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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 Malou Torres,
This is my opinion. The very best and most effective mechanics for intrusion of maxillary anteriors using self-ligating brackets uses a bonded Rapid Palatal Expansion Bite Plane Appliance as an anchor.
In other words, in my prescription to the laboratory for construction of my bonded palatal expansion system, I request placement of my standard maxillary bonded tubes to be embedded into the RPE appliance in the area lateral to the maxillary first permanent molars. The bonded bracket base is embedded into the acrylic, but the tubes are not covered.
I never activate any attachment to a bonded RPE-BP appliance system until maxillary expansion is completed. I secure the expansion screw with wire and Triad flowable acrylic.
I place brackets on the maxillary incisors and (if available) the maxillary cuspids. I use a sectional piece of square Nickel Titanium wire from cuspid to cuspid or maxillary lateral to lateral.
Then, I bend a .016 x .022 Elgilloy wire from one molar tube to the opposite molar tube.
As I exit the right molar tube (bonded into the RPE-BP appliance), I make a double helical coil which is coiled laterally. This wire extends forward to fit in a piggy-back manner under the incisal wings of the self-ligating brackets and then extend posteriorly to the molar bonded tube on the left side. Approximately 3 mm from the left molar tube, I make another double helical coil (winding toward the molar tube) and test insert this wire into the molar tube.
If all fits well, I remove this piggy-back wire and make a V-bend in this wire, extending upward from the bonded molar tubes towards the incisors. I then insert this piggy-back wire into both molar tubes and securely ligate this wire to fit under the incisal wings of the ligatureless bracket.
At each 4-6 week interval, I activate the intrusion wire with a Tweed pliers, increasing the V-bends and continuing the intrusion.
The teeth will intrude quickly and rigid oral hygiene is required or the gingiva will hypertrophy.
Full credit for this concept goes to Drs. Lloyd and Bradley Pearson of Minneapolis.
I hope this explains the technique. Mandibular incisor intrusion can use existing mechanics and maxillary incisor bite planes.
Regards,
Michael C. Alpern, DDS, MS
Dear Zeinab Altowati,
I have very limited knowledge in this area. In the past, I believe one company brought out a monocrystalline bracket. I seem to remember this bracket was very clear, but fractures may have been a problem. Again, this may be limited or incorrect knowledge. I am not an expert in this area.
To the best of my knowledge, I am unaware of a self-ligating bracket in a monocrystalline bracket. I will continue to research this topic and get back to you.
Best Regards,
Michael C. Alpern, DDS, MS
Dear Dr. Van Horn,
Thank you for your questions.
First, let us discuss the effect of the closing spring clip on torque expression. My technique is entitled "A SQUARED." or Alpern square wire orthodontic treatment. This is part of my Fixed/Functional/Splint technique. All of this is published in my two textbooks, which GAC sells at the printing cost. I receive no funds from the textbooks.
As mentioned above, I primarily use square wires. My initial wire in the .018 slot is a .018 x .018 BioForce with Ion Guard.
I have always been perplexed that we orthodontists spend extra monies to purchase a "straightwire appliance" where the final position of each tooth is programmed into the bracket slot. And then, many lecturers advise small, round wires to begin treatment. Round wires have very little torque control. By using a .018 x .018 square wire in an .018 slot, I begin torque control from day one. This is only possible with BioForce wire and I use Ion Guard, which is an ionic surface treatment, so the wire surface is slick and smooth.
The closing clip has a stop built into the bracket. The main archwire applies approximately 200 grams of gradually diminishing force on the archwire until the wire is fully seated in the bracket slot. If the dimensions of the bracket slot are accurate and have a low corner radius tolerance and if the same applies to the wire, then with the wire fully seated in the bracket slot (producing full, gentle, torque control), the closing clip does not touch or contact the main archwire. This technique is also published in "SEMINARS IN ORTHODONTICS", Volume 14, Number 1, March 2008, pages 73-86.
Much of this square wire technique comes from the late Dr. Robert Kusy. He made significant contributions to orthodontics.
So, to answer your question: "What is the effect of the clip in the Innovation series on torque expression and sliding mechanics?"
The closing clip of the R and C brackets has little affect on torque except that the closing clip gently seats the square wire into the bracket slot. Once the clip contacts the "clip stop" on the bracket, the archwire is fully seated and the clip is inactive. The wire can exert gentle but constant, full 3D control, including torque control.
For those who use the .022 slot, the "A Squared" technique uses as an initial wire a .020 x .020 BioForce with Ion Guard wire for 3-4 months. Then, a GAC Monacell wire which is .022 x .018 BioForce wire with Ion Guard. This wire full fills the .022 slot and applies full 3D control, including torque control.
Nothing is perfect. Using the .018 slot and all square wires has several disadvantages: 1) .018 x .018 wires lack the bulk of larger wires and thus they lack mediolateral control, requiring Cetlin palatal bars to augment mediolateral control and movements. This same lack of bulk can be a problem in leveling the occlusal plane (anterior-posterior control). Here a .017 x .025 wire can be used. This is rarely followed by a .018 x .025 stainless steel wire.
Now, sliding mechanics. I have found only rare problems in controlled 3D sliding mechanics using square wires and others tell me of very rare problems using .022 x .018 all BioForce with Ion Guard for sliding mechanics. Again, if mediolateral control is a problem, then adding a Cetlin Palatal Bar solves the requirements.
Finally, the large AccuArch form: Most straightwire bracket systems can not make the cuspid brackets thin enough buccolingually and seem hesitant to make (especially) maxillary incisor brackets thick enough buccolingually. Thus, previously developed archwire forms tend to move cuspids lingually and narrow the arch form. Only the large AccuArch form is more square in the anterior section, preventing lingual movement of the cuspids. Over 33 years of clinical practice has led to this conclusion. This is a clinical experience opinion. Thus, it does not qualify as evidence based knowledge.
Thank you for your intuitive questions. If I have not answered your questions correctly or clearly, please let me know.
Best Personal Regards,
Michael C. Alpern, DDS, MS
Dear Joel Gluck,
Thank you for your question. In the .018 slot, believe it on not, my first wire is usually a .018 x .018 BioForce with Ion Guard. This wire is a nickel titanium, temperature-sensitive wire with individual forces through out the wire. The Ion Guard is a surface "slickness" treatment which makes this wire have a smoother surface, minimizing friction and maximizing control.
This is the wire I primarily use to open or close spaces. I do not use springs. Instead, I use an elastic module called Sili-Chai,n which appears to retain the elasticity for 6-8 weeks.
I hope this answers your question.
Best Personal Regards,
Michael C. Alpern, DDS, MS
Dear Dr. Martines,
Thank you for your insightful question.
The key to your questions is your words, "eliminating absolutely all rotations before moving to steel or TMA wires when using self-ligation brackets."
I wear high-magnification loupes (now augmented with a xenon light) to constantly make sure original placement of brackets is as ideal as possible. Now, with AccuBond indirect, I look at the photographs from the laboratory (as seen on a protected Web site) as carefully as possible.
As we all know, sometimes accurate bracket placement is not always possible. Factors such as incomplete clinical crowns available, too much crowding to permit correct bracket placement and, many times, aberrations in clinical crown shape. As Posselt stated in 1952, each patient is a unique individual.
Now to answer your questions: The first approach has already been tried (AccuBond indirect bonding). Therefore, I have not been able to eliminate "absolutely all rotations before moving" to Beta Titanium or stainless steel wires.
Given that truth, I do have several suggestions as to what to do as your initial wires align the teeth. Using the square wire technique and filling the bracket slot as much as possible in order to give early 3D control permits visualization of teeth where ideal placement of the ligature-less bracket was just not possible. So, filling the slot early with BioForce wire with Ion Guard in the large AccuArch form arch shape permits earlier visualization of where re-positioning the brackets is necessary.
So, rule number one for me is to use a full-slot filled wire (BioForce) as soon as possible to permit visualization of bracket placement problems. If at all possible, I remove these brackets and re-position them WHILE STILL IN THE BIOFORCE wires. This is not always ideal. Sometimes, as careful as you can be in examining the alignment of each tooth at each appointment, you still find teeth that require rebracketing when you are in Beta Titanium or stainless steel.
I do have a suggestion that may be helpful. When we remove a patient's BioForce wire, we place it in a clear zip-lock bag and staple the bag to the patient's chart. Now, as the treatment archwire sequence progresses (Beta Titanium to stainless steel) and we discover a bracket which must be re-positioned, we do not remove the current archwire. Instead, we open the closing clips 2-3 teeth on either side of the bracket which requires repositioning, then slide the main archwire forward or away from the bracket to be removed. This gives access and permits bracket removal and re-bonding. As you re-slide the main archwire to the adjacent brackets, you will note in many cases, there is no reasonable manner in which you can get the main archwire engaged into the bracket clip.
At this point, we take a portion of the original, saved BioForce wire and cut a sectional piece which will apply the correct force values depending on which tooth is being re-positioned. We then piggyback the sectional piece of BioForce into the newly positioned bracket and close the clip. Then we piggyback each side of the mesial and distal extensions of the BioForce sectional on top of the main archwire and secure it to at least two adjacent brackets with traditional steel ligature ties.
Over the next few months, the BioForce sectional wire will re-align the tooth requiring re-positioning. Soon, it will be possible to remove the sectional BioForce and fully engage the re-positioned bracket into the main archwire.
This answer is very wordy and I apologize. My main technique here is to not remove the main archwire which is part of your archwire progression. You maintain the main archwire, yet re-engage mal-positioned teeth without going back to a more flexible wire which may slow or stop the progression of your treatment.
I hope this helps.
Best Personal Regards,
Michael C. Alpern, DDS, MS
After using self-ligating brackets for more than 5-6 years, I have periodically found an elastic use for the bicuspid bracket hooks. My elastic designs are available to you in my first textbook, "THE ORTHOEVOLUTION, the Science behind the Fixed/Functional/Splint system." (This textbook is available from GAC at the printing cost. I receive no funds from this textbook.)
As to why the posts are so long on my prescription? This is due again to my multiple elastic finishing designs. Before I had hooks on my brackets, I had to either add crimpable hooks to the archwire (which moved the moment of force to teeth more occlusally) or I had to add wire ligature hooks, which inherently added friction by crossing over the archwire. I try to never cross over the main archwire because of the additional friction but, more importantly, crossing the main archwire can alter or negate your desired torque movements in my prescription.
Why are the hooks so long in the metal R brackets? Because it is not uncommon in my elastic design to have two elastics attach on the same hook. A short hook would fail to retain two elastics. On the R (metal brackets) system, these hooks are a special retentive design. They have a small, rounded 1/2 mushroom to retain elastics. And the hooks are strong enough not to bend or distort under elastic force, yet malleable so that they can be contoured to each patient's anatomy.
Do I use these hooks for elastics on the actual "banding day"? For 5 years now, I have been using a new orthodontic indirect bonding system labelled AccuBond. AccuBond's new adhesive chemistry permits immediate placement of full-sized wires. I use an .018 slot. More than 90% of the time, I immediately place .018 x .018 BioForce heat-treated wire (developed by Miura), which is temperature-sensitive so it can be iced to place yet has individual forces throughout the wire. Incisors receive approximately 80-100 grams of force. Cuspids receive approximately 150 grams of force and molars receive approximately 300 grams of force, all in the same wire regardless of the size of the wire. I also order this wire with an Ion Guard treatment (which produces a more slick surface, reducing friction.) And, I only use the AccuArch large archwire form.
To answer your final question, I normally do not place elastics on this first insertion of the archwires. However, I do begin elastics and modules on the second appointment. The reasoning is that at the initial insertion of the archwire, I only want the teeth to receive the programmed forces of the BioForce arch wires. 4 to 5 weeks later, I add any required elastics or "Sili-chain" modules from Glenroe, which have more consistent elastic force that appears to not force decay for at least 5-7 weeks.
This may be more information than you requested. However, your question appeared on a weekend day in which I felt inspired. Thank you again for your questions.
Best Personal Regards,
Michael C. Alpern, DDS, MS
Dear Greg,
Thank you for your insightful question. The best information collated into one journal is in the Seminars in Orthodontics, Volume 14, Number 1 (March 2008). This particular journal was supposed to be a debate about various types of self-ligating brackets.
I wrote the chapter "Gaining control of Self-Ligation;" which is pages 73-86. Naturally, when you are charged with such a responsibility, you are very careful and send in lots of evidence. The editors did not include a lot of material that I believe would have presented more evidence-based knowledge. In all fairness, most authors feel like this when they submit a journal article.
I have written two textbooks on orthodontics, both published by GAC: The Orthoevolution and The Orthoevolution and A "Squared." The second textbook centers on the use of self-ligating brackets. The book has a significant number of cases (very difficult cases) all treated well with self-ligating brackets.
Your question is really directed towards the issue of all of the claims made by some lecturers using self-ligating brackets—which appear to question basic orthodontic principles.
Those authors will have to back up their claims with cases treated showing long-term results.
I merely incorporated self-ligating brackets into my existing mechanics because I could fill the programmed bracket slot completely (especially vertically) with my first and all other wires. Because I use a self-ligating system that has a closing spring which is flexible, this permits less friction that traditional steel-tie brackets. Please bear in mind, I made the change to self-ligating brackets after nearly 25 years of steel-tieing every bracket in my practice. Now, after entering my 33rd year of practice, I have begun to collect a significant amount of cases more than 5 years in retention.
I still believe you can only expand the maxillary arch with a bonded Rapid Palatal Expansion Bite Plane System. I upright the lingually proclined mandibular molars and bicuspids using the "tied-in" palatal expander as "disposable anchorage."
My only problem seems to be the lack of advertising or "expanding public knowledge" that seems to restrict my ability to present this evidence. I will probably be informed I should not have made this last statement, but since graduating from dental school in 1967, I am not sure I can hear them.
Thank you for asking the questions. If you want more information, ask me.
Best Personal Regards,
Mike Alpern
Dear Joshua Strattam,
Thank you for your question. You are certainly a profound thinker and thoroughly investigate orthodontic products before you try them on your patients. I applaud you.
Your question seems to focus on the supposed advantages of a passive bracket as opposed to an active bracket. I believe the terminology "passive" and "active" are commercial terms, which actually cloud the biomechanics that actually occur.
I would refer you to my second textbook, The OrthoEvolution and “A” Squared BioMechanics. This text is published by GAC and sold at the printing cost. I receive no monies from either of my textbooks. My orthodontic teachers embedded in my heart and brain that you should give something back to this marvelous profession, and teaching is how I try to do just that.
I would ask the question, can you move teeth with a "passive" system? In actuality, the Innovation R and C (clear) brackets are neither purely passive nor active. I use an .018 slot. And, when you place an .018 x .018 GAC BioForce wire with Ion Guard, this wire fills the programmed bracket slot vertically, giving full 3D-controlled movement.
If you carefully examine an article I wrote in Orthodontic Products called, "Complete Control," which Chris Piehler (the editor) can direct you to find, you will see that initially, when you place this wire, since the teeth are not aligned, this wire is not aligned with the bracket slot and therefore, the closing clip is "active" as this alloy closing clip tries to seat the wire into the slot. However, the R and C brackets have a "clip stop" built into the design. So the spring clip can only close until it contacts the "clip stop" and then it cannot contact or push on the main archwire. As the wire settles into the bracket slot and contacts the tooth-borne wall of the bracket slot, the wire moves away from the closing clip and thus it is "passive" if you want to use those terms.
I am like you. I am often puzzled by claims of companies. I would ask, "is the closing 'passive' door of the passive bracket a solid, non-flexible door? Because, if it is solid and non-flexible, then how can it be ‘passive’ compared to a closing spring clip which is flexible?”
Regarding the size of the brackets, In-Ovation is a low profile bracket with smooth swept tie wings and extremely comfortable for the patient. I see the Carriere manufacturer shows In-Ovation R to be significantly larger than a Carriere LX. I question whether or not this is an accurate representation. You can contact the product manager at GAC (800-645-5530), they can provide you with the actual dimension of an In-Ovation R bracket. In addition, the In-Ovation R bracket is a true straight wire bracket with a compound contour base that is designed to adapt to the unique anatomy of each tooth.
I hope this makes sense. You can also read, Seminars in Orthodontics, Volume 14, Number 1 (March 2008), which is a refereed journal. This edition is a debate about self-ligating brackets.
I am sure you have more questions. So please send them to me.
Best Personal Regards,
Michael C. Alpern, DDS, MS
Dear Dr. Luis Rafael Serret,
Thank you for your questions.
I do not have any knowledge or experience with the appliance are using. That does not imply that the appliance you are using is not an excellent appliance. It is just that most of my research and experience and knowledge is with a different approach. In orthodontics, there are always multiple different methods to achieve good results.
I am very sorry I can not accurately answer your excellent questions. Perhaps you could contact the company that makes this appliance and they may be able to put you in contact with the orthodontists who designed this system.
Best Regards,
Michael C. Alpern, DDS, MS
Dear Dr. Nagalakshmi Jawaharlal,
I must plead a lack of knowledge because I do not know what "PEA" stands for. Can you please define this term so I can better answer your question?
Thanks,
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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