NEWS & TRENDS IN ORTHODONTICS

A JOURNAL O F I N T E R D I S C I P L I N A RY T R E AT M E N T FOR ORTHODONTISTS

Vol. 18 Apr. 1, 2010

Treatment of Severe Class III with Buccal Shelf Miniscrews

Dr. John Lin

ABO Case Report : Correction of Bimaxillary Protrusion

with Closing of Premolar & Molar Extraction Spaces
Dr. W. Eugene Roberts

ABO Case Report : High Maxillary Canine Impaction

with Mesial and Labial Displacement
Dr. W. Eugene Roberts

Dr. Andrew Haas was reading the NTO 17 in the 2010 Angle Midwest Annual Meeting in Chicago

News & Trends in Orthodontics is an experience sharing magazine for worldwide orthodontists.
Download it at [Link]
 EDITORIAL NTO 18
Trends in Orthodontics

What are the latest trends in Orthodontics? As the publisher of 03 Editorial
News & Trends in Orthodontics, I always try my best to answer this
LIVE FROM THE MASTER
frequently asked questions. However, by definition that answer has
always been changing with time. 04 Treatment of Severe Class III with Buccal Shelf Mini-
Screws
Ever since I started learning orthodontics 25 years ago, orthodontic
history has been one of my major interests. The reason why I love NEWLY RELEASED
studying history is because I hope and believe with a better 16 Creative Orthodontics Blending the Damon System &
understanding of the past, I’ll be able to predict the future. Based on this
TADs to Manage Difficult Malocclusions
simple thought, I have devoted most of my time to study self-ligation and
20 OrthoBoneScrew
mini-screws anchorage for the past six years. I found the time was well
spent for the differences we have been seeing in patient care in terms of ABO CASE REPORT
efficiency and quality control. This fact has been proven true in my own
26 Correction of Bimaxillary Protrusion with Closing of
practice and in the 2nd edition of Dr. John Lin’s new book, Creative
Premolar & Molar Extraction Spaces
Orthodontics: Blending the Damon System & TADs to manage
difficult malocclusions. This is a book that you definitely don’t want to 36 High Maxillary Canine Impaction with Mesial and Labial
miss if you wish to enhance efficiency and quality control in your own Displacement
practice.
FEATURE
So the answers seem to be self-ligation and mini-screws. Not until I 46 Office Design 3
met with three implant giants, Dr. Homa Zadeh, director of USC Implant 48 Beethoven - A Learning Organization
Symposium, Dr. Kwang Bum Park, president of Korea MIR Dental
Hospital, and Dr. Micheal Cohen, founder of the Seattle Study Club, did I INTERDISCIPLINARY TREATMENT
truly observe the significant benefits of using orthodontic treatment to 57 Crestal Sinus Lift : A Minimally Invasive and Systematic
set up a solid foundation for implant and restoration construction in
Approach to Sinus Grafting
those complicated cases requiring interdisciplinary treatment (IDT).
70 Let’s Talk About ‘’ Biologic Width ’’
These benefits of adjunt orthodontic treatment are particularly
pronounced for elder patients who are in the process of transitioning FEEDBACK FROM THE ORTHODONTIC WORLD
the 2nd mixed dentition from natural teeth to full mouth implants. Today,
my answers to the question of trends in orthodontics are self-ligation, 76 Feedback from Beethoven’s Events
mini-screws and IDT. The era of IDT has arrived and I hope our readers
can all be a part of it.

To better prepare ourselves to meet the challenges in this new era
of IDT, since this year NTO has begun to report trends in other dental
specialties, namely, implantology, periodontology, prosthodontics and so
on, from an orthodontic perspective. Our goal for this year is to
transform into a journal of interdisciplinary treatment for orthodontists. I
hope you will find this new issue useful and informative.

Consultant Consultant
Chris HN Chang, DDS, PhD, Publisher Dr. Homa Zadeh Dr. Kwang Bum Park

Contributors ( from left to right ) :

Dr. Hong Po Chang, Consultant
Dr. Ming Guey Tseng, Consultant
Dr. John Lin, Consultant
Dr. Frank Chang, Consultant
Dr. Johnny Liao, Consultant Consultant Consultant
Dr. Chris Chang, Publisher Dr. W. Eugene Roberts Dr. Larry White

Editors ( from left to right ) :

Yu Lin Hsu, Associate Editor
Billy Su, Chief Editor
Sabrina Huang, Associate Editor
Chester Yu, Associate Editor
Dennis Hsiao, Associate Editor
Grace Chiu, Associate Editor
Consultant Guest Editor
Tzu Han Huang, Associate Editor Dr. Frederick J. Regennitter Dr. Rungsi Thavarungkul

Please send your articles to [Link]@[Link]

NTO 18 LIVE FROM THE MASTER

Treatment of Severe Class III 
with Buccal Shelf Mini‐Screws

(1) Anatomy
The buccal shelf is the buccal bone area over the mandibular molars.
It is very dense cortical bone, which makes it ideal for mini-screw
placement.

The slope of the buccal shelf around the mandibular 1st molar is
quite steep while the one around the mandibular 2nd molar is flatter,
which makes it easier for direct mini-screw placement. The slope around
the 3rd molar has the flattest buccal shelf, but usually very limited zone of
attached gingiva (Fig 1, 2). Chen’s study1, confirms the above anatomy.
The attached gingiva region is wider around the mandibular 1st molar. For
flatter surface to place mini-screws one should get close to the
mandibular 2nd molar.

Even in the same buccal shelf of mandibular 2nd molar area, the
slope of the buccal shelf varies with individuals (Fig 3). Of course the
flatter the slope is, the easier it is for direct self-drilling of mini-screws.
Clinically the slope of the buccal shelf can be diagnosed by pulpation.
Cone Beam Computerized Tomography (CBCT) can also be used for
confirmation (Fig 4). In most cases the mandibular canal is located in the
lingual side of mandibular molars. It means the chance of hitting the
Fig 1. From 1st molar toward3rd molar, the buccal mandibular canal, when placing the buccal shelf mini-screw, is close to
shelf gets flatter and the zone of attached gingiva
zero (Fig 5, 6). Anatomically buccal shelf is a very safe place for mini-
becomes more narrow.
screw placement. Also due to dense cortical bone structure, it’s an
excellent area for skeletal anchorage.

(2) Placement of mini‐screws
In cases of flatter buccal shelf, with enough attached gingiva, direct
self-drilling is possible. The author’s clinical experience and Chen’s study
confirmed that steeper shelf is more common than flatter buccal shelf
(Fig 7). For cases of steeper buccal shelf, due to a narrow zone of
attached gingiva and steeper cortical bone surface, flap surgery is often
needed. There are two types of flap surgeries for placing buccal shelf
mini-screws.
 NTO 18 LIVE FROM THE MASTER

Dr. John Jin-Jong Lin

MS, Marquette University
Consultant of NTO
President of TAO ( 2000~2002 )
Author of Creative Orthodontics

One is full thickness flap. After incision through the

attached gingiva, the full thickness flap is elevated. Use the
pilot drill to make a hole below mucosa followed by mini-
screw placement. After the placement, leave the denuded bone
area exposed2. The denuded bone area will be healed with
attached gingiva (Fig 8, 9). The advantage of full thickness flap
is that it is an easy and simple procedure without suture. The
disadvantage is the denuded bone area is usually in a lot of
pain.
The other type of surgery is partial thickness flap. It starts
with incision from mucosa and vertically up to the attached
gingiva to make partial thickness flap (Fig 10). Then use pilot
drill to make a pilot hole through the exposed periosteum. After
placing the screw, suture the partial thickness flap to wrap
mini-screws with Coe-pack covering. The advantage of partial
Fig 2. From 2nd molar toward 1st molar, the buccal shelf gets
thickness flap is that there’s less pain over the periosteum. The
steeper and the zone of attached gingiva become wider.
disadvantage is that it takes more skills to perform the
procedure (Fig 10, 11).

(3) Materials and sIze of mini‐screws
Osseointegration is not required when applying TADs
(Temporary Anchorage Devices).If major osseointegration
does happen with TADs, it, in fact, will create problems when
removing the screw at the end of the treatment. Fortunately it
seldomly occurs with TADs system. Hence, the author prefers
stainless steel mini-screws. Stainless steel is a much stronger,
more ductile type of material which can be made sharper and
of less chance of fracture when compared with titanium alloy
screws.
Generally 2 mm x 12 mm stainless steel screws are good
for buccal shelf placement. Sometimes when the site of Fig 3. Even in the buccal shelf of mesiobuccal region of
mandibular 2nd molar, different patients have different slopes; some
insertion is too low due to steep slope, one can try 2 mm x 14 are flatter and some are steeper.
mm mini-screws.
NTO 18 LIVE FROM THE MASTER

(4) Failure rate
Park et al’s study3 contribute a high failure rate of
mandibular screw placement to overheating of the bone during
drilling and irritation during chewing. The author suspected 1.2
mm titanium alloy mini-screws were used in this study. A small
diameter makes mini-screws very fragile during insertion in the
dense cortical bone of buccal shelf area. Instead, the author
used stainless steel mini-screws of 2 mm in diameter in the
buccal shelf area. There was no failure except one screw due to
placement over mucosa which induced severe peri-implantitis
and was later removed (Fig 12).
Therefore, it’s not appropriate to contribute overheating
and irritation during chewing to buccal shelf screw failures. The
main cause is screws of smaller diameter sizes and made by Fig 4. The CBCT revealed the flatter buccal shelves are located
over the distobuccal site of the lower right 2nd molar, and the buccal
titanium alloy.
site of the lower left 2nd molar.

(5) ApplicaAon force
When first switching to 2 mm diameter stainless steel
screws, compared to much smaller 1.2 mm diameter titanium
alloy screws, the author felt the stainless steel mini-screws can
tolerate heavy force. After using heavy force a while, the author
felt the failure rate seemed to have increased.
Hsieh et al4 applied force to move two osseointegrated
dental implants, using 100 gm and 200 gm for up to 6 months.
The dental implants did not move at all as expected. When
using 500 gm of force for 3 months, the dental implants started
to move. The movement was more significant after 6 months.
This study surprised the author because even osseointegrated
dental implants tend to move when applying force over 500 gm.
Now the author never uses force more than 1 pound (454 gm)
Fig 5. The most common buccal shelf area is around the mesiobuccal
to avoid undesired movement. The author uses about 12 - 16 oz region of the mandibular 2nd molar. Most of the time, the
(340 - 454 gm) of foce when placing buccal shelf mini-screws. distribution of mandibular canal is on the lingual of mandibular
molars.
Mostly the author uses crimpable hook on the main archwire,
 NTO 18 LIVE FROM THE MASTER

between mandibular lateral incisor and canine. For better force

control, always use a tension gauge to measure the amount of
force application.

(6) Main archwire size
It’s possible to retract the entire lower arch through the
use of light rectangular wire like .016 x .025 CuNiTi. The main
advantage of this method is retraction can be achieved very
easily by mostly tipping back of the lower molars but relapse
tends to occur soon. Nowadays, the author always uses .019 x
.025 stainless steel wires because they create less tipping of the
molars and more bodily movement instead. Post treatment
occlusion will be more stable.
Fig 6. From the CBCT, clearly showed the position of the buccal
shelf mini-screw is outside the molar root region, it makes the
distalization of the whole mandibular dentition possible. The (7) Bracket selecAon
screw is far away from the lingually positioned mandibular
canal. Most Class III patients have dental compensation. This is
when the upper incisor labially proclined and the lower incisor
lingually retroclined, which makes the reverse overjet smaller.
In Damon 3MX series, the author adopts Pitts’ method5 by
turning the standard four upper incisor brackets upside down to
get super low torque. On the lower arch the author places low
torque brackets upside down to get a high torque effect which
prevents dumping lower incisors while retracting the whole
lower dentition. Except extraction of the 3rd molar, it’s a
nonextraction treatment. Even in severe Class III cases we can
distalize the whole lower dentition. The post treatment
periodontal health and axial inclination of lower incisors are in
good conditions.
This wonderful treatment option provides the author a new
Fig 7. If the buccal shelf area is flat and has enough zone of thinking on young Class III patients. It is not advised to begin
attached gingiva, the 2 mm x 12 mm stainless steel mini-screw can early extraction treatment on young Class III patients unless in
be placed with self-drilling.
NTO 18 LIVE FROM THE MASTER

cases of extremely severe crowding. It is more desirable to wait

and re-evaluate the patient after the growth period is completed.

(8) Axis of the mini‐screws
Mini-screws should be placed away from the molar roots.
Sometimes due to narrow zone of attached gingiva and steep
buccal shelf, clinicians will try to place buccal shelf mini-
screws without flap surgery. Therefore, they have to angulate
the placement axis. Otherwise, mini-screws will slide through
the steep bone surface. This will cause the screw fall between
mandibular molar roots. It’s acceptable for maximal anchorage
application, but not ideal for whole arch distalization. The
effect of distalization is quite limited as a result (Fig 13).
Fig 8. If the buccal shelf area is steep and has not enough zone of
attached gingiva, the mini-screw can be placed with flap surgery
(9) Mechanics of buccal shelf mini‐screws and pilot drilling.

The center of rotation of the whole mandibular arch is

located approximately between the mandibular 1st premolar and
the 2nd premolar root region, which is far below the force
direction from the screw head to the main archwire hook.
Eventually it’ll create extrusion and lingual movement of lower
incisors and distal tipping of mandibular 2nd molars6,7. The
overall result is the whole mandibular dentition will distalize
with counterclockwise and rotate the mandibular occlusal plane
(Fig 14).
This mechanics is very useful for correcting severe Class
III patients with shallow overbite or open bite. Traditionally
treating Class III open bite cases is a nightmare for
orthodontist. Nowadays using buccal shelf mini-screws can
solve this problem easily.
Fig 9. Full thickness flap, let the denuded bone area exposed, it
healed with attached gingiva surrounding the mini-screw. The PA
(10) RetracAon device cephalogram, shows the buccal shelf mini-screw is outside the
mandibular molar roots, it makes the distalization of the whole
The retraction of the whole mandibular dentition can be mandibular dentition possible.
achieved by using either closed coil spring or power chains.
 NTO 18 LIVE FROM THE MASTER

Power chain is easy to attach, but one should choose the

miniscrews whose head design can easily fit power chain (Fig
15). The main advantage of using power chain is its ease of use;
the disadvantages are that the force decreases over time, and
powr chain tends to catch food easily. Overall it provides very
good retraction force.
The author prefers to use NiTi closed coil spring. There
are six varying combinations of length and force levels, that are
8 mm, 13 mm and light, medium, heavy, can be selected. It’s
more time consuming to push the eyelet of closed coil spring
into the mushroom head of the miniscrews. Whenever it’s
hooked on, it’s difficult and time-consuming to remove.
However, it provides a more consistent force level and more
Fig 10. Partial thickness flap. hygienic. When removing the closed coil spring, it is suggested
to use the Weingart to hold the margin of the eyelet of the
spring and use heavy duty cutter to cut off the eyelet.
The whole mandibular arch distalization takes about 6-9
months to achieve the treatment goal. We can see the patient in
every 2-3 months. For such a long visiting interval the author
thinks that closed coil spring is a more hygienic option that
provides a consistent force. When the span of coil spring gets
too long, the author routinely uses ligature wire to tie the
middle of the spring on the bicuspid bracket to prevent
dislodging and soft tissue impingemant (Fig 11, 16B).

(11)   Lingual holding arch 
  vs. Molar intrusion
Crossbite cases usually can be corrected during early
alignment stage by cross elastics (Fig 20A). If the patient has a
Fig 11. Partial thickness flap healed with attached gingiva recessive chin and open bite, then clinicians should avoid
surrounding the mini-screw. creating clockwise rotation of the mandible. A
counterclockwise rotation of the mandible will not only
NTO 18 LIVE FROM THE MASTER

improve the facial profile but also help correct the open bite
(Fig 16B).
Pure buccal shelf mini-screw retraction of the whole
mandibular arch only creates distal tipping of mandibular
molars, instead of true intrusion (Fig 19C, 20C).026 x .026
Rocky Mountain rectangular elastics thread can be used to
intrude the mandibular molar region by tying it to the .019 x .
025 stainless steel main archwire. As such, the mandibular
molars can be intruded (Fig 16 A,B,C). Mandibular molars
intrusion can not only solve open bite quickly but also help
improve a retrognathic profile (Fig 16).

(12)   NoAce the molar tube hook 
Fig 12. Peri-implantitis happend 3 months after placing the mini-
  and screw‐head relaAon screw directly on movable mucosa.
After the whole arch distalization, not only will the
dentition be distalized, so will the mini-screw be moved
forward and occlusally 8. When the distance of distalization is
significantly increased, the hook of the molar tube may be in
close contact with the head of the mini-screw. This makes
further distalization of the whole lower arch impossible. The
solution is grind off the hook of the molar tube so the
distalization can continue (Fig 17).

(13) Mini‐screw vs. Mini‐plate
Sugawara et al9 found out by using mini-plates lower 1st
molars can be distalized 3.5 mm over crown, and 1.8 mm over
the root region. Liaw10 and author found out the lower 1st
molars can be distalized 4.3 mm over crown, and 1.0 mm over
root region by applying mini-screws. Though the amount of
crown tipping is more significant when creating en-masse
Fig 13. On the upper figure, the buccal shelf mini-screw was placed
distalization with mini-screw anchorage while there is more between the roots of 1st and 2nd molars. It will be difficult to retract
root movement with mini-plate anchorage, clinically mini- the lower dentition with this screw. On the lower figure, the buccal
shelf mini-screw was placed outside the roots of mandibular molars.
It makes distalization of the whole lower dentition possible
 NTO 18 LIVE FROM THE MASTER

Fig 14. The mechanism of buccal shelf mini-screw distalization of Fig 16A. .026 x .026 square elastic thread was used to intrude
the whole lower dentition. the lower molars. Watch power chain was used to prevent space
opening before 2nd molars, put elastic thread through the hole of
the mini-screw and tie directly to the 2nd molar tube. After 2
months, the molars were intruded, notice the distance between
screw head and tube hook get much closer.

Fig 15A. The author prefer using simple coil spring head mini- Fig 16B. After just 2 months intrusion and retraction of the whole
screw and NiTi closed coil spring to distalize the whole lower lower dentition, the open bite almost closed, and mandibular
dentition. rotated counterclockwise. The lower facial height shorter and chin
Fig 15B. Power chain can be used to do the distalization either, more forward after 2 months buccal shelf mini-screw intrusion of
but special head design is needed. mandibular molars and retraction of the whole mandibular
dentition.
NTO 18 LIVE FROM THE MASTER

Fig 16C. After 2 months treatment, the cephalometric

superimposition showed intrusion of lower molars and
counterclockwise rotation of the occlusal plane and autorotation of
the mandible.

screws can distalize the whole lower dentition as efficiently as between the mesial site of the upper 1st molar to the one of the
mini-plates. lower 1st molar is greater than the width of the lower 1st molar
On one hand, placing mini-plates is an expensive and (Fig 18). During treatment peri-coronitis was found on distal of
comprehensive surgical procedure and patients suffer pain and 2nd molar. The patient was refered for periodontal treatment.
swelling at the placement and removal. On the other hand, Now the author‘s criteria for buccal shelf mini-screw are as
placing buccal shelf mini-screws, if the area is flat enough, can follows:
be a self-drilling procedure performed by orthodontists. If the 1) The distance between the mesial site of the upper 1st molar
area is steep and the case has to be refered to periodontists or to the one of the lower 1st molar should be within one lower
molar width.
oral surgeons. It’s a much simpler surgery, compared to mini-
2) An orthognathic or retrognathic CR (Centric Relation)
plate surgery. Also, removal is an easier procedure and can be profile at the beginning of treatment.
perfomed by orthodontists.
3) The patient has a little prognathic profile and prefers
nonsurgical treatment.
(14) What is the limitaAon?
The author has treated many difficult severe Class III cases
with buccal shelf mini-screws combined with the Damon
system. However, there are also several limitations for this
treatment method. One severe asymmetric Class III case can
clearly illutrated such limitations. On the left side the distance
 NTO 18 LIVE FROM THE MASTER

Fig 17. During distalization, sometimes the hook of molar tubes Fig 18. A severe Class III molar relationship, the distance between
will be right in front of the mini-screw, for continuing distalization, mesial of upper and lower 1st molar larger than the width of the
the hook should be ground off. lower 1st molar. Too much distalization caused peri-coronitis on
distal of lower 2nd molar.

Thanks to:
1. Dr. Nancy Nie-Shiuh Chang for performing partial thickness flap surgery for the cases of buccal shelf mini-screw placement
described in this article.
2. Dr. Yi-Hao Huang for performing full thickness flap surgery for the cases of buccal shelf mini-screw placement described in
this article.
3. Miss Tzu-Han Huang for English editing of this article.
4. Dr. Yu-Cheng Liaw for the cephalometric study of distalization by buccal shelf miniscrew placement.
5. Dr. Po-Jung Chen for the cone beam CT study of distalization by buccal shelf miniscrew placement.
References
1. Chen PJ, Kuang SH, Lin JJ, Wong YK. Bone thickness of the buccal shelf for orthodontic implant placement. Poster, Annual Meeting of
Taiwan Association of Orthodontists, 2009.
2. Lin JJ. Creative Orthodontics Blending the Damon System & TADS to Manage Difficult Malocclusions. Yong-Chieh Ltd, 2007:258-60.
3. Park HS, Jeong SH, Kwon OW. Factors affecting the clinical success of screw implants used as orthodontic anchorage. Am J Orthod
Dentofacial Orthop 2006;130:18-25.
4. Hsieh et al. Evaluation on the movement of endosseous titanium implants under continuous orthodontic forces: an experimental study in
the dog. Clin Oral Impl Res. 2008;19:618-23.
5. Pitts T. Begin the end in mind: Bracket Placement and Early Elastics Protocols for Smile Arc Protection. Clinical Impression 2009;17(1):
4-13.
6. Jung MH, Kim TW. Biomechanical Considerations in Treatment with Miniscrew Anchorage. Part 1 The Sagittal Plane. J Clin Orthod.
2008 Feb;42(2):79-83.
7. Nakamura A, Teratani T, Itoh H, Sugawara J, Ishikawa H. Photoelastic Stress Analysis of Mandibular Molars Moved Distally with the
Skeletal Anchorage System. Am J Orthod Dentofacial Orthop. 2007;132:624-9.
8. Liu EJ, Pai BC, Lin JC. Do miniscrews remains stationary under orthodontic forces? Am J Orthod Dentofacial Orthop 2004;126-42-7.
9. Sugawara J et al. Distal movement of mandibular molars in adult patient with the skeletal anchorage system. Am J Orthod
Dentofacial Orthop 2004;125:130-8.
10. Liaw YC, Lin JJ and Kuang SH. Whole arch distalization with TADs system. Poster, Annual Meeting of Taiwan Association of
Orthodontists, 2008.
NTO 18 LIVE FROM THE MASTER

Case 1 (Fig 19 A,B,C,D)

A female severe Class III malocclusion with prognathic profile. Her main concern was ugly looking dentition, she didn’t
care about the prognathic profile. So compromised treatment without orthognathic surgery was planned. Notice the original
edge to edge bite, after alignment and relief of lower crowding, it became big Class III open bite case. Due to deeper
vestibular depth, two 2 mm x 14 mm stainless steel mini-screws were placed over buccal shelf after alignment of the
dentitions. At 23 years old, the closed coil spring were used to distalize the whole lower dentition, by using 13 oz force on
both sides, on the .016 x .025 CuNiTi wire.
It took only 3 months to distalized the lower dentition on the soft rectangular .016 x .025 CuNiTi wire. For more stable
result, the .019 x .025 stainless steel main archwire was used to maintain the treatment result. Even with 13 oz heavy
distalization force for whole lower arch distalization, the post treatment panorex showed healthy dentition. After 1 year and 5
months follow up, though the occlusion change to shallower overbite but still stable.

Fig 19A. Fig 19B.

Fig 19C. Fig 19D.

 NTO 18 LIVE FROM THE MASTER

Case 2 (Fig 20 A,B,C,D)
A female Class III sub asymmetry patient with chin point deviate to the left and anterior open bite. Her main concern
was she couldn’t chew with her anterior teeth. She was not concerned with facial asymmetry and protruded dentition.
Orthognathic surgery was proposed and rejected. The patient requested a compromised orthodontic treatment only. After both
upper and lower dentitions were well aligned with .019 x .025 stainless steel main archwire, two 2 mm x 12 mm stainless
steel mini-screws were placed on both sides.
The author applied about 12 oz of force of coil spring on the right side and 10 oz force on the left size for not only
retracting the whole lower dentition but also correcting the lower dental midline. After 6 months of retraction, the open bite
almost closed, and the right side of buccal occlusion was close to Class I. After 2 years and 4 months of treatment the patient
reached Class I occlusion with lower dental midline overcorrected to the right side to prevent relapse. After 5 months in
retention, the lower midline deviated to the left side again. Besides this small relapse of dental midline, the occlusion and
profile are quite acceptable.
Even though heavy force was used for the whole lower arch distalization, the post treatment dentition showed healthy
roots and periodontal tissues. No lingual dumping or gingival recession of lower incisors was found. From the cephalometric
tracing, the lower molars were tipped back distally, and the lower incisors moved lingually and incisally which creates a
counterclockwise rotation of the whole occlusal plane, and the open bite was closed.

Fig 20A. Fig 20B.

Fig 20C. Fig 20D.

Upcoming New Book !

The highly anticipated new edition of Dr. John Lin's book, Creative Orthodontics will be available in May, 2010. This new
edition includes many more incredibly complex cases of renowned orthodontists worldwide and particularly, a complete
reference table of Damon's Early Light Short Elastics, created by Dr. Tom Pitts. It contains clear and detailed anatomy graphics of
minicrew placement sites, including IZC and buccal shelf created by Dr. Rungsi. In addition, Dr. Lin proposes a revolutionary non-
extraction method for CIII diagnosis and treatment by using miniscrews. This edition also contains  the most up-to-date
information on the Damon Q. system. It's a must read for all the old and new Damon users.
 !"#$%&'()*(((+,-&'(!./$"-

!"#$%&'$()**+,
Class I Open Bite
("&*&-&.$&/
Non-extraction
0.1+*)-+$123$4)*5$%6"7&+

Class I Open Bite, Non-Extraction

Wire Elastics Direction Duration Bite Turbo
Triangle & Ant Up & Over

Quail
3/16, 2 oz.
.014 NiTi * 
or Full Time L Molar
(.013 PRN)
Parrot
5/16, 2.5 oz.

Ant Up & Over

Parrot
.018 NiTi Full Time L Molar
5/16, 2.5 oz.

Ant Up & Over

Parrot
.014 x .025 NiTi 5/16, 2.5 oz.
or or Full Time --
.018 x .025 NiTi Dolphin
5/16, 3 oz.

Ant Up & Over

Dolphin
U : .019 x .025
5/16, 3 oz.
SS / TMA
or Full Time --
L : .016 x .025
Zebra
SS
5/16, 4.5 oz.

* Begin squeeze exercise at the first day. Put fingers on post. fiber of temporalis muscle area to feel the
muscle contraction whenever bites on. 50 times as a cycle, do 6 cycles a day to accelerate molar intrusion.

█! "#$%!&'()!
Class I Open Bite, Non-Extraction

79
 █! "#$%!*'! █! "#$%!+'!
Insert the screw perpendicular to bone surface, 2 mm x 12 mm stainless steel screw is sharp and
perfomr a 1-2 mm initial biting of bone, change to strong enough for self-drilling, no incision, no
55° - 70° to occlusal plane then self-drilling the IZC tissue punches needed.
screw.

█! "#$%!&'! █! "#$%!('!
The buccal plate over the mesiobuccal root region From this cross-section of the sinus wall, it is clearly
of the upper 2 nd molar is much thicker than that of showed that the buccal plate over the mesiobuccal
the mesiobuccal root region of the upper 1 st molar. root region of the upper 2 nd molar is much thicker
than that of the mesiobuccal root region of the
upper 1 st molar.

█! "#$%!)'!
The original Infrazygomatic crest placement
o f m i n i - s c re w v s . t h e n e w m o d i f i e d
Infrazygomatic crest placement which
method the author used most often
recently.

188
 !"#$%&'())*(((+,-&'(!./$"-(0(12+/

█! "#$!%&'
CT sections of buccal shelf area are 1 mm above cervical line to 10 mm.

█! "#$!%('
Pink-colored areas show the area where buccal shelf mini-screw can be inserted.
*Thanks for Mr. Ming-Shun Lin and Dr. Po-Jung Chen for preparing this series of CT cross-sections.

213
 O rthoB oneScrew
Beethoven Orthodontic Center, Taiwan

OrthoBoneScrew ( OBS ) has a double-crossed rectangular slot on its neck. This 0.019” x
0.025” rectangular slot provides a versatile use of orthodontic mechanics. A 0.018” x 0.025” wire
can be secured in the slot firmly.

A Case Report Demonstrating OBS Application on Impacted

2nd Premolar.
Yu-Lin Hsu, Chris HN Chang, W. Eugene Roberts

A 13-year old female had a lower impacted 2nd

premolar, approximately 10 mm deep on the left
side. The treatment plan was to extract the 2nd
primary molar and pull out the 2nd premolar.
During the treatment, the 2nd primary molar was first
extracted, followed by bonding an eyelet bracket on
the surgically exposed 2nd premolar. Meanwhile, the
bone surrounding the crown of the second premolar
was reduced until reaching CEJ and a lateral window
was made for bracket bonding. An eyelet bracket was
bonded on the buccal surface of the deeply impacted
second premolar. The OrthoBoneScrew was inserted on the left buccal shelf area. A power-chain
was attached between a 3D lever arm and the
eyelet bracket to extrude the second premolar.
This 0.017 x 0.025-inch TMA lever arm was
consisted of a helical coil in the middle and one
attached on one end. When this lever arm was
inserted in the square hole of the
OrthoBoneScrew and activated, it would form a
force system which extruded the second premolar
directly. Without this direct force design, it would
have taken at least 6 months before one could use
the last wire sequence of the 0.016” x 0.025” SS
arch wire to extrude the premolar.

SURGICAL PROCEDURE
1. Extract the primary molar, remove dental follicle and the bone above the impacted
tooth. (Fig. 1)
It’s very difficult for enamel to resorb the surrounding bone because there is no osteoclast cells.
OrthoBoneScrew After the 2nd primary molar extracted, we removed the bone above the 2nd premolar by high
speed hand piece to facilitate extrusion.
Corporate Headquarters
2F, No. 25, Jian-Jhong First 2. Open a lateral window for bonding and keep the marginal bone. (Fig. 2, 3)
Road, Hsinchu, Taiwan 300
The traditional way is to bone the bracket on the buccal surface of the 2nd premolar. It is a very
Tel: +886 3 5735676
Fax: +886 3 5736777 difficult procedure due to the 10 mm depth and bleeding. We have found a new method by
Contact: opening a lateral window for bonding. It becomes easy and clear for bracket bonding from a
info@[Link] buccal view. Keep the marginal bone for flap adaptation.

 1 2 3

4 5 6

7 8 9

3. Bond an eyelet on the buccal surface of L5, seal the margin with flowable resin. (Fig. 4)
The key point of bonding is to keep it dry and tie a power chain first. Reinforce the bonding by sealing the margin of the
hole in the bracket.
4. Identify the mental nerve. (Fig. 5) Identify the mental nerve carefully to avoid trauma.
5. Attach a 3D lever arm to OBS. (Fig. 6)
Insert an OBS on the buccal shelf area. Connect the lever arm to the OBS on one end and attach the power chain on the
other end.
6. Use 6-0 Nylon for minimal trauma. (Fig. 7)
Make a releasing incision of periosteum (partial thickness) apical to the flap to release tension and to facilitate coronal
position.
7. Compression and cover with Coe Pak. (Fig. 8, 9) Compress the flap with rinsed normal saline gauze.

 A Letter from
the Member of the Damon Progressive Study Club about the
Treatment of the Impacted Bicuspid.

Dear Shu-Fen & Chris,

Sue and I had such a good time in Hawaii. The meeting was most interesting and the extra-curricular activities lots of fun, but the
Progressive People are the real draw for us. Thank you for including us in your lives and letting us know more about you and your lives.
The world becomes a better place when we listen and learn for those who are not next door. Thank you.

I shared your Keynote presentation on impacted bicuspids with my local Oral Surgeon this last week. He was impressed with
the simple elegance of the technique and wanted me to say thank you as well. He uses a very similar exposure but does not do the side
window for bonding. Often the simple things are the best.

I made a presentation to the local Dental Hygienist group in my small town last Thursday. I used some of the Keynote
techniques you exposed us to in my presentation and used the Remote Controller that you so graciously provided. I almost felt like Chris
Chang up in front of all those lovely ladies! Thank you.

We look forward to seeing you the next time we are able. Hopefully it will be soon and if not, then next year in Palm
Springs. If you are skiers and would like to follow us home to the snow for some skiing we would love to show
you where we live. Until the next opportunity.
Very best regards to you both.

John & Susie 

John Coombs, D.D.S.
Coombs & Beglin Orthodnitcs
[Link]

Contact us to find out

how you can read the
most famous
orthodontic text from
your iPod or computer
screen.

Tel: +886 3 5735676

Fax: +886 3 5736777
Contact: info@[Link]

Dr. Angle’s Statue

NT1500

 iPod touch 矯正行動學習的最佳利器

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Encyclopedia
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NTO 18 ABO CASE REPORT

ABO Case Report

Correction of Bimaxillary Protrusion with

Closing of Premolar & Molar Extraction Spaces

HISTORY AND ETIOLOGY

A young adult female, aged 24 years 2 months, was
referred by her family dentist for a second opinion
(Figure 1). Her chief complaints were crooked front teeth
and irregular lower incisal edges (Figures 2 and 3). The
patient desired resolution of the crowding without
orthognathic surgery or the use of miniscrews. There was
Fig 1. Pretreatment facial photographs
no contributory medical problems but she did have dental
history of a missing lower left second premolar and
compromised endodontic treatment of both left first
molars. Clinical examination revealed a Class I molar
relationship on the right, but the left first molars were
Class III. The mandibular dental midline was 2 mm to the
left of the facial and maxillary midlines. Her maxillary
lateral incisors were palatally displaced bilaterally.

The patient had a thumb sucking habit until age 10

which apparently contributed to the relatively narrow
arches. A portion of her lower lip was habitually Fig 2. Pretreatment intraoral photographs
positioned lingual to the maxillary incisors, resulting in a
“lip trap” that contributed to maxillary incisor flaring and
overjet. The etiology for the malocclusion appears to be
predominately environmental factors because the thumb
sucking history and aberrant tongue posture.

Although the patient’s restorative problems and the

desire to avoid miniscrews presented a substantial
challenge, treatment was accomplished to her satisfaction
(Figures 4-6). This report will review the diagnosis,
treatment planning and specific mechanics to accomplish
the pleasing result for the patient’s challenging problem.
Fig 3. Pretreatment study models
 ABO CASE REPORT NTO 18

Dr. Jia Yuan Liang, Lecturer, Beethoven Orthodontic Course (left)

Dr. Chris HN Chang, Director, Beethoven Orthodontic Center (middle)
Dr. Eugene W. Roberts, Consultant, News and Trends in Orthodontics (right)

DIAGNOSIS

Skeletal: Skeletal class I (SNA 91° , SNB 86° , ANB 5° ),

high mandibular plane angle (SN-MP 41° )

Facial: Bimaxillary protrusion with lip strain.

Dental: Right side class I molar relationship and left side

class III molar relationship were noted. Lower
dental midline was 2 mm to the left of the facial
Fig 4. Posttreatment facial photographs show considerable
improvement in the facial profile midline, and the lower incisor to mandibular
plane angle was 900 with severe mandibular
crowding (space deficient more than 7 mm), and
the anterior overjet was 7 mm. #20 was missing
and #19 was hopeless. The cephalometric
values are summarized in the Table 1. The total
score of ABO Discrepancy Index was 25, as
seen in the DI worksheet.

SPECIFIC OBJECTIVES OF TREATMENT

The principal objectives of treatment were to attain

Fig 5. Posttreatment intraoral photographs
Class I canines, and an asymmetric Angle Class I/III
molar relationship, while achieving ideal overjet and
overbite, consistent with retracting the lips. Specific
treatment objectives were to:

1. Maintain the skeletal position of the maxilla and

the mandible.

2. Avoid extrusion of the molars and clockwise

rotation of the mandible during treatment.

3. Intrude mandibular incisors and retract maxillary

incisors.

4. Achieve proper overjet & overbite in a mutually

protected, Class I canine occlusion.
Fig 6. Posttreatment study models
NTO 18 ABO CASE REPORT

Fig. 7. Pretreatment pano and ceph radiographs show lip Fig. 8. Posttreatment pano and ceph radiographs show
strain , #20 lost and #19 holpless balancing lip profile, the root angulation are not parallel on
#21 and #30

5. Retract upper and lower lips to enhance facial esthetics

CEPHALOMETRIC
and achieve lip competence.
SKELETAL
ANALYSIS
TREATMENT ALTERNATIVES
PRE-TX POST-TX DIFF.
The main issues involved in developing an appropriate
SNA° 85° 84° 1°
treatment plan were the missing tooth #20 and hopeless tooth
SNB° 80° 78° 2°
#19 which left a large lower left posterior space to be closed.
Therefore three treatment options were presented to the ANB° 5° 6° -1°

patient. SN-MP° 41° 41° 0°

FMA° 32° 32° 0°

Option ❶ DENTAL
ANALYSIS

U1
TO
NA
mm 
9
mm 
4
mm 5
mm

Extract upper first premolars, left lower first molar, and
right lower first molar. Maximally retract the upper six U1
TO
SN° 119° 99° 20°

anterior teeth, align the lower anterior teeth and protract the L1
TO
NB
mm 10
mm 9
mm 
1
mm

lower left second and third molars. OrhoBoneScrewsTM L1
TO
MP° 91° 91° 0°
might be needed for anchorage to retract the maxillary FACIAL
ANALYSIS
anterior segment and protract the lower left 2nd and 3rd
E-LINE 1
mm 0
mm 1
mm
molars.
Table 1 . Cephalometric summary
 ABO CASE REPORT NTO 18

Fig. 9. Superimposed tracings show a posterior uprighting of maxillary anterior teeth and a a protraction of
mandibular posterior teeth

Option ❷ APPLIANCES AND TREATMENT PROGRESS

Extract upper first premolars, left lower first molar, and Extraction of teeth #5, #14, #19, and #28 was

right lower first premolar. Restore the remaining space of accomplished before orthodontic treatment started. To

the left lower molar with an implant-supported prosthesis. achieve a Class I left molar relation, the additional
extraction of #12 was suggested, but the patient declined.

Option ❸ Damon D3MX .022” Brackets (Ormco) were used. Both

arches were bonded with occlusal bite turbos constructed
Considering the costs of prosthetics to replace the left
with Fuji II Glass Ionomer cement on teeth #18 & #31 at
lower first molars, and the difficulty of endodontic
the first appointment. Lingual buttons were bonded on
retreatment of the upper left first molar, the 3rd option was
teeth #17 & #18, and full time cross elastics (4.5 oz) were
extraction of upper left and lower first molars, as well as the
applied to correct lingual tipping of #17 & #18. After three
upper right and lower right first premolars. Maximal
months of treatment, the posterior bite turbos were
retraction of the upper anterior teeth was planned to resolve
removed. The wire sequence was as follows: .014 copper
the lip protrusion. Correction of the lower anterior
NiTi, .014 x .025 copper NiTi, .017x .025 TMA, .019x .025
crowding and protraction of the lower left 2nd & 3rd molars
SS and finally went back to .017x .025 TMA for detailed
was to be achieved without the use of miniscrews. It was
adjustment. Class II elastics were upgraded gradually from
explained that this option was very challenging technically,
3.5 oz to 4.5 oz. After twenty-two-month of treatment,
would result in a Class III molar relationship on the left,
diagnostic models and a panoramic radiograph were taken
and would probably increase treatment time. Despite these
to determine 2nd order correction for root parallelism.
limitations, option 3 was selected by the patient.
After twenty-four months of active treatment, the
NTO 18 ABO CASE REPORT

appliances were removed and the retainers were delivered just right side, and a class III molar relationship and class I
one week earlier before she embarked for Australia. canine relationship on the left side. The lower dental
midline was shifted 1 mm left to the upper dental midline .
TREATMENT RESULTS Final results revealed the following deviations from
The patient’s facial appearance improved dramatically. ideal:
There were significant reductions of dentoalveolar • Minor rotations were noted for teeth #2, 12, 15 and 18.
protrusion which resulted in relief of mentalis strain to
• Marginal ridge discrepancies were seen adjacent to
achieve competent lips. These changes improved the chin
teeth #18, 20 and 31.
and nose projection, which substantially improved the
• Tooth #2 exhibited excessive palatal crown torque.
patient’s profile. If miniscrew skeletal anchorage had been
used, more dentoalveolar retraction would have been • Residual Class II occlusion: teeth #2, 4, 6, 11 and 12

possible and it would have been easier to accomplish the were shifted mesially about 1.5 mm relative to the
13mm of asymmetric mandibular space closure. However, interproximal embrasures of the mandibular posterior teeth.

treatment goals were achieved to the patient’s satisfaction • Residual Class III occlusion: teeth #13 and 15 were
without using any skeletal anchorage, but the final root shifted distally more than 2 mm relative to the desired
paralleling was rushed because of the impending trip to embrasures of the lower left dentition.
Australia. Post-treatment intraoral photographs and study
casts revealed class I molar and canine relationship on the

Fig 10. wire cutting between #17 and #18 Fig 11. 6 oz Moose ( 11th month )
 ABO CASE REPORT NTO 18

• Root movement: Tooth #6 needed slightly more mesial DISCUSSION

root movement, while teeth #30, 21 and 13 needed slightly Roberts2 described the bone physiology of 2nd and 3rd
more distal root movement. mandibular molar protraction into a missing 1st molar space.
The total score for the ABO cast and panoramic The relatively flat roots of the molars move through the center
radiograph grading system was 26. This score is just within of the alveolar process by resorbing primarily trabecular bone
the maximal desirable score of 26. on the mesial surface and forming cortical bone on the distal

RETENTION surface of each root. For the first few mm of tooth movement,

After the completion of active treatment, an upper clear the molars move rapidly, but when the trailing root engages the

overlay retainer was delivered and a lower anterior fixed cortical bone formed by the leading root, the rate of molar
retainer was constructed on the lingual. Stepovich1 concluded protraction decreases until space closure is accomplished.
that spaces of 10 mm or more can be closed in adults, but Radiographic images suggest that rate of tooth movement is
retaining the closed spaces was difficult. For this reason, a related to the ability of the body to remodel the relatively
fixed buccal retainer was placed from the left molar to dense, cortical bone formed by the leading root. As the molars
premolar (teeth #18-20) in the mandibular arch to prevent the
moved mesially through the denser alveolar bone, radiolucent
space from reopening during retention.
foci were noted in the cortical bone mesial to the alveolar
bone/PDL interface. This radiographic picture conforms to the
combined modeling and remodeling mechanism of tooth

Fig 12. power chain at lingual side ( 16th month ) Fig 13. Right buccal view ( 16th month )
NTO 18 ABO CASE REPORT

movement. Initialing remodeling events (resorption cavities) in Moreover, there might be an incomplete space closure. For the
the path of a moving tooth appears to be an important present patient, the spaces of 10 mm or more were closed in the
mechanism for decreasing the mass of cortical bone resisting posterior region of the mandible.1 If the edentulous ridge is at
tooth movement. least half the width of the tooth being moved into the ridge,

Vanarsdall and Swartz3 described the common sequelae then the remodeling process would probably be successful.5

for a missing mandibular first molar as (1) mesially inclined However, if the edentulous ridge is less than half the width of

second and/or third molars, (2) distal drift of the premolars, (3) the tooth root, then a dehiscence in the bone is likely to form

extrusion of the maxillary molars, (4) altered gingival form over the labial or lingual surfaces of the root.6 When closing

with constriction of the edentulous ridge, (5) infrabony defect first molar spaces in the mandible, young adults generated more

mesial to the inclined molar, (6) stepped marginal ridges, (7) alveolar bone in the edentulous space and lose less crestal bone

food impaction, and (8) posterior collapse. However, these than older adult patients.1 Furthermore, retention of space

negative results in the maxillary arch are usually not as severe closure is more difficult for older adult patients than for

as those in the mandibular arch3. Although fixed prostheses are younger adults.1 Hatasaka7 observed that the best second order

often used for replacement of two adjacent, mandibular missing postretention results were in cases which roots and crowns were

teeth in the buccal segment, the present case demonstrates that positioned in normal, upright parallel positions. Edwards8

is possible to close such a space.1 However, many clinicians suggested that excess gingival tissue could be a factor

still believe that when the buccolingual width of the alveolar associated with residual spaces and advocated the surgical

ridge is constricted, the second molar will not move mesially.4 removal of any tissue that accumulates interproximmally during

Fig 14. Lingual view (19th month ) Fig 15. Fixed retainer on #18 and #21
 ABO CASE REPORT NTO 18

treatment. As originally described by Casko et al.9 the ABO maxillary dentition. Considering the complexity of the problem,
Objective Grading deducts many points for failing to achieve and the imposed biomechanics restrictions, the authors and the
Class I buccal segments. Although good interdental contacts patient are pleased with the results.
were achieved, nine points were lost in the occlusion section of ACKNOWLEDGEMENT
the ABO cast score. One of the principle objectives of The authours would like to acknowledge our editors, Tzu
orthodontic treatment is to establish maximun intercuspation of
Han Huang, Dr. Billy Su, Dr. Chen Jin Lung and Dr. Sabrina
opposing teeth even if intermaxillary intercuspation is not ideal. Huang for English revision.
Although the left occlusal relationship is class III, the cusp to
fossa relationships are optimal between the mandibular and

         References

1. Stepovitch MI. A clinical study on closing edentulous spaces in the mandible. Angle Orthod 1979:49: 227-33.
2. W Eugene Roberts: Rate of translation of mandibular molars using implant-anchored mechanics. The Angle
Orthod 1996:66: 331-37.
3. Vanarsdall RL, Swartz ML: Molar uprighting, Ormco catalog NO. 740-0014, Glendora, Calif., 1980, Ormo
Corporation.
4. Hom BM, Turley PK. The effects of space closure of the mandibular first molar area in adults. Am J Orthod.
1984;85:457-469.
5. Kokich VG, Kokich VO. Interrelationship of orthodontics with periodontics and restorative dentistry. In: Nanda, R.
Biomechanics and Esthetic Strategies in Clinical Orthodontics. St. Louis: Elsevier Saunders; 2005:18.
6. Kokich VG, Mathews DP, Spear FM: Inheriting the Unhappy Patient: An interdisciplinary Case Report. Advanced
Esrhetics & Interdisciplinary Dentistry 2005;1:12-20.
7. Hatasaka HH: A radiographic study of roots in extraction sites. Angle Orthod. 1976;46:64-68.
8. Edwards JG: The prevention of replase in extraction cases. Am J Orthod. 1971;60:128-141.
9. John S Casko:Objective grading system for dental casts and panoramic radiographs. American J of Orthodontic and
Dentofacial Orthopedics.1998;114:589-599.
[Link]. Beethoven Orthodontic Mobile Learning Program. Advanced Damon Course No. 9:Unhappy Patient. 2010;
Newton’s A Ltd, Taiwan.
NTO 18 ABO CASE REPORT

DISCREPANCY INDEX WORKSHEET

CASE # P(Rev.
ATIENT ! !HUNG YU-FANG
9/22/08)
TOTAL D.I. SCORE 26
25
OVERJET LINGUAL POSTERIOR X-BITE
0 mm. (edge-to-edge) = 1 pt.
1 – 3 mm. = 0 pts. 1 pt. per tooth Total = 0
3.1 – 5 mm. = 2 pts.
5.1 – 7 mm. = 3 pts. BUCCAL POSTERIOR X-BITE
7.1 – 9 mm. = 4 pts.
> 9 mm. = 5 pts.
2 pts. per tooth Total = 0
Negative OJ (x-bite) 1 pt. per mm. per tooth =
CEPHALOMETRICS (See Instructions)
Total = 3
ANB ! 6° or " -2° = 4 pts.
OVERBITE SN-MP
! 38° = 2 pts.
0 – 3 mm. = 0 pts.
3.1 – 5 mm. = 2 pts. Each degree > 38° 3 x 2 pts. =6
5.1 – 7 mm. = 3 pts.
Impinging (100%) = 5 pts. " 26° = 1 pt.

Total = 0 Each degree < -2° !!!!! x 1 pt. = !!!!!

Each degree > 6° !!!!! x 1 pt. =

ANTERIOR OPEN BITE
Each degree < 26° !!!!! x 1 pt. = !!!!!
0 mm. (edge-to-edge), 1 pt. per tooth
then 1 pt. per additional full mm. per tooth 1 to MP ! 99° = 1 pt.
Each degree > 99° x 1 pt. =
Total = 0

Total = 8
LATERAL OPEN BITE
2 pts. per mm. per tooth OTHER (See Instructions)

Supernumerary teeth !!!!! x 1 pt. = !!!!!

Total = 0 Ankylosis of perm. teeth !!!!! x 2 pts. = !!!!!
Anomalous morphology !!!!! x 2 pts. = !!!!!
CROWDING (only one arch) Impaction (except 3rd molars) !!!!! x 2 pts. = !!!!!
Midline discrepancy (!3mm) @ 2 pts. = 1
1 – 3 mm. = 1 pt. Missing teeth (except 3rd molars) 1 x 1 pts. = 1
3.1 – 5 mm. = 2 pts. Missing teeth, congenital !!!!! x 2 pts. = !!!!!
5.1 – 7 mm. = 4 pts. Spacing (4 or more, per arch) !!!!! x 2 pts. = !!!!!
> 7 mm. = 7 pts. Spacing (Mx cent. diastema ! 2mm) @ 2 pts. = !!!!!
Tooth transposition !!!!! x 2 pts. = !!!!!
Total = 7 Skeletal asymmetry (nonsurgical tx) @ 3 pts. =
Addl. treatment complexities 1 x 2 pts. = 2
OCCLUSION Identify:
Class I to end on = 0 pts.
End on Class II or III = 2 pts. per side !!!!! pts. Total = 34
Full Class II or III = 4 pts. per side !!!!! pts.
Beyond Class II or III = 1 pt. per mm. !!!!! pts.
additional

Total = 4
 ABO CASE REPORT NTO 18

Occlusal Contacts
Exam Year
0
ABO ID# 96112***

Examiners will verify measurements in each parameter.

ABO Cast-Radiograph Evaluation (Rev.6-1-08)

Case # 26 Patient Huang Yu-Fang
Total Score: 25

Alignment/Rotations

1
1
2
2

Occlusal Relationships
Marginal Ridges
9
4
1
1 2
1

1 1 1 1 1 2 2

Interproximal Contacts
0
Buccolingual Inclination
1

Root Angulation
Overjet 4
5
1 1
0

12 1
INSTRUCTIONS: Place score beside each deficient tooth and enter total score for each parameter
in the white box. Mark extracted teeth with “X”. Second molars should be in occlusion.
NTO 18 ABO CASE REPORT

ABO Case Report

High Maxillary Canine Impaction with Mesial

and Labial Displacement

HISTORY AND ETIOLOGY

A 12 year 3 month female was referred by her general
dentist to evaluate a chief complaint of unerupted maxillary
canine (Figure 1). The patient was in good general health and
the dentition was developing normally except for a high
impaction of the maxillary left canine (Figures 2 and 3). The
apparent etiology was an aberrant path of eruption.
The patient was successfully treated to a near ideal result Fig 1. Pretreatment facial photographs
as documented by Figures 4-8. Three dimensional
radiographic imaging (Figure 10) revealed that the crown of
the impacted canine was lodged between the adjacent lateral
incisor and first premolar roots. A specific surgical plan1-2 was
devised to uncover the impacted canine (Figure 11).
Orthodontics mechanics tipped the tooth distally, so that it
could be extruded and properly aligned (Figure 12). Figure 9
is pre- and post-treatment cephalometric documentation. The
diagnosis and treatment details will be discussed below.

DIAGNOSIS

Skeletal:
Skeletal Class I ( SNA 84°, SNB 81°, ANB 3° ) Fig 2. Pretreatment intraoral photographs
Normal mandibular plane angle ( SN-MP 31°, FMA
22° )
Dental:
Bilaterally Class I molar relationship
Asymmetric right Class II canine relationship
3 mm overjet, 30% overbite, and all mid-lines coincide
Mesially and labially impacted upper left canine high in
the alveolar process
2 mm crowding of the lower anterior dentition
Facial:
Slightly protrusive maxillary lip

Fig 3. Pretreatment study models

 ABO CASE REPORT NTO 18

Dr. Tseng Shu Ping, Lecturer, Beethoven Orthodontic Center (Left)

Dr. Chris HN Chang, Director, Beethoven Orthodontic Center (middle)
Dr. W. Eugene Roberts, Consultant, News and Trends in Orthodontics (right)

SPECIFIC OBJECTIVES OF TREATMENT

Maxilla ( all three planes ):
A - P: Maintain
Vertical: Maintain
Transverse: Maintain
Mandible ( all three planes ):
A - P: Maintain
Fig 4. Posttreatment facial photographs Vertical: Maintain
Transverse: Maintain
Maxillary Dentition
A - P: Maintain
Vertical: Recover high impacted canine on the left side
Inter-molar Width: Maintain
Mandibular Dentition
A - P: Maintain Class I molar relationship; align anterior
segment
Vertical: Maintain
Inter-molar / Inter-canine Width: Maintain
Facial Esthetics:
Fig 5. Posttreatment intraoral photographs E-line: Maintain a normal growth pattern; slight retraction
of the upper lip.

TREATMENT PLAN

Both arches were bonded with fixed appliances and an

open coil spring was used to prepare pathway for the impacted
canine, which was subsequently exposed and bonded with a
labial approach. Closed eruption technique was chosen to
bond canine (Figure 11), which was brought into occlusion
with an orthodontic light force from a power chain and a
continuous maxillary archwire (Figure 12).
Treatment included Class II elastics to maintain a
favorable occlusion and profile. Detailing bends produced the
final occlusion. Fixed appliances were removed and the
Fig 6. Posttreatment study models corrected dentition was retained with fixed retainers from 3-3
in both arches.
NTO 18 ABO CASE REPORT

Fig. 7. Pretreatment ceph. and pano. radiographs Fig. 8. Posttreatment ceph. and pano. and radiographs

CEPHALOMETRIC
APPLIANCES AND TREATMENT PROGRESS SKELETAL
ANALYSIS

Damon D3MX brackets 0.022” ( Ormco ) were used. PRE-TX POST-TX DIFF.

Both arches were bonded and occlusal bite turbos, made with SNA° 84° 8３° -1°

glass ionomer cement, were placed on both lower first molars. SNB° 81° 81° 0°
ANB° 3° 2° -1°
An open coil spring was placed between teeth #10 and 12 to
SN-MP° 31° 32° +1°
open a pathway for the extrusion of the impacted canine. Five
FMA° 22° 24° +2°
months later, #11 was surgically exposed and a button was
DENTAL
ANALYSIS
bonded on the labial surface to tip and extrude it with a closed
U1
TO
NA
mm 4
mm 6
mm +2
mm
eruption technique (Figure 11). Following 5 months of
U1
TO
SN° 107° 107° 0°
traction, with the power chain and .014 Copper-Ni-Ti
L1
TO
NB
mm 5
mm 4
mm -1
mm
archwire, the crown of #11 was exposed and the button was
L1
TO
MP° 99° 99° 0°
replaced with a Damon bracket. After 8 months of traction and
FACIAL
ANALYSIS
alignment, #11 was optimally positioned in the arch. Once the
E-LINE 1.5
mm 1
mm -0.5
mm
impacted canine reached the occlusal plane, Class II elastics
were used to achieve proper interdigitation and close the Table 1 . Cephalometric summary
 ABO CASE REPORT NTO 18

Fig. 9. Superimposed tracings

remaining space between teeth #11 and 12. Moreover, lip Transverse: Maintained
tension exercises were prescribed to obtain a better soft tissue Mandible ( all three planes ):
profile.
A - P: Maintained
One month before removing the fixed appliances, the
Vertical: Maintained
upper archwire was sectioned distal to the cuspids. Light up
Transverse: Maintained
and down elastics ( 2 oz ) were further used for final detailing.
After 25 months of active treatment, appliances were removed Maxillary Dentition:
and 3-3 fixed retainers were delivered at the same appointment. A - P: Maintained Class I molar relationship
The wire sequences for the treatment were as follows: .014 Vertical: Impacted left canine recovered and optimally
Copper Ni-Ti, .014x .025 Copper Ni-Ti and .017x .025 TMA. aligned
Shortly after bonding the brackets and towards the Inter-molar Width: Maintained
completion of canine traction, panoramic radiographs were
Mandibular Dentition:
taken to examine the bracket positions for all teeth.
A - P: Maintained Class I molar relationship; slightly flared
and well aligned
TREATMENT RESULTS
Vertical: Maintained
Maxilla ( all three planes ):
Inter-molar / Inter-canine Width: Maintained
A - P: Maintained
Facial Esthetics:
Vertical: Maintained
NTO 18 ABO CASE REPORT

Fig. 10. 3D images show 11 in good morphology without any pathological change. The crown of 11 is just
palatal to the root apex of 10 and palatal root tip of 12 is just fitting in the lingual fossa of 11.

E-line: Maintained a normal growth pattern and slightly important diagnostic information for selecting the appropriate
retracted the upper lip surgical uncovering procedure (Figure 11) to compliment the
specific orthodontic traction to recover and align the impacted
RETENTION canine (Figure 12). For the present patient, this potentially
The upper and lower fixed 3-3 retainers were bonded on difficult canine impaction was corrected in about 8 months.
every tooth. The patient was instructed in home care and
The treatment resulted in pleasing crown length and gingival
maintenance of the retainers.
contour on tooth #11. The relatively symmetrical maxillary
labial gingival form is expected to improve after treatment and
FINAL EVALUATION OF TREATMENT
crown exposure of the lateral incisors equalizes.
Three dimensional radiographic imaging (Figure 10) was

Fig. 11 Operation procedures show as illustrated. Especially noted that the bone covering crown and the pathway for erupting cuspid
are removed.
 ABO CASE REPORT NTO 18

DISCUSSION case, an open coil spring was used to increase the space

For impacted canines, extraction should be limited to between the lateral incisor and the first premolar to create a

ankylosis, uncontrollable infection, internal or external root pathway for eruption of the impacted canine.1-5 The approach

resorption, severe root dilacerations and/or pathology that may of further increasing the width of the space between the

compromise adjacent teeth during or after orthodontics adjacent teeth was necessary because the 3D imaging revealed
treatment.1-4 3D radiographic imaging revealed a relatively that the root tip of the adjacent lateral incisor (#10) was just

normal tooth that unfavorably displaced from the normal path anterior to the superior portion of the crown of the canine, and

of eruption. An effective treatment plan was devised to recover the inferior portion of the crown (#11) was lodged between the

and align the high impacted canine that was displaced mesially roots of the premolar (#12). If orthodontic traction had been

and labially. Without properly diagnosing the unfavorable applied to the impacted canine, without opening a pathway for

position for the impaction, it may have been difficult to recover eruption, extrusion would have been inhibited and root

it without damaging the roots of adjacent teeth. resorption of the adjacent teeth was likely. The side effect was
a more anterior position of the canine once it was aligned. This
The classic treatment protocols for impacted maxillary
problem was easily corrected with Class II elastics after the
canines are opening space, performing surgical exposure, and
impacted canine was extruded into position.
applying light traction forces in an appropriate direction. In this

Fig. 12 Radiographies show first day, two months later and 8M later since traction began.
NTO 18 ABO CASE REPORT

Fig. 13 Post-Tx photo.

For a high labially-impacted canine, an excisional The high impaction of a maxillary canine is a difficult
surgical technique would probably result in compromised problem in orthodontics. Once the impacted tooth is recovered,
attached gingival, apical to the crown of canine after it had there may be a discrepancy in occlusion, root resorption and/or
erupted.2 On the other hand, an apically positioned flap (APF) gingival compromise. The force design and control is a very
would result in instability of the crown and possible reintrusion important aspect of the treatment sequence. For the present
of the tooth after treatment. Closed eruption technique was the patient, the DI score was only 5 points. However, the clinical
most appropriate method for uncovering the canine because its effort and skill to treat this patient is not adequately reflected by
position was significantly apical to the mucogingival junction. the DI. Although the DI has proven to be an effective indicator
Besides, removing the bone covering the crown and along the of treatment complexity (severity) for most patients, it
pathway of eruption at the time of surgical uncovering is underestimates the difficulty of high canine impactions. A
suggested to shorten the traction time.2 revision of the DI to more appropriately weight difficult

In assessing the final result for the present patient, the impactions is indicated.

canine position, angulation, bone level, and crown length are all
satisfactory. The disharmony of the gingival line of upper CONCLUSION

anterior teeth can easily be solved with gingivoplasty in the A thorough diagnosis, a well planned surgical strategy, and
future if it does not spontaneously correct with age. However, an efficient, force system design are essential components for
the canine eminence on the affected side is relatively more successful management of unfavorably positioned, high
prominent. This modest problem could have been prevented maxillary canine impactions. 3D radiographic imaging is
with a higher torque bracket, a torqued archwire, or a torquing important for precisely determining the relative position of the
spring. In addition, a Ballista loop or a traction force from the impacted canine to its adjacent teeth. This information is
mini-screw in the palate5 may have improved the direction of necessary for designing a treatment approach to
canine traction. Moreover, the occlusion of tooth #11 should be consistently achieve optimal outcomes for these
carefully monitored and adjusted, if needed to achieve better difficult clinical problems.
occlusion.

References
1. Heloisio de Rezende Leite et al: Labially displaced ectopically erupting maxillary permanent canine: interceptive treatment and long-term results.
Am J Orthod Dentofacial Orthop 2005;128:241-51
2. Vincent G. Kokich: Surgical and orthodontic management of impacted maxillary canine. Am J Orthod Dentofacial Orthop 2004;126:278-83
3. K. Niagara et al: Impacted maxillary central incisor, canine, and second molar with 2 supernumerary teeth and an odontoma. Am J Orthod
Dentofacial Orthop 2009;135:390-9
4. Demetrios J. Halazonetis: Horizontally impacted maxillary premolar and bilateral canine transposition. Am J Orthod Dentofacial Orthop
2009;135:380-9
5. Stella Cherish et al: Lingual orthodontic treatment and absolute anchorage to correct an impacted maxillary canine in an adult. Am J Orthod
Dentofacial Orthop 2008;134:811-9
DISCREPANCY INDEX WORKSHEET EXAM YEAR 2007
!!!!
CASE # 1199 P(Rev.
ATIENT ! CHOU-YU YANG
9/22/08) ID# A831202
TOTAL D.I. SCORE 5

OVERJET LINGUAL POSTERIOR X-BITE

0 mm. (edge-to-edge) = 1 pt.
1 – 3 mm. = 0 pts. 1 pt. per tooth Total = 0
3.1 – 5 mm. = 2 pts.
5.1 – 7 mm. = 3 pts. BUCCAL POSTERIOR X-BITE
7.1 – 9 mm. = 4 pts.
> 9 mm. = 5 pts.
2 pts. per tooth Total = 0
Negative OJ (x-bite) 1 pt. per mm. per tooth =
CEPHALOMETRICS (See Instructions)
Total = 0
ANB ! 6° or " -2° = 4 pts.
OVERBITE
Each degree < -2° !!!!! x 1 pt. = !!!!!
0 – 3 mm. = 0 pts.
3.1 – 5 mm. = 2 pts. Each degree > 6° !!!!! x 1 pt. = !!!!!
5.1 – 7 mm. = 3 pts.
Impinging (100%) = 5 pts. SN-MP
! 38° = 2 pts.
Total = 0 Each degree > 38° !!!!! x 2 pts. = !!!!!

" 26° = 1 pt.

ANTERIOR OPEN BITE Each degree < 26° !!!!! x 1 pt. = !!!!!
0 mm. (edge-to-edge), 1 pt. per tooth
then 1 pt. per additional full mm. per tooth 1 to MP ! 99° = 1 pt.
Each degree > 99° !!!!! x 1 pt. = !!!!!
Total = 0

Total = 0
LATERAL OPEN BITE
2 pts. per mm. per tooth OTHER (See Instructions)

Supernumerary teeth !!!!! x 1 pt. = !!!!!

Total = 0 Ankylosis of perm. teeth !!!!! x 2 pts. = !!!!!
Anomalous morphology !!!!! x 2 pts. = !!!!!
CROWDING (only one arch) Impaction (except 3rd molars) 1 x 2 pts. = 2
Midline discrepancy (!3mm) @ 2 pts. = !!!!!
1 – 3 mm. = 1 pt. Missing teeth (except 3rd molars) !!!!! x 1 pts. =
3.1 – 5 mm. = 2 pts. Missing teeth, congenital !!!!! x 2 pts. = !!!!!
5.1 – 7 mm. = 4 pts. Spacing (4 or more, per arch) !!!!! x 2 pts. = !!!!!
> 7 mm. = 7 pts. Spacing (Mx cent. diastema ! 2mm) @ 2 pts. = !!!!!
Tooth transposition !!!!! x 2 pts. = !!!!!
Total = 1 Skeletal asymmetry (nonsurgical tx) @ 3 pts. =
Addl. treatment complexities 1 x 2 pts. = 2
OCCLUSION Identify:
Class I to end on = 0 pts.
End on Class II or III = 2 pts. per side !!!!! pts. Total = 4
Full Class II or III = 4 pts. per side !!!!! pts.
Beyond Class II or III = 1 pt. per mm. !!!!! pts.
additional

Total = 0
 Occlusal Contacts
Exam Year 2009
0 2
ABO ID# A831202 96112

Examiners will verify measurements in each parameter.

ABO Cast-Radiograph Evaluation (Rev.6-1-08)

Case # 1199 -t=y Chou-you Yang
Patient:

Total Score: 16

Alignment/Rotations

3
1

Occlusal Relationships
Marginal Ridges
6
4 6

1 2

1 1 1

1 1 1 1

Interproximal Contacts
0
Buccolingual Inclination
3

1 1 1

Root Angulation
Overjet
0
0

INSTRUCTIONS: Place score beside each deficient tooth and enter total score for each parameter
in the white box. Mark extracted teeth with “X”. Second molars should be in occlusion.
 Upcoming International OBS Workshop
8/14-16, 2010

LECTURER: Dr. John Lin LECTURER: Dr. Chris Chang

President of the Jin-Jong Lin ABO certified orthodontist and president of
Orthodontic Clinic, Dr. Lin the Beethoven Orthodontic Center, Dr.
received his MS. from Chang received his PhD in bone
Marquette University and is an physiology and Certificate in
internationally renowned Orthodontics from Indiana University in
lecturer. He’s also the author of 1996. As publisher of News & Trends in
Creative Orthodontics and consultant Orthodontics, he has been actively involved
to News and Trends in Orthodontics . in the design and application of bone screws.

OrthoBoneScrew and
Damon workshop includes
The visit to Beethoven and two half-day lectures, two half-
Newton’s A center of this time was day chair-side observation
really an eye-opening experience sessions, one model practice
for me in many ways. Among and one case discussion session.
others, what impressed me the Cost: USD 1,200
most was the confidence of staff Next dates:
members at work. Of course. it August 14-16; December 7-9
must be the consequence of a
superb office management Dr. Tomio Ikegami, Japan (middle) Keynote Presentation
system. A lot of time and effort President of the Japan MEAW Technique workshop includes a total of
must have been poured in to and Research Foundation 6.5-hours of lecture and hands-
establish the current status, on practice, focusing on
which is well rewarded. Being improving your professional
inspired by the visit to Hsinchu, I have come back to my office with communication skills. The
several new ideas to improve my own office system. workshop will use Macintosh
computers and its native
It was also a fun to get acquainted with some new friends from presentation software, Keynote
Thailand, Malaysia and Vietnam. Thank you very much for the wonderful 09. Cost: USD 300
and refreshing 2 days. I want to return some day with my staff members
to show them how efficient an orthodontic office can be. Contact: Ms. Huang
thhuang@[Link]
NTO 18 FEATURES

Modern Orthodontic Office Design ~ Part ⅠII

Consultation table
諮詢桌的設計傳統為L型桌子搭配兩台螢幕，一個螢
幕給助理使用記錄醫師的諮詢內容，另一個螢幕為醫師向家
長或病患解說用，我們改良為簡潔一字型圓弧造型搭配大螢
幕電腦，簡單又可以滿足需求（圖一）。家長或病患正對電
腦螢幕，醫師和助理坐在電腦左右側，方便同時解說與記
錄。診療區或櫃台附近可利用小小空間也設置諮詢桌，對於
衛教或注意事項說明都相當方便。

Labortory
矯正診所中技工房的設置是相當必要的（圖二），因
Fig. 1 諮詢桌
為大量模型的製作需求，第一考量是隔音，不要讓機器運作
的聲響干擾看診；另外技工室若與消毒室合併，則要考量不
要離主要的診療區太遠，因為助理需要常打包器械消毒，動
線應注意不宜太長，以提高效率。

Reception desk
櫃台位置的決定有三點考量 : 1. 決定工作人員的主要
動線。2. 影響病患動線為圓形或直線。3. 好的設置可形成診
療區的視覺屏障。櫃台設計除了功能性之外，最主要就是決
定了病患的動線，以及作為診療區的屏障（圖三、四）。 Fig. 2 技工房

Fig. 3 圓弧式櫃台 Fig. 4 直線式櫃台

 FEATURES NTO 18

徐玉玲 醫師
安徒生兒童牙醫診所負責人
貝多芬矯正課程講師

Reception room
等候區的重要性在整個平面規劃順序上應該是敬陪末座的，大
多是利用散置的空間，並不侷限一個區域，最好是多個小空間（圖五
～七），如此可以分散等待的患者或家長，在特別忙碌的時段比較不
會讓病患有一進到診所就看到滿室的等待者。

E-office
在電腦科技如此發達的時代，許多傳統牙科不易長久妥善保存
的資料，例如X光片等都可以透過數位e化的方式呈現及保存。除此之
外，舉凡口內口外照片，手術過程等都可整理至病患個人的病歷資料
中，使醫師對於病程更能通盤掌握。此外，對於助理用於衛教以及注
意事項的解說，也能透過清楚的影像呈現讓病患更能簡單了解。除了
資料收集外，電腦在行政工作的幫忙更不僅止於預約掛號，追蹤未
就診病患等，更能進一步在忙碌的門診工作進行中分辨治療中及等
待中的病人甚至等候時間的長短。在順暢的動線硬體設計之上再加
入電腦軟體的管控，資料收集與管理，大大地為整體運作加分。

Tailer-made office
談了這麼多診所設計的原則，目的都是為了要一手打造符合
心中理想又能兼具效率的工作環境；牙醫師在診所活動的時間其實 Fig. 5-7 等候區
超過在自己家裡的活動時間 (睡覺不算)，所以好好地花心思在這個
空間設計絕對是值得的。而要建立量身訂做適合自己的診所，除了
多聽多看多學之外，筆者認為最重要的還是要回歸 “需求’’，了解自
己的工作模式及看診需要，如此方能打造真正量身訂做的診所。

Fig. 8 安徒生兒童牙科平面圖
貝多芬團隊 BEETHOVEN
貝多芬創辦人：
張慧男醫師

‧中華民國齒顎矯正專科

醫師
‧美國齒顎矯正專科醫師

學院院士（ABO）
‧News & Trends in
Orthodontics 發行人
‧美國印地安納普渡大學

齒顎矯正研究所博士
‧國防牙醫系畢

貝多芬負責人張慧男醫師
（後排中）及全體助理合影。

貝多芬牙科團隊
A Learning Organization
文 / 陳建綱、徐玉玲、黃思涵、蘇筌瑋

引言 隊還另外成立「金牛頓藝術科技」，專職負責牙醫資訊科
技，醫療器材研發以及牙科教育推廣的工作。為了能提供
更完整的牙科照顧，我們也預計在明年成立一植牙中心，
貝多芬，是世界知名的音樂家，但是在台灣，他同
希望能讓有缺牙困擾的民眾更全面的治療環境。
時也是一家牙醫診所的名字。在知名的搜尋引擎 Google
中鍵入關鍵字「貝多芬」，在第五個順序就會自動出
現“貝多芬牙醫“，點入之後有將近六千筆的結果，可見民 診療區
眾在網路上想要去了解「貝多芬牙醫」的熱烈程度。 開闊的空間
設計，面對
貝多芬牙醫團隊簡介 的是窗外中
庭的一整片
貝多芬牙科團隊是由張慧男醫師領導，從矯正牙科 綠意，舒緩
出發，包含「貝多芬一般牙科」、「安徒生兒童牙科」牙 病患看診時
周病專科、贗復專科等牙醫專科醫師及優秀的牙醫助理團 等待的緊張
隊所組成。此外，強調以「學習」為核心價值的貝多芬團 心情。
貝多芬矯正中心-環境介紹

一進到貝多芬矯正牙科，櫃台美麗而親切的助理
立即起身招呼，眼前寬敞的候診區以及初診病患的諮詢 刷牙區
台，周圍不僅有整排的書櫃，有各種張醫師精選的書刊
診所內設置多
提供候診病患自由選擇，最難能可貴的是大面積的落地
處刷牙區和鏡
窗，讓光線自然而豐富的灑入，舒適而且無壓。
子，一方面增
加診所明淨之
向內進入看診區，同樣的還是一整排的落地窗真
感，更重要的
是令人感到驚艷，這對於整天在診所內工作的牙醫師而
是方便助理隨
言，這真是一個天堂！因為只要自然的一抬頭，就可以
時可以檢查病
看到窗外中庭的綠樹，可以讓工作中的壓力與緊張感自
患是否已經把
然的舒緩；看診區是開放式的安排，平行的放置八張診
牙齒刷乾淨。
療椅，並且前方有足夠的陪診空間，方便醫師與家長溝
需要時則立刻
通，或是讓候診病患能 standby，這樣的設計方便順暢的
可以清潔，毋
處理大量病患。
須等待。

診療台後方的供應區，主要是擺放看診器械及病
歷資料，讓所有的治療過程都能有足夠的後援，供應區
台面上的 Apple 桌上型電腦 iMac 也提供醫師在治療時所
需要的資訊，舉凡術前、術中的照片記錄，治療過程的
病患獨立 Keynote 檔案，特殊檢查的X光片或是 3D 立體 貝多芬矯正中心-診療運作系統
電腦斷層掃描資料，都能毫無遺漏的完整呈現，還有還
有，櫃台掛號資訊系統也整合在 iMac 裡面了，包括病患 貝多芬矯正最值得研究的，應該是它的診療運作系
報到，等候時間，收費以及預約項目都清清楚楚，病患
統。診所內的每日看診病患量非常大，而且每天到診所
看診結束，助理也及時的將病歷記錄和照片輸入完成。
內支援的住院醫師及專科醫師組合都不相同，但是對於
當然囉，所有的工作站之間都是內部網路連線的，這
病患的處理卻都能依照標準作業流程，按步就班的貫徹
樣，不管醫師走到哪裡，只要有電腦，配合診療過程，
張醫師為病人量身訂作的治療計畫，而且效率依然一
所有的病例資料都可以一覽無遺。
流！這要歸功於精簡明暸的病歷設計，不論病患的外
觀、口內照片、主訴、基本資料、治療計畫、拔牙位
置、特殊發現等，都整合在一張病歷紙上，一目了然！
每位住院醫師只要看到病歷上的指示，依照標準操作方
式完成每個病例每次的調整，不管是由誰操作，治療的
結果都能成就完美。這表示，只要診斷正確，貝多芬矯
正牙醫的標準作業流程如果複製到其他牙醫診所，每一
位醫師都能如此輕鬆、快樂、有效率的完成矯正治療！

圖像式病歷
病患候診區 病歷第一頁是病患初診的
陪同的家長可以清楚的看到醫師進行的步驟，醫師 圖像資料，病人的相關問
也可以直接和家長溝通，創造出一個讓病人安心、 題一目了然，亦方便醫師
家長放心的看診環境。 與病人間的溝通。
貝多芬矯正中心-牙科繼續教育
也許大家都會有疑問，住院醫師的訓練不是應該 講，張醫師有機會都會邀請他們參觀診所，張醫師會為
經過4~5年嗎？為什麼大家都能這麼快的進入狀況呢？我 他們簡報介紹診所的運作以及訓練課程，我們看到這些
想答案應該是「標準訓練流程」。所有的住院醫師都需 國際大師他們專注而且驚訝的表情，相信貝多芬牙醫在
要經過張醫師的矯正基礎班、進階班的訓練，然後繼續 他們心中都留下了深刻的印象。
在精修班中逐漸精進成熟。張醫師的教學活潑而且與門
診同步，您很難看到萬年不變的教材幻燈片，因為張醫 貝多芬矯正中心-出版專業刊物
師自己一直在進步。我們會看到就在上個禮拜或是昨天
News ＆ Trends in Orthodontics
門診中遇到的病例，及時的套入當天的課程主題，而且
更令人驚奇的是，當天上完的課程，下午的門診病患裡
貝多芬矯正中心經過張醫師十幾年來的經營，深
就有同一類型的病例，真是現學現用零時差！
獲病人的信任與支持，除了提供矯正專業服務外，張醫
師也致力於繼續教育的開辦以及國內外學術活動的交
貝多芬矯正中心-國際化課程 流。為了讓更多牙醫師能有一個實務交流平台，張醫師
也出版了一份著重牙科實務經驗分享以及報導國外矯正
張醫師所設計的課程，不光適合國內醫師，就連 新知的季刊「News ＆ Trends in Orthodontics」，邀請國
國外的醫師也都踴躍報名參加 international workshop，每 內外知名牙醫師分享他們臨床上的秘訣，並且透過此平
個梯次的報名都非常踴躍，學員們結業後都說還要再來 台也讓貝多芬矯正的理念能夠透過教育，傳達給認同這
參加，可見張醫師的課程魅力非常吸引人！張醫師也同 份精神的醫師，並且對學習充滿熱忱，不斷精進。
時與國際接軌，國際間的演講邀約不斷，漸漸的成為另
一個台灣之光！另外，每每只要有國際學者到台彎演

（左）印尼國際
NEWS & TRENDS IN ORTHODONTICS
班醫師認真在模 A J O U R N A L O F I N T E R D I S C I P L I N A RY T R E AT M E N T F O R O R T H O D O N T I S T S

型上練習植入迷 Vol. 17 Jan. 1, 2010

你骨釘。 The Past, Present and Future Perfect Profession

Dr. Larry White

Why Damon System

（右）最新一期 Dr. John Lin

ABO Case Report : Management of Skeletal Class III

雜誌News ＆ Malocclusion with a Palatally Impacted Cuspid
Dr. W. Eugene Roberts
Trends in
Orthodontics，
封面為張醫師所
設計矯正之父
Dr. Angle 之塑
像。

News & Trends in Orthodontics is an experience sharing magazine for worldwide orthodontists.
Download it at [Link]
 (左圖)資深助理正在電腦上進行新進助理訓練。

(右下圖)貝多芬醫師團隊。

貝多芬醫療團隊
貝多芬醫療團隊，當然不是由張醫師一個人單打獨 準備好了之後由住院醫師先執行治療計畫，之後由張醫
鬥，因為我們面對的是廣泛的病人群，年齡從0歲到99 師檢查、微調。最後再由助理來指導病患口腔衛教，橡
歲。沒關係，小的可以送到安徒生兒童牙醫，年長者有 皮筋的佩戴、術後注意事項....等等，然後結束回診流
贗復專科解決您「無牙」的問題，牙周病及植牙方面有 程。助理在病患及醫師之間，扮演重要的關鍵角色，就
牙周專科醫師，其餘如口腔外科及根管治療、一般牙科 像鋼筋永遠需要水泥一樣，如果您診所的助理還沒能達
都有專人負責，因為都是團隊內轉診，團隊醫師群共同 到您的理想，請參加貝多芬舉辦的專業助理訓練班吧！
來照顧，對於治療計畫的擬定及溝通較為直接且方便，
對於病患的照顧當然是無微不至。

當然，有一群像貝多芬牙醫的全能助理是必要
的。助理群也是貝多芬牙醫治療標準流程的重要關鍵！
每一位新病人從進入診所開始，就由專業的公關組助理
引導填寫基本資料，並介紹環境及諮詢流程，並且拍攝
收集病患的口外及口內照片、取模。而在每日的門診治
療流程，則由資深的助理組長來指揮，跟診助理引導回
助理正在蘋果電腦上對病人進行初診諮詢。
診病患就診前刷牙，看診前對病患的關心及詢問，器械
安徒生兒童牙科 守護孩子口腔的健康
安徒生兒童牙科-緣起 入診所的場景中，並結合童趣的想像信手塗鴉，留予親
子間歡欣共處的童話氛圍。希望在寶貝的成長過程中，
在貝多芬矯正中心與一般牙科深耕新竹公學新
看牙不只是為了健康，也能是一件有趣、親子同樂的經
村社區多年後，社區的里長跑來跟貝多芬院長張醫師反
驗。從依孩童身高設計不同高度的刷牙檯面，兒童專屬
應說，社區的孩子牙齒痛都需要跑到市區才能得到專科
的廁所，到兒童專屬的遊戲區和閱讀區，安徒生從許多
的照顧，里長伯代表社區的家長們希望貝多芬也能在社
細節裡體現一個以兒童為中心的診療環境。
區開一個專門為兒童設計的兒童牙科。因為聽到社區民
眾的心聲，以及許多在貝多芬做矯正的家長也在反應一 安徒生兒童牙科-長期完整保留兒童口腔資料
樣 的 需 求 ，2 0 0 8 年 元 旦 我 們 開 設 了 「 安 徒 生 兒 童 牙
科」。安徒生的院長徐玉玲醫師表示，安徒生的理念是 對兒童牙科而言，安徒生希望能提供的是長期
希望能塑造ㄧ個父母安心，孩子開心的看牙環境，提供 照護，因為生長的過程中，除了在心理上漸漸與小朋友
永續優質的服務，照護不僅是孩子的口腔生理與心理的 建立關係之外，在口腔顏面發育的部份更希望能透過口
健康。 內外照片的收集與追蹤，充分掌握整體口腔健康，骨骼
生長的情況。所以，為了達成這個目的，每位孩子的資
安徒生兒童牙科-環境介紹
料完整收集，電腦傳輸方式以及大量資訊的統合整理，
診所以經典童話作家安徒生命名，將耳熟能詳 安徒生都採用最先進的軟硬體技術，高畫質數位單眼相
機與即時無線傳輸直接到個人病歷，以及蘋果電腦方便
的故事，如國王的新衣、賣火柴的小女孩、拇指姑娘融
的雙作業系統界面功能，兼顧健保作業及儲存個人影音
記錄等作業系統。一點一滴地保存所有小朋友的生長及
看牙記錄，藉以提升學術及研究與服務品質。

安徒生兒童牙科-兒童衛教

預防勝於治療，尤其是幫年紀尚幼的孩子處理
蛀牙更是一項挑戰父母與醫師心臟的浩大工程，有鑑於
此，衛生健康教育應向下紮根，所以安徒生兒童牙科除
了現在已有幼稚園定期來院檢查塗氟之外，希望還能定
期為社區媽媽充實口腔知識以及提供一對一教學，幫助
媽媽們從小幫助孩子養成正確的觀念與習慣。另外與孩
子口腔健康有切身相關的領域，就是乳牙幹細胞的培
養。有鑑於國內外此方面的研究發展已漸臻於成熟，聰
明的爸媽除了自寶寶出生後打好口腔健康的基礎，更要
懂得保存未來的本錢。

（左）依兒童身高所設計的高低刷牙台 （右）診療台頂上就是繽紛的花朵，讓孩子徜徉在童話的懷泡裡。
金牛頓藝術科技 牙醫科技教育中心

透過三階段的
Keynote高效簡
報課程，醫師
學習製作一流
的Keynote幻燈
片簡報，並加
強自身的簡報
魅力與技巧。

成功的牙醫師們經常要面臨的兩難就是，想學的 時授課的電腦簡報內容轉化為視訊影片，並安裝在 iPod

新技術這麼多，永遠抽不出足夠的時間讓我們好好坐下 touch 或 iPad 裡。不論是已經上過課希望溫故知新，或是
來，完整地聽一場演講或是從頭到尾讀完一本新書。金 沒時間親自來上課的牙醫師，都可以透過反覆觀看這些
牛頓藝術科技將貝多芬精湛的臨床技術以及完整的教學 包含清楚分解動作的視訊影片，來增強高效學習的效
系統，透過蘋果科技的硬體 iPod touch 以及軟體 果。由於 iPod 視訊課程是完全數位化的內容，也方便日
Podcast，變成隨時隨地可以學習矯正的行動學習工具， 後任何的修改和更新，所以完全不用擔心一旦有新的修
已經掀起國際矯正界的一場學習旋風。 正或改變，過去已經購買的珍貴資料就變成明日要被淘
汰過期的垃圾。

金牛頓藝術科技
教學利器蘋果電腦+Keynote

金牛頓除了提供牙科專業視訊課程外，也負責設
計、規劃、維護貝多芬牙醫團隊的教學資訊環境。舉例
來說，日前台大張心涪主任帶著目前仍在美國接受矯正
專科訓練，正好回台休假的女婿來參觀貝多芬。診所當
天剛好有一個門診手術的個案，訓練有素的助理們有些
協助醫師執行臨床上的步驟，有些則進行手術過程的攝
影及錄影。待手術過程結束後，助理立刻就將手術的照
片放入病人專屬的 Keynote 簡報檔案中，連同病人過去
金牛頓藝術科技 的病例照片，以及剛才的手術錄影畫面，一起整理在這
行動學習iPod touch + 視訊課程 個病人的電子病例檔案中。執刀的醫師則立刻在電腦銀
幕上秀出這個病人的治療歷程，向病患及家屬說
張慧男醫師率先研發將 Damon 高效矯正、迷你
明治療的進程以及療效，之後則繼續利用這
骨釘 OrthoBoneScrew 以及助理訓練這三種屬性完全不
個案例與張醫師進行深度的專業個案討論。
同，但是又與牙醫師在職教育密切相關的課程，透過蘋
討論結束後立刻將這個案例的電子檔燒成光
果電腦內建的簡報軟體 Keynote，製作成以照片和影片為
碟，讓張醫師和他的女婿可以帶回去做進一
主的簡報檔案，再透過軟體本身內建的轉檔功能，將平
步的研究。
金牛頓藝術科技 牙科醫療器材研發
一般醫師可能認為這需要幾個實習醫師花上一個 貝多芬未來展望-植牙中心
星期才能做出來的病例報告，利用適當的科技工具，這
一切在短短的30分鐘內就全部完成了，不論是與病人， 近年來，貝多芬
家屬溝通，訓練新進醫師、助理或與其他資深醫師進行
病人結構逐漸由兒童青
專業討論，蘋果電腦加上 Keynote 的組合，讓進行個案討
少年轉型趨向成人的比
論和製作專業訓練教材，變得輕而易舉。再搭配 Keynote
例越來越多，這意味
最新加入的即時錄音功能，醫師教學講解的內容可以透
著成人對美感的要求
過電腦內建的麥克風錄下來，透過影片轉檔的功能，新
也愈發強烈，但這也是
製作好的教學內容就可以放入 iPod，讓你立刻隨身帶著
貝多芬的全新挑戰，因為面對成人的治療時，往往
走。 除了牙齒排列的問題需要矯治外，牙周病，大範圍的缺
牙，舊有假牙補綴物汰舊以及矯正後的植牙或假牙補綴
評估，重建。因此貝多芬有義務，也必須為成人提供矯
金牛頓藝術科技-研發迷你骨釘OrthoBoneScrew
正前中後完整的全面專業的治療建議與治療。

由貝多芬矯正中心的實務經驗出發，張慧男醫師
過去一般認為成人的牙科治療只需要兩個專科；牙周與
領導開發矯正用的迷你骨釘，金牛頓的研發團隊包含國 補綴，但我們現處於強調 inter-disciplinary 科際間協同治
內外學界專家如 University of Indiana-Purdue 牙醫所所長 療的時代，其中，矯正與植牙更是扮演了協同治療中最
Dr. Eugene Roberts 教授，中央大學林上智教授，以及國 重要的兩個支柱，矯正提供了地基，植牙則是蓋房子的
內知名矯正醫師林錦榮醫師等。兩年來不斷改進，深受 支柱，因此，貝多芬植牙中心的成立，是為了要提供病
國內醫師的喜愛。透過矯正骨釘的使用，可以大大減少 人更完善的治療，以及建構更完整的貝多芬醫療專業。
因為矯正需要拔牙的機率，傳統上某些特殊需要接受手
術矯正的案例也可以透過骨釘獲得不錯的治療效果。 貝多芬體系的核心價值在於教育兩字，植牙中心也將
落實教育當作成立的最高宗旨，透過課程的建立，
會讓貝多芬各個專科的駐診醫師擁有相互溝通的舞
張 台，張醫師相信，唯有在課程中出來報告給參與的
慧 學員分享，才會真正的認真整理自己的病例或是將
男
自己的治療心得內化成有系統的 SOP。透過ㄧ次次
醫
師 的整理，相互討論，無形中能提升醫師的專業能
與 力，醫療品質也相對提升。
研
發
貝多芬植牙中心即將於 2011 年成立，在今年，
人
員 我們成立了植牙論壇，預先替矯正及植牙科際協同
討 整合治療作暖身，也希望對學習有相同熱忱的醫師
論 能夠加入我們，一起為提升醫療品質作努力。
迷
你
螺
絲
的
製
造
細
節
News & Trends in Orthodontics will be
available on the iPod / iPad soon !
NEWS & TRENDS IN ORTHODONTICS
A JOURNAL OF I N T E R D I S C I P L I N A RY T R E AT M E N T FOR ORTHODONTISTS

現今的牙科治療是各科統合彙整的時代，協同矯正、植體、牙周、補綴讓治
療成果臻於完美是我們追求的目標。此期摘錄 DR. SAMUEL LEE 的
CRESTAL SINUS LIFT PROCEDURE 與邱上珍醫師在金牛頓植牙論壇與大家
分享關於 BIOLOGIC WIDTH 的內容。
 INTERDISCIPLINARY TREATMENT NTO 18

Crestal Sinus Lift:

A Minimally Invasive and Systematic Approach to
Sinus Grafting
Samuel Lee, DDS

addition to producing superior emergence profile.21 Use of

Introduction
such implants in molar areas may also decrease fracture
risk, crestal bone stress, and allows fabrication of a natural
Due to pneumatization of the maxillary sinus, poor
occlusal table.20 The purpose of this paper is to describe an
bone quality and quantity, treatment of posterior edentulism
innovative surgical technique that combines a crestal
has been and continues to remain a challenge for dental
internal sinus lift with use of wide diameter implants.
physicians. Traditionally, these obstacles are overcome by
bone condensing and grafting into the maxillary sinus
beneath the Schneiderian membrane.1-18 Bone grafting into
Description of Surgical
the sinus has produced predictable results enabling Technique
clinicians to place longer implants for more stable
Flap Elevation
prostheses and better long term outcomes.3 Although final
outcomes have proved satisfactory, sinus augmentation via Incision design that is at least 2 mm palatal to desired

lateral window grafting procedures produces substantial implant position and flap elevation that does not extend

patient morbidity.5-7, 15, 17, 18 Because this technique involves beyond the mucogingival junction is recommended (figure
flap elevation beyond the mucogingival junction, bruising, 1). This incision design allows for minimal pain, unilateral
swelling, and pain are common postoperative flap retraction, the option of doing one or two stage implant
complications.5-7, 15, 17, 18 An additional intraoperative placement without losing keratinized tissue, and the ability
complication associated with this procedure may arise from to treat oral antral communications in case of excessive
the laceration of the intraosseous branch of posterior Schneiderian membrane perforation.
superior artery (branch of maxillary artery).15 Finally, the Location of Crestal Window
technique sensitive nature of the lateral window approach
When performing this technique, the lowest point of
carries a risk of Schneiderian membrane perforation during
the maxillary sinus should be located by means of
window preparation and membrane elevation. In an attempt
radiographic or cone-beam/ct options (see arrow in figure
to forgo the risks and complications of lateral window sinus
2). It is most favorable when this position coincides with
augmentation, a number of internal (crestal) approaches to
implant position. If implant placement at sites #17, 16, and
have been introduced such as osteotome5-7, reamers17,
15 are anticipated with site #16 being the lowest point in the
tapping drills18, piezoelectric, ISM17, and HSC.15 With most
maxillary sinus floor, site #16 should be used to lift the
of these internal techniques for sinus augmentation, poor
sinus membrane.
visibility during manipulation of the Schneiderian
membrane remains a problem. While a great solution for the Crestal Window Preparation and Membrane Lift
premolar region, use of standard diameter implants (4.0mm) To perform the crestal internal sinus lift, a round
in the molar region has limitations such as poor emergence window is made on the crestal bone with a set of specially
profile, implant fracture, and crestal bone strain.19-21 Large designed trephine burs that have a diameter 1 mm less than
platform diameter implants may overcome poor bone the final implant size. For example, if a 6mm implant is
quality by increasing bone to implant surface contact in anticipated, a 4.0mm (inner diameter) x 5.0mm (outer
NTO 18 INTERDISCIPLINARY TREATMENT

Samuel Lee, DDS (left)

Samuel Lee graduated from UCLA School oF Dentistry and UCLA

Microbiology and Molecular Genetics. He served as clinical lecturer at
Restorative Department at UCLA School of Dentistry after graduation. He
practiced implant dentistry and orthodontics at First Choice Dental Group.
Buena Park. California, until he moved to Boston at Harvard School of Dental
Medicine as Research Fellow in Periodontology.

Figure 1: Palatal incision design. Figure 4: Crestal marking after use of pointed trephine.

diameter) trephine is used. Unlike the conventional trephine

techniques that require 700-1000 rpm with ample irrigation,
this technique utilizes lower speeds of 40-50 rpm without
irrigation and is referred to as a “Waterless technique.” The
waterless technique has the advantage of not washing away
autogenous bone filings during bone manipulation, thus
allowing the surgeon to collect an increased amount of
autogenous bone.18 Conventional trephining with precision
is often challenging due to skipping or drifting of the
Figure 2: Crestal sinus lift initiated from lowest point of trephine during initial bone cutting. To minimize this
maxillary sinus (arrow). complication and maximize visualization and precision of
the trephine bur, a “pointed trephine” is used at a speed of
50 rpm without irrigation (figure 3). The pointed trephine is
used to mark the location of the intended crestal window
and only penetrates the cortical crest (figure 4). The second
step in this technique utilizes a trephine with an internal
adjustable stopper (ASBEtrephine). Radiograph or cone-
beam/CT is used to measure the width of residual native
bone from the ridge crest to the floor of the sinus and 1
millimeter is subtracted from this distance. The adjustable
stopper within the ASBE trephine is then set to such a
length to prevent perforation of the maxillary sinus floor.
For example, if 6mm of native residual bone remains from
Figure 3: Pointed trephine used to mark precise
the ridge crest to the floor of the maxillary sinus, the ASBE
location of crestal window position.
trephine adjustable stopper is set to 5 mm. At a speed of 50
 INTERDISCIPLINARY TREATMENT NTO 18

Figure 5: Adjustable stopper and bone ejector (ASBE) Figure 7: Specialized self-limiting diamond bur may
trephine used at 50 RPM to a point 1mm short of the be used to remove residual bone on sinus floor.

Figure 6: Sinus floor removed with trephine exposing Figure 8: Crestal window after use of specialized self-
Schneiderian membrane. limiting diamond bur.

rpm, the ASBE trephine is used to penetrate the ridge crest bur” is used to expose the Schneiderian membrane. The
and remove a bone core (figure 5). Although the ASBE specialized sinus diamond bur contains a shoulder stop that
trephine is set to a length 1mm short of the sinus floor, bone prevents drilling into the Schneiderian membrane.
core removal will often expose the Schneiderian membrane Additionally, as the sinus diamond bur grinds the residual
(figure 6). In cases where the sinus floor is extremely dense cortical bone, resultant fine bone particles act as a buffer
or on an inclined plane, 1mm of cortical bone may remain between sinus membrane and diamond bur (figure 7).
at the floor of the maxillary sinus. In the event that 1mm of With the third step in this technique, elevation of the
residual bone remains at the sinus floor following use of the maxillary sinus Schneiderian membrane is accomplished.
ASBE trephine, a specialized wide diameter “sinus diamond Following preparation of the crestal window, a “mushroom
NTO 18 INTERDISCIPLINARY TREATMENT

Figure 9: Mushroom elevator used to initiate Figure 10: Mushroom elevator may be used to remove
Schneiderian membrane elevation. residual bony ledges at crestal window.

Figure 11: Cobra elevator used to elevate Figure 12: Cobra elevator further elevates
Schneiderian membrane mesially and distally. Schneiderian membrane and may be used to scrape
sinus !oor to induce bleeding.

elevator” is used as a probe for tactile feel of the sinus floor Schneiderian membrane is felt, membrane elevation is
and detection of membrane exposure. The maxillary sinus initiated (figure 9). This same elevator is also used to break
floor is rarely perfectly flat, so it is common to find initial away any remaining ledges of bone in the osteotomy site
sinus membrane exposure at the corner of the osteotomy that interfere with sinus membrane elevation (figure 10).
rather than at the center (figure 8). Once the mushroom After initial Schneiderian membrane elevation, the “Cobra
elevator slightly drops into the maxillary sinus and the sinus elevator” is used to further elevate the sinus
 INTERDISCIPLINARY TREATMENT NTO 18

Figure 13: Bone graft added to prepared maxillary Figure 14: Lateral condensation of bone graft into

Figure 15: Implant insertion into prepared maxillary Figure 16: Case 1 presurgical radiograph of left
sinus. maxillary sinus.

membrane and scrape the bony sinus floor to promote A combination of lateral and vertical condensation of
bleeding in the sinus cavity (figures 11 and 12). particulate bone is used to augment the sinus and produce
additional lift of the Schneiderian membrane (figures 13
Bone Condensing and Implant Insertion and 14). Lateral bone graft condensation is critical to
To accommodate a wide diameter implant of reducing pressure on the Schneiderian membrane and, thus,
sufficient length, bone graft is added to the maxillary sinus. reducing the risk of perforation. This method facilitates
NTO 18 INTERDISCIPLINARY TREATMENT

Figure 17: Case 1 cross sectional CT images. Figure 18: Case 1 left maxillary ridge following use of
ASBE trephine. Note exposure of intact Schneiderian
membrane.
healing by increasing blood supply from the lateral and
medial wall. Underpreparing the diameter of the osteotomy
in relation to the implant is recommended to achieve bone
compaction and improve initial fixture stabilization (figure
15).

Case ▶ ❶

A 29 year old non-smoking Asian female with a

noncontributory medical history had extraction of tooth #14
three months prior to implant surgery and site #15
edentulism for 5 years. Preoperative radiographs showed Figure 19: Case 1 vertical condensation of bone into
maxillary sinus.
4-6 mm of residual bone height between the ridge crest and
the maxillary sinus floor (figure 16). Cross sectional CT
revealed no signs of sinusitis, ostium patency, and a thin
Schneiderian membrane (figure 17). Coincidentally, the
patient also had a very thin gingival biotype. There is no
known study correlating gingival biotype with Schneiderian
membrane thickness, but through the author’s clinical
experience it has been observed that patients with a thin
gingival biotype tend to have thinner sinus membranes
(unless he/she is a smoker). The patient’s sinus floor was
relatively flat, thus it was expected that the sinus floor could Figure 20: Case 1 lateral condensation of bone into
maxillary sinus.
be removed with the bone core after use of ASBE trephine
 INTERDISCIPLINARY TREATMENT NTO 18

Figure 22: Case 1 postsurgical radiograph and CT

image.

maxillary sinus. Figure 16: Case 1 presurgical radiograph of

left maxillary sinus. Figure 12: Cobra elevator further
elevates Schneiderian membrane and may be used to scrape
sinus foor to induce bleeding. Figure 13: Bone graft added
to prepared maxillary sinus. Figure 14: Lateral condensation
of bone graft into prepared maxillary sinus. Figure 17: Case
Figure 21: Case 1 closure. Note preservation 1 cross sectional CT images. implant osteotomy was under-
of buccal keratinized gingiva due to palatal
prepared in diameter to achieve good initial stability
incision design.
through compaction of porous quality bone during implant
placement. A palatal incision design allowed for
(figure 18). Trephine with the Waterless technique was used preservation of keratinized tissue following placement of
to remove the crestal bone core. Rotation of the bone core the healing abutments. (figure 21). Panoramic and CT scans
within the trephine is an indication that the sinus floor is were accomplished after surgery to verify proper grafting of
broken and no further apical pressure of the trephine is the maxillary sinus without perforation and to note
recommended to avoid cutting sinus membrane. horizontal compaction of bone graft touching the medial
Autogenous bone collected from the trephine was made into and lateral walls (figure 22).
particulate graft and condensed into the maxillary sinus.
Case ▶ ❷
After initial elevation of the Schneiderian membrane with
the mushroom and cobra elevators, slow bone compaction A 53 year old non-smoking Asian male with a
was accomplished by inserting the condenser no more than noncontributory medical history presented for implant
initial height of residual bone (figure 19). Next, lateral placement. Preoperative radiographic and CT scan
condensation was achieved by the use of a “sinus spreader” evaluation revealed a patent ostium and no signs of
instrument (figure 20). To allow for single stage implant sinusitis. The lowest point of the maxillary sinus floor was
surgery, the Figure 15: Implant insertion into prepared located at site #3 with residual bone height of 6.5mm. In
NTO 18 INTERDISCIPLINARY TREATMENT

Figure 23: Case 2 maxillary ridge following use of Figure 25: Case 3 maxillary ridge following
ASBE trephine. Note exposure of intact Schneiderian preparation with specialized self-limiting diamond bur.
membrane Note sinus membrane at center of preparation.

Figure 24: Case 2 postsurgical radiograph. Figure 26: Case 3 membrane elevation with
mushroom elevator.

this case, due to the high density of the sinus floor, removal achieved using demineralized freeze dried bone allograft
of the trephine core left approximately 1mm of residual (DFDBA) mixed with autogenous bone graft (figure 24).
bone on the sinus floor. The self-limiting sinus diamond bur
Case ▶ ❸
was used to safely expose the Schneiderian membrane
(figure 23). Next, the Schneiderian membrane was elevated A 60 year old Asian patient with a noncontributory
with the aforementioned elevators and bone grafting was medical history and current smoking status presented for
 INTERDISCIPLINARY TREATMENT NTO 18

Figure 27: Case 3 crestal osteotomy following ledge Figure 29: Case 3 cross sectional CT image. Note
removal. excellent lateral condensation.

Figure 28: Case 3 post surgical radiograph. Note Figure 30: Case 4 presurgical radiographic image of
12mm elevation at site #14. left maxillary sinus.

implant treatment. Radiographic and CT scan evaluation to penetrate to the bone directly instead of using trephine
revealed residual bone height of only 1.5mm at site #14. As bur because the residual bone height was only 1.5mm
this site was the lowest point of the maxillary sinus in (figure 25). After visual confirmation of sinus membrane
relation to the residual ridge, site #14 was used to lift the exposure, membrane elevation was accomplished with the
Schneiderian membrane and an implant was placed at sites Figure 25: Case 3 maxillary ridge following preparation
#13 and #14 after grafting. The sinus diamond bur was used with specialized self-limiting diamond bur. Note sinus
NTO 18 INTERDISCIPLINARY TREATMENT

Figure 31: Case 4 cross sectional CT image of Figure 33: Case 4 two year postsurgical radiograph.
initial bone condensation.

Figure 32: Case 4 radiographic image following Figure 34: Case 5 presurgical radiographic image of
additional implant placement. left maxillary sinus.

membrane at center of preparation. mushroom elevator was then condensed into the sinus and the implant was
(figure 26). A remaining ledge of bone in the osteotomy was inserted, skipping the last drill sequence (4.3 mm diameter
removed with an implant osteotomy drill at low speed using drill instead of 4.6 mm drill for 5.1 mm implant). Good
the waterless technique (figure 27). After bony ledge primary stabilization of the implant was achieved and a
removal, introduction of “cobra elevator” was possible to postoperative radiograph revealed adequate sinus
further elevate the sinus membrane in all directions. Bone augmentation (figure 28). Cross section from a CT scan
 INTERDISCIPLINARY TREATMENT NTO 18

Figure 35: Case 5 membrane insertion into prepared Figure 36: Case 5 postsurgical CT image. Note
maxillary sinus. excellent lateral bone condensation and resorbable
membrane (arrow).

showed the medial and lateralwall fully elevated to One mistake that the author made was not overgrafting with
maximize blood supply to the graft (figure 29). Note the DFDBA. It is the author’s experience that DFDBA tends to
thickness of the Schneiderian membrane on the unelevated resorb faster and have more shrinkage than other bone graft
lateral and medial walls. Because this patient was a smoker, materials. However, one advantage is that it is not too
the membrane is exceptionally thick. radiopaque. Therefore, when DFDBA is replaced by host
bone, the clinician can have visual confirmation by
Case ▶ ❹ observing radiopacity from new bone as well and new
A 53 year old patient with a non-contributory medical cortical bone formation on the new sinus floor (figure 33).
history and current heavy smoking status presented for
implant treatment. As was the case with the patient in Case Case ▶ ❺
3 of this series, the patient’s smoking history resulted in a
Schneiderian membrane that was very thick. Radiographic A 39 year old non-smoking Asian patient presented
and CT scans revealed a patent ostium, no signs of sinusitis, for implant treatment. Radiographic and CT scans revealed
and 2mm of residual bone height at site #15 (figure 30). The a patent ostium, no signs of sinusitis, and a residual bone
lowest point of the maxillary sinus (site #15) was used to height only about 2mm at sites #14 and #15 (figure 34).
elevate the Schneiderian membrane. Sinus augmentation Under preparing the implant osteotomy is crucial in this
was achieved with DFDBA using mostly with lateral case to make initial stabilization successful. As discussed
condensation rather than vertical condensation (figure 31). above, the crestal window approach is easier if residual
Implants were placed at sites #13, #14, and #15 (figure 32). bone height is thin as in this case. To avoid bone shrinkage
as observed in case 4, the author used a long lasting
NTO 18 INTERDISCIPLINARY TREATMENT

proper sinus instrumentation (mushroom, cobra, bone

carrier, vertical condenser, lateral condenser) and bony
cutting tools (pointed trephine, ASBE trephine,
sinusdiamond bur), the crestal window approach is
predictable and results in similar outcomes to lateral
window techniques in terms of membrane elevation and
bone condensing. Indications for the crestal window
technique are an edentulous maxillary posterior site with
residual native bone height of 1-7mm. It isthe author’s
experience that elevation of the Schneiderian membrane
with the cobra elevator is easiest when there is less residual
bone height as this reduces interference of bone on the

Figure 37: Case 5 post surgical radiograph. instrument during membrane elevation. In cases of
extremely thin residual bone, the author recommends that
the sinus diamond bur be used to penetrate to the bone
directly instead of using the trephine. This will reduce the
resorbable membrane under the Schneiderian membrane.
likelihood of Schneiderian membrane laceration. Finally, as
The crestal window in this case was only 4mm in diameter.
a terminal step prior to bone grafting, the author
Therefore, insertion of the resorbable membrane was
recommends the cobra elevator be used to induce bleeding
achieved by rolling the membrane after soaking in saline
inside the sinus by scraping the bony floor.
with tetracycline (figure 35). Lambone has excellent
plasticity, so once inserted into sinus cavity via crestal
Conclusion
window it will open and return to its original shape (see
arrow in figure 36). Postoperative radiograph evaluation The crestal window technique is an alternative to
revealed an adequate sinus augmentation housing implants conventional lateral window and closed maxillary sinus
at sites #13-15 (figure 37). augmentation techniques. This technique requires the use of
specialized instrumentation that is unique to the procedure.
Discussion

The morbidity associated with lateral window sinus Disclosure

augmentation and the “blind” nature of closed sinus lifts * Dr. Samuel Lee is the inventor of, and has a financial interest
necessitated the need for an alternative to these techniques. in, the instrumentation kit described in this article.
** All instrumentation used in this article manufactured by
As shown in the many clinical cases of this series, the MegaGen Co., LTD
“Crestal Window Technique” predictably allows for
elevation of the Schneiderian membrane without the
morbidity associated with lateral window technique. With
 INTERDISCIPLINARY TREATMENT NTO 18

References

1. Tatum H. Maxillary and sinus implant reconstruction. 12. Fugazzotto P, De P. Sinus floor augmentation at the
Den Clin North Am 1986; 30: 207-229. time of maxillary molar extraction: success and failure
2. Boyne P, James R. Grafting of the maxillary sinus rates of 137 implants in function for up to 3 years. J
floor with autogenous marrow and bone. J Oral Surg Periodontol 2002; 73: 39-44.
1980; 38:613-616. 13. Winter A, Pollack A, Odrich R. Placement of
3. Misch C. Maxillary sinus augmentation for endosteal implants in the severely atrophic posterior maxilla
implants: organized alternative treatment plans. Int J using localized management of the sinus floor: a
Oral Implant 1987; 4: 49-58. preliminary study. Int J Oral Maxillofac Implants 2002;
4. Garg J, Quinones C. Augmentation of the maxillary 17:687-695.
sinus. A surgical technique. Pract Periodontics Aesthet 14. Soltan M, Smiler D. Antral membrane balloon
Dent 1997; 9: 211-219. elevation. J Oral Implantol 2005; 31: 85-90.
5. Summers R. The osteotome technique: part 3 – less 15. Chen L, Cha J. An 8-year retrospective study: 1,100
invasive patients receiving 1,557 implants using the minimally
methods of the elevating the sinus floors. Compendium invasive hydraulic sinus condensing technique. J
1994; 15: 698-704. Periodontol 2005; 76: 482-491.
6. Summers R. The osteotome technique: part 2 – the 16. Wallace S, Froum S. Effect of maxillary sinus
ridge expansion osteotomy (REO) procedure. augmentation on the survival of endosseous dental
Compendium 1994; 15 :422-426. implants. A systematic review. Ann Periodontol 2003;
7. Summers R. A new concept in maxillary implant 8: 328-343.
surgery: The osteotome technique. Compendium 1994; 17. Yamada J, Park H. Internal sinus manipulation
15: 152-158. (ISM) procedure: A technical report. Clin Implant Dent
8. Bori J. A new sinus lift procedure: Sa-4/”O”. Dent Relat Res 2007;9: 128-135.
Implantology Update 1991; 2: 33-37. 18. Lee S, Lee G. Minimally invasive sinus grafting
9. Smiler D. The sinus lift graft: basic technique and with autogenous bone. Implant Trib 2008;3: 8-10.
variations. Pract Periodontics Aesthet Dent 1997; 9: 19. Petrie C, et al. Increasing implant diameter resulted
885-893. in 3.5-fold reduction in crestal strain. Clin Oral Impl
10. Bruschi G. Scipioni A, Calesini G, Bruschi E. Res 2005;16: 486-494.
Localized management of the sinus floor with 20. Davarpanah M, et al. Wide diameter implants: New
simultaneous implant placement: a clinical report. Int J concepts. Int J Periodontics Restorative Dent 2001;21:
Oral Maxillofac Implants 1998;13: 219-226. 149-159
11. Toffler M. Site development in the posterior maxilla 21. Degidi M, Piatelli A, Iezzi G, Carinci F. Wide
using osteocompression and apical alveolar diameter implant: Analysis of clinical outcome of 304
displacement. Compend Contin Educ Dent 2001;22: fixtures. J Periodontol 2007;78: 52-58
775-784.
NTO 18 INTERDISCIPLINARY TREATMENT

Let’s talk about “Biologic width”

What is biologic width? ensure the long term health of gingiva tissue.
Violation of biologic width can cause the gingival
Biologic width is a physiologic dimension of soft inflammation, pocket formation and possible bone
tissue around natural teeth and implant. It plays an loss. It often seen at the area of restoration or crown
important role as a protective barrier for the margin placed at 2 mm or less to the alveolar bone.
underlying bone from being insulted by the oral Surgical crown lengthening can help to re-build up the
bacteria. In 1961, Gargiulo 1 did a study to measure biologic width and regain the health of gingiva tissue.
the vertical dimension of dentogingival junction
In orthodontic treatment, we often encounter a
around natural teeth. He found that the healthy
situation of short clinical crown and which may need
gingival sulcus is about 0.69 mm, the junctional
to do some correction for better esthetic outcome.
epithelium is about 0.97 mm and the connective tissue
Fig.2 is an upper anterior view of a 22 y/o male
attachment is about 1.07 mm. The combination of
patient who just finished orthodontic treatment 2
junctional epithelium and connective tissue
months before. This patient presented with a
attachment are subsequently called the “biologic
congenital missing right lateral incisor, a secondary
width”, which is about 2 mm. (Fig 1)
caris on left lateral incisor, a mild gingival overgrowth
between two central incisors and short clinical crown
on both canine. The treatment plans include (1) crown
Clinical application
lengthening on both canine, (2) gingivoplasty on the
papilla between two central incisors (3) implant
In clinical perspective, biologic width is an
unique transition zone and should be respected to placement at right lateral incisor, and (4) veneer on
the left lateral incisor.
The patient’s treatment sequences were as
followings: We first made a diagnostic wax-up to
determine the final position of the free gingival
margin and made a surgical stent accordingly (Fig 3).
Sulcus: 0.69 mm By using the surgical stent we can outline the final
Junctional epithelium: 0.97 mm free gingival margin and remove excess tissue (Fig 4).
C.T. attachment: 1.07 mm However, after above procedure,we found out that the
free gingival margin to the bone is only 2 mm (Fig 5).
Free gingival margin to
As we know the biologic width is about 2 mm and by
bone: ~ 3 mm
adding the additional 0.69 to 1 mm for the sulcus
depth, we need about 3 mm from free gingival margin
Fig 1. to alveolar bone to ensue the long term stability of
 INTERDISCIPLINARY TREATMENT NTO 18

Dr. Shang-Chen (Grace) Chiu

Beethoven Orthodontic Clinic

Diplomate, American Board of Periodontology

gingiva margin. Therefore, we further removed 1 mm bone

(Fig.6). In Fig.6 we can see after ostectomy, the free gingival
margin (surgical stent as reference) to alveolar bone is 3 mm.
There is one thing important: When we performed the
ostectomy, we only removed the bone on the buccal side and
half of proximal area. We kept the bone on the palatal side to
provide support, more importantly, we kept half of proximal
bone to avoid the black [Link] above procedure, we Fig 2.

know the free gingiva margin will stay in the final position.
We can have the esthetic outcome and can keep the result for
the long term.
In some occasion, even though we kept the 3 mm
distance from the free gingival margin to bone, the result of
crown lengthening is not satisfying. This is maybe caused by
the individual variation of biologic width. In 1994, Vacek et al
2 did a similar study of biologic width as Garguilo. He found
Fig 3.
that even though the biologic width showed average of 2 mm
dimension as Garguilo found, the individual variation could
be from 0.75 mm to 4.3 mm. Therefore, to get the specific
individual biologic width, we can perform the “ bone
sounding” (Probing from free gingival margin to bone under
anesthesia). After subtracting the sulcus depth, we can get the
biologic width for that specific area. When performing this
procedure on a couple different healthy gingiva of that person,
by average those numbers we can get the specific biologic Fig 4.
width for the person and can get more precise treatment.

How is the biologic width of implant?

Implant also has the biologic width, which is similar to
the natural tooth (Fig.7) and is composed of junctional
epithelium and connective tissue attachment.3 Abrahamsson et
al4 examined the soft tissue dimension around three different
Fig 5.
NTO 18 INTERDISCIPLINARY TREATMENT

implant system. He found that even though there is some

variation between the implant system with regards to the
soft tissue composition of biologic width, the distance from
free gingiva margin to bone is constantly around 3 mm.
Berglundh and Lindhe5 also found that peri-implant
mucosa required 3 mm dimension to prevent bone
resorption. Applying these concepts, the position of
Fig. 6 implant platform to the free gingiva margin should be
around 3 mm. In Fig.8, we can see by using the surgical
stent, we can easily identify the “pre-determined free
gingival margin” and place the implant 3 mm from that.
Fig.9 is the 2 weeks post-operative view. The healing was
uneventful. Now, we are waiting for gingiva becoming
Free gingival margin to stable (about 3 to 6 months) and osseointegration of
bone: ~ 3 mm the implant. Then we will make an veneer for left
lateral incisor and finish the crown on right lateral
Fig. 7
incisor.

References
1. Gargiulo AW, Wentz FM, Orban B: Dimension and
relations of the dentogngival junction in humans, J
Periodontal 32:262,1961.
2. Vacek JS, Gher ME, Assad DA et al:The dimension of the
humandentogingival junction, Int J Periodont Restor Dent
14:155,1994
Fig. 8 3. Schroeder A, van der Zypen E, et al: The reactions of bone,
connective tissue, and epithelium to endosteal implants
with titanium-sprayed surfaces. J Maxillofac Surg
9:15,1981
4. Abrahamsson et al. The Peri-implant hard and soft tissues
at different implant systems. A comparative study in the
dog. Clinc Oral Implants Res 7:212, 1996
5. Berglundh and Lindhe. Dimension of the Periimplant
muscosa. Biological width revisited. J Clinic Periodontol
23, 971,1996
Fig. 9
TaiwanJulyCourse1Pager2010_TaiwanJulyCourse1Pager2010 4/12/10 11:47 AM Page 1

USC Comprehensive Surgical and Restorative

Implant Training Program in Taiwan
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演講嘉賓: Stephen Wallace ★ Lyndon Cooper ★ Fernando Rojas-Vizcaya ★ Clark Stanford

•欲知詳情，請與以下單位聯絡•
USC 金牛頓藝術科技 義大醫院植牙中心
聯絡人：Julie 聯絡人：黃思涵 聯絡人：謝依珊
E-mail: [Link]@[Link] Email: thhuang@[Link] Email: ed102030@[Link]
電話: +1-213-821-5281 電話: (03)573-5676 電話: (07)615-0011*2970
傳真: (07)615-0913 傳真: (07)615-0913
 當矯正遇上植牙

2010 Newton’s A Implant Forum

金牛頓植牙論壇
Implant Technique + DDx + Basic Knowledge

現在的牙科治療已經是各科統合彙整的時代，協同矯正、植
體、牙周、補綴讓治療成果臻於完美是我們追求的目標。

金牛頓植牙論壇 邀請您一起迎接「協同性整合」的新牙
科時代，讓我們從植體與矯正的對話出發，透過整合各科精
華，締造集美觀、功能於一身的全方位治療。

✦ 時間：2010年每月底週五















早上9:00-12:00
✦ 地點：金牛頓教育中心












新竹市建中一路25號2樓
✦ 費用：18000（一月底前匯款完成）











20000（原價）












單次2500元
費用包含講義、視訊
(iPod
or
iPhone)
✦ 匯款帳號：109-25203060-000
戶名：金牛頓藝術科技股份有限公司

✦ 報名專線：03-573-5676
 透過精讀八篇結合矯正與植牙觀點的經典文章，並運用深入的


















黃思涵小姐 個案分析討論，讓醫師們能快速掌握植牙與矯正，以達成完美
治療的目標。
 2010 Implant Forum
Implant Forum Interdisciplinary Treatment Planning
9:00 ~ 10:30 10:45 ~ 12:00
日期
( W5 ) 臨床導論
臨床祕訣 病例分析 講師 精選文章分析
主講者 張慧男

無菌觀念，手術基本觀念 Inter-relationship of Ortho, Perio,

1 02/26 臨床導論 邱上珍
植體設計與贗復組件介紹 Restorative Dentistry

2 03/26 臨床導論 引導骨再生及齒槽骨保存 王肖龍 Fundamental Treatment Planning

3 04/30 特別演講 講師 黃怡豪醫師 / 主持人 張慧男

4 05/28 臨床導論 植體的矯正考量 黃瓊嬅 Forced Eruption

5 06/25 微創手術操作 植體的軟組織處理 歐亦焜 Ant. Esthetic 1

6 07/23 特別演講 講師 謝尚廷醫師 王國華醫師 / 主持人 張慧男

7 08/27 臨床導論 前牙美觀區的植體考量 王肖龍 Ant. Esthetic 2

Inter-implant Papilla Consideration

8 09/24 臨床導論 上顎竇升高術 邱上珍
Peri-implant Architecture Preservation

9 10/29 特別演講 講師 吳碧礽醫師 / 主持人 張慧男 特別演講 講師 楊家華醫師 / 主持人 張慧男

10 11/26 臨床導論 3DCT應用與手術模板製作 歐亦焜 Save Tooth ! or Ext ?

11 12/31 臨床導論 六個植牙補綴物常見的盲點 方景亮 Establish Occlusal Scheme

實作課程 : 1. 植牙模型操作 2. 微創手術操作 ( 依學員需求另行安排時段， 費用另計 )

植牙論壇主要講師群 特別外賓
歐亦焜，王肖龍，黃瓊嬅，邱上珍 醫師
補綴顧問 : 方景亮 主任

參考書籍
Interdisciplinary Treatment Planning
吳碧礽醫師 王國華醫師 謝尚廷醫師 楊家華醫師 黃怡豪醫師
Contemporary Implant Dentistry 3rd, Misch
NTO 18 VOICES FROM THE ORTHODONTIC WORLD

Letters from
the Damon Progressive Study Club

Dear Sabrina
Just wanted to tell you how much I enjoyed Chris Chang’s presentations at
the Damon Forum in Scottsdale Arizona and Progressive Study Club in Hawaii.  
At the Forum he presented to over 1000 orthodontists and their staffs. He was
invited to speak on Impacted Cuspids and did a brilliant job.  It was one of the
finest presentations I have ever seen.  His manner of teaching should be a format
for orthodontic teachers around the world. It was very clear and precise and
amazingly he performs the necessary surgical procedures himself.   Showing
short video clips in his slides made the learning experience so easy.  He
focused on maxillary canines in Arizona.  

In Hawaii, he spoke to very progressive orthodontists and he focused his

lecture on the Mandibular impacted teeth.  Again in his wonderful presentation
style, he showed video clips and showed precisely how it is done.  Wonderful
learning experience to say the least.  Impacted teeth
are so often mishandled around the world and
now we have an exacting formula for treatment. I
appreciate the dedication of the Taiwanese
orthodontic teachers and particularly Chris Chang. I
hope that Chris can continue to teach worldwide.
Very Sincerely,

Tom
Dr. Chang's creative use of OrthoBoneScrews is truly remarkable. Deemed
impossible by well published and respected "experts" in our specialty, his case
demonstration of uprighting and recovering a severe
horizontally impacted mandibular cuspid was
nothing short of miraculous! We all have much to
learn from Dr. Chang, and I eagerly look forward to his
future presentations!

Ron Bellohusen DMD, MS

Bellohusen Orthodontics, NY, USA
 VOICES FROM THE ORTHODONTIC WORLD NTO 18

A Letter from the Visit of

the Beethoven Orthodontic Center

給我心中理想牙醫的一封信:
張醫師您好，參觀完你的診所之後，我就準備給你寫一封感謝信，因為我受
到很大的啓發。你的矯正課程實在太精彩了！回美之後，每天晚上我都沈醉其
中。你的演説深深的吸引著我，同時，我也對您產生了許多的尊敬，一種從心
底發出來的佩服，我不善於奉承別人，但是我認為我必須讓你知道你是多麼地
值得令人喝彩。

從我進入Dental School的那一天起，我就立志做一位好醫生，“Do No
Harm”是我們學校教我的第一件事情，但是有多少的醫師，為了本身的利益或尊
嚴，而不顧病人的利益。我一直認為病人找我看病，是因為他們相信我，所以
我必須做到值得讓他們信任。在你的診所，聽你對病人做 TREATMENT PLAN
的時候，我就知道你與很多很多的醫師不一樣，你的學術知識和專業理念都是
世界一流，很少人可以和你相比，但是，最令我佩服你的，不僅僅是你的知識
和專業；而是你完全以病人的利益為出發點去為病人考慮，即使你會因此而浪
費很多時間或是損失一些利益，你都願意堅持你的理念，為病人提供最好的冶
療。醫者仁也，本因該如此，可是現在的社會，又有多少人願意為了別人而犧
牲自己的利益呢？你是一位非常稱職的醫師。

當我昤聴你講課的同時，另一股敬佩由衷而生，你 生動精彩的演說，非常能
夠捉住聴眾的注意力 ，同時，我也為你喝采，因為你那種不願屈服，而又勇於
挑戰”學術權威”的個性，如今有多少人敢說真話？有多少人不怕得罪人？尤其是
那種有權威的人，而且又有多少人？可以就理論理，而不是糢糊觀念，任意批
評。當然，沒有實力的人，很難做到，可是有能力又肯說真話的人，實在太
少。另外，你敏銳的觀察力和不斷求進步的動力，都是你成功的原因，也是值
得我們學習的地方。你已經是世界一流的大師了，也有相當的成就，你還願意
不斷地創新，學習新的觀念和技術--好還要更好，更是你與一般大師不同的地
方。

太多太多的尊敬和佩服，都是出自於我的內心深處，您在AAO
的演講，相信已經給你許多的肯定。我雖然是矯正的門外漢，但
是，我深信你發表的技術課程和臨床操作的一致性。很感謝您不
藏所私，願意把你的經驗和技術分享給大家，台灣太需要像你
一樣的大師，一個願意為教育付出，帶領大家進步的耕耘者，
再一次的謝謝您！

Johnathon Lee D.D.S.

Cum Laude Art of Dentistry, General Dentistry, LA, USA
NTO 18 VOICES FROM THE ORTHODONTIC WORLD

A Letter from the Keynote Workshop

Dear. Dr. Chang:

First of all, I was much pleased to spend some time with you during your stay
in KOREA. Your lecture gave me a great inspiration to be a leading person in the
implant industry. As I mentioned before, I was taught by Dr. Park and he wants me
to be a best implant sales person in the world. Of course, my dream is the same as
Dr. Park’s plan and I hope that I will be a person who contribute enormously to the
MegaGen.

For this reason, your seminar for using Mac is very helpful for me because I
have lots of chance to do presentations and I have recently recognized that there is
a limitation to express my opinion by Power point during a presentation. I heard
about that Dr. Park is going to buy a Mac, and after that I’m going to buy a Mac
and begin to use Keynote.

Once again, thank you for giving me the great inspiration and remote controller,
it was very nice to meet you. I can definitely say that you are my Mentor for Mac.
Is it OK to ask you if I have questions during the use of Mac?

Thank you
Best regards,

Jun, Heo
Jun Heo, Dr. Chris Chang, Dr. Park (from
left to right)
 貝多芬矯正中心見習獎學金辦法

目的：
為促進國內牙科學術教育與牙科實務工作
間的學習交流，並鼓勵國內牙醫系所學生 ★ 甄選對象：全台灣牙醫系四升五年級學生
在學期間能認識牙科實務操作環境，貝多
★ 名額：每校3-5名
芬齒顎矯正中心與安徒生兒童牙科特聯合
提供本獎學金以及四天觀摩見習的機會。 ★ 獎助內容：四天三夜五星級飯店住宿以及見習期

間餐飲費補助。
實習目標： ★ 遴選方式：學期成績在全班前30%或成績平均在
1. 提昇對牙醫實務操作環境與診所管理的 75分以上，且對牙科實務展現積極學習的態度。
認識與了解。
2. 學習如何應用資訊科技來提昇實務工作 ★ 見習時間：99年7月29日-8月1日
效率。 ★ 申請截止日期：99年6月30日
3. 觀摩矯正與兒童專科診所的經營模式。
★ 檢覆文件：該學年成績單影本（一份），自傳

聯絡人：黃思涵 （請簡述學習經歷及申請目的）。
聯絡方式：03-573-5676
電子郵件：thhuang@[Link]

這是我參加過最不一樣的見習活動。
第一次看到這樣一位享譽國內、登上國際舞台的矯正醫師，願意花時間教導我們、
提攜我們晚輩；第一次看到一個牙醫診所，沒有刺眼的頭燈、狹小的隔間，而且每
位助理都可以一直保持笑容，還稱呼我們「醫師」，甚至願意停下手邊工作，只因為
要聆聽我們的問題，讓我備受禮遇、深受感動。這幾天，不管是在金牛頓、安徒生、或貝多
芬，我都可以感受到一致的風氣，那就是熱心、開朗、禮節、服務精神。我覺得張醫師以及所
有的工作團隊，儼然成為一個大家庭，每個人都帶著貝多芬「集團」特有的氣質與魅力，或許
有其老闆，必有其員工吧。 高醫

吳尚恆


 在整個見習的課程設計上分別安排了臨床見習與高效能簡報兩部分，在見習與簡報課程交錯的進行下使
整個課程設計上不會令人感到枯燥乏味，因此也使我們的學習鬥志激昂。在牙醫臨床見習的過程中，經由張醫
師活潑的解說方式帶領下，矯正治療變得生動有趣，同時也使我們觀察到一位好的牙醫師是如何與
患者進行互動。其中在本次的見習活動中有幸聽到張醫師在AAO的演講原音重現，真是使我感到
獲益良多，在簡潔活潑的簡報下很快就吸收了如何將阻生犬齒拉出的機制與方法光是這點就值
回票價。還有就是如何利用OBS迷你骨釘當作一個strong
 anchor，使矯正治療的時間縮短，
同樣也令我感到驚奇。



 
 
最後，再一次的感謝張慧男醫師能夠提供這樣的機會使我們獲益
良多，並且在此我也鼓勵學弟妹們未來若有機會一定要來參加貝
多芬獎學金所舉辦臨床見習活動，相信一定不會讓你們失

北醫

羅士傑 



望的！
2010 貝多芬矯正精修班 Part II

日期 精緻完工技巧 精選文章分析 精緻完工病例分析

( W2 ) 09:00~09:50 10:00 ~ 10:50 11:00~11:50

Saturation Training Contemporary Treatment Planning

1 05/11 10’
Tip 1 ( p.274 ~ 284 )
Class I Case

Saturation Training Treatment Planning for Skeletal

2 06/22 10’
Problems ( p.284 ~ 302 )
Class II Case
Tip 2

Saturation Training Skeletal Problems in Older Patients

3 07/13 10’
Tip 3 ( p.302 ~ 327 )
Class III Case

Saturation Training Biologic Basis of Orthodontic Therapy

4 08/17 10’
Tip 4 ( p.329 ~ 343 )
Deep Bite Case

Saturation Training Anchorage and Its Control

5 09/14 10’
Tip 5 ( p.343 ~ 358 )
Open Bite Case

Saturation Training Production of Orthodontic Force

6 10/12 10’
Tip 6 ( p.359 ~ 372 )
Low Angle Case

Saturation Training Design Factors in Orthodontic Appliance

7 11/16 10’
Tip 7 ( p.373 ~ 382 )
High Angle Case

Saturation Training
8 12/14 10’ Tip 8
Force Systems ( p.383 ~ 394 ) Gummy Smile Case

Saturation Training
9 01/08 11’ Tip 9
Removable Appliance ( p.395 ~ 407 ) Impacted Case

Saturation Training
10 02/15 11’ Tip 10
Fixed Appliance ( I ) ( p.407 ~ 418 ) Adult Complex Case

Saturation Training
11 03/22 11’ Tip 11
Fixed Appliance ( II ) ( p.418 ~ 430 ) Implant-Ortho Case

✦ 時間：2010年每月中週二
課程目標： 














早上9:00-12:00
協助每位學員了解古典到現代之文獻， ✦ 地點：金牛頓教育中心

進 而 應 用 於 實 際 病 例 ； 並 藉 由 DI 及 










新竹市建中一路25號2樓
CRE 讓 精 緻 完 工 ( Excellent Finishing ) 變 ✦ 報名專線：02-2778-8315*123

成易達到的目標。 















湧傑

劉品囷小姐
Summer 10’ 
課程
類型 課程名稱 內容 開課日期 上課對象



5/8,
6/5（六）
入門推廣 iPhone 3GS 新手上路 iPhone+iTunes 15:00～16:00
樂於嘗試生活科技應用者


iLife系列：



5/15,
6/12（六）
入門推廣 iMovie+IDVD 樂於嘗試生活科技應用者
輕鬆剪輯精彩生活影片 15:00～16:00



5/22,
6/19（六）
入門推廣 
認識蘋果世界裡的超好用小軟體 影音轉檔軟體 樂於嘗試生活科技應用者
15:00～16:00


iLife系列：



5/29,
6/26（六）
入門推廣 iPhoto 樂於嘗試生活科技應用者
管理美好生活影像 15:00～16:00

Mac OS X 
5/9,
6/6（日）
入門推廣 Mac OS X 15:00～16:00
樂於嘗試生活科技應用者
蘋果電腦新手入門

iWork系列： 5/16,
6/13（日）

入門推廣 Keynote 15:00～16:00
樂於嘗試生活科技應用者

簡單上手的多媒體簡報


 iWork系列：
 
5/23,
6/20（日）
入門推廣 Numbers 15:00～16:00
樂於嘗試生活科技應用者
整理表格數據的好幫手

iWork系列： 
5/30,
6/27（日）
入門推廣 Pages 15:00～16:00
樂於嘗試生活科技應用者
製作個人化的印刷品

Keynote簡報法
series 1 1.
常見簡報謬誤 7
月
1
日（四） 科技人、醫師、

專業簡報

簡報聖經 2.
Keynote
入門 09:00～17:00 教師、學生

Keynote簡報法
series 2 1.
多媒體影像處理 7
月
29
日（四） 科技人、醫師、

專業簡報
Kokich的10大演講秘訣 2.
簡報設計 09:00～17:00 教師、學生

Keynote簡報法
series 3 1.
賈伯斯演講秘訣 8
月
26
日（四） 科技人、醫師、

專業簡報
How to Wow’em like Steve Jobs? 2.
簡報設計進階應用 09:00～17:00 教師、學生

[Link] System International

International Damon and OBS workshop
2. OrthoBoneScrew
8/14-16, 12/7-9 Orthodontists

OBS lecture
OBS OrthoBoneScrew Workshop Hands-on Workshop
9/17 (五) 矯正醫師

注意事項：上課期間欲租借教學用電腦，酌收維護費200元，可抵用店內消費。
上課地點：金牛頓藝術科技教育中心（交大華廈2樓）新竹市建中一路25號（巴士馬偕醫院下車步行5分鐘）
報名專線：03-5735676
黃小姐





金牛頓網頁：
[Link]
Ortho Rectangular hole
Secure rectangular wire

Bone Simplest
for 3D force control

Screw System

Easy selection &
manipulation
Mushroom
Head
Maximum
patient comfort
Easy fit for power
chain & NT coil
spring

Screw types Area

Anterior-incisor
1 1.5 x 8 mm without holes
intrusion
2 2 x 12 mm without holes Posterior

Posterior-3D
3 2 x 12 mm with holes
control only









Order：+886-3-573-5676 Ms. OBS
For more information visit [Link]
“An excellent instructive and reference text for postdoctoral orthodontic students and
specialist clinical orthodontists. Definitely recommended reading!”
—Alex Jacobson, associate editor of AJODO

Dr. Samuel Lee

Dr. Samuel Lee attended Beethoven Advanced Course on 12.29.2009