Multibracket Appliance Treatment Research Articles

Limit Flow Etchant Applicator

White spot lesions (WSLs) have been reported to occur in a majority of orthodontic patients who undergo multibracket appliance treatment. WSL scores are proven to be higher in total-etch techniques as compared to partial etching, with no difference in bond strengths. It is thus very important to prevent unnecessary etching and demineralization of enamel in those areas where it is not needed and to etch only the surface intended for bracket bonding. This article describes a simple method to limit the flow of the acid etchant to the area on the tooth surface receiving the bracket, with the added advantage of a positioning gauge on the etchant applicator.

Resin infiltration versus fluoride varnish for visual improvement of white spot lesions during multibracket treatment. A randomized-controlled clinical trial

AimsThis study aimed to evaluate the visual improvement of resin infiltration of white spot lesions (WSL) during orthodontic treatment with the multibracket appliance (MBA) compared to fluoride varnish.MethodsPatients aged 12–17 years with at least one WSL with an International Caries Detection and Assessment System (ICDAS) score of 1–2 during an active MBA treatment were included and randomized to receive either resin infiltration (Icon) or fluoride application (Flairesse). Standardized digital images were obtained before, one-day, one-week, one-month, three-months and six-months after treatment using a DSLR camera and a matching polarization filter. A grey reference card was used for color standardization. A Matlab routine was used to measure the color difference between adjacent healthy enamel and treated WSL. The independent-samples t-test was used for intergroup and paired-samples t-test for intragroup comparison.ResultsImages of 116 teeth from 36 patients were analyzed. The ΔE for the “Icon” treated WSL was smaller (T1ICON = 5.0 ± 1.4) than in the fluoride group (T1Fluoride = 8.4 ± 3.2). Caries infiltration significantly improved the aesthetic appearance of WSL (p < 0.001), which remained satisfactory at six months (T5ICON = 5.2 ± 1.6).ConclusionWSL infiltration management during orthodontic treatment was superior to topical fluoridation in not only arresting the enamel lesions but also significantly improving the aesthetic appearance of demineralized regions around the brackets.Clinical relevanceWSL treatment in orthodontic patients is usually initiated after debonding. Research has shown that the earlier WSL is treated, the better the aesthetic outcome. There is limited data on the efficacy of resin infiltration of WSL during orthodontic treatment.

Long-term (≥ 15years) outcome quality after ClassII:1 bionator or Herbst multibracket appliance treatment : Acomparison.

To compare the long-term outcome quality (≥ 15years) of ClassII:1 treatment using either abionator (BIO) or aHerbst-multibracket appliance (HMB). Patients who underwent functional treatment during the ideal treatment period for the respective approach (prepuberty vs. peak/postpeak) were assessed. Inclusion criteria were overjet ≥ 4 mm, skeletal ClassII and availability of study casts from before, after and ≥ 15years after treatment. The study casts were assessed using the Peer Assessment Rating (PAR) index and standard orthodontic cast measurements. During treatment, PAR score, overjet and sagittal occlusal relationship improved significantly in all groups. Long-term, there was asignificant increase of incisor irregularity in the upper (HMB) and lower (BIO) arch and asignificant decrease of lower arch width 3 - 3 (BIO). PAR score, overjet, and sagittal occlusal relationship remained stable long-term. Intergroup comparisons revealed significant differences between the BIO and HMB groups in terms of lower arch width (6 - 6), upper and lower arch width (3 + 3/3 - 3) as well as sagittal molar relationship. The achieved improvement in PAR score, overjet, and sagittal occlusion remained comparably stable long-term in all groups. The long-term changes are probably aconsequence of natural aging.

Herbst-multibracket appliance treatment: is there an association between lower incisor position changes and the development of labial gingival recessions?

PurposeTo assess a potential association between lower incisor (LI) position changes during Herbst–multibracket appliance (Herbst–MBA) treatment and the development of labial gingival recessions (LGR).MethodsAll class II patients (Department of Orthodontics, University of Giessen, Giessen, Germany) who had undergone Herbst–MBA treatment until 2015 with study models and lateral cephalograms available from before (T0) and after treatment plus ≥24 months of retention (T3) were included (n = 259). Lateral cephalograms were evaluated regarding LI position changes: iiL/ML (angle between LI long axis and mandibular plane [MP]), ii-MLPg (distance between LI incisal edge and a line perpendicular to MP through pogonion), apex-MLPg (distance between LI apex and a line perpendicular to MP through pogonion), ii-MLii (distance between LI incisal edge and MP on a line perpendicular to MP through incisal edge). Using study models the distance between the cementoenamel junction and the deepest point of the gingival margin was defined as LGR.ResultsThe following cephalometric mean changes were recorded (T0–T3): iiL/ML +5.9 ± 5.76° (p = 0.929), ii-MLPg −0.2 ± 0.25 mm (p = 0.430), apex-MLPg +0.1 ± 0.32 mm (p = 0.363), ii-MLii +0.1 ± 0.36 mm (p = 0.206). The mean increase of LGR magnitude measured on the study models was 0.1 ± 0.35 mm. However, no association with the cephalometric LI position changes was found (|R| ≤ 0.2).ConclusionThere is no association between the amount of LI position changes and the development of LGR during Herbst–MBA treatment plus retention. Nevertheless, individual predisposition or excessive treatment changes and extraordinary treatment approaches, respectively, might still lead to development of LGR.

3D-analysis of unwanted tooth movements despite bonded orthodontic retainers: a pilot study

BackgroundRecently, reports of unwanted tooth movements despite intact orthodontic bonded retainers have increased. These movements are not subject to relapse but are classified as a new developed malocclusion. The aims of the present pilot study were to analyze the prevalence of unwanted tooth movements despite intact bonded cuspid-to-cuspid retainers and to identify possible predisposing factors.Materials and methodsPlaster casts of all patients finishing orthodontic treatment during three consecutive years were assessed before treatment (T0), after multibracket appliance debonding (T1) and after two years of retention (T2). After multibracket appliance treatment, all patients received a cuspid-to-cuspid flexible spiral wire retainer bonded to each tooth of the retained segment in the upper and lower jaw. The study group (SG) consisted of 44 patients (16 male, 28 female) with tooth movements (T1–T2) of the retained segment despite intact bonded cuspid-to-cuspid retainer and the control group (CG) of 43 patients (19 male, 24 female) without unwanted tooth movements. The casts of the SG were digitized, superimposed and measured. Using the Chi-square test, Fisher´s exact test and Mann–Whitney-U-test (p < 0.05), mandibular plane angle, incisor proclination, oral dysfunctions or habits (T0) and intercanine distance, overjet and interincisal relationship (T0, T1, T2) were compared between SG and CG.ResultsThe prevalence of patients with unwanted tooth movements in one or both jaws was 27.0%. Maxillary retainers were affected more often (20.9%) than mandibular retainers (14.1%). The median amount of tooth movements was 0 to 0.66 mm with large interindividual variations. Oral dysfunctions or habits at T0, such as a lack of interincisal contact at all time points, were associated with unwanted tooth movements.ConclusionUnwanted tooth movements occurred more often with maxillary than mandibular retainers. Patients with oral dysfunctions/habits and without interincisal contact had a higher prevalence of unwanted tooth movements.

Three-dimensional condylar changes from Herbst appliance and multibracket treatment: A comparison with matched Class II elastics

The purpose of this study was to quantify and qualify the 3-dimensional (3D) condylar changes using mandibular 3D regional superimposition techniques in adolescent patients with Class II Division 1 malocclusions treated with either a 2-phase or single-phase approach. Twenty patients with Herbst appliances who met the inclusion criteria and had cone-beam computed tomography (CBCT) images taken before, 8weeks after Herbst removal, and after the completion of multibracket appliance treatment constituted the Herbst group. They were compared with 11 subjects with Class II malocclusion who were treated with elastics and multibracket appliances and who had CBCT images taken before and after treatment. Three-dimensional models generated from the CBCT images were registered on the mandible using 3D voxel-based superimposition techniques and analyzed using semitransparent overlays and point-to-point measurements. The magnitude of lateral condylar growth during the orthodontic phase (T2-T3) was greater than that during the orthopedic phase (T1-T2) for all condylar fiducials with the exception of the superior condyle (P<0.05). Conversely, posterior condylar growth was greater during the orthopedic phase than the subsequent orthodontic phase for all condylar fiducials (P<0.05). The magnitude of vertical condylar development was similar during both the orthopedic (T1-T2) and orthodontic phases (T2-T3) across all condylar fiducials (P<0.05). Posterior condylar growth during the orthodontic phase (T2-T3) of the 2-phase approach decreased for all condylar fiducials with the exception of the posterior condylar fiducial (P<0.05) when compared with the single-phase approach. Two-phase treatment using a Herbst appliance accelerates condylar growth when compared with a single-phase regime with Class II elastics. Whereas the posterior condylar growth manifested primarily during the orthopedic phase, the vertical condylar gains occurred in equal magnitude throughout both phases of the 2-phase treatment regime.

Variation in bracket slot sizes, ligation methods and prescriptions: UK national survey

This study designed to investigate the use of fixed bracket slot sizes, ligation method and prescriptions in the UK using an online survey/questionnaire comprised of seven questions. The questionnaire link along with an explanation of its nature was circulated via the British Orthodontic Society (BOS) to all 978-email addresses of the Consultant Orthodontists Group (COG) and Orthodontic Specialists Group (OSG) (registered on the UK Specialist List for Orthodontics) members inviting them to participate. Two email reminders were sent to increase the response rate. Chi2 analyses determined the statistical differences in the use of bracket slots and prescriptions according to the regions and years of experience. The respondents represented 31.2% of the BOS specialist orthodontic members. Most of the respondents practised in the South of England with experience between 11-30years. The vast majority of the respondents routinely used brackets with the multibracket appliance treatment (MBT) prescription (81.6%) and 0.022-inch slot size (98.7%), which was statistically significantly higher in all geographical regions and experience levels (P<0.001). The majority of the respondents reported either 100% or 90% use of conventional brackets when compared to self-ligating brackets. The vast majority of UK specialist orthodontists use conventional ligating MBT prescription brackets with the 0.022-inch slot size. This was mainly because they perceive that this combination provides better treatment outcomes, whilst many respondents also indicated that they were taught and trained using this combination and that there was not enough evidence to support a change in their clinical practice.

Oral mucosal complications in orthodontic treatment.

Orthodontic therapy is used to solve numerous oral problems, but the use of fixed oral devices can also impact negatively the oral cavity, if the treatment is not steadily under control. The aim of this study is to evaluate tooth, bone and soft tissues lesions due to the presence of fixed orthodontic appliances. One hundred patients with fixed orthodontic appliances were included in the study. In particular, 20 patients with rapid palatal expander (RPE), 20 patients with Forsus appliance, 20 patients with a fixed multibracket appliance treatment, 20 patients with just the lower vestibular multibracket treatment and 20 patients with both upper and lower vestibular multibracket treatment. An accurate oral examination of the oral cavity, comprehending teeth, bone and soft tissues, was carried out thoroughly, in order to find possible lesions caused by the fixed orthodontic treatment. Concerning RPE, 35% patients had reversible palatal lesions, while 45% patients had the impression of the appliance on the tongue. Periodontal damages were observed in 5% of the patients, as well as tooth lesions (i.e. dental caries). 20% of the patients with Forsus appliance experienced the lesion on the cheek mucosa, while 10% individuals reported periodontal problems, and 15% of the subject suffered for WSL (white spot lesion) and dental caries. Upper vestibular multibracket appliance caused superior labial lesions (15%), cheek mucosal lesions (20%), gingivitis (55%), white spot lesions (WSL) of superior teeth (15%), while dental recessions and periodontitis due to the appliance were rarely observed (5%). Lower vestibular multibracket appliance was frequently the cause of inferior labial lesions (15%), cheek mucosal lesions (15%), gingivitis (50%), WSL of inferior teeth (20%) and also in lower arch dental recessions and periodontitis due to the appliance were rarely observed (5%). Patients with both superior and inferior multibracket appliance experienced upper and/or lower lip lesions (25%), lesions of cheek mucosa (25%), gingivitis (65%) and WSL (30%), and just in few cases periodontitis (10%). Data shows a more critical oral situation in patients with both superior and inferior appliances than people with one-arch therapy. Orthodontic therapy offers a considerable number of advantages, but it is important to underline what may be the adverse consequences also. This allows the orthodontist to inform the patient of all the possible effects of their therapeutic choice. In most cases, RPE can cause an impression of the device on the tongue and reversible lesions of the palate. On the other hand, the orthodontic fixed therapy can cause gingivitis, followed by mucosal lesions, labial lesions and WSL. For these reasons, an accurate assessment of the patients before the application of fixed orthodontic treatment is necessary. Oral hygiene instructions and motivation are very important, as well as periodic controls of the fixed oral device.

Assessing the effect of multibracket appliance treatment on tooth color by using electronic measurement

BackgroundThe purpose of this study was to investigate how tooth color is affected by multibracket appliance (MBA) treatment.MethodsThe color of teeth #14 to #24 of 15 patients with MBA was measured on body and gingival tooth segments using the spectrophotometer Shade Inspector™. Colors of both segments were recorded before start of MBA treatment (baseline T0), end of MBA treatment (T1; 2 years ±0.3), and 3 months after T1 (T2). A 2D color system and a 3D system served as reference systems.Multilevel models were used to analyze color change within segments and to compare the difference in color change between segments (treatment effect).Results2D system. Changes within tooth segments from T0 to T2 were at worst 2.0 units (ΔE in the gingival segment), which is less than the threshold of 2.7 units for a clinically meaningful difference. Confidence intervals for the treatment effect indicated no clinically important differences in color change between body and gingival segments.3D system. Changes within tooth segments from T0 to T2 were at worst 2.3 units (ΔE in the body segment), which is less than the threshold of 2.7 units for a clinically meaningful difference. Confidence intervals for the treatment effect indicated no clinically important differences in color change between body and gingival segments.Thus, MBA treatment did not lead to clinically relevant changes in tooth color.ConclusionWithin the limitation of this study the MBA treatment can be seen as a safe method with respect to tooth color.

Changes in white spot lesions following post-orthodontic weekly application of 1.25 per cent fluoride gel over 6 months-a randomized placebo-controlled clinical trial. Part I: photographic data evaluation.

White spot lesions (WSLs) are a frequent side-effect of multibracket appliance treatment. The effect of local fluoridation on post-orthodontic WSL is however inconclusive. Assessment of WSL changes in response to weekly 1.25 per cent fluoride gel application after multibracket appliance treatment. Randomized, single-centre, double-blind, parallel-group, placebo-controlled study. Patients with not less than 1 WSL (modified score 1 or 2) on not less than 1 upper front teeth after debonding. Professional fluoride/placebo gel application during weeks 1-2; self-administered home application (weeks 3-24). Photographic WSL assessment (dimension and luminance) of the upper front teeth (T0-T5). Random assignment to test (n = 23) or placebo group (n = 23) using a sequentially numbered list (random allocation sequence generated for 50 subjects in 25 blocks of 2 subjects each). The clinical study duration lasted from March 2011 to September 2013. Unblinding was performed after complete data evaluation. Intent-to-treat analysis set comprising 39 participants (test: n = 21, placebo: n = 18). Dimensional WSL quantification showed limited reliability. Luminance improvement (%) of WSL, however, was seen after 6 months (test/placebo: tooth 12, 24.8/18.0; tooth 11, 38.4/35.4; tooth 21, 39.6/38.3; and tooth 22, 15.2/25.0). No statistically significant group difference existed. Data suggest that WSLs are difficult to measure with respect to reliability and repeatability and methods for monitoring WSLs in clinical trials require improvement/validation. Similar adverse events occurred in both groups; none was classified as possibly related to the study product. The number of dropouts was higher than expected and the socio-economic status was not assessed. Furthermore, the unknown level of compliance during the home application phase must be considered as limitation. Based on the results of this study, no difference could be detected with respect to the development of WSL under post-orthodontic high-dose fluoride treatment. The study was registered with ClinicalTrials.gov (Identifier: NCT01329731). The protocol wasn't published before trial commencement.

Changes in white spot lesions following post-orthodontic weekly application of 1.25 per cent fluoride gel over 6 months-a randomized placebo-controlled clinical trial. Part II: clinical data evaluation.

White spot lesions (WSL) frequently occur as side-effect of multibracket appliance treatment. The clinical effects of local fluoridation on post-orthodontic WSL and oral health development are however inconclusive. In vivo monitoring of clinical WSL and oral health changes in response to weekly 1.25 per cent fluoride gel application after multibracket appliance treatment. Randomized, single-centre, double-blind, parallel-group, placebo-controlled study. Patients with not less than 1 WSL (modified score 1 or 2) on not less than 1 upper front teeth after debonding. Professional fluoride/placebo gel application during weeks 1-2; self-administered home application (weeks 3-24). Clinical evaluation of WSL index, lesion activity, plaque index, gingival bleeding index, and decayed, missing, and filled teeth index as well as saliva buffer capacity and stimulated salivary flow rate (T0-T5). Random assignment to test (n = 23) or placebo group (n = 23) using a sequentially numbered list (random allocation sequence generated for 50 subjects in 25 blocks of 2 subjects each). The clinical study duration lasted from March 2011 to September 2013. Unblinding was performed after complete data evaluation. Intention-to-treat analysis set comprised 39 participants (test: n = 21, placebo: n = 18). No clinical parameter except stimulated salivary flow rate (fluoride group: 1.1ml/min, placebo group: 0.74ml/min; P = 0.022) showed a statistically significant group difference after 24 weeks. Several adverse events occurred similarly frequent in both groups; none was classified as possibly related to the study product. The number of dropouts was higher than expected and the socio-economic status was not assessed. Furthermore, the unknown level of compliance during the home application phase must be considered as limitation. Based on the results of this study, no clinical effect of post-orthodontic high-dose fluoride treatment on WSL and oral health changes could be detected. The study was registered with ClinicalTrials.gov (Identifier: NCT01329731). The protocol wasn't published before trial commencement.

White-spot lesions during multibracket appliance treatment: A challenge for clinical excellence

White-spot lesions (WSL) are one of the most undesired side effects of multibracket appliance treatment (MB). The aim of this study was to investigate the incidence and further course of WSL during and after MB. Four hundred patients (168 boys, 232 girls) meeting the inclusion criteria--all maxillary front teeth fully erupted and visible before treatment, no fillings or structural abnormalities, MB duration of at least 1 year, and retention period of at least 1 year--were selected. The patients' average age was 13.7 years (SD, 3.5), and the average MB time was 1.9 years (SD, 3.6). All patients received standardized general prophylactic instructions. A modification of the WSL index was used to evaluate the 4 maxillary front teeth on introral photos before and after treatment, and after retention. Before treatment, 32.3% of the patients had WSL. After MB, 73.5% of the patients presented WSL. The incidence of WSL during MB was 60.9% of the patients. After treatment, most patients (63.3%) had mild lesions, but the remaining were affected severely with (26.9%) and without (9.9%) cavitations. Only 26% of the patients were free of WSL all the time. After the retention phase, most (57.1%) of the WSL patients after treatment showed improvement, 26% remained unchanged, and 16.7% deteriorated. Male WSL patients tended to show more severe WSL than did the girls. There was a tendency for increased WSL development during the adolescent years compared with the preadolescent and postadolescent age groups. With only standardized general prophylactic measures, new WSL developing on the maxillary front teeth during MB remain a frequent undesired side effect, affecting 60.9% of patients and counteracting our efforts for clinical excellence.

Orthognathic surgery and dentofacial orthopedics in adult Class II Division 1 treatment: Mandibular sagittal split osteotomy versus Herbst appliance

The aim of this study was to assess to what extent adult Herbst treatment is an alternative to orthognathic surgery by comparing the dentoskeletal treatment effects in 46 adult Class II Division 1 subjects treated with a combined orthodontic-orthognathic surgery approach (mandibular sagittal split osteotomy without genioplasty) and 23 adult Class II Division 1 subjects treated with the Herbst appliance. Lateral headfilms in habitual occlusion from before and after treatment (multibracket appliance treatment after surgery or Herbst treatment) were analyzed. All surgery and Herbst subjects were treated successfully to Class I occlusal relationships with normal overjet and overbite. In the surgery group, the improvement in sagittal occlusion was achieved by skeletal more than dental changes; in the Herbst group, the opposite was the case. Skeletal and soft tissue facial profile convexity was reduced significantly in both groups, but the amount of profile convexity reduction was larger in the surgery group. The success and predictability of Herbst treatment for occlusal correction was as high as for surgery. Thus, Herbst treatment can be considered an alternative to orthognathic surgery in borderline adult skeletal Class II malocclusions, especially when a great facial improvement is not the main treatment goal.