Cover / Editorial / Content / Biomechanical behavior of self-ligating interactive systems / Increasing practice efficiency - profitability using In-Ovation R self-ligating brackets / Abstract thinking / Sleep apnea and orthodontics: An interdisciplinary approach to treating a chronic sleep condition / Submissions / Imprint
Cover
01 - 01 viewEditorial
03 - 03 viewContent
04 - 04 viewBiomechanical behavior of self-ligating interactive systems
06 - 10 viewIncreasing practice efficiency - profitability using In-Ovation R self-ligating brackets
11 - 16 viewAbstract thinking
18 - 18 viewSleep apnea and orthodontics: An interdisciplinary approach to treating a chronic sleep condition
20 - 22 viewSubmissions
25 - 25 viewImprint
26 - 26 viewArray
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[1] =>
ortho
North America Edition • Vol. 3 • Issue 1/2014
issn 2161–7228
the international C.E. magazine of
orthodontics
1
2014
_c.e. article
_study
_study
_technique
Biomechanical behavior of
self-ligating interactive systems
Abstract thinking
Increasing practice efficiency
and profitability
Sleep apnea and orthodontics
[2] =>
[3] =>
editorial _ ortho
Using research to
drive education …
and vice versa
I
Todd Metts, professional services
director for DENTSPLY GAC.
At the university level, educational institutions typically perform three main functions: education,
research and service to their community. Two of the key points, research and education, are areas in
which DENTSPLY GAC is directly involved. So a partnership between DENTSPLY GAC and the educational
community is a natural fit.
Research and education go hand in hand, where each is strengthened by the presence of the other.
Working together, they can build on, borrow from and incrementally augment their own successes while
enhancing the accomplishments of the other.
Some of the most ground-breaking and exciting innovation is taking place in the educational community. With programs like DENTSPLY GAC Clinical Alliance Research and Education (GCARE) and Complete
Clinical Orthodontics (CCO), DENTSPLY GAC is fully committed to advancing the practice of orthodontics
through research and education.
With GCARE, we’re establishing a foundational approach to advance research and education, while our
CCO development team gives us more of an impact in the educational environment.
Unfortunately, universities are having the same problem many individuals and institutions are —
they’re trying to do more with less. That’s where private companies like DENTSPLY can make an important
difference.
The reality is that when corporations and universities form mutually beneficial relationships, both
of them can achieve incremental outcomes that exceed what they could do alone. If we can provide the
resources that give the universities a boost, and if we can connect and develop some tools that help in
education, while at the same time providing the students with a higher level of education, then it’s a win
for everyone involved.
Todd Metts
Professional Services Director
DENTSPLY GAC
ortho
I 03
1
_ 2014
[4] =>
I content _ ortho
page 06
page 06
page 06
I c.e. article
06 Biomechanical behavior of self-ligating
interactive systems
_Dr. Celestino Nobrega
I study
11 Increasing practice efficiency, profitability using
In-Ovation R self-ligating brackets
_Jerry R. Clark, DDS, MS, and Jack Gebbie, BS
18
ortho
North America Edition • Vol. 3 • Issue 1/2014
issn 2161–7228
the international C.E. magazine of
1
orthodontics
2014
Abstract thinking
I technique
20
Sleep apnea and orthodontics: An
interdisciplinary approach to treating a chronic
sleep condition
_Jim Duffy
_submissions
_imprint
1_ 2014
_study
_technique
Abstract thinking
Increasing practice efficiency
and profitability
Sleep apnea and orthodontics
I on the cover
Cover image provided by DENTSPLY GAC
page 11
04 I ortho
_study
Biomechanical behavior of
self-ligating interactive systems
I about the publisher
25
26
_c.e. article
page 11
page 20
[5] =>
[6] =>
I C.E. article_ self-ligating systems
Biomechanical
behavior of
self-ligating
interactive systems
Author_Dr. Celestino Nobrega
_c.e. credit
_Abstract
This article qualifies for C.E.
credit. To take the C.E. quiz,
log on to www.dtstudyclub.
com. Click on ‘C.E. articles’
and search for this edition
(Ortho C.E. Magazine —
1/2014). If you are not registered with the site, you will be
asked to do so before taking
the quiz. You may also access
the quiz by using the QR code
below.
The purpose of this study was to determine if
various bracket clips are strong enough to provide
a proper archwire/slot engagement. If yes, then we
wanted to determine if the active clip shows lack of
power after loading.
06 I ortho
1_ 2014
_Introduction
If a bracket system is not capable of offering an
efficient and strong ligation to properly engage the
archwire, the orthodontist will encounter varying
degrees of difficulty during treatment. These problems will not occur during the leveling phase, when
the force delivered by the archwire deflection is not
so powerful. Therefore, during the initial phase, the
ligation system doesn’t need to exert the same level
of force.
However, during the phases that demand
rectangular-geometry-archwires utilization for the
torque incorporation, we must consider the ability —
or not — of the clip to press and hold the wire firmly
engaged to the bracket slot, bringing the desired
prescription details needed for ideal positioning.
There are many reasons correct torque expression
is important. The use of an interactive bracket system,
whose clips are made of a reliable material that offers
enough resilience and flexibility, is necessary for the
application of constant and physiologic forces. These
forces will guarantee proper control of the dental
movements in the three planes of the space.
By understanding the importance of the affirmations above, this study aims to evaluate four different
models of interactive self-ligating brackets in order
to verify which group will show the best performance. In this case, “best” will be represented by the
least force loss after being submitted to a certain load
during a period of time.
_Materials
In this trial, both metallic and ceramic self-ligation
interactive brackets (second premolars, 0.022-inch
by 0.028-inch slots, Roth prescription) were tested
(Table 1). In all the groups, the clip is composed by
Cr-Co stainless-steel alloy. A number of eight brackets composed each group.
_Methods
Specific methodology was created based on a load
cell machine. A custom metallic cylinder that held
all eight brackets was designed for this experiment,
[7] =>
C.E. article_ self-ligating systems
Table 1
I
Fig. 1
Table 2
Table 3
with a piece of rectangular 0.019-inch by 0.025-inch
SS wire being used as a caliper to dampen any torque
or angular interference during the measuring of the
forces (Fig. 1).
This ensured that the wires used in the test could
be passively inserted into the slots.
The cylinders were positioned in an EMIC DL 2000
(Tesc software version 3.01/05) for load/unload trials.
Each bracket was tested in three different steps:
• M1 – Moment 1 – (Pull Out). Measurement of the
force that the clip exerts over the wire when pulled
until the limit.
• M2 – Moment 2 – (Load). Maintaining strength
of a constant load of 20 N during a period of two
hours.
• M3 – Moment 3 – (Pull Out). Repetition of step
No. 1 after the two previous steps.
For each bracket, a new piece of the SS wire was
used. In total, 120 measurements were performed.
Force values that caused maximum and minimum
deflection of the clips of five brands of self-ligating
brackets were collected.
From these values (eight brackets per group), a
mean score was calculated, representing the force
Table 1_Brackets tested.
Fig. 1_A custom cylinder designed
for the experiment.
Table 2_ The data allows the
researcher to compare the mean
scores between steps Nos. 1 and 3,
after subjecting the clips to the force
of 20 N for two hours in step No. 2.
Table 3_Results of the experiment in
all three steps.
(Tables and photo/
Provided by Dr. Celestino Nobrega)
ortho
I 07
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[8] =>
I C.E. article_ self-ligating systems
Table 4
Table 4_ The difference between the
averages of steps Nos. 1 and 3.
Table 5_ The mean scores for steps
Nos. 1 and 3 of the test for each
group of brackets.
that the clip exerts on the rectangular wire for each of
steps Nos. 1, 2 and 3. The data allowed the researcher
to compare the mean scores between steps Nos. 1
and 3, after subjecting the clips to the force of 20 N
for two hours in step No. 2 (Table 2).
The purpose of step No. 2 was to submit the clip to
a sustained effort, similar to what occurs in a complete orthodontic treatment. This made it possible to
check the difference in the mechanical behavior of
the clips between the initial and final stages.
_Results
ANOVA (analysis of variance) was utilized to
provide statistical calculation, complemented by the
Tukey test of multiple comparisons, with a significance level at 5 percent.
Among the metallic interactive brackets, the
In-Ovation R group showed the highest average,
being significantly different than the other groups
BioQuick and Empower (Table 3).
Table 5
08 I ortho
1_ 2014
_Discussion
Higher levels of force represent a disadvantage
from the traditional systems of brackets when the
load applied directly to the crowns exceeds biological limits. It is important to emphasize that the force
generated by the clip is not delivered to the teeth.
The importance is related to a proper engagement
of the archwire into the slot, putting together the
characteristics of the prescription in straight wire
appliances.
It’s interesting to observe that it’s not just the
initial force generated by the clip that’s relevant, but
also how constant the force is maintained. Although
some brands of interactive brackets showed initial
forces apparently strong enough to maintain the
archwire in position, they also showed that this
strength is lost and dissipates over time, meaning
the efficiency of an interactive bracket is related to
the consistent power generated by the clip and not
to the initial force provided by a brand new bracket.
[9] =>
C.E. article_ self-ligating systems
I
Table 6
The efficiency of an interactive system of selfligating brackets is directly related to the uniformity
and continuity of the spring clip activity over time.
Excessive loss of force brings clinical difficulties
during the treatment phases that require the utilization of rectangular-geometry archwires, such as the
space closure and the finishing stage.
Therefore, from the clinical point of view, the most
important data is the difference between the averages of steps Nos. 1 and 3 of the test (Table 4).
Through the test T at the level of significance of
5 percent, we can verify that for the majority of the
groups, the means scores M1 were significantly bigger than M3, which means that there is always some
lack of effectiveness of the spring clips, regardless
of brand.
When the calculated p value (minimum significance level) allowed rejection of the nullity hypothesis, an asterisk (*) was used to denote this. The nullity
hypothesis was rejected only on the In-Ovation
C group, which showed no statistical difference
between M1 and M3. This situation reflects a better
mechanical stability of its spring clips.
Among the metallic self-ligating brackets, the
mean score for step No. 3 (M3) was the highest for
the In-Ovation R group. The group Empower suffered
the greatest loss of tension, generating the lowest
strength. The BioQuick group performed intermediate values at the end of the third moment of the test
(M3). In the chart (Table 5), it is possible to observe and
compare the mean scores for steps Nos. 1 and 3 of the
test for each group of brackets.
Considering the differences in gF (grams of force)
between the moments M1 and M3 (Table 6), the
highest loss in terms of force magnitude between
the metallic accessories after a 20 N load during two
hours was shown by the BioQuick group (82.5 gF),
quite similar to the Empower group (80.9 gF). The best
performance (lowest lack of strength) was presented
by the In-Ovation R group (33.6 gF).
Among the esthetic brackets, the highest loss of
magnitude of force was shown by the QuickKlear
group (77.8 gF), while the group In-Ovation C presented the lowest (27.5 gF).
Table 6_The magnitude of force loss
for each of the brackets.
_Conclusion
From the above results, we can draw the following
three conclusions:
• It’s important for clinicians to understand that
the main component of an interactive self-ligation
system is the spring clip, which is supposed to provide
flexibility and resilience along the treatment time.
Therefore, the choice among the different brands
offered by the current market should be focused on
this point.
• The spring clips of the interactive self-ligating
brackets are not free from loss of force exertion
ortho
I 09
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_ 2014
[10] =>
I C.E. article_ self-ligating systems
power after being subjected to a load of 20 N for a
period of two hours.
• The differences between the stages M1 and
M3 were statistically non-significant only for
In-Ovation C group (GAC–DENTSPLY, United States),
which denoted greater mechanical stability.
There is not a perfect and ideal interactive
self-ligating bracket system. However, both groups
In-Ovation R and In-Ovation C performed better than
the other brands in all the trials when the magnitude
of force loss was considered._
_References
1.
2.
3.
4.
5.
6.
7.
Nobrega C, Motta F, Janovich C. Evaluation of the
biomechanical behavior of self-ligating interactive
bracket’s clips: part 1. Ortodontia SPO, 46 (6):565–573,
2013.
Pizzoni L, Ravnholt G, Melsen B. Fricional forces related
to self-ligating brackets. Eur. J. Orthod., Oxford, v.20, p.
283–291, 1998.
Shivapuja PK, Berger J. A comparative study of conventional
ligation and self-ligatingbracket systems. Am. J. Orthod.
DentofacialOrthop., St.Louis, v.106, p.172–180, 1994.
Sims APT, Waters NE, Birnie BJ. Pethybridget, R.J.
A comparison of the forces required to produce tooth
movement in vitro using two-self-ligating brackets and a
pre-adjusted bracket employing two types of ligation. Eur.
J. Orthod., Oxford, v.15, p.377–385, 1993.
Harradine NWT. Current Products and Practices Selfligating brackets: where are we now? Bristol: Bristol Dental
Hospital; 2003.
Rinchuse DJ, Miles PG. Self-ligating brackets: present and
future. Am. J. of Orthod. and Dentofacial Orthop., v. 132,
n. 2, p. 216–222, 2007.
Nóbrega C. Biomecânica Inteligente Interativa Autoligante:
Mitos e Fatos. Nova visão em Ortodontia e Ortopedia
_about the author
Funcional dos Maxilares. Ed. Santos, cap. 20, p.225–233,
2010.
8. Henao SP, Kusy RP. Evaluation of the frictional resistance
of conventional and self ligating bracket designs using
standardixed archwires and dental typodonts. Am.
J.Orthod. Dentofacial Orthop., St. Louis, v.74,p.202–211,
2004.
9. Nóbrega C, Silva PC. Biomecânica Interativa Autiligante:
Otimizando a prescrição Roth. Orto 2008/SPO. Nova Visão
em Ortodontia e Ortopedia Funcional dos Maxilares. Ed.
Santos, cap 08 p 07–14, 2008.
10. Berger JL. Replacement of the Spring Clip in the SPEED
Appliance. J Clin Orthod. 1994 Oct;28(10):583-6. Nova
Visão em Ortodontia e Ortopedia Funcional dos Maxilares.
Ed. Santos, cap 08 p 07–14, 2008.
11. Nóbrega C, Epstein M, Jakob SR. Biomecânica Autoligante
interativa: uma releitura após 10 anos. Orto 2012/SPO.
Nova Visão em Ortodontia e Ortopedia Funcional dos
Maxilares. Ed. Santos, p 133–178, 2012.
12. Gioka C, Eliades T. Materials-induced variation in the
torque expression of preadjusted appliances. Am J Orthod
Dentofacial Orthop. Mar;125(3):323–328, 2004.
13. Gick MR, Nóbrega C, Benetti JJ, Jakob SR, Zucchi TU,
Arsati F. Estudo comparative do movimento de torque
induzido pelos sistemas autoligantes e convencionais.
Orthodontic Science and Practice. 2012; 5(17): 37–46.
14. Guidi G. Estudo comparativo da força do clipe ativo em
três marcas de braquetes autoligantes. 50p. Dissertação
(Mestrado em Odontologia) — centro de Pós-Graduação
São Leopoldo Mandic, 2010.
15. Dahlan A, Pober R, Ferguson D, Giordano R. Evaluation
of SLB Clip Breaking Force. Boston: Boston University,
Goldman School of Dental Medicine; 2005.
16. Pandis N, Bourauel C, Eliades T. Changes in the stiffness
of the ligating mechanism in retrieved active selfligating brackets. Am J Orthod Dentofacial Orthop.
2008;132:834–837.
ortho
Dr. Celestino Nobrega completed his general dental training at Sao Paulo
State University, Brazil, in 1984. He completed his certificate in orthodontics at Rio de Janeiro State at Brazilian Dental Association. His masters
of dental science degree came in 1996, after publishing material about
MRIs of TMJs. After taking the Roth-Williams continuing education course
at Burlingame in 1997, he received the position of educator at several
academic associations in Brazil, organizing courses as post-graduate
program director. The search for innovative technologies led Nobrega
to Dr. Elliot Moskowitz, who introduced him to NYU Ortho Department
Chairman Dr. George Cisneros. Months later, Nobrega began bringing
groups of his students and former students to NYU for one-week programs
created especially for them. During these programs, Nobrega was able to
have a closer and definitive contact with ISL mechanics, learning about
biological and mechanical details. Today, Nobrega is leading a project in
his country focusing on 19 biomechanical studies regarding characteristics of the interactive self-ligating system. The research is based on friction
and flexibility studies and also on low-intensity laser and vibration therapy
during orthodontic treatment.
10 I ortho
1_ 2014
[11] =>
study_ bracket efficiency
I
Increasing practice
efficiency, profitability
using In-Ovation R
self-ligating brackets
A white paper report
Authors_Jerry R. Clark, DDS, MS, and Jack Gebbie, BS
_Many unsubstantiated claims have been made
concerning self-ligating bracket systems as to their
efficiency in moving teeth, the time savings that can
be realized by using these appliances and the “magic”
that is somehow stored up in these brackets to more
effectively align teeth.
This study was done in an effort to draw some
scientifically based conclusions to more accurately
differentiate between what is “hype” and what is
actually true regarding the purported increased efficiency and time savings of one such self-ligating
bracket system: In-Ovation R, manufactured by GAC
International.
The study was performed to determine if cases
treated with In-Ovation R brackets were actually
treated faster, with fewer and shorter appointments
with less clinical chair time needed to complete treatment, and if they truly increase practice efficiency
and profitability compared to similar cases treated
with traditional edgewise brackets.
_Are there other scientific studies
available?
Recently, there has been a cry from the scientific
community regarding evidence-based studies that
will differentiate between opinion and fact.1–4 It is
important for our profession, if we are to remain
rooted in scientific principles, to honestly research,
study and report on the claims made by our fellow
professionals and the orthodontic supply companies.
At the present time, there actually have been a
surprising number of scientific studies performed
that have reported the increased efficiency of selfligating brackets.5–13 Most of these reports, however,
have studied other bracket systems, such as Damon
and Speed.
To date, no scientific study has been applied exclusively to the In-Ovation R bracket system to measure
the treatment and chair-time savings resulting
from using this appliance. That is the reason for this
research study.
_How was this study performed?
Treated orthodontic cases were randomly selected
from the practice of Dr. Jerry Clark, a board-certified
orthodontist. No attempt was made, in this study, to
quantify the quality of the final treatment results. It
was assumed that Clark utilized all his technical skills
and abilities to achieve the best treatment results
possible for each individual patient.
One hundred fourteen cases treated with
In-Ovation R were studied and compared to 241
ortho
I 11
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[12] =>
I study_ bracket efficiency
Fig. 1
Fig. 1_ The average number
of months required to treat cases
utilizing In-Ovation R was
4.14 months less than comparable
cases being treated using traditional
edgewise brackets.
(Illustrations/Provided
by DENTSPLY GAC)
12 I ortho
1_ 2014
cases treated with traditional pre-torqued and preangulated brackets. This produced a confidence level
for this sample of 95 percent +/- 8 percent.
Certain types of cases were eliminated from the
study. Those excluded were: cases with an unusual
number of missed or broken appointments, cases
with an unusual number of loose or broken brackets,
cases that required two-phase treatment, cases with
significant skeletal discrepancies (Class III, skeletal
open bites), cases with impacted canines, cases with
extremely poor cooperation and cases where some
other circumstance significantly impacted Clark’s
ability to complete treatment in a reasonable length
of time.
This research project was managed by Jack Gebbie,
president, DATATEX Inc., an independent research
and consulting firm specializing in market research.
The data files were carefully reviewed, and marketing
research standards were applied to the sampling to
ensure comparisons would be valid across the two
alternatives being studied.
DATATEX is a member of CASRO (Council of American Survey Research Organizations) and maintains
research integrity and standards consistent with this
organization.
_What was specifically studied?
The study was fairly simple in its design. Patents
treated with traditional edgewise brackets and Roth
and Tweed-type mechanics with the goal of attaining
the Andrews 6 Keys to Occlusion14 were compared
to cases treated with In-Ovation R brackets and the
light wire mechanics typically used with self-ligating
[13] =>
[14] =>
I study_ bracket efficiency
Fig. 2
Fig. 2_ The average number
of patient appointments needed
to complete treatment was reduced
by 6.66 appointments.
14 I ortho
1_ 2014
brackets with the objective of achieving similar treatment objectives.
The time required to place brackets at the beginning of treatment and the time necessary to remove
appliances at the end of treatment was not included
because it is realistic to assume that it takes approximately the same amount of time to place and
remove brackets regardless of the type of brackets
being used.
What was studied was the actual treatment time
from the day treatment was begun to the day appliances were removed. Also, the total number of
patient visits needed to complete treatment was
measured, as was the total number of minutes of
patient chair time necessary to complete treatment.
_Are self-ligating brackets really faster?
More efficient? Better?
The answer is YES!
_What were the findings of the study?
Months in treatment
The average number of months required to treat
cases utilizing In-Ovation R was 4.14 months less
than comparable cases being treated using traditional edgewise brackets.
Number of appointments
The average number of patient appointments
[15] =>
study_ bracket efficiency
I
Fig. 3
needed to complete treatment was reduced by 6.66
appointments, which meant 40 percent fewer appointments were required to complete treatment
using In-Ovation R compared to traditional edgewise
appliances.
Chair time required to treat cases
The number of minutes of clinical chair time that
patients required in order to complete treatment was
reduced by an average of 174.21 minutes per patient
or, put another way, approximately three hours of
chair time was saved on each treated patient.
That means the average case being treated with
In-Ovation R took approximately five hours of chair
time to treat while the average case being treated
with traditional appliances took almost eight hours
to treat, a time savings of approximately 36 percent.
_How does the reduced chair time
impact practice profitability?
Suppose your practice produces a profit of $350
per hour (an average figure for an active wellmanaged practice), and you are able to save three
hours on each case you treat. Then the profit for each
case treated is increased by approximately $1,050.
However, IIn-Ovation R brackets do cost more
than traditional edgewise brackets by approximately
$5 per bracket. That means if you bond five to five,
you use approximately 20 brackets on each case for
an additional expense of about $100 per case. So
the actual estimated additional profit for each case
using this scenario is about $950. That is a pretty
good return on an additional investment of $100 for
In-Ovation R brackets.
Fig. 3_The number of minutes
of clinical chair time that patients
required in order to complete
treatment was reduced by an
average of 174.21 minutes
per patient.
ortho
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[16] =>
I study_ bracket efficiency
However, this is just an average. If your practice
profit per hour is less than $350 per hour, then your
savings will be somewhat less. But if your practice
profit is more than $350 per hour, then your profit
will increase even more.
_about the authors
Jerry R. Clark, DDS, MS, is a board-certified
orthodontist who maintains a full-time practice in Greensboro, N.C. He received his BS and
DDS from the University of North Carolina and
his MS in orthodontics from St. Louis University.
He is also chairman of the board of Bentson
Clark, a company that specializes in the sale and
transition of orthodontic practices.
_So what’s the bottom line?
Granted, a competent and conscientious orthodontist can most likely obtain excellent treatment
results regardless of the type of appliances he or
she chooses to utilize. I am often questioned by my
colleagues, “Why should I change? Why should I pay
more for In-Ovation R brackets when I am already
achieving excellent results with my present bracket
system?”
The critical and more important question is, “What
is best for our patients?”
If we as orthodontists are committed to providing
the very finest treatment for our patients, I personally feel it is important we look at the findings of this
study and draw the obvious conclusions concerning
the treatment of our patients.
If we want to provide the very finest orthodontic
care, in the most cost-effective manner with the
least amount of discomfort to our patients, with
the fewest number of visits required, and provide
shorter appointment times while completing treatment as quickly as possible, I feel it now requires us
to avail ourselves of the advanced technology of
self-ligation.
Anything less would not be providing the finest
available treatment for our patients._
Editor’s note: Dr. Jerry Clark and Jack Gebbie would
like to sincerely thank Debbie Terrell, Kyle Bechtel
and Dr. John Oubre for their efforts and invaluable
assistance in accumulating data for this study. The
complete study is available upon request by contacting DENTSPLY GAC.
_References
1.
2.
3.
4.
5.
16 I ortho
1_ 2014
Turpin DL. Evidence based orthodontics. Am J Orthod
Dentofacial Orthop. 2000 Dec; 118(6):591.
Huang GJ. Making the case for evidednce-based
orthodontics. Am J Orthod Dentofacial Orthop. 2004
Apr;125(4):405–06.
Turpin DL. Changing times challenge members…then and
now. Am J Orthod Dentofacial Ortho. 2004 Jul;126(1):1–2.
Turpin DL. Putting the evidence first. Am J Orthod
Dentofacial Orthop. 2005 Oct;128(4): 415.
Harradine NWT. Self-ligating brackets and treatment
efficiency. Clin Orthod Res 2001; 4: 220–227.
ortho
Jack Gebbie is president of Datatex Inc. and
has handled research projects for both national
and regional companies for more than 11 years
with particular experience and expertise in the
fields of health care and financial services. He
is a graduate of Wake Forest University and is a
member of CASRO (Council of American Survey
Research Organizations) and conforms to the
research integrity and standards established by
this national organization.
6.
Eberting JJ, Straja SR, Tuncay OC. Treatment time,
outcome and patient satisfaction comparisons of Damon
and conventional brackets. Clin Orthod Res 2001; 4:
228–234.
7. Shivapuja PK, Berger J. A comparative study of conventional
ligation and self-ligation bracket systems. Am J Orthod
Dentofac Orthop 1994; 106: 472–480.
8. Thomas S; Sherruff M; Birnie D. “A Comparative In Vitro
Study of the Frictional Characteristics of Two Types of SelfLigating Brackets and Two Types of Pre-Adjusted Edgewise
Brackets Tied with Elastomeric Ligatures.” Eur. J. Orthod.
283–291; June 1998.
9. Pizzoni L; Ravnholt G; Melsen B. “Frictional Forces Related
to Self-Ligating Brackets.” Eur. J. Orthod. 283–291; June
1998.
10. Henao SP, Kusy RP. “Evaluation of the frictional resistance
of conventional and self-ligating bracket designs using
standardized archwires and dental typodonts.” Angle
Orthod. 2004 Apr; 74(2):202–211.
11. Damon DH. “The rationale, evolution and clinical application
of the self-ligating bracket.” Clin Ortho Res. 1998
Aug;1(1);52–61.
12. Parkin N. “Clinical pearl: clinical tips with System-R”. J
Orthod. 2005 Dec;32(4):244–246.
13. Harradine NW. “Self-ligating brackets: where are we now?”
J Orthod.2003 Sep;30(3)262–273.
14. Andrews LA. “The six keys to normal occlusion.) Am. J.
Ortho.1972 Sept. 62(3):296–309.
[17] =>
[18] =>
I study_ lower incisor stability
Abstract
thinking
_Intro
Each year in Canada, second-year orthodontic
residents are tasked with summarizing their thesis
ideas and then converting them to a poster-style
format for the scientific session of the annual Canadian Association of Orthodontics (CAO). This annual
rite of passage does more than simply provide each
resident with a rewarding technical experience — it
also provides all of orthodontics with some valuable
research. Here is one of these resident studies.
_Study
“Lower Incisor Stability Following Orthodontic
Treatment Using a Fixed-Spring Induced Appliance.”
Crichton J*, Wiltshire WA, Hechter FJ, Ahing S. Department of Orthodontics, University of Manitoba,
Winnipeg, Canada.
Objectives
To evaluate the lower incisor (Li) changes after
completion of comprehensive fixed treatment in
subjects with different facial patterns who were
treated with a FSIA for Class II correction.
Hypothesis
Once the lower incisor position has been established at the end of a FSIA treatment, they will remain
stable in the same position after fixed treatment.
Subjects and methods
A retrospective chart review was undertaken, consisting of 115 subjects with Class II malocclusions, 43
male and 72 female. The average length of treatment
was one year and seven months (S.E ± 0.57). The average age of the subjects at T1 was 13.7 years (S.E±1.5).
18 I ortho
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Subjects were then categorized into three growth
types based on pre-treatment (T0) cephalometric
variables (MPA, Y-axis, LFH) with 29 brachycephalic,
53 mesocephalic and 33 dolichocephalic subjects
resulting. Data was compiled using digital lateral
cephalometric analysis of the post-treatment FSIA
subjects’ (T1) and post-treatment comprehensive
fixed therapy subjects’ (T2) radiographs.
Statistical evaluation used a mixed model repeated command to calculate marginal means and a
post-hoc analysis to determine pairwise differences
with the Tukey’s test, reporting least square means.
Results
Dental changes induced by fixed treatment included:
1. retroclination of the Li (LI-MP 5.7-9.7°±1.3
p<0.05)
2. retrusion of Li (LI-APo 0.1-1.0mm
±0.3mmp<0.05)
There was no significant difference among the
different facial groups (p>0.05). There was an increased trend of less incisor retroclination and retrusion for the dolichocephalic group.
Conclusions
Incisor proclination resulting from the FSIA is
reversed after fixed orthodontic treatment, and Li
tend to retrocline and retrude. Use of zero or negative
torque prescription in the Li bracket and Li uprighting mechanics throughout treatment ensure the Li
return to a position between the initial treatment (To)
and the final position established with the FSIA (T1).
Facial growth pattern demonstrate no relation
to the amount of Li movement. The dolicocephalic
group shows less Li change when compared to the
other facial patterns._
[19] =>
[20] =>
I technique_ sleep apnea
Sleep apnea and
orthodontics: An
interdisciplinary
approach to treating a
chronic sleep condition
Author_Jim Duffy
_Interdisciplinary treatment planning is a concept that’s gaining relevance among oral health
professionals.
It’s one of the chief tenets of the popular Seattle
Study Club, and many find it extremely rewarding
to work with a group of like-minded professionals
when treating their patients. This evolving holistic
approach to oral health is exemplified in the evolving role that the orthodontist can play in addressing
sleep apnea.
The notion that people should see an orthodontist
about the sleeping problems they or their children
endure might come as a surprise to the general
public, but more and more medical and orthodontic
experts are pointing toward a future that heads in
that direction.
Consider, for example, the most common type of
sleep-disordered breathing: obsessive sleep apnea
syndrome (OSAS). It’s quite common among both
children and adults, though precisely how common
can be difficult to say because the condition is significantly under-diagnosed.
A 2012 paper in the journal Pediatrics placed
sleep apnea numbers among children within the
broad range of 1 to 5 percent of the population. The
nonprofit Sleep Foundation estimates that at least 18
million adults have OSAS.
20 I ortho
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The syndrome can affect patients in a range
from mild to severe, with the more serious cases
being quite dangerous to long-term health. Among
children, OSAS has been linked with poor school performance, learning disabilities, behavior problems
and even some cardiac abnormalities. In adults, it can
boost the risk of hypertension, cardiovascular disease, coronary artery disease and insulin-dependent
diabetes.
_What causes sleep apnea?
The word apnea comes from the Greek apnoia,
which means “breathless.” That’s exactly what happens in OSAS, as sufferers stop breathing for brief
intervals in their sleep, and they do this over and over
again throughout the night.
Such breathing gaps create wide variations in the
heart rate and in levels of oxygen saturation.
In the simplest sense, this happens because either
the upper airway collapses or it’s obstructed. Why
that happens is a more complicated question.
• Excessive weight can cause upper airway
complications. An estimated two out of three OSAS
patients are obese. People with big necks are at
higher risk as well; size 17 in men and 16 in women
seem to be a cutoff point for medical professionals
[21] =>
technique_ sleep apnea
when it comes to asking patients about possible OSAS
issues.
• Some sleep apnea is linked with aging. The
natural loss of muscle tone that happens as the
years go by can lead to the development of airway
obstructions.
• Smoking and alcohol use may not cause sleep
apnea, but both can aggravate the condition.
• In recent decades, increasing attention has been
paid to OSAS cases linked with abnormalities in oralfacial development among non-obese children.
A review of the evidence supporting this hypothesis was published last year in Frontiers in Neurology.
Co-author Christian Guilleminault is a pioneering
sleep scientist at the Stanford School of Medicine
who helped to discover and name the syndrome back
in the 1970s.
The paper identifies several facial characteristics
associated with OSAS in non-obese patients, including the narrowing of dental arches, a decrease in
maxillary arch length and an increase in anterior
facial height.
What causes these developmental abnormalities is uncertain; the paper speculates that they are
sparked by something that happens in utero. They are
also common among premature births.
Harry Legan, the chairman of orthodontics at
the Vanderbilt University School of Medicine, noted
these characteristics in a 2008 presentation before
the Pacific Coast Society of Orthodontics and added
I
a couple of others to the mix, including a large tongue (Illustrations/Provided by
and an inferiorly positioned hyoid bone.
www.shutterstock.com)
The list made it clear, Legan said, that “the orthodontist is uniquely suited to recognize the symptoms
of [obsessive sleep apnea], make a tentative diagnosis
and make the necessary referral to coordinate treatment options.”
_The orthodontist and pediatric OSAS
Early diagnosis and successful treatment can
make a huge difference in the lives of young sleep
apnea patients. Among the outcomes cited in an
August 2013 paper in the journal JSM Dentistry by
developmental dentist Zheng Xu of the University
of Texas Health Science Center are improved cognitive development, better academic outcomes and
improved social skills.
The treatment of pediatric OSAS generally involves a multidisciplinary team that can include sleep
specialists, weight-loss experts and pediatricians, as
well as dentists and orthodontists.
The participation of orthodontists seems poised
to increase, given a growing body of evidence that
rapid maxillary expansion (RME) is an effective treatment.
RME has been around for more than a century
now, but its usage in disordered sleep patterns is a
relatively recent phenomenon. The treatment involves the placement of an expandable brace on the
ortho
I 21
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_ 2014
[22] =>
I technique_ sleep apnea
_The orthodontist and adult OSAS
roof of the mouth that can help increase the width of
the maxilla. As the roof of the mouth is also the floor
of the nasal passage, RME helps to increase space in
the patient’s airway, allowing more air into the throat
and lungs.
RME can be used in patients as young as age 3, but
it’s most often employed between the ages of 4 and
10. The key question is whether the child will sit still
long enough for both the placement of the brace in
the orthodontist’s office and for adjustments to the
brace that will be made at home by parents.
Xu concludes his paper in JSM Dentistry by saying,
“Pediatric dentists and orthodontists who perform a
comprehensive head-neck exam are in a unique position to identify young patients with increased risk for
OSAS.” He predicts a greater role going forward for
dentists and orthodontists on the treatment side of
things as well.
22 I ortho
1_ 2014
Formal diagnosis of sleep apnea is made by a sleep
specialist after an overnight polysomnography exam.
Once adult OSAS is identified, first steps tend to be of
the common sense variety — weight loss for obese
patients, as well as changes in sleeping habits. Many
patients do better if they sleep on the side rather than
on the back.
Another popular treatment, continuous positive
airway pressure (CPAP), involves sleeping with a
breathing mask that’s attached to a machine that
helps generate more air pressure in the throat. CPAP
is highly effective when used properly, but patient
compliance is a big problem. Many people find the
device so uncomfortable they simply stop using it.
At this point, various surgical interventions may
come into play, including tonsillectomy and adenoidectomy, cranofacial operations or tracheostomy.
These can be successful on occasion, but they are far
from sure-fire and lasting solutions in all cases.
Here is where the orthodontist comes in. Various
types of oral appliances offer partial relief to OSAS
patients, especially in cases that fall in the mild to
moderate range. The American Academy of Sleep
Medicine recommends two different types of devices
— tongue-retaining appliances that hold the tongue
in a forward position and mandibular-repositioning
appliances that keep the lower jaw in a protruded
position while sleeping.
California-based orthodontist Robert G. Keim
discussed the difference such devices can make in a
2011 article in the Journal of Clinical Orthodontics:
“Even a few millimeters of mandibular advancement
during sleep may be enough … to produce relatively
normal breathing patterns,” he wrote.
Keim also noted that sleep apnea is now receiving
significant attention in both dental and orthodontic
graduate schools — a sure sign that the trend of
increased orthodontic involvement in OSAS is likely
to continue._
‘Even a few millimeters
of mandibular advancement
during sleep may be enough
… to produce relatively
normal breathing patterns.’
— California-based orthodontist Robert G. Keim
[23] =>
[24] =>
[25] =>
about the publisher _ submissions
I
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ortho
I 25
1
_ 2014
[26] =>
I about the publisher _ imprint
ortho
the international C.E. magazine of laser dentistry
U.S. Headquarters
Dental Tribune America
116 West 23rd Street, Ste. 500
New York, NY 10011
Tel.: (212) 244-7181
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Managing Editor
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s.rendon@dental-tribune.com
Product/Account Manager
Humberto Estrada
e.estrada@dental-tribune.com
Managing Editor
Fred Michmershuizen
f.michmershuizen
@dental-tribune.com
Product/Account Manager
Will Kenyon
w.kenyon@dental-tribune.
comcom
Publisher
Torsten R. Oemus
t.oemus@dental-tribune.com
Managing Editor
Robert Selleck
r.selleck@dental-tribune.com
Product/Account Manager
Drew Thornley
d.thornley@dental-tribune.com
President/CEO
Eric Seid
e.seid@dental-tribune.com
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Feedback & General Inquiries
feedback@dental-tribune.com
Group Editor
Kristine Colker
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Editorial Board
Marcia Martins Marques, Leonardo
Silberman, Emina Ibrahimi, Igor Cernavin,
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Kamenova, T. Dostalova, Christliebe Pasini,
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Meister, Rene Franzen, Andreas Braun, Sabine
Sennhenn-Kirchner, Siegfried Jänicke, Olaf
Oberhofer and Thorsten Kleinert
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26 I ortho
1_ 2014
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Cover
01 - 01
view
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Editorial
03 - 03
view
-
Content
04 - 04
view
-
Biomechanical behavior of self-ligating interactive systems
06 - 10
view
-
Increasing practice efficiency - profitability using In-Ovation R self-ligating brackets
11 - 16
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-
Abstract thinking
18 - 18
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Sleep apnea and orthodontics: An interdisciplinary approach to treating a chronic sleep condition
20 - 22
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Submissions
25 - 25
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Imprint
26 - 26
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/ Editorial
/ Content
/ Biomechanical behavior of self-ligating interactive systems
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/ Submissions
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