Birte Melsen

The Finite Element Method: a Tool to Study Orthodontic Tooth Movement

Orthodontic tooth movement is achieved by (re)modeling processes of the alveolar bone, which are triggered by changes in the stress/strain distribution in the periodontium. In the past, the finite element (FE) method has been used to describe the stressed situation within the periodontal ligament (PDL) and surrounding alveolar bone. The present study sought to determine the impact of the modeling process on the outcome from FE analyses and to relate these findings to the current theories on orthodontic tooth movement. In a series of FE analyses simulating teeth subjected to orthodontic loading, the influence of geometry/morphology, material properties, and boundary conditions was evaluated. The accurate description of alveolar bone morphology and the assignment of non-linear mechanical properties for the PDF elements demonstrate that loading of the periodontium cannot be explained in simple terms of compression and tension along the loading direction. Tension in the alveolar bone was far more predominant than compression.

Intrusion of incisors in adult patients with marginal bone loss

Elongated and spaced incisors are common problems in patients suffering from severe periodontal disease. Thirty patients characterized by marginal bone loss and deep overbite were treated by intrusion of incisors. Three different methods for intrusion were applied: (1) J hooks and extraoral high-pull headgear, (2) utility arches, (3) intrusion bent into a loop in a 0.17 x 0.25-inch wire, and (4) base arch as described by Burstone. The intrusion was evaluated from the displacement of the apex, incision, and the center of resistance of the most prominent or elongated central incisor. Change in the marginal bone level and the amount of root resorption were evaluated on standardized intraoral radiographs. The pockets were assessed by standardized probing and the clinical crown length was measured on study casts. The results showed that the true intrusion of the center of resistance varied from 0 to 3.5 mm and was most pronounced when intrusion was performed with a base arch. The clinical crown length was generally reduced by 0.5 to 1.0 mm. The marginal bone level approached the cementoenamel junction in all but six cases. All cases demonstrated root resorption varying from 1 to 3 mm. The total amount of alveolar support--that is, the calculated area of the alveolar wall--was unaltered or increased in 19 of the 30 cases. The dependency of the results on the oral hygiene, the force distribution, and the perioral function was evaluated in relation to the individual cases. It was obvious that intrusion was best performed when (1) forces were low (5 to 15 gm per tooth) with the line of action of the force passing through or close to the center of resistance, (2) the gingiva status was healthy, and (3) no interference with perioral function was present.

Importance of the critical-size bone defect in testing bone-regenerating materials.

A substantial interest exists in developing substitute materials and human recombinant boneinducing factors to enhance bone regeneration both in the craniofacial complex and in other parts of the skeleton. A persistent problem has been to find an animal model that allows for the comparison of different osteopromotive materials. The purpose of this investigation was 1) to determine whether a 5-mm calvarial defect in adult rats fulfilled the requirements of a critical-size bone defect and 2) to discuss the use of this animal model in assessing bone repair in the craniofacial region. Bilateral full-thickness calvarial defects were trephined in the calvarial bone of 56 5− to 6-month-old Wistar rats. Except for minor amounts of bone formation limited to the margins of the defect, none of the defects revealed any signs of spontaneous bone regeneration 6 and 12 months after surgery. The full-thickness 5-mm calvarial defects thus fulfill the criteria for a critical-size bone defect. This animal model allows for an experiment with a paired design, it avoids inclusion of the sagittal suture in the osseous defect, and it thereby minimizes morbidity by reducing the risk of damaging the midsagittal sinus. An adequate experimental model has been developed to evaluate the efficiency of osteopromotive materials in the healing of bone defects in the craniomaxillofacial region.

Biological reaction of alveolar bone to orthodontic tooth movement

Direct and indirect resorption are perceived as reactions to an applied force. This is in contrast to the view of orthopedic surgeons, who describe apposition as a reaction to loading of bone. A histomorphometric study of the circumalveolar bone reaction to a force system generating translation of premolars and molars of five maccaca fascicularis monkeys is described. Three force levels (100 cN, 200 cN, and 300 cN) were applied for a period of 11 weeks. Undecalcified serial sections were cut parallel to the occlusal plane, and a grid consisting of three concentric outlines of the root intersected by six radii was placed on each section. Areas anticipated to be submitted to different stress/strain distributions were isolated. A-posteriori tests were used in order to separate areas that differed with regard to parameters reflecting bone turnover. Based on these results, a new hypothesis regarding tissue reaction to orthodontic forces is suggested. Direct resorption could be perceived as a result of the lowering of the normal strain from the functioning PDL and as such, as a start of remodeling, in the bone biological sense of the word. Indirect remodeling could be perceived as a sterile inflammation attempting to remove ischemic bone under the hyalinized tissue. At a distance from the alveolus, dense woven bone was observed as a sign of a RAP (regional acceleratory phenomena). The apposition could, according to the new hypothesis, be perceived as a result of the bending of the alveolar wall produced by the pull from the Sharpey fibers. The above suggested interpretation of tissue reaction would be shared with bone biologists.

New attachment through periodontal treatment and orthodontic intrusion.

The present study was performed to investigate the tissue reaction related to orthodontic intrusion of teeth with a reduced periodontium and further to evaluate the influence of oral hygiene on this reaction. In each of five Macaca fascicularis monkeys, periodontal tissue breakdown was induced around the premolars and the upper incisors by placing orthodontic elastic ligatures around the teeth. The breakdown procedure was continued until a minimum of four pockets could be measured on probing. Following removal of the elastics, a flap operation was performed. The pocket epithelium and granulation tissue were excised. During the surgical procedure, a notch was placed just above the bone. The teeth were divided postoperatively into four groups according to treatment: group 1 = flap operation, no oral hygiene program; group 2 = flap operation plus oral hygiene program three times per week; group 3 = flap operation plus intrusion, no oral hygiene program; and group 4 = flap operation plus intrusion plus oral hygiene. Groups 3 and 4 were subdivided into two observation periods. A total of 60 teeth corresponding to 120 approximate surfaces were studied. The animals were killed with perfusion; histologic sections were produced and stained alternatively with hematoxylin and eosin, and van Giesons solution. The histologic analysis showed that new cementum formation and new collagen attachment were observed following the surgical procedure if the oral hygiene was maintained, but also demonstrated that the intrusion improved the quantity of new attachment if carried out under healthy conditions. New attachment was a consistent finding in group 4, but varied from 0.7 to 2.3 mm. In case of intrusion without oral hygiene, the results varied from moderate new attachment to an aggravation of the periodontal bone loss. On the basis of the results presented here, the combination of periodontal treatment and orthodontic intrusion seems to be a method by which improvement of the periodontal condition can be obtained, provided that both the biomechanical force system and the oral hygiene are kept under control.

Tissue reaction following application of extrusive and intrusive forces to teeth in adult monkeys

Intrusion has been regarded as a very controversial topic in the orthodontic literature. Although it seems a logical way to handle deep overbite in adult patients who have elongated teeth, reports on iatrogenic damage have led to the suggestion of alternative methods. Considering the disadvantages of these alternatives, it seems reasonable, however, to improve our knowledge of tissue reaction as related to intrusion. Three Macaca fascicularis monkeys were used for the experiment. By means of a segmented arch approach, the upper incisors and the four first premolars were submitted to forced eruption for 8 weeks followed by 12 weeks of intrusion. A split-mouth technique was used to study the influence of oral hygiene on the tissue reaction. On the right side of the mouth, the teeth were brushed with chlorhexidine three times per week. On the left side, no oral hygiene was performed. After intrusion of the teeth, a 1-to-14 day retention period with passive appliance preceded the killing of the monkeys. A buccolingual hematoxylin- and eosin-stained serial section was produced, and soft- and hard-tissue reactions described. It appeared that the hygiene program could limit but not prevent gingival inflammation. There was, however, a marked difference in the histologic picture of the marginal bone on the two sides. On the hygiene side, clear signs of bone deposited during forced eruption were still present. This was not the case on the nonhygiene side. The extension of bone resorption was also different on the two sides.(ABSTRACT TRUNCATED AT 250 WORDS)

Material parameters and stress profiles within the periodontal ligament.

Levels and profiles of initial stress in the periodontal ligament after application of various force systems were studied. Two finite-element models, based on sections of human autopsy material, were developed to simulate one full and one partial mandible. The validity of the finite-element model was improved by identification of material parameters; the mechanical properties of the tissue were described by means of strain-gauge measurements of initial tooth movements in human autopsy material. The multiple modeling technique, in which data from a coarse global model are transferred to a more detailed one, was used to identify bone structure and boundary conditions. Parameters known to influence the results were varied to establish the validity of the finite-element model. Iterative calculation methods were used to gain stable results. However, optimizing features of the bone structure and boundary conditions did not influence the results significantly. The elastic stiffness of the periodontal ligament was determined to 0.07 MPa and tau = 0.49 (tau being the Poissons ratio). Stress profiles were obtained for various force systems--as in tipping, translation, and root movement. As we expected, there was a marked variation in the stress distribution from cervix to apex when tipping forces were applied. Bodily movement of the tooth produced an almost uniform stress distribution; root movement produced stress patterns opposite to those observed during tipping; and masticatory forces alone produced stress patterns almost identical to those achieved by masticatory force in combination with orthodontic forces.

Relationships between Swallowing Pattern, Mode of respiration, and Development of Malocclusion

A study of children in northern Italy finds positive but complex relationships between malocclusion and both respiration and swallowing patterns.

Two- versus three-dimensional imaging in subjects with unerupted maxillary canines

The aim of this study was to evaluate whether there is any difference in the diagnostic information provided by conventional two-dimensional (2D) images or by three-dimensional (3D) cone beam computed tomography (CBCT) in subjects with unerupted maxillary canines. Twenty-seven patients (17 females and 10 males, mean age 11.8 years) undergoing orthodontic treatment with 39 impacted or retained maxillary canines were included. For each canine, two different digital image sets were obtained: (1) A 2D image set including a panoramic radiograph, a lateral cephalogram, and the available periapical radiographs with different projections and (2) A 3D image set obtained with CBCT. Both sets of images were submitted, in a single-blind randomized order, to eight dentists. A questionnaire was used to assess the position of the canine, the presence of root resorption, the difficulty of the case, treatment choice options, and the quality of the images. Data analysis was performed using the McNemar-Bowker test for paired data, Kappa statistics, and paired t-tests. The findings demonstrated a difference in the localization of the impacted canines between the two techniques, which can be explained by factors affecting the conventional 2D radiographs such as distortion, magnification, and superimposition of anatomical structures situated in different planes of space. The increased precision in the localization of the canines and the improved estimation of the space conditions in the arch obtained with CBCT resulted in a difference in diagnosis and treatment planning towards a more clinically orientated approach.

Nasal respiratory resistance and head posture : Effect of intranasal corticosteroid (Budesonide) in children with asthma and perennial rhinitis

The influence of mouth breathing on craniofacial development has previously been demonstrated. Recent investigations do indicate, however, that head posture also might be related to craniofacial morphology. The aim of the present study was to analyze the effect of a topical steroid spray (Budesonide) on nasal respiratory resistance and head posture in children with asthma and nasal obstruction. Thirty-seven children, 8 to 15 years of age, with bronchial asthma, perennial allergic rhinitis, and subjectively assessed mouth breathing were selected for the study. Rhinomanometric and cephalometric analyses were performed. Head posture was defined as the position of the head relative to the cervical column and to the true vertical. After the first examination the children were randomly allocated to two groups, of which one group was treated intranasally with Budesonide (N = 18) and the other with placebo (N = 19), for a double-blind study. After one month of treatment, there was a statistically significant decrease in nasal resistance (p less than 0.001) and an increased flexing of the head (p less than 0.01) (paired t tests) in the children under active treatment. No significant changes were seen in the placebo group. The results indicate that Budesonide nasal spray is capable of reducing nasal obstruction in allergic children and that a reduced nasal resistance leads to a decrease in craniocervical angulation. The clinical importance of these results is yet to be clarified.