EJCO Vol2iss3

European Journal of Clinical Orthodontics
International Journal supported by the Italian Society of Orthodontics (SIDO)

Volume 2, Issue 3
Contents
67. EDITORIAL 90. New-Generation Light-Emitting Diode
For a Friend... Versus Halogen Light-Curing of
R. Schiavoni Orthodontic Brackets: A 24-Month
Case-Control Study of Bond Failures
68. IN MEMORY OF A. Salazar, AL. Sonis, H. Ohiomoba
Reflections on the life of Tiziano Baccetti
(19662011) 98. X-RAY ODDITIES
S.Peck An Unusual Crepitus
Editor: V. Grenga
70. WHOS WHO
Rohit Sachdeva 100. LITERATURE READINGS... FOR DUMMIES
Editor: C. Bonapace Case Reports and Case Series
Editor: B. Oliva
71. WHOS WHO CLINICAL ARTICLE
Novus Ordo Seclorum: A Manifesto for 101. WE TESTED
Practicing Quality Care - Part I The Columbus Spring
R. Sachdeva
77. CLINICAL ARTICLES

Treatment of a Class II Extremely Deep
Bite by the Tip-Edge Technique and
Mandibular Distraction Osteogenesis
Y. Deng, U. Hgg, LK. Cheung
Editorial Board Associate Editors: Contributing Editors Advisory board

Editor in Chief: Hans-Peter Bantleon, Austria Carlo Bonapace (editor Silvia Allegrini, Italy
Raffaele Schiavoni, Italy Alberto Caprioglio, Italy of Whos who column), Italy Rossella Contrafatto, Italy
Editorial Director Giampietro Farronato, Italy Gianluigi Fiorillo, Italy Ewa Czochrowska, Poland
Claudio Lanteri, Italy Chung How Kau, USA Vittorio Grenga (editor Guy De Pauw, Belgium
Co-Editor: Christos Katsaros, of X-Ray Oddities column), Italy Rafael Garca Espejo, Spain
Felice Festa, Italy Switzerland Bruno Oliva, (editor Nathamuni Rengarajan
Editorial office: Stavros Kiliaridis, of Literature Readings for Krishnaswamy, India
phone + 39 02 58102846 Switzerland Dummies column), Italy Nazan Kckkeles, Turkey
83419430 (1) Maurizio Manuelli, Italy Pedro Leitao, Portugal
fax: +39 02 93663665 Ravindra Nanda, USA Luca Mergati, Italy
[email protected] Ramon Perera Grau, Spain Leonid Persin, Russia
Publisher: Andreu Puigdollers, Spain
SIDO -Societ Italiana Arni Thordarson, Iceland
di Ortodonzia Marco Trib, Switzerland
via P. Gaggia 1, Milano, Italy Peter Van Spronsen, The
Printer: Netherlands
UNIGRAFICA SRL Carlalberta Verna,
Distributed by: Switzerland
SMC media SRL
2014 Italian Society of Orthodontics (SIDO) Disclaimer

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some other use of this journal without the written permission of di Milano n.69 on 18/03/2013.
the copyright holder. N. Repertorio ROC: 972244
EJCO_Vol2Iss3_UNICO.indd 65 11/09/14 12.56

EDITORIAL
For a Friend...
Raffaele Schiavoni On November 27th 2011, Tiziano Anyone, like me, who has had the
Editor-in-Chief Baccetti passed away. He was pleasure to meet Tiziano will agree
the greatest ambassador that with these words, which need no
Italy has ever had in the world of further comment
How to cite this article: orthodontics.
Schiavoni R. For a Friend... EJCO In his honor, the SIDO established You will always be in our hearts
2014;2:67 the Lecture in memory of , an event
which happens every two years.
In 2012, Sheldon Peck delivered the
first lecture to commemorate his
friend, and he did it in very touching
words, which we are pleased to
repeat on the occasion of the
second lecture that will be delivered
by McNamara during the 45th
International SIDO Congress.
2014 SIDO 67

IN MEMORY OF
Reflections on the life of Tiziano Baccetti (19662011)

Prologue to the 1st Tiziano Baccetti Memorial Lecture, presented at SIDO, 12 October 2012, Florence
S. Peck
University of North Carolina
Chapel Hill, NC, USA
How to cite this article:

Peck S. Reflections on the life of Tiziano Baccetti (19662011). EJCO 2014;2:68-69
I stand before you with mixed emotions this morning. little Vittorio the joys of sport and of experiencing
On the one hand, I am honoured to be part of your fun in everything he did. What a remarkable legacy
educational programme at this 24th SIDO meeting. On the has fallen on the broad shoulders of this smart and
other hand, I am still in shock knowing that dear Tiziano handsome boy, the ultimate joy of his fathers senses.
is not here with us today. Its hard to believe that Tiziano Tiziano Baccetti became a master at public presentation
Baccetti, who was full of life less than a year ago, teaching early in his acclaimed career. He was a natural at the
us, entertaining us, making us all feel better and become podium and a marvellously effective speaker in Italian
better, is no longer with us, is forever gone (Fig. 1). and English, his second language. His elaborate scientific
Tiziano Baccetti was the greatest ambassador that Italy visuals were studiously organized and entertaining to
has ever had in the world of orthodontics. He lectured follow. Humour, a prominent thread woven into all aspects
around the world, year after of Tizianos life, was always
year. Everywhere he spoke, he evident in his engaging lecture
always started his presentations style. Tizianos special charisma
with this kind of slide: Firenze and energy endeared him to the
the beautiful (Fig. 2). He huge audiences at his courses
easily showed his love for his and presentations around the
country, his city, his people. His world. He made learning fun and
appreciative audiences around memorable, the hallmarks of a
the world warmly loved Tiziano gifted teacher.
back and loved Tizianos Italy. Early in his professional career,
First and foremost, Tizianos Tiziano Baccetti formed a bond
greatest love was concentrated with his classmate Lorenzo
on his adored son Vittorio. I Franchi, who also was gifted in
remember receiving Tizianos solving research problems. He
email announcement two and Lorenzo teamed up to do
days after Vittorios birth: orthodontically related studies
Dear Friends, at the University of Florence. A
on Friday August 6, 2004, at truly complementary lifetime
8.38 a.m., my son Vittorio came research partnership was born
to the world. I want to share in the early 1990s.
with you my great happiness. I do not know of another
Enjoy his picture at 48 hours of intellectual partnership in the
life (Fig. 3). history of orthodontics that
Tiziano was a fully connected Figure 1: Tiziano Baccetti, 19662011 has been more productive or
father. He had wonderful role Reprinted from American Journal of Orthodontics and more famous than Baccetti and
models to follow since he Dentofacial Orthopedics, Volume 141, Issue 2, McNamara JA, Franchi. They produced together
was raised so lovingly by his Franchi L, Tiziano Baccetti, 1966-2011, p. 253, 2012 The and with others over 250
parents and grandparents. As American Association of Orthodontists, with permission from original important publications!
soon as he could, he taught Elsevier. This is simply an amazing output
68 2014 SIDO

whole bottle will I be instantly reminded of the special
experience of this evening. And I am told that special
bottle was proudly displayed in his home.
Tiziano was also the caring humanist, so sensitive to the
needs of others. Tiziano knew well how humans work and
interact, and he was a marvellous person to work with and
be with. He was a man for all seasons and all people.
I propose to you today that Tiziano Baccetti should be
remembered as our modern-day Vitruvian man (Background
figure). Leonardos masterpiece, created around 1487,
is probably a facial self-portrait meant to demonstrate
the proportions of a well-shaped male according to
the concept of the ancient Roman engineer Vitruvius.
Figure 2: Firenze the beautiful. Slide created by Tiziano Baccetti for But it is more. According to history, the Vitruvian mans
his worldwide presentations. outstretched limbs fit within a circle and a square, two
shapes that always have had special, symbolic powers. The
for such young scientists. We were blessed to have that circle represented the cosmic and the divine; the square
dream team in orthodontics and are blessed to have represented the earthly and the secular. I think Vitruvian
Lorenzo carrying forward this scholarly tradition. man ably represents much that was great about Tiziano
Tiziano was unquestionably the rock star of orthodontics, Baccetti: Tizianos unlimited reach and vision, his Leonardo-
but he was also a down-to-earth friend and teacher. He like mastery in all his accomplishments, his unique ability
was an unforgettable mentor to so many students. He to merge verifiable science and art to help us better
gave his all to help them succeed in their projects and understand the nature of man. This is Tiziano, reaching out
careers. Tiziano Baccetti unselfishly stayed long hours in to the perimeter of knowledge the frontier discovering,
the clinic and lab or on the podium to cater to his growing synthesizing, making knowledge relevant to the working
worldwide fan club. clinician. Tiziano Baccetti, our Vitruvian man for all time.
Lets not forget that Tiziano was the consummate With this heartfelt reminiscence about Tiziano, I humbly
researcher. He spent hours and hours at the computer, and proudly dedicate my lecture this morning to the
interpreting data and radiographs, and coming up with memory of Tiziano Baccetti, my unforgettable friend and
new exciting discoveries. At age 45, Tiziano Baccetti had our brilliant contributor, who has fully earned immortality
already achieved worldwide fame in fields he helped in the minds and hearts of us all.
create, such as facial growth modification, timing of My presentation is in a field that Tiziano pioneered, a field
skeletofacial growth and orthopaedic treatments, that he and I discussed often, the field of associated dental
and biological associations of dental anomalies. He anomalies, which was the subject of his PhD dissertation.
was a master in the application and broadening of
observational science in clinical orthodontics. Tiziano
was an adventuresome scientific explorer, a modern-day
Columbus, in our orthodontic world.
Then there was Tiziano the perceptive intellectual. He was
remarkably broad in his interests and knowledge, utterly
Tiziano, this one is for you
encyclopaedic. I remember his wonderfully animated and
informed conversations on art, world history and wine.
One evening in Boston, we shared a great bottle of red
Bordeaux. Tiziano did not want to forget this exceptional
wine, so he asked our waiter to wrap the empty bottle
for him to take back to Italy. When the waiter offered to
peel the label off to save him carrying the bottle, Tiziano
replied: The label alone will not do; only when I see the
Background figure: Leonardo da Vinci, Vitruviuss Proportions of the

Human Body, Venice, Gallerie dellAccademia, Gabinetto dei disegni e
stampe.
This masterful representation of the ideals, reach and vision of mankind
fits the great legacy left to us by Tiziano Baccetti. Figure 3: Tizianos adored son, Vittorio Baccetti, 8 August 2004, 2 days
Image courtesy of Ministero di beni e delle attivit culturali e del turismo, Venice after his birth.
2014 SIDO 69

Carlo Bonapace
Private Practice of
WHOS WHO
Orthodontics, Turin, Italy
In this section we introduce an influential orthodontist who has given a

significant contribution to the specialty. An article by the author featuring his
landmarks follows.
Correspondence:
Corso Re Umberto, 97
10128 Turin, Italy
e-mail: [email protected]

Bonapace C. Rohit Sachdeva. EJCO 2014;2:70
Rohit Sachdeva
R
ohit Sachdeva was born and His work with engineers, materials and colleagues Carl Gugino, Doug
raised in Kenya, where he scientists and designers has Haberstock, John Lohse, Antonella
received his dental training. allowed him to cross-pollinate Maselli, Jeff Johnson, Mark Knoefel,
He then moved to England, where he ideas and recognize the value of Takao Kubota and Larry White and
served as an orthodontic registrar, transprofessional collaboration. his family at OraMetrix.
and finally to the United States. In addition, he has maintained his His greatest blessing in life has been
He was thrust into academia, the primary interests in improving and will always be his unconditionally
formative stage of his professional clinical practices and patient care loving, supportive family his
career, at an early age. He soon and has pioneered the practice of parents Shanti and Chaman Lal, his
understood that the best way to remote orthodontics. He continues wife Benu and his three children
learn was, and remains, to teach. to be actively involved in teaching Maya, Nikita and Arjun who have
He had the support and guidance and practicing remote patient care. served as both his inspiration and
of remarkable mentors Andrew Sachdeva entered into industry sounding boards.
Richardson, Bill Houston, Charles when he co-founded the start-up
Burstone, Michael Marcotte, Hans- OraMetrix Inc*. and developed the
Peter Bantleon and Birte Melsen Suresmile system. He currently *OraMetrix Inc., Richardson, TX, USA
who questioned and challenged his designs and implements technology
way of thinking. Whilst in academia, that will enable the orthodontist to
Rohit Sachdeva embarked upon a practice in an all-digital environment.
path of research that culminated He believes we should all embrace
in the development of both copper failures. They evoke humility within
nickel-titanium and titanium niobium us, making us receptive to our
alloys and titanium brackets for use ignorance and clearing the path to
in orthodontics. Post-academia, new learning.
he has continued his research and He is indebted to his patients for
development activities in the areas allowing him to learn from them and
of clinical decision support systems awakening empathy within him.
and automation technology; he He is grateful and thankful for the
currently has over 90 patents. support and insight of his friends
70 2014 SIDO

Novus Ordo Seclorum:
A Manifesto for Practicing Quality Care
Part I
Rohit Sachdeva
Abstract
Chief Clinical Officer, Orametrix,
Richardson, Texas, USA
The current approach to orthodontic care is largely error-

prone and, therefore, reactive. Such error-ridden care practices
Correspondence: negatively impact the quality of the care delivered. In this article,
e-mail: [email protected] the author discusses his manifesto for BioDigital Orthodontics,
a proactive, quality-focused approach to orthodontics. The
Article history principles and practice of patient-centred care, patient safety
Received: 01/09/2014 and clinical effectiveness as they relate to the practice of quality
Accepted: 05/09/2014 care are presented.
Published online: 11/09/2014
Conflicts of Interests:
None

Sacheva R. Novus Ordo Seclorum:
A Manifesto for Practicing Quality Care-Part I.
EJCO 2014;2:71-76
Acknowledgements:
I thank Dr. Antonella Maselli, a dear friend and
colleague, for the countless conversations we
have had on improving orthodontic care and
for insisting that I write this paper. My eternal
gratitude goes to my daughter Nikita Sachdeva
for her help in both editing and preparing this
manuscript for publication.
Be a yardstick of quality.
Some people are not used
to an environment
where quality is expected.
Keywords
Quality, reactive care, proactive care
Steve Jobs
2014 SIDO 71

CLINICAL ARTICLE
INTRODUCTION Quality means doing it right the patient and establish rapport
when no one is looking. We must with the patient in addressing care
Q
uality orthodontic care is a embrace and commit to a new needs. These care teams respect the
commodity. Why? Because cultural fluency that fosters patient patients ability to assert his or her
almost all doctors believe centredness, patient safety and individuality. Patient-centred care
they provide quality care to their clinical effectiveness2 . also means complete transparency;
patients. The reason this myth prevails the care team offers full, unbiased
is that the definitions of quality PATIENT-CENTRED CARE information about the options,
practices and metrics remain vague THE PAST AND PRESENT benefits and risks of any care
at best1. Currently, said practices Historically, a paternalistic, measures planned.
measure the spatial relationships of hierarchical model defined the Potential disconnects between
the dentition and are not rooted in doctorpatient relationship. The the voice of the doctor and
scientific evidence in terms of their doctor knew best, effectively that of the patient are best
clinical or physiological significance silencing the voice of the patient. resolved using a casuistic
(such as blood pressure or body Recently, however, the consumer- approach to clinical decision-
temperature), thus diminishing their driven orthodontic care model making. This model considers
validity as effective measures of well- has redefined the doctorpatient patient values, backgrounds and
being. Also, these measures are not relationship, establishing a preferences alongside empirical
universally accepted by the specialty contractual relationship between evidence, experiential evidence,
or the profession of dentistry at large. buyer (patient) and seller (doctor) 3 . pathophysiological rationale and
In this way, the clinician acts as both In this setting, the buyer knows system features7.
judge and jury, rubber-stamping best and pays for his or her wants, As such, orthodontic patient-centred
an autonomous verdict of all looks not needs. The buyers commonly care practices carry the banner of a
well; no harm done in the treatment misinformed expectations of care patient of one5 .
delivered to his or her patients. Such now muffle the voice of the well
behaviour has a ripple effect within intentioned, evidence-driven doctor. PATIENT SAFETY
the orthodontic care ecosystem. For Both of these models of doctor THE PAST AND PRESENT
instance, this behaviour blunts the patient relationships are flawed, Conventional orthodontic care has
patients understanding of quality warranting a more balanced doctor been and continues to be craft-based
care, diminishing the value of the patient relationship. and reactive. We practice wayfaring
genuine quality-driven orthodontist. orthodontics and manage patient
Hence the rise of the non-expert WHAT EXACTLY IS care through the rear-view mirror.
expert or the dentist-orthodontist. PATIENT-CENTRED CARE? This model of care provides fertile
The ambiguous definition of quality Patient-centred care is not just soil for the seeding and proliferation
care has facilitated the proliferation about giving patients whatever of error-associated events.
of market-driven orthodontics. they want or educating them about It is important to note that human
Practices measure their success on their needs. It is, first and foremost, error is a consequence, not a cause.
the basis of business metrics, such about the doctor establishing trust Human error is the product of a chain
as profit and production, rather than and credibility with the patient4 . of causes in which precipitating
patient care outcomes. It is about orthodontists and their psychological factors include
This is not all bad news. The care teams showing empathy and lapses in attention, forgetfulness,
recognition of these deficiencies humanity in embracing the patient misjudgement and preoccupation.
provides us with the springboard as a person, not a case; a patient Errors are generally described by
from which to explore opportunities named John who is afflicted with a what I call the 8 Ms: Miscommunicate,
to better our specialty and reinforce malocclusion, not a case labelled a Misunderstand, Misdiagnose, Misplan,
the covenant of trust between Class I malocclusion. Mismanage, Misdesign, Misprescribe,
specialist and patient. Patient-centred care means Misadminister.
So how do we cure our ills? First, orthodontists recognize they are Errors are commonly long tail in
we must redefine our metrics and guests in their patients lives 5 . In nature and are often the last and
build an engine that allows us to a patient-centred practice, the least manageable links in the chain.
practice quality care. This requires patient is aware of and understands As such, errors are recognized in
improvements in both the relational her bill of rights6 . Patient-centred the finishing stage in orthodontic
and functional components of our care teams value the patients treatment, a stage in treatment
care giving. Henry Ford described opinion, engage in active listening in which the clinician intends to
this notion best when he said: and shared decision-making with correct for errors, and the patient,
72 2014 SIDO

Sachdeva R. Novus Ordo Seclorum
accordingly, is admitted into the Unfortunately, failures in outcomes conditions. Reliability is measured
intensive care unit 8 . occur more often than not (one by dividing the number of actions to
The finishing stage is challenging for just needs to see transfer patients achieve the intended result by the
both the patient and the doctor. If to appreciate the extent of this total number of actions10 .
we were to enter the patients mind problem). Failures in outcomes are Orthodontic practices must adopt
during the finishing stage, we might commonly attributed to biological the principles of High Reliability
encounter a patient who suffers from and psychosocial factors, such as Organizations (HRO). An HRO is
anxiety and orthodontic exhaustion. poor patient growth or cooperation. designed to minimize danger by
The patient falsely believes the The patient bears the brunt of balancing effectiveness, efficiency
treatment is complete and now responsibility for a less than and safety. An HRO preserves a
must undergo additional treatment. desirable result, and the doctor culture of system-wide transparency
Candidly put, the patient is burnt remains unaccountable for his or her and error reporting. An HRO is both
out. From the clinicians perspective, probable misaction. If the doctor is proactive and generative in its
much treatment remains to be brave enough to report failure, this actions and also shares the cultural
done. The clinician, too, is anxious, is at the risk of his or her reputation framework of learning organizations.
wrestling with his or her professional and potential litigation. Roberts and Bea note: More
commitment to properly treat We have yet to mature into a blame- specifically HRO actively seek to
the patient, a patient who is now free culture and recognize that know what they dont know, design
half-heartedly committed to humans commit errors. Systems, systems to make available all
treatment. At this point in treatment, processes and technology must knowledge that relates to a problem
patient adherence to the doctors be appropriately used by a skilled to everyone in the organization,
recommendations decreases, the care team to prevent or arrest the learn in a quick and efficient manner,
timing of the patients appointments propagation of errors. aggressively avoid organizational
becomes erratic, and the doctors hubris, train organizational staff to
skills are put to the test. The finishing WHAT EXACTLY IS recognize and respond to system
stage is therefore disruptive to both PATIENT SAFETY? abnormalities, empower staff to act,
the patients expectations of care Patients almost entirely depend on and design redundant systems to
and lifestyle, the clinicians mindset the skills and professional judgement catch problems early11 .
and schedule, and the orthodontic of the orthodontist and his or her The success of an HRO is partly based
practices operations. team to receive the best care. The on its ability to stay mindful. An HRO
The very fact that we accept overarching goal of an orthodontic promotes five mindful practices to
finishing as a stage in patient care practice that subscribes to patient manage safety, including 12 :
suggests that we condone a system safety is to protect patients from Preoccupation with failure. Team
that allows for error propagation. harm. This requires building a members must incessantly seek
This practice must be prevented or, trustworthy system for the delivery ways to error-proof the system and
at the very least, contained. of orthodontic care. mitigate risk.
Another shortfall in our practice Patient safety is the prevention of Reluctance to simplify. Simple
model is that we lack both errors that result in unwanted and processes are strived for, but
intrapractice and system-wide adverse effects. It is also concerned oversimplified explanations for error
transparency. We neither report nor with minimizing the incidence of are avoided. Analyses of the root
disclose error; failure is merely paid and maximizing the recovery from causes of error are performed.
lip service, not action. If we do not spurious or adverse events. Errors Sensitivity to operations. Team
document error, we cannot analyze, must be continuously reported, members must be consistently mindful
learn, and subsequently improve on analyzed and communicated to all of noting and preventing risks.
our ways. Given our avoidance of team members in an ongoing effort to Commitment to resilience. Team
error reporting, the waters always error-proof the care delivery system. members are trained to
appear calm; nothing appears The practice of patient safety is 1. anticipate, or know what to
broken, so we convince ourselves grounded in the principles and expect;
that there is nothing to fix. Thus, our practice of safety/reliability science 9 . 2. pay attention, or know what to
modus operandi continues with little Reliability refers to failure-free look for, and
recognition of the undermining forces operation over time. Practically 3. respond, or know what to do.
that affect our quality of care. Such speaking, reliability is the ability of Deference to expertise. Each and
an error-prone environment comes at a process, procedure or service to every team member carries an equal
a substantial cost to both the patient perform its intended function in voice in calling out violations or
and doctor and also delays care. the required time under existing reporting errors or adverse events.
2014 SIDO 73

CLINICAL ARTICLE
The baseline of an HRO core in interpreting unsafe or error- provide little value to the reactive
processes operates correctly 99% of prone practices, the IHI developed care practitioner in the management
the time. In health care, the baseline a broader classification to evaluate of patient care. The intelligence
of core processes is defective 50% of the failure rate (Table 1). As one can manufactured into the appliance
the time, as 50% of patients receive see, the rate of two defects per 10 overrides the clinicians cognitive
the recommended care 13 . process opportunities represents tools of reason, judgement and
Health-care practices are less less than 80% success; this measure sense making. Evidentiary practices
reliable than industrial practices; as indicates a chaotic or unreliable are reserved for the ivory tower
a result, the Institute of Health Care process. Translating this measure into and find little use for the wet-finger,
Improvement (IHI) recommends the world of orthodontics suggests reactive care orthodontist.
that health-care organizations that the incorrect placement of just Unfortunately, unscientific, dogmatic
should focus on process reliability 2 brackets on 100 teeth (5 patients) care protocols primarily designed to
as a first step on the road to safe would be classified as an unreliable maximize the use of latest and best
care before focusing on the mindful process. We know our defect rate is, smart appliances are promoted by
practices of an HRO (I would tend unfortunately, much higher, begging industry-appointed thought leaders.
to agree that orthodontics take the need for reliable processes in It then follows that the influencers
the same approach). Baseline orthodontics. who create the loudest echo
performance reliability for non- The IHIs three-step reliability design chamber are responsible for defining
catastrophic processes in health model offers a path to consider the standard of care. As a result, the
care is currently said to be less in building safer care processes doctor becomes entangled in the
than 80%. What does this mean? (Table 2). With a sense of urgency web of a la mode or market-driven
The IHI has established a measure and commitment, the profession of orthodontics, being distanced even
termed failure rate (calculated orthodontics needs to embark upon further from science and value-
as -1 reliability, or unreliability) a journey to develop and implement based practice.
as an index, expressed as an order minimal error, ultra-safe practices. Recently, the orthodontic industry
of magnitude10 . Thus, 10 1 means has adopted the practice of recruiting
approximately one defect (error) CLINICAL EFFECTIVENESS patients, or care customers, to
per 10 process opportunities. If 10 THE PAST AND PRESENT promote products through the
brackets were bonded on a patient Reactive care orthodontics powerful channel of social media14, 15 .
and one of them was misplaced, encourages a do first, think later To appeal to a wider audience, much
the defect rate would be 10 1. 10 2 is mentality. Clinically, this translates of the messaging is emotional rather
approximately one defect per 100 to: lets slap on the braces and than evidence driven. This mode of
process opportunities10 . see what happens. This practice communication commonly results in
Recognizing that strict adherence encourages epistemic complacency. a misinformed patient who attempts
to this formula may pose difficulties Diagnosis, care design and planning to drive his care with little regard for
Definition Defect Rate
Chaotic, or lack of defined, reliability-focused processes More than two defects out of 10 (less than 80% success)
101 One or two failures out of 10 (80% or 90% success)
102 Five failures or less out of 100 opportunities (95% success)
103 Five failures or less out of 1000 opportunities
Table 1: Reliability labels 10
Step 1 Prevent failure: use standardization to achieve 101 (80%90% reliable or 101 performance expected)
Identify failures and mitigate failures if possible to achieve 101 (of the 10% or 20% failures from Step
Step 2
1, expect 80% or 90% identification and mitigation in Step 2)
Prioritize failure modes and redesign Steps 1 and/or 2 if articulated goal of 102 performance has not
Step 3
been achieved
Table 2: Three-step reliability design model 10
74 2014 SIDO

Sachdeva R. Novus Ordo Seclorum
professional advice. changes to unreliable practices. patients, Anticipate issues to prevent

The combination of the reactive care This can only be accomplished if problems, Attention to processes and
model and the strong influence of doctors and their care teams are procedures and Reflective thinking
industry and its appointed thought committed to measuring the quality to continuously improve.
leaders has channeled the practice of care. Continuous improvement Four important points must be
of orthodontics into a cafeteria or methodologies such as the Plan- noted. First, the quality of our
standardized, mass manufacturing Do-Study-Act cycle may be used outcomes is driven by the quality
product- and profit-driven approach. to effect improvement 17. Measures of how we practice. Second,
The orthodontic enterprise is from such initiatives are critically change without measurement is not
populated with misguided doctors evaluated to seek evidence of what change. Third, we must rid ourselves
and misinformed patients. is effective in order to improve a of our mindset of orthodontic
The practice of orthodontics needs patients care and experience. exceptionalism and restore humility
to reframe itself. Another cultural pill The doctor and the care team should within ourselves and our practices.
it needs to be prescribed is that of always be attentive and respectful Fourth, we must take the initiative to
clinical effectiveness. of the patients care preferences. measure our personal performance
Patient-reported outcome programs and practice performance on the
WHAT EXACTLY IS such as Patient-Reported Outcome basis of our deeds, patient feedback
CLINICAL EFFECTIVENESS? Measures (PROM) and Patient- and professionalism - profit or
Clinical effectiveness is defined Reported Experience Measures production should be secondary
as the application of the best (PREM) should be implemented to determinants of success.
knowledge, derived from research, directly seek the voice of the patient More specifically, we should
clinical experience and patient in care improvement initiatives18 . implement broader system-wide
preferences to achieve optimum Also, patient literacy programs to measures at multiple levels to
processes and outcomes of care better educate patients in evaluating understand and improve upon the
for patients. The process involves a the quality and source of health-care quality of care we offer patients.
framework of informing, changing information and judge doctor skills At the patient level, measures
and monitoring practice16 . should be considered. should include whether patient care
Clinical effectiveness is concerned expectations are met, the number of
with demonstrating continual Never underestimate disruptive episodes in the patients
improvements in quality and the power of a small group life (e.g. wait times, discomfort) and
performance. The properties of of committed people the patients understanding of his or
clinical effectiveness are 16: to change the world. her care needs and treatment. Such
Doing the right thing: Evidence- In fact, it is the only thing measures would provide a gauge
based practice requires that that ever has. for the effectiveness of the patients
decisions about patient care are care experience in the practice.
based on the best available, current, Margaret Wheatley At the doctor level, measures
valid and reliable evidence; should include the proximity of
in the right way: Developing a CONCLUSIONS the initial plan to the outcome and
care team that is skilled and Our profession is at a crossroads. the conformity of the treatment
competent to deliver the care We have a unique opportunity to approach to the prevailing evidence.
required better patient care by implementing Such measures would provide a
at the right time: Accessible creative solutions. basis for assessing the doctors
services provide treatment when Change can only be achieved if we knowledge and skills and also shed
the patient needs them act with a sense of purpose; purpose light on the effectiveness of the
in the right place: Location of defined by the values and the belief quality assurance program in the
care services system we adopt - our culture. practice. I also believe that the
resulting in the right outcome all We need to acculturate ourselves doctor should periodically make his
the time: Clinical effectiveness. to a patient-first care model. or her report card available to the
Clinical effectiveness is about This requires that we migrate to a public. The societal benefit of such
improving the total care experience platform that supports mindfulness, transparency outweighs the limited
of the patient. It requires thinking is proactive in its practices and is loss of professional autonomy.
critically about what the care performance based. At the process level, measures
team does, questioning whether The orthodontic practice of the should include error rates, acts of
the team is achieving the desired future will be designed around what commission and omission, resource
result and making necessary I term the EAAR model: Empathy for utilization and cost-effectiveness of
2014 SIDO 75

CLINICAL ARTICLE
care. Learnings from these measures is only by sharing and collectively conscience to the highest of levels.
would provide an understanding learning from our failures that our Let it also be a reminder to us to serve
of the effectiveness of the specialty can better patient care. our patients to the best of our abilities.
practices quality control program. Academia should implement A positive externality of quality
Furthermore, quality should be educational and effective training patient care is the sustainability of the
measured temporally. The trend line programs on patient safety and orthodontic profession.
would reveal the effectiveness of improvement science for the This manifesto forms the bedrock
continual improvement initiatives in residents and the practicing of BioDigital Orthodontics, a
the practice. Generative practices community. They should also take philosophy of care that I have
would tend to show a positive the responsibility to regularly developed. In my next article, I will
trajectory in their efforts to report on their institutional care discuss the principles and practice
continually improve. performance to both the public and of BioDigital Orthodontics with
At the system-wide level, the professional communities. specific reference to building
profession must implement a The industry must take an active and reliable care practices through error
total quality assessment program responsible role in working with the minimization.
and patient literacy program to professional community to educate
educate the patient on the metrics the public on quality care. Always do right,
of quality care. Furthermore, we Our calling as orthodontists is to this will gratify some
must establish a national registry to carry the slogan always do right and astonish the rest
report the errors or adverse events by the patient. Let this be the
we see during our patient care. It mantra that raises our professional Mark Twain
REFERENCE LIST
1. American Board of Orthodontics. 8. Sachdeva RCL. Integrating digital 14. Fogel J, Janani R. Intentions and
Grading system for dental casts and and robotic technologies: diagnosis, behaviors to obtain Invisalign. J Med
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15. Invisalign. Invisalign Teen Mom
http://www.americanboardortho.com/ and Techniques, 5th ed. L. Graber, R.
Advisory Board disclosure statement.
professionals/downloads/Grading%20 Vanarsdall, and K. Vig, Mosby, 2012.
Invisalign, 2014.
System%20Casts-Radiographs.pdf.
9. Emanuel L, Berwick D, Conway http://www.invisalign.com/pages/mabdisclosure
2. West Norfolk Commissioning Group. J, Combes J, Hatlie M, Leape L et
16. NHS Lanarkshire. Clinical
Quality and patient safety. National al. What exactly is patient safety?
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Health Service. 2014. in Advances in Patient Safety:
National Health Service Lanarkshire,
http://www.westnorfolkccg.nhs.uk/about-us/ New Directions and Alternative
June 2009
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Henriksen, J.B. Battles, M.A. Keyes,
3. Hartzband P, Groopman J. The new Archive/2009BoardPapers/Documents/
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language of medicine. N. Engl. J. Med. June%202009/Clinical%20Effectiveness%20
Research and Quality, 2008.
2011;365:13721373. Strategy%202009-2012%20-%20June%20
10. Resar RK. Making noncatastrophic 2009%20Board.pdf
4. Goold SD, Mack L Jr. The doctor
health care processes reliable:
patient relationship: challenges, 17. Sollecito W, Johnson J. McLaughlin
learning to walk before running in
opportunities, and strategies. J. Gen. and Kaluznys Continuous Quality
creating high-reliability organizations.
Intern. Med. 1999;14(Suppl. 1):S26S33. Improvement in Health Care, 4th
Health Serv. Res. 2006;41:16771689.
ed. Burlington MA: Jones & Bartlett
5. Berwick DM. What patient-
11. Roberts KH, Bea R.G. Must accidents Learning, 2011.
centered should mean: confessions
happen? Lessons from high-reliability
of an extremist. Health Affairs 18. NHS. Patient reported outcome
organizations. Acad. Manag. Exec.
2009;28:w555w565. measures. National Health Service.
2001;15:7079.
2014.
6. American Academy of Pediatric
12. Weick K, Sutcliffe K. Managing the http://www.nhs.uk/NHSEngland/thenhs/
Dentistry. Policy on a patients bill of
Unexpected: Resilient Performance in an records/proms/Pages/aboutproms.aspx
rights and responsibilities. AAPD, 2009.
Age of Uncertainty. Jossey-Bass, 2007.
http://www.aapd.org/media/Policies_
Guidelines/P_PatientBillofRights.pdf. 13. McGlynn EA, Asch SM, Adams J,
Kelsey J, Hicks J, De Cristofaro A, et al.
7. Tonelli MR. Advancing a casuistic
The Quality of Health Care Delivered
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Clin. Pract. 2007;13:504507.
76 2014 SIDO

Treatment of a Class II Extremely Deep
Bite by the Tip-Edge Technique and
Mandibular Distraction Osteogenesis
Yumeng Deng
Abstract
Private orthodontic practice, Hong Kong
SAR, China
This case report describes the integrated orthodontic surgical

Urban Hgg* management of a 20-year-old Chinese male with a decreased

The University of Hong Kong, Hong lower facial height and skeletal class II, Angle class II division 2
Kong SAR, China malocclusion with an extremely severe deep bite (23 mm and
200%).
The upper anterior teeth occluded on the lower vestibule and
the lower anterior teeth occluded on the palatal mucosa. Both
Lim K. Cheung upper and lower anterior teeth were very retroclined and supra-
erupted, causing a severe reverse curve of Spee in the upper
The University of Hong Kong, Hong
Kong SAR, China
arch and an exaggerated curve of Spee in the lower arch.
The treatment comprised of:
1. pre-surgical orthodontics using the Tip-Edge light force
system with double-wires to level the occlusal planes,
*Correspondence:
alignment and rounding of the dental arches;
2. mandibular distraction osteogenesis to lengthen and
Article history advance the mandible;
Received: 22/05/2014 3. removal of the mandibular distractors;
Accepted: 09/07/2014
4. post-surgical orthodontics; and
5. retention.
In conclusion, the treatment adopted for the management of
The authors declare that they have no conflicts
this extremely deep bite was very successful and the good
of interest related to this research.
result remained stable in the long term.
Deng Y, Hgg U, Cheung LK. Treatment of
a Class II Extremely Deep Bite by the Tip-
Edge Technique and Mandibular Distraction
Osteogenesis. EJCO 2014;2:77-89
.....orthodontic treatment combined

with mandibular distraction
osteogenesis to treat an extremely severe
deep bite and obtain a good result stable Keywords

in the long term...... Deep bite, light wire mechanics, distraction osteogenesis
2014 SIDO 77

CLINICAL ARTICLE
INTRODUCTION treat Class II division 2 malocclusion uncertain. Camouflage treatment

in adolescent and adult patients, with extraction of the maxillary
T
he prevalence of severe deep such as the use of a fixed appliance first premolars and use of a fixed
bite more than two-thirds with/without extraction of the appliance is usually lengthy, and
of mandibular central crown first maxillary premolars with/ may compromise facial appearance
length was reported to be 4% in without temporary anchorage with the nose becoming magnified
Chinese adults1. Many of these patients devices (TADs), a fixed functional due to retraction of the upper lip.
have a Class II division 2 incisor appliance, and orthognathic surgery. Moreover, anchorage position is
relationship, which was reported to be Common surgical procedures are a critical due to retraction and palatal
3.5% in Chinese adult males2 and 3.4% combination of advancement of the root torque, the upper anterior
in an Asian cohort of adolescents3. mandible with bilateral sagittal split teeth usually becoming retroclined.
The correction of severe deep bite in osteotomies (BSSO) of the mandible A better appearance is typically
Class II division 2 malocclusion is a with/without maxillary osteotomy419 . achieved with the non-extraction
challenge for orthodontists and the According to the literature on Class approach aiming at normalizing the
stability of treatment results uncertain. II division 2 malocclusion, optimal angulation of the incisors to allow
In the literature, various treatment aesthetic results are difficult to forward positioning of the mandible
strategies have been proposed to achieve and long-term stability is with Class II mechanics with/without
Figures 1 - 3: Pre-treatment (T0) extra-oral photographs.
Figures 4 - 9:
Pre-treatment (T0)
intra-oral photographs.
78 2014 SIDO

Deng Y. Treatment of a Class II Extremely Deep Bite
Figures 10 - 15: Pre-treatment (T0) study models.
fixed functional appliances or Bock et al.14 reported that the profile The aim of this case report is to
orthognathic surgery17, 20. Treatment became straighter after treatment present the treatment plan and result
results have been reported to be less with a Herbst-multibracket appliance in a 20-year-old Chinese male with
than ideal particularly in severe Class in adults but that treatment outcome Angle Class II division 2 malocclusion
II division 2 malocclusion because of was less stable in adults compared with an extremely deep bite (23 mm
limited mandibular advancement by to adolescents12. In adults with and 200% of mandibular central
conventional orthognathic surgery. In Class II division 1 malocclusion, it crown length) with the use of Tip-
patients who underwent first maxillary was reported that minimal skeletal Edge orthodontics and distraction
premolars extraction and fixed changes occurred following the Class osteogenesis to achieve a satisfactory
appliance treatment in combination II correction and the occlusion was aesthetic result and occlusion.
with TADs, the nasio-labial angle was maintained at 3 year follow-up22.
reported to become more obtuse18. BSSO is a widely used surgical EVALUATION OF A PATIENT WITH
Yousefian et al.10 described a 15-year- procedure to lengthen the mandible AN EXTREMELY DEEP BITE
old male who underwent treatment in order to improve the sagittal A 20-year-old Chinese male
with extraction of the first maxillary mandibular position and its occlusal was referred to the Orthodontic
premolars, which resulted in a relationship with the maxillary teeth. Department of the Prince Philip Dental
worsening profile. Later, the spaces for The average forward positioning Hospital with the chief complaint of
the missing premolars in this patient exceeds 56 mm, and the average ugly front teeth (Figs. 117). The upper
were opened up and implant supported relapse was reported to be about one front teeth were found to be biting
restorations and BSSO were carried third after 12 years6, 23, 24 . on the mandibular labial gingiva and
out to advance the mandible, making In a systematic review, distraction the mandibular teeth were biting on
it more prognathic and achieving a osteogenesis was reported to the palatal mucosa. The overclosure
better profile. The addition of TAD have a more stable result than of the occlusion had caused pain in
support to the extraction strategy, BSSO. However, the difference in the temporomandibular joint, which
so-called camouflage treatment, skeletal relapse between BSSO subsided following conservative
improved the occlusion but put the and distraction osteogenesis in the treatment. The patients medical
patients profile at risk. Use of a fixed preliminary result of a randomised history was unremarkable.
functional appliance did not correct controlled trial was reported to not Extra-oral evaluation (Figs. 13)
the skeletal Class II discrepancy18. be statistically significant25 . revealed that the patient had a
2014 SIDO 79

CLINICAL ARTICLE
Variable T0 T1 T2 T3 T4 T1T0 T2T1 T3T2 T3T0 T4T3 T4T0
SNA () 82.8 83.6

82.8 83.3 83.4 0.8 0.8 0.5 0.5 0.1 0.6
SNB () 79.4 80.4 83.7 83.7 84.7 1.0 3.3 0.0 4.3 1.0 5.3
ANB () 3.4 3.2 0.9 0.4 1.3 0.1 4.1 0.5 3.8 0.9 4.7
Wits (mm) 0.5 2.0 4.0 4.5 4.0 1.5 6.0 0.5 5.0 0.5 4.5
U1/MxPl () 94.9 124.0 127.8 125.5 125.9 29.1 3.8 2.3 30.6 0.4 31.0
L1/ MnPl () 73.2 105.4 106.9 105.4 106.0 32.2 1.5 1.5 32.2 0.6 32.8
Interincisal angle () 170.8 125.0 119.4 122.2 122.3 45.8 5.6 2.8 48.6 0.1 48.5
MxPl/MnPl () 2.8 5.6 5.9 6.8 5.8 2.8 0.3 0.9 4.0 1.0 3.0
Upper face height (mm) 62.2 60.7 61.8 62.0 61.5 1.5 0.2 0.2 0.2 0.5 0.7
Lower face height (mm) 62.6 69.6 71.4 72.4 71.3 7.0 1.8 1.0 9.8 1.1 8.7
Face height ratio (%) 50.2 53.4 53.6 53.9 53.7 3.2 0.2 0.3 3.7 0.2 3.5
L1 to APo line (mm) 14.5 2.1 2.2 1.8 1.8 12.4 4.3 0.4 16.2 0.0 16.3
LL to E line (mm) 1.0 1.6 2.1 2.5 2.7 2.6 0.5 0.4 3.5 0.2 3.7
Table 1: Dentofacial morphology and changes

Dentofacial morphology before treatment (T0), at the start (T1) and end (T2) of distraction osteogenesis, at completion of treatment (T3) and
at 1 year follow-up (T4) is indicated. Changes during pre-DO (Distraction Osteognenesis) orthodontics (T1T0), DO (T2T1), post-DO
orthodontics (T3T2), treatment period (T3T0), 1 year follow-up (T4T3) and the whole observation period (T4T0) are indicated.
MnPl, mandibular plane; MxPl, maxillary plane.
square-shaped, symmetric face, with Class II division 2 malocclusion. There The panoramic radiograph (Fig. 16)
a mild convex profile with an acute was a full unit Class II molar and canine showed that all permanent teeth
nasolabial angle and deep labiomental relationship on the right, and three- were present with the third molars
fold. His lower facial height was quarter unit Class II molar and canine impacted, and a supernumerary upper
reduced with a prominent gonial relationship on the left. Overbite was right molar was noted.
angle and a shortened chin. His lips extremely deep at 23 mm and 200%, Cephalometric analysis before
were competent at rest. The upper lip with upper anterior teeth occluded on treatment (T0) (Fig. 17 and Tab. 1)
was slightly protrusive and the lower the lower vestibule and lower anterior showed a markedly reduced lower
lip was everted. Maxillary gingival teeth occluded on the palatal mucosa. facial height, an extremely parallel
display was 3 mm when smiling Both upper and lower arches were maxillary to mandibular plane (MxPl/
(Fig. 2). There was no tenderness of omega shaped with a constricted arch MnPl) angle of 2.8 which was about
the temporomandibular joints and in the premolar regions. Both upper 4.5 SD below the normal mean value
involved muscles, but clenching and lower anterior teeth were severely of 26 (SD 5.1) (for details see Wu
of bilateral masseter muscles was retroclined and over-erupted, causing et al.26. The SNB value (79.4), which
noticed and the movement was within a very marked increase in the reverse indicated a normal sagittal position
normal range. curve of Spee of the upper arch, and of the mandible, was very misleading,
Intra-oral examination (Figs. 49) an exaggerated curve of Spee of as was the ANB value (3.4). This is
revealed that the maxillary midline was the lower arch (Fig. 13). The overjet likely related to the severe overclosure
coincident with the facial midline, and between the retroinclined incisors of the mandibular occlusion making
the mandibular midline was displaced was only 2 mm. Diastema was present the mandible autorotate upwards
2 mm to the right of the facial midline. between the maxillary central incisors. assuming a more forward position.
Mild gingival recession and attrition Space analysis showed a 2 mm space Both upper and lower incisors were
of lower central incisors were seen in deficiency in the maxillary arch and 7 extremely retroclined. The position of
the lower anterior region. Generalized mm in the lower arch. Upper second the mandibular incisors to the APo line
mild gingivitis and inadequate oral premolars were palatally displaced was 14.5 mm (SD 8.3 mm) compared
hygiene were noted. and rotated. The upper left second with the normal value for Chinese
The study model analysis (Figs. 1015) premolar was in crossbite with the individuals (mean 5.4 mm, SD 2.4
showed that the patient had severe lower left second premolar. mm). The maxillary incisors inclined
80 2014 SIDO

94.9 to the maxillary plane, tipped

palatally approximately 22 (SD 3.7)
lower compared to the normal value
(mean 117, SD 5.9).
To summarize, this adult male patient
presented with severe Class II division
2 malocclusion, extremely deep bite,
on a skeletal Class II base and low
mandibular plane angle. He had a
square-shaped face, decreased lower
facial height, a deep labiomental
fold, and excessive gingival display
on smiling. Both upper and lower Figure 16: Pre-treatment (T0) radiograph
anterior teeth were severely over-
erupted and retroclined, causing an
increased reverse curve of Spee in the Class II pattern and increasing the
upper arch and an exaggerated curve lower-third facial height. Dentally, the
of Spee in the lower arch. The upper objectives were to procline the upper
anterior teeth occluded on the lower and lower incisors, align the arch and
labial vestibule and the lower anterior level the occlusal plane, decrease
teeth occluded on the palatal mucosa, the overbite, eliminate crowding and
causing mild labial gingival recession midline diastema, correct the dental
on the lower incisors. There was also midline, and achieve molar and canine
a 7 mm space deficiency in the lower Class I occlusion. The skeletal and
arch. dental treatment objectives also aimed
to improve the soft tissue profile, and Figure 17: Pre-treatment (T0) lateral
TREATMENT OBJECTIVES reduce the excessive gingival display cephalogram.
The treatment objectives were to upon smiling and the accentuated
increase the lower facial height labiomental fold.
while maintaining the position of the alone would not be able to achieve a
mandible in a correct sagittal plane TREATMENT PLAN good and stable result for this patient.
position, and normalize the smile Due to the extremely severe deep However, orthognathic surgery in
and soft tissue profile. Therefore, the bite, the extent of the retroclination combination with orthodontics was an
primary skeletal objectives were to of both upper and lower incisors, the option. Since large movement of the
improve the sagittal and vertical basal Class II skeletal pattern, and the age of mandible was required in this case,
relationship by correcting the skeletal the patient, orthodontic camouflage it was felt that mandible distraction
Figures 18 - 23:
Intra-oral photographs
after (T1) pre-surgical
orthodontics.
2014 SIDO 81

CLINICAL ARTICLE
Figures 24 - 25: Radiographs before (T1) and after (T2) distraction osteogenesis of the mandible.
was preferable to BSSO. This patient removal of distractors, post-surgical performed when the distraction
would benefit both functionally orthodontics and retention. regenerate of the mandible
and aesthetically from appropriate matured to mineralized bone as
pre-surgical orthodontic treatment 1. Preparation consisted of jaw confirmed by orthopantomograph.
revealing the full extent of the skeletal exercise, restorative dentistry, 5. Post-surgical orthodontics
discrepancy allowing correction by oral hygiene therapy, and surgical completed minor postoperative
mandibular distraction. removal of all third molars and the adjustment by correcting axial
With an extremely deep bite, the supernumerary upper right molar. inclinations, alignment, closing
challenge to the orthodontist was 2. Pre-surgical orthodontics used the interdental spaces, and closing
how to level such exaggerated Tip-Edge light force technique2729 posterior inter-occlusal spaces.
curves of Spee (Fig. 13) and how to to reveal the true extent of the
normalize the angulation of the skeletal discrepancy, and hence PRE-SURGICAL ORTHODONTICS
severely retroclined incisors. The Tip- allow full surgical correction of the (T0T1)
Edge light wire technique was chosen anomaly. The treatment objectives All permanent teeth were included in
for this patient with severe deep bite were to round off and harmonize the orthodontic appliance, with the
as the special design of the Tip-Edge the dental arches, and reduce the band cemented initially on all first
bracket would facilitate intrusion and curve of Spee in both arches. The permanent molars, and later also on
proclination of the anterior teeth in treatment plan was to align the the second permanent molars, and
combination with extrusion of the teeth, procline and intrude the 0.022 inch slot Tip-Edge* brackets
posterior teeth, resulting in flattening anterior teeth, and extrude the were placed on the remaining teeth
of the occlusal planes and subsequent posterior teeth. (Figs. 1823). Initial alignment and
bite opening2729. 3. Surgical procedures included levelling was accomplished with 0.014
bilateral mandibular distraction inch nickel-titanium archwires. Glass
TREATMENT to lengthen the mandible and ionomer cement was placed on the
The treatment comprised preparation, increase its prognathism and occlusal surface of the upper molars
pre-surgical orthodontics, mandibular improve the lower facial height. to raise the bite. After 5 months, a
distraction osteogenesis and 4. Removal of distractors was 0.016 inch A.J. Wilcock Australian
archwire with a sweep curve was used
for the upper arch, while a nickel-
titanium archwire was applied to the
lower arch to align the posterior teeth
and procline the incisors. To further
enhance flattening of the curve of
Spee on both arches, a 0.016 inch
Australian archwire with anchor bands
was placed on the first permanent
molars with auxiliary gingival tubes 2
months later, combined with 0.014 inch
and 0.016 inch thermo nickel-titanium
archwires inserted in the main tubes
Figures 26 - 27: Lateral cephalograms before (T1) and after (T2) distraction osteogenesis of the
mandible. *TP Orthodontics, La Porte, Indiana, USA
82 2014 SIDO

Figures 28 30: Post-treatment (T3) extra-oral photographs.
of the molar bands in the maxillary SURGICAL TREATMENT (T1T2) alveolar canal, the osteotomy cuts
and mandibular arches, respectively. Surgical treatment (T1T2) was penetrated the lingual cortex above
After 24 months of treatment, a 0.018 conducted in the 32nd month of and inferior to the inferior alveolar
inch Australian archwire and bilateral treatment and bilateral mandibular canal in an oblique backward position.
E-links were used to close the residual distraction osteogenesis was The residual middle lingual cortical
space of the upper arch. In the lower conducted under general anaesthesia. connection was fractured by placing
arch, a 0.02150.028 inch rectangular Osteotomy cuts were performed an 8 mm thick osteotome above
stainless steel archwire was placed to with a 0.18 mm Lindemann bur at and below to achieve mobilization
achieve the anterior lingual root torque. the mandibular body behind the last of the mandible and confirmation of
The pre-surgical orthodontics (T0T1) molar on each side. Buccal cortical the integrity of the inferior alveolar
was completed after 31 months of bone was cut from the alveolus to bundle in this case. Upon completion
orthodontic treatment. Stainless steel the lower border of the mandibular of mobilization of the mandible on
ligature ties were placed on all teeth body until cancellous bleeding was both sides, the occlusion was placed
and the patient was ready for surgery seen through the cut. Confirming the in a pre-fabricated surgical wafer
(Figs. 1824, 26). vertical relationship of the inferior with the vector for the distractor
Figures 31 - 36:
Post-treatment (T3)
2014 SIDO 83

CLINICAL ARTICLE
curve of Spee, which the treatment

was designed to close post-surgically
in order to restore the lower anterior
facial height. Panoramic and
lateral cephalographs were done
at 1 week, 6 weeks and 3 months.
Upon radiographic confirmation of
ossification in the distraction gaps
at 34 months, the distractors were
removed under general anaesthesia.
POST-SURGICAL ORTHODONTICS
(T2T3)
Figure 37: Post-treatment (T3) radiograph. Post-surgical orthodontics (T2T3)
started 35 months into treatment
indicated by an embedded wire. was parallel with the vector guidance and lasted for 10 months, i.e. the
Temporary intermaxillary fixation splint before the placement of the total treatment time was 45 months.
with stainless steel wires was used to second screw on the second plate. The final positioning of the teeth was
stabilise the occlusion. The concept Once the vector was determined,
and fabrication of this vector the remaining screw holes were
guidance splint was described by drilled and screws placed with final
Cheung et al. 30 tightening. Intermaxillary fixation
A pair of mandibular internal was released and the distractors
distractors of clover leaf design with were turned with an activator rod
a body length of 30 mm (KLS Martin, to confirm smooth opening of the
Mhlheim, Germany) were selected distraction gap without resistant. The
pre-operatively for this case. The wound was then closed primarily with
mesh plates were adapted over the 3/0 Vicryl sutures.
mandibular body with the foot plates Activation of the distractor by 1 mm
in front and behind the osteotomy cut. per day started 6 days after surgery,
Mono-cortical fixation was by three and after 18 days activation, the
28 mm titanium screws on each side. overjet was reduced to 2 mm (Figs.
The vector director of the distractor 25 and 27 ). A posterior open bite was
body rod was checked to ensure it noted due to the lower exaggerated Figure 38: Post-treatment (T3) lateral
cephalogram.
Figures 39 - 41: Follow-up (T4) extra-oral photographs.
84 2014 SIDO

accomplished with 0.02150.028 and overbite was decreased from 23 case (Fig. 51) seems to be no less than
inch stainless steel archwires and side mm to 9 mm before surgery (Figs. that reported using mini-screws15.
winders to make the teeth upright, 427). The teeth were aligned, levelled During the pre-surgical phase, the
and Class II elastics. and decompensated, i.e. the upper and sagittal jawbase relationship became
lower anterior teeth were markedly 2 mm more Class II according to Wits
RETENTION DEVICES changed (proclined from 94.9 and appraisal (Table 1), probably because
Retention devices were made using 73.2 to 125.9 and 106.0 , respectively, of posterior rotation of the mandible
a fixed permanent lingual retainer with the lower incisors protruding a caused by extrusion of the upper
bonded to the lower anterior teeth total of 12.4 mm (Table 1). The lower molars, which also supports findings
and removable retainers on both face height was also increased by 7.0 that the mandible was not posteriorly
upper and lower arches (Figs. 2838 ). mm due to the advancement of the displaced in Class II division 2
The use of the removable retainers mandible with a deep curve of Spee, malocclusion9, 31.
was gradually reduced. hence improving the anterior facial
proportion ratio from 49.8/50.2% DISTRACTION OSTEOGENESIS
ONE-YEAR FOLLOW-UP (T3T4) to 46.6/53.4%, which is close to the PHASE (T1T2)
At 1 year follow-up (T3T4) after 1 year normal value. The increase in the After completion of the activation
in retention (Figs. 3949), the patient lower face height was mainly due to of the distractors (T2) , the sagittal
was advised to use both retainers one extrusion of the posterior teeth in the forward movement of the mandible
night per week indefinitely. upper arch, initially presented with a was quite favourable, the overjet was
severe reverse curve of Spee, which reduced from 13 mm to 2 mm, and
TREATMENT AND POST-TREATMENT in combination with the intrusion and the distance between the markers
CHANGES (TABLE 1) proclination of the upper anterior (assessed from the cephalometric
This adult with Angle Class II division teeth resulted in flattening of the radiographs; Figs. 26 and 27) had
2 malocclusion presenting with an upper occlusal plane. In the lower arch, increased by 11 mm. The distraction
extremely deep bite, a deep lower the flattening of the occlusal plane process went smoothly with the
curve of Spee, and a flat mandibular was mainly due to a combination of patient being very cooperative in
plane angle was successfully treated proclining of the lower anterior teeth turning the activation rods twice a
by a combination of orthodontics with and extrusion of the posterior teeth day at home. No overcorrection was
Tip-Edge brackets and mandibular (Fig. 50). Tip-Edge appears to have a performed as the occlusion reached
distraction osteogenesis. superior effect on reducing a severe stable contact with the anterior teeth
curve of Spee when compared with with good cooperation from the
INITIAL PRE-SURGICAL the conventional continuous archwire orthodontist, and the posterior open
ORTHODONTIC PHASE (T0T1) technique, which was reported to be bite was closed by extrusion of the
During the initial pre-surgical effective to treat a curve of Spee of 24 intruded teeth, particularly from the
orthodontic phase (T0T1), the overjet mm only (11). Moreover, the intrusion reverse curve of Spee of the upper
was increased from 2 mm to 13 mm of the maxillary anterior teeth in this arch. Bone ossification occurred at
Figures 42 - 47:
Follow-up (T4)
2014 SIDO 85

CLINICAL ARTICLE
orthodontics before mandibular

distraction osteogenesis (T0T1), both
occlusal planes were flattened and the
anterior teeth decompensated, with
the upper incisors markedly proclined
and intruded (Fig. 51), and the lower
incisors similarly proclined but not
intruded (Fig. 52 and Table 1).
Figure 48: Follow-up (T4) radiograph.
about 3 months after distraction and the active treatment. The treatment
hence the distractors were removed. time of 45 months seemed long, but
However, after distraction, a posterior was within the expected duration
open bite was presented which was for orthognathic patients treated
regarded as too difficult to correct in the UK (mean 33 months, SD 11.3
with post-surgical orthodontic months)32 but markedly longer than
treatment alone. Subsequently, the that reported from Norway33.
mandible was partially positioned with
an additional osteotomy to reduce FOLLOW-UP (T3T4) Figure 50: Superimposition before (T0)
the posterior open bite when the During follow-up (T3T4), the lower and after treatment (T3) registered on the
distractors were removed. facial height was seen to have markedly anterior cranial base.
increased, and the lower lip was no
POST-SURGICAL ORTHODONTICS longer everted (Figs. 13, 17, 2830, 38,
(T2T3) 50). The excessive gingival display
During the post-surgical orthodontics on smiling was eliminated because
(T2T3), the residual posterior space of the intrusion of the maxillary
was closed and occlusion settled incisors (Figs. 2, 30, 51). No gingival
well (Figs. 3133, 36). After 45 months recession was noted. No symptoms
(T3), although some anterior teeth of temporomandibular disorders were
could have benefited from further recorded. Dentally, the overjet and
treatment, the patient was very happy overbite were normal, the midline
with the result and urged us to finish was on, and a good intercuspation
of occlusion had been achieved (Figs.
3133, 36). Figure 51: Maxillary superimposition before
Panoramic radiographs obtained at (T0) and after treatment (T3) registered on
post-treatment and at 1 year follow- the anterior palatal contour.
up showed good bone support of
all the teeth, normal angulation of
the roots without evidence of root
resorption, and no signs or symptoms
of temporomandibular joint pathology
(Figs. 37 and 47).
The cephalometric radiographs (Figs.
17, 27, 38, 4952 and Table 1) showed
that, after treatment, the mandibular
prognathism and lower face height Figure 52: Mandibular superimposition before
Figure 49: Follow-up lateral (T4) had increased and markedly (T0) and after treatment (T3) registered on
cephalogram. improved. During the pre-surgical Bjrks stable mandibular structures.
86 2014 SIDO

POST-TREATMENT CHANGES AND provide the consistent low forces difficult case was the application of
OVERALL CHANGES required for dental intrusion. It does, mandibular distraction osteogenesis.
One year after completion of however, often require a prolonged This patient presented with a 13 mm
treatment (T3T4), the patient stage III to finish the case to a high overjet after pre-surgical orthodontics
retained an excellent facial balance standard. The originality of the Tip- (Figs. 23 and 26), and mandibular
and stable Class I molar, canine and Edge technique2729 lies in its ability to advancement of about 11 mm was
incisor relationships (Figs. 3949). combine the advantages the Begg and required to achieve a final overjet of 2
Edgewise techniques. With different mm. However, the distractors required
FINAL COMMENTS anchorages, bite opening is more to be activated by 1 mm a day for 13
Although deep overbite malocclusion rapid and correction of all occlusal days (from day 6 to day 18), which was
is not commonly seen, it needs abnormalities is easy during stage I. slightly (2 mm) more than required.
a throughout investigation and During stage III, the original design This was not an overcorrection
treatment plan in accordance with of the Tip-Edge bracket permits a but was necessary in light of the
the dental and skeletal diagnoses progressive torque, the uprighting of slight backward movement of the
contributing to the excessive roots and an Edgewise finish. mandibular ramus from the distractors
overbite20, 21. Clinically, incisor deep In this case, both upper and lower which pushed the mandible forward
overbite has always been considered incisors were proclined about 30 by but also pushed it slightly backwards.
as an anomaly difficult to correct using the Tip-Edge technique. Despite The extent of backward movement
orthodontically21. Nanda20 classified this large amount of proclination, no was minimized mostly by maintaining
the correction of deep overbite by four root resorption, gingival recession pterygomandibular sling stability
types of tooth movement: extrusion or other periodontal damage was with the osteotomy cut in front of the
of posterior teeth, flaring of anterior found in this patient (Figs. 3138), masseter muscles and the use of heavy
teeth in the case of lingual tipping of which was in agreement with the Class II orthodontic elastic during the
the incisors, intrusion of incisors, and findings of Melsen and Allaia36 who activation period by suspending the
by surgical methods. The severe deep studied important factors influencing occlusion in a forward position. This
bite with extremely retroclined incisors the development of dehiscence post-surgical elastic suspension has
presented in this case required all four during labial orthodontic movement the added advantage of minimizing
types of tooth movement as proposed of mandibular incisors. They noted the compression of the mandibular
by Nanda20, mainly flaring of the that the amount of proclination was condyle pushing against the condylar
palatally or lingually tipped incisors not correlated with changes in the fossa during the activation period.
of the upper and lower jaws, intrusion periodontium. They concluded that, This would theoretically reduce the
of the upper incisors and extrusion if orthodontic treatment is carried chance of condylar resorption, which
of the posterior teeth of both jaws, out under controlled biomechanical was supported in this case with no
particularly the upper in correction and sound periodontal conditions, condylar changes being noted.
of the reverse curve of Spee and the the risk of periodontal damage The most common surgical method
lower in correction of the exaggerated secondary to proclination of the to advance the lower jaw is by sagittal
curve of Spee for restoration of incisors is small. Moreover, there was split osteotomy. Advancing the lower
anterior facial height. In order to avoid a risk of pronounced root resorption jaw by 11 mm is possible with this
root resorption and gingival recession, when the alveolar osseous housing technique. However, maxillofacial
it is extremely important to use a very was narrow relative to the extent of surgeons are fully aware of the
light force to align the incisors and tooth movement required37, 38. No literature stating that mandibular
level the reverse or exaggerated curve root resorption was noted throughout advancement with BSSO exceeding 6
of Spee of the upper and lower jaws, treatment in this male patient despite mm will induce marked postoperative
respectively. large dental treatment changes (Fig. skeletal relapse (24, 39) and risk of
From the technique point of view, a 37), which might be due to the good condylar resorption. (40, 41) Hence
straight wire appliance gives excellent width of the anterior mandibular overcorrection of the mandible is
control and finishing potential34, but dentoalveolar bone and the light required. In this case, the mandible
there can be difficulties during the forces applied with the Tip-Edge had to be advanced by 1314 mm
overbite reduction phase because of technique. with the incisors touching edge-to-
the continuous arch mechanics. The In additional to the appropriate pre- edge to allow for the anticipated
Begg appliance35 is well known for surgical orthodontic preparation, occlusal relapse to take place. Relapse
its superb ability to reduce overbite the key procedure contributing to can be immediate in many cases
and overjet because it is able to the successful treatment of this very because mandibular advancement
2014 SIDO 87

CLINICAL ARTICLE
also causes the soft tissue to be pulled from its malpositioned segment, or distraction osteogenesis was not
forward, and hence the condyles with there is large mandibular movement. significantly better than that of
their ligaments commonly cannot The extent of mandibular movement sagittal split osteotomy when the
be seated back in their posteriorly in this case required consideration of mandible was advanced 610 mm.
condylar position even with a lot of whether an alternative treatment with This insignificant finding was likely
pressure applied to force them into less relapse and less neurosensory due to the small sample size and the
the retruded contact position during numbness was available; distraction study is still on-going.
fixation. Further relapse will occur osteogenesis was considered the In the current case, the orthodontic
with condylar remodelling as this most suitable technique. treatment combined with mandibular
instant mandibular advancement The above considerations are well distraction osteogenesis achieved
causes a significant increase in covered in the literature when large the desired results as assessed
condylar compression on the glenoid mandibular advancement is required. clinically and radiographically. The
fossa. Patients with pre-existing Distraction osteogenesis has several skeletal problem was resolved and
small condyles are particularly prone advantages: less postoperative a good facial profile was achieved
to condylar resorption, which we skeletal relapse due to the relatively by increasing the mandibular length
consider an exaggerated response of slow expansion of the soft tissue and the facial height to correct
condylar remodelling to mechanical complex, a lower incidence of the severe dentofacial skeletal
compression. Furthermore, one of the progressive condylar resorption, deformity. The patient showed an
most common morbidities of sagittal and less inferior alveolar nerve excellent post-treatment outcome
split osteotomy is numbness of the damage4245. In particular, it was of Class I occlusion and good dental
inferior alveolar nerve, which can occur reported that mandibular distraction interdigitation. The patient also has no
in 2050% of cases. Although the osteogenesis was effective in patients inferior nerve numbness in the mental
severity and extent of numbness will particularly with an average to low region on either side. No periodontal
reduce with time, some patients will mandibular angle in a skeletal Class damage and no signs or symptoms
experience permanent paraesthesia, II malocclusion4647 as this case. of temporomandibular disorder or
particularly in cases where the nerve However, the preliminary results from resorption were noted at the end
was exposed when the mandible was a clinical trial by our centre25 showed of treatment. No dental or skeletal
cut, the nerve requires dissection that the outcome of mandibular relapse was noted at 1 year follow-up.
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2014 SIDO 89

CLINICAL ARTICLE
New-Generation Light-Emitting
Diode Versus Halogen Light-Curing of
Orthodontic Brackets: A 24-Month Case-
Control Study of Bond Failures
Armando Salazar*
Abstract
Private Practice of Orthodontics, Miami,
FL, USA
OBJECTIVES To compare survival of brackets polymerized

with a new-generation light-emitting diode (LED)-based or a
Andrew L. Sonis halogen-based lamp unit.

Childrens Hospital Boston, MA, USA
Harvard School of Dental Medicine, MATERIAL AND METHODS This case-control study involved 60
Boston, MA, USA
patients who received comprehensive orthodontic treatment.
Patient records were assigned to the case (LED) or control
(halogen) group for analysis. Second premolar to second
Henry Ohiomoba premolar brackets were bonded in both arches for a total of
1200 brackets examined. The exposure variable was the type of
Harvard School of Dental Medicine,
Boston, MA, USA
curing unit: FlashMax 2 LED (3 sec) versus Optilux 501 halogen
(30 sec). The outcome variable was the mean survival time of
brackets. Multivariate statistical analysis was performed, setting
p<0.05 as significant.
Correspondence:
RESULTS Both methods performed similarly, irrespective of
Article history arch or anteriorposterior bracket location. No differences
Received: 22/11/2013 were found in the overall bracket failure rate (p1), survival
Accepted: 26/02/2014
time (p=0.83) or failure risk (p=0.79). Posterior teeth (p=0.001)
failed more frequently; neither the LED nor halogen method
decreased this tendency (p 1).
The authors declare that they have no conflicts
CONCLUSION The bracket survivals produced by LED and
of interest related to this research.
halogen were similar. More brackets failed in posterior than
How to cite this article: anterior teeth irrespective of polymerization method. The LED
Salazar A, Sonis AL, Ohiomoba H. New- unit provided 9 min of time saving per patient when compared
Generation Light-Emitting Diode Versus to the halogen unit.
Halogen Light-Curing of Orthodontic Brackets:
A 24-Month Case-Control Study of Bond
Failures. EJCO 2014;2:90-97
The study results add validation

to LED curing lamp technology as
a reliable, effective and evermore
efficacious polymerization method for Keywords

the placement of orthodontic brackets . LED, bracket failures, clinical time savings
90 2014 SIDO

Salazar A. New-Generation Light-Emitting Diode
INTRODUCTION become the standard for comparing

newly introduced curing lamps1420 .
T
he advent of light-activated More powerful curing systems, such
polymerization of resins as argon lasers and xenon plasma arc
introduced by Buonocore in lamps, were introduced beginning in
1970 1 revolutionized the practice of the 1980s, allowing for a reduction
orthodontics by allowing clinicians in curing times to as low as 3 sec 21,22 .
to transition away from chemically However, their high cost compared
cured resins with limited bracket to halogen units and concerns
placement times 24 . Although a about high pulpal temperatures
marked improvement, this method during exposure have hindered their
produced poor curing depths needed adoption by clinicians compared to
for adequate bonding strengths and halogen units2325 . Figure 1: Polymerization lamps.
it required an ultraviolet light source Light-emitting diodes (LED) were Halogen Optilux 501, Kerr/Demetron,
for polymerization, potentially proposed in 1995 as a new light Orange, CA, USA
exposing patients to hazardous source for polymerization lamps26,27.
radiation 59 . In 1978, Bassiouny In gallium nitride LEDs, electrons
and Grant introduced visible-light and holes recombine under forward
polymerized resins, an advance made biased conditions at the p-n doped
possible by camphorquinone (a semiconductor junctions for the
photo-initiator), which reacts to light generation of unfiltered blue light. 28
with 470 nm of wavelength, causing Much of the radiant energy of blue
hardening of the polymer resin LEDs lies in the 468 nm region,
and concurrent bracket bonding to close to the 470 nm optimal value
teeth1013 . Resin polymerization is a necessary for photo-initiation of Figure 2: Polymerization lamps.
function of the intensity, wavelength camphorquinone 16 . LED FlashMax2, CMS Dental ApS,
and length of time of exposure to Further development of LED Copenhagen, DK.
light. Improvements in curing lamp technology has allowed for new
technology have thus focused on the lamps that produce intensities
production of light with wavelengths higher than 4000 mW/cm, necessary to test new models and
close to 470 nm, increasing light thus improving the speed of the compare them with established
output intensities which produce bonding process without sacrificing halogen-based standards. Therefore,
a concurrent decrease in exposure reliability29,30 . In addition, LEDs this study aims to compare the
times11,13 . produce high bond strengths 3133 survival of brackets cured with a well-
Tungsten filament halogen lamps and acceptable temperature levels documented halogen light unit and a
produce blue light of 400500 nm on pulpal tissues 34,35 , have lifetimes new generation of LED curing lamp.
with output intensities near 1000 of 10,000 hours or more 36 and are
mW/cm, resulting in reliable bracket affordable. Furthermore, they are MATERIALS AND METHODS
bondings in 30 sec of exposure 14,15 . resistant to vibration 20 and have This case-control study reviewed the
Because of their efficaciousness low energy consumption 28 , making treatment records of orthodontic
and long-term presence in dental them suitable for battery operation. patients whose brackets were bonded
settings worldwide, they have As LED technology evolves, it is using two different types of curing
light systems. Sample selection
was derived from the population of
LED Halogen patients that received comprehensive
Model FlashMax2 Optilux 501 orthodontic treatment in a private
Mode of use (sec) 3 30 practice setting in Newton, MA. The
Nominal power (W) 15 80 treatment records of 60 patients (28
males, 32 females) were randomly
Output intensity (mW/ 40005000 1000
selected and reviewed for meeting
cm2)
the following inclusion criteria:
Wavelength (nm) 450470, peak 460 400505
1. having a full permanent
Manufacturer CMS Dental ApS, Co- Kerr/Demetron, dentition and undergoing non-
penhagen, Denmark Orange, CA, USA extraction therapy;
Table 1: Technical specificationos of curing lamps 2. exhibiting no dental anomalies
2014 SIDO 91

CLINICAL ARTICLE
that could affect bonding in a controlled environment and by and brackets were bonded with
including enamel hypoplasia, one clinician, matching of case and composite resin (Transbond XT, 3M
dental restorations, moderate control groups was assumed. All Unitek Monrovia, CA), according to
to severe dental fluorosis bracket bondings were completed the manufacturers guidelines.
(Deans index) and morphologic with a single curing lamp (FlashMax 2 The bonding technique was
variations affecting adaptation LED or Optilux 501 halogen) following standardized. All patients received
of the bracket base to the the manufacturers specifications new stainless steel brackets with the
enamel surface; (Tab. 1, Figs. 1,2). same bidimensional prescription:
3. having predicted treatment A total of 1200 bracket bondings 0.018x0.025 slot on incisors and
times of 24 months or longer. were examined: 600 cured with 0.022x0.028 on canines and
The mean age of patients was the LED and 600 cured with the posteriors (GAC MicroArch).
13.1 years (CI: 10.86, 15.28); the halogen unit. Both curing units were Brackets were placed in an ideal
age range was 11.0816.42 years. purchased new on the open market. tooth position to avoid, as much as
No exclusion was based on the Direct bracket bondings, assessment possible, premature contacts. Resin
type of malocclusion. of bond failures and data collection was polymerized by aiming the curing
All patients were treated with full were conducted by one operator lamp at the occlusal surface of the
orthodontic appliances in the maxilla (A.L.S.). In all patients, teeth were bracket base for the total curing time.
and the mandible. This study was isolated with cheek retractors Brackets of patients in the LED and
approved by the Institutional Review and cleaned with a mix of water halogen groups were polymerized
Board (IRB) at Boston Childrens and fluoride-free pumice using a for 3 and 30 sec respectively. Patients
Hospital. rubber polishing cup and a low- were given standardized instructions
Selected patients records were speed handpiece. Bands were then to avoid excessive occlusal pressure
assigned to either the case (LED) fitted and cemented on the first should toothtooth or toothbracket
or the control (halogen) group permanent molars. Then, second interarch interferences occur.
depending on the type of curing premolar to second premolar teeth All brackets were bonded in one
light used during treatment. Both the of both dental arches were rinsed, appointment and patients were
case and control groups each had a dried with an oil-free air syringe and unaware of which curing light
total of 30 patients. Since all treated etched with 37% phosphoric acid system was used. Active wires were
patients were close in age, had similar for 30 sec. After thorough washing, placed immediately thereafter. The
inclusion criteria and were treated the teeth were carefully dried wire sequence in all patients was
LED Halogen Total

Brackets (n) 600 600 1200
Failures (n) 11 12 23
Percent failed (%) 1.83 2.00 1.92
Two-sided Fishers exact test (p) 1.00 (ns)
Mean survival time (days) 721.20 719.56 720.38
95% Confidence interval
Lower bound 714.91 712.52 715.76
Upper bound 727.49 726.60 724.99
Logrank test of equality (p) 0.83 (ns)
ns, Not significant
Table 2: Bracket failure comparison between LED and halogen lamps
Bracket failures (%)

Months LED Halogen Total
06 30.40 43.50 73.90
612 8.70 0.00 8.70
1218 4.30 0.00 4.30
1824 4.30 8.70 13.00
TOTAL 47.80 52.20 100.00
Table 3: Bond failure percentages according to time period
92 2014 SIDO

0.014, 0.016x0.016, 0.016x0.025

nitinol and 0.016x0.022 stainless
steel (G&H, arch form Europa).
Patients received the same
appliance home care instructions
and were seen at 6-week intervals.
They were instructed to brush with a
manual toothbrush, according to the
modified Bass method 37 twice daily
and with toothpaste.
Both patient groups were monitored
for a period of 24 months. Data
collected during the retrospective
chart review included type of curing
light, date of initial bonding, date
of reported bond failure and tooth
number associated with the failure.
The duration of retention of each
bracket was calculated as the
difference between the initial
bonding date and date of reported
bond failure. Only the first bond
failure event per tooth was recorded
for analysis.
Figure 3: KaplanMeier survival plot Because of the retrospective nature

Standard
Hazard
Parameter robust Wald 2 z p>{z} Label
ratio (HR)
error Lower Upper
Factor 0.31 0.07 0.27 0.79 0.92 0.48 1.76 LED
Standard error adjusted for 60 clusters in patient
Table 4: Cox proportional-hazards regression analyzing LED curing lamp

Standard
Hazard
Parameter robust Wald 2 z p>{z} Label
ratio (HR) Lower Upper
error
Factor 0.32 0.09 0.929 0.97 0.50 1.87 LED

Gender 0.34 0.10 0.919 1.03 0.54 1.98 Male
Age (years) 0.13 0.92 0.357 0.87 0.65 1.16
Position 18.65
Posterior
2.07 3.02 0.003 4.30 1.67 11.09 Posterior
vs. anterior
Maxilla vs.
0.28 1.02 0.307 0.64 0.27 1.51 Maxilla
mandible
Standard error adjusted for 60 clusters in patient. Also, adjusting for age, gender and tooth position.
Table 5: Cox proportional hazards regression analysis accounting for confounding factors
2014 SIDO 93

CLINICAL ARTICLE
of the study and because all patients the course of the study. No patients was found between the two curing
previously had full-mouth bondings ended treatment or transferred methods (logrank test p=0.83) (Tab. 2).
completed in a single visit, a split- during the 24-month observation Using the Cox proportional hazards
mouth study design was not possible. period. Of the 1200 initially bonded regression analysis (HR) and
Statistical analyses were computed brackets, there were a total of 23 clustering within patients, there was
with SPSS Statistics Version failures (1.92%), of which 11 (1.83%) no significant difference in bracket
20 (IBM Corporation, New York). occurred in the LED and 12 (2.00%) failure probability between the two
Variables were curing method (LED in the halogen group (Table 2). curing methods (HR=0.92, p=0.79)
vs. halogen), gender, arch (maxilla The difference in the overall (Table 4 ).
vs. mandible), location within the bracket failure recorded between Adjusting for variables such as age,
arch (anterior vs. posterior) and time the case and control groups was gender and arch, the HR remained
saving. Cumulative bracket survivals not statistically significant (p=1) non-significantly different for both
were plotted using the KaplanMeier (Table 2). Most bracket failures groups (HR=0.97, p=0.929) (Table 5 ).
method and the cumulative survival (73.90%) occurred during the first The only significant category in the
between groups was compared using 6 months of treatment (Table 3 ). analysis was posterior teeth, which
the logrank and Fishers exact tests. The KaplanMeier survival analysis had a higher probability of bracket
Risk factors affecting survival were showed that the total mean survival failure compared to anterior teeth
assessed by the Cox proportional time of brackets was 720.38 days (HR=4.30, p=0.003) (Table 5 ).
hazards regression model. The level (23.66 months). The mean survival Although pooled data from both
of significance was set at p<0.05. time was 719.56 days (23.64 months) curing light groups and dental
for brackets in the halogen group arches showed an increased failure
RESULTS and 721.20 days (23.69 months) for rate on posterior teeth (p=0.001),
No pulp, gingival or other negative brackets in the LED group (Tab. 2, Fig. no advantages could be attributed
side effects were reported during 3). No difference in bracket survival to the use of either curing light in
Two-sided Fishers
Total bonded (n) Failed (n) Failure (%)
exact test (p)
Bracket position
Anterior 720 6 0.83 0.001 (s)
Posterior 480 17 3.54
Posterior segment
only
LED 240 9 3.75 Approx. 1 (ns)
Halogen 240 8 3.33
s, Significant; ns,
not significant
Table 6: Segment failures in pooled arch bondings and effect of curing method on posterior segment
Time saved per Total time

Polymerization Polymerization Total polyme-
patient saved by LED
Type of light Total brackets time per time per rization time in
bonding by light use
bracket (sec) patient* (sec) the study (h)
LED light use during the study
LED 600 3 60 0.50

9 min 4.5 h
Halogen 600 30 600 5
*Assumes bonding of 20 teeth (second premolar to second premolar in both arches)
Table 7: Time savings represented by usage of LED lamp.
94 2014 SIDO

decreasing this tendency (p>0.05) in the Layman study. are sufficient for producing optimal
(Table 6 ). When comparing bond failures of resin bond strength. 43,44 The Penido
The use of the LED lamp resulted brackets in the LED versus halogen et al. study, which examined shear
in 9 min of time saved per patient groups, no significant differences bond strength of brackets bonded
compared to the use of the halogen were detected. This finding is to enamel using LED or halogen,
lamp in a 20-teeth bonding consistent with those of a similar study, concluded that the type of light-
procedure (Table 7 ). by Krishnaswamy and Sunitha16 . In curing unit does not interfere with
their 15-month study, even though shear bond strength in both in vitro
DISCUSSION the curing time was much longer (10 and in vivo settings. 31 Although our
This study demonstrates that sec) and the LED unit less powerful study did not test bond strength,
there are no differences in bracket (440480 nm, up to 1000 mW/cm), the comparable debonding rates
survival between brackets bonded bond failure rates in the LED group between the LED and halogen curing
with the Optilux 501 halogen and were not significantly different from units would suggest that curing
the FlashMax 2 LED lamps during those in the conventional halogen brackets for 3 sec with the LED light
the first 24 months of treatment. light group. In contrast to our finding, provides sufficient bond strength
This finding remained consistent a significant difference was seen for orthodontic bracket retention.
independently of age, gender in bond failure rate between the We conducted an analysis to quantify
or interarch appliance position. maxillary and the mandibular arches, the time-saving benefits of the LED
Brackets located on posterior teeth but this was not related to the type of light compared with the halogen
had a lower survival probability polymerization lamp. unit. The aggregate light exposure
compared to those located on A significantly higher bracket failure time for the bonding of 600 brackets
anteriors, independent of the curing rate was found in the posterior with LED light took approximately 30
method used. Neither the use of (probability of failure four times min (0.5 h) considering each bracket
LED nor the use of halogen units higher) versus the anterior segment, was cured for 3 sec. In contrast,
proved advantageous in decreasing independent of curing method the aggregate light exposure time
posterior failures. The use of the used. This is in agreement with for bonding the same number of
LED lamp resulted in significant previous reports, which suggest brackets with the halogen light took
time savings. KaplanMeier survival that difficulty of moisture isolation a cumulative time of 300 min (5 h).
analysis showed that bracket survival and poor access and visibility in Thus, the total clinical time-saving
probability was equal during the the posterior dentition may result advantage provided by the LED unit
24-month observation (censored) in more failures for posterior was 4 h and 30 min. This translates
regardless of the type of light-curing teeth. 6,23,38,42 Other factors such to 9 min of time savings per patient
unit used. Although a slightly higher as the surface of premolars having assuming a bonding from second
probability of survival was present more aprismatic enamel that could premolar to second premolar. Other
in the LED group during the first 18 affect micromechanical bond studies have shown similar time
months of treatment, this difference properties may also contribute to saving advantages of LED over
was deemed not significant by the higher bond failure rates16 . halogen-curing units. 33,38
logrank test. The bracket failure rates Most bond failures occurred within Because there were no negative
of 1.83% in the LED group and 2.00% the first 6 months of bracketing, symptomatic reports from patients
in the halogen group were more which was also not related to the type at any point during treatment, it is
favourable than those previously of light used in curing the adhesive. our opinion that the higher power
reported in the literature. 6,16,3840 Early bond failures were also seen of the FlashMax2 LED light is not
Possible explanations for this could by Krishnaswamy and Sunitha 16 iatrogenic to dentoalveolar tissues.
be differences in patient habits, diet and OBrien et al. 38 Factors such as This is likely due to the short exposure
and operator skill. In a three-month patient acclimatization to appliance, time required for polymerization 29 .
study by Layman and Koyama, 41 occlusal interference with brackets Ophthalmic tissues, however, do
which compared LED to halogen during the early stages of treatment require protection as focused short-
light polymerization, bracket failure and poor technique during bracket wavelength light could predispose
rates of 1.9% were seen in the LED placement could explain the early them to premature retinal ageing
and 4.9% in the halogen group, with nature of bracket failures. and macular degeneration45 .
no statistically significant difference In vitro studies on bond strength have Therefore, eye protection allowing
between the two groups. These reported no significant differences transmission of less than 1% of
rates are more comparable to those between LED and halogen lights20,32 light with wavelengths below
from our study considering that all and have asserted that exposures 500 nm is recommended during
brackets were placed by a resident ranging from 10 to 20 sec for LEDs bracket polymerization46 . This point
2014 SIDO 95

CLINICAL ARTICLE
becomes critical for operators and are similar to those of prospective resulting bond failures between
possibly patients as technological studies that have demonstrated brackets cured with FlashMax 2 LED
developments allow for the the reliability of LED curing units in and Optilux 501 halogen. Brackets
introduction of lamps producing orthodontic bonding procedures16,47. on posterior teeth were four times
increasingly higher intensities. Future research should concentrate more likely to fail compared to
Despite the limitations present in on the evolution of LED lamp anterior teeth, independent of
case-control trials such as unknown technology as it will arguably polymerization lamp. The LED
confounding factors, we feel the become the most efficient of all unit provides a 9 min timesaving
results of this study are highly polymerization methods. per patient compared to halogen,
reliable since all bondings were without increasing the probability of
conducted by a single experienced CONCLUSIONS bracket debonding.
operator and a limited number of In this case-control trial, we conclude
variables were analyzed. Our results that there are no differences in
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pits and fissures for caries prevention, on polymerization of light cured 20. Mills RW, Jandt KD, Ashworth SH.
with use of ultraviolet light, J Am resins, Dent Mater J 1997;16:6073. Dental composite depth of cure with
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3. Wilson SJ. Resin based restoratives,
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Br Dent J 1988;164:326330.
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4. Forsten L. Curing depth of light 2000;70:2833.
1994;13:198205.
activated composites, Acta Odont
14. Rueggeberg FA, Caughman WF, 22. Talbot TQ, Blankenau RJ, Zobitz ME,
Scand 1984;42:2328.
Curtis JW Jr. Effect of light intensity Weaver AL, Lohse CM, Rebellato J.
5. Salako NO, Cruickshanks-Boyd Effect of argon laser irradiation on
and exposure duration on cure
DW. Curing depths of materials shear bond strength of orthodontic
of resin composite, Oper Dent
polymerized by ultra-violet light, Br brackets: an in vitro study, Am
1994;19:2632.
Dent J 1979;146:375381. J Orthod Dentofacial Orthop
15. Swartz ML, Phillips RW, Rhodes B.
6. Armas Galindo HR, Sadowsky PL, 2000;118:274279.
Visible light-activated resins: depth of
Vlachos C, Jacobson A, Wallace D. An 23. Manzo B, Liistro G, De Clerck H.
cure, J Am Dent Assoc 1983;106:634
in vivo comparison between a visible Clinical trial comparing plasma arc
637.
light-cured bonding system and a and conventional halogen curing
chemically cured bonding system, 16. Krishnaswamy NR, Sunitha C. Light-
lights for orthodontic bonding,
Am J Orthod Dentofacial Orthop emitting diode vs halogen light curing
1998;113:271275. of orthodontic brackets: a 15-month
2004;125:3035.
clinical study of bond failures,
7. Birdsell DC, Bannon PJ, Webb PB. 24. Hannig M, Bott B. In vitro pulp
Harmful effects of near ultra violet chamber temperature rise during
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radiation used for polymerization of composite resin polymerization with
sealant and composite resin, J Am 17. Sfondrini MF, Cacciafesta V, Pistorio
various light curing sources, Dent
Dent Assoc 1976;92:775778. A, Sfondrini G. Effects of conventional
Mater 1999;15:275281.
and high-intensity light-curing on
8. Grover D, Zigman S. Coloration of 25. Zach L, Cohen J. Pulp response to
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human lenses by near ultraviolet externally applied heat, Oral Surg Oral
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Dentofacial Orthop 2001;119:3035. 26. Mills RW. Blue light emitting diodes:
9. Zigman S, Griess G, Yulo T, Schultz J. another method of light curing? Br
18. Dunn WJ, Bush AC. A comparison of
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polymerization by light-emitting diode
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10. Bassiouny MA, Grant AA. A visible J Am Dent Assoc 2002;133:335341. RS. LED curing lights: whats
light cured composite restorative new? Compend Contin Educ Dent
19. Martin FE. A survey of the efciency
material, Br Dent J 1978;145:327329. 2005;26:586,588,590591.
of visible light curing units, J Dent
11. Nomoto R. Effect of light wavelength 1998;26:239243. 28. Kramer N, Lohbauer U, Garcia-Godoy
96 2014 SIDO

F, Frankenberger R. Light curing of 36. Mills RW, Jandt KD. Blue LEDs for thermocycling, Angle Orthod
resin-based composites in the LED curing polymer based dental filling 2011;81:510516.
era, Am J Dent 2008;21:135142. materials: lasers, electro-optics, Soc 44. Thind BS, Stirrups DR, Lloyd CH.
29. Christensen GJ. Save time, effort, Inst Electl Electron Eng Newslett A comparison of tungsten-quartz-
and money with fast, new LED curing 1998;12:910. halogen, plasma arc and light-
lights, Clin Rep 2010;3:13. 37. Zhang JH, Sha YQ, Cao CF. emitting diode light sources for the
30. Ferrante M, Dottore P, Petrini M, Comparative study of the effects polymerization of an orthodontic
Trentini P, Spoto G. Evaluation of of removing plaque by two adhesive, Eur J Orthod 2006;28:78
different light-curing lamps: halogen toothbrushing methods, Beijing Da 82.
versus new-diode lamp, J Therm Anal Xue Xue Bao 2005;37:542544. 45. Ham WT. Ocular hazard of light
Calorim 2012;109:939944. 38. OBrien KD, Read MJ, Sandison RJ, sources: review of current knowledge,
31. Penido SM, Penido CV, dos Santos- Roberts CT. A visible light-activated J Occup Med 1983;25:101103.
Pinto A, Gandini LG Jr, Bagnato VS. direct-bonding material: an in vivo 46. Council on Dental Materials,
In vivo and in vitro study of the shear comparative study, Am J Orthod Instruments and Equipment. The
bond strength of brackets bonded to Dentofacial Orthop 1989;95:348351. effects of blue light on the retina
enamel using halogen or LED light, 39. Fricker JP. A 12-month clinical and the use of protective filtering
World J Orthod 2009;10:2128. evaluation of a glass polyalkenoate eyeglasses. J Am Dent Assoc
32. Dunn WJ, Taloumis LJ. Polymerization cement for the direct bonding of 1986;112:533535.
of orthodontic resin cement with orthodontic brackets, Am J Orthod 47. Fleming PS, Eliades T, Katsaros
light-emitting diode curing units, Dentofacial Orthop 1992;101:381384. C, Pandisd N. Curing lights for
Am J Orthod Dentofacial Orthop 40. Millett DT, Hallgren A, Cattanach D, orthodontic bonding: a systematic
2002;122:236241. McFadzean R, Pattison J, Robertson review and meta-analysis, Am
33. Swanson T, Dunn WJ, Childers DE, M, Love J. A 5-year clinical review of J Orthod Dentofacial Orthop
Taloumis LJ. Shear bond strength of bond failure with a light-cured resin 2013;143:S92103.
orthodontic brackets bonded with adhesive, Angle Orthod 1998;68:351
light-emitting diode curing units 356.
at various polymerization times, 41. Layman W, Koyama T. A clinical
Am J Orthod Dentofacial Orthop comparison of LED and halogen
2004;125:337341. curing units, J Clin Orthod
34. Sddk M, Tancan U, Serdar U, Eren 2004;38:385387.
I, Asl B. In-vitro assessment of 42. Linklater RA, Gordon PH. Bond
temperature rise in the pulp during failure patterns in vivo, Am J Orthod
orthodontic bonding, Am J Orthod Dentofacial Orthop 2003;123:534
Dentofacial Orthop 2010;137:379383. 539.
35. Aslihan U, Tamer B, Mustafa K, Ilter Ul. 43. Cerekja E, Cakirer B. Effect of short
Temperature rise during orthodontic curing times with a high-intensity
bonding with various light-curing light-emitting diode or high-power
units: an in vitro study, Angle Orthod halogen on shear bond strength
2006;76:300334. of metal brackets before and after
2014 SIDO 97

Vittorio Grenga
Private Practice
X-RAY ODDITIES
of Orthodontics, Many times, when we see in our practice a radiograph, we have the opportunity
Rome, Italy
to note images that may or may not influence directly our diagnosis and our
treatment plan.
This column of EJCO gives us the opportunity to show these images and to make
Correspondence: some brief observations about them. The style is concise: the images largely speak
Via Apuania, 3 00162 Rome Italy for themselves.
Your suggestions for future topics as well as your comments will be very welcome.
Grenga V. An Unusual Crepitus. EJCO
2014;2:98-99
An Unusual Crepitus
The patient, a 55-year-old woman, DISCUSSION cavitation. Lack of fluid within the
presented to the dentist with crepitus Crepitus of the TMJ during functional articular cavity creates a negative
of the left temporomandibular joint movements of the jaw generally pressure that attracts gas from
(TMJ) during opening and closing appears very late in degenerative adjacent tissues into the spaces2 .
of the jaws. Anamnesis showed that joint disease according to Pipers Sometimes air can be also present in
the patient had breast cancer with classification of intracapsular the glenoid fossa of the TMJ in the
cerebral metastasis and for this temporomandibular disorders. A case of temporal bone fractures 3 .
reason had received radiotherapy palpable crepitus is detectable in The anatomic relationship between
(RT) to the head. Clinical examination Stage V when a perforation of the this part of the temporal bone and
revealed no pain, and no limitations disk is present together with chronic the TMJ enables air to pass from
in functional movements were degenerative joint disease. In most the auditory canal into the joint4 .
present. Computed tomography of patients, the TMJ can support a Moreover, osteoradionecrosis after
the left and right TMJ showed air in firm load with no discomfort 1 . In RT for head and neck tumours can
the upper and lower compartments some cases, air inside the joint can induce resorption of the bone of
of the left TMJ with perforation of create a sensation like crepitus the posterior wall of the TMJ cavity,
the intra-articular disk (Figs. 1, 2). The palpable or heard by the patient allowing the passage of air from
images showed discontinuity of the during functional movements of the external auditory canal into the
posterior wall of the left TMJ cavity the mandible. The presence of air articular capsule of the TMJ.
corresponding to the anterior wall of in a closed joint space like the TMJ
the external auditory canal (Fig. 3 ). is a vacuum phenomenon called
Figure 1: Sagittal reconstruction of the left Figure 2: Coronal reconstruction of the left temporomandibular joint. Note the air in the upper
temporomandibular joint. Note the air in the left compartment.
upper and lower compartments of the joint.
98 2014 SIDO

Figure 3: Axial scan of the temporomandibular joint (TMJ). Note the discontinuity of the
posterior wall of the left TMJ cavity corresponding to the anterior wall of the external auditory
canal, allowing air to pass in.
Images courtesy of Studio Radiologico DAmbrosio, Rome, Italy
REFERENCE LIST
1. Dawson P. Functional occlusion. 3. Betz BW, Wiener MD. Air in the
From TMJ to Smile Design. St. temporomandibular joint fossa:
Louis, Missouri: Mosby, 2007. CT sign of temporal bone fracture.
2. Hayashi T, Ito J, Koyama J. Gas Radiology 1991;180:463466.
in temporomandibular joint: 4. Mercuri V, House RJ.
computed tomography findings. Temporomandibular joint air
Oral Surg Oral Med Oral Pathol in fracture of the skull base.
Oral Radiol Endod 1998;86:751 Australas Radiol 1992;36:129130.
754.
2014 SIDO 99

Case Reports and Case Series
LITERATURE READINGS
for Dummies
C
ase Reports and Case Series Recently a series of publications 3-
5
are descriptive observational took into consideration the CARE
studies1 . Their characteristic guidelines that give the key points
is that there is no control group so that should figure in a good Case
they do not permit of effective or Report.
reliable analysis. The case studies The Case Reports website (http://
are the base level of hierarchy of w w w.care -statement.org/index.
evidence 2 , and even though very html) provides a template for the
exposed to the possibility of bias proper writing of Case Reports and
Bruno Oliva they do have great clinical utility. has some interesting links to other
Catholic Univeristy of Sacred Heart, Rome, Italy
The simplicity of Case Reports mean resources that we shall look at in the
Private Orthodontic Practice, Brindisi, Italy
that in theory any clinician can next issue.
organise and carry them out.
Despite a high number of dentistry
publications being Case Reports,
little attention is paid to appraisals
How to cite this article: of their quality.
Oliva B. Case Reports and Case Series.
EJCO 2014;2:100
According to the instructions on how to prepare case reports published

in the BMJ (British Medical Journal) Case Reports - Instructions for
authors section - case reports should address the following subjects
REFERENCE LIST
Remind of important clinical lesson
1. Oliva B. Introduction to
Findings that shed new light on the possible pathogenesis of a
Clinical Studies, EJCO 2014;
disease or an adverse effect 2:63
Learning from errors
2. Oliva B. Hierarchy of
Unusual presentation of more common disease/injury Evidence, EJCO 2014;1:35
Rare disease
3. Gagnier JJ, Kienle G, Altman
New disease DG, Moher D, Sox H, Riley
Novel diagnostic procedure D. CARE Group. The CARE
Novel treatment (new drug/intervention; established drug/ guidelines: consensus-
procedure in new situation) based clinical case reporting
Unusual association of diseases/symptoms guideline development. BMJ
Case Rep2013;doi:10.1136/bcr-
Unexpected outcome (positive or negative) including adverse drug
2013-201554
reactions
100 2014 SIDO

WE TESTED...
The Columbus Spring
Ensuring torque movement of The auxiliary archwire must then be low load/deflection ratio thanks
front incisors is one of the most tied to the main arch. to TMA wire and snail shape of
challenging tasks when planning As the torque is provided by the the spring;
orthodontic treatment. Columbus spring, a full thickness more rational selection of the
The Columbus spring is a simple archwire is not required for this anchorage teeth
device that has recently been task; this allows torque movements
patented and introduced to the to be planned at the initial phase of Moreover this device avoids:
market with CE certification. treatment and in association with friction
The kit comes with a 0.0170.025 other mechanics. bone-anchorage need
TMA auxiliary arch and two laser- The segmented approach that is patient compliance
welded SS springs. proposed allows:
The arch intrudes or extrudes the teeth compatibility with most common
according to the bends provided (Fig. brackets on market;
1). The springs are placed at the level torque control from the early
of the teeth that require torque, with stages of treatment, in association
the springs free end engaged within with other mechanics;
the 0.020 vertical slot of the bracket more gentle forces applied on
(Figs. 2 and 3). the element;
Figure 1: The Columbus springs device consists
of a 0.0170.025 TMA archwire with two
crimpable springs (0.018 SS) in the anterior
region.
Figure 2: The auxiliary archwire, with

activation, before engagement.
Clinical example: 25 Of incisor torque in 6 months
Figure 3: The Columbus springs, activated for

REFERENCE LIST
torque correction (20 bend), are crimped to
1. Archambault A, Lacousiere R, 3. Cash C, Good SA, Curtsi RV,
correspond with the vertical slots of the incisor
Hirshan B, Major PW, Carey J, McDonald F. An evaluation of slot
Flores-Mir C. Torque expression in size in orthodontic brackets are brackets and then inserted in them.
stainless steel orthodontic brackets. standards as expected? Angle
A systematic review. Angle Orthod Orthod 2004;74:450453.
2010;80:201210. 4. Kusy RP, Whitley JQ. Influence of CONTACT INFORMATION:
2. Articolo LC, Kusy K, Saunders archwire and bracket dimensions on SAVVY Oral Solutions
CR, Kusy RP. Influence of ceramic sliding mechanics (derivations and c/o Recchia Ambulatorio Polispecialistico
and stainless steel brackets on determinations of critical contact Medico ed Odontoiatrico Via Mameli
the notching of archwires during angles for binding). Eur J Orthod
5 37126 Verona (VR) Italy
clinical treatment. Eur J Orthod 1999;21:199208.
2000;22:409425.
phone: 0039 3282182928
2014 SIDO 101

An international journal supported by
the Italian Society of Orthodontics (SIDO)
A premier research journal

with the aim of fostering orthodontic basic research as well
as innovative clinical techniques, with an emphasis on the
following areas:
mechanisms to improve orthodontics;
clinical studies and control animal studies;
orthodontics and genetics, genomics;
temporo-mandibular-joint (TMJ) control clinical trials, as
well as efficacy of orthodontic appliances and animal models.
Progress in Orthodontics will consider for publication only
Online-only meritorious and original contributions, i.e.:
Original articles reporting the findings of clinical trials,
Free Open Access clinically relevant basic scientific investigations or novel
therapeutic or diagnostic systems;
Review articles on current topics;
Techniques and novel clinical tools or exceptional levels of
clinical competence may be considered;
Published by Springer Open Articles of contemporary interest.
The publication costs for Progress in Orthodontics are covered by the Italian Society of
Orthodontics (SIDO), so authors do not need to pay an article-processing charge.
www.progressinorthodontics.com
Editor-in-Chief Editorial Director Co-Editor
Ravindra Nanda (USA) Claudio Lanteri (Italy) Felice Festa (Italy)
Associate Editors
Ding Bai (China) Mark Guenther Hans (USA) Adriano Piattelli (Italy)
Theodore Eliades (Switzerland) Sunil Kapila (USA) Yijin Ren (Netherlands)
Carla Evans (USA) Claudio Marchetti (Italy) Bhavna Shroff (USA)
Padhraig Fleming (UK) Keiji Moriyama (Japan)
Advisory Board
Dror Aizenbud (Israel) Lorenzo Favero (Italy) Marie Pierryle Filleul (France)
Silvia Allegrini (Italy) Daniela Garib (Brazil) Jonathan Sandler (UK)
Gerassimos Angelopoulos (Greece) Odile Hutereau (Luxembourg) Franka Stahl (Germany)
Nayla Bassil-Nassif (Lebanon) Rosalia Leonardi (Italy) Angel Alonso Tosso (Spain)
Anna Bocchieri (Italy) Alessandra Lucchese (Italy) Tancan Uysal (Turkey)
Vittorio Cacciafesta (Italy) Roberto Martina (Italy) Carlalberta Verna (Denmark)
Alberto Caprioglio (Italy) Fraser McDonald (UK) Leslie Will Boston (USA)
Paola Cozza (Italy) James A McNamara (USA) Abbas R Zaher (Egypt)
M. Ali Darendeliler (Australia) Moschos Papadopoulos (Greece) Giliana Zuccati (Italy)
Giampietro Farronato (Italy) Letizia Perillo (Italy)

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European Journal of Clinical Orthodontics

International Journal supported by the Italian Society of Orthodontics (SIDO)

77. CLINICAL ARTICLES

Editorial Board Associate Editors: Contributing Editors Advisory board

2014 Italian Society of Orthodontics (SIDO) Disclaimer

EJCO_Vol2Iss3_UNICO.indd 65 11/09/14 12.56

EJCO_Vol2Iss3_UNICO.indd 67 11/09/14 12.56

Reflections on the life of Tiziano Baccetti (19662011)

How to cite this article:

EJCO_Vol2Iss3_UNICO.indd 68 11/09/14 12.56

Background figure: Leonardo da Vinci, Vitruviuss Proportions of the

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In this section we introduce an influential orthodontist who has given a

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The current approach to orthodontic care is largely error-

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Definition Defect Rate

101 One or two failures out of 10 (80% or 90% success)

102 Five failures or less out of 100 opportunities (95% success)

103 Five failures or less out of 1000 opportunities

Table 1: Reliability labels 10

Table 2: Three-step reliability design model 10

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professional advice. changes to unreliable practices. patients, Anticipate issues to prevent

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This case report describes the integrated orthodontic surgical

.....orthodontic treatment combined

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INTRODUCTION treat Class II division 2 malocclusion uncertain. Camouflage treatment

Figures 1 - 3: Pre-treatment (T0) extra-oral photographs.

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Figures 10 - 15: Pre-treatment (T0) study models.

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Variable T0 T1 T2 T3 T4 T1T0 T2T1 T3T2 T3T0 T4T3 T4T0

SNA () 82.8 83.6

Table 1: Dentofacial morphology and changes

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94.9 to the maxillary plane, tipped

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Figures 28 30: Post-treatment (T3) extra-oral photographs.

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curve of Spee, which the treatment

Figures 39 - 41: Follow-up (T4) extra-oral photographs.

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orthodontics before mandibular

Figure 48: Follow-up (T4) radiograph.

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OBJECTIVES To compare survival of brackets polymerized

The study results add validation