotogrammetry, 159
Sectional Multiloop Edgewise
Arch Wire (MEAW)
Asymmetric deep bite with a canted
occlusal plane: a case report, 115
Severe crowding
Treatment of a high angle Class II
malocclusion with severe crowding and
enlarged adenoids: a case report, 105
Sleep-disorder
Paediatric sleep-disordered breathing
due to upper airway obstruction in the
orthodontic setting: a review, 184
Smile
Effects of four premolar extractions on
vermilion height and lip area during a
posed smile in patients with bimaxillary
protrusion, 176
Snoring
Paediatric sleep-disordered breathing
due to upper airway obstruction in the
orthodontic setting: a review, 184
240 Australian Orthodontic Journal Volume 29 No. 2 November 2013
Sonic digitisation
The evidence supporting methods of
tooth width measurement: Part I. Vernier
calipers to stereophotogrammetry, 159
Spectrophotometer
Colour stability of aesthetic brackets:
ceramic and plastic, 13
Spurs
The impact of spur therapy in
dentoalveolar open bite, 145
Stability
Surgically-assisted rapid maxillary
expansion of narrowed maxillae: a
case-cohort study, 21
Sterilisation
Evaluation of the cytotoxicity of
elastomeric ligatures after sterilisation
with 0.25% peracetic acid, 139
Stereophotogrammetry
The evidence supporting methods of
tooth width measurement: Part I. Vernier
calipers to stereophotogrammetry, 159
Streptococcus mutans
Effect of chlorhexidine varnish
application on Streptococcus mutans
colonisation in adolescents with fixed
orthodontic appliances, 52
Surgically-assisted rapid
maxillary expansion (SARME)
Surgically-assisted rapid maxillary
expansion of narrowed maxillae: a
case-cohort study, 21
Survey
2003 Survey of Australian Orthodontists’
procedures, 170
Transverse discrepancy
The validity of transverse intermaxillary
analysis by traditional PA cephalometry
compared with cone-beam computed
tomography, 86
Tooth agenesis
Bilateral missing lower permanent inci-
sors: a case report, 193
Tooth widths
Mesiodistal tooth dimensions and
anterior and overall Bolton ratios
evaluated by cone beam computed
tomography,153
The evidence supporting methods of
tooth width measurement: Part I. Vernier
calipers to stereophotogrammetry, 159
The evidence supporting methods of
tooth width measurement: Part II. Digital
models and intra-oral scanners, 164
Ultrasound stimulation
Morphological effects of mesenchymal
stem cells and pulsed ultrasound on
condylar growth in rats: a pilot study, 3
Upper airway
Paediatric sleep-disordered breathing
due to upper airway obstruction in the
orthodontic setting: a review, 184
Validity
The validity of transverse intermaxillary
analysis by traditional PA cephalometry
compared with cone-beam computed
tomography, 86
Vermilion height
Effects of four premolar extractions on
vermilion height and lip area during a
posed smile in patients with bimaxillary
protrusion, 176
Vernier calipers
The evidence supporting methods of
tooth width measurement: Part I. Vernier
calipers to stereophotogrammetry, 159