Dental Press Jounal of Orthodontics
Dental Press International

v. 14, no. 6

Dental Press Journal of Orthodontics – ISSN 2176-9451

Dental Press J. Orthod.

v. 14, no. 6

November / December

2009


Editorial

When compliance fails, which is to blame: the patient or the appliance?

Jorge Faber

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In the early years of my life as an orthodontist I sometimes heard comments about the behavior of patients undergoing treatment. These comments were targeted at patients’ compliance in the use of the orthodontic appliance itself or its accessories, such as intermaxillary elastics, headgear, etc.. Such remarks were often uttered disapprovingly. “That’s a lousy patient. Never wears his headgear,” or “No way, she’ll never wear her removable appliance.” That’s the crux of this editorial. When compliance fails, which is to blame: the patient or the appliance?

This issue is deeply rooted in the scientific method and in the design of different clinical trials as well as in how we read and understand research articles. To illustrate this point, try to envisage the following hypothetical scenario.

A study is conducted to compare the efficacy of two different treatment protocols. A total of 300 patients are involved in the research and are randomly distributed among three groups. One hundred patients for treatment A, 100 for B and 100 in a control group. These treatments could be, for example, (A) new device for Class II correction and (B) extraoral appliance. In this study, 82 patients completed the treatment in group A (new appliance) and 93 in group B (headgear). The hypothetical results, excluding the control group, are gathered in Table 1.

The results of our study show different hypothetical success rates. Treatment A (new appliance) had a success rate of 97.5% while treatment B (headgear) had a success rate of 92.5%. Now comes the intriguing question: Which is the best treatment in light of these results?

The answer is clear. Treatment B (headgear), with a 92.5% success rate, apparently proved BETTER than treatment A (new appliance), with a 97.5% success rate. That’s right, the treatment with the lower success rate was the best treatment for Class II correction. Why?

The number of individuals who completed the treatment in both groups was different. It was smaller in treatment A (new appliance) than in treatment B (headgear). We have compelling reason to take this difference into account as part of the treatment outcomes. In other words, most people give up on the new appliance because it is unsightly, or very uncomfortable, or because it has some negative feature that leads to lower rates of compliance. This fact should always be weighed when comparing treatments, or even when evaluating a series of cases.

What´s new in Dentistry

Orthodntics and temporomandibular disorders: the state of art

Paulo César Rodrigues Conti

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It is increasingly common to receive individuals referred by colleagues in the medical field from various specialties, for treatment of pain and or dysfunction of the Temporomandibular Joint (TMJ) and masticatory muscle, known as Temporomandibular Disorders (TMD). These patients are usually teenagers or young adults, who have some type of skeletal or dental malocclusion, and were already assessed for the possible presence of other disturbances with the potential to cause pain or dysfunction in the orofacial area, such as primary headaches, ear infections or sinusitis, among many others.

When examining the patient, the clinician, not uncommonly, will find a malocclusion, with an indication of orthodontic treatment to correct it. At this moment, a storm of thoughts, doubts and fears starts in the head of the professional. Is indicated the treatment of malocclusion for the relief of signs and symptoms of TMD? Is there some kind of appliance or mechanics that should be avoided for these cases? What is the risk of worsening of symptoms with orthodontic therapy?

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Orthodontic Insight

The gene and epigenetics: the dental and maxillofacial characteristics are related to environmental factors or The genes do not control everything! or Is the genetic determinism over?

Alberto Consolaro

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The word gene was coined in 1909 by Wilhelm Johannsen to replace the concept of units of inheritance called “gemmules”, created by Charles Darwin. Before Darwin, the prevailing concept was the “determinants” created by Weismann. Before these, there was the concept of “pangenes” initially proposed by Hugo de Vries9,13.

The concepts of gemmules, determinants and pangenes had a built-in meaning: they were preformationists, i.e. everything was predetermined. However, Johannsen knew this was wrong: the transmissibility of characteristics between generations was not as such, and thus the term gene was created to eliminate this meaning9,13.

The creation and concept of gene ultimately gave rise to the genetic determinism: the characteristics of live beings are determined by units of inheritance called genes. This concept was very keen and closed and was finally dogmatically used. The transmissibility of characteristics between generations does not depend exclusively on the genes; we should consider the cell as a whole with the cytoplasm, mitochondria and genetic material present in its structure, as well as the entire organism and the complexity of the environment.

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Interview

Roberto Carlos Bodart Brandão

Telma Martins de Araújo

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• Bachelor in Dentistry – UFES, 1987.

• Master’s in Orthodontics –UFRJ, concluded in 1991.

• Doctorate in Orthodontics – UNESP/Araraquara, concluded in 2000.

• Professor of Orthodontics – UFES, since 1991.

• Professor of the Specialization Course in Orthodontics – FAESA.

• Charter member of the BBO, since 2005.

• Vice-president of the Brazilian Orthodontics Association – Espírito Santo

Section (ABOR-ES).

• Consultant of the Dental Press Journal of Orthodontics and Facial Orthopedics.

• Has given more than 200 lectures and courses, has had articles published in Orthodontics and Aesthetics journals.

Online Article

Analysis of general dentist orthodontic practice in Brazilian legal system

Ivan Toshio Maruo, Maria da Glória Colucci, Sérgio Vieira, Orlando Motohiro Tanaka, Elisa Souza Camargo, Hiroshi Maruo

Postgraduate course. General dentist. Legality. Human person dignity.

Aim: Due to the conflict, in Brazilian legal system, between legal principle and human person dignity principle in the issue of general dentist orthodontic practice, this paper aimed to analyze laws and courts decisions concerning this matter.

Methods: Regulations of orthodontic education and practice were sought in Federal Government and professional organizations. Courts decisions were sought in Brazilian Superior Courts utilizing “Orthodontics”, “orthodontic” and “orthodontist” keywords.

Results: Brazilian laws classify Orthodontic Postgraduation as stricto sensu and lato sensu, and each of them have their own specific regulations. National Education Guidelines determine that Dental Graduate Course must only teach preventive Orthodontics. Brazilian courts understand that, in order to practice corrective Orthodontics, Orthodontic Postgraduation Course is necessary.

Conclusion: Dentistry Graduate Courses are only able to teach Preventive Orthodontics; only stricto sensu and lato sensu Orthodontic Postgraduate courses are able to teach Corrective Orthodontics; it is unacceptable to understand that law permits that general dentists practice Corrective Orthodontics; and general dentists may only practice Preventive and Interceptative Orthodontics.

Comparative evaluation among facial attractiveness and subjective analysis of Facial Pattern

Olívia Morihisa, Liliana Ávila Maltagliati

Orthodontics. Diagnosis. Facial analysis. Photograph.

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Aim: To study two subjective facial analysis commonly used on orthodontic diagnosis and to verify the association between the evaluation of facial attractiveness and Facial Pattern definition.

Methods: Two hundred and eight standardized face photographs (104 in lateral view and 104 in frontal view) of 104 randomly chosen individuals were used in the present study. They were classified as “pleasant”, “acceptable” and “not pleasant” by two distinct groups: “Lay people” and “Orthodontists”. The individuals were either classified according to their Facial Pattern using lateral view images.

Results and Conclusion: After statistical analysis, it was noted a strong positive concordance between facial attractiveness in lateral view and Facial Pattern, however, frontal view attractiveness classification did not have good concordance with Facial Pattern, tending to have good attractiveness classification even in Facial Pattern II.

Original Article

Prevalence of malocclusion in children aged 12 to 36 months in João Pessoa, Paraíba state

Sabrina Sales Lins de Albuquerque, Ricardo Cavalcanti Duarte, Alessandro Leite Cavalcanti, Érika de Morais Beltrão

Epidemiology. Malocclusion. Infant. Child, preschool.

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Aim: This study aimed to verify the prevalence of malocclusion in children aged 12 to 36 months, attending public daycare centers in the city of Joao Pessoa, Paraiba.

Methods: The sample consisted of 292 children, 161 boys (55.1%) and 131 girls (44.9%) randomly selected from various daycare centers. They were all examined in their daycare centers environments under natural illumination and the findings entered into a pre-structured form, carried out by one calibrated examiner (Kappa = 0.85), concerning overbite, overjet, anterior open bite and posterior crossbite. The data were analyzed through the statistical program SPSS.

Results and Conclusions: The prevalence of malocclusion in the sample was 40.7%, with anterior open bite detected in 35.6%, posterior crossbite in 5.1%, and moderate overjet and overbite in 35.5% and 24.7%, respectively. With the development of the occlusion, the prevalence of anterior open bite increased, with the results draw attention to the magnitude of the problem in childhood.

Inter-relationship between the upper lip and the maxillary positioning with upper incisors in adult patients

Luciano Del Santo, Marco Aurélio Bachega, Marinho Del Santo Jr.

Facial profile. Labial profile. Upper lip.

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Introduction:Professional evaluations and lay person evaluations as well do not show a clear relationship between hard tissue and soft tissue profiles in orthodontic patients. However, there are concrete evidences that the orthodontist can change the facial profile of the patients.

Aim: This research project aimed to measure the contribution of the bone structure of the maxilla and the upper incisors inclination to the upper lip profile. Methods: A sample of 147 adult patients, 58 male and 89 female, aged from 15 to 49 years, the most of them Caucasians, was retrospectively selected from the private practice of one of the authors. It was assumed that the esthetic facial profile depends of the hard tissues that support it besides its own features as thickness, strength and composition. The present research model was not set to control the intrinsic features of the soft tissue. To compose the Ricketts and Burstone esthetic lines, the main cephalometric variables were SNA and U1PP, when concomitantly considered.

Results: The regression coefficients, although statistically significant, did not contributed expressively to explain the regard variables, the pre-defined esthetic lines. Furthermore, the results suggested a negative correlation between the maxillary position (SNA) and the anteroposterior inclination of the upper incisors (U1PP), possibly due to the compensatory action of the lips and the tongue.

Conclusion: The results did not presented conclusive scientific evidences about the contribution of the hard tissues for the soft tissue facial profiles.

Civil liability of dental surgeons: the importance of technical experts

Ricardo Henrique Alves da Silva, Jamilly de Oliveira Musse, Rodolfo Francisco H. Melani, Rogério Nogueira Oliveira

Civil liability. Dentistry. Forensics.

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Introduction: dental surgeons may be subject to responsibilities that encompass penal, civil, ethical and administrative obligations during the practice of their profession. As such, if results are verified to have been harmful to the patient – either by imprudence, ineptitude or negligence – the dental surgeon will be subject to the penalties set forth in the Brazilian Civil Code, which include repairing the damage and compensating the victim according to the harm caused. In civil lawsuits, the parties can hire technical experts to provide scientific and technical information on the issue at hand to their respective attorneys.

Objective: to inform on the importance of technical experts in civil lawsuits, giving the parties a better understanding of the technical, ethical and legal aspects in these proceedings.

Conclusion: there is need for greater knowledge on the part of dentistry professionals of the ethical and legal aspects that guide their profession.

Orthopedic treatment with the Herbst appliance: Do vertical changes occur in facial growth pattern?

Luís Antônio de Arruda Aidar, Gladys Cristina Dominguez, Patrícia Lopes de Souza Alvarez Gonzalez, Melissa Gusmão Dutra Mantovani

Herbst appliance. Cephalometrics. Facial type.

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Objective: This prospective study featured 32 adolescents with Class II, division 1 malocclusion in conjunction with mandibular retrognathia, treated using the Herbst appliance, built on metal bands and crowns, with the objective of cephalometrically evaluating any possible changes in facial growth pattern.

Methodology: lateral cephalometric radiographs were taken at the beginning of treatment (T1) and immediately after 12 months of treatment, with the aforementioned orthopedic appliance (T2). The Jarabak ratio and Ricketts VERT index (modified) were used to determine facial pattern at T1 and T2.

Results: using the Jarabak ratio, the results showed that 27 cases (84.4%) featured hypodivergent patterns at T1 and remained so at T2. Five cases (15.6%) featured a neutral pattern at T1 and did not change at T2. When the Ricketts VERT index (modified) was evaluated, no changes were observed in the facial patterns of 31 patients. Facial type changed in only one case.

Conclusion: based on the obtained results, it can be concluded that, after 12 months of treatment with the Herbst appliance, no vertical changes occurred in the facial growth patternof the studied patients.

Effects of the jasper jumper appliance in the treatment of Class II malocclusion

Rafael Pinelli Henriques, Guilherme Janson , José Fernando Castanha Henriques, Marcos Roberto de Freitas, Karina Maria Salvatore de Freitas

Class II malocclusion. Cephalometrics. Functional Appliance.

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Introduction: The Jasper Jumper is a fixed functional appliance which keeps the mandible in a protruded position by applying continuous light forces. Even though previous studies have revealed the clinical outcome of the appliance, there is still some debate about how much correction is achieved by skeletal changes vs. dentoalveolar changes. Objective: The objective of this study was to evaluate the skeletal and dentoalveolar effects of the treatment of Class II malocclusion with the Jasper Jumper appliance associated with fixed orthodontic appliances, compared to an untreated control group.

Material and Methods: The sample comprised 47 subjects, divided into two groups: Group 1, with 25 patients at a mean initial age of 12.72 years, treated with the Jasper Jumper appliance for a mean period of 2.15 years; and Group 2 (Control), included 22 subjects at a mean initial age of 12.67 years, who were not submitted to any type of orthodontic treatment and presenting Class II malocclusion, observed by a mean period of 2.12 years. Lateral cephalograms before and after orthodontic treatment for group 1 and during the observational period for group 2 were evaluated. Initial and final dentoskeletal cephalometric variables and changes with treatment were compared between the groups by independent t tests.

Results: When compared to the control group, the Jasper Jumper group presented greater restriction of anterior displacement of the maxilla and a greater maxillary retrusion, improvement of maxillomandibular relationship, reduction of facial convexity, greater protrusion and intrusion of mandibular incisors and a greater extrusion of mandibular molars, besides a greater reduction of overjet and overbite and improvement of molar relationship.

Conclusion: The correction of the Class II in the group treated with the Jasper Jumper and fixed appliances was mainly due to restriction of maxillary growth, protrusion and intrusion of mandibular incisors and extrusion of mandibular molars.

Evaluation of the mesiodistal angulations of lower canines, pre-molars and molars with and without lower third molars

Rodrigo Castellazzi Sella, Marcos Rogério de Mendonça, Osmar Aparecido Cuoghi

Third molar. Panoramic radiography. Dental angulation. Tooth movement.

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Objectives: The purpose of the present research was to compare the normal average values of the mesiodistal axial angulation, proposed by Ursi in 1989, with the mesiodistal axial angulation of canine teeth, pre-molars and lower molars in individuals with and without the presence of the third lower molars and ages between 18 and 25 years. Additionally, the values of the mesiodistal axial angulation of these teeth were compared in these two situations.

Methods: Forty panoramic x-rays were used from individuals of both sexes who had not received orthodontic treatment. These subjects were divided into two groups: Group I, containing 20 x-rays that didn’t present third lower molars and Group II, formed of 20 x-rays with the presence of the third lower molars.

Results and Conclusions: Through statistical analysis of the results, it was concluded that both Groups exhibited lower pre-molars and molars with enhanced angulation in the mesial direction, when compared to normal occlusion. On the other hand, the mesiodistal axial angulation of lower canine teeth was shown to be similar to the angulation presented in cases of normal occlusion. The two Groups, when compared together, exhibited similar angular values of the canine teeth, pre-molars and lower molars, indicating that the presence of the third molars didn’t exercise an influence on these dental angulations.

Evaluation of dental changes in the maxilla of patients submitted to surgically-assisted rapid maxillary expansion without pterygomaxillary suture involvement*

Paulo Roberto Pelucio Camara, Fernanda C. Goldenberg, Dov C. Goldenberg, Nivaldo Alonso , Marco A. Scanavini

Maxillary expansion. Orthognathic surgery. Dental cast models.

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Objective: to evaluate transverse changes in the maxillary dental arch and the amount of tipping of the anchoring teeth caused by the Hyrax expansion appliance in patients submitted to surgically-assisted rapid maxillary expansion (SARME), as well as the effectiveness of this surgical technique. The sample consisted of 34 pairs of plaster cast models of 17 patients, 6 male and 11 female. Methods: measurements of the changes in the vertical and transverse planes were taken in plaster cast models.. The surgical procedure performed was an osteotomy on the lateral maxillary walls without pterygoid plate involvement, osteotomy from the nasal spine to the dental midline (upper central incisors), separation of the midpalatal suture using a chisel, and nasal septum separation. Activations were initiated on the third day post-surgery, once in the morning and once at night. Results: there was a statistically significant expansion – 6.03mm, 9.82mm, 8.66mm, 9.72mm and 5.67mm, in the canine, first and second pre-molar areas, respectively. When the amount of crown tipping was evaluated for the anchoring teeth, an asymmetrical buccal tipping was observed , sincethe values found for first molars were 6.89o (right) and 9.56o (left), while the values for first pre-molars were 4.74o (left) and 3.26o (right) – the latter being considered statistically non-significant. Conclusions: the surgical technique applied in this study proved to be effective in achieving maxillary transverse change, resulting in dentoalveolar tipping of the appliance anchoring teeth.

Evaluation of dental changes in the maxilla of patients submitted to surgically-assisted rapid maxillary expansion without pterygomaxillary suture involvement*

Paulo Roberto Pelucio Camara, Fernanda C. Goldenberg, Dov C. Goldenberg, Nivaldo Alonso , Marco A. Scanavini

Maxillary expansion. Orthognathic surgery. Dental cast models.

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Objective: to evaluate transverse changes in the maxillary dental arch and the amount of tipping of the anchoring teeth caused by the Hyrax expansion appliance in patients submitted to surgically-assisted rapid maxillary expansion (SARME), as well as the effectiveness of this surgical technique. The sample consisted of 34 pairs of plaster cast models of 17 patients, 6 male and 11 female. Methods: measurements of the changes in the vertical and transverse planes were taken in plaster cast models.. The surgical procedure performed was an osteotomy on the lateral maxillary walls without pterygoid plate involvement, osteotomy from the nasal spine to the dental midline (upper central incisors), separation of the midpalatal suture using a chisel, and nasal septum separation. Activations were initiated on the third day post-surgery, once in the morning and once at night. Results: there was a statistically significant expansion – 6.03mm, 9.82mm, 8.66mm, 9.72mm and 5.67mm, in the canine, first and second pre-molar areas, respectively. When the amount of crown tipping was evaluated for the anchoring teeth, an asymmetrical buccal tipping was observed , sincethe values found for first molars were 6.89o (right) and 9.56o (left), while the values for first pre-molars were 4.74o (left) and 3.26o (right) – the latter being considered statistically non-significant. Conclusions: the surgical technique applied in this study proved to be effective in achieving maxillary transverse change, resulting in dentoalveolar tipping of the appliance anchoring teeth.

Prevalence of malocclusion in children aged 9 to 12 years old in the city of Nova Friburgo, Rio de Janeiro State, Brazil

Daniel Ibrahim Brito , Patricia Fernanda Dias, Rogerio Gleiser

Prevalence. Malocclusion. Children. Public health.

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Introduction: Knowledge of a population’s epidemiological situation is important in the planning and provision of dental services.

Objectives: Assess the prevalence of malocclusion in children aged 9 to 12 years old from public schools in the city of Nova Friburgo, Rio de Janeiro State, Brazil.

Methods: A randomly selected sample consisting of 407 children (53.1% female) who were evaluated by a trained professional, after parental consent.

Results: The most prevalent malocclusions were crowding (45.5%), excessive overjet (29.7%), posterior crossbite (19.2%), anterior diastema (16.2%), partially erupted teeth (12.0%) and excessive overbite (10.8%). Class I molar relationship prevailed (76.7%). The presence of diastemas was higher in females and excessive overbite was more prevalent in males, both in mixed dentition. Negative overjet and the presence of partially erupted teeth had a higher prevalence in permanent dentition.

Conclusion: It was observed that the mere evaluation of malocclusion prevalence does not reveal case severity or treatment need, both of which are important factors in public health planning.

Maximum interincisal distance in mouth breathing children

Débora Martins Cattoni , Fernanda Dreux Miranda Fernandes, Renata Cantisani Di Francesco, Maria do Rosário Dias de Oliveira Latorre

Face. Measurements. Mouth. Child. Mouth breathing.

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Introduction: The maximum interincisal distance is a very important aspect during myofunctional orofacial evaluation, because myofunctional orofacial disorders can limit mouth opening.

Purpose: To describe the maximum interincisal distance of mouth breathing children, according to age, and to compare maximum interincisal distance means of mouth breathing children to those of children with no history of speech-language pathology disorders.

Methods: Ninety-nine mouth breathing children, of both genders, with ages ranging from 7 to 11 years and 11 months, leukoderms, in the mixed dentition took part in this study. The control group was composed of 253 children, with ages ranging from 7 to 11 years and 11 months, leukoderms, in the mixed dentition period, with no history of speech-language pathology disorders.

Results: The results show that the maximum interincisal distance mean of mouth breathing children was, considering the total sample, 43,55 millimeters, and did not show statistically significant difference according to age. There is no statistically significant difference between maximum interincisal distance means of mouth breathing children and of the control group children.

Conclusions: The maximum interincisal distance is a measure that did not modify in mouth breathing children, during the mixed dentition period, according to age, and seems not to be altered in this population. The importance of the use of the caliper in objective evaluation of the maximum interincisal distance was also observed.

BBO Case Report

Angle Class I malocclusion with congenitally missing and retention of mandibular second premolars*

Eduardo Silveira Ferreira

Angle Class I Malocclusion. Tooth Retention. Congenitally Missing Tooth. Corrective Orthodontics.

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This article reports the orthodontic treatment of a 14 year and 6 months old patient that had a Class I malocclusion with an ectopic position and retention of the tooth 45. This case was treated the extraction of the tooth 45 and space closure in the lower arch. Initial, final and post-treatment orthodontic records will be presented and discussed. This case was presented to the Brazilian Board of Orthodontics and Facial Orthopedics (BBO), category 7, free choice, as part of the requirements of achieve the title of BBO diplomate

Special Article

Orthodontic wires: knowledge ensures clinical optimization

Cátia Cardoso Abdo Quintão, Ione Helena Vieira Portella Brunharo

Orthodontic wires. Mechanical properties. Shape memory effect. Orthodontics.

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The wide range of orthodontic wires available in the market can raise doubts about the best choice for different clinical situations. Thus, knowledge of their mechanical properties can facilitate the choice of wire required to achieve a given orthodontic movement based on the treatment phase. The evolution of wire manufacturing technology and the development of new orthodontic techniques have led to the search for better quality alloys, more biologically effective for the teeth and supporting tissues. This article summarizes the main characteristics of the wires used in orthodontics, their history, mechanical properties and clinical application, according to specific treatment phases.

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