Passive Self-Ligation from A to Z E-Book

Nasib Balut

• Herausgeber: Quintessence Publishing Co, Inc
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 298

Veröffentlichungsjahr: 2022

Beschreibung

The specialty of orthodontics is full of techniques and camps, each offering specific protocols to achieve the best results. The Damon System is different; it's a philosophy that focuses on the why to get to the how, challenging orthodontists to think and reason their way to a successful finish. The philosophy is predicated on the notion that teeth treated with passive self-ligation (PSL) move faster than teeth treated with traditionally ligated brackets; the increased play between the slot and bracket reduces friction and enables greater movement, even with low forces. This low-force, low-friction system is also more biologically sound for the periodontal apparatus, which is good news for the patient and for treatment stability. This book is the how-to guide for PSL in orthodontics, from diagnosis to bracket placement to finishing—and everything in between.

Leseprobe

Passive Self-Ligation from A to Z

Dedication

I dedicate this book to my family—especially to Susu for your understanding, love, support, and everything you have done for me—and to my daughter, Nur, and my son, Samir, who have always been my focus, my love, and my happiness.

Library of Congress Cataloging-in-Publication Data

Names: Balut, Nasib, editor.

Title: Passive self-ligation from A to Z / edited by Nasib Balut.

Description: Batavia, IL : Quintessence Publishing Co, Inc, [2022] |

Includes bibliographical references. | Summary: “This book is

the how-to guide for passive self-ligation in orthodontics, from

diagnosis to bracket placement to finishing—and everything in between”--

Provided by publisher.

Identifiers: LCCN 2021059954 | ISBN 9781647240998 (epub)

Subjects: MESH: Orthodontic Brackets | Orthodontic Wires | Orthodontic

Appliance Design

Classification: LCC RK521 | NLM WU 426 | DDC 617.6/43--dc23/eng/20220113

LC record available at https://lccn.loc.gov/2021059954

A CIP record for this book is available from the British Library.

ISBN: 9781647240998

© 2022 Quintessence Publishing Co, Inc

Quintessence Publishing Co, Inc

411 N Raddant Rd

Batavia, IL 60510

www.quintpub.com

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All rights reserved. This book or any part thereof may not be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, or otherwise, without prior written permission of the publisher.

Editor: Leah Huffman

Design: Sue Zubek

Production: Sue Robinson

Contents

Forewordvi

Prefacevii

Contributorsviii

Diagnosis Using the BEST Philosophy1

Nasib Balut/Enrique Gonzalez/Juan Carlos Solorio

Damon System Philosophy29

Juan Carlos Solorio

PSL Bracket Placement41

Nasib Balut/Jorge García/Enrique Gonzalez

Torque Selection Protocol Using Damon System Brackets61

Nasib Balut/Nora Hernández/Enrique Gonzalez

Disocclusion with Bite Turbos89

Rodrigo Eluani/Enrique Gonzalez

Intermaxillary Elastics and PSL99

David Ortiz

Archwire Sequence with the Damon System121

Juan Fernando Aristizábal/Juan Carlos Solorio

Early Treatment with PSL157

Nasib Balut/Isabel Zapata/Jaime A. Tapia/Enrique Gonzalez

Damon Space-Gaining Appliance (D-Gainer)187

Alan Bagden

Finishing with PSL215

Stuart Frost

Extractions with the Damon System225

Matias Anghileri/Nasib Balut

Anchorage in the Damon System247

Ricardo Medellin Fuentes

TADs and PSL263

Nasib Balut/Daniel Cerrillo/Hector Luis Rodriguez

Surgery-First Orthognathic Approach and PSL277

Juan Fernando Aristizábal/Nasib Balut/Carlos Villegas

The Impacted and Transposed Canine293

Khaled S. Aboul Azm/Hassan E. Kassem

Damon Q2303

Michael J. Mayhew

Damon Ultima System313

Thomas Barron

vi

Foreword

The orthodontic profession was first exposed to the extraordinary cases of Dr Dwight Damon in the Ormco publication Clinical Impressions in Novem- ber 1999. In this article, Dwight related a novel concept of applying orthodontic forces with low force and light friction, which allowed him to achieve results rarely seen previously in our profession. His concept hinged on a li- gation theory described as “passive self-ligation” (PSL).

His article posited that teeth treated with PSL moved faster than teeth treated with traditionally ligated brackets, so I decided to try it out. Much to my surprise, his theories were confirmed by simple clinical observations. When I related my findings to him, Dwight unexpectedly invited me to come to his clinical facility in Spokane, Washing- ton, suggesting that I “stay as long as you feel you need to stay in order to understand my technique.” So I went, and after working with him daily, we struck up a friendship that has lasted more than 20 years now. We have written books together, discussed concepts together, shared fam- ily moments together, traveled and lectured together, and watched his amazing technique become the worldwide gold standard for orthodontic treatment results.

Through it all, Dwight has never changed in his focus. His efforts have always been and continue to be directed at improving the lives of our patients as well as the lives of the orthodontists who embrace his theories. Unlike many previ- ous orthodontic innovators, he has never stopped upgrading his system, and in doing so, he has improved our ability to care for our patients. This book is an accumulation of chapters written by those of us fortunate enough to be a part of the development and introduction of Dwight Damon’s system of PSL. It is meant as an educational tool, as a reinforcement of what Dwight envisioned, and hopefully as an inspiration to embrace the gift Dwight has given to our profession.

As Dwight would say, “Read and react to what you see.” This book is meant to serve that purpose.

Alan Bagden, dmd

Private Practice in Orthodontics

Springfield, Virginia

vii

Preface

During the past two decades, considerable energy has been devoted to the concept of passive self-ligation for the correction of different types of malocclu- sions, including continuous and critical evaluations of our treatment methods and results. This cumulative experience has resulted in significant improvements in the quality of treatments.

This book is a practical guide to the Damon System of passive self-ligation, which allows more efficient treatment with lower levels of force and friction. The objective is to achieve nice arch development while improving smile esthetics, all with a system that is easy to use. All the cases presented in this book were treated according to the prin- ciples of the Damon System, and the goal is to empower

students and clinicians to apply these principles into their own work to improve patient outcomes and solve various problems encountered in clinical orthodontic practice.

Acknowledgments

My sincere thanks to all the contributors for agreeing to be part of this book. I owe each one a debt of gratitude. I also want to express my respect and gratitude to Dr Dwight Damon for his teachings. Thanks to him, I have become a better orthodontist. Finally, Dr Enrique Gonzalez deserves special recognition for his support and collaboration in making this book a reality. Thanks for your friendship.

viii

Contributors

Khaled S. Aboul Azm, BDS, MSc, PhD

Associate Professor and Chair

Department of Orthodontics

Pharos University in Alexandria

Private Practice in Orthodontics

Alexandria, Egypt

Matias Anghileri, DDS

Private Practice in Orthodontics

Ormco Key Educator

Bahía Blanca, Argentina

Juan Fernando Aristizábal, DDS, MS

Chairman, Department of Orthodontics

Universidad del Valle

Private Practice in Orthodontics

Cali, Colombia

Alan Bagden, DMD

Private Practice in Orthodontics

Ormco Consultant

Springfield, Virginia

Nasib Balut, DDS, MS

Professor of Orthodontics

Universidad Autónoma de Baja California

Mexicali, Mexico

Professor of Orthodontics

Universidad del Valle

Cali, Colombia

Private Practice in Orthodontics

Mexico City, Mexico

Thomas Barron, DMD, MS

Dean’s Faculty

University of Maryland Dental School

Ormco Consultant, Ormco Speaker’s Bureau

Lutherville, Maryland

Daniel Cerrillo, DDS

Chairman, Department of Orthodontics

Universidad Autónoma de Baja California

Ormco Key Educator

Tijuana, Mexico

Rodrigo Eluani, DDS

Private Practice in Orthodontics

Hermosillo, Mexico

Stuart Frost, DDS

Associate Clinical Professor of Orthodontics

University of the Pacific

Stockton, California

Private Practice in Orthodontics

Mesa, Arizona

Jorge García, DDS, MS

Chairman, Department of Orthodontics

Universidad AME

Private Practice in Orthodontics

Monterrey, Mexico

Enrique Gonzalez, DDS

Professor of Orthodontics

Universidad Tecnológica de México

Professor of Orthodontics

Universidad Intercontinental

Private Practice in Orthodontics

Mexico City, Mexico

ix

Nora Hernández, DDS

Private Practice in Orthodontics

Mexicali, Mexico

Hassan E. Kassem, DDS

Lecturer of Orthodontics

Alexandria University

Alexandria, Egypt

Michael J. Mayhew, DDS, MS

Private Practice in Orthodontics

Ormco Key Educator

Boone, North Carolina

Ricardo Medellin Fuentes, DDS

Chairman, Department of Orthodontics

Universidad Nacional Autónoma de México

Private Practice in Orthodontics

Mexico City, Mexico

David Ortiz, DDS

Professor of Orthodontics

Universidad Nacional Autónoma de México

Mexico City, Mexico

Professor of Orthodontics

Universidad Cuauhtémoc

San Luis Potosí, Mexico

Private Practice in Orthodontics

León, Mexico

Hector Luis Rodriguez, DDS

Orthodontic Department Coordinator

Universidad Nacional Pedro Henríquez Ureña

Private Practice in Orthodontics

Santo Domingo, Dominican Republic

Juan Carlos Solorio, DDS

Invited Professor of Orthodontics

Universidad Autónoma de Baja California

Mexicali, Mexico

Private Practice in Orthodontics

Autlán, Mexico

Jaime A. Tapia, DDS, MS

Private Practice in Orthodontics

Cuenca, Ecuador

Carlos Villegas, DDS, MS

Professor of Orthodontics

Universidad de Antioquia

Antioquia, Colombia

Private Practice in Orthodontics

Medellín, Colombia

Isabel Zapata, DDS, MS

Professor of Orthodontics

Centro de Estudios Superiores en Ortodoncia

Private Practice in Orthodontics

Mexico City, Mexico

1

Diagnosis Using the BEST Philosophy

Nasib Balut/Enrique Gonzalez/ Juan Carlos Solorio

In this chapter:

• What is BEST?

• General anatomical assessment using CBCT

• Anatomical assessment of para- nasal sinuses and upper airways

• Static and dynamic assessment of the TMJ

• Assessment of teeth and their cortical bone

• 3D cephalometric analysis

• Esthetic assessment

• Assessment of records before removing appliances

• Clinical case

• BEST forms

“To know how to cure an illness, you must first have to know it exists.”

—Peter E. Dawson

Diagnosis is the cornerstone of success in the medical field, including dentistry. A diagnostic analysis allows us to know each patient’s therapeutic boundaries and clinical needs and understand if we have a real possibility to provide an integral solution by establishing short-, medium-, and long-term goals within our treatment. Above all, diagnosis allows us to define a solution prognosis.

Since the 1950s, cephalometry has been the main diagnostic method in orthodontics. Historically, diagnosis in orthodontics has mainly consisted of analyzing clinical findings and data gathered from a lateral cepha- lometric radiograph, a periapical series, and a panoramic radiograph; intraoral and extraoral photographs; and plaster study models.1 While study models allow the orthodontist to analyze all the aspects of occlu- sion, precise skeletal relationships based on these models are a matter of conjecture. Therefore, in the second half of the 20th century, routine application of the cephalometric analyses developed by Bolton, Broad- bent, Jarabak, Ricketts, Steiner, and others allowed orthodontists to study facial growth, make superimpositions, and observe treatment results in more detail.1 This led to significant advancements in the fundamental science and daily practice of orthodontics and dentofacial orthopedics.2

The greatest defect of cephalometric analysis is the inability to project 3D structures in bidimensional representations.3,4 Instead we have always had to divide the difference between bilateral anatomical landmarks such as gonion and orbitale, leaving us to wonder whether the variations between sides were due to radiographic projections or real asymmetries.5

But things have changed. The adaptation of cone beam computed tomography (CBCT) to orthodontics in the last decade has given way to more precise diagnoses of anatomical issues, showing in detail the characteristics of the temporomandibular joint (TMJ), the state and amount of cortical bone surrounding the tooth, any impacted teeth, and facial asymmetries, among other things. It also allows for volumetric assessment of the patient’s airways. CBCT is not only an exploratory tool but also a unique and complete 3D cephalometric measurement system that allows us to make comparisons with the same patient, so the effects of growth and the treatment can be analyzed and compared quantitatively.5–7

DIAGNOSIS USING THE BEST PHILOSOPHY

2

In other words, modern-day orthodontists have the opportunity to carry out a more thorough assessment of the patient from a static and dynamic perspective; however, with so much data available, it is essential that the clinician is prepared to generate accurate information without excess or deficiency.2,3

What Is BEST?

BEST is the diagnosis and treatment method created by Drs Nasib Balut, Enrique González, and Juan Carlos Solorio. This method uses cutting-edge technology and a defined and practical protocol to allow for customized treatment mechanics for each case. New technologies do not seek to discard traditional concepts; on the contrary, they should be combined with diagnostic data to offer a broader knowledge of our patients and help us generate more comprehensive diagnoses, elevating the quality standards of orthodontic treatments regardless of the philosophy followed by the clinician.

The BEST diagnosis and treatment method involves evaluation of seven areas:

1. General anatomical assessment using CBCT

2. Anatomical assessment of paranasal sinuses and upper airways

3. Static and dynamic assessment of the TMJ

4. Assessment of teeth and their cortical bone

5. 3D cephalometric analysis

6. Esthetic assessment

7. Assessment of records before removing appliances

General Anatomical Assessment Using CBCT

Before carrying out the anatomical assessment, it is neces- sary to know and identify the three planes: coronal, sagit- tal, and axial. They must be interpreted separately, but we should also know how these planes interact with each other.

Fig 1-1 Three planes of the face. (a) Coronal plane. (b) Sagittal plane. (c) Axial plane.

•Coronal plane: It faces the anterior portion of the face, parallel to the facial surfaces of the anterior teeth. It divides the skull into an anterior and posterior portion. We can observe the structures from back to front or front to back (Fig 1-1a).

•Sagittal plane: It divides the skull into two symmetric portions. It runs transversely and allows for the study of two segments: right and left (Fig 1-1b).

•Axial plane: It is parallel to the ground and faces the occlusal plane. It divides the skull into two equal sections—upper and lower—so we can observe the structures from the top down and from the bottom up (Fig 1-1c).

Anatomical assessment in the three planes is an invaluable opportunity provided by CBCT, because we can perform a complete exploration and assessment of the 3D anatomy. Very frequently we are able to observe anatomical vari- ants or very subtle findings that are crucial to treatment planning.

We recommend observing and measuring the patient’s enamel thickness during the general anatomical assess- ment. This information is important because when there is a Bolton discrepancy or a need to gain space, interproximal reduction (IPR) will be required, and you have to know the starting enamel thickness to avoid rubbing away too much. Many patients have had previous orthodontic treatments and will not remember if IPR has already been performed; even if they do remember, they usually do not remember on which teeth this has been performed, so it’s best to measure every time.

Enamel thickness is obtained by generating coronal and sagittal slices in each of the teeth and precisely locating the crown’s middle third. This is measured directly over the axial plane. Filters that distinguish the boundaries between enamel and dentin based on density are used to aid visu- alization (Fig 1-2).

3

Anatomical Assessment of Paranasal Sinuses and Upper Airways

Anatomical Assessment of Paranasal Sinuses and Upper Airways

Breathing is a fundamental process in human development. It influences the growth and development of the craniofa- cial structures and contributes to important physiologic, cognitive, and esthetic processes as well as oral and general health. A 3D assessment of the airway completely changes the specialist’s perception and, most importantly, poten- tially the life of the patient.

Once again, we recommend performing the assessment methodically and systematically, in the following order:

1.Paranasal sinuses:

- Frontal sinuses

- Maxillary sinuses

- Sphenoid sinuses

2.Upper airway:

- Nasopharynx

- Oropharynx

- Laryngopharynx

We recommend performing 3D reconstructions to evalu- ate the anatomy from a volumetric perspective and observ- ing the upper airways internally through virtual endoscopy. Figures 1-3 and 1-4 show normal conditions for the sinuses and airway, and Fig 1-5 shows the significant clinical find- ings in an airway assessment in adolescent patients.

Fig 1-2(a) Location of the middle third in a sagittal slice. (b) Location of the middle third in a coronal slice. (c) Location of the middle third in an axial slice.

Fig 1-3 Normal conditions for patient sinuses: (a) frontal; (b) maxillary; (c) sphenoid.

4

DIAGNOSIS USING THE BEST PHILOSOPHY

Static and Dynamic Assessment of the TMJ

The diagnosis of the TMJ is complex, and so is its explora- tion. To make it simpler and avoid omitting information,8 the clinician must perform the following.

Comprehensive history taking

Based on previous knowledge of the disorders that affect the TMJ, the clinician must gather as much information as possible by asking clear, direct, and precise questions, emphasizing what exactly the patient experiences, be it

Fig 1-4 Normal conditions for patient airway: (a) sagittal slice, (b) coronal slice; (c) sagittal 3D reconstruction; (d) coronal 3D reconstruction.

Fig 1-5 Clinical findings in airway assessment in adolescent patients. (a) Coronal 3D reconstruction: hypertrophy of lower right turbinate (red arrow); nasal septum deviation (yellow arrow). (b) Sagittal 3D reconstruction: polyp on right maxillary sinus (orange arrow). (c) Coronal 3D reconstruction: total opacification of right maxillary sinus (red arrow) and partial opacification of left maxillary sinus (yellow arrow).

5

Static and Dynamic Assessment of the TMJ

Fig 1-6(a to c) Dynamic assessment of the muscular structures and joints.

pain, tension, joint noises, deviations, excessive or limited joint movement, vertigo, etc.

It is worth mentioning that many patients who have emotional stress report chronic craniofacial pain and tend to depend on medication or other treatments; they also often experience low self-esteem or apathy and may engage in hostile behaviors. Patients who suffer from chronic pain could also show signs of depression.8,9

Meticulous clinical examination

Observation of mandibular movements

This must include all the eccentric mandibular movements, including lateral, protrusive, opening, and closing.

Exploration of the TMJ

This must include external palpation of the TMJ and its surrounding structures, internal palpation through the external auditory canal, and auscultation.

Exploration of the masticatory muscles

Muscle parafunction may produce damage to the TMJ, periodontal damage, and dental wear. Therefore, it is neces- sary to evaluate the muscles.10 Palpation can be used to eval- uate the neuromuscular system and determine the volume (hypertrophy, atrophy) and tone of the muscles involved. A systematic and bimanual analysis is recommended, which will allow for a comparative exploration between the right and left sides. We suggest doing this at rest and during muscular contraction activity8,9,11–13 (Fig 1-6).

As previously mentioned, before evaluating the bony structures of the TMJ, the specialist must locate the anat- omy of the glenoid fossa and condyle in all three planes of space. This can be performed with a 3D reconstruc- tion of a CBCT or any diagnostic software that allows for

evaluation of the joint spaces in the sagittal, coronal, and axial planes. We suggest utilizing the method proposed by Ikeda and Kawamura.14,15 This method consists of making linear measurements in the reconstruction of sagittal images obtained from CBCT. The assessment must be performed in both condyles and the three planes in the following order: sagittal, coronal, axial.

Sagittal assessment

A horizontal line is traced on the glenoid fossa’s uppermost point to be used as a plane of reference. Tangent lines are drawn from the same point to the most prominent part of the anterior and posterior condylar surfaces.

The distances from the anterior and posterior tangent points to the glenoid fossa correspond to the anterior joint space (AS) and posterior joint space (PS), respectively. The distance from the uppermost point of the mandibular con- dyle to the uppermost point of the glenoid fossa corre- sponds to the superior joint space (SS; Fig 1-7).

Ikeda and Kawamura evaluated the joint spaces of healthy TMJs and found the following values for sagittal assessment:

AS: 1.3 mm ± 0.2 mm

SS: 2.5 mm ± 0.5 mm

PS: 2.1 mm ± 0.3 mm

Coronal assessment

This corresponds to the measurement of points selected using the Ikeda and Kawamura method to locate the posi- tion of the medial, lateral, and upper part of the condyle concerning the glenoid fossa in a coronal view (Fig 1-8).

Coronal lateral space: 1.8 mm ± 0.4 mm

Coronal central space: 2.7 mm ± 0.5 mm

Coronal medial space: 2.4 mm ± 0.5 mm

6

DIAGNOSIS USING THE BEST PHILOSOPHY

Fig 1-7 Sagittal view of the mandibular condyle and its glenoid fossa. SS, superior joint space; PS, posterior joint space; AS, anterior joint space.

Fig 1-8 Coronal view of the mandibular condyle and its glenoid fossa. CLS, coronal lateral space; CCS, coronal central space; CMS, coronal medial space.

Fig 1-9 Axial view of the mandibular condyle and its glenoid fossa. AMS, axial medial space; ALS, axial lateral space.

Axial assessment

Ikeda and Kawamura establish two measurements for this axial view of the condyle in relation to its glenoid fossa (Fig 1-9):

Axial medial space: 2.1 mm ± 0.6 mm

Axial lateral space: 2.3 mm ± 0.6 mm

The BEST philosophy utilizes the Avantis 3D system, a software that integrates CBCT and intraoral scanning to allow identification of all structures in all three planes of space as well as their whole surface (Fig 1-10). This precision is important because no patient is perfectly symmetric, and their anatomy may vary from right side to left side (Fig 1-11).

Other advantages include automatic analysis of the joint space between the mandibular condyle and its glenoid fossa

as well as the ability to obtain measurements for the height and inclination of the articular tubercle and the dimensions of the mandibular condyle. We can also perform dynamic assessments by modifying the mandibular position auto- matically or manually and observing the simulation and calculation of mandibular movement parameters, the posi- tion of the condyles, and the occlusal contact points during functional movements (Fig 1-12).

In the BEST diagnosis concept, we suggest utilizing these values as a reference; however, the reader must consider that there could be anatomical variations according to the brachyfacial, dolichofacial, and mesofacial pattern of the patient as well as racial or ethnic variations. The values expressed here are intended to guide the clinician to deter- mine the location of the space between the glenoid fossa and the mandibular condyle.

7

Static and Dynamic Assessment of the TMJ

Fig 1-10 Assessment of the precision of the volumetric reconstruction. (a) Condyle and glenoid fossa in coronal slice. (b) Condyle in axial slice. (c) Condyle and glenoid fossa in sagittal slice.

Fig 1-11(a) Right condyle in coronal slice. (b) 3D reconstruction of right condyle. (c) Left condyle in coronal slice. (d) 3D reconstruction of left condyle.

Fig 1-12(a) Habitual occlusion, where we can observe the posterior condylar position. (b) Ideal anatomical location of the mandibular condyle within its glenoid fossa and the change in occlusion.

8

DIAGNOSIS USING THE BEST PHILOSOPHY

Fig 1-13(a) Patient at the beginning of treatment with a gingival recession on the mandibular left central incisor. (b) Final photograph after orthodontic treatment where the recession worsened due to poor hygiene, orthodontic movement, and frenum traction.

Fig 1-14(a) Final CBCT of the maxillary left lateral incisor shows that the root is con- siderably devoid of cortical bone. (b) Final clinical photo- graph of the same tooth after orthodontic treatment. Clin- ically, the missing bone plate is not visible.

Assessment of Teeth and Their Cortical Bone

The possibility of alveolar bone damage during orthodon- tic movement depends on several factors, including the magnitude and direction of the applied forces, the gingival phenotype, and the volume and anatomy of the cortical bone. The risk becomes exceptionally high if the teeth move to positions outside of the cortical bone. These risky move- ments include inadequate torque, tooth proclination, and arch expansion.16,17

When orthodontic appliances are involved, inadequate oral hygiene could negatively affect the periodontium by transforming gingivitis into periodontitis with extensive alveolar bone loss.18

One of the consequences of risky movements without prior assessment of the amount of cortical bone of the patient is a gingival recession, which can be localized or generalized, but it always affects at least one dental surface.1

It happens more often in the mandibular arch than in the maxillary arch.17 Gingival displacement can become a critical complication that could cause esthetic discomfort, root sensitivity, periodontal insertion loss, difficulty in per- forming oral hygiene, and a greater risk of root cavities.19 Exposed root surfaces are also more prone to dental abrasion due to brushing.20

Other causes for gingival recession as primary underlying factors include traumatic brushing, localized periodontal inflammation due to plaque, and generalized destructive periodontal disease.17,21 Among the possible secondary factors are anatomical causes (such as frenum traction), smoking and other stimulants, as well as orthodontic treatments without previous assessment of cortical bone dimensions.19,22

There are cases where we apply negative torques to avoid the proclination of teeth with cortical bone plates that are too thin, especially in patients with thin phenotypes. In these cases, we are at risk of leaving the root of a tooth

9

3D Cephalometric Analysis

Fig 1-15 Assessment of tooth relationships. (a) Maxillary right central incisor. (b) Maxillary right first premolar. (c) Maxillary right first molar with its cortical bone.

over the cortical bone or even outside of it. Clinically, it is difficult to see a root that is slightly outside of the cortical bone, as can be seen in Figs 1-13 and 1-14.

Palatal expanders generate heavy intermittent forces to cause hyalinization of the periodontal ligament of the anchorage teeth where the expander is fixed. During the hyalinization phase, all the forces exerted by the expander must be released onto the median palatine suture23 to obtain a more orthopedic and less orthodontic effect24; however, we always observe a buccal movement of the anchorage teeth.25

The dislocation of the teeth outside of the alveolar pro- cess could damage the periodontal support or reduce the thickness and height of the cortical bone, causing a gingival recession, fenestration, and reabsorption, as shown by many recent studies with the use of CBCT.26,27

It is crucial to evaluate the cortical bones before starting orthodontic treatment in order to know the amount of cortical bone surrounding each tooth in the facial, palatal, and lingual areas, especially for the mandibular incisors. This will help us determine the amount of torque we can use. We recommend doing a CBCT to carry out this assess- ment in the final treatment stages to ensure there is enough cortical bone before removing the appliances.

To assess the position of the roots and the cortical boundaries, one must do a superimposition of the CBCT’s DICOM format and the STL format of the intraoral scan. This method allows us to evaluate in one dynamic scene, slice to slice, the relationship between these structures, and

we can simulate with more precision the exact intrusion, extrusion, sagittal or transversal movements, and the degrees of torque to be used. This way, we can know the anatomical and physiologic boundaries we must consider during our treatment mechanics (Fig 1-15).

3D Cephalometric Analysis

With the BEST protocol, pretreatment and progress CBCT scans are taken so that we can assess a 3D point of view. We suggest that the clinician performs the measurements they deem necessary for each case and utilize the software they prefer. We use 3D CITEG cephalometry.

This 3D cephalometry proposed by Dr Enrique González is based on Jarabak and Steiner’s cephalometries, with some added measurements, that provide information from the frontal, sagittal, and vertical perspectives that are not possi- ble to evaluate with a 2D radiograph. Additionally, we can observe the spatial positions of the maxilla and mandible and see, among other things, the degree of symmetry of our patients (Fig 1-16).

It is worth mentioning that before tracing, each point must be evaluated in the axial, sagittal, and coronal planes, and a volumetric reconstruction should be performed in the needed density for each case. However, 3D anatomical location is much simpler than bidimensional location, as shown in Fig 1-17.

10

DIAGNOSIS USING THE BEST PHILOSOPHY

Fig 1-16(a) Steiner analysis. (b) Spradley line for profile esthetics assessment. (c) Frontal symmetry assessment. (d and e) Assess- ment of mandibular symmetry: location of measurements on a 3D volume and repre- sentation of the left and right mandibular dimensions.

Fig 1-17 Correct 3D location of point S. (a) 3D reconstruction and sagittal superimposition. (b) Axial plane. (c) Sagittal plane.(d) Coronal plane.

Esthetic Assessment

11

Fig 1-18 Photographic protocol to evaluate patient esthetics. (a) Profile at rest. (b) Frontal view at rest. (c) Frontal smile view. (d) Oblique smile view.

Fig 1-19 Additional photographs for better assessment of the maxillary arch’s facial esthetics and relationship with the lower lip. (a) Left-side oblique view. (b) Profile smile view. (c) Neutral zone.

Fig 1-20 Close-up of profile smile view.

Esthetic Assessment

In the BEST concept, we use the photographic protocol described by Dr David Sarver.28 Dr Sarver suggests the following extraoral photographs in this order: profile at rest, frontal at rest, frontal smiling, and oblique (45-degree) smile (Fig 1-18). The goal is mainly to evaluate the pro- portions and harmony of the facial structures (harmony, symmetry, proportions) and how they relate to the position of the maxillary dental arch. We also include a left-side oblique view, profile smile view, and posteroinferior view of the relationship of the maxillary incisors to the curvature of the lower lip (neutral zone; Fig 1-19).

By including both right- and left-side oblique smile views, we can determine any occlusal plane canting, narrow

buccal corridors, muscular hypertonicity, or symmetry or asymmetry of the corners of the mouth when smiling. The close-up smile in profile view assesses the torque of the max- illary incisors and records the profile relationship between the incisal edge of the maxillary incisors and the lower lip, analyzing the function coverage concept29 (Fig 1-20).

The posteroinferior or neutral zone view allows us to assess the relationship of the maxillary incisal edges with the lower lip when smiling. In esthetic dentistry terms, this refers to function coverage, which is described as an esthetic parameter that establishes as an ideal that the lower lip touches or softly grazes the facial of the maxillary incisors. This is the “normal” or ideal position that should be one of the final goals of orthodontic treatment, considered an ideal stability condition of the new position of the incisors. In

DIAGNOSIS USING THE BEST PHILOSOPHY

12

Fig 1-21(a) Retruded position of the maxillary arch in relation to the lower lip. (b) Normal or ideal position of the maxillary arch in rela- tion to the lower lip. (c) Forward position of the maxillary dental arch in relation to the lower lip.

Fig 1-22(a) Compensatory hyperextension position. (b) Correct head position.

other words, this records the relationship of the musculature of the lip orbicularis with the maxillary arch, including the maxillary incisors and canines. There is no occlusal scheme that can stabilize the teeth if they are in an unbalanced relationship with the muscular forces acting over them.3

For practical purposes, this photograph should be taken with the patient in a supine position. The operator should stand behind the patient’s head and ask the patient to smile.

The maxillary arch’s position in relation to the lower lip can be classified as retruded, normal or ideal, and forward (Fig 1-21).

Assessment of Records Before Removing Appliances

In this section, we use a case to show the importance of records assessment before removing appliances using the BEST diagnosis protocol. Please note that we followed the entire sequence but only include the relevant data here.

During the anatomical assessment of the paranasal sinuses and upper airways, we found a hyperextension position caused by an effort to get more air volume when breathing (Fig 1-22). Note the transverse development of the arch prior to treatment (Fig 1-23a) and during treatment (Fig1-23b), which resulted in an improvement of the lingual position. The static and dynamic assessment of the TMJ resulted in a stable condylar position without signs or symp- toms of joint dysfunction (Fig 1-24).

The assessment of cortical bones was performed in all teeth to make sure that the movements would be stable and the integrity of the cortical bones would be maintained (Figs1-25 and 1-26). CBCT is ideal for generating a panoramic image that allows us to assess root parallelism and the dis- crepancy between marginal crests (Fig 1-27).

Once we evaluated compliance to our goals and con- sidered that the result was satisfactory without any adjust- ments, the appliances could be removed.

Assessment of Records Before Removing Appliances

13

Fig 1-23(a) Stereolithography of the patient at 7 years. (b) Stereolithography of the patient at 11 years.

Fig 1-24(a to c) Assessment of joint spaces and position in 3D reconstructions.

Fig 1-25(a) Final position of the root of the mandibular right central incisor. (b) Final position of the root of the maxillary right central incisor.

Fig 1-26 Photography of mini-esthetics to assess the smile arc.

Fig 1-27 3D panoramic reconstruction where we can observe the root parallelism obtained before removing the appliances.

DIAGNOSIS USING THE BEST PHILOSOPHY

14

Fig 1-28(a to i) Initial extraoral and intraoral photographs.

Clinical Case

The following clinical case exemplifies the diagnosis struc- ture in the BEST protocol.

This 25-year-old man presented with a skeletal Class I malocclusion with mesocephalic pattern, straight profile, and thin lips. The molar and canine relationships were Class I, with significant crowding in the mandibular arch and moderate crowding in the maxillary arch but adequate incisor inclination. The treatment plan was to align the teeth with the goal of maintaining the patient’s harmonic profile (Fig 1-28).

General anatomical assessment using CBCT

A supernumerary tooth was observed in the mandibular left quadrant between the premolars (Fig 1-29). Slices were made in the CBCT software to evaluate whether this tooth had damaged the roots of the premolars. These slices also help

the surgeon to determine the surgical approach. Retained mandibular third molars can also be observed.

A referral to a maxillofacial surgeon specialist was sug- gested for extraction of the supernumerary tooth and the third molars.

Anatomical assessment of paranasal sinuses and upper airways

There was an obstruction of the nasolacrimal ducts (Fig1-30a), a deviated septum (Fig 1-30b), and a sialolith on the left side (Figs 1-30c and 1-30d). Although these findings are not crucial for diagnosing and planning the orthodon- tic treatment, it is important to inform the patient. The patient was referred to an otorhinolaryngologist to further examine these issues.

The patient showed good volume in the upper airways (Fig 1-31a). Normal upper airways were observed when evaluating the virtual endoscopy (Figs 1-31b and 1-31c).

Clinical Case

15

Fig 1-29(a) Panoramic CBCT showing a super-numerary tooth in the mandibular left quadrant.(b) Volumetric reconstruc-tion. (c) Transaxial CBCT slices.

Fig 1-30(a) Obstructed nasolacrimal ducts and deviated septum. (b) Deviated nasal septum. (c) Sagittal slice showing the sialolith.(d) Coronal slice showing the sialolith.

Fig 1-31(a) Upper airway volume. (b) Virtual endoscopy by the entrance of the left nostril. (c) Virtual endoscopy by the oropharynx.

DIAGNOSIS USING THE BEST PHILOSOPHY

16

Fig 1-32 Assessment of spaces in centric occlusion on sagittal and coronal slices.

Fig 1-33 3D assessment. (a) Maxilla and mandible at rest. (b) Centric occlusion. (c) Mandibular dynamics.

Fig 1-34 Thin cortical bone plates in the maxillary right canine (a), maxillary right lateral incisor (b), and maxillary right central incisor(c). Lack of root torque is notice-able, especially at the level of the apex.

Fig 1-35 The patient has a normal periodontal phenotype and a good amount of attached gingiva.

Clinical Case

17

Fig 1-37 The vertical measurements and transversal lines reflect a symmetry between the left and right sides.

Static and dynamic assessment of the TMJ

The patient did not show any symptomatology of TMJ dysfunction. There were no joint sounds or pain, no devi- ations  or limited movement was observed, and no pain or discomfort was reported upon internal and external palpa- tion. There were no occlusal interferences or discrepancies between centric occlusion and centric relation (Fig 1-32), so the TMJ of this patient was diagnosed as normal and showed adequate and regular spaces without pathologic data (Fig 1-33). We must mention that the diagnosis of joint dysfunction deserves its own chapter explaining in detail the procedures used and the clinical history of each specific patient with this condition.3

Assessment of teeth and their cortical bone

Upon review of the patient’s cortical bones, we observed that the maxillary right incisors and canine had negative torque, which caused them to have thin cortical bone plates (Fig 1-34). Adding more negative torque could risk the integrity of the cortical bones in this area. Despite the thin cortical plates, the patient’s gingival phenotype is normal (Fig 1-35).

3D cephalometric analysis

3D cephalometric analysis is shown in Figs 1-36 and 1-37.

DIAGNOSIS USING THE BEST PHILOSOPHY

18

Fig 1-38(a to e) Recommended pho-tographs to evaluate macro-, mini-, and micro-esthetics.28

Fig 1-39 Enamel thickness assessment at the mandibular right central incisor (a) and mandibular right canine (b).

Esthetic assessment

The patient has a straight profile without facial asymmetry, along with proportional facial thirds, thin lips, a good smile height, and –6 mm of crowding in the maxillary arch and –7.5 mm of crowding in the mandibular arch. The patient has a flat smile arc and shows the mandibular incisors more when he smiles. The gingival contours are altered due to crowding (Fig 1-38).

Due to the patient’s Bolton discrepancy and crowding, it was necessary to perform IPR in the maxillary and man- dibular anterior teeth. We used CBCT to evaluate enamel thickness at the beginning of treatment, so IPR was per- formed without issue (Fig 1-39).

Treatment plan

A referral to a maxillofacial surgeon specialist was requested to extract the supernumerary premolar and the third molars with the findings obtained. A consultation with an oto- rhinolaryngologist was also requested due to the deviated septum and the presence of a sialolith. It was decided to maintain the anatomical and functional integrity of the TMJ, keep the shape of the arches, keep the correct position of the incisors, improve the torque of the maxillary right incisors and canine, improve the position of the maxillary incisors and gingival contour, and use IPR to correct the Bolton discrepancy and help eliminate crowding.

19

BEST Forms

There was a particular dilemma in the treatment plan for this case: to extract or not to extract? On the one hand, we had a significant amount of crowding, especially in the mandibular arch, and on the other hand, we did not want to alter the patient’s profile. If we did not extract, we could leave a protrusive profile, and if we did, we could leave a very flat profile, so we needed to find a treatment plan that fell in the middle to keep the profile and eliminate crowding.

Upon observation of the mandibular arch crowding and the position of the mandibular canines, we knew that when placing the appliances with the first-round wire we would cause proclination of the mandibular anterior teeth. There- fore, it was essential to evaluate the cortical bones using BEST diagnosis, among other significant factors such as the TMJs and airways.

We decided to treatment plan without extractions besides the third molars and the supernumerary tooth, perform IPR and transversal remodeling, as well as use intermaxillary elastics to achieve better torque: high torque on the four canines and low torque on the incisors.

The main goal of our treatment was to keep the profile, avoid incisor proclination, improve smile esthetics, and eliminate crowding. The treatment prognosis was good.

20

DIAGNOSIS USING THE BEST PHILOSOPHY

Fig 1-41 BEST forms for diagnosis and evaluation of treatment.

21

BEST Forms

Fig 1-41(cont) BEST forms for diagnosis and evaluation of treatment.

22

DIAGNOSIS USING THE BEST PHILOSOPHY

Fig 1-41(cont) BEST forms for diagnosis and evaluation of treatment.

23

BEST Forms

Fig 1-41(cont) BEST forms for diagnosis and evaluation of treatment.

24

DIAGNOSIS USING THE BEST PHILOSOPHY

Fig 1-41(cont) BEST forms for diagnosis and evaluation of treatment.

25

BEST Forms

Fig 1-41(cont) BEST forms for diagnosis and evaluation of treatment.

26

DIAGNOSIS USING THE BEST PHILOSOPHY

Fig 1-41(cont) BEST forms for diagnosis and evaluation of treatment.

27

References

Fig 1-41(cont) BEST forms for diagnosis and evaluation of treatment.

References

1. Quintero JT. Diagnostic methods in orthodontics. Int J Orth- od Oral Surg Radiogr 1930;16(4).

2. Ishaq R. The orthodontic patient: Examination and diagnosis. EC Dent Sci 2019;18.5:975–988.

3. González García E. Sistemas 3D y su utilidad en la ortodoncia actual. Medellin, Colombia: Amolca, 2019.

4. Joerd van der Meer W, Vissink A, Ren Y. Full 3-dimensional digital workflow for multicomponent dental appliances: A proof of concept. J Am Dent Assoc 2016;147:288–291.

5. Hodges RJ, Atchison KA, White SC. Impact of cone-beam computed tomography on orthodontic diagnosis and treatment planning. Am J Orthod Dentofacial Orthop 2013;143:665–674.

6. Schwarz R. Cephalometric methods and orthodontia. Int J Orthod Oral Surg Radiogr 1926;12: 1078–1101.

7. Neelapu BC, Kharabanda OP, Sardana V, et al. Automatic localization of three-dimensional cephalometric landmarks on CBCT images by extracting symmetry features of the skull. Dentomaxillofac Radiol 2018;47:20170054.

8. Avellaneda Mesa JL. Compromiso articular temporomandib- ular. Revista mexicana de odontología clínica 2008;3:4–8.

9. Valmaseda E, Gay Escoda C. Diagnóstico y tratamiento de la patología de la articulación temporomandibular. ORL 2002;29:55–70.

10. Perea Pérez B, Labajo González E, Santiago Sáez A, Ochandi- ano Caicoya S. Propuesta de una metodología de explora- ción y de valoración de las secuelas de la articulación temporomandibular. Mapfre Medicina 2007;18:1–9.

11. Rubiano Carreño M. Tratamiento con placas y corrección oclusal por tallado selectivo. Medellin, Colombia: Amolca, 2005:48–105.

12. López López J, Chimeneas Kustner E, Blanco Carrión A, Reselló Llabrés X, Jané Salass E. Diagnóstico por la imagen de los trastornos de la articulación craneomandibular. Avanc- es en Odontoestomatología 2005;21:71–88.

13. Bottino MA. Nuevas tendencias articulación temporoman- dibular, vol 6. Sao Paulo: Artes Médicas Latinoamérica, 2008:1–36.

14. Ikeda K, Kawamura A. Disc displacement and changes in con- dylar position. Dentomaxillofac Radiol 2013;42:84227642.

15. Ikeda K, Kawamura A. Assessment of optimal condylar posi- tion in the coronal and axial planes with limited cone-beam computed tomography. J Prosthodont 2011;20:432–438.

16. Handelman CS. The anterior alveolus: Its importance in limit- ing orthodontic treatment and its influence on the occur- rence of iatrogenic sequelae. Angle Orthod 1996;66:95–109.

17. Wainwright WM. Faciolingual tooth movement: Its influence on the root and cortical plate. Am J Orthod 1973;64:278–302.

18. Thilander B, Nyman S, Karring T, Magnusson I. Bone regen- eration in alveolar bone dehiscences related to orthodontic tooth movements. Eur J Orthod 1983;5:105–114.

19. Mandelaris GA, Neiva R, Chambrone L. Cone-beam com- puted tomography and interdisciplinary dentofacial therapy: An American Academy of Periodontology best evidence review focusing on risk assessment of the dentoalveolar bone changes influenced by tooth movement. J Periodontol 2017;88:960–977.

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20. Molina-Berlanga N, Llopis-Perez J, Flores-Mir C, Puigdollers A. Lower incisor dentoalveolar compensation and symphy- sis dimensions among Class I and III malocclusion patients with different facial vertical skeletal patterns. Angle Orthod 2013;83:948–955.

21. Joss-VassalliI, Grebenstein C, Topouzelis N, Sculean A, Katsaros C. Orthodontic therapy and gingival recession: A systematic review. Orthod Craniofacial Res 2010;13:127–141.

22. Loubele M, Van Assche N, Carpentier K, et al. Comparative localized linear accuracy of small-field cone-beam CT and multislice CT for alveolar bone measurements. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;105:512–518.

23. Greenbaum K, Zachrisson B. The effect of palatal expansion therapy on the periodontal supporting tissues. Am J Orthod 1982;81:12–21.

24. Cross DL, McDonald JP. Effect of rapid maxillary expansion on skeletal, dental, and nasal structures: A postero-anterior cephalometric study. Eur J Orthod 2000;22:519–528.

25. Lagravere MO, Heo G, Major PW, Flores-Mir C. Meta-analysis of immediate changes with rapid maxillary expansion treat- ment. J Am Dent Assoc 2006;137:44–53.

26. Balut N, Hansa I, González E, Ferguson DJ. Bone regen- eration after alveolar dehiscence due to orthodontic tooth movement: A case report. APOS Trends Orthod 2019;9:117–123.

27. Ballanti F, Lione R, Fanucci E, Franchi L, Baccetti T, Cozza P. Immediate and post-retention effects of rapid maxillary expansion investigated by computed tomography in growing patients. Angle Orthod 2009;79:24–29.

28. Sarver DM. The importance of incisor positioning in the esthetic smile: The smile arc. Am J Orthod Dentofacial Orthop 2001;120:98–111.

29. The Dawson Academy. Comprehensive Examination and Records course. https://thedawsonacademy.com/live- course/examination-records/. Accessed 22 September 2021.

29

Damon System Philosophy

Juan Carlos Solorio

In this chapter:

• Damon System Philosophy

• Anchorage

• Neutral zone

• Orbicularis activation hypothesis: Differential forces

• Light forces

• Damon passive self-ligating brackets

• Four treatment phases

• Extractions in the Damon System

An orthodontic philosophy is not the same as an orthodontic tech- nique. A system that is based on a philosophy allows the ortho- dontist to have the necessary tools to solve the clinical problems that arise every day in the office. The philosophy focuses on the why to get to the how; it focuses on principles and general concepts that invite clinicians to exercise thought and reasoning based on the information at hand. In clinical language, this means having a clear understanding of the concepts needed to select the appropriate procedures to achieve your objectives.

In orthodontics, if the philosophical principles are not clear, spe- cific treatment decisions can become arbitrary, such as deciding which method to employ to retract the canine (ie, with either a retroligature or laceback, a sectional arch, a mini-implant, a power chain, a closing spring, etc). Without a clear philosophy underpinning our procedures, how do we know which will be the most effective for our treatment goals? First we need an anchorage philosophy.

Damon System Philosophy

The Damon System philosophy is centered on three basic principles1: friction, the lip bumper effect, and posterior transverse adaptation.

Friction

With the Damon System, there is very little or no friction between the archwires (especially in the initial phases) and the bracket slot (Fig 2-1) because the principle is to use a very wide bracket slot (0.022 × 0.027 inch) and a smaller-diameter archwire during all phases of treatment. This setup allows us to work with the lowest possible forces in the four treatment phases, remaining in what we call the “optimal force zone,” trying to keep the periodontal ligament (PDL) from being compressed in such a way that it leads to an ischemic zone. The intention is that the force stimulus only partially compresses the dental support structures (ie, PDL and alveolar bone), leading to optimal cellular response of the tooth (ie, movement) and better health of the surrounding bone and tissues.

30

DAMON SYSTEM PHILOSOPHY

Fig 2-1(a and b) Freedom between the slot of the passive self-ligating (PSL)bracket and the first archwire.

Fig 2-2 Position of incisors within the coverage of the lower lip.

Fig 2-3(a and b) Example of posterior transverse adaptation in the mandibular arch.

Fig 2-4(a and b) Example of posterior transverse adaptation in the maxillary arch.

Lip bumper effect

It is important to start with light force at the first appoint- ment, either with a 0.013 or 0.014 CuNiTi (copper-nickel- titanium) archwire to not overload the muscles of the face, as they work and act as a lip bumper (containment) to control the torque of the incisors (Fig 2-2). A technologi- cally advanced archwire was recently brought to market by Ormco—the SmartArch 0.016-inch archwire. This arch- wire is treated with a laser system, which allows it to exert differential forces in three areas of the archwire, at the level of incisors, premolars, and molars. This means that differ- ent force levels can be used to stimulate tooth movement without overloading the periodontium, allowing controlled movements in the first phase of treatment.

Posterior transverse adaptation

Using archwires that release light forces also facilitates movement of the posterior zone toward the buccal, leading to a posterior transverse adaptation, or as it is commonly but mistakenly called, “posterior expansion.” In reality, there is no true expansion; instead, the movement in the posterior area that increases arch length is simply a verticalization of the alveolar processes (Figs 2-3 to 2-5).

Figure 2-6 exemplifies the Damon System with its use of light wires, passive self-ligating (PSL) brackets, the lip bumper effect, and posterior transverse adaptation.

31

Damon System Philosophy

Fig 2-5 Verticalization of dentoalveolar structures after orthodontic treatment with the Damon System.

Fig 2-6(a to c) Clinical case treated with the following archwire sequence: 1st phase, 0.013 CuNiTi both arches, 0.016 CuNiTi both arches; 2nd phase, 0.014 × 0.025 CuNiTi both arches; 3rd phase, 0.019 × 0.025 co- ordinated steel archwires; 4th phase, same archwires from 3rd phase. The most import- ant part is to let the archwires work until each phase’s goals are met and to respect the philosophy of each phase (explained in more detail later in the chapter).

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DAMON SYSTEM PHILOSOPHY

Fig 2-7(a to c) Invaded function coverage; the maxillary incisors rest on the lower lip. (d to f) Changes during treatment: The incisors are in good harmony with function coverage; the maxillary incisors respect the boundary of the lower lip.

Fig 2-8(a and b) Hypertrophied pharyngeal tonsils and low tongue rest position.

Fig 2-9 Inferior turbinate hypertrophy and total maxillary sinus obstruc- tion.

Anchorage

The philosophy of orthodontics is considered to be the study and control of anchorage, which is inherent in the design of an appliance.2 Anchorage is the universal principle that all orthodontic systems or techniques must abide by. Anchorage is a 3D concept; as such, we should always talk about in a 3D sense: in the sagittal, vertical, and transverse planes.

“A second chance”

The Damon System philosophy focuses its concept of anchorage on the orofacial musculature, mainly the orbi- cularis (sagittal anchorage), buccinator (transverse anchor- age), masseter (vertical anchorage), and tongue (centrifugal force) muscles and how all these muscle groups interact with respiratory function and mastication (Fig 2-7).

This philosophy aims to establish a new balance of the forces that act on the dentoalveolar processes and its dental components. In other words, we are trying to get a second chance to develop the arches, as the effects of an unbalanced musculature during the stages of growth and development could have caused dental malposition.

It is widely recognized in the orthodontic world that a respiratory alteration such as hypertrophy of lymphatic tissue (eg, adenoids and tonsils), partial or total obstruction in the paranasal sinuses, nasal septum deviations, turbinate hypertrophy, or ostial obstruction (Figs 2-8 and Fig 2-9