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Antonino Secchi, DMD, MS
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Dr. Secchi is Assistant Professor of Orthodontics-Clinician Educator and Clinical Director of the Department of Orthodontics at the University of Pennsylvania USA and Visiting Professor at the University of Los Andes, Chile. Dr. Secchi received his DMD, Certificate in Orthodontics, and a Master of Science in Oral Biology from the University of Pennsylvania. Dr. Secchi is a Diplomate of the American Board of Orthodontics and member of the Edward H. Angle Society of Orthodontists. At the University of Pennsylvania, he has developed and implemented courses on Orthodontic Treatment Mechanics, Straight Wire Appliance Systems and Functional Occlusion in Orthodontics. In addition, he maintains an active orthodontic practice at the Dental Care Center of the University of Pennsylvania. |
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Dear Dr. Christiansen,
Thank you for your question.
I assume you are using the Innovation brackets in the .018 slot. If that is correct, then I do use the .018 x .018 BioForce with Ion Guard wire in the AccuArch form. BioForce is temperature-sensitive with individual forces from the incisors to the molars. Ion Guard is a special ionic bombardment of the BioForce wire to make the surface very smooth and further reduce friction.
To answer your question, I slide onto the main archwire, custom-cut sections of stainless .051 steel tubing in the extraction sites. This tubing is cut to be a total of approximately 3 mm from the mesial and distal abutment teeth. It is important to note the total reduction is 3 mm from abutment teeth. This steel tubing is usually approximately 1-1.5 mm from each abutment tooth. As space closes, the steel tubing slides with the teeth. The steel tubing does not interfere with sliding mechanics, yet it prevents the BioForce wire from causing unwanted tipping movements.
I see patients every 5 to 6 weeks. At each appointment, we quickly open the self-ligating brackets, slide the steel tubing off the archwire, and reduce the tubing length by approximately 2 to 3 mm. Once the steel tubing is reduced, we slide it back on the archwire and close the bracket closing clips. This technique permits good control of abutment teeth in space closure, yet the lack of friction also permits rapid and safe space closure. I especially use this in extraction of first molars. The tubing ensures no tipping and also prevents patients from biting on hard food which could force the BioForce wire out of the second molar tubes and into the gingiva.
I purchase this steel tubing from Summit Orthodontics (800-321-9124). The order number is 076-050. One container contains enough tubing to last a long time.
In my hands, we close extraction spaces with Dentsply Glenroe Ultra Slide Elastomeric chain in the "open" design. This chain tends to retain the elasticity for 6 to 8 weeks.
If you are using the .022 slot, then the same size tubing works using a .020 x .020 BioForce wire with Ion Guard in the large AccuArch form.
I hope this clearly answers your question. If you have additional questions, please e-mail me.
Regards,
Michael C. Alpern, DDS, MS
Dear Dr. Ronald Miller,
I wrote in my 2003 orthodontic textbook, "Orthodontics stands at its crossroads. Many potential pathways will define our profession."
For 33 years, as an orthodontist, I have published more than 20 articles, authored two orthodontic textbooks, and been one of the few orthodontists to have co-authored a chapter in a major medical textbook, Operative Arthroscopy. I introduced many innovative ideas with very clear, evidence-based information.
I agree with your claim and your concern. The subject of self-ligating brackets is filled with some amount of evidence-based knowledge. In March 2008, I was asked by the editor of Seminars in Orthodontics to participate in a debate on self-ligating brackets. This journal is published by Elsevier.
My article, which displayed evidence-based knowledge, was met with no criticism.
Self-ligating brackets are a continued evolution of the basic orthodontic bracket concept. There are various differing designs which enclose and secure the main archwires without requiring stainless steel ligatures. The steel ligatures may not always apply a standardized force as these steel ties are operative-specific. A majority of the friction of previous non-self-ligating orthodontic brackets occurs from the stainless steel ligatures crossing the main archwire. At a minimum, stainless steel ligatures cross the main archwire at four corners. I believe one of primary factors of orthodontic friction and orthodontic control arises from the "archwire corners." The more contact with the corners, the more friction or control. Thus, a self-ligating bracket is generically a bracket with a closing door. There are various designs.
All the above is science.
The others who you believe are making "magical" claims must answer your concerns. I can only speak for myself.
There are two forms of information disseminated to orthodontists: One is science, and the second major source of information is marketing.
With the above information, you might consider writing a letter to the editor of the AJO/DO and the Angle Journal about your concerns and ask for others to join you in suggesting a hearing or a debate at one of our national meetings?
Michael C. Alpern, DDS, MS
Dear Katherine Kelly,
This column is primarily designed to answer problems and challenges that existing orthodontists present for discussion.
Any discussion of fees is between the doctor and the patient. By traditional ethics, I do not interfere in any existing doctor-patient relationship.
I can only suggest certain facts that bear consideration. In the hands of a qualified orthodontist, trained in the use of self-ligating brackets, it is conceivable that treatment time might be shortened given complete patient cooperation.
Another answer to your question is that new technology usually requires higher fees for this technology. In general, I have found that self-ligating brackets cost more than traditional orthodontic brackets, and the Nickel Titanium and Beta Titanium wires usually associated with these brackets also cost the orthodontist more funds to purchase. Some of these technological advances require additional courses to learn the various treatment approaches to this new technology. These courses require time and travel expenses.
When I lecture across the United States, I have choices of transportation. A plane costs more, permitting me to travel in a shorter period of time. Or I could drive my car or take a train, which costs less but requires more time in traveling.
Every time I reach for my cell phone, I realize that I am paying more (than traditional land-line telephone service.) However, the convenience and increased speed of communication makes the cost well worth it.
I have found that self-ligating brackets and high technology wires permit me to move teeth with less force and achieve faster tooth movement. I choose to use this technology because I truly believe this offers my patients a better service in a shorter period of time. However, purely from an economic standpoint, my total overhead cost is higher (using this new technology.) I suggest you discuss this issue with your local orthodontist.
Michael C. Alpern, DDS, MS
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Dear Dr. Gluck, |
Thank you for your intuitive question.
I will give you an honest answer. I have written two articles in refereed journals and my second textbook, "A Squared." This stands for Alpern square wire technique. This book is available for the printing cost. I do not receive any funds for writing this textbook.
If I were you, I would begin with my article in Orthodontic Products entitled, COMPLETE CONTROL. And, I debated two of the other types of self-ligating brackets in SEMINARS IN ORTHODONTICS, Volume 14, No 1, March 2008, pages 73 to 86. My article is entitled, "Gaining Control with Self-Ligation." published by Elsevier.
If you take away all the advertising and boil it down to clinical practice, ask yourself what do you require from any bracket system?. You and I use brackets to move teeth in a controlled manner. If you are like me, you want to place wires in the bracket slot and move from initial position of teeth to final completed position with the fewest wire changes and the least amount of placing bends in the archwires.
It all boils down to how much work do you have to do on each patient in "finishing." Ask other orthodontists who use the different systems available. Ask them how much work they have to do to "finish." Do they have to place tip, torque and in/out bends in finishing wires or are these bends incorporated into the bracket slot?
My vision of orthodontics' future is we will use self-ligating, clear, ceramic brackets with tooth-colored wires in Nickel and Beta Titanium to accomplish most of the tooth movement.
However, most importantly, you and I need "control" of the teeth. Control is achieved by fully filling the bracket slot, especially vertically. In the .018 slot, I use Innovation C brackets, and 90% of the time, my first wire is a .018 x .018 GAC BioForce with Ion Guard wire in the large AccuArch form.
My control comes from the manufacturing process, which keeps a very tight corner radius tolerance. That equates to a .018 x .018 wire that is actually .018 x .018 with a corner radius tolerance of approximately .003 and a deviation of 2.44. The inside dimensions of the bracket slot is .0185. Thus a .018 x .018 wire will fill the bracket slot vertically and will not touch the closing clip. Thus, I am going for the final, finished tooth position from day one.
I am always amazed at other bracket systems which begin with round wire. Round wires lack corners and thus have limited control. A SQUARE WIRE IS A ROUND WIRE WITH CORNERS. More control.
I should mention that I place all my brackets indirectly with the AccuBond system available from GAC Laboratory.
I hope this has shed some light on your decision for choosing a self-ligating bracket system for your patients.
Since I am still in full-time clinical practice, I know you will have additional questions. Please e-mail me and I will try to answer them.
Thank you again for your question.
Best Regards,
Michael C. Alpern, DDS, MS
Dear Dr. McElhinney,
Thank you for your questions. I will attempt to answer them in the order in which you asked them.
My work is based on my friendship with and the knowledge of the late Dr. Robert Kusy of the University of North Carolina. Dr. Kusy's work stimulated me to develop the "A Squared" orthodontic technique which I have been using for over 6 years. You can ask your GAC representative for a copy of this (my second textbook). I receive no funds from this or my first textbook, THE ORTHOEVOLUTION.
Now, to answer your question: I try to fill the orthodontic bracket slot (especially vertically) in order to gain control as soon as possible. I do not use any round wires because they have limited control of each tooth. Therefore (since I use the .018 slot), my first wire (except in rare cases) is a .018 x .018 GAC BioForce with Ion Guard. This unique Nickel Titanium wire is temperature-sensitive. We store it in our freezer and bring it to the patient on a frozen aluminum slab coated with Teflon. In nearly 90% of our patients we are able to comfortably insert this wire in the Innovation C (for clear) brackets and in the R brackets. The spring closing clip has flex so for the first time, I have significant flex in the wire and flex in the closing clip.
BioForce is a patented Nickel Titanium wire that has a range of force throughout the wire. Incisors generally receive approximately 80-100 g of force. Cuspids receive approximately 150 g of force and molars receive approximately 250-350 g of force—all in the same wire, regardless of the size of the wire.
The second quality that I request when I order these BioForce wires is Ion Guard. This is a process in which the wires are subjected to an ion bombardment, which alters the surface smoothness. It gives this Nickel Titanium wire a slick, smooth surface, very similar to stainless steel wires. This assists in reducing the sliding friction. My good friend and mentor Dr. Raymond Thurow wrote in his textbook, "when you have similar metals against similar metals, the friction component is reduced and often negated."
So, for a vast majority of my patients in the .018 slot, our initial wire is a .018 x .018 BioForce with Ion Guard iced to place. If the patient's teeth are not sensitive to cold, I advise the patient to take a mouth full of ice water and hold it around the orthodontic appliances for 60 seconds and then spit it out. In my opinion, this lowers the temperature of the wire to the threshold where it softens. Then, slowly and gradually, the wires are warmed up to mouth temperature. I believe this tends to "refresh" the original wire shape and prevent the wire from taking a "set" where the wire had to make a significant bend. I ask patients to use the ice water three times per week.
Now to the specifics of your question: yes, there are specific individual patients who have severe crowding or a blocked-out high canine, or crowding where one tooth may be rotated 90º to the normal position. In these unique patients, I have several approaches. One is to place a .016 x .016 BioForce wire with Ion Guard. It is extremely rare that I cannot ice and place this wire and not achieve full bracket engagement.
I maintain the .016 x .016 BioForce wire for 3–5 months, then change to a .018 x .018 BioForce with Ion Guard wire.
Where a high cuspid is blocked out of the arch, I place a push coil between the lateral incisors and first bicuspids on the .018 x .018 BioForce wire. I use elastic thread tied from the cuspid down to the push coil surrounding the BioForce arch wire. As the push coil opens the space, elastic thread pulls the cuspid down (or up) to a point where the push coil can be removed and the cuspid bracket can engage the main .018 x .018 arch wire.
These are general principles and should not be accepted as a given. I treat each patient as Ulf Posselt wrote in 1952: each patient is treated as an unique individual.
In extreme 90º rotations, I use another technique. My main archwire is a .018 x .018 BioForce arch wire with a push coil to open space for the rotation. Then I place a sectional piece of .016 x .016 BioForce wire steel ligature-tied "piggy back" on top of the main archwire. This .016 x .016 BioForce sectional wire is fully engaged into the rotated tooth's bracket slot and then iced to place mesial and distal on top of the main archwire and steel ligature-tied in place. The push coil opens space for the rotation to be corrected and the sectional BioForce wire gently rotates the tooth to where the push coil and and the sectional wire can be removed. Then the main BioForce archwire is iced to place in the rotated tooth's bracket slot.
Your second question is "what are my torques and does that change the forces to the teeth?"
My bracket prescription has been available from GAC in the traditional Micro Arch system for more than 15 years. It is also available from GAC in the self-ligating "R" (for reduced size). However, for reasons I do not comprehend, it is not yet available in the "C" (clear) brackets. I do not receive any royalty or funds for anyone ordering this prescription.
Max central incisors: 17 degrees torque, 5 degrees of angulation
Max lateral incisors: 8 degrees torque, 9 degrees of angulation
Max cuspids: -3 degrees of torque, 10 degrees of angulation
Max bicuspids: -7 degrees of torque, 0 degrees of angulation
Maxillary molars: -10 degrees of torque, 0 angulation, 15 degrees of rotational offset.
Mandibular central & laterals are: -5 degrees torque, 0 angulation
Mandibular cuspids are: -7 degrees. and 6 degrees of angulation
Mandibular first bicuspids are: -11 degrees torque, no angulation
Mandibular second bicuspids are: -17 degrees of torque and 0 angulation except, now I use the gingival offset.
Mandibular molars are: -25 degrees torque, no angulation, and no offset
If you follow the principles of BioForce wire with Ion Guard, these torques do not change the forces applied to the teeth.
I normally maintain the .018 x .018 BioForce wires for 4-6 months. My second wire is a .018 x .018 Beta Titanium "Resolve" wire for 6-8 months, and I finish most cases in a .018 x .018 stainless steel wire. Again, there are always individual exceptions.
I hope this answers your questions. If you have any additional questions, please email me.
Regards,
Michael C. Alpern, DDS, MS
Dear Dr. Oubre,
Thank you for your question.
I have been using the Innovation R brackets with the "supermesh" for more than 5 years. My bonding success rate at initial placement of the brackets and after 3-4 months is approximately 99.5 %. In other words, I have almost no problems with the "supermesh."
There are a number of reasons for this success rate and they are:
1. Pumice is obsolete in my office. You cannot achieve a secure bond to enamel unless the enamel is thoroughly cleaned. Scanning electron microscopy shows clearly that abrasive pumice does not effectively remove the "scummy or mucinous" layer from the surface of the enamel. Worse, pumice tends to actually abrade multiple microscopic craters from the enamel. This limits the amount of enamel available for bonding.
Instead of pumice, we use Danville Materials Ortho Prophy SA-85 powder. This powder can be used to spray the teeth clean with a Micro Etcher or a DENTSPLY Prophy Jet. Both should be equipped with a Raintree Essix Aerosol Reduction device. The tip of the Prophy Jet or Micro Etcher inserts into a silicone cone-shaped device. In addition to an opening for the Prophy Jet or Micro Etcher, a separate tube attaches to your small suction tubing. Thus, the powder is sprayed on the surface of the tooth to be bonded and is suctioned out.
Ortho Prophy SA 85 is a patented powder in which hundreds of 1-3 micro alumina particles are ionically bound together to make 85-micron-sized clumps. When the SA-85 powder strikes the enamel surface, each 85-micron particle gently explodes like a soft, wet snowball striking a glass window. Each clump breaks up into hundreds of 1-3-micron particles. This process cleans enamel (with minimal abrasion) much better. Most of the "scummy or mucinous" layer is cleaned off of the enamel surface, leaving raw enamel rods available for bonding. SA-85 powder should only be sprayed on each tooth for 2 seconds twice. So, we spray each arch to be bonded twice.
SA-85 is so effective that we have been able to reduce our etching time to 3-6 seconds. Then, the key here is what most cosmetic dentists practice: the cleaned and etched enamel must be washed thoroughly with air-water spray for 10 seconds at 90 degrees to the tooth surface to remove the material dissolved by the etching gel so the bonding process can be successful. Each tooth is suctioned dry.
2. Now to address using the "supermesh." The key here is combined in an existing indirect bonding system available from the DENTSPLY GAC ORTHOWORKS orthodontic laboratory. The process is the AccuBond indirect bonding process. Each bracket's "supermesh" is first injected with a new flowable composite with very high flow. This high-flow material penetrates through the "supermesh" and is cured in the laboratory. As the material is cured, it chemically bonds and mechanically locks to the stainless steel mesh or the ceramic base undercuts.
Then, a separate low-flow, dense, and strong composite material is added to the the light-cured, high-flow material already cured to the "supermesh." The bracket with both the high flow (in the mesh) material and covered with the low-flow, high-strength material is place on the model and cured on the model, creating an accurate custom base for each bracket.
New internal and separate external non-warping covers are applied to all the brackets bonding on the model. This AccuBond indirect tray system is delivered to your office.
The end result is we can currently bond maxillary and mandibular arches and immediately place a full bracket slot filled Nickel Titanium wire in each arch in 20-25 minutes per patient—and with the previously mentioned bonding success rate.
If you are interested, please call Dan Riegelman at (800) 645-5530 for the AccuBond prescription material and a DVD showing the intraoral technique. The AccuBond technique solves all previous conceived problems with "supermesh."
Let me be very clear here. The problem is not the "super mesh." The problem was trying to force a low-flow material incapable of penetrating the mesh that did not chemical bond to the mesh or mechanically lock to the excellent mesh design.
I hope this answers your questions.
In closing, we have redesigned orthodontic bracket bonding from the "ground up." I should also mention that debonding AccuBond brackets is much safer. This bonding system was designed so that in debonding a bracket, the fracture occurs within the bonding composite and not at the enamel surface. AccuBond is also FDA-approved, and I have been using it for 5 years.
Also in closing, this much-too-long answer may (on the surface) appear to have many differing, new steps. That is true. However, the 20-25-minute chairtime procedure more than justifies these efforts.
You should be aware that I have a small financial interest in the AccuBond process.
If you have any additional questions, please email me.
Best Regards,
Michael C. Alpern, DDS, MS
Dear Dr. Carlos,
Thank you for your question. Professional ethics prevent me from interfering in your current doctor/patient relationship.
In addition, I cannot render an opinion without a clinical examination and a number of radiographs.
If you have these types of questions, you might want to consider getting additional opinions in your area.
I regret I cannot offer any help.
Michael C. Alpern, DDS, MS
Dear Dr. Mani Kandan,
Thank you for your question. However, before I can give you an accurate answer, would you be kind enough to give me the complete name of the wires you are referring to? For example, TMA appears to be a brand name for one type of Beta Titanium wire. To be accurate, it would help if you did not just give me the commercial label of the wire, but more importantly, the label should specify the exact metallurgical components of the wire.
This is especially important given the difference in commercial names in different countries in which the product is sold. Please give me more information so I can give you accurate information.
Regards,
Michael C. Alpern, DDS, MS
Dear Ken Highland,
I am a clinician and I do not have access to information of that nature. I am sorry I can not be of more assistance to you.
Regards,
Michael C. Alpern, DDS, MS
Dr. Marco A. Pinto
Specialist in Orthodontics and Dentofacial Orthopedics
Antonino Secchi,
DMD, MS
Straight Wire Appliance,
Self-ligation,
Treatment Mechanics
Richard Cousley BSc, BDS, MSc, FDS, FDS(Orth) RCS
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