Topics of the day:
1. How to bond to porcelain
Dear ESCO readers,
In 1998 I wrote an article "the effect of different porcelain conditioning techniques on the shear bond strength of stainless steel brackets" (Gillis and Redlich : AJODO 1998;114:387-92) in which the different techniques of bonding brackets to porcelain were evaluated regarding both the bond strength but also, and possibly more important, regarding the damage to the porcelain following debonding .
In my practice I use the following technique:
I have been using this technique since 1998 and have exellent results regarding bond strength, as well as no damage to the porcelain upon debonding .
I would like to stress that sandblasting ( aka microetching ) or roughening of the porcelain surface with a diamond or any other rotatory means only serves to damage the porcelain surface without enhancing the bond strength.
Jerusalem , Israel
Recently I read about a light cured sealant for caries/ enamel scar prevention in this forum. My first thought was that would never fly. I have researched the Reliance (Itasca, IL) product for this purpose, but the more I thought about it the more I liked the idea of a colored sealant. The obvious advantage is that you can actually see if it is still present. I do not know if it is my age or that I am just getting soooo tired of trying to avoid cooperation that leads me to this product. But, if I offer this service at the beginning of treatment and explain the risk / benefit return, it then becomes their problem. Jorge Mestre provided me with a tagline I use daily." I cannot treat you against your will." Thanks, Jorge. If anyone can point me to the "yellow" sealant, and let me know thir experience, I would be gratefull.
Dear Dr. Speck,
I too share your concerns about the limitations of traditional edgewise orthodontic treatment. I have struggled with the same issues you discuss in your previous message.
I have not used Tip-Edge orthodontic appliances even though I practice in the shadow of the company. I live and practice in LaPorte, IN and am a neighbor to the Keslings. I have instead been using what I am convinced is the next revolution in fixed appliance orthodontic treatment, which is passive ligation. Specifically the Damon bracket system which I have been using exclusively for over a year. Each day I see things I have never seen using the traditional edgewise bracket system. Some of you maybe using this method and have seen the same remarkable results. This is truely the lowest friction and force system that I am aware of. If anyone that is not using this and would like to obtain more information I would encourage you to attend one of the many workshops held around the country. I have no financial interest in the product, just an immense excitment for the results I see using this system.
In the Feb 22 digest, Dr. Speck wrote a suggestion to use sequential tooth movement rather than en-masse movement. That is, to protract maxillary posteriors by first protracting the second bicuspids with the molars blocked by a stop on the archwire, and then removing the molar stop bend and placing a stop bend distal to the second bicuspid brackets to stop the 8 teeth anterior to the gaps while the molars are brought foward. This is symmetrical with the often used procedure of retracting canines first, then retracting incisors when upper first bicuspids have been extracted and maximum anchorage is desired.
I have never understood the rationale for sequential versus en-masse retraction once the incisors have been unraveled from their crowding. It seems to me that during the first retraction step, you lose a little anchorage and in the second step you lose the rest of it. I think you end up exactly in the same place either way. That is, in the typical application for retracting anteriors in a first-bicuspid extraction case, you would first be moving the posteriors and incisors forward as anchorage loss during canine retraction, and then you lose posterior and canine anchorage when the incisors are retracted.
The only possible rationales I can think of are (1) the theory that there is a threshold of force below which a tooth will not move, and (2) the possibility that the occlusal forces would be better able to stabilize fewer anchor teeth in each step. Neither of these make sense to me. The threshhold of tooth moving force (which Begg believed in) seems to have been discredited by research, at least as far as any practical level of force goes. And the occlusal forces would be proportional to the number of teeth occluding. A corollary to this is the concept that you can somehow "blow anchorage", that is, willfully or inadvertently lose more anchorage with some alteration of the appliance or by using en-masse movements.
Does anyone know of any science behind the clinical procedure of sequential retraction to minimize anchorage loss, or is it just an unsubstantiated procedure; that is, is it a clinical myth?
I've toyed around the Fuji blue (ortho cement) but I've never used it for a Herbst. When I was doing Herbst appliances, I used Fuji I Luting cement. I just looked on the website to see if there was a psi comparison between blue and Fuji I but there was none. You might touch base with a Fuji rep and see what they advise. When I was doing Herbst appliances I had very few loosen with the Fuji and I handled it by drilling a hole in the center of the crown and injecting more Fuji I into the crown and then holding it until it set. It was hard to remove also but the DA's seemed to do all right with a cavitron.
When I was a young lad, my mother always tried to protect me from the evil creatures who inhabited the "dark side." Alas, despite her best efforts, I've fallen in with them in the guise of kindly, senior citizen types by the name of Mort Speck, senior recruiter for the dark side.
I've been teaching at Harvard now for 10 years and about five years ago, Mort asked me to consider becoming a Tip Edge instructor. Since I had done Begg one day a week back at Tufts in the late 70's it was an intriguing offer. I reread the available literature and ventured into the heartland of America (where I thought giant beasts lived) but all I found were the Keslings. After taking the Tip Edge course, I started doing Tip Edge for most of my class II cases or those cases where substantial tooth movement was going to be required. Naturally, my staff was "over the top excited" by the thought of another treatment protocol to deal with. Luckily I keep a stun gun in the office for just those types of motivational issues and I was able to bring them around to my way of thinking just before the batteries gave out. Even they eventually saw the wisdom of it and commented after several years: "Do you know that we currently have no Herbst and no HG patients in treatment?" My reply was "Nice, uh?" To which they replied, "Really nice."
Before you try to virtually lynch me or sit shivas to mourn the loss of another poor soul to the dark side, here are my thoughts after five years of Tip Edge:
1. I feel more like an orthodontist and less like a mechanic because I'm forced to think about each and every case. How much growth is left, is it enough, etc. How many of us have had 14 year old female patients who are not going to wear a HG for anchorage control, don't really have enough growth left for the Herbst to be a slam dunk and yet are 3/4 class II give or take. Taking out upper bis is the appropriate tx in these cases unless you still live in a part of the world where insurance covers orthognathic surgery (and before you rant a rave about microscrews as the answer: I've personally inserted 48 or so and they are not predictably the answer). The problem is how to manage anchorage. So since there is no easy way to manage anchorage in these cases, we say "I'll put a Herbst in and hope for the best. Maybe she'll grow enough." Then after 24 months of tx as you are trying to finish tx, the patient has relapsed to between 1/4 and 1/2 class II. That's when I felt the worst.
2. Unless you still think you can grow a mandible, what does any appliance system do to treat class IIs? We try to uncouple the occlusion and take advantage of growth. If there is inadequate growth, we take teeth out. So it all boils down to growth and anchorage. AND before you condemn Tip Edge as an extraction technique, it is a really nice nonextraction growth oriented approach to orthodontics. It opens the bite and uncouples the occlusion. Whatever growth will happen will happen without the extra mess of a Herbst or whatever.
3. If you tx the lower arch non extraction, you can usually extract two upper bis without any serious negative results.
4. Many patients have small 2s, Tip Edge allows you to extract upper 5s routinely and still conserve enough anchorage to treat to a good occlusion. AND the smile looks great with the large 4 balancing the small 2.
1. Patients have to cooperate with elastics. Luckily most do, although some don't. For those that don't wear elastics, I'd rather know that during the first six months than during the last six months. I find that patients are like my own kids: treat them like adults and you usually will not be disappointed.
2. There is no perfect system of braces. Tip Edge is a low friction system so it can be difficult to finish some cases. Bracket position is hypercritical. Thank god for indirect bonding and yes I sometimes use a positioner according to the one week intensive program of Bowman.
Best wishes to all. Oh yes, I asked Mort why he recruited me and not one of the other faculty. He said, "You are the most pragmatic guy I know." Nice! I can see it now "Here lies a pragmatist."
After many hundreds of crowned herbst and the issues with them in regards to cement removal,cleaning out the occlusal anatomy, cutting them off etc etc.. I switched to specialty labs banded herbst, They have a good video by Dr Mike Rogers.
They use an extra thick band by TP orthos and reinforce the occlucal with a wire that also acts as a rest on the tooth mesial to the bands(helps counter act the mesial tipping of the cantiliever affect)
I have never has a band break(as I have with the hub shearing off a crown) and it is simple to remove and clean up is not tedious because there are no occlusal surfaces to deal with) I have turned a few of my friends onto this that were big crown users and they have never looked back) I have no financial interest in specialty appliances just a desire to never take out a highspeed to cut a crown off
Dr. Speck Morton deserves Congratulations for his excellent listing of limitations of edgewise brackets. he has drawn a cautious end lest he hurt the 'big brothers' in orthodontics and marketplace.
As has been stated, it is very difficult to move posteriors, with edgewise bracket. This has been recently admitted by McLaughlin in a response to Charlie Ruff's quiery in ASk Us coloumn of AJO DO-July, 2004.In fact this leaves one thinking that the molar tube and the wire interface(022x028x250 tube with filling rectangular rigid wire) is specifically designed to prevent whatever movement of the molars,in three planes of space. It is also true, that mostly in the finishing stages, one has to disengage the bracket/wire interface of posteriors to allow the occlusion to settle with 'M' or 'W' with tail elastics. Again indicating the inability of the bracket to allow settling.
The analysis of anchorage defficiency of the bracket and need for the dog to wag for the weakness of tail is humourous and factual.
Yet another problem with the 'same prescription for all faces' is the fact that in class II cases one needs less positive torque on upper anteriors and more positive torque on lower. In class III cases vice versa is true, i.e,.more torque on upper antreriors and less or negative torque in the lower anteriors for compensations(Unless, of course, one plans surgical correction requiring decompensation) It is well known that negating the built in torque is almost impossible/impractical in PEA. It will be much easier in pure edgewise(non tipped, non torqued) brackets.
The readers are referred to an excellent article by Burstone C.J.(Diagnosis and treatment planning of patients with asymmetries:Seminars in Orthodontics:4.3-Sept.1998.p153-164) wherein he discussed the compensatory tips in subdivisions malocclusions(midline deviations) and adaptive torques in unilateral cross bite/scissorsbites. These conditions, he infered, would require negating the tip and torque built in the bracket/tube, which is rather difficult, if not impossible.
This may not be well received by 'brand ambassadors' or market Gurus. I have no financial interest, whatsoever in orthodontic products/publishing houses. Once again, can we look forward to more candid and objective observations like Speck Morton's ?
I enjoyed your well thought out reply to the ESCO on Tip Edge. I have been practicing for 11 years. Certificate from Columbia. I was trained in Edgewise, Begg and Tip edge. For the first several years of practice I tried a little of all the systems. I always had trouble with extraction cases and Edgewise for the reasons you described. I also became frustrated with the lack of interbracket space in the twin brackets. About five years ago I went with Tip edge for about all my cases, and in October 2003 I went back to Tp for a course in Tip edge Plus and have been using it since. Are you using the plus brackets? The course really put things back into my head. I relate it to doing a "disc defragmenting" of my brain. It was all there but had gotten mixed up! I had tried too many systems and had them all mixed together!
The only time I stray from Tip Edge is in a Class I case with minor anterior irregularities. Cases that do not require much torquing. On these cases I bond Edgewise brackets on the centrals and laterals. I can work a bit faster this way, not worrying about getting any tipping as it is not needed. I see edgewise as a good method to "hold" teeth and Tip edge good for moving teeth. Nothing works faster in a Class II exo case!
A few years ago I had a very crowded Class II case that transferred to another office about 8 months into treatment. I was just getting ready to start uprighting. It was a nice case. The orthodontist, much older and more experienced than myself, called me to remark on good the case looked. It really made me feel good. Of course, he removed my appliances and placed straightedge. The case ended up back in my office about a year later, and looked about the same as when it left, except the bite was deeper! I wish more schools would at least give the Tip Edge system some consideration. I am sure there is a lot of politics in Orthodontic education that I do not understand. I love being an Orthodontist as much today as the day I started. If I had to endure Herbsts, Headgear, Nances, biteplates, etc. I am sure I would have burned out a long time ago! Maybe that's why us Tip Edge guys are soo much better looking!!
All the Best,
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