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Practice Growth Str ess Growing Your Practice While Reducing Stress. New Advances in the Ortho Evolution. Practice Growth
Str
ess
Growing Your Practice
While Reducing Stress.
New Advances in the Ortho Evolution.
by
Michael C. Alpern, D.D.S, M.S. Growing Your Practice
While Reducing Stress.
New Advances in the Ortho Evolution.
By: Michael C. Alpern, D.D.S, M.S.
The struggle towards the most efficient method to
accomplish orthodontic treatment is an evolution-
ary process. It began with Edward Angle and his
contemporaries. Even they quickly realized their
attempts must constantly evolve. Improvements led
to controversy and sometimes heated discussions;
thus leading to ideas that provided advancements.
From Angles time forward, this process has contin-
ued. Recent innovations are proving very exciting.
After more than twenty years of using a combina-
tion Single Wing and Siamese bracket system, I
have completely transformed my treatment
approach. The multiple advantages gained will be
discussed in detail. The new GAC In-Ovation
�
R
micro-sized, ligature-free bracket system combined
with my existing Fixed/Functional/Splint System,
using BioForce
�
arch wires, has produced synergistic
results that I could not have conceived a year ago.
Initial malocc
Initial malocc
lusion
lusion
Initial
Initial
3 months
3 months
4 months
4 months
Initial
Initial
4 months
4 months
Initial
Initial
3 months la
3 months la
ter
ter
1 A Brief History of My Orthodontic Evolution
Over the nearly three decades since my introduc-
tion to orthodontics, changes have improved our
ability to treat patients, achieving improved results
and less treatment time with greater patient com-
fort and satisfaction. Functional therapy (head-
gears, palatal expanders, bite plates, etc.) has
improved our ability to not only align teeth, but
also to redirect growth in many cases. Splint thera-
py had presented us with the opportunity to poten-
tially diminish TMJ symptoms and protect TMJ com-
ponents during occlusal corrections.
The introduction of what is termed Straight Wire*
Appliances by Dr. Larry Andrews improved achieving
proper tooth position. Bracket prescriptions with
set formulae of tip, torque, and in/out tooth posi-
tions contributed significantly to improved ortho-
dontic results. Soldered or pre-formed hooks for
elastic attachments increased efficiency. Choice of
bracket slots and Siamese or Single Wing designs
with auxiliary leverage arms offered orthodontists
varying methods of achieving improved tooth move-
ment due to reduced resistance while maintaining
control.
The primary method of arch wires moving teeth has
undergone a significant improvement. In the past
two decades, major innovations have occurred in
arch wire metallurgy. Multiple types of NiTi
1,2
and
Beta Ti wires have been introduced and proven suc-
cessful.
With a few exceptions, the method of securing
these new arch wires to the brackets had just
begun to change. The traditional method of stain-
less steel ligatures has endured because these liga-
tures securely hold the arch wire into the pro-
grammed bracket slot without discoloration or force
loss. Elastomeric ligatures made application easier
and provided increased patient comfort but most
lacked long-term traction and completely lost their
effectiveness after 4-6 weeks. Elastic fatigue and
discoloration still remain concerns today.
Arch wire binding to the brackets surfaces has now
become a major focus of attention. A certain level
of resistance necessarily results from the require-
ment of holding the arch wire securely into the
base of bracket slot to appreciate the program-
ming, but too much force can bind the wire and
interfere with leveling and sliding mechanics. This
slows treatment until the elastomers stiffness
starts to relax or the ligature wire is tied precisely.
Previous ligature-free brackets attempted to solve
the aforementioned problem. A variety of opening
and closing devices attempted to achieve an ideal
window between enough force application to secure
the arch wire, yet permit a degree of freedom to
permit sliding along the arch wire.
Twenty years ago I combined differing brackets
from existing systems of brackets to create what I
perceived as a system to produce ideal control ver-
sus sliding in dental arches. I changed the tip,
torque and especially mandibular first rotation to
create a bracket system that formed an ideal tooth
position based on the principle of always work
towards an ideal goal. Each bracket or tube was
created to go from malocclusion directly to the fin-
ished tooth position and avoid all intermediate
bracketing procedures.
The prescription was titled TMJ Bio-Compatible
3,4
because the bracket system was augmented with
removable and bonded splints primarily to unlock or
disclude the locked malocclusion and to protect the
fragile TMJ fibro-cartilage during the cusp-fossa
corrections required.
The foundation of the concepts remains. Nearly all
malocclusions involve deficient width and many
involve deficient functional tongue room. Thus,
many patients began treatment with a maxillary
bonded Rapid Palatal Expansion Bite Plane System,
most with either auxiliary cross bite hooks or
Monacell hooks.
The mandibular arch was treated with tubes and
bands on mandibular first molars with zero rota-
tion. Brackets were bonded on all other teeth,
including bondable second molar tubes, which were
augmented with flowable composite over either the
buccal cusps or the entire occlusal edge of the
molar tube.
Most palatal expansion was completed in four to six
weeks, activating the expansion screw once per
day. Immediately following screw fixation, the
patient is instructed to use six ounce, 1/4 cross-
bite elastics from lingual pre-welded cleats on the
mandibular first molars to either the cross bite or
Monacell hooks on the palatal expander. A full-sized
mandibular arch wire is required to prevent buccal
tipping of molars and bicuspids, permitting upright-
ing of the teeth and to support the needed alveolar
processes.
* Straight-Wire is a registered trademark of Ormco /"A" Company
2 The requirement for an early treatment full-size
arch wire was successfully met with the introduc-
tion of the GAC BioForce
�
superelastic biologically
correct force Nickel Titanium wire. BioForce wires
apply near-constant force of about 90 100 grams
to central incisors, about 150 grams of force is at
the cuspids, and about 300 grams at molars regard-
less of the size of the wire. In a traditional .018
slot, this innovation permits a .018 x .025 wire as
the initial wire in most cases. The torque control
applied by this wire to the slot effectively prevents
molars and bicuspids from tipping and instead, cre-
ates uprighting with bodily movement. The most
notable orthodontic result of this process is very
rapid, comfortable, and biologic orthodontic resolu-
tion in the mandibular arch.
Non-extraction or extraction tooth movement
occurred faster than any technique Id used.
Periodontal and alveolar health was excellent and
no root resorption was noted.
The reasoning for these results included:
1. The flat bite planes of the bonded expander
efficiently unloaded cuspids and incisors verti-
cally. Molars and bicuspids received only pin-
point vertical contact. The occlusion was
unlocked. The gate to the corral was opened
and the puppies were free to move, observed
one clinician.
2. The secured bonded expander served as dis-
posable anchorage, uprighting and expanding
the mandibular arch.
3. Many patients reported significant increases in
ease of swallowing and the ability to breathe
through their nose. This effectively changed
and stabilized the total oral environment. All
this happened in less than five months.
Following atraumatic removal of the maxillary
expander, maxillary bonded brackets were placed
on all teeth except first molars. The previously
sized and adapted maxillary molar bands were
bonded in place and a Cetlin Palatal Bar system was
placed to further preserve maxillary expansion and
begin molar torque, rotation and distalization if
required. Additional flowable, light-cured compos-
ite was added to the mandibular molars to continue
TMJ and occlusal vertical unloading and vertical
control.
Ten years ago I labeled this concept of orthodontic
treatment Fixed/Functional/Splint System. Fixed
for brackets, bands and wires; Functional for the