Virtual Journal of Orthodontics

Managing impacted canines: traditional surgery versus laser technique

Read full issue in pdf format: VJO 13.2

Authors:

– Dr. Mazzocchi Susanna
(DDS, private practice, Bergamo, Italy)

– Dr. Mazzocchi Alberto
(MD DDS, private practice, Bergamo, Italy)

– Ferdeghini Claudia
(DDS, private practice, Monza, Italy)

The corresponding author’s address:

Dr. Alberto Mazzocchi

E-mail address:

Introduction: Maxillary canines are considered the most commonly impacted teeth, after the third molars ^(1,2).

The incidence of impaction ranges between 1% and 3%.
The cause of canine impaction can be the result of localized factors or can be a polygenic multifactorial inheritance and associated with other dental anomalies. There are a number of possible sequelae to canine impactions, ranging from loss of space in the arch to resorption of the roots of the neighboring teeth ⁽³⁾.

Although the treatment of choice for an impacted canine is a combined surgical-orthodontic approach, there are differences in technique ^{(4, 5, 6)}. According to the clinical situation, open or closed surgical uncovering might be required to bond an attachment. However, generally, those techniques did not show any significant clinical distinction in the outcome assessments ⁽⁷⁾.Surgical techniques that can be used to manage impacted canines vary depending on whether the impactions are labial or palatal, and orthodontic techniques vary according to clinical judgment and experience ⁽⁸⁾. Laser exposition, recently introduced, seems to have some advantages both in patient’s comfort than in periodontal result ⁽⁹⁾.

Keywords: Impacted canines, surgical orthodontic technique, diode-laser

RESULTS

No complications were observed after the 4 different surgical procedures. Moderate pain and swelling have been reported after the traditional full thickness, vestibular and palatal, flaps for 2 days. Very moderate pain has been reported after laser procedure for a few hours.

Periodontal conditions at the end of the orthodontic treatment were good in all cases (foto 7,8,9,10).

DISCUSSION

Combined surgical orthodontic treatment has been considered to be very efficient in resolution of impacted canines since ‘80s when bonding materials and techniques allowed for reliable bracket placement on ectopically positioned teeth ^(4,10,11,12).

Complete canine crown exposure is not required yet, as a bracket can simply be bonded to small exposed surfaces ⁽¹³⁾. Two types of surgical approach are commonly used: simple exposure, or exposure and bracketing at the time of surgery ⁽¹¹⁾. In the past, forced orthodontic eruption of impacted maxillary canines with a well bonded orthodontic traction hook and legation chain, used in conjunction with a palatal flap or an apically repositioned labial flap, resulted in predictable orthodontic eruption with few complications ^{(2, 4, 7, 14, 15)}. During surgical exposure and bonding procedure, the main problem is the control of blood, saliva and fluid contamination to obtain a stable and durable bracketing of the impacted tooth (12) (photo 6-7).

Laser exposition showed no bleeding during and after the procedure, decontaminant effect on the surgical area, no need for suture, and a faster spontaneous eruption ⁽⁹⁾

According to many Authors, periodontal conditions following surgical and orthodontic treatment seemed better after traditional closed palatal exposition ⁽¹⁶⁾.

Laser exposition is a new technique which seems to show excellent periodontal condition and more comfortable results for the patient and it could provide simplified, predictable, and quicker aesthetic outcomes ⁽⁹⁾.

BIBLIOGRAPHY

1.Alqahtani H. Management of maxillary impacted canines: A prospective study of orthodontists’ preferences. Saudi Pharm J. 2021 May;29(5):384-390. doi: 10.1016/j.jsps.2021.03.010. Epub 2021 Mar 31

2.Bishara SE Clinical management of impacted maxillary canines. Semin Orthod 1998 Jun;4(2):87-98

3.Langberg B.J Peck S. Adequacy of maxillary dental arch width in patients with palatally displaced canines. 2000; AJO Vol. 118 n. 2: 220-223

4.Mazzocchi A Clivio A Rebaudi L. Validità e limiti del recupero chirurgico ortodontico dei canini inclusi. 1989; Dentista Moderno 6:1359-1376

5.Kaban B L Pediatric Oral and Maxillofacial Surgery. 1990; W.B. Saunders Philadelphia

6.Taffarel I P et Coll. Clinical Outcome of an Impacted Maxillary Canine: From Exposition to Occlusion. Case Reports J Contemp Dent Pract. 2018 Dec 1;19(12):1552-1557.

7.Izadikhah I et Coll. Different Management Approaches in Impacted Maxillary Canines: An Overview on Current Trends and Literature. Review J Contemp Dent Pract. 2020 Mar 1;21(3):326-336.

8.Bedoya M M Park J H. A review of the diagnosis and management of impacted maxillary canines. J Am Dent Assoc. 2009 Dec;140(12):1485-93. doi: 10.14219/jada.archive.2009.0099.

9.Impellizzeri A et Coll. Uncovering and Autonomous Eruption of Palatally Impacted Canines-A Case Report. Dent J (Basel). 2021 Jun 9;9(6):66. doi: 10.3390/dj9060066.

10. Pearson MH Robinson SN Reed R Birnie DJ Zaki GA Management of palatally impacted canine s: the findings of a collaborative study. 1997; Eur J Orthod Oct;19(5):511-5

11.Caminiti MF Sandor GK Giambattistini C. Outcomes of the surgical exposure, bonding and eruption of 82 impacted maxillary canine. 1998; J Can Dent Assoc Sep;64(8):572-9

12. Mazzocchi A.R. Transbond MIP primer : an useful tool for impacted canines bonding technique. 1999; Virtual J Orthod. [serial online] Apr 17; 2(4) https://vjo.it/wp-content/uploads/2010/09/mip.pdf

13.Mazzocchi A Ectopic upper canine associated to ectopic lower second bicuspid. Case report. 2001; Virtual J Orthod Jun 15; 4(1) https://vjo.it/wp-content/uploads/2010/09/mazzen.pdf reprinted in J Am Orthod Soc 2003, vol 3: 33- 35

14.Kornhauser S et Coll. The resolution of palatally impacted canines using palatal occlusal force from a buccal auxiliary. 1996; AJODO Vol. 110 n.5: 528-533

15.Kajiyama K Hai H. Esthetic management of an unerupted maxillary central incisor with a closet eruption technique. 2000; AJODO Vol. 118 n.2: 224-228

16. Hansson C Rindler A. Periodontal conditions following surgical and orthodontic treatment of palatally impacted maxillary canines. 1998; Angle Orthod. 68 (2): 167-172

Read full issue in pdf format: VJO 13.2

CORREZIONE SPONTANEA DELLA POSTURA DOPO TRATTAMENTO ORTODONTICO
FUNZIONALE: Presentazione di 3 casi clinici.

AUTHORS:

Mazzocchi S.* Mazzocchi A.**

(*DDS Private practice, Bergamo, Italy)

(** MD, Maxillofacial surgeon, private practice, Bergamo)

PAROLE CHIAVE: occlusione dentale, postura scheletrica, ortodonzia funzionale

KEY WORDS: dental occlusion, skeletal posture, functional orthodontic therapy

Read full issue in pdf format: VJO 13.2

Address for correspondence:

Dr. Alberto Mazzocchi

SUMMARY: The correlations between dental arches, Angle classes, swallowing and posture have been studied for many years. In our study we analyze three cases of mixed and permanent dentitions patients treated by nocturnal functional appliances, reporting a correction not only of dental occlusion but also of general posture.

RIASSUNTO:

Già da molti anni sono state studiate le correlazioni tra arcate dentarie, classi di Angle, deglutizione e postura. Nel nostro studio gli Autori mostrano tre casi di pazienti in dentizione mista o permanente, trattati con apparecchi funzionali notturni, osservando che il trattamento ha portato a un miglioramento occlusale e alla postura generale.

INTRODUZIONE

Come già scritto in un nostro precedente articolo, da parecchi anni si discute sui rapporti tra occlusione dentaria e postura e, anche in questo caso, data la presenza di numerosissime variabili nella regolazione posturale del corpo umano, è molto difficile trarre conclusioni accettate da tutti gli specialisti ⁽¹⁾.

Alcuni studi sulla postura della testa rilevano correlazioni con l’occlusione dentale, altri non mostrano tali rapporti ^(2,3,4,5). Una ricerca realizzata su numerose pubblicazioni scientifiche, che pareva indicare una relazione tra l’apparato masticatorio e le patologie vertebrali, data la mancanza di studi in doppio cieco, non permette di trarre conclusioni definitive ⁽⁶⁾.

Pur con queste premesse, vogliamo presentare alcuni casi clinici, dove la terapia ortodontica funzionale, eseguita con dispositivi di riprogrammazione muscolare orale (Equilbratori, Eptamed Cesena), ha permesso di osservare modifiche positive dell’atteggiamento posturale dei pazienti.

DISCUSSIONE E CONCLUSIONI

L’eziologia della malocclusione, pur rivestendo una notevole importanza nel suggerire il trattamento ideale, non è ancora del tutto compresa; come già affermato in passato, genetica, componenti embriologiche e funzionali (abitudini viziate, deglutizione atipica, respirazione orale, ipertono muscolare) giocano un ruolo molto importante.

Se è difficile giudicare l’eziologia delle malocclusioni, ancora più complessa è quella che riguarda la postura vertebrale, dove le informazioni provenienti dai recettori propriocettivi muscolo-articolari di tutto il corpo e in particolare del piede, sembrano siano affiancate da quelle visive.

In precedenti ricerche abbiamo evidenziato che la correzione di abitudini viziate muscolari, in particolare nei movimenti di deglutizione, riesca a modificare non solo l’allineamento occlusale, ma anche il corretto atteggiamento posturale, almeno da un punto di vista clinico⁽⁷⁾.

I tentativi di misurare la postura vertebrale con esami strumentali, come le pedane stabilometriche, hanno dato sempre risultati controversi, non fosse altro per le difficoltà di trasformare, in valori numerici, un equilibrio muscolo-tendineo sempre dinamico ⁽⁸⁾. Ammesso che la postura dipenda solo da questo, poiché ricerche recenti ⁽⁸⁾ suggeriscono l’esistenza di una rappresentazione interna corporea non basata su informazioni sensorie. Questa rappresentazione preesistente interna dello schema corporeo dipenderebbe dalla massa corporea, dall’inerzia corporea e dall’orientamento del corpo rispetto al verticale. Questo modello implica un ruolo ridotto dei riflessi attivati in periferia.

Un’interessante teoria ⁽⁹⁾ sostiene che la salute in generale possa essere definita come una “dynamic balance”, sottolineando ancora una volta due termini chiave: dinamico e equilibrio.

La nostra piccola casistica di pazienti in età evolutiva, pur non potendo trarre conclusioni definitive, sembra confermare l’ipotesi che un’adeguata rieducazione della muscolatura periorale (riequilibrio dinamico), effettuabile con apparecchiature ortodontiche funzionali, come l’equilibratore, permette un cambiamento generale della postura, nel senso di correzione di lievi cifosi o lordosi. Gli apparecchi ortodontici come l’equilibratore, sono realizzati in materiale morbido che evita traumi ai tessuti molli della bocca, riducendo i discomfort tipici degli apparecchi fissi e migliorando le possibilità di eseguire, con facilità, le corrette manovre d’igiene orale. L’utilizzo prevalente notturno degli equilibratori, ha inoltre l’indubbio vantaggio di favorire la collaborazione del paziente, che non deve rinunciare alle sue quotidiane abitudini, scolastiche ed extrascolastiche.

BIBLIOGRAFIA

1.Mazzocchi A Paratico S Mazzocchi S. Trattamento ortodontico e osteopatico in paziente portatore di scoliosi. 2019; Virtual Journal of Orhodontics. Issue 12.1 http://www.vjo.it/2019/05/13/issue-121/

2.Korbmacher H, Eggers-Stroeder G, Koch L, Kahl-Nieke B. Correlations between dentition anomalies and diseases of the of the postural and movement apparatus–a literature review. J Orofac Orthop. 2004 May;65(3):190-203

3.Lippold C, Danesh G, Schilgen M, Drerup B, Hackenberg L Relationship between thoracic, lordotic, and pelvic inclination and craniofacial morphology in adults. Angle Orthod. 2006 Sep;76(5):779-85

4.Pachì F et Al. Head Posture and Lower Arch Dental Crowding. Angle Orthodontist, 2009; Vol 79, No 5:873-879

5.T. Andresen, C. Bahr, C. Ciranna-Raab. Efficacy of osteopathy and other manual treatment approaches for malocclusion. A systematic review of evidence. International Journal of Osteopathic Medicine (2012).

6.Hanke BA et Al Associations between orthopedic and dental findings: what level of evidence is available? J Orofacial Orthop 2007; 68: 91-107

7.Mazzocchi S. Mazzocchi A. Postura e occlusione: considerazioni cliniche e terapeutiche: parte prima la deglutizione. 2020; https://vjo.it/issue-12-3

8.Perinetti G Dental occlusion and body posture: no detectable correlation. Gait and Posture 24 (2006) 165-168

9.Capra F. Lisi PL The systems view fo life: a unifying vision. 2014; Cambridge University Press

Read full issue in pdf format: VJO 13.2

Virtual Journal of Orthodontics

Editore e Direttore Responsabile: Dr. Gabriele Floria

https://www.floria.it

DENTAL SEO (SEARCH ENGINE OPTIMIZATION) FOR PRIVATE PRACTICE

AUTHOR:

Gabriele Floria*

(*DDS Orthod. Spec. Private practice, Firenze, Italy)

KEY WORDS: SEO, keyword, keyphrase, backlinks, dental marketing, online reputation

Read full issue in pdf format: VJO 13.2

Address for correspondence:

Dr. Gabriele Floria

INTRODUCTION

In this article we will talk about what dental SEO is and why it is important to improve positioning on search engines, thus obtaining more contacts on your website. We hear more and more about dental marketing and online reputation, let’s clarify some basic concepts that can be used by the dentist who wishes to work to obtain an organic indexing of their contents offered to patients, or potential ones.

The term SEO is the acronym for SEARCH ENGINE OPTIMIZATION, and consists of all those activities that serve to make it more likely that the contents of a particular web page, be it a blog, a website, an e-commerce or other, are found by search engines

If you are designing or redesigning your site it is advisable to keep in mind many concepts used by search engines so that your quality content does not have difficulty in being found in the first results. Let’s clarify immediately that the objective should not be aggressive advertising of your office/practice, both for the limits imposed by the Medical Associations but above all because it is not the purpose of SEO which is to bring out useful content for readers. Obviously related to our profession, informing and educating about correct behavior.

Those who, like me, for reasons of age, unfortunately, but also for passion for the subject matter, have seen the birth and development of search engines such as Lycos, Altavista, Yahoo, are aware of the evolution of algorithms that has taken place over the years.

If once it was enough to write in white on a white background many times the word you wanted to propose to be first in the results, today the algorithms are so sophisticated and refined that a real job has been born for many employees that goes by the name of Search Engine Optimization .

These are the most common questions that friends and colleagues often ask me:

What is dental SEO?
But paying to pay, isn’t it more convenient to invest everything in advertising and save on SEO?
What is SEO for?
How do search engines work?
What does the search engine evaluate?
How should you write a page that appeals to search engines?
Which language should be used for dental SEO?
How should the keywords for dental SEO be chosen?
What are keyphrases?
What are backlinks?
Is it better to do it yourself or to rely on professionals?
What ready-made tools can help us in the SEO of dental content?
How are the results obtained?
How much does SEO cost?
Conclusions

What is dental SEO?

There are various types of SEO, the main three are:

Local also called organic
Pay per Lead
Affiliate SEO

The first, organic SEO, uses semantic algorithms and is the one that interests us most as dentists because it aims to bring out the contents that we want to convey to the public through our website or blog through the most used search engines.

The second, called Pay per Lead, uses highly targeted and optimized advertisements to reach a highly profiled audience, and is more suitable for companies. For example, it is used for the launch of new dental products by companies in the sector, affecting the final cost as an advertising expense. In this regard, eDentist, the first dental network in Italy has launched a price comparison service that can help the dentist save on products purchased in the office.

eDentist price comparison

The third concerns those sites that aim to make an external salesperson make sales to earn percentages by recommending specific products in niche areas.

So clarified that by “organic” content we do not mean anything edible or organic 😉 but everything that is not sponsored, let’s see how to try to appear before many others in search engines.

Appearing earlier means being visible on the first pages and therefore having more hope of getting a click that will lead the user to learn more about our site and perhaps make an appointment at our office/clinic.

But paying to pay? Isn’t it more convenient to invest everything in advertising and save on SEO?

No, personally when I’m looking for something I always skip paid listings and apparently I’m in good company. It is estimated that more than 70% of clicks go to organic results and we are also investing in the long term in something that does not interfere with the available budget.

But how do search engines work?

If the network has been defined as a cobweb (web), whoever takes care of it and moves on it well can only be a spider. With “spider” you identify a software that visits the sites on the network and catalogs them, indexes them, and creating the conditions to find them creates an order, or a ranking of relevance to a single keyword. Since these little spiders have become very advanced they are not easily fooled and in order to always provide a relevant and high-caliber result to the visitor they evaluate a whole series of parameters.

It is clear that in drafting a text it must take into account the parameters that contribute to the drafting of the SERP (Search Engine Result Page) or the list of results with the relative links to the resources present.

The search engine not only scans text, but also images, graphics, links, documents and many other files.

What does the search engine evaluate?

Given a certain search, one or more keywords, the search engine first of all evaluates the security of the site, but also accessibility, response times, readability, relevance to the search.

So if two people search for the same thing they get the same results?

No. Because the SERP, the results page, is also affected by the history of the searches that the individual has previously carried out…. and not only. But let’s not digress because this article would become very long and disturbing.

This creates a difference, for example, in the search performed by a dentist from that carried out by the patient, but also between patient and patient.

How should you write a page that appeals to search engines?

It is a mistake to try to forcibly write something that is not meant for the end user, that is, our patient. The content must be readable, consistent with the title and to the liking of the reader who will not leave the page too soon. Therefore it is essential to write things that are understandable, well explained and useful. This will help improve the ranking and allow readers to find it. Another mistake is trying to enter a lot of keywords or writing excessively long texts. Instead, you need to structure the text well and optimize the content by selecting keywords with good traffic volumes. Some useful tools in this phase can be SemRush, Seozoom, and Keyword Planner.

Which language to use for dental SEO?

Just as we adapt our technical language by speaking with the patient in the chair according to the cultural abilities of the individual, in the same way we must start from the assumption that our reader does not have the tools and the specific technical vocabulary. Therefore a hypothetical question to the search engine will not be what is the best technique for the therapy of periodontal disease but what to do for receding gums, or how to straighten teeth or how to whiten them.

Using simple and very educational language leads to reaching a wider audience although sometimes it can introduce limitations or inaccuracies in more complex technical explanations.

Do not underestimate the importance of the window “people have also asked” which looks for similarity and synonyms. An analysis of the text in this perspective provides useful additions and suggestions to be more complete and exhaustive by integrating the FAQ (Frequently Asked Questions) so that the search engine is more likely to intercept the content.

How to choose the keywords for dental SEO?

First of all: what is a keyword? It is the keyword that is entered in the engine search bar. The best known is Google, but not to be overlooked are also Bing, Yahoo, Ask, Baidu, DuckDuckGo etc …

Today the algorithms are able to search even more words and even whole sentences, finding web and blog text content but also videos and images if properly inserted.

We must therefore distinguish three types of keywords:

Short keyword
Long tail keyword
Keyphrase

Only a careful use of all three, without forcibly adding some, leads to obtaining a good positioning in the SERP, demonstrating the complexity and efficiency achieved by the latest generation algorithms.

Let’s see how to make the most of them, always keeping in mind that all three types are needed, wisely distributed but that an artificial text, too dense in keywords, will be heavily punished by the algorithms and relegated to the last positions, or even discarded by the results.

Short keywords are quite common, they bring a lot of traffic but this is generic, not very profiled and they are very inflated. On the other hand, long tail keywords bring less traffic but of better quality because the search is already more targeted from the outset.

Identifying these long tail keywords can be long and difficult but always asking the question of what the user is really looking for on the page they should find.

What are keyphrases?

They are phrases made up of keywords, with the difference being that the search will take place cumulatively and for the literal meanings of the individual words.

A Keyphrase on average should be no longer than 4 words because the search would become too complex for the search engine or too selective. However, there are exceptions for which a higher number of words may be recommended if the identification requires a very vertical search.

What else do I need to remember?

Well, there is much more to know to improve dental SEO, for example: Don’t forget to help search engines by optimizing your text by entering, for example, Title Tags, descriptions and H1s. Let me explain better, firstly the text must be between 300 and 500 words long. Then enter the title as a Tag, remembering that it must be the main search key of the page and must be unique on your site.

Also enter the metatag description being careful not to exceed 155 characters because this will appear in the SERP and will explain the content of the page.

H1 stands for header1 and is the title of the page and it is a good idea that it includes the search key of the proposed text, this too must be only one. The H2 and H3 are the paragraphs and subparagraphs, these instead can and indeed must be repeated. For images the speech is simpler, they have an alt Tag which is nothing more than a descriptive text of the image, obviously it must be relevant.

What are backlinks?

This is a topic that deserves a separate discussion because there is really a lot to understand and explain, however in brief a backlink is a link that from an external page to your site leads to your web page. They are interpreted by search engines as citations and as happens in the scientific literature the more citations you get, the higher your ranking will be. Of course, the algorithms also give weight to the page of origin of the backlink and variably transfer that data to the value of the link itself. Let’s take an example: if I have a page that talks about scientific astronomy and I get a backlink from NASA, this will certainly have a different value from a backlink that comes from a page with low “Domain Authority” written by the magician “Gigi” who deals with astrology.

Another evaluation that the search engine, Google or others, makes is relevance. If I have backlinks from a page that deals with hats that always links to my astronomy page I will be penalized because the content is lacking. In this case we are talking about toxic backlinks.

Is it better to rely on professionals or to do dental SEO yourself?

If what you have read above has frightened you or you have not understood much, perhaps it is better that you rely on IT experts, but given the peculiarity of our sector all the texts must at least be verified, if not really written, by dentists. There are also professionals or expert agencies in this field . You will hear about SEO Stategist to indicate the one who develops positioning strategies or SEO copywriter to mean those who write SEO-optimized texts, a human who thinks with the metrics of a search engine

In the short future it will then be conceivable to entrust all external and internal marketing communication to a dedicated resource who must also have these skills.

What ready-made tools can help us in the SEO of dental content?

Excluding paid tools, sometimes even expensive ones, which require a learning curve and are more suitable for professionals in the sector, we can identify simple Chrome extensions that are useful and free.

To obtain related keywords and short keywords it is possible to install Keyword Surfer, while to volumetrically analyze the searches Uber Suggest allows three free searches a day to improve dental SEO.

Another useful tool for identifying long tail keywords is Semrush but although it offers a short trial period, it is essentially a paid tool.

How are the results obtained?

The main search engine, Google, offers you two tools called Google Search Control and Google Analytics. While the first is used to send the site map containing the list of pages to the engine, the second is a set of information about the traffic to your site. It would take a long time to explain it well, for the moment let’s simplify it by saying that it provides you for example visitor volume, page views and visits but also session duration, bounce rate and pages per visit. By checking this dashboard, this control panel, you can check the performance of your site and introduce changes to make it more efficient.

How much does SEO cost?

Look at this graph showing the average cost per click. Dentistry ranks second after legal services

Look at the competition: $ 6.5 per click for advertisements, astronomical stuff destined to rise again.

So whatever the cost of SEO is it will still be worth it in comparison to advertising.

The greatest cost is undoubtedly time but if you compare it with the investment in advertising it will certainly be more rewarding in the long run. Furthermore, the results need time to be perceptible, let’s say at least 4 or 5 months from the completion of the work. Admittedly it may never end. 😉

Conclusions

The patient of today’s dentist is a user much more accustomed to searching for information online and for this reason it is essential to have a website, blog and social media that are able to convey useful information even on mobile devices. Therefore, the first step for those who do not have it is to take care to have a well-made, fast and responsive site. The responsive site is the one that, understands whether the site was accessed from a mobile phone or computer and conforms to the screen used.

The second step is to enhance the information by making the carefully prepared page easily accessible. It is known that 75% of Google users do not reach the second page, which is why the fight for the first page is crazy.

Clear, well expressed and honest content is rewarded by search engines and will bring readers who will hopefully turn into patients in the dental office. However, it should be noted that these are not advertisments, which is quite ubiquitous on the internet, rather it is suggestions, advice on innovative therapies, management of the dental problem, or correct behaviors to follow.

Bibliography

Virtual Journal of Orthodontics

Editore e Direttore Responsabile: Dr. Gabriele Floria