On the management of extraction sites

Longitudinal behavior of orthodontic extraction spaces: A retrospective dental cast analysis

INTRODUCTION

This retrospective study aimed to qualitatively and quantitatively evaluate orthodontic extraction space behavior and size at the end of treatment and the short- and long-term stages in Class I, II, and III malocclusions.

METHODS

The sample comprised records of 1283 orthodontic patients treated with extractions (cross-sectional group). From these patients, 1- and 5-year posttreatment records of 214 patients were additionally evaluated (longitudinal group). Orthodontic extraction sites of immediate (end of treatment), short-term (1-year posttreatment), and long-term (5-year posttreatment) stage dental casts were measured with a digital caliper. Extraction spaces were classified according to their qualitative behavior in the open, closed, reopened, and recently closed spaces. Space qualitative longitudinal behavior was compared among the malocclusion types with chi-square tests. Kolmogorov-Smirnov normality tests were performed to check the variable's distribution. All variables showed normal distribution, except the malocclusion group ages. Therefore, parametric tests were used for all comparisons between the malocclusion groups, except for age comparisons in each stage, which were compared with the Kruskal-Wallis tests. Thus, space size and its reduction were compared among the 3 stages, in general, and between the maxillary and mandibular arches, with analysis of variance followed by Tukey tests and t tests, respectively.

RESULTS

Classes I, II, and III malocclusion patients presented similar ages at each stage. At the end of treatment, 71.4% and 65.1% of the quadrants were closed in the cross-sectional and longitudinal groups, respectively, and 43.6% and 38.2% of patients presented all quadrants closed at this same stage in both groups. The reopening and late closure tendencies were 2.9 and 2.3 times greater in the short term than in the long term. Reopening tendency in the short-term was greater in Class II than in Class I malocclusion. Of the quadrants closed at the end of treatment, 87% were stable in the long term. From the quadrants with residual spaces at the end of treatment, 28.4% persisted openly in the long term. Residual space size reduced significantly in the short and long term, primarily in the mandibular arch.

CONCLUSIONS

The percentage of patients with residual spaces at the end of treatment was 56.4%. Space reopening and late closure occur mainly in the first year after treatment. There was long-term stability in 87% of the quadrants closed at the end of treatment. There was a significant reduction in orthodontic extraction space size in the short and long term, especially in the mandibular arch.

Orthodontic management of a horizontally impacted maxillary incisor in an adolescent patient

Horizontal maxillary incisor impaction is not common, but it affects facial esthetics, phonetics, and the patient's self-esteem. Therefore, it is necessary to manage this problem as early as possible. This case report presents a patient with an unerupted maxillary left central incisor combined with anterior and left posterior crossbite, edge-to-edge overbite on the right and left anterior open bite, low smile line, and mild skeletal Class III discrepancy. The treatment consisted of 3 stages: (1) maxillary expansion and sufficient space creation for the impacted tooth; (2) surgical exposure by closed-eruption technique; and (3) induced eruption of impaction. The treatment outcome was highly favorable. Maxillary impaction erupted in the proper position with a normal clinical crown height and consonant gingival line with the adjacent teeth. Maxillary and mandibular teeth had normal and stable occlusion. The 3-year follow-up demonstrated an esthetically functional outcome after orthodontically induced tooth eruption. This treatment required a good treatment plan by the orthodontist to obtain satisfactory results.

Frictionless segmented mechanics for controlled space closure

Extraction spaces may be needed to achieve specific orthodontic goals of positioning the dentition in harmony with the craniofacial complex. However, the fundamental reality that determines the occlusion final position is the control exerted by the orthodontist while closing the extraction spaces. A specific treatment objective may require the posterior teeth to remain in a constant position anteroposteriorly as well as vertically, while the anterior teeth occupy the entire extraction site. Another treatment objective may require the opposite, or any number of intentional alternatives of extraction site closure. The present case report describes a simple controlled segmented mechanic system that permitted definable and predictable force systems to be applied and allowed to predict the treatment outcome with confidence. This case was presented to the Brazilian Board of Orthodontics and Dentofacial Orthopedics (BBO) in partial fulfillment of the requirements for Diplomate certification.

Initial forces experienced by the anterior and posterior teeth during dental-anchored or skeletal-anchored en masse retraction in vitro

OBJECTIVE

To investigate initial forces acting on teeth around the arch during en masse retraction using an in vitro Orthodontic SIMulator (OSIM).

MATERIALS AND METHODS

The OSIM was used to represent the full maxillary arch in a case wherein both first premolars had been extracted. Dental and skeletal anchorage to a posted archwire and skeletal anchorage to a 10-mm power arm were all simulated. A 0.019 × 0.025-inch stainless steel archwire was used in all cases, and 15-mm light nickel-titanium springs were activated to approximately 150 g on both sides of the arch. A sample size of n = 40 springs were tested for each of the three groups. Multivariate analysis of variance (α = 0.05) was used to determine differences between treatment groups.

RESULTS

In the anterior segment, it was found that skeletal anchorage with power arms generated the largest retraction force (P < .001). The largest vertical forces on the unit were generated using skeletal anchorage, followed by skeletal anchorage with power arms, and finally dental anchorage. Power arms were found to generate larger intrusive forces on the lateral incisors and extrusive forces on the canines than on other groups. For the posterior anchorage unit, dental anchorage generated the largest protraction and palatal forces. Negligible forces were measured for both skeletal anchorage groups. Vertical forces on the posterior unit were minimal in all cases (<0.1 N).

CONCLUSIONS

All retraction methods produced sufficient forces to retract the anterior teeth during en masse retraction. Skeletal anchorage reduced forces on the posterior teeth but introduced greater vertical forces on the anterior teeth.

Effect of activation and preactivation on the mechanical behavior and neutral position of stainless steel and beta-titanium T-loops

Objective

To quantify, for each activation, the effect of preactivations of differing distribution and intensity on the neutral position of T-loops (7-mm height), specifically the horizontal force, moment to force (M/F) ratio, and load to deflection ratio.

Methods

A total 100 loops measuring 0.017 × 0.025 inches in cross-section were divided into two groups (n = 50 each) according to composition, either stainless steel or beta-titanium. The two groups were further divided into five subgroups, 10 loops each, corresponding to the five preactivations tested: preactivations with occlusal distribution (0°, 20°, and 40°), gingival distribution (20°), and occlusal-gingival distribution (40°). The loops were subjected to a total activation of 6-mm with 0.5-mm iterations. Statistical analysis was performed using comprised ANOVA and Bonferoni multiple comparison tests, with a significance level of 5%.

Results

The location and intensity of preactivation influenced the force intensity. For the M/F ratio, the highest value achieved without preactivation was lower than the height of the loop. Without preactivation, the M/F ratio increased with activation, while the opposite effect was observed with preactivation. The increase in the M/F ratio was greater when the preactivation distribution was partially or fully gingival.

Conclusions

Depending on the preactivation distribution, displacement of uprights is higher or lower than the activation, which is a factor to consider in clinical practice.

En masse retraction versus two-step retraction of anterior teeth in extraction treatment of bimaxillary protrusion

In the present report, two techniques of space closure; two-step anterior teeth retraction (TSR) and en masse retraction (ER) were used in two adult patients who had bimaxillary protrusion and were treated with four premolar extractions and fixed orthodontic appliance therapy. Both patients had a Class I dental malocclusion and the same chief complaint, which is protrusive lips. Anterior teeth were retracted by two-step retraction; canine sliding followed by retraction of incisors with T-loop archwire in the first patient and by en masse retraction using Beta titanium alloy T-loop archwire in the second case. At the end of treatment, good balance and harmony of lips was achieved with maintenance of Class I relationships. The outcome of treatment was similar in the two patients with similar anchorage control. ER can be an acceptable alternative to the TSR during space closure since it is esthetically more acceptable. However, it requires accurate bending and positioning of the T-loop.

Effectiveness of en-masse retraction using midpalatal miniscrews and a modified transpalatal arch: Treatment duration and dentoskeletal changes

Objective

The purpose of this study was to compare the treatment duration and dentoskeletal changes between two different anchorage systems used to treat maxillary dentoalveolar protrusion and to examine the effectiveness of en-masse retraction using two miniscrews placed in the midpalatal suture.

Methods

Fifty-seven patients (9 men, 48 women), who had undergone level anchorage system treatment at Aichi-Gakuin University Dental Hospital (Nagoya, Japan) were divided into two groups according to the method of maxillary posterior anchorage reinforcement: midpalatal miniscrews (25 patients, mean age 22 years) and conventional anchorage (32 patients, mean age 19 years). The en-masse retraction period, overall treatment duration, pre-treatment effective ANB angle, and change in the effective ANB angle were compared with an independent-samples t-test.

Results

Compared to the headgear group, the duration of en-masse retraction was longer by approximately 4 months in the miniscrew group (p < 0.001). However, we found no significant difference in the total treatment duration between the groups. Moreover, a greater change in the effective ANB angle was observed in patients treated with miniscrews than in those treated with the conventional method (p < 0.05).

Conclusions

The level anchorage system treatment using miniscrews placed in the midpalatal area will allow orthodontists more time to control the anterior teeth during en-masse retraction, without increasing the total treatment duration. Furthermore, it achieves better dentoskeletal control than does the conventional anchorage method, thereby improving the quality of the treatment results.

Extrações de molares na Ortodontia

O tratamento ortodôntico com extração de molares em pacientes adultos é tecnicamente mais complexo, devido a inúmeros fatores. Em geral, o espaço a ser fechado é maior do que o espaço dos pré-molares e, por isso, a ancoragem é crítica e o tempo de tratamento mais longo. É comum esses casos apresentarem algum grau de comprometimento periodontal por causa da idade dos pacientes e, portanto, necessitam de maior controle da mecânica ortodôntica para reduzir os efeitos colaterais do fechamento do espaço. Por isso, bons resultados de finalização são mais difíceis de ser alcançados. Sendo assim, este artigo tem como objetivo apresentar as razões para a indicação de extração de molares nos tratamentos ortodônticos, as contraindicações, as diferentes fases da mecânica ortodôntica, esclarecer os fatores envolvidos nesse tipo de planejamento e tratamento e apresentar casos clínicos tratados com extração de molares.

Mechanical behaviour of a prototype orthodontic retraction spring: a numerical-experimental study

The purpose of this study was to examine the mechanical behaviour of orthodontic delta retraction springs. Twelve titanium-molybdenum (0.016 × 0.022 inch) delta loops were studied. The springs were analysed by means of the finite element (FE) method and experimental tests using a platform transducer. Each spring was activated from 0 to 6 mm. Statistical analysis of the data was carried out by one-way analysis of variance and Games-Howell parametric multiple comparison test for heterogeneous variances. FE analysis revealed that the stress level varied from 277 to 1273 MPa. At 6.1 mm (773 MPa), the springs were still in the elastic range. Force levels varied from 0.1 N (10 g) to 2.2 N (224 g) at 1.4-8.1 mm of activation for the numerical study and from 0.44 N (45 g) at 1 mm to 2.02 N (206 g) at 6 mm of activation in the experimental study. The spring rate was within the levels that are appropriate for clinical use (34 g/mm). Vertical forces (Fy) showed constancy and were of low magnitude. The anterior moment/force ratio from the experimental tests was 14 at 3 mm of activation decreasing to 10.7, 8.7, and 7.2, for 4, 5, and 6 mm of activation, respectively. The springs could be activated up to 7 mm without exceeding the elastic limit.

Experimental Investigation and Neural Network Modeling for Force System of Retraction T-Spring for Orthodontic Treatment

In this work three different cross section groups of stainless steel T-Spring, for tooth retraction, have been tested; each spring is activated for 1 mm, 2 mm, and 3 mm, and the resultant force system is evaluated by using a testing apparatus. The results showed that when the cross section and activation distances are increased, the horizontal force and moment increased, while for the moment-to-force ratio, the lowest mean value was at the first activation distance of the first group, and the highest mean values were at the third activation distance of the third group. All three groups at all activation distance are insufficient to produce bodily tooth movement. T-springs of the (0.016×0.022 in.) cross section and with frequent activation provide the best in force system production. An artificial neural network model was trained for simulation of the correlation between input parameters: spring cross section and activation distance, and the outputs spring force system. The network model has prediction ability with low mean error of force prediction (5.707%), and for the moment is (4.048%), and it can successfully reflect the results that were obtained experimentally with less costs and efforts.

Curvature Versus V-Bends in a Group B Titanium T-Loop Spring

Objective: To compare the system of forces acting on curvature and preactivated V-bends in titanium T-loop springs (TTLSs) made of 0.017- × 0.025-inch TMA (titanium molibdenium alloy) wire.

Materials and Methods: Pictures of TTLSs preactivated by curvature and V-bends were inserted in the LOOP software program to design both TTLSs. Symmetry was assured using the program. Both TTLSs used the same amount (length) of wire and had the same angulation between their anterior and posterior extremities when passive. The loops were activated 7 mm, and forces and moments were registered after each 0.5 mm of deactivation. The brackets were at the same height, separated by 23 mm and angulated 0°.

Results: The preactivated curvature TTLS delivered horizontal forces ranging from 34 gF to 456 gF, while the TTLS preactivated by V-bends delivered forces ranging from 54 gF to 517 gF. The forces decreased more (30 gF vs 33 gF) with every 0.5 mm of activation on the preactivated V-bend TTLS than on the preactivated curvature TTLS. Vertical forces were low and clinically insignificant for both TTLSs. The moment to force (MF) ratios were systematically higher on the preactivated curvature than on the preactivated V-bend TTLS (from 5.8 mm to 38.8 mm vs 4.7 mm to 28.3 mm).

Conclusions: Although both loops show symmetrical moments in their anterior and posterior extremities and can be used for group B anchorage, the curvature preactivated TTLS delivers lower horizontal forces and higher MF ratios than the acute preactivated V-bend TTLS.

Occlusal Changes Following Posterior Tooth Loss in Adults. Part 2. Clinical Parameters Associated with Movement of Teeth Adjacent to the Site of Posterior Tooth Loss

PURPOSE

Much anecdotal evidence is available on tooth positional changes following loss of an adjacent tooth, but only a few studies are available. In Part 1 of this series, supraeruption was assessed and Generalized Linear Models were made to determine the clinical parameters associated with the supraeruptive process. The models demonstrated that clinical parameters were not only associated with the extent of supraeruption, but also with the type of eruption present. This investigation of tooth positional changes adjacent to sites of posterior tooth loss attempts to provide increased understanding of the magnitude, direction, and associated features that may be helpful in decision making and treatment planning in the clinical setting.

MATERIALS AND METHODS

One hundred patients with an unopposed posterior tooth, with 100 age, sex, and bone level matched controls, were drawn from patients undergoing routine restorative care at Leeds Dental Institute. Study models were scanned, and the extent of eruption, type of eruption of the unopposed tooth, the overbite, overjet, buccal occlusion, and degree of crowding in the dentition, tipping, rotation, and buccal movement of the teeth associated with the edentulous site were recorded. Generalized Linear Models were developed to examine associations between each tooth movement and patient or dental factors.

RESULTS

A statistical significance in the degree of tipping of teeth both mesial and distal to the extraction site was detected between the subject and control groups. There was also a significant difference in rotation of the tooth mesial to the site. Four Generalized Linear Models were produced of the types of non-vertical movements found in teeth associated with sites of tooth loss.

CONCLUSIONS

Teeth adjacent to the site of tooth loss may undergo non-vertical movements. Teeth mesial to the extraction site had a tendency to tip distally. The degree of tipping was increased in upper teeth and in subjects with a cusp-to-cusp buccal occlusion. Rotation of teeth mesial to the extraction site was more prevalent in the lower arch. Tipping of the tooth distal to the extraction site could be extreme and was found to be more prevalent in subjects with a reduced (Code 1) overbite and in the lower arch. Rotation of teeth distal to the extraction site was greater in the upper arch and was also associated with a reduced (Code 1) overbite. It also had an association with rotation of the tooth mesial to the extraction site. Models of non-vertical movement are likely to be of limited value due to overdispersion, indicating a high degree of variability within the model.

Extraoral appliances: a twenty-first century update

With the locations of the centers of resistance of the dentomaxillary complex having recently been defined, and with the newly acquired knowledge of the critical interplay between part-time extraoral and full-time intraoral force systems, the basic designs of all types of extraoral appliances are discussed in depth. Armed with this information, the clinician can improve the efficiency of all extraoral appliances to obtain better dentomaxillary-complex growth control and negate or enhance appliance-induced intraoral force systems.

Unusual orthodontic retreatment

This case report describes the retreatment of a patient with a Class II Division 1 malocclusion; she had the same anteroposterior discrepancy after undergoing fixed appliance treatment with extraction of 4 first premolars.