Following are the final New Member Forum contributions from our current panel. I sincerely thank each of them for the time and effort they put into their responses. It is not easy to put yourself out there for possible scrutiny by your colleagues. The challenge of the New Member Forum is to encourage dialogue and foster an interchange of ideas that will be interesting to all, but especially useful to our younger members.

Drs. Clarice Law, Jonathon Lee, and Rob Sheffield have, with their input over the past year, provoked all of us to think a little more deeply about a number of orthodontic issues. We wish them much success in their future careers and look forward to hearing from them in other venues. —Michael Sales

Rob Sheffield

I am currently using the Orthos appliance system with a .022 x .028 slot size by Ormco as my primary fixed appliance system. I wish I could say that I made my selection based on extensive clinical study of finished cases but I cannot. This was the appliance system in place in the practice I joined following my residency. That being said, in general I am happy with the appliance and am pleased with the finished results of my cases so far.

The appliances we use are the tools with which we strive to achieve the nicest occlusal result balanced with pleasing esthetics. In that regard we are obligated to look critically at each patient as they finish in order to identify deficiencies so that we can continue to improve. As I think about the common problem areas for me in detailing a case, four issues come to mind.

First, at times the maxillary laterals appearto have too much labial crown torque. Second, at times, I feel as though the maxillary cuspids have too much lingual crown torque. I have noticed this more so in my extraction cases. My preference as I examine the smiles of my finished patients is to have the cuspids more upright. Third, I notice that the palatal cusps of the maxillary second molars tend to hang down. I closely inspect the band position but often cannot blame that as the cause. Fourth, I occasionally struggle to upright lingually tipped mandibular second molars and, once again, I cannot fault band placement as the primary culprit.

While I feel that the overall appliance I am using provides an excellent platform, I expect that over time, I will make modifications that will eliminate some of the common detailing bends I am forced to make. My goal is to find the system or combination of systems that allows me to achieve the best results with the greatest frequency all else being equal.

With all the new technology becoming available, I suspect that at some future time it will be possible to have a set of models scanned and then set up the ideal torque and angulations prescribed for each tooth to achieve the desired result. My concern is that this starts to remove some of the art from the "Art and Science of Orthodontics," which feels strange to me. Additionally, our supply system would have to be monumentally streamlined because the inventory challenge would be immense.

As a young practitioner, I am not sure if I am the appropriate individual to address this question and I would love to hear from the more experienced members of our specialty about the appliances they use and the rationale behind their choices.

I am enjoying our profession immensely for the continuing myriad of challenges it presents each day as I strive to deliver the best possible care to my patients. I thank Mike for including me in these discussions and I look forward to future issues.

Jonathon Lee

One of the many decisions to be made during the transition from an orthodontic resident to a private practice clinician is the choice of the prescription, type, and manufacturer of the appliance that he or she will use in daily practice. For some, the senior doctor will already have made that decision.

I entered a practice that used two edgewise prescriptions. The senior doctor, who also is my father, used Ormco-A Company’s Andrew’s Straight Wire 022 appliance for extraction cases and Unitek’s Gerald Samson’s Straight Wire 018 appliance for Two Phase and non-extraction cases. Fortunately, my father allowed me the freedom to choose the appliance of my own choice.

The decision was complex but I was fortunate to have received a well-rounded orthodontic education where the residents treated many patients and we were taught a number of treatment philosophies incorporating both fixed and removable techniques.

We commonly used Lang’s Standard Edgewise Single Wing Appliance, Unitek’s Roth Mini Twin Appliance, Ormco’s Orthos Appliance, GAC’s Bidimensional Appliance and RMO’s Synergy Appliance. We had four different ceramic/plastic appliances available, as well as Speed, Damon and Twinlock ligatureless appliances. Each had its advantages and disadvantages. I enjoyed working competently with all the appliances, but found it difficult to choose one that would be the best.

Prior to graduation every resident had to present all of his or her finished cases — 30-40 on average. By reviewing the treatment notes and records, I gained a better appreciation for the progression of orthodontic treatment. The successes and the shortcomings of each case and appliance can be compared to each other.

It was this experience that led to my decision to choose the Gianelly Bi-Dimensional edgewise orthodontic technique. I found that the cases treated with the Bi-Dimensional technique finished on time, produced esthetic and stable results, and worked well in extraction, non-extraction, single and two phase plans, and surgical cases.

One case treated in the Bi-Dimensional technique can be seen in Fall 2000 PCSO Bulletin Vol. 72 No. 3. That case report illustrated the clinical application of extracting maxillary first bicuspids using Bi-Dimensional technique as a protocol for treating Class II dental maxillary protrusions in the non-growing adult patient. The technique provides excellent anchorage and orthodontic control. Additionally, asymmetric space closure can be performed efficiently as is illustrated in the above- referenced case.

The Bi-dimensional technique utilizes 018 x 025 Roth prescription brackets for the maxillary central and lateral incisors. The mandibular incisors use 018 x 025 0° angulation and 0° torque brackets. All other brackets carry 022 x 028 slots, hence, the bi-dimensional. Maxillary canines have 7° angulation and 0° torque. Maxillary first molars utilize bands with triple tubes, 0° angulation, 0° torque, a 6° offset, and a lingual sheath.

Lower canines come with 5° angulation and 0° torque. Lower first molars utilize bands with double tubes, 0° angulation, torque, and offset. They also have lingual sheaths. All bicuspids are 0° angulation and torque and all canines and bicuspids have distally placed hooks. There is
a vertical slot in every bracket except the molars.

I tried the Bi-dimensional Prescription in two versions: GAC’s Omni Arch and GAC’s Micro Arch. The Omni Arch was easier to tie because it is larger. The Micro Arch demonstrated better hygiene because there was less surface area for plaque and debris to stick to. Being a pediatric dentist as well as an orthodontist, I wanted an appliance that did not interfere with oral hygiene. So I chose the Micro Arch. I also use RMO’s Wilson mandibular lingual sheaths on the lower 6’s. For bondable 6’s, I utilize Ormco-A Company. For esthetic brackets on the upper 3 to 3, I use Unitek’s Clarity in Roth Prescription.

The Bi-dimensional edgewise technique utilizes sliding mechanics for all movements including space closure. According to the Boston University Department of Orthodontics Bi-Dimensional Manual, this reduces the need for more conventionally used looped arch wires, reducing both wire bending and chair time. However, you may utilize closing loop mechanics. Efficient treatment time is important in regard to patient satisfaction, cooperation, and hygiene.

Clarice Law

My clinical training was problem-based and driven by part-time clinical faculty members who came from a multitude of different clinical backgrounds. At the time we were residents, there wasn’t much consensus on a uniform appliance system for the clinic. Therefore, we were exposed to several different prescriptions and representative manufacturers.

We expected to get a taste for each different system and then develop our own preferences within the first few years of practice. However, unlike my colleagues, who have settled into their own practices, I haven’t yet had an opportunity to develop my personal preferences for a particular appliance system.

The two years of residency provided a unique opportunity to sample from the smorgasbord of choices we orthodontists have available to us. I believe at one time we had probably a dozen different systems from which to choose. These represented various manufacturers, prescriptions, and even slot sizes, although the 018 slot was favored. Among the different appliance systems we were exposed to, I was particularly pleased with Ormco’s Orthos system, GAC’s bi-dimensional prescription, and Unitek’s Mini-Uni and V-slot systems.

During my next two years in practice, I was presented with a new group of systems. I practiced temporarily in two different general practices, where the managing partners had purchased appliances from Ortho Organizers and American Orthodontics. Both systems were in the Roth prescription. My main practice gave me even more opportunities to sample different systems. When I first started, our office used TP Orthodontics’ Roth formula V-slot bracket exclusively, then transitioned briefly into Ormco’s Orthos before settling on American Orthodontics’ Orthos prescription during my last year in private practice.

My last two years have been rather unique. As a full-time dental school faculty member, I have very limited opportunities to practice. The majority of my orthodontic clinical practice has been supervising dental students in their rotations at a clinic serving underserved populations. We rely on the donations and generosity of orthodontic companies, which include American Orthodontics, GAC, Dentaurum, and Unitek. In this context, I have been forced to be rather creative, as we will sometimes run out of certain appliances before completing treatment.

Thus, some patients will have appliances from different manufacturers in their mouths. All of this sampling has led to my bottom line response – I’m not so sure the difference between appliance systems is significant enough to merit the great diversity of products pushed into the market.

I have certainly had opportunities to develop some preferences, but these are less specific than what orthodontic companies seem to emphasize. For example, I started out strongly favoring the vertical slot appliance because of the potential for diverse mechanical options. But I observed a higher bond failure rate, which I attributed to the higher profile. Thus, I now favor lower profile appliances, which seem to fail less often.

I also prefer the offset premolar brackets, in which the bases extend further gingivally, covering more surface area. Again, this is due to an observed decrease in failure rate. As for prescriptions, I haven’t developed specific preferences yet. I do like to have premolars without tip and torque. The universal premolar prescription allows for more options in my clinical context and reduces the complexity of ordering.

Overall, I have been able to achieve great treatment results with any of the appliance systems I have used. I believe that these results are more dependent on proper treatment planning and appropriately managed treatment mechanics than they are on the appliances themselves.

I’m sure that certain configurations may reduce bond failure and some may allow for more creative mechanics options. But since I am currently not concerned about reducing chair time, I will relish the teach-ing opportunities created by having multiple appliance systems and enjoy the creativity that results from not necessarily having brackets that automatically produce what I envision as the ideal tooth position. So as for my vote for the best appliance system – the jury’s still out. I’ve learned to make do with whatever I’m given.

Editor’s Comment

Preaching theology does not make one holy and simply applying some Duzitall® edgewise appliance will not automatically result in an ideal orthodontic outcome. We all learned the basics during our training. Most basic of all—diagnosis. Without a proper diagnosis, including facial form periodontal and temporomandibular joint health, and occlusal function, the outcome is unlikely to be ideal no matter what the appliance choice.

Bracket positioning is critical to the progress and outcome of every case using any bracket system. Proper bracket positioning allows the appliance to express the appropriate torque, angulation, and marginal ridge relations. Small variations in placement can result in significant deviations from ideal. We should also be aware that different appliance systems call for differing placement on the crown to express the outcome meant to be built into a particular system.

Hence, the practitioner who switches from one appliance to another without adjusting bracket position to accommodate for the requirements of the new system may be unjustly disappointed with the performance of the new appliance.

Quality orthodontic care presumes an excellent occlusion. Yet there seems to be widespread disagreement on what constitutes an excellent occlusion. Preferably, we should have a concept and understanding of occlusion that is scientifically and physiologically well grounded. That given, we want to be consistent in achieving orthodontic outcomes that meet the definition of good occlusion. Arbitrary outcomes resulting from a failure to set goals for occlusion are not acceptable in modern day orthodontics.

Fixed appliances are merely handles by which we can hold and manipulate individual teeth and segments of a dentition as well as transmit orthopedic forces. There is no appliance yet available that is perfect for every case. So much of the choice to use one system over another seems to be based on circumstance. What you were exposed to in your residency, what was used by a senior partner, what is used in a geographical location, cost, relationship with a supplier’s representative, admiration for a mentor or seemingly accom- plished clinician, or the mere perception a system "seems to make sense."

Certainly there are features that make one system easier to work with or more reliable in the hands of some practitioners. Quality control and technical design may offer genuine advantage to some appliances as compared to others. There are justifications and limitations with any system. What is essential, however, is to know where and why you want any case to finish before you begin the journey. The vehicle driven is far less consequential.

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