Treatment of Angle Class II Division 1, impacted canine and
The Philippine Journal of Orthodontics
Vol. 4 No. 1 August 2005
Treatment of Angle Class II Division I, impacted canine
and mandibular deviation
Marlon Alvaro Moldez, D.M.D., D.Ortho., Ph.D.
Comparative Study of S. Mutans adherence to Ceramic
and Metal Brackets treated with 20% Astring-O-Sol®
Freshmint Mouthwash: an In Vitro study
Josievitze Umali Tan-Zafra, D.D.M, MS
Presurgical Nasoalveolar Molding
Janet M. Pandan, D.M.D.
The Mother of Smiles
Monica Luz M. Sison-Quiambao, D.M.D.
Dr. Sandra S. Adriano, APO President 2004 - 2006
Dr. Angelica Cabral, PBO Chair 2004-2006
Board of Editors
Dr. Martin V. Reyes, Chair
Dr. Robert I. Eustaquio
The Philippine Journal of Orthodontics is the official journal of the Association of Philippine Orthodontists (APO) and the Philippine
Board of Orthodontics (PBO) and is published for its members and subscribers by Kathlean Commercial, Inc.
It is dedicated to the continuing professional advancement of the orthodontist by publishing original articles and related clinical
Manuscripts, prepared in accordance with the Information for Authors should be submitted to the Editors, Dr. Robert I. Eustaquio c/o
PBO Secretariat 561 Wack Wack Road 66-7, Mandaluyong City, M.M. Tel/Fax 718-4588
Printed in the Philippines by Kathlean Commercial, Inc., Quezon City, M.M., Philippines
Treatment of Angle Class II Division 1, impacted canine
and mandibular deviation
Marlon Alvaro Moldez, D.M.D., D.Orth., Ph.D.
Dr. Marlon Moldez received his dental degree from Centro Escolar University in 1990. From the Tohoko University in Japan, he
received his Diploma in Orthodontics in 1999 and his Doctor of Philosophy (PH. D) in 2001 where he was a Monbusho Scholar
A case report is presented of a Class II, Division 1 malocclusion with an impacted upper right canine and
The case report that follows describes the orthodontic
treatment of a male patient with a chief complaint of an
unerupted maxillary right canine. The patient was 16 year, 7
month-old Filipino with slightly straight profile and a
mesocephalic facial pattern. He had a deviated mandible, a
Class II division 1 malocclusion and upper right impacted
canine (Figure 1).
Interference between the upper and lower left 1st molars was considered a major contributing factor for the mandibular shift.
Analysis of Records
The patient presented a slightly straight profile characterized by a medium sized nose, protrusive lips, slightly acute
nasolabial angle and a deep labiomental fold (Figure 1).
Lateral cephalometric evaluation showed an average
jaw relationship and slightly short lower facial height (Figure
2). The PA radiograph revealed a mandibular left shift of 6.0
mm (Figure 3).
The patient's medical and dental records showed no
Class II, Division 1 malocclusion with an unerupted upper
right canine. The upper and lower lips were slightly protrusive with slightly acute nasolabial angle and deep mento-labial furrow respectively.
The molar relationship was half cusp in the right and
full cusp Class II in the left side of the arch. The upper and
lower left 1st molars were in crossbite. There was a 6.1 mm
overjet, 5.3 mm deep anterior overbite and maxillary dental
midline shift approximately 1 mm to the patient's right.
The molar relationship was half cusp in the right and full
cusp Class II in the left. The upper and lower left 1st molars
were in crossbite. The maxillary dental midline was 1.0 mm to
the right of the facial midline. The upper incisors were proclined
while the lower incisors were retroclined. The overbite was
6.5 mm while the overjet was 6.1 mm (Figure. 1).
A Bolton anterior tooth size analysis showed a mandibular excess of 1.0 mm. Model cast revealed a deep curve
of Spee of 4 mm. Panoramic radiograph showed, the presence of all permanent teeth with root structure and alveolar
bone levels to be within normal limits. It was also noted that
the upper right canine was unerupted.
• Short Face due to short mandibular posterior dentoalveolar height
• Mandibular left shift (6.0 mm)
Molar Class II
• Impacted upper right canine
Labio-version of U1
• Linguo-version of LI
• Deep bite
• Large overjet
• Deep curve of Spee
• Upper dental midline shift to the right
• Slightly straight profile
Slightly acute nasolabial angle
Slightly protrusive lips
• Deep labio-mental fold
Intraoral examination revealed acceptable oral hygiene
and the teeth without caries. A buccal groove restoration on
the mandibular left 1st molar maxillary molars was evident.
Attached gingiva appeared adequate both anteriorly and posteriorly in both arches.
The patient had a skeletal Class I pattern, slightly short
lower face, mandibular left deviation of 6.0 mm, and Angle's
1. Coordinate upper and lower arches
2. Achieve proper position of the impacted maxillary
3. Flatten the Curve of Spee
4. Reduce the overbite and overjet.
5. Eliminate mandibular deviation (identical centric
occlusion and centric relation)
6. Establish a good, functional Class I occlusion.
7. Improve facial esthetics.
Because of the acceptable position of the jaws to the
Figure 5. Schematic representation of multi Lloop wires and vertical elastic during leveling the
curve of Spee
anterior cranial base, it was believed that extractions would
have an adverse effect on facial balance. The plan of treatment was therefore presented as non-extraction and initiated
as such. An occlusogram was constructed and showed that
by a 2 mm expansion of the molar and premolar areas would
allow leveling/alignment of the upper right impacted canine
(Figure 4). Both arches would receive full Straightwire
bracket system (0.022 x 0.028-inch slot size). Multi L-loop
wires and vertical intermaxillary elastics (3/16" 4.5 oz) were
to be used to gain arch leveling and to help guide the mandible to centric relation (Figure 5). In detailing stage, insertion of Ideal Arch wire (0.017 x 0.025-inch stainless steel
wire) with lingual crown torque was planned to minimize upper incisor proclination. Overcorrection of the malocclusion
was a goal to minimize future relapse. The patient was informed that long-term retention would be an absolute necessity. The overall treatment prognosis was considered good.
Figure 4. Occlusogram. Pre-treatment occlusal
tracing (broken line) of patient c o m p a r e d with
occlusal treatment objective (solid line).
Treatment began at the age of 17 years, with
Straightwire bracket system (0.022 x 0.028-inch slot size).
Arch development was initiated with 0.016 Cu Ni-Ti wires.
A slightly activated open coil spring was placed between the maxillary right lateral incisor and maxillary right
first premolar to prevent them from drifting into the canine
space (Figure. 6).
Figure 6. Slightly activated open coil spring was placed
between the maxillary right lateral incisor and maxillary
right first premolar during leveling and alignment to
prevent them from drifting into the canine space.
The arches were leveled with 0.016 x 0.022-inch Cu
L-loops were fabricated using 0.016 x 0.22-inch stain-
Ni-Ti wire, followed by a 0.017 x 0.025-inch stainless steel
less steel wire with vertical intermaxillary elastics to level
arch wire with a lingual crown torque for upper incisors. A
the arches (Figure 9). Final arch coordination was made
0.016-inch Cu Ni-Ti wire was used to bring the maxillary right
with 0.017 x 0.025-inch ideal arches (Figure 10).
canine into the arch supported by 0.17 x 0.25-inch stainless
steel (Figure 7).
Figure 7. A 0.016-ineh Cu Ni-Ti wire was used
to bring the maxillary right canine into occlusion
supported by 0.17 x 0.25-inch stainless steel
A mandibular repositioning splint (MRS) was inserted
Figure 9. L-loops were fabricated using 0.016 x 0.22inch stainless steel wire with vertical intermaxillary
elastics to level the arches and help guide mandible
to centric relation.
Figure 10. Final arch coordination was made
with 0.017 x 0.025-inch ideal arches.
in the lower arch to stabilize the mandible in centric relation
(Figure 8). The splint was equilibrated, reduced, and discontinued after six months.
Figure 8. A mandibular repositioning splint
was inserted in the lower arch to stabilize the
mandible in centric relation.
Evaluation of post-treatment orthodontic records
showed positive response of maxillary and mandibular arches
to non-extraction therapy. Facial profile showed nose-lipchin harmony. Mandibular deviation was corrected. The teeth
were aligned over supporting bone with Class I molar relationship, ideal overbite and overjet, flat curve of Spee, identical centric occlusion-centric relation and coincident dentalfacial midline. Posterior interdigitation was improved and functional excursions were established (Figure 11).
Figure 13. Post-treatment panoramic radiograph shows
that the parallelism of the roots is reasonably good.
Figure 11. Functional excursions
Right Lateral Excursion
Left Lateral Excursion
Cephalometric comparison reveals lower facial height
increased with downward-forward growth of the mandible
(Figure 12, Table 1).
The total treatment period was 21 months. After the
removal of the fixed appliances, wrap-around retainers were
placed. The patient was advised to wear retainers full time
for 1 year and part time (i.e. night only) in the second year.
Currently, the patient is on recall list at 6-month interval.
Angle Class II, Division 1 malocclusion was successfully treated with non-extraction therapy. Non-extraction
therapy gave this patient an attractive smile that balanced
Intraorally, there is adequate attached gingiva throughout the mouth. Alveolar bone level is adequate. There is no
discernible evidence of bone loss or root resorption. The postTeatment lateral tracing shows improved jaw relationship and
harmonious facial profile (Figure 12). The axial inclination of
both upper and lower incisors remained within acceptable
degree. Panoramic radiograph shows that the parallelism is
reasonably good (Figure 13).
nicely with his other facial features (Figure 14). His profile
changes were favorable and esthetically pleasing. Review of
post-treatment records reveals an excellent occlusal and esthetic result. Overbite, overjet, and posterior interdigitation
appear favorable, and the dental midline is well centered to
the face. Stability of the posterior occlusion should be good.
No signs or symptoms of temporomandibular disorder were
detected. The patient was pleased with the esthetic and functional results.
Table 1. Cephalometric Measurement
* Normative data is based on the author's research entitled Filipino Dentofacial Norms According to Age
and Gender (due for publication in Angle Orthodontist)
Comparative Study of S. mutans adherence to Ceramic
and Metal brackets treated with 20% Astring-O-Sol®
Freshmint Mouthwash: an In vitro study
Josievitz Umali Tan-Zafra, D.D.M., M.S.
Dr. JosievitzU. Tan-Zafra obtained her DMD from the University of the Philippines in 1996 and completed her orthodontic
training from the University of the Philippines Graduate Program in Orthodontics in 2003. This paper fulfilled the thesis
requirement for her Master of Science in Dentistry (Orthodontics) in 2004. She currently practices in Makati City.
Carious lesions during orthodontic therapy have been widely observed due to the high cariogenic challenge
prevailing around brackets. S. mutans has been established as the etiologic agent of dental caries. It is the
aim of this study to investigate the mean bacterial adherence of S. mutans to orthodontic metal and ceramic
brackets. The effect of the use of a mouth rinse such as 20% Astring-o-sol® Fresh mint versus sterile
distilled water on S. mutans adherence to brackets was also compared. 20 metal and 20 ceramic brackets
were saliva-coated and exposed to S. mutans. All brackets were rinsed with sterile distilled water. 10 metal
and 10 ceramic brackets were further immersed in mouth wash for 30 seconds. All samples were immersed
in Dey-Engley broth. The immersed broth was cultured (Broth method) while the brackets were subjected to
a Maki method of culture. CFU counts were done using Automated Counting Machine. The results of the
study indicate that metal brackets present with a reduced potential for S. mutans adherence in comparison
to ceramic brackets after rinsing with sterile distilled water. On intervention with AOS®, the type of material
does not affect the effectiveness of the mouthwash, thus resulting in an almost equal post-immersion CFU
level for both types. For both metal and ceramic brackets, the 20% AOS® Fresh mint solution was better
at eliminating bacterial colonies than sterile distilled water. The results suggest that a less caries inducing
microflora may develop with metal brackets and prophylactic use of a mouthwash as an adjunct to plaque
Bacterial Adherence, Streptococcus mutans (S.mutans), Metal Brackets, Ceramic Brackets, Astring-O-Sol
(AOS®) Mouth Rinse, Sterile Distilled Water
In the correction of malocclusion problems, orthodontists make use of fixed appliances (i.e. molar bands, brackets,
arch wires, elastics and adhesives) to facilitate tooth movement. Such orthodontic appliances bonded to the tooth may
provide a focus for the retention of plaque. The fixed appliances serve as stagnant areas for plaque to accumulate even
in oral hygiene motivated individuals. It has been widely observed that local factors such as irregularly aligned teeth, faulty
restorations or the presence of overhangs, ill-fitting crowns,
removable dentures 1 and orthodontic brackets2 favor plaque
Plaque is a known causative agent for gingival and periodontal infections. Streptococcus mutans, which has been
identified as one of the component microorganisms in plaque,
is further implicated as the primary etiologic agent in the formation of dental caries. S. mutans is the single most important organism in the initiation of caries.
Experiments have shown that development of carious
lesions during fixed orthodontic appliance therapy is an extremely rapid process. This is probably due to a high cariogenic challenge prevailing around brackets since plaque re-
moval is difficult in these areas. An almost linear correlation
O-Sol® Freshmint, a commercially available mouthwash in
between plaque accumulation and development of carious
reducing the am ountof S. mutans adherence on orthodontic
lesions has been demonstrated in orthodontic patients3.
metal and ceramic brackets.
Knowing that dental plaque causes these diseases
makes it detrimental to the oral health status especially in
orthodontic patients treated with comprehensive fixed appliance therapy. These fixed appliances last for more than 18
To compare the mean bacterial adherence of S.
months so the longer will be the time that the teeth surfaces
mutans to saliva-coated orthodontic metal and ceramic
will be at risk for enamel decalcification and the much worse
brackets when treated with either sterile distilled water
scenario of dental caries. It would naturally be unacceptable
or further treatment of 20% dilution of Astring-O-Sol®
to have obtained proper occlusion and yet at the same time
Fresh Mint mouthwash.
producing teeth with many and unsightly enamel decalcification, a high dental caries index, and gingival or periodontal
Tooth-brushing and flossing are the primary methods
of reducing plaque and oral microbiota. As an adjunct to plaque
1. To determine the mean bacterial adherence of
S. mutans to saliva-coated metal and ceramic
brackets treated with sterile distilled water alone.
control, patients are also advised to use mouthrinses. Fedi
2. To determine the mean bacterial adherence of
S. mutans to saliva-coated metal and ceramic
brackets further treated with 20% Astring-OSol.
and Vernino (1995) recognized that a good mouth rinse should
have: (1) the ability to totally remove bacterial colonies once
they have formed, (2) be able to gain access to areas that
need to be cleansed and (3) must have ample substantivity
3. To compare the mean bacterial adherence of S.
mutans to saliva-coated metal brackets when
treated with either sterile distilled water or further
treatment of 20% Astring-O-Sol mouthwash.
which is the ability of an antimicrobial to bind to anionic groups
on the tooth surface, oral mucosa and bacterial surfaces, thus
producing a sustained release of the active ingredients, which
extends the antimicrobial effectiveness of the product.4 There
4. To compare the mean bacterial adherence of S.
mutans to saliva-coated ceramic brackets when
treated with either sterile distilled water or further
treatment of 20% Astring-O-Sol mouthwash.
are several different commercially available preparations in
the market today. Astring-O-Sol® mouth rinse (manufactured
and distributed by GlaxoSmithKline) is one of the more marketable brands, advertised to be able to kill up to 99% of mouth
germs. In a recent study commissioned by GlaxoSmithKline
Phil., it was shown that the use of AOS® Fresh Mint and
The research design of the study is experimental in nature.
AOS® Gold as a mouth rinse using a 20% dilution is more
The following were the steps conducted:
effective against pathogenic microorganisms than water
With these in mind, the study further investigates the
cleaning ability of the recommended 20% dilution of Astring8
Saliva Collection: Saliva was obtained from one
individual with low caries index, meaning S. mutans
level within normal oral microflora, detected and
Such saliva would have its inherent
antimicrobial components. Saliva will be obtained
from only one person with good oral health status
(no existing carious activity) one hour after scaling
and polishing. The volunteer was asked to refrain
from eating and drinking before sample collection.
Saliva collection was performed between 9 AM 11 AM to minimize the effects of diurnal variability
in salivary composition6. The volunteer was asked
to chew on a piece of paraffin wax for one minute to
stimulate salivary flow7 8.
2. Culture of Saliva: The mouth of the container of the
saliva specimen was passed through a flame. A loopfull of saliva was spread over the surface of
Fastidious Anaerobe Agar plate (Primary Streaking).
Saliva specimen was incubated anaerobically at 37°C
for 48 hours.
3. Identification of Streptococcus viridans: After
incubation, plate interpretation and identification was
performed for isolation of suspected microorganisms
(alpha or gamma streptococci) using Tolerance test
(6.5% NaCl), Bile Esculin test and Optochin test.
Susceptibility testing was performed on the identified
4. Culture of Standard Organism of Streptococcus
mutans (ATCC #35668): using the direct streak
method, the appropriate plate media was warmed to
37°C, loop was laid flat on the warm agar surface
for 10-15 seconds, pressing gently onto the surface
of the media and streaked for isolation. The standard
organism was also incubated at 37°C for 48 hours,
subjected to the same biochemical (6.5% NaCl, Bile
Esculin and Optochin) and Susceptibility tests for reidentification.
Saliva Coating of Brackets: Brackets are of 2 kinds:
Metal and Ceramic Brackets. All brackets will come
from a commercial brand. 21 Metal brackets are
3M® Unitek Standard Edgewise type, stainless steel
upper right canine brackets with hooks. 21 Ceramic
brackets are 3M® Unitek Clarity upper right canine
brackets with hooks. All brackets were sterilized in
an autoclave, placed in a sterile scintillation vial,
immersed in 1 ml saliva for ten minutes.
6. Adherence of S. mutans to Brackets: The second
source of S. mutans is the quality control S. mutans
American Tissue Culture Collection (ATCC) # 35668.
In order to make an infective concentration of S.
mutans, each bracket placed in a sterile scintillation
vial was immersed in 1 ml of S. mutans ATCC#
35668 specimen (0.5 McFarland standard of S.
mutans with an infective concentration of 108 CFU/
ml9) for 10 minutes without agitation at 20°C in
Thioglycollate broth serving as anaerobic condition.
7. Two tubes labeled as "C" (Control Tube) serving as
baseline for metal and ceramic bracket, a loop-full
of the Thioglycollate broth where bracket was
immersed (broth method) was streaked in an
appropriate media; the bracket was seperately
subj ected to a Maki method of culture. Both methods
were incubated anaerobically at 37°C in 48 hours.
Colony count of both methods using Spiral Autoplate
The remaining 20 metal and 20 ceramic brackets
were collected in the tubes and dried inside an
incubator at 37°C for 6 hours.
9. All 20 metal/ceramic brackets were each rinsed
three times in 1 ml of sterile distilled water. Half of
the brackets, the second group of 10 metal/ceramic
brackets were further immersed each in 1 ml 20%
dilution of Astring-O-Sol® Fresh mint mouthwash
for 30 seconds.
10. Each bracket was immersed to Dey-Engley Broth
for 6 hours. A loop-full of the broth was further
cultured in Fastidious Anaerobe agar plate. This
culturing of the broth where the bracket was
immersed is called the Broth Method.
11. The brackets were then streaked to a Maki method.
This involves rolling the individual brackets with slight
pressure across an agar surface. All plates were
incubated anaerobically at 37°C for 48 hours.
12. The numbers of survivors were then determined by
a spread plate method. Precision count of both
methods was done using Spiral Tech Autoplate 4000
Method or Automated Plating Method.
Quality Assurance Procedures for Preparing Culture Media
and Reviving Quality-controlled Strains 10:
This research is classified under Inferential Statistics.
Being an experimental intervention study, it deals with measuring the S. mutans colonies that adhered to orthodontic brackets in CFU/ml unit, which is a quantitative variable. It is thus
appropriate to use t-test as test-statistic since samples are independent and population variance is not known. SPSS Statistical software program was utilized for statistical analysis.
Adhered S. mutans on Brackets Prior to Rinsing
The control / baseline values of the adhered S. mutans
prior to rinsing showed that there are more colonies in Ceramic brackets than in Metal brackets for both methods.
Adhered S. mutans on Metal and Ceramic Brackets
in Sterile Distilled Water
The adherence of S. mutans to ceramic brackets after
rinsing with water was significantly higher than the adherence to metal brackets for both maki and streak methods,
pO.OOl and p = 0.01, respectively.
Adhered S. mutans on Metal and Ceramic Brackets
with further treatment of 20% AOS® Freshmint
There is no sufficient evidence to say that the number
of colonies differ between metal and ceramics in the AOS
solution. The p-value computed is not significant, (p computed is greater than 0.05 - this is using a level of significance = 0.5).
Adhered S. mutans on Metal Brackets after rinsing
with sterile distilled water and further treatment of
AOS® Freshmint mouthwash
T-test showed that there is a statistically significant difference in the mean number of colonies between the two
solutions using metal brackets in the Maki and Streak methods, p=0.001? p<0.01, respectively. There are more colonies
in water solution for both methods.
Table 1. Level of Adherence of S.mutans to Metal
Brackets after Rinsing with Sterile Distilled Water and
20% AOS® Fresh mint mouthwash - in CFU/ml
Adhered S. mutans on Ceramic Brackets after rinsing
with Sterile Distilled Water and further treatment of
AOS® Freshmint Mouthwash
There is a statistically significant difference in the mean
number of colonies between water and AOS solution using Ceramic brackets for Maki method (p<0.001) and Streak method
(p =.005) . There are more colonies in the water solution.
creased adhesion of S. mutans 11 to orthodontic brackets; and
(3) Oral hygiene practices of rinsing with water and
the use of mouthwash practiced by patients and advised by
dental professionals for the management and control of plaque.
The results of the study indicate that there are more
Table 2. Level of Adherence of S.mutans to Ceramic
Brackets after Rinsing with Sterile Distilled Water
and 20% AOS® Fresh mint Mouthwash - in CFU/ml
colonies of S. mutans adherent to the ceramic brackets than
metal brackets after rinsing with sterile distilled water (refer
to Figure 2) on both Maki and Broth Methods.
Figure 1. Comparison of Adhered S. mutans to Metal
& Ceramic Brackets after Rinsing with Sterile
The main objective of the study was to determine if the
type of orthodontic bracket used affects the bacterial affinity
of these appliances in an in vitro simulation of clinical use.
Changes manifested in the oral flora have been documented
to include elevated Streptococcus mutans colonization which
imposes a potential risk for enamel decalcification.
In order to bring the experiment closer to actual in vivo
conditions, the following factors were simulated and standardized across samples:
(1) the use of body temperature (37°C) during incubation, it being the optimum temperature for the growth of S.
(2) the exposure of brackets to saliva, since all teeth
surfaces including fillings and/or appliances bonded on teeth
are always immersed or coated with saliva within the oral cavity. The presence of histatins and lysozymes in saliva, which
possess antibacterial properties, may also contribute to the de-
The resulting colony counts derived from this study
supports the outcome of Graber & Vanarsdall's study in 1994,
and Fournier et aPs in 1998 which showed that the adherence of S. mutans is weaker on metal than ceramic brackets 12. It was concluded by Vanarsdall that ceramic brackets
have a rougher surface and are more porous; thus facilitating
increased plaque and stain deposition^.
Fournier's results indicate that the initial affinity of S.
mutans to metal brackets was significantly lower than the
affinity to plastic brackets and porcelain brackets. They found
no significant difference between porcelain and plastic brackets. They further immersed the brackets in sterile distilled
water for varying amounts of time. At time 24, 48 and 72
hours, there was no significant statistical difference among
the adherence of S. mutans to metal, plastic or porcelain brackets. Their study found no statistical difference in adherence
over time; it stipulated that it is difficult to make a clear as11
sessment that metal brackets have a lower cariogenic effect
Likewise, the same can be observed when ceramic
on the teeth than plastic and ceramic.
brackets were rinsed with either solution (Refer to Fig. 9). A
Clarity™ ceramic orthodontic brackets have metal-rein- greater number of colonies of S. mutans were left on ceforced wire slots made up of Transtar™, a very high purity ramic brackets rinsed with sterile distilled water alone than
translucent grade of aluminum oxide used for orthodontic brack- on those further immersed in the mouthwash. Once again,
ets. The Unitek Division of 3M has exclusively teamed with the broth method yielded statistically similar results as with
Ceradyne since the late 1980's to develop and manufacture the Maki method. Furthermore, these results concur with
ceramic brackets. Ceradyne produces Transtar™ material.
those found in the study of Hernandez who reported that the
Various related literature have shown that S. mutans most number of microorganisms (including S. mutans) were
and plaque accumulates in orthodontic appliances, even in sub- eliminated at the 30 second mark 14.
jects with good oral hygiene. There is a need to implement a
rigorous home care program that is geared towards the educa- Figure 3. Comparison of Adhered S. mutans to Ceramic
tion and motivation of the patient toward correct oral hygiene Brackets After Rinsing with Solutions
practices. The use of mouth rinses with anti-plaque formulations are among the newest applications of technology in the
control of microflora associated with dental diseases. Other
therapies of oral hygiene include tooth-brushing, flossing, and
scaling of the teeth during routine dental appointments.
On the metal brackets, both methods indicated that
there were more colonies present in those that were rinsed
with sterile distilled water alone than those brackets treated
further with 30 seconds immersion of 20% AOS® Fresh mint
(Refer to Fig. 8). As indicated in the results, the use of 20%
AOS® Fresh mint mouthwash appears to be very effective in
reducing the number of colony forming units of S. mutans on
Figure 2. Comparison of Adhered S. mutans to Metal
Brackets After Rinsing with Solutions
In comparing the treatment of rinsing with water vs.
immersion in AOS®, both metal and ceramic brackets had a
significantly lower CFU count after exposure to the mouth
rinse, results which clearly support those of Dr. Hernandez'
study. This obviously indicates the effectivity of AOS® in
reduction of S. mutans.
Substantivity is the ability of an antimicrobial to bind to
anionic groups on the tooth surface, on the oral mucosa and
on the bacterial surfaces thus producing a sustained release
of the active ingredient and extend the antimicrobial effectiveness of the product. 15 Mouth rinses come in two general
types. The first generation mouth rinse is capable of reducing plaque and gingivitis by 20-50% when used 4-6 times daily
and have limited or no substantivityl6. The second genera-
Hernandez' study on effectiveness of Astring-o-sol® used
tion mouth rinses on the other hand, are capable of reducing
sterile distilled water as a control mouth rinse and revealed that
plaque and gingivitis by 70-90% when used 1-2 times daily
all microorganisms exhibited various degrees of re-growth af-
and have an effective substantivity lasting 12-18 hours or
ter initial exposure21. These data clearly supports the finding
of the study that there is decreased adherence of S. mutans to
Astring-o-sol® concentrate is a good example of a second-generation mouthwash. It is composed of several active
both metal and ceramic brackets after rinsing with 20 % AOS®
Fresh mint than sterile distilled water.
ingredients which contribute to its germ-killing power: methyl
This research has a single treatment arm: Astring-o-
salicylate, alcohol, zinc chloride, mint flavor, citric acid and
sol® as mouth rinse. It is significant to mention that other stud-
ies have explored the effect of other brands of antiseptic mouth
Ethyl alcohol is the most widely used material for disin-
rinse on S. mutans levels. A clinical study substantiated that
fection because of its inhibitory effect on bacterial growth
2x-daily rinsing with an essential oil-containing antiseptic
and is most effective in 50 to 70% solution. Alcohol is used in
mouthrinse (Listerine Antiseptic) produced S. mutans reduc-
mouth rinses as a solvent and taste enhancer. Ethyl alcohol
tions of 75.4% in plaque and 39.2% in saliva22. They recom-
acts as a bactericidal agent by denaturizing the soluble pro-
mended the inclusion of the essential-oil mouthrinse as an
teins in bacterial 8.
Zinc on the other hand plays a role in the mouthrinse
as an anti-halitosis agent. Bad breath or halitosis originates
mainly from the oral cavity. The unpleasant smell is due to
the retention of anaerobic, Gram-negative bacteria. These
bacteria use sulphur-containing amino acids as substrates in
their production of volatile sulphur-containing compounds
VSC). VSC have a distinctly unpleasant odour even in low
concentrations. Zinc can be retained in the oral cavity for
approximately 2-3 hours after tooth brushing by binding to
acidic substances on the oral mucosa, in the saliva or on bacterial surfaces 19.
AOS® Fresh mint was selected as the mouth-rinse of
choice in this study primarily because it was cited by the study
of Hernandez. The study compared the effectiveness of different variants of AOS® (Gold, Freshmint and Ice), and showed
that more microorganisms exhibited the lowest kill time in
AOS® Fresh mint20. AOS® is commercially available in the
ocal market, and now comes in four variants: Gold and Fresh
mint concentrates, Ready-to-use Ice and Specialist (0.06%
adjunct to daily oral hygiene procedures.
Figure 4. Comparison of Adhered S. mutans to Metal
& Ceramic Brackets after Rinsing with 20% AOS®
It is observed from the results of this study that the
concentration of the samples exposed to sterile distilled water or to 20% AOS® Fresh mint is actually less than the infective concentration of S. mutans, which is 2 x 105 CFU/ml
saliva23. Since these samples did not attain a high enough
level of concentration to be identified as infective, the S.
mutans count is not sufficient to start carious process or even
enamel decalcification. There are other components of fixed
orthodontic therapy such as wires, cements, adhesives and
modules which also serve as additional areas for S. mutans
and other bacteria to adhere.
The use of two methodologies of measuring bacterial
growth serves to confirm the resulting CFU counts from either test. It is assumed that the S. mutans in the broth will
have an easier time to multiply as compared to those found in
the brackets due to the challenging task of seeping into the
crevices of the bracket.
Based on the results of the study, both methods yielded
significantly (1) higher concentrations of S. mutans on the
ceramic brackets than metal brackets exposed to sterile distilled water;(2) higher CFU counts on both types of brackets
rinsed with sterile distilled water as compared to further treatment with 20% AOS® Fresh mint mouthwash; (3) lower S.
mutans counts on metal and ceramic brackets treated with
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Presurgical Nasoalveolar Molding
Janet M. Pandan, DMD
Dr. Janet Mapa-Pandan graduated from Centro Escolar University in 1991, finished her Orthodontic Preceptorship under Dr.
Ranilo Tuazon in 1997 and is an Associate member of the Association of Philippine Orthodontists. She became a member of
the ME AW Study Club of the Philippines in 2004. Presently she holds Orthodontic practice at Asian Hospital and Medical
Center; Alabang and is a member of the Craniofacial Team at Our Lady of Peace Hospital, Paranaque
G l e n d a H . d e Villa, DMD
Dr. Glenda de Villa graduated from the University of the Philippines in 1992, finished her Oral and Maxillo-Facial Residency at
St. Martin de Porres Charity Hospital in 2000, and her Fellowship in Craniofacial Surgery at the Chang Gung Memorial Hospital
in Taipei, Taiwan in 2002. She is on staff at the Asian Hospital and Medical Center, Alabang and is the Chairman of the
Craniofacial Center at Our Lady of Peace Hospital, Paranaque.
Our Lady of Peace Craniofacial Center, Our Lady of Peace Hospital, Paranaque City
Email: [email protected]
The role of the orthodontist in the care of the cleft lip
at 3-5 months. This results in improved symmetry of the na-
and palate patient starts as early as infancy because of the
and palate. Tissue repair then can be done under minimal
use of presurgical orthopedics. This involves the early cor-
tension - which results in less scar formation, so future scar
rection of the osseous and soft tissue deformities in the oro-
revision procedures are either eliminated or minimized.
sal cartilage and narrowing or closing of the clefts of the lip
nasal area while taking advantage of the increased plasticity
of the nasal cartilage in newborn infants. This temporary plasticity is believed to be caused by high levels of hyaluronic
acid found circulating in the infant's blood brought about by
increased level of maternal estrogen during the first three
months of life.1
Infants with complete unilateral cleft lip and palate
(UCLP) usually present with asymmetry of the alar base and
columella, abnormal nasal cartilage morphology - the lower
lateral alar cartilage is often depressed and concave, and cleft
of the lip, alveolus and palate (Case Example 1-A). Infants
with complete bilateral cleft lip and palate (BCLP) usually
present with protrusive and/or deviated pre-maxilla, short or
absent columella - nasal cartilages slant obliquely downward
and inserts straight into the upper lip, separated floor of the
nostril, and cleft of the lip, alveolus and palate (Case Example
2-A). These oro-nasal deformities present a challenge to surgeons to achieve a satisfactory surgical outcome.
Presurgical nasoalveolar molding is an orthopedic technique used in infants 0-3 months of age to restore the form of
the nose, non-surgically increase the height of the columella
and approximate the cleft lip and lateral segments of the cleft
palate as close together as possible prior to primary lip repair
Technique of Nasoalveolar Molding
The design of the nasoalveolar molding (NAM) plate
has evolved from those used by the early proponents of
presurgical infant orthopedics - McNeil, 19502; Hotz and
Gnoinski, 19763; Latham, 19804. The NAM appliance used at
our center is a modification of an earlier design by Dr. Barry
Grayson of the Institute of Reconstructive Plastic Surgery at
New York University Medical Center (Fig. 1). The
nasoalveolar molding plate used for UCLP (Fig. 2) and BCLP
(Fig. 3) is simple in design, easy to fabricate and very well
tolerated by patients.
An impression of the upper arch of the infant is taken
(Fig. 4) with the patient fully awake and in supine position
with the head slightly elevated. This is done preferably in a
hospital setting in case of any emergency situations. Using a
custom-made acrylic impression tray, the material used to
make the impression is a silicone rubber impression material
due to its low viscosity.
The NAM appliance consists of an acrylic plate which
is inserted into the patient's mouth with one (for UCLP) or
two (for BCLP) nasal wire prongs (gauge .028-.032 SS) attached to it. One end of the nasal prong, is imbedded in the
acrylic plate, and the other end terminates with a nasal bulb
also made of acrylic. The wire is bent to fit and go underneath the cleft side nostril. The appliance is held in place on
the palate and alveolar ridge by using a denture adhesive paste.
Petroleum jelly is applied on the acrylic nasal bulb to insert
smoothly into the nose.
Lip taping (Fig. 5) is always used in conjunction with
NAM. A narrow width micropore tape is placed across the
upper lip pulling the cleft lateral lip segments together to simulate action of the surgically closed cleft.
Correction is maintained every week until the columella
is at least 3-4 mm in length, the weight of the patient has
reached five kilos or more, the patient has reached three
months, and the lateral segments of the palate and cleft lip
are approximating each other. When this has been achieved,
primary lip/nose surgery is done under general anesthesia
using a modification of the rotation advancement technique.
Care is taken to obtain symmetrical lateral lip lengths, a balanced wet and dry vermilion and adequate nasal symmetry.
In a three-year follow up study after nasoalveolar molding and primary cheiloplasty at the Chang Gung Memorial
Hospital, Taiwan, the progressive changes of nasal symmetry, growth and relapse were assessed5. The authors found
that nasal asymmetry was significantly improved after NAM
and was further corrected to symmetry after surgery. There
was a significant relapse of the cleft side nasal height and
Once the NAM has been fabricated the patient is re-
width after one year due to a difference in growth between
called weekly for adjustments. Alveolar molding is achieved
the cleft and non-cleft nostrils. The results remained stable
by selective grinding and relining of the palatal surface of the
afterward to the third year. To compensate for this relapse,
molding plate. It gradually molds and aligns the lateral seg-
the authors recommend narrowing down of the alveolar cleft
ments of the cleft palate, approximating them as close to-
as much as possible by NAM, overcorrection of the cleft
gether as possible (Case Example l-E,F and 2-E,F). The na-
nasal dimensions by surgery and maintenance of the surgical
sal cartilage on the cleft side rests and is supported by the
results using a nasal conformer.
acrylic nasal bulb. Acrylic is added on the bulb to gradually
improve the shape of the nasal cartilage, and make it sym-
metrical to the other nasal cartilage. When the nasal bulb is
The design and techniques used in pre-surgical infant
big enough, further adjustments are made by bending the wire
orthopedics has evolved, and so has the proposed benefits
upwards and outwards to further mold the cleft side nostril.
from use of this appliance. Previously proposed benefits were
Care should be taken not to overstretch the nasal cartilage
improved feeding, growth guidance, development of palatal
when adjusting the acrylic bulb. For bilateral cleft lips, the
segments, minimization of treatment at a later age, and nor-
columella is non-surgically lengthened by retracting the pre-
malization of tongue position and positive psychological ef-
maxilla, rather than by pushing the nasal tip forward. The
fect on the parents were found not to be achieved, according
retraction of the pre-maxilla is achieved by the combined ac-
to a study by Kuijpers-Jagtman and Prahl6. The current ben-
tion of the lip tape, molding plate and nasal projections.
efits of the use of the NAM appliance are improved longterm nasal esthetics, reduced number of nasal surgical pro-
cedures, and reduced need for secondary alveolar bone grafts
if gingivoperiosteoplasty is done. Less number of future revisions means savings in cost to the patient.
Grayson BH, Cutting CB. Presurgical nasoalveolar
orthopedic molding in primary correction of the nose,
lip, and alveolus of infants born with unilateral and bilateral
clefts. Cleft Palate Craniofac J. 38:193-198, 2001.
McNeil CK. Orthodontic procedures in the treatment
of congenital cleft palate. Dent Rec. 70:126-132,1950.
Hotz M, Gnoinski W. Comprehensive care of the cleft
lip and palate children at Zurich University: a preliminary
report. Am JOrthod. 70:481-504, 1976.
Latham RA. Orthodontic advancement of the cleft
maxillary segment: a preliminary report. Cleft Palate J.
Liou EJ, Subramanian M, Chen PK, Huang CS. The
progressive changes of nasal symmetry and growth after
nasoalveolar molding: a three-year follow-up study.
Plast Reconstr Surg. 114:858-64,2004.
Figure 5 Infant with nasoalveolar molding plate and lip tape
1st Case - Complete unilateral cleft lip and palate
1 - A Seventeen day old infant with left complete cleft
lip and palate
1 -B Nasolalveolar molding plate installed
1-C The same infant after ten weeks of NAM
1-D Two weeks post-surgery
1 -E Maxillary arch of the same infant before NAM
1-F Maxillary arch of the same infant after NAM
Kuijpers-Jagtman AM, Prahl C. A study onto the effects
of presurgical orthopaedic treatment in complete
unilateral cleft lip and palate patients. Interim analysis.
Nijmegen, The Netherlands: Nijmegen University Press
Legend to Figures
Figure 1 New York University design of the nasoalveolar
Figure 2 Nasoalveolar molding plate for unilateral cleft
Figure 3 Nasoalveolar molding plate for bilateral cleft
Figure 4 Maxillary impression of a cleft palate with silicone
2nd Case - Complete bilateral cleft lip and palate
2-A Twelve day old infant with bilateral complete cleft
lip and palate
2-B The same infant after fifteen weeks of NAM
2-C Two weeks post surgery, frontal view
2-D Two weeks post-surgery, worm's eye view
2-E Maxillary arch of the same infant before NAM
2-F Maxillary arch of the same infant after NAM
THE MOTHER OF SMILES
By Monica Luz M. Sison - Quiambao
I grew up knowing her simply as Lola Luz, my
services will also be available in the provinces instead of the
grandfather's sister. She was a jolly rotund person with the
patients from all over the country coming all the way to Ma-
typical Macapanpan hair - thin and graying. We were all
nila just for treatment. She did everything she could to uplift
very luck to have her in the family. We all loved to hang out
the dental profession.
in her room when she hosted family Sunday lunches at
To list down all her accomplishments and firsts would
Kamias. We all got braces for free because of her and we
take up a lot space. To name all the famous people she
didn't wait for months to get an appointment. She was even
knew would include legendary local and international names
more loved during Christmas when she made everyone line
in orthodontics and dentistry. To describe her as a teacher
up to give away tons of gifts and money. She was feared
or mentor is something all the hundreds of her former stu-
though once we entered her clinic - late^ Her strictness with
dents could do. And the same would go when described as
time taught all her patients and their parents the value of time
an orthodontist. To say that s r e was generous or talented is
- specially HER time. Later, I found out how valuable her
nothing new. To say that she was a practical joker with a
time really was.
great sense of humor is no longer surprising specially to the
"Mother of Philippine Orthodontics" is the title given
people who knew her.
to her. She did extensive research on the history of orthodon-
She was everyone's "Ma*am~. She didn't hold back
tics in the Philippines tracing it way back to the first Filipino
anything when she mentored all of us. She motivated and
dentist, Kapitan Chencheng. But if history were to be writ-
inspired us. She w ould force us to think and dared us to
ten now, she would be written as the first Filipino to have
excel. She nourished our minds and also our souls. It made
gotten an education abroad and returned home to propagate
us all love her and remember her dearly-
orthodontics and dentistry in the country. Not only did she
set-up her own clinic at Carriedo upon her return, she also
went to Clark or Guam or some other place just to be able to
provide the service to a larger population. Most notably, she
made it her mission to teach others so that quality orthodontic
Thinking of her w ould make us all smile — which is
exactly what she had always intended everyone to do.
"Farewell. Shed no tears for me but rejoice for I am
past all suffering and torment."
- from the last will and testament of LCM
The Philippine Journal of Orthodontics
Vol 4 No. 1