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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 Rick Stevens,
Thank you for your questions and kind comments.
I was very fortunate to work with Dr. Carolyn Primus, who has a PhD in medical and dental materials. Together we looked at the basic challenges of indirect bonding and we developed a series of materials which bond to stainless steel mesh and/or ceramic bases. Then we use a second material that is strong and forms a custom base. The final material is a very thin amount of a flowable composite added just before we seat the tray holding all the brackets. One unique feature is that ceramic brackets present no debonding problems as we designed this system to fracture within the bonded custom base and not at the enamel surface. We also have over 90% immediate bonding strength, permitting immediate placement of a full-sized BioForce wire in nearly all patients. And our bonding time averages approximately 20 minutes, including wire placement.
Now, to answer your questions.
1) Do we offer an indirect bonding course (hands-on) in my office? Yes, we offer courses. Prior to AccuBond, the course was held twice a year. Now, with the launch of AccuBond, we are noting an increased demand for my courses. Please stay in touch with me or GAC to find out when the next courses will be held. We also conduct an online training every second Friday of the month (excluding holidays) at 12:00 noon EST. The next one is scheduled for May 8.
Accubond was designed from the beginning as an outside laboratory procedure. Because of the unique materials, you cannot have an assistant place the brackets on the model and then have you critique or tweak the bracket positions. It is a complex procedure to break the bracket off the model, repair the model, then redo the materials to reposition the brackets. Each bracket has a custom base. The GAC laboratory has the technology permitting any changes in bracket position in a seamless manner.
We developed this procedure with the GAC orthodontic laboratory in Racine, Wisconsin. From the get-go, Accubond is set up to be a 5-day, in-lab procedure. With overnight shipping both ways, you can take the PVS impressions and ship them out the same day. Within 24 hours, you will receive an e-mail message that your brackets are placed on the models and you can access them with a password-protected Web site.
You will see images of your brackets taken with a 10 megapixel camera with a macro lens. You will view each bracket from three dimensions. Each bracket is photographed with an adjacent millimeter ruler. You can quickly make any modifications over the Internet and once you approve the bracket positions, you will receive your brackets in a special shell with all the materials ready for bonding.
Originally, I did make these indirect trays in my office laboratory. After 2 years in development and 3 years of testing, the AccuBond system is FDA approved. And I use the GAC laboratory to place my brackets and make my indirect bonding shells. They trained in my office and I flew to Racine to double-check.
In today's present economy, believe it or not, I have found it more efficient and more profitable to outsource many of my office procedures. Office letters, laboratory procedures, and many other items are completed quickly and accurately without paying the multiple benefits employees currently require. I am blessed to have a son who is a nationally recognized business and corporate consultant. Micah keeps me up to date on the best, most current business practices.
Finally, I predict that many orthodontists will spend more time looking at production on a high-resolution monitor with high-speed Internet than previously doing it all in-house.
Thank you again for your questions and kind words. Do not hesitate to e-mail me if I did not adequately answer your questions.
Best Personal Regards,
Michael C. Alpern, DDS, MS
Dear Drsaba Fouad,
Thank you for your question.
You can still use the Alpern Square Wire approach in the .022 slot by using the Monacell wire design, which is a .022 x .018 Monacell BioForce with Ion Guard wire in the large AccuArch form. Some doctors have found that it is sometimes easier to begin treatment with a .020 x .020 BioForce with Ion Guard in the AccuArch form for three months and then change over to the .022 x .018 wire size (first in Bioforce) and then the same wire size (.022 x .018) in Resolve (Beta Titanium), and then the same size wire in stainless steel to finish. By always trying to completely fill the bracket slot, you maintain full 3D control of the prescription in your bracket slots.
Best Personal Regards,
Michael C. Alpern, DDS, MS
Dear Dr. Gluck,
Thank you for your question. Bracket positioning is one of the keys to successful orthodontic treatment. In the past, some have suggested differing positions. I use an indirect technique called AccuBond with Innovation C brackets. These are clear, ceramic self-ligating brackets. I use the .018 slot in my own prescription. This technique is available from the GAC Ortholaboratory (866-463-4300). Ask for Dan Riegelman.
My bracket positioning is individualized for each patient based on each patients unique skeletal and dental patterns. The key here is individualization based on cephalometric photographic and clinical findings. There are three differing patterns: hypodivergent, hyperdivergent, and normal.
And, placing brackets on indirectly gives me a 3D view of each tooth. And, as DNA's have mixed with the mixing of our differing types of peoples, now, more than ever, I stress individualization.
Given all that verbiage, here is my basis: I try to place the bracket slot in the center of the clinical crowns of molars and bicuspids. The bicuspids limit this process. However, the more bicuspid bonded brackets are manufactured with a gingival off-set, the better I can achieve what I want. However, given the challenge, I start with the maxillary and mandibular first molars. I do not vary these bracket slots. I place the bracket or tube slot in the center of the adult clinical crown. For children and teenagers, I try to place the bonded mandibular brackets in the center of the clinical crown as I would imagine it when full, normal eruption occurs. If this involves compromise due to a short clinical crown, then I note the compromise and this continues (where I can) with the bicuspids. In other words, bicuspids are set at the same height as the molars.
For hyperdivergent (vertical growing patterns) I set the cuspid bracket slots 0.5 mm more gingival than I would for normal patterns. Conversely, for hypodivergent and normal patients, I set the cuspid bracket slots 0.5 mm more incisal to the bicuspids. The maxillary lateral incisors are placed 0.5 mme more gingival to the cuspid bracket slots. In the maxillary arch, the maxillary central incisor bracket slots are set identical to the maxillary cuspids.
For the mandibular arch, everything is the same except the four lower incisor bracket slots are always 0.5 mme more gingival than the mandibular cuspids. To be absolutely clear, in the finished treatment, the mandibular cuspids are 0.5 mm more occlusal than the mandibular incisors.
The facial surface of all teeth is changing. Many have irregularities, grooves, chips and enamel defects. Thus the AccuBond indirect bonding system makes a custom base for each tooth to be bonded.
Yes, I plan a smile design at the diagnosis and treatment time plan, including the anterior-posterior position of the incisors. My goal to try for is a 90 degree naso-labial angle. I can not make this happen, but it does give me a reference for incisor positions.
Dr. Ray Bertolotti taught me smile design. Mine is to try and make the incisal edges of the maxillary teeth follow the contour of the lower lip in a full smile.
It is a challenge to try and make the software in my brain come out of my fingers as I type this. If any of this philosophy is unclear or does not make sense, please e-mail me. I type this rushing to leave for a lecture in Rhode Island. I have re-read it twice, but at this time of the day, I may not have been perfect.
Please e-mail with any questions.
Michael C. Alpern, DDS, MS
Dear Kenneth Hrechka,
Thank you for your question. Significant calculus build-up is a problem in non-self-ligating brackets or self-ligating orthodontic brackets in adults and certain teenagers.
I have not found anything to prevent this problem that did not have a significant risk or side effect. When you and I treat adults, you know you have to be very careful with their periodontium. In my experience, (others may disagree) the most significant risk in adult treatment is losing alveolar bone or attached gingiva. When you orthodontically stress the periodontium, you do not want any other chemical or toothpaste or mouthwash that might further stress the periodontium, or you could lose attached gingiva or bone or both.
I do have a solution. We have three Dentsply Cavitrons and two Prophy Jets with Ortho Shields in our clinical area. My wife is a registered dental hygienist and she schedules these patients when she has time to use the Dentsply P 1000 Cavitron tip and the Cavitron to completely remove calculus from around the brackets. Ada Hinda also opens the "R" clips. Once the clips are open, she continues using the P 1000 tip to cavitate the clip and slot the clip slides in as well as the bracket slot so there will not be any additional friction.
NOTE: Teeth which have calculus interproximally and around the bracket tend not to move because the calculus acts like a cement to prevent the tooth sliding in the bracket.
Cavitrons are an investment, but we find it a one-time investment which permits us to finish adults quickly and comfortably.
If you have any additional questions, please e-mail me.
Michael C. Alpern, DDS, MS
Dear Arul Prakash,
Thank you for your question. Dr. F. Miura and associates first published their paper, "The Super-Elastic Property of the Japanese NiTi alloy for use in orthodontics" (Am J Orthod Dentofacial Orthop 90:1-10) in 1986. He wrote another article (Miura, F. et al., New Appliance of super-elastic NiTi wire in the J Clin Orthod 23:353-363) in 1990. Dr. Miura was issued an American Patent on March 3, 1992.
This wire was to address the work of Story and Smith "Force in orthodontics and its relation to tooth movement," which was published in the Aust Dent J (56:11-18, 1952.) Story and Smith (and many others after them) found the ideal force to move each different size of teeth. For instance, lower incisors only require approximately 80-100 grams of force, while cuspids require approximately 140 to 150 grams of force and molars require approximately 250-350 grams of force. Story and Smith found this range of force created the most ideal force within the periodontal ligament to cause normal bone remodeling.
The unique characteristics and physical properties in BioForce wire simulate approximately this individualized force to differing teeth from the incisors to the molars, all in the same wire and regardless of the size of the BioForce wire.
In addition, BioForce wire is temperature-sensitive. We store the BioForce arch wires in a freezer and bring them to the patient on a frozen aluminum slab coated with Teflon. Thus, we are able to insert the archwire with minimal force and maximum patient comfort. Should we encounter an unusual mal-posed tooth, we spray a cotton swab with Ortho Ice and freeze only that portion of the wire that we require to have increased flexibility. Area freezing of the wire permits insertion of a more full-sized wire, vertically filling the bracket slot much earlier in treatment and permitting more tooth movement control almost from the very first wire. Yet in spite of the many bends in the inserted wire, BioForce only delivers the approximate force to the teeth and the alveolar ligament and bone that Story and Smith found is required many years ago.
Many NiTi wires have a rough surface, which increases friction and can slow tooth movement. GAC DENTSPLY found an ionic bombardment process called Ion Guard which changes the surface of the BioForce wire to make it much smoother and slick for sliding mechanics, yet does not change any of the other great physical properties of BioForce.
Most recently, a Rhodium coating of BioForce with Ion Guard is available that is much more aesthetic. This coating is called High Aesthetic Arch Wire.
I routinely have used a .018 x .018 BioForce with Ion Guard with the High Aesthetic coating as my first arch wire in a .018 slot using the new GAC DENTSPLY Innovation "C" (for clear)
self-ligating brackets. I think this offers my patients the very best in cutting-edge orthodontic bio-mechanics in a safe, comfortable and quick method of treatment.
If you have any additional question, please e-mail Chris Piehler at Orthodontic Products.
Best Regards,
Michael C. Alpern, DDS, MS
Dear Dr. Raphael,
This is an excellent question. Like you, I have been using an .018 slot for 32 years. The key answers here is control and friction.
The .018 does have limitations, primarily in the final leveling and finishing torque of Class II, Division II patients. I normally use three archwires: Nickel Titanium BioForce, Ion Guard, then Beta Titanium "Resolve," and finally stainless steel. All are .018 x .018. The problem is that an .018 x .018 stainless steel wire sometimes does not have enough thickness for stiffness or rigidity to apply enough reverse curve or additional anterior torque movements.
In these cases, I add an additional wire: an .018 x .025 stainless steel wire that does have enough thickness, stiffness, and rigidity to apply the forces necessary to achieve the final movements I require. This wire does answer all my requirements. I have also used a .017 x .025 when getting the wire into the molar tubes is too uncomfortable for the patient and I ALWAYS USE A BROWN STONE IN A SLOW SPEED LABORATORY HANDPIECE TO FINISH OFF THE ROUGH EDGES OF THE ENDS OF THE ARCHWIRE. THIS IS CRITICAL FOR EASE OF INSERTION AND PREVENTION OF TOO MUCH FORCE, WHICH CAN BECOME UNCOMFORTABLE FOR THE PATIENT AND COULD BREAK A BONDED TUBE OFF A MOLAR.
These cases are exceptions, however. The .018 slot has so many advantages over the .022 slot that I will not change over. Reasons: using the .018 slot, nearly 90% of the time, my first wire is a .018 x .018 Nickel Titanium, temperature-sensitive, BioForce with Ion Guard (slick surface treatment). This wire in the GAC R and C brackets is "interactive." It gives full 3D control (including torque), which is active while aligning the tooth, then passive once the wire is seated into the slot. This wire does not touch the closing clip once seated. This combination (and many other advantages) makes orthodontics fast, comfortable, and most healthy for the roots and periodontium.
You can get additional information on this technique by reading my article, "Complete Control," which was published in Orthodontic Products, and my article "Gaining Control of Self-Ligation," just published in Seminars in Orthodontics.
This answer has been a short synopsis of a complete evidence-based technique of more than 6 years published in a refereed journal and presented nationally and in Canada.
If you have any questions, please ask.
Thank You,
Michael C. Alpern, DDS, MS
Dear Dr. Gluck,
Thank you for your question. If you e-mail Chris Piehler, he can forward to you a digital copy of my article in Orthodontic Products entitled "Complete Control."
I have also published an article in the March 2008 issue of Seminars in Orthodontics by Elsevier publishing and GAC has published this discussion in two of my textbooks, the first is a blue hard cover book titled The Orthoevolution, and the second is The Orthoevolution and A Squared.
In all of these publications I explain at length the science and clinical application of this concept.
In short, if you measure the interior dimensions of the In-Ovation R and C brackets, the vertical wall and the gingival wall are .0185 inches each. The occlusal wall is .0255.
The importance of these measurements is if you place a GAC wire such as a BioForce wire, which is .018 x .018, once the wire is seated into the slot, it does not touch the closing clip.
When the tooth is out of alignment, the wire will contact the closing clip and and the closing clip and the wire will be "active." However, once the wire moves the tooth to the correct position, the clip has a stop built into the bracket. So, once the clip finishes moving the wire and the clip contacts the "clip stop" on the bracket, the clip no longer contacts the wire and the clip and the wire are passive.
This concept of a closing clip and an orthodontic archwire being sometimes active and sometimes passive has been termed "interactive." The key here is using a properly manufactured bracket slot and wire which have the highest tolerance or corner radius tolerance. The GAC R and C brackets and their archwires do have this tolerance and thus they are able to be "interactive."
This concept of "interactivity" is very important clinically, because this minimizes friction yet maximizes three-dimensional control from day one if your first wire in a .018 slot is a temperature-sensitive nickel titanium BioForce wire with Ion Guard.
BioForce is a special wire developed by Miura which has individual force throughout the wire. Incisors get 80-100 grams of force. Cuspids receive 150 grams of force, while molars receive 350 grams of force--all in the same wire, regardless of the size of the wire. So teeth move faster with lighter and more constant force and in a safe, predictable manner.
And, if you order BioForce with Ion Guard, the wire surface is subjected to ion bombardment, which appears to make the surface very slick and smooth, further diminishing friction.
If you have further questions, please refer to all the publications above or call your GAC rep to order the articles and books.
Best Personal Regards,
Michael C. Alpern, DDS, MS
Dear Dr. Gluck,
Thank you very much for your questions.
You have brought up a very current and ongoing question which has multiple answers. I wrote my master's thesis on distortion calculation in panoramic radiography so perhaps I can shed some light on this dilemma.
Part of the answer lies in the focal trough of the many differing types of panoramic radiographic machines available. As the tube head and film holder or digital sensor rotate around the patient, a focal trough is created. This focal trough is unique to each machine and also differs with patient positioning. The wider the focal trough, the more teeth may be included within the focal trough and appear somewhat in focus. Over 36 years ago, Gendex produced one of the first panoramic machines with an adjustable focal trough. Patients with wide faces required a different focal trough than those with long narrow faces. Today, there appear to be two differing types of panoramic radiographic machines: those with one generic focal trough and those with adjustable focal troughs. To achieve an accurate image of the crowns and roots of the teeth, the key is to use a machine which can individualize the focal trough to the shape of the patient's teeth and apical base (which contains the roots).
A generic focal trough may not necessarily take an accurate image of the teeth. In my research, many studies have shown that inaccuracies in the focal trough to the actual size of the teeth can lead to unquantifiable horizontal, vertical, and angular magnification and diminution. In other words, some machines may produce a distorted image. Recent research comparing panoramic, periapical images to models of the patient revealed some distortion, particularly in the cuspid area where the machine has to go around the arch curvature.
As I stated at the beginning, this is a complex problem with multiple opinions and evidence-based findings.
Here is what I do. I selected a Planmeca panoramic digital machine. Why? The Planmeca ProMax panoramic unit has three completely separate axis of rotation, all of which are programmable. One program even produces a 90 degree cut similar to bite wing radiographs. Even here, sometimes there appears to be excessive root tip (especially in the cuspid regions). So I look at the image, compare it carefully to the crown positions in the mouth, and finally try to palpate the root positions as they compare to the radiographic images. Some I change and some I do not.
So, even with the best panoramic machines, there still may be some distortions. Use your best clinical judgement.
Now, you second question: what do I use to determine how to correct any root corrections? For 5 years now, I have been using a new indirect bonding system. This is new from the ground up. I was fortunate enough to treat one of the world's experts with a PhD in dentomedical materials, Dr. Carolyn Primus, and I formed a team and developed an entirely new indirect bonding system which (according to GAC) will launch in August 2008.
Two years in development and 3 years of testing have yielded a very good system. We can bond 7-7 upper and lower, buccal and lingual in 20-35 minutes including immediate placement of a full-sized wire. We use an .018 slot and in 95% of our cases, our first wire is a .018 x .018 BioForce with Ion Guard Nickel titanium wire, which is temperature-sensitive, and we ice it to place.
The end result (after 3 years) is my root parallelism is almost 95%. So, with or without radiographic distortion, accurate bracket placement is the key to avoiding removing and re-positioning brackets.
Lastly, unless I see a marked deviation in crown-to-root alignment, (such as a dilacerated root) I use the long axis of the tooth to align the brackets.
The new system from GAC is called AccuBond and is available from the GAC OrthoLab in Racine, Wis. You can e-mail Dan Riegelman at driegelman1@gacintl.com or call toll free at (8660 463-4300 for information. Please take the time to tell Dan and his technicians all the little special things you do in bonding, including what bracket height for each patient and any additional torques or root positioning. AccuBond makes a custom base for every tooth.
After the lab technicians have bonded the brackets, they will e-mail you a macro image of each bracket on each tooth from three differing directions. You must approve each bracket before they will make the indirect trays.
If you have additional questions, please e-mail me or Orthodontic Products.
Best Regards,
Michael C. Alpern, DDS, MS
Dear Dr. Javier,
Thank you for your questions.
I will try and answer them in the order in which you presented them. Your first question is do I think that if I use an .018 x .018 stainless steel archwire to open or close spaces, that the system I use would generate too much friction as I fill the archwire slot vertically.
My answer is (for the 5 five years) I have opened and/or closed nearly all spaces with an .018 x .018 Nichol Titanium BioForce (temperature-sensitive) wire which is subjected to ionic penetration (Ion Guard). This makes the surface of the wire slick and smooth. Thurow and Kusy offer evidence-based knowledge for friction. If we disregard all the politics and commercialism, only Thurow and Kusy have actually performed the tests clearly defining friction. Essentially, stainless against stainless produces a very low coefficient of friction. The Ion Guard surface on BioForce wire simulates the friction effect of stainless against stainless steel.
I refer you to my article to be released this month in Syllabus in Orthodontics which discusses this particular issue at length.
I am unaware of the Forsus appliance. However, I open and close nearly all my spaces on .018 x .018 BioForce wire and, since my roots and periodontium stay healthy and since I have reduced my treatment time, it would appear that friction is not a problem.
Second and third questions:
I have used TADs to intrude molars. However, more often, I intrude molars with flowable composite bond built up to the occlusal surfaces of the teeth to be intruded. Here again, you can refer to my textbook, THE ORTHOEVOLUTION, which is published by GAC and is sold at the printing cost with no profit to me.
However, you do bring up a very critical deficiency of the .018 x . 018 wires, and that is they lack the bulk strength or stiffness (even in stainless steel) from posterior to anterior. When I have a very steep curve of Spee or when I want to torque upper incisors, sometimes the .018 x . 018 wire lacks the stiffness to apply the proper force. In those instances, I do use .017 x .025 or .018 x .025 stainless steel wires.
Fourth question: At this time, GAC Resolve wires are not available with Ion Guard. However, these wires are manufactured with a very smooth surface and I do not encounter frictional problems using this wire to finish any space closure or space opening with sliding mechanics. Again, nearly all of my sliding mechanics are completed on the .018 x .018 GAC BioForce wire with Ion Guard.
I hope this answers your questions. Thank you for submitting the questions.
Best Personal Regards,
Michael C. Alpern, DDS, MS
Dear Dr. Boin,
I think I can more accurately answer your question if you define exactly which kinds of auxiliaries you are asking about.
TADs can be used as auxiliaries. While I have not used traditional auxiliaries (torquing springs, etc), I routinely use piggy-back Nichol titanium BioForce sectionals with the Innovation R and C ligatureless brackets that I currently use. I stainless steel tie this piggy-back sectionals over top of the main archwire.
My concept of ligatureless brackets is simply that they have a closing clip as part of the bracket. Therefore, almost any mechanical systems that I have used in the past can be used with the ligatureless brackets.
Again, I have not found it necessary to use torquing spring auxiliaries, so I cannot specifically give you a positive answer.
The reason I have not found it necessary to use torquing spring auxiliaries is because I fill the prescription bracket slot completely with my square wire approach for the .018 slot. So, in most cases, my original archwire is a .018 x .018 Nichol titanium GAC BioForce wire with Ion Guard. This wire is temperature sensitive and can be "iced" to place. Since I fill the slot completely, I achieve full 3D control from the very first wire. This includes torque control.
This may be more clearly defined for you if you ask your GAC representative for a copy of my new syllabus called "A SQUARED BIO-MECHANICS."
Best 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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