Dental Press Jounal of Orthodontics
Dental Press International

v. 18, no. 3

Dental Press Journal of Orthodontics – ISSN 2176-9451

Dental Press J. Orthod.

v. 18, no. 3

May / June

2013


Editorial

Orthodontic brackets – between passion and science

David Normando

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In Orthodontics we grew up with passionate discussions around brackets. During Orthodontic’s childhood we contemplated brackets systems that have been stamped as the “last and best” — to paraphrase Angle — but that vanished even before we reached Orthodontic’s adolescence. Topics such as slot dimensions, influence of manufacturing material and, recently, the ligation system, are eloquently debated. Leaving alone high-spirited discussions, the lack of scientific information regarding the influence of the bracket system on treatment efficiency is frightening. It is important to understand efficiency as good results with short treatment time.

While there are few studies which would offer us good scientific background on bracket slot (0.018-in or 0.022-in) or prescription (Straight-Wire or Standard Edgewise) choice, orthodontic science has produced an enormous amount of clinical trials to prove the efficiency of self-ligating brackets.

At the beginning, a great number of laboratory studies have demonstrated friction reduction with self-ligating brackets compared with conventional ones. However, the power of these studies, as with this editorial, isn’t enough to justify the system choice or the treatment speed. There are limitations in this study design in representing what really happened in the oral environment. A question arises here regarding the reliability of the study designed to investigate the effectiveness of self-ligating brackets on orthodontic treatment. The gold standards for health clinical studies are randomized trials. How are they designed? Why are they ideal for researches?

For randomized clinical trials researchers select patient groups with similar characteristics regarding malocclusions, called inclusion criteria. Treatment type (conventional or self-ligated for example) is determined randomly, most of the time by a computer program. Even the orthodontist that will treat the case is chosen in the same manner, in order to eliminate the operator effect. In this way, neither the patient, nor the professional will have any influence on the treatment choice and result.Once patients have been allocated randomly into their respective groups, the cases are monitored to the end. Data such as treatment time, quality of results, patient abandonment and other variables are collected. It is assumed that differences shown at the end of the study are an exclusive consequence of the treatment option.

I am not aware of any randomized clinical trial showing how Straight-wire brackets are more effective then standard Edgewise or how 0.018-in slots are better than 0.022-in ones. Would metal brackets produce better results than the ceramic ones?
What about self-ligating brackets? Are there any randomized studies about their efficiency? Yes, there are. What kind of information do they offer? These studies are consistently — and uniquely — showing no benefits in using self-ligating brackets to reduce treatment time with quality final results. There are plenty of studies proving this and by the time this article reaches you, there will be even more.

Unfortunately, in Orthodontics, very frequently products are launched by the industry without scientific proof. This is unaccepted in Medicine. Based on this fact, the belief in a bracket-wire system that promises to answer our patient’s key question — “When am I taking the brackets off, Doctor?” — is surprising.

Even though passion persuades us to hear a sweet answer, science remind us that truth is yet to come, and seems not to be hidden in metal clips or slide ligatures.

We are left with the need to dive into science, to find the answers to shorten treatment time. In the meanwhile — and science always has space for an appealing “while” — there is no reason to change our bracket system with the goal of treatment time reduction.

However, there is always something good to take from different systems. With self-ligating brackets there is enough clinical and scientific evidence that they reduce chair time since the opening and closure of bracket clips is faster than changing elastic modules by about 2 minutes. If you have a busy practice, this will make a difference at the end of the day. But apart from this it can’t be counted as an advantage.

Another reason to choose self-ligating brackets is to avoid the inconvenient discoloration of clear elastic ligatures, a constant issue for patients with esthetic brackets.

With regard to its convenience for orthodontists, there is a strong feeling that self-ligated brackets constitute a one-way street in Orthodontics. Treatment costs are significantly reduced, however, orthodontic science hasn’t confirmed them as a tool to reduce treatment time. Unfortunately, many young orthodontists who believed, or still believe, in this promise will later realize the power of the message in the epigraph.

BBO good seeds and the specialty excellence

Roberto Lima Filho

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From now on, the Dental Press Journal of Orthodontics begins an important collaboration with the Brazilian Board of Orthodontics and Facial Orthopedics (BBO). This significant partnership between Dental Press and BBO allow readers of this renowned journal to follow the breakthroughs and remarkable work of the BBO.

I was invited by the current BBO president, Dr. Sadi Flavio Horst, to write this editorial, a space that will annually be occupied by a member of the Board. Just as a beautiful smile gives a wonderful impression at first sight, I would like to underline what the BBO represents to our specialty in the new millennium. I hope this first impression can awaken a desire to know the Board better. This is our goal with the first BBO editorial hosted in this DPJO issue. 

The Brazilian Board of Orthodontics and Facial Orthopedics (BBO) was born from the initiative of the Brazilian Association of Orthodontics and Facial Orthopedics (ABOR) to create ?Quality standards for clinical excellence? in this field. BBO Diplomate orthodontists are recognized as professionals that were evaluated by a strict and renowned examining committee, demonstrating to have great knowledge and skills in the art and science of Orthodontics.

With the establishment of the BBO on the 2nd of September 2002, Orthodontics became the first health specialty in Brazil to have a certification process for specialists. Orthodontics was the first specialty in global dentistry to create a board in 1929 during the 28th American Society of Orthodontia meeting in America ? the American Board of Orthodontics (ABO). In 1950, the Council on Dental Education of the American Dental Association (ADA), recognized the ABO as the official certifying agency in Orthodontics.

Having a board certification demonstrates the specialist?s commitment to the necessary knowledge to treat patients with the highest quality standards. Everybody benefits by this arrangement: The society gains with the option of counting on recognized well prepared professionals; science is supported by high standard studies and breakthroughs; representative orthodontic associations are elevated as they improve standards to meet the needs of their associates. For orthodontists, in particular, having the board certification has a significant impact on their ethics and values of conduct. The demand for excellence is a way of achieving seriousness, respect and commitment to the best results for patients.

BBO certification is a demonstration of the right direction, namely, the highest level of quality work. Looking for excellence in each action is a sign of kindness and gentleness with our own life. A quote by Willian Lyon Phelps, an American writer, uniquely communicates the importance of seeking for knowledge and wisdom: ?Every time you acquire a new interest, even more, a new accomplishment, you increase your power of life.? In the same way, we can increase our power of life by becoming better, doing more, offering the best of our capacity and potential to our patients. Regarding the principle of desiring the best, Gilberto Amado remind us that, ?Wisdom is the art of climbing higher inside ourselves.? Wisdom is looking for the best, it is to take a step forward, becoming an expert, walking where few are willing to go. It is a hard way, but all the rewards we have achieved so far reassure us that it is worth it.

The Board can rise the spirit of constant update and, also, offer references and parameters of the specialist work to the general public. Board candidates are assessed by their knowledge in diagnosis, treatment plans and orthodontic therapeutics. The exam gives the opportunity for candidates to review their skills, consider the importance of taking good records, mechanics control during treatment, and commitment until the end of treatment.

Among the benefits of having the certification, it is worth highlighting the changes in professional conduct ? shown by patient?s satisfaction ? and the safety of working with good quality standards, with records taken from the beginning to the end of treatment. Also, candidates have the opportunity for self-assessment via a strict and detailed review of their clinical practice. Therefore, the certification process represents an important step on the way to improve Orthodontics quality.

Board certification implies that orthodontists become life long students. Learning experiences with the Board are crucial and there is no progress without apprenticeship. Orthodontists have a need for continued learning and the Board represents a good way of doing this. In March 2014, as an example of ABO, BBO launches the recertification process, as its bylaws sets out. This is an important tool to validate continued competency.

Upon the creation of the BBO, I said that the one who works only with the hands is just a worker, the one who works with the hands and head is an artisan, and the one who works with the hands, head and heart is an artist. It is important though to understand Orthodontics as science and art, to became a daily artist. It is well known that every artist needs dedication, studying, training and commitment. Talent is not magic, one has to work hard to achieve excellence. BBO gives the tools, conditions and parameters for this continued specialization. As BBO?s certification is not mandatory to practice orthodontics, the consolidation of its best goals (excellence in practice) comes with time and propagation of its principles and philosophy. This resembles the seeds a farmer sows with faith in its results. This is the mission of the Brazilian Board of Orthodontic and Facial Orthopedics today: to sow the good seeds of desire and consciousness to orthodontic specialists as to become more prepared and capable of making their patient?s face and smile more beautiful and better.

Roberto Lima Filho

Former chairman of the BBO
rlima@me.com

Tribute to

Prof. Dr. Décio Rodrigues Martins

Maria Fernanda M-O Consolaro

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Goodbye, Dr. Décio. We deeply thank you!

“Perseverance is the key to success, nothing is impossible

for the man impelled by intrepid believes!”

Décio Rodrigues Martins,

in interview for Dental Press (October, 1996).

With a life marked by happiness, delight and accomplishments, Dr. Décio Rodrigues Martins rested after an intrepid journey. He passed away on the 29th of May, after five years of an unceasing battle trying to keep alive a heart that made many others beat fast, in a rhythm of intensity and enthusiasm. Innumerable people in his family, students, colleagues, followers and friends, remain full of gratitude for the intense life this man lived, accomplishing his mission in his “own way” — as in the lyrics of his favorite song.

By paraphrasing Socrates, he claimed to be satisfied with his journey: “The secret of having a happy death is having a happy life!” Being face-to-face with death, he repeated many times: LIFE, I THANK YOU VERY MUCH!

Dr. Décio always claimed that what we take from this life is the good we do to others and the emotional ties we build along the way. Professor Décio leaves a valuable legacy of personal and professional values.

He was oftentimes excessively demanding, unseasonable, impetuous, tempered and brave. If he was demanding towards his children, grandchildren and students mainly, it is because he had always dedicated himself considerably. Should he not see the development of one’s potential, he would become furious. He had a lot to give. Valuable exchanges between him and his students truly fed his professor’s soul which was combined with a father, provider, and protector figure.

He overwhelmed everyone he met not only with his family ties which were beyond blood ties, but also with the science and the art of Orthodontics. Nevertheless, he emanated and taught excellence in teaching by means of valuing discipline, severity, good domain of Portuguese and general culture, always improving his intellect, his reason and his way of living: with wisdom and humbleness, especially when acknowledging his own mistakes. He always had plenty of love and generosity to give, as these were peculiar to him.

He was pleased and proud to say that many Brazilian orthodontists had been his students or students of his former students. Therefore, they were his “children” and “grandchildren”, directly or indirectly. Along with his great partners, pioneers in Brazilian Orthodontics (Dr. Muler de Araujo, Dr. José Édimo Martins and Dr. Décio’s closest friend, Dr. Sebastião Interlandi), Dr. Décio Rodrigues Martins has directly or indirectly influenced the lives of many generations of professionals.

I once read a quite old text written by Dr. Interlandi, which impressed me very much. In his text, he expressed his wish to make Orthodontics available to barefoot boys. We owe the popularization and diffusion of Brazilian Orthodontics to these four men who were at our disposal to teach Orthodontics beyond their clinics, democratizing their clinical practice and allowing competition to improve quality and promote research and education initiatives.

Within a global context, Brazilian Orthodontics is surely one of the best in the world. I would dare to claim that no other country makes good orthodontic treatment available for such reasonable price.

We will miss Dr. Décio’s first classes, in which he used to present the history of both national and international Orthodontics. We felt we were very privileged pupils who were inserted in an invincible and indefatigable militant group of “sculptures in vivo”! At first, he would congratulate us for having chosen the Orthodontics field, convincing us that we would have a magnificent professional future — following the steps of those who had established our path and taking care of the legacy to which these great men devoted their lives, leaving their sublime example to us.

When I became aware of my grandfather’s case, knowing that it was irreversible and that it had been aggravated in the past days, I called Dr. Interlandi who went to visit him in hospital. Their friendship as well as their closeness was always heartwarming. But in the end, at this last moment, the feelings they had for each other opened the doors to what my grandfather meant by “what we take from life”. A remarkable moment, inexpressible in words. There are fissures in time and space, moments when only silence may express what words cannot. Nevertheless, at this moment, I attempt to share my feelings towards the last lesson I learnt from these two partners who have strongly influenced our lives in many respects.

Keeping Dr. Décio company in hospital was an extremely significant lesson! He gave classes while he was sleeping! He asked questions such as: “What are the mouth appendages?” I answered: “The teeth!” He was given excruciating injections in his abdomen and when the nurse entered the room saying it was time to do so, he said: “Let’s go for it!” He underwent physiotherapy as if he was working out, until his last day. He was so humbly gallant. His last words to me were: “I have noticed I am getting worse, but we must remain resolute until the end!”

A colleague of his mentioned on Facebook, where many heartwarming farewell tributes were rendered, in capital letters: BRAZILIAN ORTHODONTICS IS IN MOURNING! How should we go into mourning, face our sadness for losing and missing him, and move forward with Dr. Décio’s vivacity?

Quoting the philosopher Antisthenes, Dr. Décio used to say that: “Gratitude is the memory of heart”. We are certain that he lived his life completely and happily, and this comforts us. The steps we have to follow are strong and the legacy he left us is extremely valuable. His thunderous voice shall echo forever in our affective memory, making many hearts beat fast, freeing us from inertia, encouraging us to improve in personal and professional matters, acting as the propelling spring of Brazilian Orthodontics.

We affectionately surrender to the Lord this great source of inspiration, great father, grandfather and great-grandfather of many students and followers, someone who has contributed to the lives of many. Everything that could have been done was done. Everything that could have been said was said. All hugs were given. The journey comes to an end with plenitude and peace!

The opportunity of paying tribute to Dr. Décio, preserving and keeping his memory in Brazilian Orthodontics is the best way of being in mourning for Dr. Décio as he would like us to do. Dental Press Journal of Orthodontics is indeed the most appropriate place to do so. For being one of the main supporters of this Journal, Dr. Décio was the first person to be interviewed.
He lives in every person who was inspired and welcomed by his life. We have never felt more fraternized by his lessons, his example, the impression he has left on our lives, the valuable legacy he has left to us, by our pride for having him as our preceptor and certainly, by his absence.

Deep is our mourning because incommensurable is our lost, but immense is our love. Gratitude is certainly the greatest feeling we have: GOODBYE, DR. DÉCIO. WE DEEPLY THANK YOU.

Orthodontic Insight

The four mechanisms of dental resorption initiation

Alberto Consolaro

Dental resorption. Root resorption. Tooth movement. Internal resorption. Cervical resorption.

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The aim of this study is to present a classification with a clinical application for root resorption, so that diagnosis will be more objective and immediately linked to the source of the problem, leading the clinician to automatically develop the likely treatment plan with a precise prognosis. With this purpose, we suggest putting together all diagnosed dental resorptions into one of these four criteria:

1) Root resorption caused by cementoblast cell death, with preservation of the Malassez epithelial rests.

2) Root resorption by cementoblasts and Malassez epithelial rests death.

3) Dental resorption by odontoblasts cell death with preservation of pulp vitality.

4) Dental resorption by direct exposure of dentin to gingival connective tissue at the cementoenamel junction gaps.

Orthodontics Highlights

Matheus Melo Pithon

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Mini-maxillary protractor appliance:

a new option for Class III treatment

The search for an esthetic appliance to treat Class III malocclusion has intrigued researchers for years. More recently, emphasis has been laid on the early correction of this malocclusion with the use of skeletal anchorage, associated with intermaxillary elastics with Class III orientation. Although this technique has revolutionized Orthodontics, there is still a need for surgical intervention. Some patients have accepted this proposal well, and others have not. Therefore, the initial problem goes back to “square one”, raising a new question. How to treat this malocclusion without surgical intervention, but at the same time, without the appliance being anti-esthetic? In seeking improvement in the esthetics of protractor appliances, an infinite number of new designs have appeared, among these the mini maxillary protractor appliance (Fig 1). But would this appliance with reduced dimensions be effective in protracting the maxilla? Searching an answer to this question, Turkish1 researchers conducted a clinical study, in which they verified the effectiveness of this appliance, in comparison with a control group. The results obtained were encouraging, seeing that this device with reduced dimensions was capable of applying traction to the maxilla, leading to dental and facial skeletal changes. Therefore, this device has become another option for the orthodontist in the early treatment of Class III malocclusion. It is worth pointing out that long term studies must be conducted due to the great potential for relapse of this type of malocclusion.

Interview

An interview with Won Moon

Andre Wilson Machado

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All in life have a positive side. In 2010, I was studying for my Doctorate in Orthodontics in UNESP-Araquara, Brazil, when for some personal reasons I had to drop my academic activities and return to Salvador city for a while. Luckily or by divine providence I received a great gift: The opportunity to meet Dr. Won Moon while he was visiting Brazil to present a lecture in the specialization course in Orthodontics at the Federal University of Bahia. It was admiration and friendship at first sight. A second opportunity to enjoy the contact with Won occurred in 2011, when I was taking part of my sandwich PhD at UCLA. Perceiving his qualities more closely became a motivation for new learnings. Won is a role model teacher and this is exemplified by the many tributes received by his students. His clinical aptitude is striking! In various challenging circumstances I have heard from his residents the following: “Cases like that only Dr. Moon handles...”. There is no need for long descriptions concerning the excellence of his career as an international lecturer. After he has visited the most important centers of Orthodontics worldwide you all will be able to appreciate this aptitude by your own! I did not take so long to notice that his qualities go beyond the professional sphere. Despite being blessed for having a very special family, he still manages his time for practicing radical sports such as climbing and mountaineering. Always accompanied by his wife Miran and his daughter Crystal, there is no lack of stories of trips around the world. It is clear the complicity of a marriage that began in their adolescence! Given the proper introduction of our distinguished interviewee, I also give my cordial thanks to the friends Sergei Rabelo, Richard Kulbersh, Greg Huang and Barry Briss, for accepting the invitation to actively participate of this interview. I also thank to Dental Press for the granted honor to conduct this experience. I wish all the readers a moment as pleasant and rich as the scientific path that led us to this interview.[...]

Original Article

Sagittal changes in lower incisors by the use of lingual arch

Helen Carolina Becker Letti, Susana Maria Deon Rizzatto, Luciane Macedo de Menezes, Chalana Sangalli Reale, Eduardo Martinelli de Lima

Incisor. Orthodontics. Cranial circumference.

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Objective: The objective of this study was to evaluate a sagittal variation on the lower incisors with the use of the lingual arch on the transition from mixed to permanent dentition.

Methods: The sample was constituted of 44 Caucasian patients (26 girls and 18 boys), divided in two groups: CG, control group, monitoring the lower arch space with no orthodontic/orthopedic treatment during the rated period (n = 14); EG, experimental group, presenting anterior inferior mild crowding and installation of the lingual arch for space maintenance (n = 30). The position of the lower incisors was analyzed on computerized cephalometric tracings performed at the beginning of the monitoring (T1) and at the and, on the permanent dentition (T2). In order to evaluate the position of the incisors it was used Tweed and Steiner measurements: IMPA, 1.NB and 1-NB. The alterations were analyzed through the “t” test for paired samples, while the differences between the groups were analyzed through the “t” test for independent samples, as for sexual dimorphism.

Results: The values in T2 were greater in relation to T1 for all measurements on EG (IMPA, p = 0.038; 1.NB, p = 0.007 and 1-NB, p < 0.0001). On comparing the differences (T2-T1) between CG and EG, it can be gauged differences significantly superior for measure 1.NB (p = 0.002) and 1-NB(p < 0.0001) on EG. There was no difference significantly statistic between genres.

Conclusion: It was concluded that the lower incisors were projected after using the lingual arch to control the space on the transition from mixed dentition to permanent, however, within acceptable standards, not having difference between genres.

Mechanical evaluation of quad-helix appliance made of low-nickel stainless steel wire

Rogério Lacerda dos Santos, Matheus Melo Pithon

Orthodontic appliances. Hypersensitivity. Nickel.

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Objective: The objective of this study was to test the hypothesis that there is no difference between stainless steel and low-nickel stainless steel wires as regards mechanical behavior. Force, resilience, and elastic modulus produced by Quad-helix appliances made of 0.032-inch and 0.036-inch wires were evaluated.

Methods: Sixty Quad-helix appliances were made, thirty for each type of alloy, being fifteen for each wire thickness, 0.032-in and 0.036-in. All the archwires were submitted to mechanical compression test using an EMIC DL-10000 machine simulating activations of 4, 6, 9, and 12 mm. Analysis of variance (ANOVA) with multiple comparisons and Tukey’s test were used (p < 0.05) to assess force, resilience, and elastic modulus.

Results: Statistically significant difference in the forces generated, resilience and elastic modulus were found between the 0.032 and 0.036 inch thicknesses (p < 0.05).

Conclusions: Appliances made of low-nickel stainless steel alloy had force, resilience, and elastic modulus similar to those made of stainless steel alloy.

Transversal changes in dental arches from non-extraction treatment with self ligating brackets

Liliana Ávila Maltagliati, Yasushi Inoue Myiahira, Liana Fattori, Leopoldino Capelozza Filho, Maurício Almeida Cardoso

Corrective orthodontics. Dental models. Orthodontic brackets.

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Objective: The present study aimed at analyzing, with the use of dental casts, the transverse changes of the upper and lower dental arches, after non-extraction orthodontic treatment, with self-ligating brackets.

Methods: The sample comprised 29 patients, all presenting Class I malocclusion with upper and lower crowding of at least 4 mm and treated only with a fixed appliance, without stripping, extraction or distalization. The dental casts were obtained before and after leveling with 0.019 x 0.025-in stainless steel archwires.

Conclusion: The results indicated that the majority of transverse changes occurred at the premolar areas, both the first and the second, as well as on the upper and lower dental arches. The intercanine distance increased 0.75 mm, on average, in the upper arch and 1.96 mm in the lower arch. The molars also demonstrated a tendency towards an increase in their transverse dimension, however, at a lower intensity comparing to premolars. All measurements presented statistically significant differences with the exception of the maxillary second molars.

Long-term stability of maxillary anterior alignment in non-extraction cases

Luiz Filiphe Gonçalves Canuto , Marcos Roberto de Freitas, Karina Maria Salvatore de Freitas, Rodrigo Hermont Cançado, Leniana Santos Neves

Relapse. Corrective orthodontics. Malocclusion.

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Objective: The purpose of this retrospective study was to evaluate long-term stability of maxillary incisors alignment in cases submitted to non-extraction orthodontic treatment. 

Methods: The sample comprised 23 patients (13 female; 10 male) at a mean initial age of 13.36 years (SD = 1.81 years), treated with fixed appliances. Dental cast measurements were obtained at three different time points (T1 ? pretreatment, T2 ? posttreatment and T3 ? long-term posttreatment). Variables assessed in maxillary arch were Little Irregularity Index, intercanine, interpremolar and intermolar widths, arch length and perimeter. The statistical analysis was performed by one-way ANOVA and Tukey tests when necessary. Pearson? correlation coefficients were used to investigate possible associations between the evaluated variables. 

Results: There was no significant change in most arch dimension measurements during and after treatment, however, during the long-term posttreatment period, it was observed a significant maxillary incisors crowding relapse. 


Conclusion: The maxillary incisors irregularity increased significantly (1.52 mm) during long-term posttreatment. None of the studied clinical factors demonstrated to be predictive of the maxillary crowding relapse.

Influence of surface treatment on shear bond strength of orthodontic brackets

Ione Helena Vieira Portella Brunharo, Daniel Jogaib Fernandes, Mauro Sayão de Miranda, Flavia Artese

Shear bond strength. Dental materials. Orthodontic brackets. Orthodontics.

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Introduction: The shear bond strength of orthodontic brackets bonded to micro-hybrid and micro-particulate resins under different surface treatment methods was assessed. 

Methods: Two hundred and eighty test samples were divided into 28 groups (n = 10), where 140 specimens were filled with Durafill micro-particulate resin and 140 with Charisma composite. In 140 samples, a coupling agent (silane) was applied. The surface treatment methods were: Phosphoric and hydrofluoric acid etching, sodium bicarbonate and aluminum oxide blasting, stone and burs. A Universal Instron Machine was used to apply an occlusal shear force directly to the resin composite bracket surface at a speed of 0.5 mm/min. The means were compared using analysis of variance and multivariate regression to assess the interaction between composites and surface treatment methods. 

Results: Means and standard deviations for the groups were: Sodium bicarbonate jet 11.27±2.78; burs 9.26±3.01; stone 7.95±3.67; aluminum oxide blasting 7.04±3.21; phosphoric acid 5.82±1.90; hydrofluoric acid 4.54±2.87, and without treatment 2.75±1.49. An increase of 1.94 MPa in shear bond strength was seen in Charisma groups. Silane agent application reduced the Charisma shear bond strength by 0.68 Mpa, but increased Durafill means for bicarbonate blasting (0.83), burs (0.98) and stone drilling (0.46).


Conclusion: The sodium bicarbonate blasting, burs and stone drilling methods produced adequate shear bond strength and may be suitable for clinical use. The Charisma micro hybrid resin composite showed higher shear bond means than Durafill micro particle composite. 

The evolution of cephalometric diagnosis in Orthodontics

Maurício Barbosa Guerra da Silva, Eduardo Franzotti Sant’Anna

Cone-Beam Computed Tomography. Digital dental radiography. Computer-assisted diagnosis.

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Introduction: Although the development of CT have represented a landmark in diagnostic imaging, its use in Dentistry turned out very discretely over the years. With the appearance of programs for analysis of three-dimensional images, specific for Orthodontics and Orthognathic surgery, a new reality is being built. 


Objective: The authors of this study aim to inform the orthodontic society of fundamentals about digital cephalometric radiographic image and computed tomography, discussing about: Field of view (FOV), radiation doses, demands for the use in Orthodontics and radiographic simulations.

Transverse maxillary and mandibular growth during and after Bionator therapy: Study with metallic implants

André da Costa Monini, Luiz Gonzaga Gandini Junior, Luiz Guilherme Martins Maia, Ary dos Santos-Pinto

Activator appliances. Angle Class II malocclusion. Maxillofacial development.

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Introduction: This study evaluated posteroanterior cephalograms before and after treatment and long term follow-up of Class II division 1 patients treated with bionator. 

Objective: The objective was to demonstrate the transverse growth of maxilla and mandible during and after bionator therapy. 

Methods: Measurement of transverse dimensions between posterior maxillary and mandibular implants, as well as the distances between the buccal, gonial and antegonial points were recorded. Measurements were analyzed at three periods: T1 = before bionator therapy, T2 = after bionator therapy and T3 = 5.74 years after T2

Results: There was statistically significant transverse increase due to growth and/or treatment for all variables, except for the distance between the anterior maxillary implants. 

Conclusions: During the study period only the anterior maxillary area did not show transverse growth.

The influence of patient's motivation on reported pain during orthodontic treatment

Marcio José da Silva Campos, Robert Willer Farinazzo Vitral

Pain. Orthodontics. Motivation.

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Introduction: Patients usually experience pain during orthodontic treatment. This fact can affect cooperation and the development of treatment. Reporting pain during treatment seems to be influenced by emotional aspects such as the patient?s motivation. 

Objective: To assess the relationship between patient?s motivation and the intensity of reported pain during two stages of treatment. 

Methods: Twenty males (11-37 years old) answered a questionnaire divided into five categories regarding their motivation towards treatment. The subjects were studied for 14 days (7 days with bonded brackets and 7 days with the initial arch inserted) and the intensity of pain was evaluated on a daily basis. All the issues, including the intensity of pain, were measured through the visual analog scale (VAS). 

Results: The VAS-associated questionnaire proved to have good temporal reliability and reasonable internal consistency, being that the ?perceived severity? domain had the greatest, although not significant (p = 0.196) correlation with pain intensity. Only the question asking the patients if they thought that their teeth were too uneven showed a positive correlation with pain intensity (p = 0.048). 

Conclusion: The results seem to indicate that the five categories related to treatment motivation cannot be used to predict discomfort during treatment. In addition, patients who think their teeth are too uneven may experience more severe pain due to greater force application after insertion of the initial arch.

Comparative evaluation of cephalometric and occlusal characteristics between the Long Face pattern and Pattern I

Elisa Gurgel Simas de Oliveira, Célia Regina Maio Pinzan-Vercelino

Cephalometry. Orthodontics. Diagnosis.

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Objective: To compare the cephalometric and intraoral characteristics between Long Face pattern and Pattern I patients, besides evaluating associations between subjective facial patterns, cephalometric facial patterns and the intraoral characteristics. 

Methods: Through evaluation of frontal and right side extraoral photographs, three previously calibrated and experienced examiners selected 30 Long Face patients (Group 1) and 30 Pattern I patients (Group 2), aged between 9 and 19 years, of both genders. The cephalometric characteristics were assessed by the following variables: SN.GoGn, NS.Gn, AIFH, SNA, SNB, ANB, 1.1, 1.NA,1-NA, 1.NB, 1-NB, NA.Po, nasolabial angle and H-Nose. Clinical evaluations were also performed to determine the presence of posterior crossbite, anterior open bite and type of Angle?s malocclusion. The cephalometric data were compared by independent t test. The chi-square test was used to evaluate the association between qualitative variables. 

Results: Significant differences were observed between groups regarding the variables SN.GoGn, NS.Gn, AIFH, ANB, NA.Pog, 1-NA, 1.NB and 1-NB, with an increase of these measures in Group 1. There were also significant differences between groups on variable 1.1, being lower in Group 1 than in Group 2. 


Conclusions: The Long Face was associated to Angle Class II malocclusion, to the presence of posterior crossbite and to anterior open bite. The Long Face subjective facial pattern was associated to dolichofacial cephalometric pattern.

Surgical-orthodontic treatment of Class III malocclusion with agenesis of lateral incisor and unerupted canine

Bruno Boaventura Vieira, Ana Carolina Meng Sanguino, Marilia Rodrigues Moreira, Elizabeth Norie Morizono, Mirian Aiko Nakane Matsumoto

Orthodontics. Angle Class III malocclusion. Oral surgery.

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Introduction: Orthodontic-surgical treatment was performed in patient with skeletal Class III malocclusion due to exceeding mandibular growth. Patient also presented upper and lower dental protrusion, overjet of -3.0 mm, overbite of -1.0 mm, congenital absence of tooth #22, teeth #13 and supernumerary impaction, tooth #12 with conoid shape and partly erupted in supraversion, prolonged retention of tooth #53, tendency to vertical growth of the face and facial asymmetry. The discrepancy on the upper arch was -2.0 mm and -5.0 mm on the lower arch. 

Methods: The pre-surgical orthodontic treatment was performed with extractions of the teeth #35 and #45. On the upper arch, teeth #53, #12 and supernumerary were extracted to accomplish the traction of the impacted canine. The spaces of the lower extractions were closed with mesialization of posterior segment. After aligning and leveling the teeth, extractions spaces closure and correct positioning of teeth on the bone bases, the correct intercuspation of the dental arch, with molars and canines in Angle?s Class I, coincident midline, normal overjet and overbite and ideal torques, were evaluated through study models. The patient was submitted to orthognathic surgery and then the post-surgical orthodontic treatment was finished. 

Results: The Class III malocclusion was treated establishing occlusal and facial normal standards.

Evaluation of metallic brackets adhesion after the use of bleaching gels with and without amorphous calcium phosphate (ACP): In vitro study

Sissy Maria Mendes Machado, Diego Bruno Pinho do Nascimento, Robson Costa Silva, Sandro Cordeiro Loretto, David Normando

Tooth whitening. Dental bonding. Shear bond strength. Orthodontics. Tooth enamel.

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Objective: To evaluate in vitro the effects of tooth whitening using gel with Amorphous Calcium Phosphate (ACP) on the bond strength of metal brackets. 

Methods: Thirty-six bovine incisors were sectioned at the crown-root interface, and the crowns were then placed in PVC cylinders. The specimens were divided into 3 groups (n = 12) according to whitening treatment and type of gel used, as follows: G1 (control) = no whitening; G2 = whitening with gel not containing ACP (Whiteness Perfect - FGM), G3 = whitening with gel containing ACP (Nite White ACP - Discus Dental). Groups G2 and G3 were subjected to 14 cycles of whitening followed by an interval of 15 days before the bonding of metal brackets. Shear bond strength testing was performed on a Kratos universal test machine at a speed of 0.5 mm/min. After the mechanical test, the specimens were assessed to determine the adhesive remnant index (ARI). The results were subjected to ANOVA, Tukey?s test and Kruskal-Wallis test (5%). 

Results: Significant differences were noted between the groups. Control group (G1 = 11.10 MPa) showed a statistically higher shear bond strength than the groups that underwent whitening (G2 = 5.40 Mpa, G3 = 3.73 MPa), which did not differ from each other. There were no significant differences between the groups in terms of ARI. 


Conclusion: Tooth whitening reduces the bond strength of metal brackets, whereas the presence of ACP in the whitening gel has no bearing on the results.

Superficial morphology and mechanical properties of in vivo aged orthodontic ligatures

Glaucio Serra Guimarães, Liliane Siqueira de Morais, Margareth Maria Gomes de Souza, Carlos Nelson Elias

Elastomers. Elastic ligature. Degradation.

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Introduction: The degradation of elastic ligatures in the oral environment results in the need of periodic replacement to maintain the optimal force during the orthodontic treatment. The purpose of this study was to perform a clinical prospective randomized study of the degradation of orthodontic elastomeric ligatures in the oral environment by scanning electron microscopy (SEM) and tensile strength test. 

Method: Two hundred elastic ligatures were randomly selected and placed around the brackets of 5 volunteers and removed in groups of 10, at different times (1, 2, 3, and 4 weeks). The control group was performed by another fifty ligatures which were not submitted to the oral degradation. The analyses were done by scanning electron microscopy (SEM) and strength mechanical test. 

Results: The tensile strength test results showed reduction in the ultimate strength values after four weeks ageing in the oral environment and no statistical difference in the yield strength values (p < 0.05). The orthodontic elastomeric ligatures surface was significantly degraded in the oral cavity after four weeks. The elastomeric degradation began in the first week when the increase in the roughness could be detected just in some areas. Afterwards, the surface became gradually rougher and, after 4 weeks, it was totally rough with some crack areas. 


Conclusions: The elastic ligatures aged in the oral environment showed higher superficial degradation and lower loss of mechanical properties after the maximum experimental period.

Time of guard of orthodontic records versus legal time for their prescription

Luiz Renato Paranhos, Mariana Paula Maggiorini de Magalhães, José Francio, Hélio Hissashi Terada, Henrique Damian Rosário, Rhonan Ferreira da Silva

Documentation. Orthodontics. Forensic dentistry. Legislation.

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Introduction: After promulgation and wider dissemination of the Code of Consumer Protection, there was an increase in the number of legal conflicts between patients and dentists, leading these health professionals to increasingly guard themselves from possible lawsuits. As such, it becomes critical the preparation of an adequate and complete clinical record, even though the keeping time remains uncertain. 

Objective: To review the literature and discuss the keeping time of orthodontic records versus the legal time for their prescription, as well as to propose a model of a Term upon Completion of Dental Treatment. 

Conclusion: It is advised to return part of the clinical records to their rightful owners by means of an itemized receipt. The Term upon Completion reflects the patient?s awareness and could be considered by the CCP as the initial term of the prescription time, because it implicates that the patient recognizes the quality of service provided and satisfactory results achieved.

Short-term efficacy of mandibular advancement splint in treatment of obstructive sleep apnea-hypopnea syndrome

Calliandra Moura Pereira de Lima, Laurindo Zanco Furquim , Adilson Luiz Ramos

Sleep apnea syndrome. Snoring. Polysomnography.

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Objective: The aim of the present study was to determine the short-term efficacy of treatment for snoring and obstructive sleep apnea-hypopnea syndrome (OSAHS) using a mandibular advancement splint. 

Methods: The sample comprised 20 patients (13 men and 7 women; mean age = 48 years; mean body mass index = 27.07) with OSAHS. Polysomnograms were performed before and 60 days after mandibular advancement splint therapy. 

Results: There was a significant reduction in the apnea-hypopnea index (AHI) following treatment (mean pretreatment AHI = 20.89 ± 17.9 versus mean posttreatment AHI = 4.43 ± 3.09) (p < 0.05). The snoring reduced and the sleep efficiency improved, as registered by polysomnograms (p<0.05). 


Conclusions: The sleep quality improved in patients using mandibular advancement splint. Further studies evaluating long-term effects are needed. 

In vitro analysis of shear bond strength and adhesive remnant index comparing light curing and self-curing composites

Murilo Gaby Neves, Gustavo Antônio Martins Brandão, Haroldo Amorim de Almeida, Ana Maria Martins Brandão, Dário Ribeiro de Azevedo

Composite resins. Shear strength. Scanning electron microscopy.

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Objective: To evaluate, in vitro, the shear bond strength of self-curing (ConciseTM ? 3M and Alpha Plast ? DFL) and light-curing composites (TransbondTM XT ? 3M and Natural Ortho ? DFL) used in orthodontics bonding, associated to Morelli metal brackets, with further analysis of adhesive remnant index (ARI) and enamel condition in scanning electron microscopy (SEM). 

Methods: Forty human premolars, just extracted and stored in physiologic solution 0.9 % were used. Randomly, these samples were divided in four groups: G1 group, the brackets were bonded with ConciseTM ? 3M composite; in G2 group, Alpha Plast ? DFL composite was used; in G3 group, TransbondTM XT ? 3M was used; in G4 group, Natural Ortho ? DFL composite was used. These groups were submitted to shear strength tests in universal testing machine, at 0.5 mm per minute speed. 

Results: Statistical difference between G3 and G4 groups was recorded, as G4 showing higher strength resistance than G3. In the other hand, there were no statistical differences between G1, G2 and G3 and G1, G2 and G4 groups. ARI analysis showed that there was no statistical difference between the groups, and low scores were recorded among then. The scanning electron microscopy (SEM) analysis revealed the debonding spots and the enamel surface integrity. 


Conclusions: Shear bond strength was satisfactory and similar between the composites, however Natural Ortho ? DFL revealed best comparing to TransbondTM XT ? 3M.

Comparison of mesiodistal tooth widths in Caucasian, African and Japanese individuals with Brazilian ancestry and normal occlusion

Thais Maria Freire Fernandes, Renata Sathler, Gabriela Letícia Natalício, José Fernando Castanha Henriques, Arnaldo Pinzan

Orthodontics. Balanced dental occlusion. Tooth.

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Objective: To observe the presence of sexual dimorphism and compare the mesiodistal width of the teeth in Caucasian, African and Japanese individuals with Brazilian ancestry not orthodontically treated and with normal occlusion. 

Methods: One hundred pairs of dental casts were used. It was measured, from first molar to first molar in both arches, the teeth?s mesiodistal widths, using a digital caliper. For the statistical analysis of results Kolmogorov-Smirnov, t test, ANOVA and Tukey?s test (p < 0.05) were used. 

Results: Sexual dimorphism occurred on the three evaluated groups, and the highest mesiodistal widths were found in males. There was statistically significant difference between racial groups in all evaluated teeth in males. However, in females, this same difference was found only on upper lateral incisor and first molar; and lower lateral incisor, canine, first premolar and first molar. 


Conclusion: Most of mesiodistal measures present particular characteristics in relation to gender, with higher values for males, and to race, with a tendency for African to present greater mesiodistal distance of the teeth, followed by Japanese and Caucasians, respectively, important for the correct diagnosis and orthodontic planning.

Deformation of elastomeric chains related to the amount and time of stretching

Denise Yagura, Paulo Eduardo Baggio, Luiz Sérgio Carreiro, Ricardo Takahashi

Elastomers. Tensile strength. Permanent deformation.

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Objective: To investigate a potential relationship between degree of stretching and resulting permanent deformation of elastomeric chains (ECs) as well as whether or not stretching time has any bearing on the degree of permanent deformation. 

Methods: Five-module segments of closed elastomeric chains manufactured by 3M Unitek were stretched to 10-100% of their original length in devices especially designed for this purpose, remaining submerged in artificial saliva at 37 ± 1° C and were removed sequentially after 1, 2, 3 and 4 weeks. Upon removal, each segment was measured and, once recorded the values, were statistically analyzed with the purpose of assessing the degree of permanent deformation. 

Conclusions: It was concluded that permanent deformation is directly proportional to the degree of stretching of the ECs assessed. The mean percentages found were 8.4% to 10% of stretching, and exceeding 20% (21.3%) when stretched by 40%, and reaching 56.6% permanent deformation when stretched 100% of their original length. Finally, the highest percentage of permanent deformation occurred during the first week and was not statistically significant after this period.

Cephalometric analysis for the diagnosis of sleep apnea: A comparative study between reference values and measurements obtained for Brazilian subjects

Patrícia Superbi Lemos Maschtakow, Jefferson Luis Oshiro Tanaka, João Carlos da Rocha, Lílian Chrystiane Giannasi, Mari Eli Leonelli de Moraes, Carolina Bacci Costa, Julio Cezar de Melo Castilho, Luiz César de Moraes

Obstructive sleep apnea. Comparative study. Cephalometry

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Objective: To verify if the reference values of Sleep Apnea cephalometric analysis of North American individuals are similar to the ones of Brazilian individuals presenting no craniofacial anomalies. The study also aimed to identify craniofacial alterations in Obstructive Sleep Apnea-Hypopnea Syndrome (OSAHS) patients in relation to individuals without clinical characteristics of the disease through this cephalometric analysis. 

Method: It were used 55 lateral cephalograms consisting of 29 for the control group of adult individuals without clinical characteristics of OSAHS and 26 apneic adults. All radiographs were submitted to Sleep Apnea cephalometric analysis through Radiocef Studio 2.0. The standard values of this analysis were compared, by means of z test, to the ones obtained from the control group and these were compared to values from apneic group through Student?s t test. 

Results: There were no significant differences between values obtained from control group and standard values. On the group of OSAHS patients it was observed a decrease on the dimensions of upper airways and an increase on the soft palate length. 


Conclusions: The standard values of Sleep Apnea analysis can be used as reference in Brazilian individuals. Besides, through lateral cephalograms it was possible to identify craniofacial alterations in OSAHS patients.

BBO Case Report

Angle Class I malocclusion treated with lower incisor extraction

Vanessa Leal Tavares Barbosa

Crowding. Lower incisor extraction. Gingival recession.

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In planning orthodontic cases that include extractions as an alternative to solve the problem of negative space discrepancy, the critical decision is to determine which teeth will be extracted. Several aspects must be considered, such as periodontal health, orthodontic mechanics, functional and esthetic alterations, and treatment stability. Despite controversies, extraction of teeth to solve dental crowding is a therapy that has been used for decades. Premolar extractions are the most common, but there are situations in which atypical extractions facilitate mechanics, preserve periodontal health and favor maintenance of the facial profile, which tends to unfavorably change due to facial changes with age. The extraction of a lower incisor, in selected cases, is an effective approach, and literature describes greater post-treatment stability when compared with premolar extractions. This article reports the clinical case of a patient with Angle Class I malocclusion and upper and lower anterior crowding, a balanced face and harmonious facial profile. The presence of gingival and bone recession limited large orthodontic movements. The molars and premolars were well occluded, and the discrepancy was mainly concentrated in the anterior region of the lower dental arch. The extraction of a lower incisor in the most ectopic position and with compromised periodontium, associated with interproximal stripping in the upper and lower arches, was the alternative of choice for this treatment, which restored function, providing improved periodontal health, maintained facial esthetics and allowed finishing with a stable and balanced occlusion. This case was presented to the Brazilian Board of Orthodontics and Dentofacial Orthopedics (BBO), as part of the requirements for obtaining the BBO Diplomate title.

Special Article

Brachycephalic, dolichocephalic and mesocephalic: Is it appropriate to describe the face using skull patterns?

Fernanda Catharino Menezes Franco, Telma Martins de Araújo, Carlos Jorge Vogel, Cátia Cardoso Abdo Quintão

Face. Terminology. Classification.

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The use of a standardized terminology in the medical sciences is essential for both clinical practice and scientific research. In addition to facilitating communication between professionals, it enhances the reliability of comparisons made between studies from different areas, thereby contributing to a higher level of scientific evidence. Examples of attempts made to standardize the terminology in other areas dedicated to the study of craniofacial morphology can be found in the literature. On the other hand, one can find in the orthodontic literature a variety of terms that render the consensus and communication between orthodontists and other researchers even more problematic. As an example, one could cite the use of the terms brachyfacial, mesofacial and dolichofacial, which form part of a cranial index terminology used to describe facial types. Thus, a reflection on the origin and differences of the terms used to describe the human facial phenotype may pave the way toward a consensus regarding the meaning that best represents the craniofacial patterns.

Dental Press Journal of Orthodontics - v. 18, no. 3 Download full issue pdf