Antonino Secchi, DMD, MS
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. Esguerra,
Unfortunately, I have never used the Carriere Self-Ligating bracket. Therefore, it would be inappropriate for me to make any comments. I am sorry.
Michael C. Alpern, DDS, MS
Dear Dr. A. Joel Gluck, DDS, MS
Thank you for your questions. I appreciate the opportunity to discuss biomechanics.
Your first question is “How are they different in performance from rectangular arch wires?” The .018 “R” bracket is very unique and I am happy for you that you are using it. Many of the answers to your questions are answered in an article I wrote in Orthodontic Products entitled “COMPLETE CONTROL.” Please ask Chris Piehler for a digital copy of this article. The key to the concept is that a square wire is a “round wire with corners.”
If you look at the article, the InOvation “R” bracket slot measurements permit insertion of a .018 x .018 GAC BioForce wire as your initial wire in 85-90% of your patients. BioForce is a unique Nickel Titanium, temperature-sensitive wire. We freeze the wire and insert it in a very cold state. Often, we can freeze sections of the wire for full engagement without breaking brackets off or causing discomfort. The truly unique additional benefit of BioForce is this wire applies only 85-100 grams of force to the incisors, 150 grams of force to cuspids and 350 grams of force to molars--all in the same wire, regardless of the size of the wire. So, this is my first wire. In very severely crowded cases, we compromise and use a .016 x .016 BioForce wire for 2 months, then go to the .018 x .018 BioForce wire.
We normally leave the BioForce wire in for 3-5 months and this levels and aligns all teeth. If I extract, the BioForce square wire works very well with excellent control. Same for expansion.
The real benefit of .018 x .018 BioForce is if the teeth are not aligned initially, the wire is activated by the “R” clip until the wire is seated into the bracket slot. The closing “R” clip has a stop on the bracket so it only closes to a certain point. Once the clip is full closed, the clip no longer contacts the square wire and you have full 3D control with minimal friction.
Rectangular wires (such as .016 x .022) exceed the bracket slot interior dimensions and they are always active against the clip. This produces constant clip friction, while square wires do not exhibit this constant clip friction. And, by filling the slot vertically, the square wire produces full 3D control with minimal friction. In my opinion, square wires have all the benefits of rectangular wires without the constant clip friction.
Your second questions are: If a patient starts out with generalized spacing in upper, how would you close it? Can you close this space with a rectangular (or square) wire?
My answer is, I close spacing with the .018 x .018 BioForce wire with a “Sili-Chain” from Glenroe and GAC. This chain does not tend to lose elastic force for as much as 8 weeks. You can also close spaces with elastics on the square wire. Here again, the space closure tends to be faster because I have full 3D control without constant clip friction.
Your third questions is: If they start out crowded can you use open coil-spring to make space on a rectangular (square) archwire?
My answer is yes, you can use open coil springs on square wire.
Your fourth question is: Do you see lateral arch "development" to make space in crowded arches with Inovation like the Damon users claim they get with that technique?
My answer is that one of the deficiencies of nearly all titanium wires is lack of mediolateral forces. I develop arches by first using a Rapid Palatal Expansion Bite Plane system (published in my GAC textbook, “‘THE ORTHOEVOLUTION”, which contains more than 30 years of evidence based knowledge of lateral arch development, including long range studies of stability during retention. I cannot speak for others. They will have to demonstrate their claims with long term studies.
Once the Rapid Palatal Expansion Bite Plane system has completed expansion, then I lock the expansion screw and use the bonded expansion device as “disposable anchorage” to expand the mandibular arch by running crossbite elastics from cleats or buttons bonded indirectly to the lingual surface of the mandibular first molars to the buccal crossbite hooks built in to the Bonded Palatal Expansion Bite Plane System. Again, please refer to the textbook which is sold at the printing cost only.
Thank you for your questions. If you would like to see my patients live with hand-on training, twice a year, I teach a 3-day, in-office course with patient demonstrations. The next course is Thursday, February 21 through Saturday, February 23, 2008. If interested, please call Ada at (941) 629-2221.
Michael C. Alpern, DDS, MS
Dear Dr Duncan,
Thank you for your questions.
Your first question: “Have you had any problems with detailing/finishing cases with these brackets?”
Answer: I am currently experiencing very few problems finishing and retaining patients. The credit goes to Dr Robert Kusy, a brilliant researcher and teacher. Dr Kusy opened a window of knowledge by explaining exactly what our archwires are doing inside the bracket slot and how this combination affects frictional forces. One of the principles Dr Kusy taught is to fill the slot vertically in the In-Ovation R bracket. I have been doing so for more than 5 years using the .018 slot.
95% of the time, my first wire is a .018 x .018 GAC BioForce wire with Ion Guard in the large Accu-arch form. This unique, temperature-sensitive wire has individual forces throughout the wire. These forces are what Storey and Smith published more than 30 years ago as the ideal forces for all the differing teeth in the dental arch. BioForce applies approximately 80-100 g of force to incisors (which have small roots). Cuspids receive approximately 150 g of force and multirooted molars receive 350-400 g of force--all in the same wire, regardless of the size of the wire. We store BioForce wire in the freezer with Teflon coated aluminum slabs. We bring the BioForce wire to the chair on the frozen slab and insert the wire while still nearly frozen. During the insertion, the mouth warms the BioForce wire to mouth temperature, which causes the wire to become slightly stiffer (but only to the correct force levels). If we encounter a marked rotation or a malposed tooth, we spray a cotton swab with Ortho Ice to chill only the section of the wire which needs to be softened or made more flexible. In addition to this, if a patient has no sensitivity to cold on his or her teeth, I usually encourage him or her to (three times a week) take a mouth full of ice water and hold it around the wires for 60 seconds, then spit out. This tends to “refresh” the wire and makes teeth move more gently but quickly.
Now, more specifically to detailing/finishing wires. If you use the .018 x .018 BioForce wire, you will vertically fill the slot of the In-Ovation R brackets, ensuring that you achieve full, 3D control with the very first wire. Please ask Chris Piehler (the editor of Orthodontic Products) to send you a reprint of my article “COMPLETE CONTROL,” which details this technique.
If you use the .022 slot, you first wire should be a .020 x .020 GAC BioForce wire with Ion Guard in the large Accu-arch form. I would maintain this wire in for 3-4 months, then switch to the .022 x .018 Monacell GAC BioForce wire with Ion Guard in the large Accu-arch form. With this wire, again, you will fill the slot vertically, achieving full 3D control, but in both cases (.018 and .022 slots), once the wire has completed the 3D correction, the wire will not touch the closing clip, minimizing friction.
The second part of this answer is that, once you have filled the bracket slot vertically, DO NOT CHANGE THE WIRE SIZE. Instead change the wire metallurgy technology. From the .018 x. 018 BioForce wire, go to an .018 x .018 Resolve beta titanium wire. Your third archwire should be an .018 x .018 stainless steel wire . All archwires are the large Accu-arch form. All the same size, just differing wire technology. The only addition to this technique is the fact that all .018 x .018 wires do not have a significant amount of medio-lateral strength. Therefore, I always use a Cetlin Palatal Bar system to obtain the required maxillary width.
In the .022 slot, the second and third wires are .022 x .018 Resolve beta titanium and stainless steel, respectively.
The second answer to your question about finishing and detailing is PLACING THE BRACKETS IN THE CORRECT FINISHED POSITION.
I have practiced orthodontics for 32 years. No matter how hard I try to directly place brackets in the correct position, it is very difficult to accomplish that at the chair. It does not matter whether you are right-handed or left: you have a skewed view of the tooth and where you need to place the bracket exactly in the finished position. The only answer is indirect bonding. When you place brackets on an accurate model of the patient’s teeth, you have a 3D view of exactly where the brackets should be placed.
You might say, “I have tried indirect bonding before and it was never accurate and I had multiple bonding failures or worse." If the tray was warped or if they taught you to push on the tray occlussally and from the buccal or facial, there was always the chance that the bracket could be pushed from its intended position. We have developed a completely new indirect bonding system that solves all these problems. In a 2.5-year study, we had a 99% bonding success and 99% accurate bracket placement. This system should be available from GAC Orthodontic laboratory in the next few months.
In addition, we teach a certification course which completely informs you and your team every little step to ensure success. You also save chairtime. We can bond a single patient from second molar to second molar buccal and lingual attachments in 20 minutes.
If you place the brackets in the correct positions and then use the above wires, you will be on your way to a quickly and accurately finished case. I also place indirect buttons on the mandibular molars to use crossbite elastics to the maxillary molars supported by the Cetlin Palatal Bar system.
Now, to answer the question about the GAC dual mesh and your problems of using existing bonding pastes to penetrate the mesh and also bond to the teeth. GAC’s new STRATA indirect bonding system solves all of those paste/mesh problems. You might want to contact your GAC representative to ask about STRATA. And you and your team may want to consider taking an indirect, hands-on clinical course from my team in Port Charlotte, Fla.
Presently, twice a year, we offer an in-office, hands-on, 3-day course. During this 3-day course, we will also teach you and your team (if you wish to bring them) all the answers you are asking about. Our next course (which includes the STRATA indirect bonding system) is available on Thursday through Saturday, February 21–February 23, 2008.
You can call our office at (941) 629-2221 to reserve a place for you and members of your team. Port Charlotte is on the west coast of Florida.
Thank you for your interest and your questions.
Michael C. Alpern, DDS, MS
Dear Jeanette Abdeljawad,
Thank you for your question.
The American Association of Orthodontics has a library in St. Louis. You can call (800) 424-2841 and ask for the librarian. The librarian should be able to do a computer search to give you more than just my opinion to answer your questions. Additionally, Chris Piehler, the editor of Orthodontic Products, may be a source of articles written in his journal.
Advances in technology have changed nearly every aspect of orthodontic diagnosis, treatment, and retention. Let me site just a few examples: In the area of orthodontic diagnosis, technology has changed how we make and keep diagnostic records and actually how we can make more accurate diagnosis.
Many orthodontists (including me) now take molds of patients teeth and gums and instead of making plaster models of the teeth, we send the molds to a special laboratory which optically or, using a laser, scans the molds and sends us back digital 3D models of the teeth, gums, and bone of the jaws. The laboratories use the internet to send 3D images back to my office. These 3D digital images can be moved, rotated, segmented, and viewed from many directions. Accurate measuring of the size of teeth and space available can be digitally accomplished. More importantly, the orthodontist can then digitally manipulate each tooth to simulate the proposed orthodontic correction. In addition, once the corrected models have been conceived, the computer systems can then show the orthodontist where each orthodontic bracket should be located. Several digital systems can then make a shell of the exact position of each bracket and send this to the orthodontist who can bond these digitally corrected models to the patient’s teeth. These systems can potentially permit the orthodontist to not just visualize in his or her brain what the orthodontic correction should looks like. Now, with 3D virtual images, we can morph the crooked teeth into the corrected positions, see how they will fit and make individualized adjustments. This should permit more accurate diagnosis and faster treatment or less time in braces.
There are advances in radiology or x-rays of orthodontic patients. Many orthodontists use digital radiography, which exposes patients to less radiation--and we can see the image in 8 seconds. Some orthodontists are beginning to use small cone beam CT scans of the head which can produce 3D images. 3D facial photographs are possible. All these continue to aid our ability to more accurately diagnose exactly what treatment options the patient requires and, potentially, what the results may resemble. There continues to be no accurate method to exactly predict how each unique individual patient will grow. However, general ideas can be gleaned permitting more information for patients to choose the best course of treatment.
The types, sizes, and functions of actual braces have undergone significant changes. For years now, orthodontists have been able to actually bond the individual braces onto the surface of teeth without having to make a stainless steel band (or ring) around each tooth. Braces are smaller and more comfortable, and some even have built-in springs or closing doors to secure the main archwire to each bracket. Some braces are very clear and are almost invisible. Wires are becoming whiter and less visible.
The types of archwires we use to align the teeth in each jaw have evolved from space-age technology. We now use nickel titanium and beta titanium wires, which permit much lighter forces and permit treatment or tooth alignment much faster. Lighter forces permit safe, fast tooth movement. In the past, some thought fast tooth movement might damage the roots of teeth. Now, there is significant evidence documenting faster tooth movement with safe, healthy roots, and gum tissue. There is even one special type of nickel titanium archwire that produces individualized forces for differing teeth. The incisors (very front teeth) require light forces (around 80-100 grams of force), while large cuspids require slightly more force (around 150 grams of force), and large, heavily rooted molars require about 350 grams of force. This unique nickel titanium wire offers individualized forces throughout the same arch wire, regardless of the size of the wire. And this special wire (called BioForce) is temperature-sensitive, so the orthodontist can freeze the wire to make it very flexible and insert it into very crooked teeth without any discomfort. As the BioForce slowly warms up to mouth temperature, each individual tooth receives only the correct amount of force to safely and comfortably and quickly move the tooth to the correct position.
Now, there are very accurate and consistently reliable methods to indirectly bond all the braces on to all the teeth using flexible trays. More accurate placement of braces shortens treatment time and can potentially produce better results.
There are many new methods being developed to expand the upper jaw which can make it easier to breathe through your nose amd more comfortable to swallow by increasing functional tongue room, as well as producing broad, attractive smiles. All without any surgery in children and young adults.
Finally, the methods of retaining or holding the teeth after braces have dramatically changed. Many retainers are nearly invisible because of advances in the chemistry of plastics, and some retainers are bonded to the inside of mostly lower front teeth.
These are just a few of the dramatic changes in orthodontics thanks to technology. And the future is wide open. More to follow.
Michael C. Alpern, DDS, MS
Dear Dr. Isabel Mendoza,
Thank you for your question. I assume you are using the Innovation "R" ligatureless micro bracket. If not, please let me know.
I basically use a square-wire technique which has been very effective and quick with ideal forces on most teeth.
My first wire is usually a .018 x .018 BioForce with Ion Guard. Only if there is severe crowding, I compromise down to a .016 x .016 BioForce with Ion Guard. In both wires, I only use the large Accu Arch form or shape. BioForce is a special temperature-sensitive wire which has individual forces through out the wire. Incisors usually receive from 85-100 g of force, cuspids receive 150 g of force, and molars receive 350 g of force, all in the same wire regardless of the size of the wire.
This wire provides ideal forces to each tooth while being temperature-sensitive. You can ice it to place; in other words, we freeze the wire during storage, then,we bring the wire to the orthodontic chair on a Teflon-coated aluminum slab (which keeps the wire frozen and very manipulatable). As we insert the wire into very crooked teeth, we also use Ortho Ice which is a spray. We spray a cotton swab with Ortho Ice and place the frozen cotton swab on the wire where I need it to soften and become pliable. As the wire section freezes, it becomes very flexible and, most of the time, my team and I are able to insert the wire into the bracket slot. Then as the wire warms up to mouth temperature, the wire applies only the correct amount of force for that particular wire.
If you order the wire with Ion Guard, you will find the surface has been ionically treated to be very slick and smooth, making sliding movements with very little friction. Where appropriate, you can place push coils to open spaces between crowded teeth. I maintain this BioForce wire in the mouth for at least 3-5 months or until nearly all crowding has been resolved.
My second wire is a .018 x .018 Resolve, beta titanium wire in the large Accu Arch form. In this wire, you can make individual bends where needed, such as asymmetric arch formation, reverse curve, etc. Resolve has nearly twice the flex of stainless steel wires and half the force. Resolve is the bridge I use to change from BioForce to stainless steel. In some cases, I require only these two wires. I leave the Resolve wire in place for 3-6 months.
Usually, my final wire is a .018 x.018 stainless steel wire. Rarely do I require a larger wire such as a .017 x .025 stainless steel wire.
If you have additional question, please let me know.
Michael C. Alpern, DDS, MS
Dear LT Mike Oviatt,
Thank you for your question. The In-Ovation system is a new ligature-less development in orthodontics. There are many advantages to this system. However, like any new development, it does take time for this technique to become part of every orthodontist’s technique. The company that manufactures and markets the In-Ovation system is DENTSPLY GAC International and they are located at 355 Knickerbocker Ave, Bohemia, NY 11716. You can call them at (800) 645-5530 and ask for the national sales manager. DENTSPLY GAC has a record of all theorthodontists who use the In-Ovation system and where they are located. They also have regional and state technical representatives who personally call on all orthodontists. It is just a question of finding the representative who covers the Tullahoma, TN area.
I will try to contact DENTSPLY GAC with your request and someone should be contacting you within the next few days. If not, please email me at firstname.lastname@example.org and I will get the information for you.
Best Personal Regards,
Michael C. Alpern, DDS, MS
Thank you for your interesting question. I am puzzled by your question because I routinely use the In-Ovation “R” ligatureless bracket system for severe rotations without problems. I cannot speak for other bracket systems. The “R” stands for "reduced size," and the “R” clip actually has two arms which contact the archwire. This equates into a single-wing bracket like the Lewis or Lang single-wing brackets, which have mesial and distal arms that can act independently to correct rotations.
The other reason I do not have problems with “R” brackets for treatment of severe rotations is that I use a GAC BioForce temperature-sensitive nickel titanium wire. This wire can be chilled with ice, which turns the wire into a “spaghetti strand." The wire becomes very flexible and easily fully engages most severe rotations. BioForce wire has individualized forces through out the wire. This wire is unique in that centrals and laterals receive only 90 to 100 g of force. Cuspids receive 150 g of force and molars receive 350 g of force all in the same wire, regardless of the size of the wire. This permits insertion of a near-full-sized nickel titanium immediately after indirect bonding of the brackets.
I have a documented case where one maxillary lateral incisor was rotated 90 degrees. The initial main archwire was a .018 x .018 BioForce with Ion Guard wire. This wire did not engage the 90 degree rotation. A .016 x .016 BioForce, Ion Guard sectional wire was used to fully engage the 90º rotation and piggy-back over top of the main archwire, covering two adjacent brackets on either side of the rotated tooth. In less than 2 months, the piggyback wire was removed and the .018 x .018 BioForce with Ion Guard main archwire was iced and engaged in the remaining 45º of rotation. In 4 months, the 90º rotation was fully corrected without pain or discomfort.
No rebracketing was required. I have been using the “R” bracket system for 3 to 4 years and have never had to begin with a traditional bracket and then switch to a ligatureless bracket. However, the “R” bracket is unique in its many features, especially when combined with BioForce wire with Ion Guard surface treatment.
I hope this adequately answers your question.
Michael C. Alpern, DDS, MS
Dear Shelly Sandoval,
Thank you for your questions. The exact answers are a little complicated. Yes, GAC International, Inc is the orthodontic company which manufactures and sells the new “C” bracket. It is a little difficult to specifically say if “C” “is same thing as the regular braces.” The “C” bracket does function like regular braces except much faster, using lighter forces and moving teeth more safely and quickly. That is not exactly like regular braces.
”C” stands for clear. What GAC did was create a new clear bracket, but in addition, the “C” bracket has a built-in spring clip. This spring clip eliminates the need for the traditional stainless steel wire tires. And when you combine the “C” bracket with other high-tech Nichol and Beta titanium wires, teeth tend to move faster and more gently. This can equate into shorter treatment time.
You also ask if “C” has the same results. While “C” is a new bracket, initial testing has shown similar results to regular braces.
Your next question was, “If I have an overbite do I need to use a Herbst or a splint to fix the problem? Or will I be okay if I don't use anything and just get the braces alone?” The only accurate method to answer your question is for you to be examined by an orthodontist. Each orthodontist is a unique specialist. Many of us have selected appliances that work for us. While many orthodontists use the Herbst appliance, not all orthodontists use this appliance. Personally, I combine splints with palatal expanders and “C” brackets to solve overbite problems. Again, I suggest you see your local orthodontist to treat your specific bite problems and smile problems with the correct appliances.
I hope this has been helpful. Thank you again for your questions.
Regards, Michael C. Alpern, DDS, MS
Dear Dr. Anthony Monteiro,
Thank you for your question. When I first began using self-ligating brackets, I maintained my normal interval for seeing patients. If you use In-Ovation “R” or the new “C” brackets and combine them with BioForce as your first wire, my own personal technique is to see patients between 5-8 weeks apart. However, this must be individualized to each patient. For example, while I do not have to change the wire for at least 4-6 months (while the spring clip in the “R” and “C” brackets continue to apply light, continuous forces to malaligned teeth) and the BioForce wire continues to level and align the teeth, we usually see all patients a week after initial bonding to reinforce proper oral hygiene requirements and make any small comfort adjustments. If a patient responds to our requests of proper oral hygiene, then I will see them between 5-8 weeks for their visits. However, if the patient does not respond to proper oral hygiene requests, then my hygienist will see them in 2-3 weeks to quickly bring them up to proper oral hygiene requirements and health.
There is much discussion on this subject. Other clinicians may advise 8-10 week visits or more; however, I find a 5-8 week interval important not so much for adjusting the appliance, but for continued oral hygiene and cutting distal ends of wires as they extrude from the most distal molars.
Michael C. Alpern, DDS, MS
Dear Dr Rowe,
Thank you for your excellent question. In my experience, there have been very few times when the In-Ovation R clip has become distorted from trauma from opposing occlusion. The clip does not break (as some titanium clips may tend to break). However, the heat-treated alloy clip, with a special plasma coating, can be distorted from opposing occlusal trauma.
If the clip is distorted, it may not be able to completely close. While this problem is rare in my office, in the few times it has occurred, I have used Weingart-type pliers and carefully removed the clip occlusally. Then, using the same pliers, I have gently squeezed the ovoid clip back to its original shape. Then, if you carefully re-insert the clip, it will function normally.
The real question is why is this happening. Why do brackets come under occlusal trauma? In the past, I began treatment with round wires that had no torque control. Without maxillary dental torque control, the maxillary teeth can impinge on the mandibular brackets, especially in deep-bite cases. This is one of the reasons my initial wire, in an .018 slot, in many cases, is either a .016 x .016 or .018 x .018 BioForce with Ion Guard. BioForce has individual forces within the same archwire regardless of the size of the wire. Centrals receive 90 g to100 g of force, cuspids get 150 g of force, and molars receive 350 g of force. Nickel titanium BioForce is temperature-sensitive, so it can be “iced” to place. Using this wire in an .018 slot gives all the features of a round wire, except that (especially in .018 x .018) each bracket gets full torque and all other 3-D controlled movement. This permits torque control to incisors and, with other mechanics, can relieve a deep bite.
If you use the .022 slot, BioForce now is manufactured in a .022 x .018 Monacell wire. This wire will also help relieve a deep bite with full 3-D control.
Additional deep bite treatment modalities include using flowable composite on the occlusal surfaces of mandibular molars and adding a full-time anterior bite splint that can be soldered to a maxillary palatal bar.
One quick technique is to use Glenroe thick separators around the In-Ovation R brackets. These will temporarily prevent maxillary incisors from damaging the closing clips of the In-Ovation R brackets.
If you can prevent occlusal trauma to the In-Ovation R closing clips, you may find the clips will stay functional and useful to you and your orthodontic team.
If you have additional import_expert_question, please ask.
Michael C. Alpern, DDS, MS
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