Ortho Tribune U.S. No. 6, 2012

A review of the Original Combination Technique and Philosophy / What is pragmatic research? / Tooth positioning appliances: an orthodontist’s experience / Events / Industry

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ORTHO TRIBUNE
The World’s Orthodontic Newspaper · U.S. Edition

WINTER 2012 — Vol. 7, No. 6

www.ortho-tribune.com

A review of the Original
Combination Technique
and Philosophy
By Dennis J. Tartakow, DMD, MEd, EdD,
PhD, Editor in Chief

Fig. 1b

Fig. 1c

Fig. 1a

uring the 1960s, when the
Begg lightwire and the Tweed
edgewise were the mainstream techniques of orthodontic therapy, Dr. Maxwell Fogel and
Dr. Jack Magill introduced their “Combination Technique” (Fogel & Magill, 1969).
The Combination Technique’s philosophy was based on combining the positive
and significant attributes of Begg lightwire and Tweed edgewise techniques to
produce a system that corrected malocclusions quickly and easily for the orthodontist, with much less pain and a shorter period of time for the patient, while
producing American Board of Orthodontics quality, standards and results.

Outline of the Combination
Technique
Fig. 2a
Fig. 2b

Fig. 2c

Stage I: Light-wire phase (Tipping)
1. Reduce protrusion
2. Un-crowd incisors
3. Open the bite (restore vertical dimension)
4. Class I molars and cuspids
5. Begin closing extraction spaces
6. Upright mandibular incisors

Fig. 3c

” See COMBINATION, page 3

Fig. 3a
Photos/From Fogel and Magill’s ‘The
Combination Technique in Orthodontic
Practice.’

Fig. 3b

Sobler Orthodontics:
Father-son team serves N.Y.
By Sierra Rendon, Managing Editor

ather-son duo Dr. Terry Sobler
and his son, Dr. Ian Sobler, together make up Sobler Orthodontics, which has been providing family-friendly orthodontics in New
York for more than 35 years.
“We’ve been doing it together for five
years,” Dr. Ian Sobler said. “We work well
together; and I learn a lot from him.”
Dr. Terry Sobler has been practicing
for more than 40 years. Despite — or
because of – these four decades, the So-

Dr. Terry Sobler, left, and Dr. Ian Sobler.
Photo/Provided by Sobler Orthodontics

” See SOBLER, page 8

Dental Tribune America
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From the Editor

Ortho Tribune U.S. Edition | WINTER 2012

What is pragmatic
research?

ORTHO TRIBUNE
Publisher & Chairman
Torsten Oemus t.oemus@dental-tribune.com
Chief Operating Officer
Eric Seid e.seid@dental-tribune.com
Group Editor
Robin Goodman r.goodman@dental-tribune.com
Editor in Chief ORTHO Tribune
Prof. Dennis Tartakow
d.tartakow@dental-tribune.com
International Editor Ortho Tribune
Dr. Reiner Oemus r.oemus@dental-tribune.com

By Dennis J. Tartakow,
DMD, MEd, EdD, PhD, Editor in Chief

As my last two editorials concentrated
on research, it would be fitting to present another research matter known as
pragmatic research, which is certainly
not new but essential and practical to
life and research. A research problem
must be examined through various
social science theories in order to structure the interpretive lens of the postmodern perspective for classification of
those factors that serve all individuals,
including disadvantaged and excluded
individuals of different races, cultures
and genders. The focus of this dialogue
deals with changing ways of thinking,
rather than expecting action-based
thoughts based on these changes. Conditions in the world determine the basis
of knowledge and are centered upon the
perspectives of gender, class, race and
other group affiliations.
In the beginning of the 20th century,
one the most influential philosophies in
America was pragmatism, which has influenced the study of law, education, political and social theory, art and science.
The pragmatic research philosophy
encompassed six fundamental theses.
It was, however, doubtful that any one
scholar would have subscribed to all
of them. Varying interpretations even
on points of agreement would temper
the major Pragmatists. The six hypotheses and methodologies of pragmatism
were:
1. Idealism and evolutionary theory,
emphasizing the “plastic” nature of
reality and the practical function of
knowledge as an instrument for adapting to reality and controlling it.
2. Critical Empiricism, highlighting
the priority of actual experience over
fixed principles and a priori reasoning
in critical investigation.
3. Experimental or practical consequences, resulting from the use, application, or entertainment of the notion.
4. The process of verification, underscoring a proposition, or the successful working of an idea. Crudely, truth is
“what works.”
5. The functional character of ideas

and behaviors, interpreting ideas as instruments and plans of action.
6., The formation of concepts, hypotheses, theories and justification, accentuating reality motivated and justified by
efficacy and utility in serving interests
and needs critical to maximum usefulness and purpose.
There are four paradigms of pragmatic research (postpositivism, constructivist, participatory and pragmatism)
that provide special and different prospective on the practice of this research.
The basic set of beliefs (the paradigm
or worldview) that I chose to guide my
own dissertation titled, “An Analysis of
Factors that Align with Faculty Vacancies in Orthodontic Education,” was
pragmatic research. Although there are
many forms of pragmatism, the focus
centered upon outcomes, actions, situations and consequences of discovery
rather than the forerunner or precursor
of the situation. Instead of concentrating on the methodology, the important
concern to this researcher was the problem being studied and the questions
asked regarding the problem. There are
important aspects regarding how pragmatism creates the design of a proposed
research study; these features:
1. are not dedicated to any one philosophical system of reality.
2. provide researchers the freedom
to chose the methods, techniques, and
procedures of research that best meet
his or her needs and purposes.
3. do not see the world as an absolute unity, or only one way; rather the
pragmatist views research as mixed
methods researchers, who view many
approaches to collecting and analyzing
data – both qualitatively or quantitatively.
4. allow for truth to be reported as
what works at the time rather than as
a duel between reality that is independent of the mind or reality that is within
the mind.
5. permit the researcher to discover
“what” and “how” rather than to research based upon intended consequences.
• suggest that research occurs in social, historical, political, or other context.
• encourage the belief of an external
world independent of the mind as well
as those within the mind and implies
that researchers stop asking questions
about reality and laws of nature.
Often times, these conditions are
negative and occur in the presence of
hierarchies, power and control by individuals of the hierarchy setting. Thus,
honest examination of that which is
concealed (such as domination, opposition, inconsistency and contradictions)
must be identified. Such discussions

will therefore address the grounded
theories that draw upon researchers
studying turning points of problematic
situations in which transitional periods occur. Confrontation of centrality
regarding media-created realities are
also addressed and sometimes further
advanced through informational technology, such as the Internet.
This interpretive stance of postmodern perspectives shape the participants selected for a study in order for
them to explore the issues, develop the
modes of data collection and contemplate the use of the study as follows:
1. Participants address and examine
that which is concealed as domination,
opposition, inconsistency and contradictions that must be brought to the
surface.
2. Interview questions address the
presence of hierarchies, power and control by individuals of the hierarchy setting.
3. Collection of data is served and carried out by the researcher.
4. Results of the study can be documented in peer-reviewed articles, jour” See RESEARCH page 6

Managing Editor ORTHO Tribune
Sierra Rendon s.rendon@dental-tribune.com
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Editorial Board

Image courtesy of Dr. Earl Broker.

Corrections
Ortho Tribune strives to maintain the utmost
accuracy in its news and clinical reports. If
you find a factual error or content that
requires clarification, please report the details
to Managing Editor Sierra Rendon at
s.rendon@dental-tribune .com.

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Jay Bowman, DMD, MSD (Journalism & Education)
Robert Boyd, DDS, MEd (Periodontics & Education)
Earl Broker, DDS (T.M.D. & Orofacial Pain)
Tarek El-Bialy, BDS, MS, MS, PhD
(Research, Bioengineering & Education)
Donald Giddon, DMD, PhD (Psychology & Education)
Donald Machen, DMD, MSD, MD, JD, MBA
(Medicine, Law & Business)
James Mah, DDS, MSc, MRCD, DMSc
(Craniofacial Imaging & Education)
Richard Masella, DMD (Education)
Malcolm Meister, DDS, MSM, JD (Law & Education)
Harold Middleberg, DDS (Practice Management)
Elliott Moskowitz, DDS, MSd (Journalism & Education)
James Mulick, DDS, MSD
(Craniofacial Research & Education)
Ravindra Nanda, BDS, MDS, PhD
(Biomechanics & Education)
Edward O’Neil, MD (Internal Medicine)
Donald Picard, DDS, MS (Accounting)
Howard Sacks, DMD (Orthodontics)
Glenn Sameshima, DDS, PhD (Research & Education)
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Keith Sherwood, DDS (Oral Surgery)
James Souers, DDS (Orthodontics)
Gregg Tartakow, DMD (Orthodontics) & Ortho
Tribune Associate Editor

[3] =>

CLINICAL

Ortho Tribune U.S. Edition | WINTER 2012

“ COMBINATION, Page 1
7. Cephalometric X-ray to check uprighting of the mandibular incisors
Stage II: Bracket alignment phase (Leveling)
1. Level and align maxillary and mandibular arches
2. Closure of extraction spaces
3. Preliminary uprighting of cuspids
and bicuspids
4. Preliminary correction of rotations
5. Preliminary correction of axial positions
Stage III: Edgewise phase (Uprighting)
1. Detailed axial positioning of all teeth
2. Lingual root torque for labial axial
inclination of the maxillary incisors
3. Root paralleling in extraction areas
4. Desired uprighting of molars
5. Artistic positioning of incisor segments
6. Complete correction of rotations
7. Residual space closure
Retention
Two years — indefinite

Overview of the Combination
Technique philosophy
The Combination Technique incorporated three stages of appliance therapy:
Stage I
The initial stage was called the lightwire or tipping phase, employing 0.014,
0.016 and 0.018 round wires, which
required approximately four to eight
months to achieve desired results. This
first phase employed Dr. Raymond Begg’s
concept of light, continuous forces to uncrowd anterior teeth, open the bite (restore vertical dimension), reduce the protrusion, begin closing extraction spaces
and uprighting mandibular incisors, all
without straining the posterior anchorage unit.
The Begg philosophy and mechanotherapy produced light, physiologic forces through the use of one-point contact,
free-sliding, non-binding and continuously moving teeth that were connected
to the archwire (Begg, 1961). Fogel and
Magill created this appliance by uniting
the light-wire vertical insert pin (Fig. 1a)
with the widely spaced twin edgewise
bracket (Fig. 2b) into a single appliance
unit (Fig. 1c).
The joining together of these two attachments enabled the development of
a system for controlled light-wire therapy in the first stage of the Combination
Technique. (All figures are from Fogel
and Magill’s “The Combination Technique in Orthodontic Practice.”)
During Stage I (light-wire and tipping),
a single light archwire with multiple
loops and hooks was snapped into the
vertical insert pins to produce simple
tipping of the incisors, placing them
in harmony with and upright over the
apical base (Figs. 2a, 2b). This included
correction of overjet, overbite and jaw
relationships by means of controlled anchorage through the use of differential
inter- and intra-arch elastic forces.
Stage II
The second stage was the called the leveling phase, employing a multi-stranded
” See COMBINATION, page 4

Fig. 4a

Fig. 5

Fig. 4b

Fig. 4c

Fig. 6

[4] =>

CLINICAL

Ortho Tribune U.S. Edition | WINTER 2012

“ COMBINATION, Page 3
light wire, which was later replaced by
0.014, 0.016 and 0.018 round flexible
wires, ligated into the edgewise brackets,
requiring approximately three to four
months to achieve the desired results.
This second phase included leveling
and aligning maxillary and mandibular
arches, closing extraction spaces, uprighting cuspids and bicuspids and correcting rotations of all teeth.
During Stage II (bracket alignment and
leveling), a multi-stranded light-wire
(Figs. 3a, 3b) was used to create controlled
general alignment of all teeth, including leveling, correction of rotations, preliminary correction of axial positions,
continued overbite correction and establishment of general arch form. Stage II
prepared the brackets for the edgewise
phase.
Stage III
The third stage was the called the edgewise phase, employing 0.016 x 0.016
square wires, followed by 0.017 x 0.025
rectangular wires, also ligated into the
edgewise brackets and taking approximately six to 12 months to achieve results. This third phase included detailed
positioning, proper uprighting and ideal
axial inclinations of all teeth. The Combination Technique was excellent for treating extraction cases and difficult malocclusions, as well as being very capable of
obtaining outstanding results in nonextraction cases.
During Stage III (edgewise), the rectangular archwire (Figs. 4a–4c) was used
to achieve ideal arch form and detailed
axial positioning of both the crowns and
roots of all teeth.
This included: (a) root paralleling of
teeth adjacent to the extraction areas, (b)
uprighting of molar teeth, (c) artistic positioning of the incisor segments, (d) continued overbite correction if necessary, (e)
final closing of residual extraction spaces,
and (f) lingual root torque for labial axial
inclination of the maxillary incisors.
Torquing auxiliary
During the correction of many severe
malocclusions, the maxillary incisors required root torque as a result of lingual
crown tipping. In order to accomplish
incisor root torquing, an auxiliary wire
was employed similar to that used by
Begg during Stage III. The torquing auxiliary (Fig. 5) was an 0.014 wire constructed
with two loops in the same plane as the
archwire, which when snapped into the
insert pins placed the loops onto the
maxillary central incisors slightly subgingival. After snapping the torquing
auxiliary into the insert pins anteriorly
(Fig. 6), it was cinched behind the molar
tubes posteriorly.
This torquing auxiliary was used in addition to the main edgewise wire, which
had been ligated into the horizontal
slot of the widely spaced twin edgewise
bracket to carry out the desired objectives of Stage III as well as providing anchorage and stability during the torquing
procedure. The torquing auxiliary forces
produced approximately one degree of
lingual root movement per month. This
was substantiated by cephalometric and
visual examination.

Example of the Combination
Technique in a severe malocclusion
Treatment of a Class II, Division I severe

Fig. 7a

Fig. 7b

Fig. 7c

Fig. 7d

Fig. 7e

Fig. 7f

Fig. 7g

Fig. 7h

Fig. 7i

Fig. 7j

Fig. 8a

Fig. 8b

maxillary protrusion and deep overbite is shown, using maxillary first and
mandibular second bicuspid extractions
(Figs. 7a–7j).
Incisor coverage biteplate (Figs. 8a–8c)
was required as a preliminary step as a
result of the severe deep anterior overbite. This created initial bite opening
and avoided shearing of brackets, tearing of bands and occlusal interferences.

Combination Technique mechanics
Stage I — Single strand light-wire stage
(Figs. 9a–9c).
The objectives of Stage I were to
achieve: (a) reduction of the protrusion
(edge-to-edge incisor relation), (b) bite
opening (molar uprighting and incisor
intrusion), (c) incisor uncrowding and (d)
Class I cuspid and molar relationships.
Stage II — Leveling with a multi-strand
light-wire stage (Figs. 10a–10c).
The objectives of Stage II were to
achieve: (a) leveling and aligning of all
brackets for edgewise archwire placement, (b) preliminary uprighting of
cuspids and bicuspids, (c) correction of
rotations and labiolingual malpositions,
(d) continued bite opening, and (e) arch
symmetry.

Fig. 8c

The advantages of the multiple leveling appliance when compared to the single strand wire included a longer range
of action, better resistance for distortion, increased flexibility, gentler forces
and less fatigue.
Stage III — Edgewise stage (Figs. 11a–
11c).
The objectives of Stage III were to
achieve: (a) a stable anchorage for Class
II elastics, (b) correct axial inclinations,
(c) root paralleling in extraction areas,
(d) uprighting of the molars and bicuspids, (e) ideal arch form, (f) continued
overbite correction and (f) final closure
of residual spaces.

Summary
Historically, Dr. Maxwell Fogel and Dr.
Jack Magill believed that the unification
of the Begg light-wire and the Tweed
edgewise philosophies produced an
ideal milieu for (a) universal action and
controlled tooth movement in all directions; (b) automatic, self-acting appliances, with a long span of action, a few
adjustment periods; and (c) simple, uniform design, painless and compatible
with the tissues surrounding the teeth.
According to Fogel and Magill (1972),

anchorage was the focal point in successful treatment; gentle, free tipping
movements of the canines in a distal
direction into the extraction spaces
imposed less stress on the anchor units
than did bodily distal of the solidly embedded teeth. For many years, tipping
movements for anchorage preservation
was looked upon with great skepticism.
The widely spaced twin edgewise
bracket, as suggested by Dr. Brainerd
Swain in 1949, was used to solve the
problem of paralleling roots when closing extraction spaces. As Dr. Cecil Steiner succinctly stated: “A single arch wire
of uniform standard design and size
cannot serve with equal efficiency for
the various purposes necessary” (Fogel
& Magill 1972). It follows that different
types of appliance units require appropriate construction and design so that
a variety of wire sizes may be used for
proficient and controlled performances
effecting an assortment of significant
assignments.
Fogel and Magill combined the twin
edgewise bracket with a vertically placed
insert pin to produce a natural union as
a receptacle for both pliable light-wires
and rectangular wires simultaneously.
The Combination Technique’s single ap-

[5] =>

Ortho Tribune U.S. Edition | WINTER 2012

pliance receptacle offered the ability to
achieve the desired treatment procedures and objectives. Their goal was to
produce a technique that would correct
average as well as severe malocclusions
with better results in less time and with
greater ease.
This original Combination Technique
incorporated a system for moving teeth
whereby the teeth remained in place as
a result of the equilibrium that existed
among the oral musculature including
the lips, tongue and the muscles of mastication. Axial correction of root angulations was no longer a problem.
Positioning the mandibular incisors
over the basal bone enhanced anchorage potentialities and helped to achieve
a more functional and stable occlusion.
Any force that disrupted this equilibrium created an environment for the
teeth to move. When a very light resilient wire is ligated into a crowded dentition, the wire attempts returning to the
original shape. If the wire is tied tightly
to the teeth, forces are transmitted reciprocally between the individual teeth
in the arch. Any extraneous forces are
controlled as a result of the anchorage
unit.
During the late 1970s, Fogel and
Magill
introduced
a
secondgeneration
combination
bracket, which featured a double selfligating attachment bracket to facilitate
wire insertion.
It was called the “Modular Self-Locking Appliance System: Variation of the
Combination Technique.” The success
of this bracket was hindered by the deficiencies in the metallurgy technology.
The locking mechanism fatigued after several adjustments. The availability of light memory wires had not yet
appeared, necessitating more frequent
wire changes.
Still, the concept was sound. The Combination Technique was used well into
the 1990s and was modified by many of
its proponents. During the 1990s, most
orthodontists employed some form of
light-wire edgewise technique with preangulated and pre–torqued brackets.
Ligatureless Edgewise brackets first
appeared in the 1930s with the Russell
Lock appliance (Sathler et al 2011), which
was an attempt to improve the clinical
effectiveness for moving teeth while reducing the time required to ligate a wire
into the brackets.
Numerous articles regarding selfligating orthodontic brackets can be
found in the literature (Self-ligating
brackets, 2012), with more than 20 original patents for new self-ligating brackets; some have gone by the wayside
and some have lasted the test of time.
Sathler et al (2011) provided an excellent
review of the literature regarding selfligating brackets used in orthodontics.
It is interesting to note that many articles describe self-ligating brackets as either the new buzzword or as a faster and
more efficient method of tooth movement in orthodontic treatment.
However, in reality the self-ligating
bracket has prevailed since the 1930s. It
has been more than 50 years since Dr.
Raymond Begg introduced his “Light
Arch Wire Technique” in the late 1950s
(Begg 1961), and Fogel and Magill introduced their Combination Technique in
the late 1960s (Fogel & Magill 1969), yet
” See COMBINATION, page 6

CLINICAL

Fig. 9a

Fig. 9c

Fig. 9b

Fig. 10a

Fig. 10b

Fig. 10c

Fig. 11a

Fig. 11b

Fig. 11c
AD

[6] =>

Industry
CLINICAL

6

Ortho Tribune U.S. Edition | WINTER 2012

Tooth positioning appliances:
an orthodontist’s experience
By Barry Raphael, DMD

I’ve been actively involved with early
treatment ever since I first saw Jim McNamara in the early 1980s. Since that time,
I’ve seen a lot of theories and “systems”
come and go. As a specialist with a university training that taught me 14 different
treatment styles (University of Pennsylvania, DMD, 1978, and Fairleigh Dickinson
University, orthodontics, 1983) I’ve become
accustomed to evaluating different ideas,
both clinical and research-based and offering my patients the best of all the options
available.
I keep my mind open to new ideas but am
always skeptical of the “quick-fix” solutions
to age-old problems. However, though I
think research is the key to establishing
a real understanding of issues, evidencebased dentistry or evidence-based orthodontics just cannot keep up with clinical
innovations and, thus, our experience and
judgment is tested on a daily basis.
For years, I wondered about the claims
being made about tooth-guidance appliances and whether there was really a place
for this type of appliance in my practice.
I started to see things differently after

about to finish up, and the bite just won’t
settle down. And getting these cases referred out for the oral myology they need
doesn’t always happen. I now have a certified oral myologist in my practice.
What caught my eye about toothguidance appliances when I first read about
them was the fact that they were not solely
aimed at influencing the teeth, but that
they were focusing on the musculature.
Fig. 1a

Fig. 2a

seeking a solution to one of the many vexing problems I encounter with fixed appliance therapy every single day: namely,
closing open bites. It all started when I

8)

9)

References
1)

2)

3)

4)

5)

6)

7)

Begg, R. (1961). Light arch wire technique.
American Journal of Orthodontics; 47(1):
pp. 30–48.
Fogel M. and Magill J. (June 1969). A fundamental re-appraisal of popular techniques with a collective approach toward appliance therapy. American
Journal of Orthodontics; 55(6):705–713.
Fogel M. and Magill J. (July 1970). Retrospective on progressive dentofacial
changes after treatment and retention.
Journal of Clinical Orthododontics;
4(7):407–417.
Fogel M. and Magill J. (1972). The Combination Technique in orthodontic practice. J.B. Lippincott Co: Philadelphia, PA.
Fogel M. and Magill J. (Sept 1976). The
modular self-locking appliance system
— A variation in the Combination Technique (Part 1): Journal of Clinical Orthododontics; 10(9):653–660.
Fogel M. and Magill J. (Oct 1976). The
modular self-locking appliance system
— A variation in the Combination Technique (Part 2): Journal of Clinical Orthododontics; 10(10):728–741.
Fogel M. & Magill J. (Nov 1976). The modular self-locking appliance system — A

Case 1
This patient presented in my practice at
the age of 10 with severe crowding. Treatment involved the use of an upper Farrell
Bent Wire System (BWS) combined with
MRC’s Soft Pre-Orthodontic (T4K) appliance (Figs. 1a, 1b).
The patient also took part in Trainer Activities to improve oral habits. After a period of 11 months, the BWS was removed
and the hard T4K was used. Treatment continues and will use the Myobrace to finish
the case (Figs. 2a, 2b).

Fig. 2b

Photos/Provided by Dr. Barry Raphael

“ COMBINATION, Page 5
seldom are they cited in articles, reference lists or bibliographic lists for selfligating brackets.
As John F. Kennedy (1963) so adroitly
stated, “A man may die, nations may rise
and fall, but an idea lives on … we must
find time to stop and thank the people
who make a difference in our lives.”

Fig. 1a

10)

11)

12)

13)

14)

15)

variation in the Combination Technique
(Part 3): Journal of Clinical Orthododontics; 10(11):826–835.
Fogel M. and Magill J. (Dec 1976). The
modular self-locking appliance system
— A variation in the Combination Technique (Part 4): Journal of Clinical Orthododontics; 10(12):906–917.
Fogel M. and Magill J. (Jan 1977). The
modular self-locking appliance system
— A variation in the Combination Technique (Part 5): Journal of Clinical Orthododontics; 11(1):51–59.
Fogel M. and Magill J. (1982). Begg and
straight wire: a combination approach
to treatment” American Journal of Orthodontics; 81(3):253.
John F. Kennedy. (1963). Quotations by
President John F. Kennedy. www.
goodreads.com/author/quotes/3047.
John_F_Kennedy
Messinger, S. & Tartakow, G. (2008).
Combination Technique 1976 vs. 2008
utilizing Leone’s revolutionary slide™
‘no-friction’ ligature — Part I, Ortho Tribune, New York City: (3) 2/3, p 8–9.
Messinger, S. & Tartakow, G. (2008).
Combination Technique 1976 vs. 2008
utilizing Leone’s revolutionary slide™ ‘no
friction’ ligature — Part II, Ortho Tribune, New York City: (3) 4, p 22.
Sathler, R., Silva, R., Janson, G., Cabral, N.,
Branco, C., & Zanda, M. (2011). Demystifying self-ligating brackets. Dental Press
Journal of Orthodontics; 16(2): 50.e1–8.
Self-ligating brackets. (2012). http://
scholar.google.com/scholar?q=Selfligating+orthodontic+brackets&hl=en&
as_sdt=0&as_vis=1&oi=scholart&sa=X&
ei=AB1TT8ioIMeViALW8YQ&ved=0CEIQg
QMwAA

had a run of lateral open bites with tongue
thrusts that resisted vertical elastics,
spurs and everything else I could throw at
them. You know the ones when you’re just

Case 2
This patient entered my clinic at nine years
of age with a Class II Division 1, bimaxil” See POSITIONING, page 7

About the author

“ RESEARCH, Page 2

Dennis J. Tartakow, editor in chief of Ortho Tri-

nals and textbooks.
As a pragmatist and realist, I see the
worldview of a research question for
allowing the researcher to be open to
(a) multiple methods of data collection, such as qualitative and quantitative sources; (b) focus on practical
implications of research; and (c) emphasize the importance of conducting research that best addresses the
research problem.
When exploring a pragmatic research problem from the most relative aspects of our social environment, postmodern perspectives
must be addressed and interspersed
with racial, gender and ethnic considerations.
As ADEA Executive Director Richard W. Valachovic stated in a monthly
newsletter, we must ensure that all
graduating dental students glean an
appreciation for accessing and applying the knowledge research provides
and the value of research.

bune, practiced orthodontics, temporomandibular
joint (TMJ) disorders
and orofacial pain
therapy

in

Palm

Beach, Fla., and now
resides in Marina del
Rey, Calif. Tartakow
is a consultant in
orthodontics,

TMJ

disorders, orofacial
pain, practice management

and

health-care administration. He counsels pre- and postgraduate students,
orthodontists and health-care practitioners and
has provided expert testimony in numerous orthodontic, TMJ and medico-legal litigation cases. His
professional accomplishments include being a diplomate of the American Board of Orthodontics; a
diplomate of the American Board of Special Care
Dentistry; and a certified dental editor. He is clinical
associate professor and former director of the TMD
section, postgraduate orthodontic department,
Nova Southeastern University, College of Dental

References

Medicine, Fort Lauderdale, Fla.; senior attending,

1)

postgraduate orthodontic section, Albert Einstein
Medical Center, The Maxwell S. Fogel Department
of Dental Medicine, Philadelphia; and clinical associate professor, orthodontic department, craniofa-

2)

cial sciences and therapeutics, University of Southern California, School of Dentistry, Los Angeles;
former primary adjunct professor, the Union Institute and University, Graduate College, North Miami Beach, Fla.; and Research Council member of
the J. Paul Getty Research Institute and Library, Los
Angeles.

3)

Dewey, J. (2005). The Quest for Certainty: A Study of the Relation of
Knowledge And Action. Kessinger Publishing.
Tartakow, D. (2010). An analysis of factors that align with faculty vacancies
in orthodontic education. Dissertation
Abstracts, University of Michigan. Ann
Arbor, MI.
Thayer, H.S. (1968) Meaning and Action: A Critical History of Pragmatism.
The Bobbs-Merrill Company, Inc.

[7] =>

clinical

Ortho Tribune U.S. Edition | WINTER 2012

Fig. 3a

Fig. 4a

Fig. 5a

Fig. 6a

Fig. 5b

Fig. 6b

Fig. 3b

Fig. 4b

‘Every orthodontist knows the musculature
is influential on growth and development.’

“ POSITIONING, Page 6
lary retrusion. She had a narrow maxillary
arch, lip entrapment under the excess over
jet, deep anterior overbite and crowding of
the lower anterior teeth. She had a forward
head posture with habitual open mouth
posture. Facial muscles were overactive
on swallowing. She also has a low maxillary frenum and a midline diastema (Figs.
3a,3b).
After one year of treatment with an upper and lower BWS (six and four months,
respectively), i2n trainer (for three months)
and an i2 trainer (for six months), the malocclusion and the soft tissue dysfunctions
were corrected. The bi-maxillary retrusive
skeletal pattern and profile remains at this
point, though much growth remains (Figs.
4a,4b).

Case 3
This patient presented in my clinic at age
7 with an adequate arch form but a deep
overbite. This is a perfect case to show how
a little interceptive treatment can go a long
way to solving problems that would be
harder to correct later on (Figs. 5a,5b).
The Soft T4K was used for four months,
followed by the Hard T4K for three months
longer, at which point the overbite was resolved. The Hard T4K was used for seven
more months, at which point less intensive use of the Hard T4K was prescribed.
The T4K was used to assist 10 minutes of
daily trainer activities to improve poor oral
habits during a period of 18 months, after
which the use of the T4K was discontinued.
The patient still performs posture exercises for the long term (Figs. 6a,6b).
Correcting deep overbites with fixed
appliances can be difficult, requiring bite
planes or turbos along with full strap ups.
This case was essentially solved in the first
four months and continued to improve
thereafter. No other treatment is anticipated
Every orthodontist knows the musculature is influential on growth and development. For this, the evidence is clear.
Angle1 knew it. Alfred Rogers2 knew it.
Graber3 knew it and raised holy hell about
it. Straub4 helped create a subspecialty
around it. Harvold5 showed us how critical
airway is. The same Proffit6 signed off on
Tulloch’s7 work taught us about postural
tongue position. Moss8 and Enlow9 showed
us how it worked. Estuki Kondo’s “Muscle
Wins”10 shows soft tissues and local factors
to be critical in the development of malposition and malocclusion of the teeth.
” See POSITIONING, page 8

[8] =>

clinical

Ortho Tribune U.S. Edition | WINTER 2012

“ POSITIONING, Page 7
The question that all these icons of our
specialty raised is whether the soft tissues
and skeletal structures of the mouth and
face are indeed genetically determined, or
if perhaps they are subject to the same environmental influences as all other bones
and muscles of our body (Boyd 2012)11. Indeed, you can change the muscle mass of
your biceps in two weeks just by stressing
it with weights. Likewise, two weeks prone
in a hospital bed can render them weak.
Why can’t the same apply to the muscles
of the mouth?
We also know that bone responds to the
forces that surround it, in both the functional and capsular matrices.8 The action
of the muscles certainly influences hard
tissues.
The capsular matrices of the mouth are
constantly active: if we are not talking,
eating, swallowing, laughing or drinking,
we are certainly breathing. There is never
a moment of non-activity of the oro-nasopharynx, and the way it is being used is
reflected in how the structures that surround it grow. Again, muscle rules.
Isn’t it likely that all relapse we deal
with, both orthodontic and orthognathic,
has less to do with the teeth than it does
with the muscles that created the malformations in the first place? It seems so
simple a concept, why is it still considered
so radical a thought?
We can’t say that muscles can’t be
trained. We teach the tongue and the
masticatory muscles to speak a language,
don’t we? Why can’t we teach muscles
to swallow and posture properly, too?
The tongue doesn’t need to be pushing
against the teeth, ruining all my good
orthodontic work. I want to teach it to go
up on the palate where it belongs during
rest and swallowing.
Tooth positioning and myofunctional
orthodontic appliances have provided me
with a treatment modality that I can use
in my office to train the musculature. Yes,
these appliances do have the disadvantage of requiring cooperation. So do elastics. So do piano lessons and dance lessons and schoolwork for that matter. And
sometimes we suffer the children. But
when they comply, I am finding that controlling the musculature — getting the
tongue away from the teeth and calming
the lips and cheeks during swallowing
and rest - has been a godsend for my orthodontics.
When it comes to early treatment, the
same thinking applies. The muscles of the
functional matrix are certainly active way

“ SOBLER, Page 1
blers aim to utilize the most up-to-date
and advanced orthodontic technology,
including the Roth/Williams method of
treatment, laser dentistry, craniofacial
treatments, lingual braces and cleft palate treatments.
One of Dr. Terry Sobler’s highest honors came in 1981 when he became a
diplomate of the American Board of Orthodontics. Less than 20 percent of practicing orthodontists have completed the
rigorous requirements to become a diplomate of the ABO.
“He’s definitely still in the mix, and he
stays on top of things,” Ian Sobler said.
“He’s not going anywhere. It’s a nice
blend of old school and new school.”

At left, Farrell Bent Wire System (BWS). At right, pre-orthodontic trainer (T4K) by Myofunctional Research (Queensland, Australia).
Photos/Proviced by Myofunctional Research.

before we ever get to see these kids. Tongue
thrusts develop early. Mouth breathing —
and all the allergies, asthma and URT infections that go with it — are present even in
the very young. Can we say that it is having
no effect on the growing osseous structures? Could the way the bones of the face
form be free from their influence? With all
that the evidence shows, it becomes impossible, even irresponsible, to overlook the
potential that muscle has to influence the
teeth and face.
However, the question of how much of
facial growth is genotype and how much is
phenotype is indeed a legitimate one and is
certainly open to debate. Personally, with
my reading of the literature (Mew, 2004)12
and what I’ve come to learn about musculature, I am leaning more toward the “phenotype” side than ever before. I think we
are missing the point when we talk about
the “growth and development” that we give
so much lip service to. Instead, we should
be talking about “growth, development
and adaptation” with an emphasis on the
latter element.
In my view, and in Tom Graber’s view3,
the musculature is doing “early treatment”
to the face whether we are there or not. And
what we see by the time kids are “ready for
braces” is the by-product of that muscular
treatment.
So, to me, the debate over genotype or
phenotype and the credibility of early
treatment and the influence of the muscles
begs the question: Am I going to stand by
with benign neglect while the muscles are
literally distorting this child’s teeth, alveolus, maxilla and, yes, even face? Isn’t that
like saying, “We can’t change people’s behavior (diet and exercise), so let’s just wait
for them to have a heart attack and then

argue about whether a bypass or stent is
best” (like we argue about one-phase and
two-phase therapies)?
It’s a fallacious argument. The crooked
teeth aren’t the disease. Like a heart attack,
they are merely symptomatic of a problem that has been festering for years. And
just as physicians have a responsibility to
teach their patients about the benefits of
good diet and exercise (whether we listen
or not), I believe we have a responsibility to
teach our patients and parents about good
and bad muscular habits and their affect
on their precious children’s faces. We are
the physicians of the face, not just tooth
mechanics. The periodontists know this. I
think it is time we orthodontists learn this
as well.
And once you learn this lesson, well, the
teeth will guide themselves into place.

Dr. Ian Sobler was awarded Align Technology’s Invisalign Leader Award for
having treated the most successful Invisalign cases and was the chief resident
at New York University’s orthodontics
program.
Being involved in serving the community is another important component of
Sobler Orthodontics.
Both Soblers are consultants for the
Camp Jawonio Cranio-facial Anomalies
Center and REFUAH health center.
“We treat most of the special needs
patients in the county, focusing on cleft
palates,” Ian Sobler said. “We serve with
Jawonio as the only orthodontists on
that team. We donate our time there because we really believe that anyone can
and should be treated.”

Jawonio is a provider of lifespan services in the Hudson Valley for people
with developmental disabilities, mental
illness and chronic health needs. For
more than 60 years, Jawonio has provided support and services for individuals
with developmental disabilities and special needs throughout the lower Hudson
Valley and Northern New Jersey.
In addition to their philanthropic efforts, the Soblers stay abreast of orthodontic trends and news in a number of
organizations.
Dr. Terry Sobler is a member of the
College of Diplomates of the American
Board of Orthodontics, the American
Association of Orthodontists, Northeastern Society of Orthodontists (NESO)
and the New Conn Orthodontic Founda-

References
1)

5)
6)

Angle Edward H. Treatment of Malocclusion
of
the
Teeth.
In:
Philadelphia:
S. S. White Dental Mfg. Co; 1907.
Rogers, Alfred, A Restatement of the Myofunctional Concept in Orthodontics, AJO,
1950, 36(11), 845-855. ; Rogers, Alfred, Simplifying
Orthodontic
Treatment,
IntJOrtho, June, 1926, xii.
Graber, Thomas M., The 3 M’s: Muscles, Malocclusion, and Malformation, AJO, 1963,
49(6), 418–450.
Straub, Walter., Malfunction of the Toungue,
AJO, 1960, 46(6), 404–424 (The first of 3 installments).
Harvold, Egli, Primate experiments on oral
respiration, 1981, 79(4), 359–372.
Proffit WR, Fields HW, Sarver DM. Contemporary Orthodontics, Fourth Edition, Mosby
–Elsevier, 2005, chapter 2, pp. 27–39.
Tulloch, J.F.C, et.al., The effect of early inter-

9)
10)

11)

12)

vention on skeletal pattern in Class II malocclusion: A randomized clinical trial, AJODO,
1997, 111(4), 391–400.
Moss, M and Salentijn, L, The primary role of
functional matricies in facial growth. AJODO, 1969, 55(6), 566–577.
Enlow, D, and Moyers, R, Handbook of Facial
Growth, Saunders, 1982.
Kondo, Estuko, Muscle Wins!: Treatment in
Clinical Orthodontics : Muscle and Respiration Oriented Orthodontic Treatment and
Long Term Occlusal Stability, DaehanNarae,
2008.
Boyd, Kevin, Darwinian Dentistry, An Evolutionary Perspective on the Etiology of Malocclusion, JAOS, 2011, Nov/Dec, 34–40.
Mew, John, The Postural Basis of Malocclusion, a philosophical overview, AJODO, 2004,
126(6), 729–738.

About the author
Barry Raphael, DMD, has
practiced orthodontics for 27
years. During this time, he
has benefited from all the
advances that modern orthodontic treatment has to offer, including functional orthodontics and low-force,
low-friction techniques. Although Raphael has been practicing orthodontics
for almost three decades, he has only recently begun to recognize the benefits of myofunctional
therapy in his practice. He also has first-hand experience with moving from a “tooth-centric” philosophy of orthodontic mechanotherapy to a “musclecentric” philosophy of orofacial development.
Raphael offers clinical insight into the changes he’s
made in his own practice and where he thinks orthodontic practice and education are heading. He
may be contacted at drbarry@alignmine.com

tion. He has served as past president of
the Rockland County Dental Society and
former president of the New Conn. Orthodontic Foundation. He also serves as a
clinical faculty member at NYU College
of Dentistry, department of Orthodontics and Dento-facial Orthopedics, and is
a consultant for the Montefiore Medical
Center Cranio-facial Anomalies Center.
Dr. Ian Sobler is a consultant for
Camp Jawanio Cranio-facial anomalies
center and REFUAH health center. He
is a member of the American Association of Orthodontists; the Northeastern Society of Orthodontists (NESO),
new and young members committee; and the New Conn Orthodontic
Foundation. He was the chief resident at NYU’s orthodontics program.

[9] =>

Ortho Tribune U.S. Edition | WINTER 2012

events

9

Scenes from MASO

The Middle Atlantic Society of Orthodontists hosted
its annual session at the Hilton Baltimore in September

T

he Middle Atlantic Society of
Orthodontists’ new member on
its board of directors is Dr. Tarun (Ty) Saini from Maryland.
He joins its existing directors: Dr. Doug
Harte, Dr. Russell Sandman, Dr. Robert
Penna, and Dr. Normand Boucher, as well
as Dr. Lawrence Wang (president elect),
Dr. Stephanie Steckel (secretary), Dr. Jean
Asmar (treasurer), Dr. Robert Williams
(editor), Dr. Nahid Maleki (MASO trustee)
and Anita Field (executive director).

Photos
by Gina
Davison,
Dental
Tribune
AD

[10] =>

industry

Ortho Tribune U.S. Edition | WINTER 2012

3Shape announces official
launch of TRIOS for sales
in North America
3Shape TRIOS is a complete digital impression solution
that includes intraoral scanning, clinical scan-validation,
plus seamless communication with the lab

Shape, a global leader in 3-D scanning technologies and CAD/CAM
software for dental applications,
declares “all systems go” for nationwide sales of its TRIOS® solution in
the United States and Canada. The official announcement was at the American
Dental Association’s Annual Session in
San Francisco, and now, TRIOS resellers
are busily taking orders for next-month
delivery of new systems to clinics in the
United States and Canada.

Strong network of reselling partners
and supporters
3Shape has signed up a wide network of
prominent national and local resellers
to distribute TRIOS throughout North
America to dentists, dental specialists,
dental schools and more. 3Shape’s strong
distribution foundation has been carefully constructed to ensure optimal
geographical coverage and fulfillment
of 3Shape’s high standards for customer service and support of its products.
TRIOS resellers are all experienced dental
supplier professionals and amply trained
by 3Shape to install and support TRIOS
for their customers in local clinics.

Certification and full regulatory
compliance in place
The TRIOS system, as a medical device, is
continuously developed under the strict
regulations of the FDA and ISO 13485 requirements. 3Shape has passed all final
safety tests and production inspections
required for authorized sales and marketing of the TRIOS system in the USA.

Closing in on complete digital
workflows between clinic and lab
TRIOS enables dentists to rapidly capture
the complete intraoral situation and send
the 3-D model directly to the lab. It does
not require pre-spraying of the teeth.
The system clinically validates the impression, and includes flexible tools allowing dentists to edit their scans. Labs
and dentists can communicate about the
case using 3-D design visualizations, annotations and messages. The unique fulldigital workflow is designed to enhance
close collaboration with the lab and allow the dentist to focus more on treating
patients. By utilizing the lab’s CAD/CAM

3Shape’s TRIOS provides state-of-the-art intraoral scanning technology, the company says. Photo/Provided by 3Shape

expertise, along with its wide range of
indications, and materials possibilities,
dentists can provide their patients with
more treatment options and restorations
of the best possible quality and fit.

A market ripe for TRIOS unique
impression technologies
In recent months, 3Shape has been touring the United States, demonstrating
TRIOS for dental professionals, and the
success of these live events affirms the
great interest in this new digital impression solution throughout the U.S. dental
market.
“We are very excited to bring state-ofthe-art intraoral scanner technology to
the largest dental market in the world,”
said Flemming Thorup, 3Shape’s president and CEO. “The many North American labs that are using 3Shape Dental
SystemTM , or those who order our TRIOS
InBox separately, will be able to connect
with clinics using TRIOS.

“We believe that 3Shape will soon become a strong brand in clinics — just as it
has in labs,” Thorup concluded.
In order to further strengthen support and services and closely backup its
partners, 3Shape recently established a
new office near Los Angeles, ensuring
business-hour coverage throughout the
country.

About 3Shape
3Shape is a Danish company specializing in the development and marketing
of 3-D scanners and CAD/CAM software
solutions designed for the creation, processing, analysis and management of
high-quality 3-D data for application
in complex manufacturing processes.
3Shape envisions the age of the “full
digital dental lab,” and its more than
130 developers provide superior innovation power toward reaching this goal.
3Shape’s flexible solutions empower dental professionals through automation of

real workflows, and its systems are applied in thousands of labs in more than
90 countries worldwide, putting 3Shape
technologies at the peak of the market
in relation to units produced per day by
dental technicians. With TRIOS, 3Shape
now brings its vast expertise and innovation power directly to dentists. 3Shape
boosts its first-line distributor support
network with a second-line support force
of more than 30 in-house experts placed
in five support and service centers strategically located around the globe.
3Shape is a privately held company
headquartered in Copenhagen, with the
market’s largest team dedicated to scanner and software development for the
dental segment based in Denmark and
Ukraine, production facilities in Poland,
and business development and support
offices in New Jersey and Asia. For further
information regarding 3Shape, refer to
www.3shapedental.com. Also visit 3Shape
on www.facebook.com/3shape

[11] =>

Ortho Tribune U.S. Edition | WINTER 2012

Industry

11

[12] =>

12

industry

Ortho Tribune U.S. Edition | WINTER 2012

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[cover] => Ortho Tribune U.S. No. 6, 2012

[toc] => Array ( [0] => Array ( [title] => A review of the Original Combination Technique and Philosophy [page] => 01 ) [1] => Array ( [title] => What is pragmatic research? [page] => 02 ) [2] => Array ( [title] => Tooth positioning appliances: an orthodontist’s experience [page] => 06 ) [3] => Array ( [title] => Events [page] => 09 ) [4] => Array ( [title] => Industry [page] => 10 ) ) [toc_html] =>

Table of contents

[toc_titles] =>

A review of the Original Combination Technique and Philosophy / What is pragmatic research? / Tooth positioning appliances: an orthodontist’s experience / Events / Industry

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