Professional Documents
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222
During the 1920s, Ketcham9,10 examined jaw radiographs of 385 orthodontic patients and discovered that
some had iatrogenic tissue damage, whereas others had
sailed through treatment unscathed. He found that
patients with and without tissue damage frequently had
similar malocclusions and were treated by the same
techniques. Yet, the outcomes of treatment were significantly different. He concluded that something in
addition to the orthodontic appliance might have played
a role in determining the results of treatment. He
attributed this effect to hormonal and dietary factors.9,10
Those pioneer pathfinders helped to formulate a
biologically oriented explanation of the reasons for
tooth movement in response to applied forces and also
highlighted the finding that responses differ from person to person. This dichotomy emphasizes the difference between a typodont and a real patient. A typodont
is a training device consisting of artificial teeth embedded in dental wax that hardens at room temperature,
enabling the user to freeze the teeth in normal and
many abnormal positions. In the latter case, one can
then bond or cement orthodontic attachments to the
dental crowns and fabricate a simulated orthodontic
appliance. When the typodont is dipped into warm
water, the wax softens, and the roots of the teeth that
had been subjected to mechanical forces move with
ease through the soft wax. Hence, this apparatus might
suggest that orthodontic tooth movement results predominantly from a judicious application of force systems to teeth, which react like free bodies in space, with
a small contribution of biologic processes to this
phenomenon. Thus, an erroneous supposition might be
formulated, magnifying the role of orthodontic mechanics, while not emphasizing sufficiently the role of
biology in tooth movement. Actually, the practice of
orthodontics should depend on equality between 2
components:
Orthodontics
Mechanics Biology
Fig 1. Patient 1. A, Panoramic radiograph of patient 1s dentition at age 16 years before orthodontic
treatment aimed at closing her open bite. The open bite extended from the second molars on the
left to the second molars on the right. B, Panoramic radiograph of the same dentition at age 19.5
years, after 3.5 years of orthodontic treatment to close her open bite. The radiograph shows that,
despite the long effort, the bite was not entirely closed, and that many teeth in both jaws were
substantially shortened by root resorption.
Fig 2. Patient 2. A, Frontal view of patient 2s dentition in occlusion during the orthodontic
consultation appointment. Note poor oral hygiene, general gingivitis, and gingival recession,
especially in the posterior segments of both dental aches. A right mandibular midline shift and a
bilateral posterior crossbite are visible. B and C, Lateral photographs of the left and right sides of
his occlusion. Note the large extraction spaces in both sides of the arches. The molars in both
arches tipped into the extraction spaces. D, Occlusal view of the maxillary dental arch. A narrow
arch and a high vaulted palate are visible. E, Palatal view of the maxilla shows an ectopically erupted
second premolar (palatally).
Fig 3. Patient 2. A, Periapical radiograph of the maxillary right posterior teeth shows that all teeth,
especially the premolars, have short roots. B, Periapical radiograph of the molar-premolar region of
the maxillary right side shows short roots in the second premolar and the molars (distal roots). C,
Periapical radiograph of the mandibular right side. The premolar roots appear to have normal length,
but their apices are blunted. D, Periapical radiograph of the mandibular left side. The premolars
appear to be of normal length, but the alveolar bone height is reduced.
biologically, it would seem helpful to take these differences into account when considering a malocclusion.
Optimally and ideally, an orthodontic diagnosis should,
therefore, contain biologic information that might impact the treatment outcome. At a minimum, variables
such as age, sex, systemic diseases, diet, and drug
consumption should be included. Basic medical tests
pertaining to the assessment of the patients health
status might shed additional light on their actual biological profile. Genetic tests on the molecular level
might facilitate classification of patients according to
their effectiveness in resorbing bone and their susceptibility to root resorption. For an orthodontist, a malocclusion can be obvious and easy to classify. However,
frequently the degree of success in treating it and the
ability to avoid complications depend on well-defined
biologic entities.
In the intact organism, the sensitivity of PDL and
alveolar bone cells to mechanical force can be overshadowed by cellular interactions with many signal
molecules, derived from local cells, remote organs, the
subjects diet, or consumed drugs. Basic biologic research in orthodontics showed that, when 2 or more
factors interact simultaneously with target cells, they
Fig 4. Patient 3. A, Frontal view of patient 3s dentition in occlusion, showing an excessive overjet.
B, Lateral view of incisor occlusion, showing a 15-mm overjet. C, Lateral cephalogram before
orthodontic treatment, showing soft- and hard-tissue convex profiles, well-developed chin, excessive overjet, and Class II Division 1 malocclusion. D, Panoramic radiographic view of jaws before
treatment shows a small amount of root resorption, particularly in the frontal zone of both dental
arches; this could be attributed to previous mechanotherapy.
served professional attention. However, the orthodontist of patient 2 decided not to treat him, even though
his illnesses (diabetes, thyroiditis, and depression) were
being treated by medications. The orthodontist was
apparently concerned about the short roots of the
maxillary teeth and the 3 diseases, treated or not. On the
other hand, the orthodontists of the other 2 patients
treated them despite the systemic diseases. It can be
argued that the severe maxillary root resorption of the
other 2 patients resulted from the use of round wires in
closing the open bite of patient 1 and in reducing the
anterior maxillary protrusion of patient 3. These wires
inadvertently tipped the teeth uncontrollably, with the
root apex first pushed into contact with the labial plate
of compact bone and then torqued palatally. The
systemic diseases (allergies in patient 3; bruising,
allergies, and asthma in patient 1) apparently did not
faze these orthodontists.
Asthma, an inflammatory disease, is triggered by
Fig 5. Patient 3. A, Panoramic radiographic view of patient 3s jaws 18 months after the start of
treatment. Excessive root resorption can be seen in many teeth, particularly in the maxillary incisor
region. B, Periapical radiograph of the maxillary front teeth when the orthodontic appliances were
removed after 2 years of treatment. The roots of all teeth were apparently resorbed excessively
during treatment that included retraction of these teeth with Class II elastics from round archwires,
causing the teeth to tip uncontrollably. C, Periapical radiograph of the maxillary right canine region
after orthodontic treatment. The length of the canine root is about 25% of its pretreatment length.
Fig 6. Patient 3. A, Frontal view of patient 3s dentition 1 year after orthodontic treatment. Root
resorption continued unabated during that period, prompting the extraction of all maxillary anterior
teeth. B, Frontal view of her dentition, while she was wearing a temporary prosthetic device, before
the surgical placement of dental implants to replace the lost teeth.
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CONCLUSIONS
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