October, 1999

What’s Really New in Orthodontics

En Español

Terry A. Sellke, D.D.S., M.S.

Appliance Innovations

Many innovations have enhanced the profession of orthodontics since the days of Edward H. Angle. By 1928 he had already added the edgewise mechanism to his pin and tube and ribbon arch appliances. By 1928 the labiolingual appliance and universal appliances were also in use. By 1912 orthodontists were placing full fixed (banded) appliances and by the 1960’s, preformed bands were being sold by Rocky Mountain and UNITEK.

Straightwire® Appliance

In 1970 Andrews introduced the first true “straightwire appliance”1. Shortly after that, the (.018 slot) Bioprogressive ™ Straightwire Appliance was born. [2] With it began the controversy between .018 and .022 appliances. What followed was a host of Straightwire appliances, each one having its own “guru” extolling the virtues of his torque, tip, and offsets. Today a dizzying variety of choices exist for the clinician to choose from. The widespread acceptance of direct bonded brackets only accelerated the process. It is important to note, however, that the basic appliance that is the foundation for the myriad appliance systems commercially available today is the edgewise appliance introduced in 1928!

Archwire

Technological advances in archwires also graced the profession over the years. The gold and nickel silver wires of Angle’s era were augmented by stainless steel in the 1950’s. Soon to follow was Elgiloy wire, designed to provide some of the properties of gold wire at a fraction of the cost, and without some of the drawbacks that came with stainless steel. Next to emerge was Australian “wildcat wire,” which provided greater resiliency than existing wires. Then beginning in the 1980’s came a continual progression of “high tech” wires such as Nitinol Classic, TMA™, and more recently, Nitinol Heat-Activated.

The Bottom Line

Each one of these technological advances increased our efficiency, reduced our chair time, and as a result, increased our profitability. They are also widely believed to reduce our treatment time. It can be arguably said that what has driven the development of new products and techniques was ease, consistency, efficiency, and profitability. If it made the orthodontist’s job easier to do without sacrificing quality, it was embraced. It is interesting to note, however, that aside from the wire technologies and the new adhesives, the appliance innovations we enjoy today all had their roots more than 30 years ago!

Treatment Innovations

Dentofacial Orthopedics

Dentofacial orthopedics became a hot “new” treatment approach in the 1970’s and 1980’s. Interestingly, in 1803 Fox showed histologically that sutures were susceptible to treatment modification. By 1908 Andreasen had developed the activator and demonstrated hyperpropulsion for sagittal orthopedic correction. In 1934 Herbst had published all there was to know about the appliance given his name and then the information was quietly forgotten for nearly 50 years. [3] This was long before functional appliances received the interest they enjoy today.

Functional appliances are by no means “new” in orthodontics. Although there is most certainly a place for them in orthodontics, recent evidence by investigators who have been their greatest champions [4,5] indicates that our ability to grow mandibles when viewed from a long term perspective is essentially a myth.

Does this mean that early orthopedic correction of dentofacial discrepancies is no longer appropriate? Of course not! There is an exciting place for early orthopedics in today’s mechanics. The key is in understanding when to do early treatment, what you are accomplishing, and how to use the appliances available.

Non-Compliance Appliances

Another group of “new” appliances appearing today fall under the classification of “non-compliance appliances”. The Herbst™, Pendulum™, and Jasper Jumper™ Appliances represent this group. They evolved not to improve the quality of our treatment results, but rather to simplify them by taking patient compliance out of the treatment equation. The profession has been swept up in the search for simplified mechanics. The question that must be asked is, do non-compliance mechanics enhance treatment results or do they merely simplify treatment?

Diagnosis

Are there new innovations in diagnosis? Until 1931, diagnosis was performed using a clinical exam, models, and facial photographs as tools. In 1931 the Broadbent-Bolton cephalometer was introduced and an era of intensive study of human facial growth ensued.

  • In 1948 the Downs Analysis was introduced
  • In 1953 the Steiner Analysis was developed
  • In 1954 came the Tweed Analysis
  • In 1955 the Coben Analysis was born
  • In 1960 the Ricketts Analysis was first published
  • In 1967 the Wits analysis was introduced

No significant new cephalometric analysis has been added for more than 30 years!

Computer Diagnosis

Perhaps computer diagnosis is a new innovation. Ricketts published several articles about computer driven diagnosis by 1972, a quarter century ago. Today numerous vendors are selling computer driven diagnostic systems. The analyses they offer are digitized formats of analyses that date back more than 30 years. The computer offers enhanced efficiency in diagnosis and the opportunity for sophisticated case presentations (which many believe increases case starts). It is interesting to note that today’s popular computer diagnostic systems were not based upon new diagnostic capabilities. They are sold because they lead to improved efficiency (viz., the “paperless office”) and because they enhance our marketing.

Practice Management and Marketing

Much new has occurred in the areas of practice management and marketing in recent years. Computers have allowed us to organize our scheduling, management systems, and marketing activities. The current “gurus” of management and marketing take their roots from Frank Edwards and the Millennium Society, which dates back to before 1964. No doubt the computer plus the management and marketing gurus have enhanced our skills in the business aspects of orthodontics. The question that needs to be asked is do these new tools enhance treatment quality?

Cynicism or Reality?

What I have presented here may be perceived as a cynical view of what has been happening in orthodontics over the last couple of decades. This is not my intent, but I do ask you to consider the following questions:

  • Does straightwire improve results over standard edgewise?
  • Does a heat activated wire improve the treatment results over stainless steel?
  • Do direct bonded brackets improve the treatment results over full banded treatment?
  • Do current computer driven diagnostics offer anything more in diagnosis than hand traced x-rays?
  • Do computer management systems improve treatment results?
  • Will the new marketing systems available improve treatment results?

Numerous excellent studies in the orthodontic literature support the position that the “advances” that have driven our profession in recent years have not lead to improved treatment outcomes. [6,7] My point is that these innovations have increased our efficiency and our profitability, but not necessarily our quality.

Is this bad? The following are also true:

  • Profit is not a “four letter word”. The Hippocratic Oath does not preclude making a comfortable living.
  • The new technologies in bands, brackets, and wires allow us to see patients less frequently, to have shorter appointments, and to deliver lighter forces (which leads to less tissue destruction and less pain). They are also credited with reducing our treatment time. This is a good thing not only for us, but for the patient!

The management techniques that have evolved afford the opportunity to give the patient/parent what they want, which minimally means:

  • Run on time
  • Schedule fewer appointments
  • Finish treatment on time

Consumerism drives today’s society. The “advances” of the past 30 years have given us the tools to provide our patients and their parents what they demand.

What Will Drive Orthodontics in the Future?

I believe that enhanced diagnosis and associated technology will drive orthodontics in the next century. Based upon improved diagnosis, improved treatment methods will arise. New “high tech” wires will continue to emerge; better adhesives, better brackets, better computer management systems, and new innovative ways to market orthodontics will as well. To me, however, the next true advancements (not enhancements) that will drive orthodontics will be those that IMPROVE QUALITY OF CARE!

Zerobase Orthodontics™

What will truly allow the orthodontic community to enhance the quality of treatment results without losing efficiency or profitability? The key is to move away from a universal appliance that is applied to all patients toward an individualized appliance that fits the specific needs of each patient.

Enhanced Diagnosis

The simplest way to improve (individualized) treatment would be to enhance the diagnosis. I submit that the only way to enhance diagnosis is with new diagnostic tools. Let me list some possible examples:

Enhanced cephalometrics

  • Age, sex, and race related norms are used for treatment planning
  • “Facial growth to maturity” is projected in advance of initiating treatment (i.e., using “visual treatment plans” or VTP’s)
  • Simplified and easy progress evaluation separates treatment results from normal growth (i.e., the 4-position analysis)

Frontal x-ray analysis

  • Age, sex, and race related norms are used for treatment planning
  • Transverse plane treatment planning enhances stability

Tomograms

  • Joint position problems in TMD are better identified
  • Joint morphology changes are better identified
  • Tomograms are cost effective vs. MRI, CT scan, etc.

Mounted casts

  • Occlusal evaluation (pre and post treatment) is refined
  • The denture is added to frontal and lateral cephalometric analysis

Rhinomanometry

  • Airway problems are accurately evaluated
  • Awareness training/treatment of airway problems is improved

EMG (Electromyography)

  • Muscle dysfunction is identified and treated
  • Habit control improves

The above represent only a few of the diagnostic enhancements that can improve the quality of our diagnosis and through them the quality of our treatment results.

Taken collectively, these diagnostic enhancements seem like a lot of extra work. They represent new tools to learn, and a seemingly overwhelming amount of extra time to use them. Well…

  1. Suppose that you had the capability of using existing technology to add these tools with little additional effort? Would you be interested?
  2. Suppose that you could add any or all of them at your own pace. Would you be interested?
  3. Suppose that the diagnostic regimens listed are universal in the sense that you can use whatever treatment mechanics you desire to achieve the individualized treatment plan once it is developed. Would you be more interested?
  4. Suppose that all of the above diagnostic tools integrate with an inexpensive computer diagnostic system? Would you be interested in using it in your practice?

What I have been discussing is the ZeroBase Orthodontic™ diagnostic regimen developed by Drs. Carl Gugino and Ivan Dus. Founded in the principles of the Bioprogressive™ Philosophy, there is a logic flow that organizes your thoughts as you treatment plan a case. Although it is possible for all of these diagnostic enhancements to be done by hand, there exists a computerized system that will perform any or all them in a fraction of the time. If you believe, as I do, that the future of orthodontics is in enhanced diagnosis, this is the next technological step toward achieving that goal.

Enhanced Treatment

It does not make sense to sophisticate your diagnosis if your appliance restricts your ability to match your treatment objectives. 3M Unitek has developed the ZeroBase Orthodontic Appliance System to address this issue.

Table 1.

Maxillary Facial Type Torque Angulation
Central Brachyfacial 22°
  Mesofacial 17°
  Dolichofacial 14°
Lateral Brachyfacial 14°
  Mesofacial 10°
  Dolichofacial
Cuspid Brachyfacial 10°
  Mesofacial
  Dolichofacial
Mandibular Facial Type Torque Angulation
2nd Molar Brachyfacial -25° -5°
  Mesofacial -25° -5°
  Dolichofacial -30° -5°

The Zerobase Orthodontic Appliance System

The ZeroBase Orthodontic system can best be described as the “next generation of Bioprogressive”. It advances the concepts and mechanics that were originally developed by Dr. Robert M. Ricketts. Using today’s technological advances, the ZeroBase Orthodontic Appliance System provides a patient specific prescription that takes advantage of 3M Unitek ‘s Victory Series ™ Appliance with the added advantage of the APC™ Adhesive Coating System.

Brackets

You can now choose the exact brackets appropriate for the individual needs of each patient. We all know that “high angle” (dolicofacial) cases require less torque than mesofacial ones, and low angle (brachyfacial) cases require more anterior torque. Observe the chart in table 1 to see how you can now apply case specific torque.

Finally there is a bracket system that allows you to individualize your treatment based upon the needs of each patient. Enhanced quality with increased efficiency is at hand!

But bracket innovations alone are not enough to achieve the enhanced treatment objectives of ZeroBase Orthodontics™.

Inventory Management

Inventory Management

APC™ Adhesive Coating and APC Inventory Dispensing System will allow your practice to manage individual prescription brackets using the ZeroBase Orthodontic concept in an organized and cost effective manner without creating inventory chaos for the staff.

Wires

The ZeroBase Orthodontic™ Treatment Philosophy takes its roots from Bioprogressive™ principles. With contemporary wire technology, it is now feasible to replace Elgiloy™ wires and multiloop arches of the past (e.g., quad T sections, retraction sections, double delta arches, etc.), with a simplified mechanics system. This means fewer arch changes and far fewer expensive and time consuming multilooped arches; today’s utility arch is fabricated of improved stainless steel preformed arches.

ZeroBase Orthodontics uses the following pre-formed archwires. Each patient’s wire sequence is of necessity, individualized. Only the wires needed to treat each case are chosen from the following inventory. The result is minimal archwire changes, minimal fabrication, and minimal costly inventory.

.018 Slot Appliance wire inventory needs
Permachrome Resilient .016″ round
Nitinol Heat-Activated .016″ round
Permachrome Resilient .016 x .016″ square
Unitek” Twist .0175″ round
Permachrome Resilient .016 x .022″ rectangular
Nitinol SE SuperElastic .016 x .022″ rectangular
Nitinol SE Reverse Curve .016 x .022″ rectangular
.022 Slot Appliance wire inventory needs
Permachrome Resilient .018″ round
Nitinol Heat-Activated .018″ round
Permachrome Resilient .018 x .018″ square
Unitek Twist .0195″ round
Permachrome Resilient .019 x .025″ rectangular
Nitinol SE SuperElastic .019 x .025″ rectangular
Nitinol SE Reverse Curve .019 x .025″ rectangular

The Marriage of Proven Principles with New Information

Intensive study on the fundamentals of growth and development and their effects on treatment has occurred in recent decades. Significant research has been done on the forces appropriate for orthopedics and for orthodontic movements of teeth. The biomechanics to confidently achieve orthodontic movements have become known. The effects of airway obstruction as well as oral habits and other myofacial disorders have been studied in depth. The complications and limitations of advancing age on treatment outcomes as well as the effects on craniofacial development of early intervention have been studied and reported.

This emerging body of knowledge has provided additional opportunities to enhance our treatment results in the next century. The ZeroBase Orthodontics treatment system incorporates all the biological and mechanical principles that must guide our mechanics in the future. The clinician has the freedom to choose from appropriate available options the appliance he/she desires to accomplish the individualized treatment objective. Confidence in treatment will be the ultimate result, along with the knowledge that your treatment plan will be the most efficient and cost effective possible.

Summary

I believe that basic and clinical research, plus innovative technology will drive orthodontic advances in the next century. I believe that what will direct these advances will be improved treatment results. Improved treatment results will come from enhanced, individualized diagnosis. The ZeroBase Orthodontic diagnostic system (manual or computer) represents the first organized advancement of our diagnostic capabilities in nearly 30 years!

I believe that computer technology will drive diagnostics in the next century. Computers will enhance not just the speed of our diagnostic decisions, but more importantly, the decisions themselves.

I believe that new diagnostic technology such as Rhinomanometry, EMG, and 3-D imaging (with skeletal and facial morphing) will some day become the standard of (diagnostic) care. I believe that the future of diagnosis will soon routinely involve incorporating growth into reliable treatment decisions.

Innovations in appliances, wires, adhesives, and computers have dramatically improved our efficiency, our case acceptance, and our profitability. The area that offers the greatest potential for change, for additional efficiencies, and for practice satisfaction in the coming years lies in the realm of individualized diagnosis followed by individualized care.

ZeroBase Orthodontics represents the next giant step in the ongoing evolution of orthodontic care.

References

1. Andrews L. “The Straight Wire Appliance: Origin, Controversy, Commentary” JCO 1976:10:99-114.

2. Ricketts R.M. “Features of the Light Progressive Technique 1972″, Rocky Mountain Communication.

3. Herbst E. “Dreissgjährige Erfahrungen mit dem Retentions-Scharnier”. Zahnärztl Rundschau 1934;43: 1515-24, 1563-8, 1611-6.

4. Pancherez H. “The Effects, limitations, and Long-Term Dentofacial Adaptation to treatment With the Herbst Appliance” Semin Orthod 1997;3: 232-243.

5. McNamara J. recent lectures and presentations.

6. Kattner PF, Schneider BJ. “Comparison of Roth Appliance and Standard Edgewise Appliance Treatment Results”. AJO/DO 1993;103:24-32.

7. Reuker E. “straight wire appliance versus conventional full edgewise”, Universiteitsdrukkerij Nujmegen, Netherlands. 1996, 217 pgs.


Contributed by:

Terry A. Sellke, D.D.S., M.S.
Associate Professor, University of Illinois at Chicago. Private Practitioner in Lake County, Illinois


Bioprogressive and Elgiloy are trademarks of Rocky Mountain Orthodontics
Herbst is a registered trademark of Dentaurum Inc.
Jasper Jumper is a trademark of American Orthodontics
TMA is a trademark of Ormco
ZeroBase Orthodontics is a trademark of Dr. Carl Gugino
APC, Unitek and Victory Series are trademarks of 3M Unitek

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Comments One Response

  1. THANH

    31. Dec, 2012

    I would like to have information relating to RM norm

    Reply to this comment

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