Barcelona, Spain Rzeszów, Poland Porto, Portugal Bangkok ... · Orthodontics in mixed and permanent dentition. Appliances. Part 2 Management and administration of a dental clinic

Rzeszów, PolandBarcelona, Spain

Bangkok, ThailandPorto, Portugal

Vol. 2, Nº 3, 2020www.atheneainstitute.comEdited by Athenea Dental Institute

Summary

Editorial ...................................................................................................................................................................................................... 5

Visiting professors at Athenea from March to June 2020 ............................................................................................................................ 6

“Pablo Chat With Friends” ........................................................................................................................................................................... 8

Case report 1070. Lateral open bite. Dr. Pablo Echarri, Dr. Miguel Ángel Pérez Campoy and Dr. Javier Echarri ......................................11

Interdisciplinary treatment: A case report presentation. Dr. Regina Bass and Dr. Nayre Mondino ............................................................ 23

Interdisciplinary treatment of an adult patient. Dr. Katarzyna Ziółek-Paszt ............................................................................................... 32

Included bicuspids in lock down. Dr. Emma Vila Manchó ......................................................................................................................... 39

Is early treatment always a good treatment option? Dr. Noelia Cima ....................................................................................................... 45

Editorial

Dr. Pablo EcharriDirector of ATHENEA DENTAL INSTITUTE

Dear colleagues,

At last we are reaching the “new normality” that will involve many changes at personal, health, work and political levels. Throughout this period, the entire Athenea team has made an effort to follow the necessary recommendations to ensure the protection for everyone. For this reason, since March 13, since the state of alarm was declared, we have dedicated ourselves to adapting to these new conditions, and I want to thank the efforts of everyone: teachers, administrative staff, laboratory and clinical staff, students and patients, for adapting to these new conditions.

• We want to highlight that:• Since the beginning of the state of alarm, we have adapted to the digital conversion of the classes in the form of webinars,

video-classes, online consultation classes and interviews with outstanding professionals from all over the world. To prove the quality of this program, it is enough to look at the chart of teachers invited to give webinars for our students during this period, outstanding professionals known worldwide, in addition to the webinars and video-classes of our teaching staff. Note also the quality of the teachers interviewed in “Pablo chats with Friends” in the enclosed chart. We would also like to announce that all the videos of “Pablo chats with Friends” will be available briefly on our website, in the “Athenea Watch” section.

• Hands-on classes and clinical practices had to be paused but we are already returning to normal life.• Hands-on classes at the courses of Specialist and Expert in Orthodontics and Dentofacial Orthopaedics will be make

up in July.• The make up of clinical practices for 2nd year students of the Master of Orthodontics and Dentofacial Orthopedics

from Spain is already programed for September.• In September, we will also resume the clinical practice of the 1st year of Master of Orthodontics and Dentofacial

Orthopedics from Spain.• The clinical practice of the 2nd year students of the Master in Orthodontics and Dentofacial Orthopedics from Poland

has already been resumed, and the 1st year students of the same Master will start their practice in September.• The students of the Master of Implantology in Spain have already resumed their clinical practices.• The students of the Master of Implantology in Poland will resume them in July.

• During this period, 3 issues of the Journal of the Athenea Dental Institute have also been published.We had to reorganize the September classes due to the clinical sanitary protection protocol and these changes will be send to you soon.It is our wish that we can return to the situation we had before the pandemic as soon as possible and that no new situations arise to which we have to adapt. In this issue we present several clinical cases of doctors: Pablo Echarri, Miguel Ángel Pérez Campoy, Javier Echarri, Regina Bass, Nayré Mondino, Katarzyna Ziolek, Emma Vila and the article by Noelia Cima “Is early treatment always a good treatment option? ”.

Kind regards, take good care of yourself.

Pablo Echarri

Adriana Pascual Alberto Albaladejo Carla Mª Melleiro Gimenez

Asif ChatooArmando Dias

Katalina Ros

Henrique Valdetaro Jorge D. AguirreJaviera BongiornoHatto LoidlGraciela Bonfanti

Francisco MarichiLuis F. Pérez VargasEmilia MilicinDerek Mahony

Rita Baratela Thurler

Ricardo GallardoRegina BassRavindra NandaNayre MondinoMiguel Hirschhaut

Antonio SantosSilvia GeronSanhay Labh

Rodolfo de la FlorRoberto Lenarduzzi

Adriana Pascual Ana Molina Benedict WilmesAsif ChatooArmando Dias

Birte Melsen

Francesc Matas

Juan C. Pérez VarelaJorge D. AguirreJavier EcharriJavier Bara

Henrique ValdetaroHee Moon KyungHatto LoidlGraciela MaffiaGiuseppe Scuzzo

Giuliano MainoFrancisco Marichi

Juan Ruiz

Emilia MilicinDerek Mahony

David M. SarverCristobal GarcíaChristian San MartínCarlos Flores

Kim Jeong-Ii Lorenzo Favero Majd RasheedMª José CristoboLuis F. Pérez Vargas

Manuel Lagravere

Regina Bass

Zakaria Bentahar

Won MoonAntonio SantosTakis KanarelisSanhay LabhRodolfo de la Flor

Roberto JustusRicardo GallardoRavindra NandaRafi Romano

Pedro MayoralMiguel HirschhautMarino MusilliManuel Míguez

Dates: Friday, October 2, 2020, from 4:00 p.m. to 8:00 p.m. and Saturday, October 3, 2020, from 9:30 a.m. to 1:30 p.m. and from 3:00 p.m. to 6:00 p.m.

Place: Atocha, Madrid. Spain

Diagnosis of malocclusions in the vertical plane. Etiology and management of etiological factors Gingival smile and interdisciplinary treatment: orthodontics, periodontics, cosmetic surgery, ortHognathic surgery Treatment of open and deep bites in mixed dentition with removable appliances Treatment of open and deep bites in permanent dentition with or without microimplants Treatment of rotation and canting of the occlusal plane Leveling of the curve of Spee and Wilson Hands-on - Insertion of microimplants in typodont Diagnosis of the vertical dimension and its increase with prosthesis Retention and prevention of relapse

The course price includes the book:“Treatment Of Malocclusions In The Vertical Plane: Open And Deep Bites And Occlusal Plane Rotations”

(volume 8 of the CSW collection).

Objectives:1. Train professionals in the diagnosis and treatment of malocclusions in the vertical plane.2. Train professionals to carry out an interdisciplinary plan to correct these malocclusions.3. Train professionals to insert the microimplants in these treatments.Theoretical-practical course

Cartagena 248-256 local 5. 08025 Barcelona, Spain+34 93 513 74 81 | +34 678 725 860

www.atheneainstitute.com | [email protected]

TREATMENT OF MALOCCLUSIONS IN THE VERTICAL PLANE: OPEN AND DEEP BITES AND OCCLUSAL PLANE ROTATIONSVolume 8 of the CSW Collection

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Case report

Case report 1070. Lateral open bite

Dr. Javier EcharriProfessor of the Master of Orthodontics and Dentofacial Orthopedics at Athenea Dental Institute. San Jorge University

Dr. Pablo EcharriDirector of the Master of Orthodontics and Dentofacial Orthopedics at Athenea Dental Institute. San Jorge University

Dr. Miguel Ángel Pérez CampoyCoordinator of the Master of Orthodontics and Dentofacial Orthopedics of the Athenea Dental Institute. San Jorge University

Figs. 1, 2 and 3 Initial records.

Case 1070 is a 15-year-old female patient with Class I molars with an anterior deep bite. She also presents in the upper left quadrant: ankylosis and retention of 65 and retention of 25; in the lower left quadrant: ankylosis of 75 and agenesis of 35; in the lower right quadrant: permanence of 85 and 45 has not erupted. She also presents agenesis of the 4 wisdom teeth.

TREATMENT:1. Extraction of 65 and transpalatal bar with bands in 16-26 to maintain the anchorage and wait for the possible spontaneous

eruption of the 25.

2. If 25 does not erupt, it is exposed and pulled with an elastic chain to the TPB to avoid possible pressure on the root of the 24 and the reabsorption.

3. When 25 erupts, the fixed appliance and open coil-spring with elastic chain are placed to open space and to align the 25.

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Case report

Figs. 4-10 Initial records.

Figs. 11-15 Extraction of 65 and bands 16-26 with TPB.

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Figs. 16-17. Exposure of 25

Figs. 18-19 Traction of the 25 with elastic chain to the TPB.

Figs. 20–24 Beginning of the fixed orthodontic treatment in the maxilla with .016 ” heat treated NiTi arch to start the alignment and continue the traction of the 25 with elastic chain.

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Figs. 25-28. The space is opened for 25 with open-coil-spring and elastic chain from 24 to mesial.

Figs. 29-33 Traction of the 25 from the labial arch and beginning of treatment of the mandible with .016 ”heat treated NiTi arch.

Figs. 34-38 Continuation of the treatment with open coil-spring in the lmandible.

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Figs. 39-43 Treatment evolution.


Figs. 49-53 Upper and lower .016”x.022” arches.

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Figs. 54-56 Z elastics on the right side for transverse correction.

Figs. 57-61. Treatment evolution.

Figs. 62-66. A .016 ”x .022” NiTi with upper reverse curve arc is placed.

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Figs. 67-71. The patient fails to come to appointments for 6 months due to personal problems, the CRS arch has a rolling effect and the bite opens. It will be corrected with intermaxillary elastics.



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Figs. 92-94. Final records.

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Figs. 95-101. Final records.

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Figs. 102-103. Before and after.

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Figs. 104-105. Before and after.

Case report

Spain: Beginning of the 5th edition in September 2020Poland: Beginning of the 5th edition in January 2021Thailand: Beginning of the 1st edition in August 2020

Anatomy and physiology Diagnosis Treatment plan Interceptive orthodontics and malocclusions etiology Orthodontics in mixed dentition. Appliances. Part 1 Orthodontics in permanent dentition. Appliances. Part 1 Syndromes and pathologies associated to malocclusions. Orthodontics in mixed and permanent dentition. Appliances. Part 2 Management and administration of a dental clinic Skeletal anchorage Invisible plastic orthodontics. Interdisciplinary orthodontics. Orthodontics and orthognathic surgery. Treatment of roncopathy and OSAHS Lingual orthodontics. Craniomandibular dysfunction. Retention and prevention of relapse Master’s Thesis

Master’s Degree validated by San Jorge UniversityThe students will get 90 ECTSType: Part time, two years, 2 3-days modules per month.Language: Spanish (Spain) | English (Poland and Thailand)

The Master of Orthodontics and Dentofacial Orthopedics of the Athenea Dental Institute is aimed at those who want to have an adequate pofesssional training to be able to deal with the situations of malocclusions which require the advanced orthodontic treatments. It is a Theory&practice Master Course, validated by San Jorge University, with 90 ECTS and two years of duration you will be able to combine with your professional practice.



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Interdisciplinary treatment: A case report presentation

D. Regina Bass Doctor in Dentistry- Specialist in Orthodontics an Dentomaxillofacial Orthopedics- Director of Specialist Degree in Orthodontics at the National Northeast University-Argentina. Professor at the CREO Fundation for the Continuing Progress in Dentistry, Cordoba, Argentina

Case report

Figs. 1a, b y c.

Dr. Nayre MondinoDoctor in Dentistry- Specialist in Orthodontics an Dentomaxillofacial Orthopedics- Coordinator of Specialist Degree in Orthodontics at the National Northeast University-Argentina. Professor at the CREO Fundation for the Continuing Progress in Dentistry, Cordoba, Argentina

Interdisciplinary treatments require the interaction of different participants to achieve the esthetic results and optimal functionality. In continuation, we will develop a clinical case which required the intervention of several specialists for its resolution.

A male patient comes to the office, requiring orthodontic treatment and expressing as a chief complaint that he dislikes the size and shape of his teeth. The first records are taken to prepare the diagnosis and treatment plan.

According to the cephalometric analysis, the patient has a brachifacial biotype, skeletal Class II due to mandibular retroposition, Class II 2 molar relationship gives rise to division and persistence of the temporary canines. There is an incisors retroclination and a marked height difference of the gingival margins.

The arches are compressed with a marked negative torque of the posterior sectors and bone exostoses at the level of the dentoalveolar processes. (Fig. 1 and 2)

In the panoramic x-ray, the retention of both upper canines is recorded.

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Case report

Next, a Cone Beam is requested in order to make a three-dimensional assessment of the position of the upper canines, to plan their liberation as well as to determine the correct traction vector for their eruption. (Fig. 3)

Figs. 2a-d.

Figs. 3a, b y c.

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Case report

The patient has a high aesthetic demand and requests lingual orthodontics for the resolution of the case. In this case, the lingual mechanics turns out to be very favorable because it will allow the correction of the overbite generated due to the anterior contact, and of the posterior disocclusion which promotes extrusion, and consequently the resolution of the overbite. The second aspect in which lingual orthodontics favored this particular case is that the retention of both canines was palatine one, which allows traction with an adequate vector.

It begins with the installation of appliances, initial arch wires for alignment, leveling and rotation control and the liberation of both upper canines is indicated together with the extraction of the temporary teeth. An arch wire is bent using a heat treated cobalt chrome wire (Elgiloy 0.016 ”blue) with loops at the canine level to be used to hook the elastic traction force of the vertically retained teeth. The extraction of the first bicupids is requested in order to perform a skeletal class II compensation of the patient. (Fig. 4)

Figs. 4a-d.

A palatal bar is placed, designed by Prof. Dr. Alfredo Bass, which has lateral loops in order to increase the length of the wire and thus decrease the release of force. The bar is used for a dual purpose, on the one hand to carry out a moderate anchorage control and lateral and forward extension to generate a vertical traction arm for both canines. Once they erupt, the corresponding brackets are cemented and the arch wire sequence is completed. (Fig. 5)

Figs. 5a-d.

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The case is finished in the canine class and with corrected overbite in addition to the correct positioning of 13 and 23 retained and rounding of the arches. (Fig. 6)

Figs. 6a-d.

After the orthodontics, the rehabilitation team begins to work. The patient dislikes the color, shape and size of his teeth. A digital smile design is made through the Digital Smile Design software. This allows us to establish an action plan for rehabilitation planning and constitutes a powerful communication tool with the patient to be a part of the treatment. An superimposition of the scanned model is made with the patient’s digital waxing over the photo of the patient in order to assess incisor exposure, smile curve, etc. (Fig. 7)

Fig. 7.

This digital tool allows us to obtain three printed models, the first is a motivational model that is exclusively additive. In this way, a test (Mock Up) can be made in the patient’s mouth to assess shape, size and that he himself can visualize the proposed changes. The second model consists of the superimposition of the patient’s mouth on a digital waxing, which allows

Case report

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viewing those areas where more trimming is needed per tooth. The third model consists of a classic digital waxing. This will allow assessing the need for trimming or being able to just add veneers without trimming. (Fig. 8)

Figs. 8a-d.

The motivational model is printed in order to transfer that information to the patient’s mouth. For this, a silicone impression is required, which must have a 45 ° cut on palatal and drainage grooves made with No. 11 scalpel in order to allow the test material to flow. (Fig. 9). A bis-acrylic resin (3M Protemp) is used (Fig. 10)

Figs. 10a y b

Fig. 9.

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It is suggested that the patient observes the change through photographs or videos, so he can compare it with previous records and not directly through the mirror since the test material presents certain porosities and imperfections that can distract the patient’s focus of assessment regarding shape, size, incisor exposure, smile curvature, etc.

It was decided that a gingivectomy is required to generate a larger tooth size. The digital smile design allows to generate a composite model in which the cone beam tomography is combined with the STL file of the model. This allows to measure exactly the distance between the cementoenamel junction and bone crest to guarantee the biological space. It is carried out tooth by tooth allowing the construction of a virtual cut periodontal guide. It is printed and the periodontist must make the cuts inside each arch, providing high predictability and accuracy to the surgical procedure. (Fig. 11)

Figs. 11a, b y c.

Despite whitening in the lower arch, after the bonding of the veneers a color difference is observed. The patient states that he is not interested in making lower veneers because they are not visible during speech and smile. (Fig. 13)

Figs. 12a, b y c.

After the crown lengthening, the preparation proceeds with a minimum enamel trimming for the bonding of the veneers. (Fig. 12)

Fig. 13a.

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Current digital tools allow the planning of different clinical maneuvers with great predictability of results and the possibility of establishing a dialogue with the patient, which transforms him into an active participant regarding decisions. This work structure allows the understanding of patient’s wishes regarding the result in order to meet their expectations.

Figs. 13b y c.

Figs. 14a-f.

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BIBLIOGRAPHY

1. Ortodoncia con excelencia. de la perfección. Jurandir Antonio Barbosa. Amolca. 2015. ISBN :978-958-8816-82-1.

2. Meereis CT, de Souza GB, Albino LG, Ogliari FA, Piva E, Lima GS.Oper Dent. 2016 Jan-Feb;41(1):E13-22. doi: 10.2341/14-350-S. Epub 2015 Oct 28.

3. Invisible restauraciones estéticas cerámicas.Ed médica Panamericana. Sidney Kina y August Bruguera. Maringá, Brasil/Barcelona, España.2007.

4. Color, Estética y Blanqueamiento Integrados: “Atlas de procedimientos y técnicas”. Sergio G. Kohen. Carla de Franceschi. Guillermo A. Rodriguez. Sacerdoti. Buenos Aires Argentina 2007. ISBN 978-987-23406-0-5

5. Biomecánica y Estética. Estrategias en Ortodoncia Clínica. Rovindra Nanda. Amolca.2007. ISBN 980-6574-66-4

6. Digital smile design and mock-up technique for esthetic treatment planning with porcelain laminate veneers. Garcia PP, da Costa RG, Calgaro M, Ritter AV, Correr GM, da Cunha LF, Gonzaga CC.J Conserv Dent. 2018 Jul-Aug;21(4):455-458. doi: 10.4103/JCD.JCD_172_18.

7. Estética em Ortodontia. Um sorriso para cada face. Carlos Alexander Camara. Dental Press. 2018/Maringá/PR

8. Evolution. Contemporary Protocols for Anterior Single Tooth Implants- Iñaki Gamborena. Markus B. Blatz.

9. The application of parameters for comprehensive smile esthetics by digital smile design programs: A review of literature. Omar D, Duarte C.Saudi Dent J. 2018 Jan;30(1):7-12. doi: 10.1016/j.sdentj.2017.09.001. Epub 2017 Sep 23

10. Comparative tomographic study of the maxillary central incisor collum angle between Class I, Class II, division 1 and 2 patients. Feres MFN, Rozolen BS, Alhadlaq A, Alkhadra TA, El-Bialy T.J Orthod Sci. 2018 Feb 15;7:6. doi: 10.4103/jos.JOS_84_17. Collection 2018

11. Fully digital workflow, integrating dental scan, smile design and CAD-CAM: case report. Stanley M, Paz AG, Miguel I, Coachman C.BMC Oral Health. 2018 Aug 7;18(1):134. doi: 10.1186/s12903-018-0597-0

12. Clinical Outcome of an Impacted Maxillary Canine: From Exposition to Occlusion. Taffarel IP, Saga AY, Locks LL, Ribeiro GL, Tanaka OM.J Contemp Dent Pract. 2018 Dec 1;19(12):1552-1557

13. Dental Restorative Digital Workflow: Digital Smile Design from Aesthetic to Function.Cervino G, Fiorillo L, Arzukanyan AV, Spagnuolo G, Cicciù M.Dent J (Basel). 2019 Mar 28;7(2):30. doi: 10.3390/dj7020030

14. Orthodontic traction of impacted canines: Concepts and clinical application.Cruz RM.Dental Press J Orthod. 2019 Jan-Feb;24(1):74-87. doi: 10.1590/2177-6709.24.1.074-087.bbo

15. Digital smile design for gummy smile correction. Levi YLAS, Cota LVS, Maia LP.Indian J Dent Res. 2019 Sep-Oct;30(5):803-806. doi: 10.4103/ijdr.IJDR_132_18

Case report



Anatomy and Physiology. Diagnosis. Treatment planning. Timeline. Basic principles of oral and implantologic surgery and osseointegration. Medical evaluation of a patient. Medically compromised patient. Endovenous sedation. Informed consent. Surgical techniques. Oral surgery. Complications in implantology and oral surgery. Prevention and treatment. Periodontal disease. Diagnosis and treatment. Advanced implantology. Sinus lift, short implants, pterygoid implants, zygomatic implants. Membrane-guided bone regeneration, crest expansion, block graft. Implant-supported prosthesis. Implant-supported prosthesis in edentulous maxilla and mandible. Complex interdisciplinary treatments. Masterís Thesis.

Master of Implantology of Athenea Dental Institute is a coursework program aimed at students who want to obtain the adequate professional training which will help them to manage the edentulism cases and carry out the necessary implantology treatments. It is a 2-year theory & hands-on master program validated by the University San Jorge which offers 60 credit points (ECTS), and which you can easily combine with your professional practice.

Start: September 2020 (2020-2022 edition)

Start: September 2020 (2020-2022 edition)Master’s Degree validated by San Jorge UniversityThe students will get 60 ECTSModality: Part-time Master, 2 years, 2-3 days per monthLanguage: Spanish (Spain) | English (Poland)

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Interdisciplinary treatment of adult patient

Dr. Katarzyna Ziółek-PasztMaster of Orthodontics and Dentofacial Orthopedics of Athenea Dental Institute and San Jorge University

Case Report

• A 49-year old female patient, with class I malocclusion, anterior deep bite, crowded upper and lower incisors. Patient complains of clenching and grinding the teeth during the night and day. In the extraoral profile examination, patient presents concave profile, significantly retruded lips, very prominent chin. Her occlusion study revealed mild occlusal plane canting to the left side probably due to flat fillings in the teeth 35, 36 and 37. In the cephalometry we can observe a skeletal class III and brachyfacial pattern.

• The treatment was carried out in the Ortodent Dental Clinic in Rzeszow in Master’s Orthodontics Program.

TREATMENT PLAN:

• To improve the profile, the patient needs orthognathic surgery.

• Without surgery: treatment with fixed appliances, possible stripping, intrusion of upper incisors, possible intrusion of 16 with microimplants.

• Habits control.

• Possible relaxation splint after treatment.

• Retention after treatment and implant for 46.

The patient wasn’t interested in profile improvement, her chief complaint was crowded teeth.

Before the treatment the patient was referred to the dentist and the periodontist for consultation. The dental treatment was carried out: higher fillings in the teeth 35, 36, 37 and temporary build-ups on the teeth 45, 47.

Figus. 1 to 4. Facial initial photographs.

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Case Report

Fig. 5 to 9. Intraoral initial photographs.

Fig. 10. Initial panoramic X-ray: absence of 18, 28, 38, 48 and 46.

Fig. 11. Initial lateral X ray and cephalometric tracings.

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Case Report

Figs. 12a,b. Initial lateral X ray and cephalometric tracings.

Fig. 13 to 16. Bonding H4 self-ligating brackets in upper arch and alignment and levelling with .014” heat-activated NiTi archwire.

Fig. 17 to 18. Progress in alignment. 14x25 heat-activated Niti in upper arch.

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Case Report

Fig. 19 to 23. Bonding of the lower brackets. .014” heat-activated Niti in lower arch.

Fig. 24: CBCT was taken to reveal aggressive acute periodontitis affecting the teeth 14 and 37.

Fig. 25 to 29. Progress in treatment. Upper arch: 17x25 TMA with vertical and horizontal curvatures and antemolar omegas. Build-ups on the teeth 11, 21 because of deep bite.

17x25 heat-activated Niti in upper arch.

Lower arch: 17x25 heat-activated Niti. 8-figure ligature from 44 to 43 and powerchain 42-43.

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Case Report

Fig. 30 to 34. Lower arch: 19x25 TMA +CV+CH. Lower incisors are still in retroclination.

Upper arch: the periodontal treatment with regenerative procedures in the area of the teeth 13 and 14 was carried out and that is why it’s forbidden to orthodontically move these teeth for the next 6 months.

Fig. 35 to 39. Continuation of treatment in lower arch: Figure 8 ligature from the teeth 42 to 33 and the powerchain from the teeth 33 to 34.

Fig. 40 to 44. Evolution of the treatment. Permission for resumption of treatment in upper arch. Upper arch: 19x25 TMA with “L” loops and off-set of the teeth 13, 23. Class II elastics 3/16’ 6,5oz. 34.

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Fig. 45. Final panoramic X-ray. The implant for 46 was inserted.

Total treatment time was 20 months. After debonding of upper and lower brackets, the build-ups on the teeth 11 and 21 remain permanent to prevent the deep bite relapse . CA retainers in upper and lower arch.

Fig.46 to 50. Intraoral final photographs.

Fig.51 to 53. Facial final photographs.

Case Report

Subjects: Early treatment in mixed dentition. Treatment in permanent dentition. Class I treatment. Treatment of maloccusions in transverse and vertical plane.Class II treatment. Class III treatment. Case finishing and retention. Expertise Thesis.

The objectives of this theory&hands-on course leading to the Univerisity Expertise Degree in Orthodontics and Dentofacial Orthopedics are: 1: Make up for the training deficiencies in dentistry related to the orthodontic and orthopedic field. 2. To train the students to deal with the situations which require mild or moderate mal occlusion treatments with conviction and quality. 3: To prepare the students to work as a part of an interdisciplinary team, carrying out the orthodontic and orthopedic treatments.



Master Course validated by University of San JorgeThe students will obtain 20 ECTS.Type: 144 h face-to-face classes and 356 h of independent work. Total 500 h

DATES BARCELONASession 1: October 22-24, 2020session 2: December 10-12, 2020Session 3: February 11-13, 2021Session 4: April 8-10, 2021Session 5: May 6-8, 2021Session 6: June 10-12, 2021

DATES MADRIDSession 1: October 15-17, 2020session 2: November 26-28, 2020Session 3: January 21-23, 2021Session 4: February 25-27, 2021Session 5: April 15-17, 2021Session 6: July 1-3, 2021

DATES PORTO, PORTUGALSession 1: September 17-19, 2020session 2: October 22-24, 2020Session 3: November 19-21, 2021Session 4: January 28-30, 2021Session 5: March 11-13, 2021Session 6: May 13-15, 2021

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Included bicuspids in “lock down”

Dr. Emma Vila ManchóDoctor in DentistryProfessor of Master in Orthodontics Athenea Dental Institute

It is curious how we, orthodontists, use the word “inclusion”, as something that is “out of normal”, when in reality the inclusion is an integrating word. If we refer to it as it is, in this case of included bicuspids, we understand it as the teeth which have not erupted with the rest of the dentition. But if we take another look to its meaning, we should say that they are the teeth that we are going to include together with the rest of the teeth that are already present in the mouth. Inclusion foments something that is part of and integrates with the rest. And this is precisely what we are going to foment in this case.

A 18-year old patient who presents upper right deciduous canine in the mouth and upper right permanent canine erupted in ectopic position due to the presence of a deciduous one. Figs. 1, 2 and 3)

Case report

Fig. 1. Upper right canine in ectopic position and deciduous canine.

Fig. 3. Left lateral view.Fig. 2. Frontal view.

The X-ray shows that the upper first left and right bicuspids and and the upper second right bicuspid are included. The latter is in a very bad position as it can be see in the lateral X-ray (Figs. 4 and 5).

Fig. 4. Panoramic X-ray.

Fig. 5. Lateral X-ray.

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Case report

In maxilla, there are two erupted canines, a deciduous one and a permanent one (Fig. 6) and in mandible, there are deciduous molars and ectopic eruption of permanent bicuspids. (Fig. 7)

Fig. 6. Upper occlusal. Fig. 7. Lower occlusal view.

We proceed with the diagnosis and treatment planning. A surgery is carried out to extract upper right bicuspid because it is impossible to position it in a stable way in its location and the included bicuspids are uncovered. Figs. 8-11)

Fig. 11. Upper included bicuspids are uncovered.

Fig. 8. Upper right canine ligated with atypical ligature.


Deciduous molars are extracted to allow the correct positioning of ectopic bicuspids. (Fig. 12)

Fig. 12. Extraction of deciduous lower molars

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Case report

Once we have the necessary alignment to place a .016” x.016” SS arch wire, we change it to start the traction of the upper right canine. It is important to have this canine in the mouth and in its position so we can use it as an anchorage and begin to traction the included bicuspids. We ligate the bicuspids with atypical ligatures and very light forces.

Placement of .016” x.016” SS arch wire for traction of the upper right canine. (Fig. 13) Buttons are cemented in 2nd upper right bicuspid and 1st upper left bicuspid. (Figs. 14 and 15).

Atypical ligatures in the right upper canine, 2nd upper left bicuspid and 1st upper left bicuspid. (Fig. 16) Bonding of brackets in the 2nd lower bicuspids. They are not ligated to the arch wire to not produce undesirable movements in the 1st bicuspids (Fig. 17)

Fig. 13. Canine with atypical ligature. Fig. 15. Left upper bicuspid, atypica ligature.Fig. 14. Frontal view.

Fig. 16. Upper occlusal view. Fig. 17. Lower occlusal view.

Double arch wires are inserted, a .016” x .016” SS arch wire and a .016” NiTi arch wire, to bring the canine in its correct position. (Figs. 18-21)

Lower bicuspids are ligated to the arch wire with atypical ligature. (Fig. 22)

Fig. 18. Right lateral view with double arches. Fig. 20. Left lateral view.Fig. 19. Frontal view.


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Replacement of .016” x .022” SS arch wire.

Kobayashi ligatures are inserted to hook the intercuspation elastics and achieve the improvement of occlusion. (Figs. 23-27)

Fig. 23. Right lateral view. Fig. 25. Left lateral view.Fig. 24. Frontal view.


At the case finishing, a retention device with a provisional tooth is placed while a definitive tooth is scheduled to be replaced prosthetically. Figs. 28-33)

Fig. 28. Right lateral view, the end of the treatment.



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Fig. 34. Panoramic X-ray, beginning of the treatment.

Fig. 35. 5. Panoramic X-ray, the end of the treatment.

Fig. 33. Retention device with prosthetic tooth.

Case report

Level I.Start: September 2020 (every Tuesday). End: July 2021Level II:Start: September 2020 (every Monday). End: July 2021

Diagnosis and treatment plan. Treatment in permanent dentition. fixed appliances 1. Treatment in mixed dentition. Removable appliances 1. Retention and stability. Clinical organization. Interdisciplinary diagnosis. Treatment in permanent dentition. fixed appliances 2. Treatment in mixed dentition. removable appliances 2. Interdisciplinary treatment. Specialist’s Thesis

Specialist Degree validated by the University of SAN JORGE.Students will earn 39 ECTS.Course duration: 2 academic years and a total of 975 h. Type: one morning per week.

This theory&hand-on course objectives are: 1. Make up for the training deficiencies in dentistry related to the orthodontic and orthopedic field. 2. To train the students to deal with the situations which require mild or moderate malocclusion treatments with conviction and quality. 3. To prepare the students to work as a part of an interdisciplinary team, carrying out the orthodontic and orthopedic treatments.



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Is early treatment always a good treatment option?

Dr. Noelia CimaSpecialist in Orthodontics and Functional OrthopedicsPractice limited to OrthodonticsProfessor at ATHENEA DENTAL INSTITUTE

In the current practice of orthodontics, there are two practically antagonistic schools: orthodontists in favor of early treatment in temporary or mixed dentition, and those rejecting this proposal, radically opposing it and waiting for the growth to be completed to apply fixed appliances.

Those who support interceptive orthodontics or early treatment consider that it allows the partial or even total correction of a malocclusion in a growing child. Such early treatment is often brief, uses simple mechanisms, and prevents the anomaly from worsening. The main orthodontists who have advocated early orthodontic treatment include Ricketts, Gugino, McNamara, Frânkel, Delaire, Graber, among others.

In clinical practice, one of the dilemmas that an orthodontist often faces is when to intervene and when not. Interceptive treatment is generally performed in growing patients with mixed dentition. The European Society of Orthodontics proposes interceptive orthodontics as a therapy that tries to avoid major alterations, usually starting and ending during temporary or mixed dentition. They do not rule out the possibility of a subsequent correction, in the event of the appearance of another similar or different anomaly. This type of treatment is regularly used to correct habits, atypical deglutition, mouth breathing which can interfere with the regular growth pattern of the face and jaws.

Some malocclusions arising from habits such as thumb sucking can correct on their own on cessation of the habit. Unfortunately, in many other cases, there are malocclusions that require early interceptive treatment, even though with simple devices.

Therefore, interceptive orthodontics is aimed at correcting any incipient alteration, since the malocclusion would worsen if some type of measures are not taken.

The goal of early treatment is to correct skeletal, dentoalveolar, and muscular discrepancies, either existing or in development, in order to prepare a better orofacial environment before the permanent dentition eruption is complete. By initiating treatment at a younger age, the need for subsequent complex orthodontic treatments is minimized, especially those involving permanent tooth extraction and orthognathic surgery.

Despite different opinions, the clinical orthodontist will routinely perform minor treatments on children in temporary or mixed dentition, whenever necessary.

Such limited interventions can be described as simple interceptive treatment. They usually have short duration and can include:

• Control of habits

• The use of passive devices (such as space maintainers)

• Simple alignment of incisors

• Correction of cross bites, both anterior and posterior

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It is clear that when we talk about early treatment, we will be intercepting the problem, we prevent it from getting bigger. The interception can be carried out in many ways, from a simple space maintainer which will help us maintain the length of the arch and thus avoid future dentoalveolar discrepancies, passing through a functional appliance that will provide the re-education of stimuli and inputs to a face mask in skeletal class III cases. The range of treatments is always very wide and the choice of one or the other will depend, in part, on the training and skill of each orthodontist. The important thing is always to achieve an adequate diagnosis. In-depth knowledge of the functions of the stomatognathic system will give us the key to reach an accurate diagnosis and its correct treatment plan (Fig. 1).

Fig. 1.

To speak of diagnosis, we must possess the perfect knowledge of the etiology of malocclusions, and in this way, by identifying the cause that produces it, we can find the best treatment to eliminate it and avoid as many relapses as possible (FIG. 2).

Fig. 2.

Among the most frequent etiological factors, we can find:

• MOUTH BREATHING OR MIXED BREATHING

• ATYPICAL OR DYSFUNCTIONAL DEGLUTITION

• HARMFUL HABITS

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RESPIRATION

The respiration highly conditions the solid craniofacial growth and development (fig. 3).

Fig. 3.

Fig. 4a. Balanced deglutition.

Fig. 4b. The effect of an environmental force breaks the balanced situation of skeletal and dental structures.

DEGLUTITION

It is a complex neuromuscular activity which involves coordinated movements of facial muscles.

It`s main function is transport of liquid, semisolid and solid food. Deglutition should be safe and efficient.

The effect of an environmental force can alter the balances situation between centripetal and centrifugal forces which maintain an adequate deglutition activity (fig. 4).

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HABITS

A habit is defined as:

The fixation of a permanent repetitive practice of a certain action. If the repetition is frequent enough it can be relegated completely to unconsciousness and in this way it becomes a unconscious model with duration in time (fig. 5).

Fig. 6.

Fig. 7.

Fig. 5. Thumb sucking habit.

An early treatment in growing children will try to intercept these etiological factors which interfere in correct expression of the phenotype of each individual. By means of functional orthopedics, we can achieve: new muscular and skeletal adaptations and introduction of a new pattern of functional model.

FACTORS TO BE CONSIDERED WHEN PLANNING AN EARLY TREATMENT

Growth modification

In the last years, there has been a controversy among orthodontists regarding the extension and localization of neuromuscular skeletal adaptations induced in an early treatment in the craniofacial complex. The major number of orthodontists agree that downward and forward growth of maxillary complex can be affected when carrying out therapies like headgear traction and different functional appliances treatments. The maxillary transverse dimension modification through the RPE has not been especially controversial, in spite of the fact that the long term stability of this treatment is always the topic of the dilemma.

There are different procedures which can be successfully used in mixed dentition to produce the significant changes in skeletal, dentoalveolar and muscular structures.

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Patient’s cooperation

According to Graber (1975), the weak point of many procedures in early treatment is patient’s cooperation. The ability to motivate a patient to cooperate is essential in a successful orthodontic treatment, whether it is initiated during the mixed or permanent dentition. One of the main fears of many orthodontists is that, after starting the treatment in mixed dentition, the cooperation and enthusiasm of parents and patient disappear before the successful completion of the fixed orthodontic treatment. The objectives and goals of a treatment should be firmly established in order to avoid unnecessary and long periods which can make a patient run out of patience.

Therefore, when selecting a treatment plan to be carried out in mixed dentition, we should make an effort to minimize the necessary cooperation required from a patient to ensure the treatment success, without compromising its quality and stability.

For Bennett, a growing patient must be cooperative, and says it is not possible to foresee in precise way the patient’s cooperation, but a poor cooperation has a negative influence on the treatment.

Relative factors for patient’s cooperation:

• Orthodontist-patient relationship as positive factor

• Functional appliance design as a factor for cooperationn

Clinical practice management

If we accept the concept that growth can be modified, and we have a patient who shows a high level of cooperation and enthusiasm for the treatment, we should count on the possibility to plan an early treatment.

In a treatment of a patient in mixed dentition we want to carry out the same type of reasonable estimation with the same level of faith. Nevertheless, we should admit that due to the fact that the growth quantity and direction, as well as the teeth eruption level are the determining factors in early treatment, the treatment time is more variable than when we have patients with permanent dentition.

In optimal situation, the treatment of a patient in mixed dentition should be divided in phases with defined duration, as well as with a predictable result. In general terms, we would like to propose to a patient an initial phase of treatment of approximately one year, followed by a periodical observation during the transition between the mixed and permanent dentition.

In this way, we can number four treatment success factors (fig. 8)

1. Treatment timing

2. Case selection

3. Patient collaboration

4. Appliance selection

Fig. 8.

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Interceptive orthodontics is a trustworthy treatment, as any other method of orthodontic treatment, but it requires timing, case selection, motivation and selection of correct appliances.

Fig. 9.

CLINICAL APPROACH TO DIFFERENT DIAGNOSES

For example, a problem of discrepancy between the dental arch size and teeth size in a Class I malocclusion is perfectly treated when a patient has mixed dentition. This treatment usually is started after the eruption of four lower incisors, and upper central incisors. In many cases there is no sufficient space for correct eruption of upper lateral ones. Depending on the size of permanent teeth it can be used, whether it is a treatment with serial extractions or with orthopedic expansion.

Some Class I should also be intercepted, such as those in which harmful habits are identified (thumb sucking habit, mouth breathing or deglutition disorders) or in case of premature loss of temporary teeth where a corresponding space maintainer should be placed to favor the correct eruption of permanent teeth. On the other hand, the simple alignment of incisors is a very effective early treatment which reduces significantly future occlusal problems.

Posterior uni o bilateral cross bites should be usually intercepted with early treatment using transverse expansion mechanics in mixed dentition, where we can use from an expansion plate to McNamara separation appliance depending on the correct skeletal or dentoalveolar diagnosis.

When thinking of early treatment of Class III malocclusions, bibliographic revision offers a great controversy regarding the best moment to start Class III malocclusion treatment, but there is agreement on great importance of early treatment.

As far as the growth of Class III malocclusion patient is concerned, McNamara claims that there are few studies in Europe and the USA with the sufficient number of subjects, X-ray studies sufficiently extended in time for conclusions to be definitive. Nevertheless, these studies do exist in Asia where the Class III prevalence is much higher than in Europe.

Early diagnosis and treatment of Class III is very important because the spontaneous evolution of this malocclusion towards severe Class III is very possible.

Here, the essential importance lies in the diagnosis and interception of etiological factors which can worsen even more the prognosis, such as forward position of mandible due to occlusal interferences, habits, forward position of the tongue, mouth breathing due to hypertrophy of adenoids and tonsils.

There are different opinions regarding to the best moment to start Class III malocclusion treatment. The arguments in favor of an early treatment are: spontaneous evolution toward worse malocclusion without treatment and the younger the patient, the better the results of orthopedic treatment.

Those who are against point out that the complete correction of malocclusion is not always achieved and that it often develops relapse due to late growth. Mandibular growth is quite unpredictable and sometimes the skull (especially at the level of sphenooccipital synchondrosis) compensates the mandibular growth deficiency.

For many authors, in many cases of diagnosed Class III malocclusion in late deciduous dentition or in early mixed dentition, the treatment can be started earlier than in Class I cases, as it was described before. The appropriate time for the initiation of treatment (e.g. for the placement of the face mask, chin cup or Fränkel RF-3) matches the exfoliation of the upper deciduous incisors and the eruption of permanent central incisors. This early intervention will obviously result in a longer period of time between the start of the initial phase of treatment and the end of the complete treatment, once the permanent dentition has erupted. Early treatment of Class III malocclusion may also be characterized by more than one period of interventions during mixed dentition.

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On the other hand, the time for initiation of treatment of mandibular deficiency is a bit different from those described for Class I and Class III malocclusions. Just as there is a tendency to early intervention in Class III cases, in patients with Class II malocclusion with skeletal mandibular deficiency, some authors recommend delaying the placement of orthopedic maxillary functional devices until late mixed dentition. Clinical and experimental studies have shown that there is an increased growth response with functional devices when treatment is initiated during the circumpuberal growth period. The therapy with functional devices (Klammt, Andresen or with the Bionator) will be ideally continued with a fixed appliances phase in order to align the permanent dentition.

However, it is very important to know how to detect and diagnose patients who have more severe neuromuscular and skeletal problems, in whom the beginning of treatment in early mixed dentition is recommended. We have talked about the importance of intercepting the etiological cause when diagnosing function disorders (breathing, deglutition or habits) to achieve the state of balance between form and function in order to allow optimal phenotype expression of the patient.

In many patients between the ages of six and eight with a diagnosed Class II malocclusion, the treatment should be started during this period with the aim of managing the skeletal or dentoalveolar problems e.g. crowding, spacing and vestibularization of upper incisors; intermaxillary discrepancies may be treated in a later period.

In other words, the same procedures (such as orthopedic expansion and serial extraction) used in Class I patients can also be initiated in Class II patients with arch length discrepancies. However, it will be better to delay correction of the anteroposterior skeletal relationship until late mixed dentition in patients with mild or moderate problems.

Bennett describes the clinical possibility of performing a single late treatment for Class II 1st div. malocclusion cases without crowding.

As previously mentioned, from the historical point of view, there have been two basic strategies commonly used in the treatment of class II malocclusions in children and they can be: TWO TREATMENTS (INITIAL AND LATE) OR ONLY ONE LATE TWO TREATMENTS: INITIAL AND LATE (fig. 10)

TWO TREATMENTS: INITIAL AND LATE (fig.10)

Tras un periodo de tratamiento inicial en la preadolescencia, a la edad de 8-10 años, se prosigue con un segundo periodo de tratamiento definitivo durante la adolescencia, al a edad de 11-14 años

Fig. 10.

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ONLY ONE LATE TREATMENT (fig:11)

All correction is carried out in a single treatment during adolescence, at the age of 11-14 years and is the strategy recommended by Bennett for Class II, 1st div. malocclusions without crowding.

Bennett describes and defends the single late treatment approach, for selected Class II, 1st div. malocclusions, beginning in early adolescence. Treatment involves a functional appliance stage followed immediately by a fixed appliance stage. All corrections are carried out in a single treatment: this avoids the pause between functional and fixed treatment.

During the functional stage, an Andresen appliance is used, usually 6 to 9 months, to reduce overjet and overbite.

Four factors in the success of the treatment:

1. The treatment timing: the treatment begins at the end of the mixed dentition or at the beginning of the permanent dentition

2. Case selection: Class II, 1st div. malocclusion with reduced angle, with little or no crowding and a an overjet of up to 12 mm

3. Patient cooperation: a functional device easy to wear, a good relationship between the orthodontist and the patient

4. Appliance selection

Total treatment time:

If treatment begins at the age of 11, it can be completed at age of 13. However, if you start at the age of 8, it still cannot end before the age of 12-13, because it is not possible to finish an orthodontic treatment before the eruption of bicuspids and the permanent 2nd molar which happens at the age of 12-13.

It has not been possible to demonstrate any advantage of early treatments in terms of therapeutic results. The results of two-phase treatments appear to be no better than those of a single phase. In a study by Chapel Hill, Tulloch et al, the conclusion was: “…. In children with moderate to severe class II problems, early treatment followed by a subsequent exhaustive phase does not, on average, produce significant differences in the relationship between the jaws or dental occlusion, compared to those of a single late phase treatment.”

It is not logical to be in favor of early treatment at the age of 8-10 only for growth reasons, since there is still a great potential for mandibular growth at the age of 11-13. Growth studies only give average values for the amount, direction and time of growth, but there is great variation between individuals.

So for Bennet, late mixed dentition is an ideal time to start functional therapy in many patients.

He recommends early treatment only in Class II 1st division malocclusion cases due to special circumstances such as:

1. Early reduction of overjet for social or psychological reasons

2. Early overjet reduction to reduce the risk of enamel lesion

Fig. 11.

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FINAL THOUGHT

To be honest, not all orthodontic therapy under the name “early treatment” is always a good option. Experience has shown young patients, treated for long periods without well-defined objectives and without predictable results. In this situation, inconveniences arise not only regarding the patient’s cooperation, but also regarding the parents’ satisfaction and even the fatigue regarding both the orthodontist and the patient.

Therefore, the early treatment concept should be defined within the context of general orthodontic therapy and with this principle a specialist should be guided in order to provide an effective early treatment..

Those who practice it, should possess a profound comprehension of craniofacial growth and dental arches development to offer the most efficient treatment to a patient.

When evaluation all possible early treatment plans, a realistic vision of the growth modification possibilities should be taken into account. Besides, the growth differences related to the age (for example, increased mandibular growth in prepuberal growth period) should also be taken into account.

All effort should be made to select the treatment plan which requires the least patient’s cooperation, when appropriate. When the treatment requires the maximal cooperation of a patient, then they and their parents should participate in the selection of the procedure. Both the estimated daily time of the use of appliance and the expected treatment time should be previously defined.

It should be also stressed that the early treatment is not always necessary nor appropriate. n some cases, the early intervention will not significantly change the dentofacial development environment nor the permanent dentition eruption. In such cases, the early treatment can offer only the increase of treatment time and bring the “worn out” patient as a result. These worries should also be considered when evaluating the treatment options.

Finally, if all necessary effort is made to start the treatment in the adequate moment in order to maximize the therapeutic benefits in the shortest time possible and if the proposed treatment plan offers predictable results and duration, the early orthodontic intervention can be carried out successfully in great variety of patients in mixed dentition.

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Fig. 12. Growth studies confirm that at the age of 11-13 there is a great mandibular growth potential.

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BIBLIOGRAPHY

1. Woodside, Metaxas, Altuna. The influence of functional appliance therapy on glenoid fossa remodeling.Am J Orthod Dentofacial Orthop 1987; 92:181-98.

2. American Association of Orthodontics. My Life. My Smyle. My Orthodontist. 2013. Glossary of Orthodontic Terms. Almeida, R.; Almeida, M.; Oltramari-Navarro, P.; Conti, A.; Navarro, R. & Marques, H. Posterior crossbite-treatment and stability. J. Appl. Oral Sci., 20(2):286-94, 2012

3. Alam, M. K. A to Z Orthodontics. Preventive and Interceptive Orthodontics. Vol 9. Kota Bharu, PPSP Publication, 2012. pp.3-13

4. Baccetti, T.; Mucedero, M.; Leonardi, M. & Cozza, P. Interceptive treatment of palatal impaction of maxillary canines with rapid maxillary expansion: a randomized clinical trial. Am. J. Orthod. Dentofacial Orthop., 136(5):657-61, 2009.

5. Becker, A. Palatally impacted canines. Orthodontic treatment of impacted teeth. 3rd ed. Chichester, Wiley- Blackwell, 2014. pp.111-70.

6. Brin, I. & Bollen, A. M. External apical root resorption in patients treated byserialextractions followed by mechanotherapy. Am. J. Orthod. Dentofacial Orthop., 139(2):129-34, 2011

7. Castañer-Peiro, A. Interceptive orthodontics: The need for early diagnosis and treatment of posterior crossbites. Med. Oral Patol. Oral Cir. Bucal, 11(2):E10-4, 2006

8. McNamara JA, Bookstein FL, Shaughnessy TG. Skeletal anddental changes following functional regulator therapy on Class II patients. Am J Orthod 1985; 88:91-110.

9. Baccetti T, Franchi L. Maximizing esthetic and functional changes in Class II treatment by means of appropriate treatment timing. In: McNamara JA, Kelly K, eds. New Frontiers in Facial Esthetics. Ann Arbor, Mich: Center for Human Growth and Development, The University of Michigan; 2001.

10. Faltin K, Rolf M, Faltin TB, Franchi L, Ghiozzi B, McNamara JA. Long-term Effectiveness and Treatment Timing for Bionator Therapy Angle Orthod 2003; 73:221-230.

11. McNamara JA, Brudon WL. Orthodontics and Dentofacial Orthopedics. Ann Arbor Mich: Needham Press; 2001. 67-80.

12. Condò, R.; Costacurta, M.; Perugia, C. & Docimo, R. Atypical deglutition: diagnosis and interceptive treatment. A clinical study. Eur. J. Paediatr. Dent., 13(3):209-14, 2012

13. Ericson, S. & Kurol, J. Early treatment of palatally impacted maxillary erupting canines by extraction of the primary canines. Eur. J. Orthod.,10(4):283-95, 1988

14. Harrison, J. E. & Ashby, D. Orthodontic treatment for posterior crossbites. Cochrane Database Syst. Rev., (2):CD000979, 2001.

15. Jolley, C. J.; Huang, G. J.; Greenlee, G. M.; Spiekerman, C.; Kiyak, A. & Kingf, G. J. Dental effects of interceptive orthodontic treatment in a Medicaid population: interim results from a randomized clinical trial. Am. J. Orthod. Dentofacial Orthop., 137(3):324-33, 2010.

16. King, G.; Spiekerman, C.; Greenlee, G. & Huang, G. Randomized Clinical Trial of Interceptive and Comprehensive Orthodontics. J. Dent. Res., 91(7 Suppl.):59S-64S, 2012.

17. King, G. J. & Brudvik, P. Effectiveness of interceptive orthodontic treatment in reducing malocclusions. Am. J. Orthod. Dentofacial Orthop., 137(1):18-25, 2010.

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Chapter 7 CA® CLEAR ALIGNER “AESTHETIC” 3-3. Crowding treatment: Expansion and stripping

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