Table Of ContentOrthodontic and Dentofacial
Orthopedic Treatment
Thomas Rakosi, DDS, MD, MSD, PhD
ProfessorEmeritusandFormerChairman
DepartmentofOrthodontics
SchoolofDentalMedicine
AlbertLudwigsUniversity
Freiburg,Germany
Thomas M. Graber, DMD, MSD, PhD,
†
Odont Dr hc, DSc, ScD
FormerClinicalProfessorofOrthodontics
DepartmentofOrthodontics
CollegeofDentistry
UniversityofIllinoisatChicago
Chicago,IL,USA
Withcontributionsby
R.G.“Wick”Alexander,WilliamJ.Clark,JasonB.Cope,JackG.Dale,
M.AliDarendeliler,JohnDeVincenzo,MagdalenaKotova,Andrew
Kuhlberg,MichaelR.Marcotte,Rainer-ReginaldMiethke,C.Brian
Preston,JohnJ.Sheridan,AlexanderVardimon,BjørnZachrisson
1260illustrations
Thieme
Stuttgart·NewYork
IV
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1 2 3 4 5 6
V
In Memoriam
ThomasM.Graber,DMD,MSD,PhD,OdontDrhc,DSc,ScD,MD,FDSRCS(Eng)
*1917,†2007
VI
Contributors
R.G.“Wick”Alexander,DDS,MSD AndrewKuhlberg,DMD,MSD
ProfessorofOrthodontics PrivatePractice
BaylorCollegeofDentistry Avon,CT,USA
TexasA&MHealthScienceCenter
Dallas,TX MichaelR.Marcotte,DDS,MSD
PrivatePractice PrivatePractice
Arlington,TX,USA Bristol,CT,USA
WilliamJ.Clark,BDS,DDO Rainer-ReginaldMiethke,Dr.med.dent.,PhD
Orthodontist ProfessorandChair
Fife,Scotland,UK DepartmentofOrthodontics,DentofacialOrthopedics
andPedodontics
JasonB.Cope,DDS,PhD Charité,CenterforDentalMedicine
Diplomate,AmericanBoardofOrthodontics Berlin,Germany
AdjunctAssociateProfessor
DepartmentofOrthodontics C.BrianPreston,BDS,PhD,MSandCertificateinOrthodontics
St.LouisUniversity DepartmentofOrthodontics
St.Louis,MI,USA SchoolofDentalMedicine
UniversityatBuffalo
JackG.Dale,DDS TheStateUniversityofNewYork
PrivatePractice Buffalo,NY,USA
Toronto,Ontario,Canada
JohnJ.Sheridan,DDS,ABO
M.AliDarendeliler,DDS AssociateProfessor
ProfessorandChair SchoolofOrthodontics
DisciplineofOrthodontics JacksonvilleUniversity
FacultyofDentistry Jacksonville,FL,USA
UniversityofSydney
Head,DepartmentofOrthodontics AlexanderVardimon,DDS
SydneyDentalHospital AssociateProfessorandChairman
Sydney,NSW,Australia DepartmentofOrthodontics
TheMauriceandGabrielaGoldschlegerSchool
JohnDeVincenzo,DDS,MS ofDentalMedicine
ClinicalProfessor Head,TheInternationalPostgraduatePrograminOrthodontics
UCSF,DivisionofOrthodontics TelAvivUniversity
SanLuisObispo,CA,USA TelAviv,Israel
MagdalenaKotova,DDS,PhD BjørnZachrisson,DDS,MSD,PhD
ClinicalDepartmentofStomatology ProfessorII
ThirdFacultyofMedicine DepartmentofOrthodontics
CharlesUniversity FacultyofDentistry
Prague,CzechRepublic UniversityofOslo
Oslo,Norway
VII
A Clinical Roadmap for the New Orthodontics
TomGraberoriginallypreparedthisprefacebutunfortunatelyhe whichwasprintedinmorelanguagesthananyotherorthodontic
couldnotfinishit.Tomʼsinterestwasininternationalandnotna- text.“Droppingtheothershoe,”sotospeak,isthisnewtextOr-
tional orthodontics—with no dogmatism but looking pragmati- thodonticandDentofacialOrthopedicTreatment.Forthiswehave
callyinalldirectionsformethodsthathelpsolvevarioustypesof assembledanimpressivegroupofworld-classclinicianstocover
treatmentproblemswithselectiveindication.Thiswasthenature thoseaspectsthatwefeelaremostimportantforrenderingthe
ofTomandhisvision. highestlevelofserviceinthesafest,mostpractice-efficientway.
AfterTomʼsdeath,itwasdecidedtodedicatethisbooktohis Chapter1(TomRakosi)recapitulatesthefundamentalsofor-
memory.Asoriginallytheco-editorofthebook,Ihavecompleted thodonticdiagnosisaspreviouslypresentedinOrthodonticDiag-
thisprefacebutmaintainedthespiritofTomaswellthecontentof nosis, with special emphasis on therapeutic diagnosis. Eachpa-
theoriginal. tientvisitisadiagnosticexercise,assessingwhathasbeenaccom-
Inwhatfollows,essentiallyTomisspeakingtous.First-person plished,possibleproblems,andwhatremainstobedoneinthe
references convey his own experiences, enthusiasms, and wis- most time- and technique-efficient manner and with the most
dom.Myowninterpolationswillbeobvious. tissue-consciousapproach.
T.Rakosi Chapter2(BrianPreston)isonpreventiveorthodontics.Notall
orthodontic patients havefull-blown malocclusions. Experience
hasshownthatmanyproblemscanbeinterceptedearlyandfully
Ninevolatileyearsintoamillenniumweareallacutelyawareof corrected,thuspreventingfurtherdamageorsmoothingtheway
manychallengesthatconfrontusindiversefields.Everycountry forfullmechanotherapylater.Theexperienceddiagnosticianrec-
in the world faces political, financial, and economic quicksand, ognizesthesepatientsandinstituteslimitedproceduresthathave
andthefutureislesscertainthananyonewouldwish.Inamore adefinitecost–benefitratioforallconcerned.Someoftheseprob-
professionallyparochialsurvey,thefieldoforthodonticsandden- lemsarecoveredinOrthodonticDiagnosis,butthischapterdelin-
tofacialorthopedicshasseennocataclysmicevents,onlysteady eatessuchinstancesinmoredetail—withmoreofa“how-to”ap-
progressbasedonextensiveresearcharoundtheworld.Thede- proach.Theoldsaying“Anounceofpreventionisworthapound
mand for our services has encouraged the brightest minds to of cure” is most appropriate here. Such efforts are particularly
comeintoourspecialty.Thefinancialreturnshaveattractedcom- worthwhileintheareaofabnormalperioralhabits,withtheirpo-
mercialfirmstoprovidethearmamentariumweneed,andtech- tentialfordeformingthedevelopingdentition.Thesameistrue
nicaldevelopmentshavekeptpacewithscientificprogress.Not for abnormalrespiration. Theway toapproacheachproblem is
onlyaremorepatientsbeingtreated,but“service”isbetterthan to ask yourself “If this were my child, what would I think was
everbefore.Long-termevidence-basedassessmentoftreatment bestforthechild?”
resultsisnowavailable.Weknowprettywellwhatwecanand Chapter3(JackDale)coversinterceptiveguidanceofocclusion
cannotdoindentofacialorthopedicsandorthodontics. andextraction:theraisond’être,thetechnique,andlong-termre-
Ontheothersideofthecoin,thepotentialiatrogenicsequelae sults.JackDaleʼsmagnificentchaptersinotherbooks,hislectures
ofourservicesarecommonknowledgebothwithinourspecialty aroundtheworld,andhisdedicationtoexcellencehaveearned
and in the contingency-fee legal profession. The question “At him the preeminent status he now enjoys. His service on the
whatpriceorthodontics?”isanswerednowinbiological,biome- American Board of Orthodontics has provided exemplary guid-
chanical,andrisk-managementarenas.Someofthemostcompre- ancetoagenerationofyoungorthodontists,stimulatingthemto
hensivesearchesinMedlineemanatefromlawoffices,asmotivat- become applied biologists, not merely good mechanics, which
edyounglegalstaffsearchforallpossibleuntowardeffectsresult- earnedhimtheprestigiousAlbertH.KetchamAward.Thischap-
ingfromourservices.Nolongeraresuchtermsas“crestalbone ter,liketheothers,mustbereadandre-readtoappreciatethefull
loss,”“dehiscence,”“decalcification,”“fenestration,”“gingivalre- impactoftheprinciplesandpracticeofthebestpossiblecombi-
cession,” “hypermobility,” “interseptal bone loss,” “periodontal nationofdiagnosticacumenandtherapeuticachievement.
problems,” “root resorption,” “TMD,” and “traumatic occlusion” Chapter4(TomRakosi)discussesthescopeandlimitationsof
exclusivetotheprofessionalorthodonticvocabulary! functionaltherapy.Itemphasizestheprinciplesofdifferentiation
Itisimperativethatwepracticeevidence-basedorthodontics. and individualization. We can differentiate between functional
Defensiveorthodonticsisimperativeforboththepatientandor- orthodonticandfunctional orthopedic treatment.The principle
thodontist. This, of course, means proper diagnosis and patient ofthefunctionalorthodonticappliancescanbethatofforceappli-
selectionbeforeanythingelse.ItwastothatendthatTomRakosi, cationorforceelimination.Thepreconditionforsuccessfultreat-
IrmtrudJonas,andIproducedthewidelyusedOrthodonticDiag- mentisacomprehensivetreatmentprotocoltakingintoaccount
nosisintheColorAtlasofDentalMedicineseries(Thieme,1993), theindividualrequirementsandpeculiaritiesofthepatient.
VIII Preface
Chapter5(WilliamClark)takesappliedbiologyastepfurther, thereismorebasalskeletalcorrectionasaresultofgrowthguid-
utilizingtheTwinBlockapplianceforposturingthemandiblefor- ance,atleastintheshortrun,sinceuseoftheHerbstapplianceis
wardandstimulatingtemporomandibularjointmetabolismand limitedto6–7monthsDeVincenzofeelsthatoverthelonghaul
optimalgrowthresponse.TheBionatorhasthesamemandibular the response is essentially dental—i.e., tooth movement. Long-
posturingapproach,andinadditionutilizesascreeningeffectto termstudiesbyPancherzandRufshowthatactualgrowthofthe
preventdeleteriouspressuresonthedentitionbythescreening condyle achieved byadulthood is only1–2mm morethan nor-
musculature.TheTwinBlockappliancemayhavestartedwithoc- mal.Buttwofactorsareoperativehere:Oneisthattheseappli-
clusalguideplanesasrecommendedbyA.M.Schwartz,butithas ances are worn for onlya small portion of the growth period–
comealongwayandisnowcapableoftreatingthree-dimension- only6–7months;butgrowthoccursover9–15years.Predomi-
al problems (i.e., sagittal, vertical, and transverse deficiencies). nance of morphological pattern is likely to re-manifest itself in
The reader is referred to Dr. Clarkʼs excellent textbooks for a suchcasesunlesssubsequentgrowth guidancethroughtheuse
more comprehensive discussion of Twin Block therapy. Like so of activator/bionator/twin block continues the postural propul-
manyofoureminentworld-classauthors,Dr.Clarkisindemand siontosomedegree.Thentoo,asUlrichPaulsenshowsinhisex-
aroundtheworldtoexplainhisapproachtoClassIIproblems.As cellent CAT‑scan studies, the modification of the glenoid fossa
withotherfunctionalappliances,thisdoesnotnegatetheuseof posteriorstructureissignificant,andmostresearchershavenot
expansionscrewsorfixedattachmentsatoneormorephasesof measured this important area. Orthopedic surgeons correcting
activetreatment.Buttheapproachmakessagittalcorrectioneas- scoliosisorlongbonedeformitieswouldneverlimittheirguid-
ier,withlesspotentialiatrogenicdamage. anceto6monthsandstillexpectapermanentchange.Wecan
Chapter6(AlexanderVardimon)employsmostoftheconcepts learn much from medical orthopedics as we resort to growth
promulgatedbyDr.Clarkbutaddstheuseofrare-earthmagnets guidanceforlongerperiodsoftime,aswehavedonesuccessfully
to help in the mandibular propulsion. Having done major withClassIIImalocclusions.Asanoften-quotedmaximhasit:“It
NIH‑sponsoredresearchwithmeattheADAResearchInstitute, isnot thetoolthatyouuse,but when,why,forhowlong,with
ProfessorVardimonwasabletoshowthetissue-consciousnature howmuchforce.”
oftheseminusculeandpowerfulcoatedmagnets,inboththeat- Chapter9(MichaelMarcotte)isessentialforanyoneseekingto
tractingandrepellingmodes,toachievejawpositioningaswellas understand the biomechanics of orthodontic therapy for both
toothmovement(i.e.,bringingdownpalatallyimpactedcanines). fixed and removable appliances. Advertisements for newexotic
JamesMosshasdonethesame. wiresandcomplexbracketsmaycreatetheimpressionthatthey
Afullpictureofthebeneficialeffectsofthemagnetshasnot arelargelyautomatic,butthatisfarfromtrue.Orthodonticbio-
beencompletelydetermined,butallevidencepointstofaster,po- mechanical principles were pretty elementary when I finished
tentiallylessdamagingtoothmovement[1].Useinpalatalexpan- my specialty training. Learning by experience was not always
sion appliances has proven quite successful, with less potential pleasant,asso-calledanchorageunitsmovedasmuchasthetar-
iatrogenic damage such as root resorption, buccal plate dehis- get teeth. Fundamental concepts stressed appliances that pro-
cence,andfenestration[2,3]. ducedsomuchfrictionthatheavyforceswererequiredtoover-
Chapter 7 (Ali Darendeliler) on early maxillary expansion is cometheresistanceand,intheprocess,theyproduceddamage
authoredbyatrulyinternationalorthodontist whohasworked intoomanypatients.Wewerehandedanedgewisebracketand
at renowned universities all over the world; Istambul, Geneva, aseriesofthreeorfourarchwires,leadingtoa0.022×0.028wire
NorthCarolina,andSouthernCaliforniahavebeenhisfieldsofac- thatsnuglyfitthebracket.Butevenheavyelasticshaddifficulty
tivity.HeisnowtheheadoftheleadingOrthodonticDepartment movingteeth.Thedegreeofforceandlengthoftreatmentalmost
of Australia, in Sydney. Within a very comprehensive research alwaysproducedsomerootresorptionandsoft-tissuedamage.
program,researchinterestsincludethedentalandskeletaleffect Withleadersinthefieldsuchaswehavenow,ourspecialtyis
oforthodonticappliancesandthescopeandpossibilitiesofmax- wellfoundedinbiomechanicalaspects,withtheemphasisonthe
illaryexpansion.Aswellasthediagnosticpreconditionsoftheex- “bio.”Muchcreditforthisrevolutiongoestotheorthodonticde-
pansion,thecontentsofhischapterincludetiming,typesofmax- partmentatIndianaUniversity,tosageclinicianslikeJamesBald-
illaryexpanders,forcesproducedwithmaxillaryexpanders,and winandCharlesBurstone,andtotheirbrightyoungstudentslike
theirskeletalanddentaleffects.Hestressestheimportanceofpa- MichaelMarcotteandThomasMulligan,whoareteachinggener-
tientsʼagefortheindicationofvariousproceduresofexpansion ationsaroundtheworldthebasicsofmoments,couples,andvec-
andgivesimportantguidelinestothepractitionerforsuccessful torsandofcontrolwithoutthesevereattendantdamagewepro-
maxillaryexpansion. ducedbeforetheIndianainfluenceonthespecialty.Notonlyhas
Chapter8(JohnDeVincenzo)recognizestheuseofmandibular Indiana been the font of biomechanical knowledge (all those
propulsion,butusesafixedinter-archmechanism,similartothat mentioned above and many more are outstanding clinicians),
ofHansPancherzandtheJasperJumper,withreciprocalanchor- buttheseeminentleadershavemadewhatappearstobeacom-
ageinthemaxillaryarch.Theideaofcombiningmaxillarymolar plexaspectofphysicsveryunderstandableforall.Without this
distalizationwithmandibularpropulsionandpotentialfavorable background,nocliniciandeservestocallhimselfanorthodontist.
condylarandglenoidfossachangeswithfixedapplianceswasin- Admittedly, reading this chapter for thefirst time mayconfuse
troduced by Emil Herbst in 1906 and expanded in his book of somenoviceorthodonticstudents,butlikeasacredtext,itmust
1910.Hisappliancesandconceptswereamazinglycontemporary, bereadagainandagain!Withtheinformationgained,theclini-
as many orthodontists using the Herbst appliance can attest. cian canunderstand the raison d’être ofall appliances—the ad-
WhereasPancherzandhisfollowers(TerryDischingeretal)feel vantages and disadvantages of specific problems. Too many or-
Preface IX
thodontic“piedpipers”whoneverreallyunderstoodtheunderly- inhisphilosophyandapplianceunitsashisexperiencesandthose
ingprinciplesoftheappliancestheyused,the“set-up”theyap- ofhisstudentsanddisciplespointthewaytoevenbettercontrol.
pliedtoallpatients,orthe“rulesofuse,”havetootedtheirhorns There is a common thread in the remaining chapters, though:
toattractwillingfollowers.Thisistheuglysideofourhistory. light forces, the lowest possible level that moves teeth. We all
Unfortunately, this lack of understanding still pervades our havelearnedthehardwaythatwithtoomuchforcewecausehy-
specialty.Inaddition,manynonspecialistsreadonlytheadvertis- alinization,stopcellularactivitybyfrontalassault,reducemetab-
ingclaimsandlearnthehardwaybymisuseandiatrogenicdam- olism,retain catabolicbyproducts,andmovethetoothor teeth
age.Withthoseeager-beaverlegalvulturescirclingoverhead,we onlybyunderminingresorptionmechanotherapy.
can no longer afford the luxury of learning by trial and error, ReaditinGraberandVanarsdall[4].Thereareotherchapters
buryingcorrecteddentitionsunderpermanentretainers.Tome, ofvalue,butthisisanabsolutemustforperiodontics,etc.Their
this is the most importantchapter in this book for orthodontic tissue work is, in myopinion, unexcelled, though European re-
students. There are many roads to Rome,manyappliances that searchersarenotfarbehind.StartingwithSandstedtofNorway
canaccomplishthesameresult,butonlyonesetoffundamental in1904,throughOppenheimofAustria,NoyesofChicago,Sicher
tissue-consciousprinciples.Readandunderstandanddonʼtfeel and Weinmann of Austria and the USA, Kaare Reitan, Per Rygh
handicapped if it takes three readings to get the full meaning andBirgit Thilander andAnnika Isbergof Norwayand Sweden,
andimplications.Trytotakeshortcoursesgivenbytheseleaders wehave a fineheritage of research scientists that matches any
if possible. Most graduate orthodontic resident programs have fieldintheworld.
“in-house” teachers of biomechanics: Robert Isaacson, editor of Thelong-termresultsofAlexander,aswellasthoseofother
TheAngleOrthodontistandlong-timedepartmentheadatMinne- authors in the light-wire chapters, are bound to be impressive,
sota,California,andVirginia;leaderslikeRaviNandaatConnecti- butstandingthetestoftimeisparamount.Abalancedocclusion
cut,Rohit SachdevaofBaylor,AndrewKuhlbergofConnecticut, isessential:balancedincontactwiththeopposingteeth,withthe
StevenLindauerofVirginia,amongothers—andIknowIhaveleft neuromuscular envelope, with function and parafunction, and
out some names. Most schools donʼt have these biomechanical withfacialesthetics.Thisisnotaneasyassignmentwiththemyri-
gurusonstaff,butifyougotoIllinois,forexample,youwillhave adoffacialtypesweencounter.Studyofthecasereportsshould
all the leaders giving seminars and guiding clinical units, from beaffordedconcentrationandconsiderabletime.Lookforcriteria
JamesBaldwinandBillHohlt,throughCharlesBurstone,Michael ofstability,lookfortissuehealthaswellasestheticachievement.
Marcotte,ThomasMulligan,andBobIsaacson.Learntheseprinci- Chapter 12 (Magdalena Kotova), authored by a well-known,
plesearly,andallapplianceswillmakemoresense,ornonsense, leading orthodontist of the Orthodontic Department of the
toyou.Noshortcutshere! Charles University Prague; deals with implants in orthodontics.
Chapters9through11assiduouslyapplytheprinciplesofthe Czech orthodontics has had some internationally well-known
biomechanicalBiblegiveninChapter9.Theearlychaptersinthis representatives such as Miroslav Adam, Frantisek Kraus, Ferdi-
bookalsodo,ofcourse,buttheguidelinesaremoreimportantfor nandSkaloud, andBedrichNeumann.DuringWorld WarIIand
fullfixedmechanotherapy.Atleast75%ofyourpracticeloadwill thefollowingIronCurtainperiod,communicationwiththeWest
beinthiscategory,perhapsmore,asyouapplyfixedappliancesto wasinterruptedanditwasdifficulttoobtaineventhescientific
fine-tune growth guidance cases. As you read the chapters by literature, let alone equipment or material. As soon as the Iron
Marcotte,Kuhlberg,andAlexander,makeitapointtoreturnto Curtaindropped,thenewgenerationmadeupforthelosttime.
theprofuseillustrationsinChapter9tohelpyouunderstandtheir Theyworkedenthusiastically,studyingthenewliterature,visit-
implications. ing famous universities, organizing courses with leadingortho-
Ifyouneedfurtherindoctrination,gototheoutstandingchap- dontistsandsoon,aimingtoliftCzechorthodonticstoaninter-
ter by Burstone in the Graber–Vanarsdall graduate orthodontic nationallevel.Twoof theexponentsof thisnewgenerationare
text[4],tothebooksbyBurstone,Marcotte,andMulligan,andto Magdalena Kotova and Milan Kaminek. Proof thatCzech ortho-
theshortcoursesofferedbyallofthem. donticshascomeabreastofthetimesisfoundinDr.Kotovaʼsre-
Chapter 10 (Andrew Kuhlberg) on the segmented arch tech- searchtopics.Implantsareoneofherresearchprioritiesandshe
niquedealswiththeculminationofbiophysicalandbiomechani- hasmanyyearsofexperiencesinthisfield,publishingandlectur-
cal design developed by Burstone and his staff. It is a popular ingon the subject. The qualityof her contribution tothis book
choice,particularlyintheConnecticutarea.MarcotteandKuhl- demonstratesherreputationasanexpertinthefield.
bergwereproductsofthisenvironmentandlearnedtheadvan- TomGraberwasalwaysbuildingbridgesbetweennationsand
tagesofthesegmentedarchapproach.Theywilloftenmodifyit orthodontistsallovertheworld.Hewouldbehappyandproudto
withcontinuousarchesatvariousstagesoftreatment.Thischap- havethiscontributioninhis“MemorialEdition.”
tergivesyouafinedescriptionofthetechnique,itsbiomechanical Chapter 13 (Rainer-Reginald Miethke) describes treatment
justification,andexamplesofthecorrectionpotentialifthetech- withtheInvisalignsystem.ProfessorMiethkeholdsthechairof
niqueishandledproperly.Againcomparethesecaseswiththose the Charité University, Berlin. He was thefirst in Germanyand
of the other fixed-appliance chapters and judge for yourself oneofthefirstinEuropetoincludethescopeandpossibilitiesof
whetherthisisyour“cupoftea.”Thesegmentedarchtechnique treatment with the Invisalign system in his comprehensive re-
maybethemostbiomechanicallyorientedapproach. searchprogram.Hecontributedtoimprovementof theefficacy
Chapter11(WickAlexander)isagoodplacetoturnnext.Dr. ofthetreatmentwithnewideassuchas“ledtooth”orwaysofus-
Alexanderisapioneerinlight-wiretechniquesandhasdevoted ingtheattachments.Heisactiveacrosstheworld,publishing,lec-
hislifetoteachingothers.He,too,hasconstantlymadechanges turing,andteachingtreatmentwithInvisalign.
