Short epithetic implants for orthodontic anchorage in the paramedian region of the palate. A clinical study

Orthodontic movement of teeth often requires maximum anchorage, so that additional resistance must be added to teeth to avoid reaction to reciprocal forces. Thus, use of endosseous implants may be a valuable alternative for ensuring stable intraoral anchorage. This study was designed to evaluate the efficacy of short epithetic implants for orthodontic anchorage in the paramedian region of the palate. Twenty-one patients (15 female, 6 male; mean age 25.8+/-9.9 yrs, min 12.7, max. 48.1) were included in this study. Following adequate preoperative planning, an implant system with reduced length, which had already been used for anchorage of epitheses, was placed in the paramedian region avoiding the anterior palatine suture. After a mean period of 4 months with unloaded healing, the implants were subjected to direct or indirect orthodontic loading. Despite varying bone quality and varying vertical bone volume in this region, adequate primary stability was achieved for all of the implants. No implant was lost during the healing period. Three out of the 21 implants placed were considered as failures. Two implants loosened shortly after the start of orthodontic loading. One of these was lost at a later stage due to peri-implant inflammation, while the other one was left in place during the 9-month follow-up period because no inflammation developed and this implant is still indirectly included in the orthodontic treatment. Another implant loosening was observed after 8.5 months following direct loading with 8 N. This implant was also lost due to peri-implant inflammation. The time-related survival probability was 84.8% after 22.9 months. As yet, 4 implants have been removed due to completion of orthodontic treatment. The results of this study indicate that short epithetic implants are suitable to achieve maximum anchorage in the paramedian region of the hard palate in orthodontic treatment.

Bicortical titanium screws for critical orthodontic anchorage in the mandible: a preliminary report on clinical applications

Critical anchorage during orthodontic treatment in the mandible needs both time and effort and patient compliance. In 8 patients, 12 bicortical titanium screws (BIS) were used as anchorage units for orthodontic molar protraction. The criteria for patient selection were: critical anchorage in the lower jaw (i.e. retraction of anterior teeth undesirable) and molar extraction sites. After insertion of the screws in local anesthesia, orthodontic forces were applied immediately. One screw worked loose and had to be removed before the end of treatment. Problems encountered included impingement of the screw head and slight inflammatory reactions of the surrounding mobile mucosa, which necessitated premature removal of two screws. After healing, a new insertion site was chosen. Further treatment was uneventful. Anchorage for orthodontic forces as described offers several advantages. The total treatment time is reduced as the screws can be loaded immediately. The line of action of the orthodontic force coincides with the level of the center of resistance of the molar resulting in a favorable translatory tooth movement. Treatment does not depend on patient cooperation.

Functional magnetic resonance imaging of temporomandibular joint disorders

Fifty-eight temporomandibular joints (TMJs) from 40 patients with TMJ-related symptoms were examined by means of magnetic resonance scans with modified gradient echo sequences and a special double coil. This technique yielded a good spatial resolution of the intra-articular soft tissues, especially the articular disc and the bone structure of the TMJ. In combination with an incremental jaw opener, the disc-condyle complex was analysed in various closed and open mouth positions, depending on the clinical examination. Open mouth movement with differentiation of disc-condyle rotational and translation movement was demonstrated. Disturbances of TMJ motion showed interrupted condylar translation combined with mandibular deviation during open mouth movement (n = 8/58). Early phases of internal derangement of the TMJ with partial anterior disc displacement with (n = 12/58) or without (n = 2/58) reduction, total anterior disc displacement without reduction (n = 10/58), disc deformation (n = 10/58), disc adhesion (n = 2/58), condylar hypermobility (n = 6/58), condylar displacement (n = 8/58), and late phases of internal derangement of the TMJ with osteoarthrosis (n = 14/58) were clearly identified. Bilateral TMJ disorder was found in 72.5 per cent of the patients. By using motion-adapted, semi-dynamic magnetic resonance imaging (MRI), it is possible to improve the understanding of the complexity of TMJ movements.

Contemporary treatment of the resorbed avulsed tooth: a case report

This report describes the treatment sequence after traumatic loss of a maxillary central incisor in a 15-year-old patient. Following extraoral root canal treatment and initially successful replantation, the case presented 9 years later with complete root resorption. After augmentation with an autologous mandibular corticocancellous graft, a dental implant was placed in a second stage surgery. The case highlights the challenge facing clinicians in providing the appropriate standard of care for today's treatment options.

Secular trends in malocclusion in Austrian men

A comparison between occlusal deviations in the permanent dentition in the skulls of 94 19th century and 157 present-day Austrian males was made by means of the PAR Index. It was found that the contemporary dentitions showed significantly higher malocclusion scores than the 19th century sample (weighted PAR Index 11.79 and 6.62, respectively). The results show that secular changes in malocclusion have occurred during the last 100 years.

Initial effects of treatment of Class II malocclusion with the Herren activator, activator-headgear combination, and Jasper Jumper

The initial effects of treatment of Class II, Division 1 malocclusion with an activator, according to Herren (27 patients), with an activator-headgear combination (20 patients), or with the Jasper Jumper appliance (25 patients) were studied on lateral cephalograms from before and after 6 to 8 months of treatment. The patients' ages ranged from 9 to 12 years. At the end of the period of observation, the correction in overjet and molar relationship was more complete in the patients with the Jasper Jumper than in the patients with the activator. Whereas all the patients with the Jasper Jumper showed neutral occlusion, this was the case in only 20 of the 47 patients with the activator. The correction of the distal occlusion occurred through a combination of skeletal and dentoalveolar adaptations. Skeletal changes accounted for 42%, 35%, and 48% of the overjet correction by the Herren-type activator, the headgear-activator, and the Jasper Jumper, respectively. The correction of the molar relationship occurred to 55%, 46%, and 38% by skeletal changes in the respective groups. Dentoalveolar compensation (distal movement of the upper molars, mesial movement of the lower molars) appeared to be inversely related to skeletal adaptation. The patients with the Jasper Jumper showed a marked intrusion of the lower incisors with a consequent reduction in overbite.

Evaluation of continuous arch and segmented arch leveling techniques in adult patients--a clinical study

The purpose of this study was to compare the efficacy of overbite correction achieved by a conventional continuous arch wire technique and the segmented arch technique as recommended by Burstone. The sample comprised 50 adult patients (age 18 to 40 years) with deep bites. Twenty-five patients were treated with a continuous arch wire technique (CAW); in the second half of the sample, the segmented arch technique (Burstone) was used for correction of the vertical malocclusion. Lateral cephalograms and plaster cast models taken before and immediately after treatment were evaluated. Statistical analysis was performed on the collected data. The results showed that both techniques produced a highly significant overbite reduction (CAW: -3.17 mm, p < 0.001; Burstone: -3.56 mm, p < 0.001). The CAW group showed an extrusion in the molar area with subsequent posterior rotation of the mandible (6occl-ML: +1.30 mm; 6occl-NSL: +1.63 mm; ML/NSL: +1.94 degrees, all p < 0.001). The Burstone group, however, showed overbite reduction by incisor intrusion without any substantial extrusion of posterior teeth (upper 1-NSL: -1.50 mm; lower 1-ML: -1.72 mm; both p < 0.001). As a consequence, no significant posterior rotation of the mandible took place (ML/NSL: +0.52 degrees, n.s.). It is concluded that in adult patients the segmented arch technique (Burstone) can be considered as being superior to a conventional continuous arch wire technique if arch leveling by incisor intrusion is indicated.

Moments and forces delivered by transpalatal arches for symmetrical first molar rotation

The moments and forces delivered by round transpalatal arches of steel and of beta-titanium (TMA) for symmetrical derotation of molars were studied in laboratory experiments. Three sizes of arches were tested in two series. In the first series, the degree of activation was checked for symmetry in a computer-based strain-gauge measuring system. In the second series, the activation was carried out in a way simulating clinical use. The mesio-distal and transverse forces and the derotating moments at full activation and during derotation in steps of 5 degrees were measured. At full activation, the steel arches delivered relatively large moments which, however, decreased rapidly during deactivation. The TMA arches had a larger working range. It was not possible to achieve full symmetry of the moments at the two ends of the arch. The difference of the two moments resulted in forces acting on the two anchorage teeth in a mesio-distal direction. These forces were generally small but could reach clinically relevant magnitude. The derotation resulted in a contractive force of up to 2.7 N which has to be compensated for by expansion. The mode of activation simulating clinical use resulted in reasonably constant forces and moments. The use of a vice to hold the arch during activation was found to be of great help and is recommended in the clinical setting. Because of the larger working range, TMA arches are recommended if substantial derotation is needed.

Treatment of Class II malocclusions with the Jasper Jumper appliance--a preliminary report

The effect of the Jasper Jumper appliance (American Orthodontics, Sheboygan, Wis.) on the dentofacial complex was studied in 17 consecutive growing patients who had Class II, Division 1 malocclusions. Lateral cephalograms taken before treatment and immediately after removal of the Jumpers were analyzed according to the method of Pancherz. The following results were found: (1) Class I occlusal relationships were achieved in all patients in an average treatment time of 6 months. (2) The correction of the Class II malocclusion was a result of skeletal (40%) and dental (60%) changes. (3) Skeletal Class II correction was predominantly restricted to the mandible. (4) The dentoalveolar part of total molar relationship correction took place to the same extent in both jaws, whereas in overjet correction the maxillary dental changes outweighed the mandibular changes by far. (5) When compared with normal growth changes (Bolton standards), treatment with Jasper Jumpers distalizes the upper dentition and moves the lower teeth mesially. Mandibular growth seems to be increased to some extent. It was concluded that treatment with the Jasper Jumper appliance presents an effective method to correct Class II malocclusion in growing patients.

The centered T-loop--a new way of preactivation

The force system of a prefabricated and preactivated T-loop used for reciprocal space closure was determined by simultaneously measuring the horizontal and vertical forces, as well as the moments using a computer controlled measuring apparatus. Interbracket distances of 21, 24, 27, and 30 mm were used to mimic typical clinical situations. At a loop activation of 7 mm, the anterior and posterior segments first underwent controlled tipping, then translation, and finally, root uprighting as the moment-to-force ratio increased with deactivation. After the loop has been deactivated to 4 mm, however, it should be exchanged to avoid root abutment.

Force delivery from a transpalatal arch for the correction of unilateral first molar cross-bite

The forces and moments delivered by prefabricated transpalatal arches of the makes Unitek, GAC, and Ormco were studied in laboratory experiments. The Unitek and GAC arches were made of steel, and the Ormco arch of beta-titanium alloy (TMA). Three types of activation were investigated: for bilateral expansion in a statically indeterminate system and for unilateral expansion in a statically determinate system with and without torque activation. In addition to the arch design, composition, and mode of activation, the influence of arch size and degree of activation were studied. It was found that activation for unilateral expansion with the inclusion of torque in the statically determinate system produced forces and moments suitable for the correction of a unilateral cross-bite.

[The orthodontic treatment of deep bite in adults--a comparison of the straight-wire appliance and the segmented arch technic]

The purpose of the study was to analyse and compare deep overbite correction in adult patients carried out by a straight wire appliance and the segmented arch technique as recommended by Burstone. The sample comprised 50 adult, deep bite patients, 25 each treated with straight wire appliance and segmented arch technique. Plaster casts and lateral cephalograms made before and immediately after finishing treatment were analysed. Both techniques were successful in overbite correction; overbite reduction amounted to 3 to 3.5 mm. The straight wire appliance group demonstrated predominantly molar extrusion and as a result posterior mandibular rotation. A slight intrusion of 1 mm was seen in the lower incisor area. The segmented arch technique resulted in an incisor intrusion of 1.5 mm in the upper and 1.7 mm in the lower jaw. No substantiate extrusion in the molar area was found. The advantages of this technique are discussed.

[A new method for the quantitative and qualitative measurement of tooth movements]

A new method for the in vivo measurement of the movements of teeth is described. Measuring blocks are attached to brackets and tubes. Calibrated holes are drilled in each side of the blocks. Using an electronic sliding caliper, measurements are made in all three dimensions between moving teeth and blocks of anchored segments. With the aid of a computer programme, these measurements can be used to construct pictures of various teeth. By taking measurements at different stages of treatment, the movements of the teeth can be shown in three-dimensional images.

[The tooth transplant in orthodontic treatment planning]

The analysis of all examined transplant cases combined treated with orthodontics shows a success rate of 76%. It must be underlined that the germ development at the time of the transplantation is of utmost importance. The best possible time proved to be at a root development of 2/3 to 3/4. Exact indication position, a careful atraumatic operation method and a short time of operation are also important factors of a successful transplantation. If all these preconditions are met, this method can be recommended.

[Anterior tooth intrusion with the base arch: preactivation by tip-back bending or curvature?]

Burstone's intrusion mechanics has been found to be effective in the treatment of a deep bite due to intrusion of the anterior teeth. The pre-activation of the intrusion arch by a tip-back bending shows a shortening in the activation. Measurements objectified the extent of the shortening and the resulting horizontal forces for TMA arches of a dimension of 0.017 x 0.025 inch relating to different distances between molars and anterior teeth and pre-activation by means of tip-back bending or curvature. The change of the vertical force in connection with a simulated intrusion of 5 mm was also registered. Clinical consequences of the therapy are discussed.

[The uprighting of mandibular molars during pre-prosthodontic treatment]

The dentist is often confronted with mesially tipped molars in the mandible which make good restorative treatment impossible. Some methods for uprighting molars using partial edgewise appliances are described.

[The effect of the vertical bracket position on the orthodontic finish]

As during orthodontic treatment and in particular during the phase of the precise adjustment of occlusion by applying the "straight-wire technique" problems arise as far as the vertical dimensions are concerned, the usual distances between the bracket slots and the edges of the incisors respectively the top of the cusps have been verified. Measurements were done on models at the end of treatment of ten patients treated with fixed attachments who may represent ideal occlusion as far as profile radiographs and gnathology were concerned. After regulation of the plane of occlusion the vertical distances between the slot base plane (parallel to the plane of occlusion) and the edge of the incisors respectively tops of cusps were measured by means of a modified parallelometer in connection with a special slot and tube support as well as a specially developed dial test indicator, while a maximum fit between bracket base and buccal crown surface was given. In case of the upper front brackets (torque + 22 degrees) large vertical measurement to the edge of the incisors were recorded, 8.25 respectively 8.33 mm). This may be attributable to excessive torque of the applied brackets. Only approximate figures for the vertical positioning for other teeth could be given, as anatomical variations have to be considered.

[The positioner--a possibility for the fine adjustment of the occlusion objectively assessed by condylar measurements of the discrepancy between the ICP and RCP]

A group of ten adolescents was treated with fixed appliances at the Department of Stomatology and Oral and Maxillofacial Surgery, Graz. Subsequently the patients were fitted with a gnathological positioner. On the day of band removal ten sets of models were made and subsequently two, four and twelve weeks later. They were mounted on an articulator and cephalometric measurements were taken three times by each of the examiners. These records served to provide evidence of discrepancies of the condylar position between ICP and RCP in all three planes. In the second part of the examination, the patients were instructed to wear the appliance at night for another year. Casting of models, mounting in articulators and condymetric measurements were repeated as above. After wearing the positioner for three months, we observed a definite improvement of the occlusion and a wide conformity of the RCP and ICP measurements. After one year of night-time retention there was a slight increase of the mean values. In addition, we could establish statistically that condymetric model measurements are independent of the examiner and the method employed.

[Fixed appliances current state of the art]

Recent advances in fixed appliances are reviewed and discussed. These include cosmetically more appealing brackets (ceramic, lingual); new wires (nickel-titanium and titanium-molybdenum alloys); new biomechanical approaches (accurate computation of forces and torques according to Burstone resulting in the use of new mechanical concepts); experiences in the treatment of transplanted teeth made in the past 15 years; new approaches to the orthodontic finish (implementation of Andrews' "six keys to normal occlusion" with straight wires, accurate positioning of brackets, and gnathological positioners). Cases will be demonstrated.

Changes in occlusion and condylar positioning during retention with a gnathologic positioner

To investigate whether orthodontic cases can fulfil gnathologic requirement, models of 10 adolescent patients (of the Department of Orthodontics at the University Dental Clinic, Graz) were mounted in an articulator at band removal and 2, 4 and 12 weeks and one year later. During this year the patients wore a gnathologic positioner. Using a condymeter, discrepancies between RCP and ICP in three spatial planes were measured and the spatial diagonal computed. Statistical analysis showed a clear reduction of the means of slide in centric during continuous wearing of the positioner, after 3 months, RCP and ICP being almost identical. After a further 7 months, during which the positioner was worn only at night, the amount of slide increased again slightly. The increase of the spatial diagonal was due to an increase of the sagittal and vertical slides whereas the lateral slide remained constant.

[New wires and their force delivery--consequences for orthodontic therapy]

Levelling arches made of stainless-steel wires were compared with nickel-titanium wires of the new generation which are distinguished by their shape memory, superelasticity and their excellent spring-back. The data received from a bending test have been analysed statistically and revealed a linear unloading curve of the twisted stainless-steel wires. The nickel-titanium wires, however, showed a clear deviation form the linearity with a curviform course. Besides the unusual unloading curve with a constant force mechanism in the middle range of deactivation the wires give off the same amount of force irrespective of the degree of activation (that is to say, regardless whether the level difference between the brackets amounts to 1 or to 4 mm). The diagram shows that the greater the activity between the brackets, the longer the period of superelasticity. Therefore the nickel-titanium wires are suited for large level differences or deflections. At a low activation rate the characteristic line takes a very steep and almost linear deactivation curve. In these cases twisted stainless steal wires should be preferred because of their lower load deflection rate and flexibility.