Dental Press Jounal of Orthodontics
Dental Press International

v. 16, no. 6

Dental Press Journal of Orthodontics – ISSN 2176-9451

Dental Press J. Orthod.

v. 16, no. 6

November / December



We need practical proposals to improve the quality of dental care in Brazil

Jorge Faber

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?We sell a dream and deliver a nightmare.? With this sentence the minister of the Brazilian Supreme Court, Marco Aurélio Mello, summed up his vote for the constitutionality of the bar examination of the Order of Attorneys of Brazil. He defined, in a sense, the process of formation of a law graduate in Brazil. The question of the constitutionality of this examination was presented as a legal recourse by a graduate in Law. Earlier in the day of the manifestation of the minister, the general-prosecutor of the Brazilian Republic, Roberto Gurgel, said that: ?The bar examination is, therefore, clearly adequate to ensure qualification of the professional and protect the rights of third parties.?1 

This important fact, necessarily, makes us to reflect on the possibility of a examination for dentistry (and other healthcare areas, such as medicine): The examination of the Brazilian Federal Council of Dentistry (CFO). Many countries, like the UK and the USA, see the obligatoriness of these examinations for our profession as the only way to ensure the qualification of the professional and protect the health of the population. In Japan, graduates in dentistry are submitted to a qualification exam after a six years undergraduate course. It is very important to warn that healthcare professionals must have some minimum knowledge to act in this area, otherwise they will become ?disease professionals?. 

Obviously, this is not the only action needed to improve the quality of healthcare to our people. Mandatory continuing education is also one of them. In Italy, this apprehension is so intense that dentists needs to be out of service for nearly two weeks every year, to achieve the number of credits of continuing education that will enable them to keep their work permit valid. Perhaps this is an exaggerated number of hours. Some states, like Illinois, require 48 hours of continuing education every three years to renew the work permit.2 The continuing education credits can be obtained with both in-person classes and answering to questionnaires compiled from articles, as those present in DPJO. In Brazil, there is no legal requirement of any kind and it is common that many professionals will graduate and never seek for update. 

However, this discussion could not eclipse the main star of this issue, which is higher education in the dental field. There is a debate about the quality of this education. Surely it is not perfect, however, if we judge this quality from the objective point of view of knowledge production, it is among the best in the world. On the other hand, of course, good schools share space with the weak ones, not to mention the fact ? known by almost all the teachers in Brazil ? that several institutions of higher education pressure teachers to promote students who have not reached the required notes for approval. And the controversy do not end here. If there is currently so much evasion in our profession, it means that many schools are simply unnecessary. The student buys a worthless diploma, because he will not exercise the profession. 

So we have a problem underpinned, mainly, on a tripod. We have several weak schools ? which the Brazilian population does not need ? training professionals without verified qualification and, to make it worse, many of them do not maintain a continuing education. This scenario contrasts with the fact that we have dental professionals that are among the bests in the world and it means that a parcel of the population is attended with excellence and another, possibly, is attended by ?disease professionals?. 

What is the ideal model? Effective actions to close the unnecessary weak schools? The introduction of mandatory continuing education programs? The selection of those proven to be suitable for healthcare professionals, through a test conducted by the CFO and applied to graduates? Or adopt both of these actions? Any new proposal, since concrete and feasible, is welcomed. 

I?m open to criticism, suggestions and discussions.* 

Good reading.

Special Editorial

And now: Professor Dr. David Normando

Jorge Faber

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Over the past five years, I have served aseditor-in-chief of the Revista Dental Press deOrtodontia e Ortopedia Facial which, from2010 on, is being published in English and is,now, called Dental Press Journal of Orthodontics.I read, then, thousands of articles and wrote30 editorials. This is the 31st and the last of them.

The closure of all cycles moves us, naturally,to reflect and to list important peopleand facts. Unfortunately, I could not, in thiseditorial space and with justice, mention allthe people who were so important for thisjournal and me as its editor. To represent allthis group of fabulous minds, I will commentbriefly on five people. Each one represents asection of the journal. [...]

What´s new in Dentistry

Tele-orthodontics: Tool aid to clinical practice and continuing education

André Luciano Pasinato da Costa , Alcion Alves Silva , Cléber Bidegain Pereira

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Introduction: Information technology is revolutionizing interpersonal relations. Thisnew context has made possible the pursuit of professions in the health area, a conceptknown as telehealth. The essence of this area is the provision of health information atdistance. In this context, orthodontics as a specialty can not remain oblivious to advances.

Objective: This article, through a non-systematic literature review, set out toinvestigate which of the available technologies are likely to be used in the developmentof tele-orthodontics services as tools to aid clinical practice and continuing education.The use of technologies already available in the market can enable tele-orthodonticsservices. Even though this article has analyzed the technical conditions and technologiesrelated to the study object, it tends to the ethical, moral, legal and economicalaspects of this process.

Orthodontic Insight

Orthodontic movement does not induce external cervical resorption (ECR) or Orthodontic movement does not change gingival color and volume, and does not induce gingival inflammation

Alberto Consolaro, Renata B. Consolaro

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This study sought to explain, both anatomically and functionally, how the cervical regionof human teeth is structured and organized in order to address the following questions:1) Why does External Cervical Resorption (ECR) occur in human dentition? 2) Why isthere no ECR in gingivitis and periodontitis? 3) Why ECR can occur after dental traumaand internal bleaching? 4) Why does orthodontic movement not change the gingival colorand volume during treatment? 5) Why does orthodontic movement not induce ECR althoughit is common knowledge that the cervical region can undergo much stress? Theexistence of sequestered antigens in the dentin, the presence of dentin gaps in the cervicalregion of all teeth, the reaction of the junctional epithelium and the gingival distributionof blood vessels may explain why ECR does not occur, nor do gingival color and volumechange when teeth are orthodontically moved.


Interview with Lysle E. Johnston Jr.

Cristiana (Kika) Vieira de Araújo

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? Graduated in Dentistry from University of Michigan School of Dentistry and in Orthodonticsfrom Michigan?s Horace H. Rackham School of Graduate Studies.

? Specialist in Anatomy from Queen?s University of Belfast.

? PhD in Anatomy from Case Western Reserve University.

? Former head of the Department of Orthodontics and Pediatric Dentistry at the Universityof Michigan.

? Program Director of Orthodontics at Case Western Reserve University (1971-76) andSaint Louis University (1976-91).

? Professor at the University of Michigan, Saint Louis University and Case Western ReserveUniversity.

? Member of the American College of Dentistry, the International College of Dentistryand the Royal College of Surgeons, England.

? Former director of the Edward H. Angle Society of Orthodontists.

? Editor of several journals, including the American Journal of Orthodontics and DentofacialOrthopedics and the British Journal of Orthodontics.

Online Article

Analysis of the use of sample size calculation and error of method in researches published in Brazilian and international orthodontic journals

David Normando, Marco Antonio de Oliveira Almeida, Cátia Cardoso Abdo Quintão

Biostatistics. Sample size. Error of methods.

Introduction: Reliable sample size and an appropriate analysis of error are important steps to validate the data obtained in a scientific study, in addition to the ethical and economic issues. Objective: To evaluate, quantitatively, how often the researchers of orthodontic science have used the calculation of sample size and evaluated the method error in studies published in Brazil and in the United States of America. 

Methods: Two major journals, according to CAPES (Brazilian Federal Agency for Support and Evaluation of Graduate Education), were analyzed through a hand search: Revista Dental Press de Ortodontia e Ortopedia Facial and the American Journal of Orthodontics and Dentofacial Orthopedics (AJO-DO). Only papers published between 2005 and 2008 were examined. 

Results: Most of surveys published in both journals employed some method of error analysis, when this methodology can be applied. On the other hand, only a very small number of articles published in these journals have any description of how sample size was calculated. This proportion was 21.1% for the journal published in the United States (AJO-DO), and was significantly lower (p= 0.008) for the journal of orthodontics published in Brazil (3.9%). 

Conclusion: Researchers and the editorial board of both journals should drive greater concern for the examination of errors inherent in the absence of such analyses in scientific research, particularly the errors related to the use of an inadequate sample size.

In vitro evaluation of force delivered by elastomeric chains

Andréa Fonseca Jardim da Motta , Adriana de Alcantara Cury-Saramago , Lincoln Issamu Nojima

Orthodontic appliances. Dental materials. Elastomers.

Objective: To evaluate and compare, in vitro, the decrease in the forces delivered in three groups of elastomeric chains, produced by the same manufacturer, according to the distance between links (short, medium, long). 

Methods: The segments of elastomeric chains were stretched and kept activated during the trial using a device developed especially for this purpose, which also allowed force readings. Force degradation was evaluated by measuring force along time and calculating the percentage of force decrease from initial force at each time interval and for each specimen under test. Results and 

Conclusions: Data were statistically analyzed and results showed that at the different time points after initial readings, force intensity varied within and between groups. Readings of remaining forces at each time moment compared with the initial reference force revealed statistically significant differences in all the comparisons in each group of elastics (short, medium, long). Although the comparisons between forces delivered at each time point revealed statistically significant differences, these differences do not seem to have a clinical significance. The space between links does not seem to be a clinically significant characteristic in force degradation along time.

Prospective cephalometric study of the effects of maxillary protraction therapy associated with intermaxillary mechanics

Juliana de Oliveira da Luz Fontes, Guilherme Thiesen

Objective: The early diagnosis and treatment of skeletal Class III (Pattern III) is still a much debated topic in orthodontic literature. Maxillary protraction associated with rapid maxillary expansion is the most popular and widely researched approach, producing the best results in the shortest period of time. This study aimed to evaluate the gradual changes that occur in the dentofacial complex in children with Pattern III growth treated with maxillary protraction associated with intermaxillary mechanics. 

Methods: The sample consisted of 10 patients with Pattern III, whose mean age was 8 years and 2 months at the beginning of treatment, consecutively treated with a modified Haas expander, modified lingual arch, intermaxillary elastics and Petit facemask for maxillary protraction during a 9-month period. Four lateral cephalograms were taken of each patient, one at the beginning of treatment and the other three at regular 3-month intervals (T1, T2, T3 and T4). Cephalometric measurements at each of the four times were compared using ANOVA variance for repeated measures and supplemented by Tukey?s multiple comparisons test. 

Results: It was observed that the most significant skeletal changes occurred in the first 3 months of treatment. After that period the changes remained constant until the end of treatment. There were few dental compensations and the vertical changes which occurred showed reduced clinical significance. 

Conclusions: The therapy used in this study accomplished not only the correction of overjet but also improvements in the sagittal relationship of the basal bones and in soft tissue esthetics.

Original Article

Cephalometric study of tooth position in young Afro-Caucasian Brazilian individuals with normal occlusion

Eduardo Jacomino Franco , Arnaldo Pinzan , Guilherme Janson , José Fernando Castanha Henriques, Célia Regina Maio Pinzan-Vercelino

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Objective: The purpose of this study was to achieve a specific cephalometric pattern for young Afro-Caucasian Brazilian individuals and verify the presence of dimorphism between sexes. 

Methods: The sample was composed of 40 lateral cephalograms of young Afro-Caucasian Brazilian individuals (mulattos), 20 males (mean age 13.25 years) and 20 females (mean age 13.10 years), with normal occlusion and no previous orthodontic treatment. The cephalometric variables were determined according to the analyses of Downs, Steiner, Riedel, Tweed, McNamara, Ricketts and Interlandi. Independent t test was applied to compare the variables between sexes. 

Results: The maxillary and mandibular incisors were protruded and buccally tipped. There was no statistically significant difference between sexes in all variables. 

Conclusions: It was observed that young Afro-Caucasian Brazilian individuals without skeletal alterations and with normal occlusion showed specific tooth position and facial features in relation to the other Brazilian ethnic groups.

Cephalometric evaluation of the effects of a mandibular protraction appliance (MPA) combined with fixed orthodontic appliance on dentoalveolar and soft tissue structures of Class II, division 1 patients

Alexandre Magno Negreiros Diógenes, Rildo Medeiros Matoso, Emmanuelle Medeiros de Araújo, Kenio Costa Lima, Raniere Luiz dos Santos Sousa

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Objective: To perform a cephalometric evaluation of dentoalveolar and soft tissue changes in Brazilian youths with Class II, division 1 malocclusion, treated with a mandibular protraction appliance (MPA) combined with fixed corrective orthodontics. Methods: The sample consisted of 28 patients (16 females and 12 males) with a mean age of 13.06 years, treated for a mean period of 14.43 months. The changes were measured on 56 specific cephalometric analysis obtained from lateral cephalograms taken before and after treatment by two calibrated examiners in order to identify soft tissue and dentoalveolar changes using linear and angular cephalometric measures. The independent variables sex, age, facial pattern, MPA model, archwire, technique and treatment time were registered and analyzed using linear and angular cephalometric measures. Treatment responses were analyzed and compared by the Wilcoxon Signed Ranks and Mann-Whitney tests at a significance level of 5%. Results: The results showed dentoalveolar changes of great magnitude, which caused positive changes in soft tissue. It was also noted that the variables age, MPA model and technique influenced the treatment. Conclusions: MPA proved to be an effective alternative in the treatment of Class II, division 1 malocclusion, inducing dentoalveolar and soft tissue changes with satisfactory clinical results.
Shear bond strength of Concise and Transbond XT composites with and without bonding agent

Alexandre Maêda Neves , Fábio Lourenço Romano, Américo Bortolazzo Correr

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Objectives: The aim of this study was to evaluate the shear bond strength of brackets and the adhesive remnant index (ARI) of Concise and Transbond XT composites with and without the use of a bonding agent. 

Methods: The sample consisted of 60 bovine incisors divided into four groups (n=15). All teeth were subjected to prophylaxis with pumice and enamel etching with phosphoric acid at 37%. In Groups 1 and 2 brackets were bonded with Concise composite with and without application of enamel bond resin, respectively. In Groups 3 and 4, Transbond XT was used with and without XT Primer application, respectively. In these latter groups bonding was light cured for 40 seconds. Specimen shear strength testing was performed on an Instron machine at 0.5 mm/min, and ARI was subsequently evaluated. 

Results: Shear bond strength in Group 4 was statistically higher than in Groups 1 and 2 (p<0.05) but not when compared to Group 3 (p>0.05). There were no statistically significant differences between Groups 1, 2 and 3 (p>0.05). ARI in Group 3 was statistically higher than in Group 2 (p<0.05), but not statistically different from Groups 1 and 4 (p>0.05). There were no statistically significant differences between Groups 1, 2 and 4 (p>0.05). 

Conclusion: The composites Concise and Transbond XT showed adequate bond strength with or without the use of their respective bonding agents.

Bolton analysis: An alternative proposal for simplification of its use

Karina Eiras Dela Coleta Pizzol , joão roberto gonçalves , Ary dos Santos-Pinto, adriano porto peixoto

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Introduction: Mesiodistal size discrepancies of upper and lower teeth and their effect on occlusion have been related. Bolton?s method for tooth size discrepancies is, undeniably, one of the most commonly-used methods in orthodontics because of its simplicity. However, the application of this method requires mathematical calculations and use of tables, which often prevents its clinical use. Purpose: Evaluate an alternative method for Bolton?s analysis proposed by Wolford that does not require table information. 

Material and Methods: The sample was composed of 90 initial dental casts of adult patients, with different malocclusions. The ratio between the sum of widths of maxillary and mandibular teeth was calculated for each patient, resulting in the attainment of two indices: The overall ratio and the anterior ratio. Indices were calculated by Bolton?s method and by an alternative method, using two different formulas (one simplified and a variation of the same formula) that were separately analyzed. 

Results: In comparison with Bolton?s method, the Simplified Formulas demonstrated a slight trend towards an overestimation of the inferior dental discrepancies (overall and anterior). 

Conclusion: Both formulas employed for the alternative method may be used to substitute the traditional method, since each demonstrated, on average, differences of less than 0.58 mm when compared with Bolton?s method and no clinical significance.

Changes in pogonion and nose according to breathing patterns

Orlando Motohiro Tanaka, Suelem Tisiane Fabianski , Lílian Mary Karakida , Luégya Amorin Henriques Knop ,

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Introduction: The soft tissue profile results from complex changes in the hard and soft tissues of the face. The pogonion and the nose are dominant facial structures that determine the degree of profile convexity and should, therefore, be analyzed and included in orthodontic treatment planning. 

Objective: To conduct a longitudinal evaluation of the anteroposterior dimensional changes of the pogonion and the nose of individuals with Angle Class II, division 1 malocclusion at two time points during craniofacial development. 

Methods: Lateral cephalograms were obtained for 40 individuals ? 23 nasal breathers (NB) and 17 mouth breathers (MB). 

Results: Linear and angular measures were obtained: UL?-Pog?, UL?-B?, B?-Pog?, Pog?-PogTeg?, NB Line, Pog-NB, N?-Prn, Prn-NPog, N-Prn-Sn and Prn-Sn-UL. Two-way ANOVA was used to detect differences between mean values according to time points and/or breathing patterns. The UL?-B?, Pog?-PogTeg?, NB line and Pog-NB, N?-Prn, Prn-NPog, N-Prn-Sn and Prn-Sn-UL variables had significant differences (p?0.05) between the two time points, but there were no significant differences between breathing patterns. No interaction was found between breathing patterns and time points for any variable. 

Conclusion: The pogonion and the nose undergo significant changes in the anteroposterior plane during growth, but breathing patterns do not significantly affect changes.

Mouth breathing within a multidisciplinary approach: Perception of orthodontists in the city of Recife, Brazil

Valdenice Aparecida de Menezes , Luiza Laranjeira Cavalcanti , Tâmara Cavalcanti de Albuquerque, Ana Flávia Granville Garcia , Rossana Barbosa Leal

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Objectives: To assess the knowledge of a mouth breathing pattern among orthodontists in the city of Recife, Brazil, and to examine their treatment protocols. 

Methods: In this cross-sectional study, members of the Orthodontics and Facial Orthopedics Association of Pernambuco responded individual structured interviews. A form with 14 questions, validated using the face value method, was used to collect data. The level of significance was set at 5%. 

Results: Of the 90 participants, 55.6% were women; 78.9% were specialists (the highest educational level); 67.8% worked full-time in private practice, and 38.9% were also professors. The most frequent diagnostic criteria were: Body posture (97.8%), lip competence (96.7%), and dark circles under the eyes (86.7%), with similar results among young and old orthodontists. The use of the Glatzel mirror was infrequent (3.3%). The most frequently mentioned mouth breathing sequelae were craniofacial (94.4%) and body posture (37.8%) changes. According to interviewees, mouth breathing duration (84.4%) was the item most often associated with sequelae. There were no significant associations between time since graduation and any of the factors under analysis. Most respondents, whether working in private clinics or in the public healthcare system, believed that mouth breathers should be treated by a multidisciplinary team. 

Conclusions: Most orthodontists, regardless of experience, have knowledge of the mouth breathing syndrome and understand the need of a multidisciplinary treatment.

Assessment of force decay in orthodontic elastomeric chains: An in vitro study

Claudia Kochenborger , Dayanne Lopes da Silva , Ernani Menezes Marchioro , Diogo Antunes Vargas , Luciane Hahn

Elastics. Synthetic elastics. Elastomeric chain.

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Introduction: Elastomeric materials are considered important sources of orthodontic forces. 

Objective: To assess force degradation over time of four commercially available orthodontic elastomeric chains (Morelli, Ormco, TP and Unitek). 

Methods: The synthetic elastics were submerged in 37 ºC synthetic saliva and stretched by a force of 150 g (15 mm ? Morelli and TP; 16mm ? Unitek and Ormco). With a dynamometer, the delivered force was evaluated at different intervals: 30 minutes, 7 days, 14 days and 21 days. The results were subjected to ANOVA and Tukey?s test. 

Results: There was a force decay between 19% to 26.67% after 30 minutes, and 36.67% to 57% after 21 days of activation. 

Conclusions: TP elastomeric chains exhibited the smallest percentage of force decay, with greater stability at all time intervals tested. Meanwhile, the Unitek chains displayed the highest percentage of force degradation, and no statically significant difference was found in force decay between Ormco and Morelli elastomeric chains during the study period.

Orthodontic-surgical treatment of skeletal facial asymmetry: Case report

Susiane Allgayer , Fernanda Santos Mezzomo , Waldemar Daudt Polido, Gabriella Rosenbach , Carlos Alberto E. Tavares

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Introduction: Facial asymmetries consist of an imbalance between the homologous skeletal structures of the face. Most people present some degree of facial asymmetry, since a state of perfect symmetry is rare. This common asymmetry only becomes relevant when it is perceivable by the patient. In this situation, either orthodontic surgical correction or orthodontic treatment is normally chosen. 

Objective: This study, based on literature review, has been illustrated by a case report comprising Le Fort I orthognathic surgery for maxillary advancement and rotation, with conservative treatment for the mandible. 

Conclusion: Knowledge of the patient?s chief complaint and expectations, as well as proper diagnostic exams, are important factors to decide the treatment plan and for the final treatment outcome.

Collection and culture of stem cells derived from dental pulp of deciduous teeth: Technique and clinical case report

Alan Araujo de Jesus , Milena Botelho Pereira Soares, Ana Prates Soares , Renata Campos Nogueira , Elisalva Teixeira Guimarães , Telma Martins de Araújo, Ricardo Ribeiro dos Santos

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Introduction: Stem cells (SCs) are capable of inducing tissue regeneration and are, therefore, potentially therapeutic. Similarly to bone marrow and umbilical cords, dental pulp is one of the available sources of SCs. The fact that these cells are easily accessible and that deciduous teeth are not vital organs, and are normally discarded after exfoliation, make them particularly attractive for use in safety and viability tests. 

Objective: To describe the collection, isolation and culture of SCs obtained from the pulp of deciduous teeth as well as their characterization by flow cytometry, and the induction of differentiation into osteogenic and adipogenic lineages. 

Methods: SCs were obtained in a relatively straightforward manner and showed good proliferative capacity, even from a small amount of pulp tissue. 

Results: Analysis by flow cytometry confirmed the characteristics of mesenchymal SCs with low expression of CD34 and CD45 antigens, which are markers for hematopoietic cells, and high levels of expression of CD105, CD166, CD90 and CD73 antigens, which are markers for mesenchymal SCs. Cell plasticity was confirmed by identifying calcium deposits in cultures that received osteogenic medium, and intracellular lipid accumulation in adipogenic cultures that received adipogenic medium. 

Conclusions: SCs collected from deciduous teeth show promising potential for application in tissue regeneration. Therefore, it is important that knowledge about the existence and characteristics of this source of stem cells be disseminated among dentists and that the technique, its limitations and possible indications are highlighted and discussed.

BBO Case Report

Angle Class I malocclusion with bimaxillary dental protrusion and missing mandibular first molars*

Aldino Puppin Filho

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This case report describes the orthodontic treatment of a 24-year-old patient presenting with Angle Class I malocclusion, bimaxillary dental protrusion and recent loss of mandibular molars. Treatment involved extraction of the maxillary first premolars and closing of mandibular first molar spaces. Treatment outcomes demonstrate the need for individualized treatment planning and highlight the key role played by biomechanical concepts in achieving proper orthodontic tooth movement. This case was presented to the Brazilian Board of Orthodontics and Facial Orthopedics (BBO) as representative of the free choice category in partial fulfillment of the requirements for obtaining the BBO Diploma.

Special Article

Molar extractions in orthodontics

Marco Antônio Schroeder , Daniela Kimaid Schroeder, Diego Junior da Silva Santos, Michelle Machado Leser

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Orthodontic treatment with extraction of molars in adult patients is technically more complex due to a number of factors. In general, the space to be closed is greater than premolar spaces rendering critical anchorage and longer treatment time. Often such cases exhibit some degree of periodontal involvement due to patient age. Hence, the need for greater control over orthodontic mechanics to reduce the side effects of space closure. Therefore, good finishing results can be more difficult to achieve. Thus, the purpose of this article is to determine the reasons for molar extraction indications, describe different stages of orthodontic mechanics, and explain the issues involved in this kind of planning and treatment. Additionally, it aims at describing some treatments with molar extractions.
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