Topics of the day:

1. Re: A few MORE words on lingual retainers
2. Re: DVD
3. Re: Digital Camera Settings
4. Re: Digital Camera Settings
5. Re: Digital Camera Settings
6. Re: GERD
7. Re: acrylic - toxic?
8. Re: acrylic - toxic?
9. Management and imaging software
10. Sydney Conference on the Unerupted Tooth in Oct
11. ESCO - The Electronic Study Club for Orthodontics

Dear Dr. Speck,

I read your comments with great interest. I must confess they did get under my skin a bit, not because of your comments themselves, but rather because your comments are representative of the many misconceptions about bonded fixed retainers that even orthodontists seem to have accepted as the truth. It is my sincerest belief that most of these misconceptions are due to practitioners misusing or abusing fixed bonded retainers by utilizing either incorrect techniques or incorrect materials, and not due to the bonded fixed retainer concept itself.

I can think of few procedures with less merit than the use of twist wire as a lingual retainer. With all of its deficiencies ably described by others, I see no justification for its use. Furthermore, because of its inherent weakness, you are committed to the bonding of all of the incisors, even those which were never misaligned. Why would you do that when you are not only increasing your chances of bond failure, but also not exactly ingratiating yourself with your referring dentist and his/her hygienist?

I have utilized twisted wire (GAC .0175” Wildcat) as fixed retention 3-3 (lower) or 2-2 (upper) for over 10 years. I do not use them on every patient but I use them when they are indicated.  Wildcat wire is not passive, instead it is quite stiff and requires fabrication on a model for an exact fit. I am a strong believer that a fixed bonded retainer should be passive as long as the teeth remain in their proper position, but REACTIVE  if they move out of place, much like the labial bow of a Hawley retainer. Two examples of adult patients with such fixed retainers placed by me can be seen at the top of this page:

http://mywebpages.comcast.net/myorthodontist/cases.html

I fail to see how either one of these adult patients could have been retained long term without a fixed 3-3 individually bonded retainer save for significant and probably periodontally detrimental reapproximation and cornerstoning. Please note that both of these patients in fact had retroclined dentitions and were, in my opinion, not good candidates for extraction treatment.

Bond failures are related to bonding technique, not the retention modality. By your logic orthodontists would all still be banding their premolars and molars. I can tell you that I have much more Hawley retainer breakage (not counting the amount of retainer loss) in my office than fixed retention debonds. In terms of hygiene, if the bonded retainer is PROPERLY fabricated and placed, it is extremely easy to clean and maintain, and will not debond. It should be placed in the middle third of the lingual / palatal surface, and the amount of composite necessary is very minimal. Most oral hygiene problems I have encountered with fixed bonded retainers from other practitioners may be partially due to poor patient cleaning technique, but more often are due to excessive composite or poor placement of the retainer by the orthodontist.

Anyone that claims to be able to predict orthodontic relapse suffers from hubris. I would refer you to the AJO-DO Volume 1988 May (423 - 428): Changes in mandibular anterior alignment 10 to 20 years postretention - Little, Riedel, and Årtun article, an article on the ABO literature list, which has many nice illustrative pictures of relapse where the relapsed incisors were NOT the incisors that were rotated or displaced pre-treatment. Therefore I would suggest it is unwise to exclude an incisor from a retention system simply because it was not misaligned “to begin with.”

One highly doubtful reason for the use of twist wire is that the functional movement it affords is somehow necessary for the health of the attached teeth. That is extremely questionable when one considers the long term health of multiple splinted teeth. There seems to be no sound reasoning for the use of any flexible type lingual retainer.

I have no disagreement with you here. It supports the use of a non-passive, reactive fixed bonded retainer long term.

I believe a perio/ortho colleague of mine has it right. For over 25 years he has used Almore International’s Markely finely threaded wire. It is extremely stiff and available in various sizes. The threading lends itself to the retention of bonding material if you feel the need to bond individual incisors. He will frequently make small preparations in the approximating marginal ridges of maxillary incisors and imbed this wire with composite for permanent retention.

This technique seems to have become more and more popular with periodontists in my area also.  The splints I have seen typically suffer from the same deficiencies as ones placed by orthodontists: Poor placement, over-abundance of composite, and usually an excessively large diameter wire. I don't discourage periodontists from using these splints, I just wish they were more judicious and exact in their application.

I strongly favor Zachrissen’s method of 3-3 retention. I feel the method described by Greg Scott also has much merit. (ESCO 12 April 2005). Generally, I do not favor the bonding of individual incisors. I feel the very minor relapse which may occur with a well fitting 3-3 is far outweighed by the many disadvantages of multiple bonding. Where there has been little if any initial irregularity, I favor a removable Hawley and suggest very minor stripping for overly tight contacts, a procedure that should be considered with any retention regime.

I do not favor padded fixed canine to canine retention. It has several deficiencies:

1) Typically the practitioner uses some sort of holding method while bonding this device in place. If this method applies force during the bonding, this force is expressed afterwards as unwanted tooth movement. This is also a reason why I fabricate my Wildcat wire retainers to fit absolutely passively, and do not use auxiliary holding methods like floss.

2) It utilizes large pads which tend to create significant darkening of the bonded teeth (canines) in patients with translucent enamel.

3) The pads are often overflowing with composite and are difficult to clean. Indirect bonding techniques in particular leave excessive composite on these teeth.

4) If one pad debonds, the connecting wire is so stiff that the patient often does not notice the debond. I have seen 2 patients from other offices that required endodontic treatment on their canine because of caries formation under debonded canine pads.

We all should look at the patients’ models before debonding to be certain that all rotations have been fully corrected or overcorrected. Furthermore, very slightly offsetting your brackets where necessary at the initial bonding will assist your rotation correction and ultimate retention.

I realize I have expressed some definite ideas here, but experience will do that. I look forward to any of your remarks in response.

Certainly pre-treatment conditions should be seriously considered when choosing retention mechanisms. Where appropriate, I utilize many different retention techniques, including removable and fixed retention. I believe one of the most important aspects of orthodontics is to be aware of all the options available, and for retention, one should consider all things like Hawleys, Wraparounds, Spring Aligners, Vacuuformed, Pre-finishers, Positioners, Bonded, Passive Bite Plates, and many others. They all have their place in the right patient!

I appreciate your comments and I hope you appreciate mine, and that we can agree to disagree.

Rene S Johe, DMD

johe@umdnj.edu

Faculty, UMDNJ – New Jersey Dental School

Dear Dr. Ruff – There are many products available to “RIP” a segment of or an entire DVD (movie, for example) to an MPEG or standard video formatted file. You can then insert the output file(s0 into your PowerPoint presentation. One such program (that I personally have used) is “DVD Ripper” ( http://www.1stdvdripper.com/ ).

This particular product might be Windows-specific. It allows you to record a portion of all of a DVD content to file. Free trial version is available (limits how long of a segment you can record). You can find similar free-ware or share-ware for the Mac OS as well.

Of course, when using products like these, do mind/observe all copyright laws (and have plenty of available disk space)! Let me know if you have more questions concerning this area.

Good luck,

Chester Wang

Dolphin

====

When the world ran on videotape, it was rather a simple matter to grab part of a videotape and convert it to digital and then to use it in a Powerpoint presentation. Typically, you might use part of a commercial to illustrate a point or to lighten the moment at the end of a section.

Can the same thing be done with a DVD? I have access to both Windows and Macs.

Thanks,
Charlie Ruff

Dear Dr. Hirsch – While I'm not an expert on the Canon EOS 20D, we at Dolphin do find, across the board with all digital camera flash units, NOT to trust the ETTL (or TTL) settings. I'd suggest to set your flash settings manually (fixed) to gain full control of your flash/lightness.

With our experiences with the Canon Rebel/Rebel XT with the same ring flash (I assume Canon Macrolite MR-14 EX), a manual setting to “1” or “1/2” is ideal for facials, and “1/2” or “1/8” for intraorals. Again, this will need to be experimented based on your backflash configuration (if any), camera settings (aperture/speed) and distance from the patient.

Not using TTL settings might be a controversial claim amongst the other photo experts, such as Mr. Peter Grey of PhotoMed (cc'd). But, we do find our photos extremely consistent when all the settings are fixed manually. Also, I'd recommend to never set the exposure compensation other than “0” to simplify your knob adjustments between facials and intraorals.

I hope this helps. Good luck!

Chester Wang

Dolphin

===

Does anyone have the following digital system?  

Canon (EOS 20D, 100mm macro and ring flash)

I have been using this system with the following settings, but the pictures seem too light:
ISO = 200
(M) Manual setting
F 5.6 portrait
F 22  close up
Flash set on ETTL and +1 2/3 flash exposure compensation

Does anyone have any suggestions to obtain more natural looking gingival and skin tones, or to darken the pictures? It seems the flash is putting out too much light? Thanks!

Richard Hirsch
Tampa , Fl.

When I had the problem with too much light from a ring light, Dr. Hirsch, I placed electrician's tape at intervals around the flash until the light was right. Orm

Dear Richard Hirsc,

Regarding your query about better adjustments for your camera, I do not have this type of camera but I think you might be better to try this setting:

ISO 100
F 11 extra oral
F 32 intraoral (Front and buccal shots)
F 27 intra oral (mirror shot)

Regards,
Mojtaba Abdi
Manchester UK

Gastroesophogeal Reflux Disease-GERD- is common, and often mistreated by internists.  The first Rx is for oral antacids.  Many OTC chewable antacids have sugar.  GERD is at a peak when lying on the back (sleeping) so most patients chew most antacids (Gaviscon, Tums, etc.) at bedtime.  The result is the oral enamel erosion described by Dr Mastroianni of lingual upper incisor erosion, buccal erosion especially on lower premolars, and flattening of molar cusps.  It may be very rapid, similar to bulimia lesions.  The etiology is usually a hiatal hernia, allowing stomach acid with a pH of 1 to back up into the esophagus and eventually the mouth.  Heartburn! And the chewing of sugar containing antacids compounds the damage.  Add a few Cokes and lifesavers, and you have a dental disaster in a hurry. 

You can bond to this enamel and/or dentin.  In my experience, filling in the potholes with glass ionomer (Fuji, using capsules in an applicator gun) works well.  Then I bond brackets as usual to the ionomer and enamel, being less than fastidious about a little excess.
Now, as health professionals, we should be concerned about more than teeth.  What does acid strong enough to melt enamel do to the delicate mucosa lining the esphagus?  You guessed it, it burns.  And the endothelium responds by thickening.  The reulting PRECANCEROUS lesions are called "Barrett's endothelium".  Many patients are subjected to annual endoscopies to "monitor" the precancerous tissue changes.

There is a simple operation which takes about an hour, and usually cures the condition if it is as severe as described.  After 24 hour testing with a nasoesophogeal monitoring tube, confirmation of severe GERD, and the usual DPARQ, an endoscopic Fundoplication is done, whereby the end of the esophagus is "banded" by the fundus of the stomach, much like rolling up the cuff of a sweater, and the tissues sutured or stapled, creating a new hiatal valve to block the acid reflux.  You don't have to be a physician to give this explanantion to your patient. 

Print this blog out and save it. 

In today's managed care environment, primary care docs are often given protocols which don't mention surgery.  The same surgery codecheckers, who say your orthognathic surgery is unnecessary, will say the same thing about GERD and tonsillectomies.  So the patient duly follows instructions and the heartburn is "better when I chew them immediately after eating".  Meanwhile, the endothelial pathology remains or increases, and the dental pathology is often unnoticed even by the dentist until it's a condition calling for extensive prosthodontic care.

Get out your mental calculator.

Annual exams @ internist  $125, COVERED BY INSURANCE
OTC antacids not covered   up to $300 per year for patient
Rx antacids or acid prevention drugs (Prevacid, etc)  costs insurance ? maybe 0 patient $1200/year unless insurance pays for drugs
Annual endoscopy  $300  COVERED BY INSURANCE
Cost of 20 dental crowns= $20,000
Cost of fundoplication in outpatient surgical venue = about $5000

So, I calculate that denying or delaying hiatal hernia surgery is often not a financially sound decision when the whole patient is considered. And medical insurance is very adept at passing on the old maid, so someone else ends up with the bill.  I once had an insurance executive (an orthognathic surgery patient who sailed through preauthorization)   tell me that her company routinely denied the first request for most surgery not deemed life-threatening.  They contended that over half of the insured patients would not pursue the surgery due to:     

most people don't want SURGERY so denial is patients' first response    
most patients feel thai if their insurance says "unnecessary", the physician must be pushing it    
most people are uncomfortable challenging doctors and insurers    
often, the alternative seems reasonable and is comfortable for awhile

One final observation; perhaps insurers should have to provide the same informed consent that we do.  Perhaps if patients were provided the real risks and benefits of various treatments, more surgery would be done at the appropriate time.  My surgeon colleagues complain about receiving baskets of wornout parts, and being expected to make them new, when earlier referrals and treatment would provide better surgical results.  So, insurance companies often cause some of the poor outcomes they decry.

I know a little about this subject personally.  In 1975, I was diagnosed with a hiatal hernia after suffering severe chest pains.  For years, I took antacids, then Zantac, then Prilosec, Prevacid, etc. I had annual endoscopic biopsies, with increasingly nasty Barrets disease.  I asked each internist and gastroenterologist about surgery.  The response was always "you don't want surgery".  Then one day at the hospital, visiting an orthognathic patient, I met a young surgeon who was doing "radical" operations endoscopically.  I talked to him.  The procedure seemed reasonable and safe.  In 1995 I had a Fundoplication, and have never had heartburn since.  For 4 years I continued annual biopsies, and the esophageal tissue returned to near normal.  I had 8 gold onlays at my own expense, to repair eroded molars. I did not ask permission to have surgery - I just did it and they billed my insurance.  Most surgeons won't do that unless you prepay or somehow guarantee the fee.  I figure I saved money even if I would have paid the whole thing in cash, but the real kicker is, the insurance company paid more over the years than it would have cost to proceed directly to surgery!

Dr Dick Carter
Orthodontist
Portland OR USA
drdcarter@mac.com

Date: Wed, 11 May 2005 19:46:16 -0400
From: "Elliot Taynor" < etaynor@abest.com >
Subject: acrylic - toxic?
To: esco@listserv.uic.edu

Hi, A parent of a patient, who is a scientist, noticed that the acrylic overlays on a removable expansion appliance had wear facets and even a perforation. She asked if acrylic is toxic to the body and where does it go. What is the correct answer?

Thanks,
Elliot Taynor,
Port Jefferson, NY

I'm not a complete expert on this but I do recall that before the onset of titanium hip prosthesis, which as you know osseointegrate, they used to use stainless steel and they were cemented in with acrylic just like a retainer. In fact, I've had more than one nurse ask when I was relining a splint (this is in the old days) what was that smell? And when I explained what it was, they would say "I thought I recognized that from the operating room" hope this helps

Charlie Ruff

Wed, 11 May 2005 Dr. Elliot Taynor (etaynor@abest.com) asked if polymerized acrylics in attachments are toxic.
       The answer is " All substances are poisons.There is none which is not a poison. The right dose differentiates a poison from remedy" (Paracelsus, 1493-1541). However, once acrylics are cured, the amount of monomer leaching is small. The problems arise especially whenever the curing takes place in vivo (milder conditions):  factory-polymerized acrylics release less monomers and additives. Keep the expansion screw attachment in boiling water for ten minutes : this will extract what has not been properly caught in the crosslinked polymer network....

Claude G. Matasa, DCE, DSc., DHC
Professor of Oral Biomaterials
www.Matasa.net
2026 Scott St.,
Hollywood, Florida 33020, USA

Can anyone point me to studies of the clinical performance of "name brand" vs "brand-X" archwires? Any personal opinions?

Joshua Wachspress
Modi'in, Israel

For the past 15 years, we have operated our practice with Orthotrac (OMS) software.  We have always had the “classic” version which operates in Unix and have been on “Treatment Card” for the past 10 years.   Most of our clinical computers also have Windows XP to allow us to access the imaging part of Orthotrac's software.

Now, Orthotrac (run by Kodak) has decided not to invest time in upgrading the “classic” version and wants us to go to the windows version.  The cost for this will be about 30K and it is now time to investigate other software companies before we blindly follow Orthotrac just because it's what we have.   At the recent AAO meeting in San Francisco , I checked out Dolphin, Oasys, and IMS/Vistadent and found all three to be close to the same cost.  However, before making any plunge, I would like some advice from anyone out there who has these systems and is either happy or upset with them for any reason.  Especially valuable would be someone who has gone from the Orthotrac “classic” to the windows version or  Orthotrac “classic” to another system and the reasons for the switch in companies.

Thank you in advance for your help in this matter.

Mike Bernard – AAO
Orthodontist
North Canton , Oho

Dear Esco Readers,

Adrian Becker is a Clinical Associate Professor in the Department of Orthodontics of the Hebrew University - Hadassah School of Dental Medicine, in Jerusalem and Director of its Centre for the Treatment of Craniofacial Disorders and Special Needs Children. He authored "The Orthodontic Treatment of Impacted Teeth", which is translated into five other languages so far, and has written over one hundred papers published in leading refereed international journals.

I am delighted to advise that Professor Becker has accepted an invitation to be Visiting Professor (KGVP) in the Orthodontic Discipline at the University of Sydney in late October this year. He will be giving a two day course (27 & 28 Oct) together with Dr Stella Chaushu on "The Whole Truth About the Unerupted Tooth". They will also be giving a workshop at The International Paediatric Dental Conference 31October - 5 November 2005 in Darling Harbour, Sydney on treatment of special needs children.

If you were looking for another good reason to visit Sydney, this is it.

Looking forward to welcoming you during our mid Spring

/------\
  0--0
   LI
  \_/
  Morris Rapaport
Orthodontist/Lecturer p. t.
President of Sydney University Orthodontic Alumni

(Please see attached PDF flyer for further information.)

Dear Colleague:

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