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PDF | 2MB | Clinical Impression Vol 6 (1997) CLINICAL ® ImpressionsPUBLISHED BY ORMCO CORPORATION • VOL. 6, NO. 2, 1997 Dr. Turley Interviews Dr. Nanda Page 2 Dr. Scott Takes a New Tack to Close Spaces Page 6 Mr. McMahan on Managed Care Page 12 Ms. Brunner on the Upbeat Office Page 13 Dr. Clark on Marketing Plan Implementation Page 16 Dr. Nanda Biomechanics Dr. Patrick Turley Interviews Dr. Ravi Nanda r. Turley: Ravi, biomechanics in improve them. The specialty is moving orthodontics has taken a backseat for away from technique-oriented approaches years, but recently, more and more that treat, for example, all Class II, orthodontists are paying attention to division 1 patients with wire “X” and it. Where do you think we are headed extraction cases with wire “Y.” Now we in this area? want to know the “guts” of a wire, loop or a spring, such as magnitude, moments, Dr. Nanda: Yes, Pat, I have noticed a keen constancy, direction of force, as well as interest in biomechanics by the ortho- side effects and methods to prevent and dontic specialty in recent years. We are reduce them. more and more curious about how our D appliances work and what we can do to I have always said that we orthodontists Dr. Patrick K. Turley received his D.D.S. Dr. Ravindra Nanda currently serves as degree from UCLA and his M.S.D. degree and professor and head of the Department of certificates in both orthodontics and pediatric Orthodontics, University of Connecticut. dentistry from the University of Washington. He received his orthodontic training first at He currently serves at UCLA as professor Lucknow University, India, then from the and chairman of the Section of Orthodontics University of Nijmegen, The Netherlands, and director of the postgraduate program and the University of Connecticut. He also in orthodontics, as well as the combined received a Ph.D. from the University of orthodontic/pediatric dentistry postgraduate Nijmegen. Dr. Nanda has done extensive program. Dr. Turley is president of the Pacific research, most recently concentrating on Coast Society of Orthodontists. His interests clinical orthodontic trials and the application have focused on the areas of early treat- of biomechanics in a busy orthodontic ment (especially Class III malocclusion), practice. He has authored and coauthored treatment of traumatic injuries in children three orthodontic books and more than and the use of endosseous implants as 100 scientific and clinical articles in major orthodontic anchors. journals. 2 “Simple, sound principles of biomechanics often spend half our time treating can be applied to any technique.” patients’ problems and the other half correcting the problems we create, often due to inadequate mechanics. Such examples include loss of anchorage and faulty root inclination of incisors and posteriors. If we apply sound A mechanics, side effects can be minimized, treatment time shortened, and chair time A B C saved, not to mention the benefits of peace of mind. Since Edward Angle invented the edge- wise appliance, there have been few, if B any, revolutionary advances in mechano- therapy. Most of our progress has been D E F made through improvements in and Third-order side effects from space closure. variations on bracket design and the A – Vertical forces acting on the molar clinical application of new wire alloys. secondary to unequal moments used for Yet, 100 years later, we are still vexed by Group A space closure; the beta moment the same problems as our forefathers. is greater than the alpha moment. An Anchorage control, predictable and extrusive force occurs at the bracket. precise results, stability and compliance C B – The equivalent force system at the are still confounding difficulties in center of resistance of the molar; the orthodontics. Many clinicians have extrusive force at the bracket results in offered solutions by making refinements a moment rotating the molar in a crown lingual direction. C – The predicted tooth in the appliance itself. The tremendous movement from this force. D – The vertical Clinical examples of moments of a force. number of bracket prescriptions and forces acting on the canine secondary to A – A mesial force at the molar bracket orthodontic techniques advocated by unequal moments used for Group A space creates a moment tending to rotate the the leaders in this field are evidence of closure. E – The "equivalent force system" tooth "mesial-in." B – An expansion force our focus on the appliance. Perhaps the at the center of resistance of the canine; on a molar creates a moment tipping the problems are not in the appliance, but the intrusive force at the bracket results crown bucally. C – An intrusive force at the in our analysis of its use. Incorporating in a moment rotating the canine in a crown molar bracket creates a moment tipping biomechanical concepts into everyday buccal direction. F – The predicted tooth the crown bucally. patient care may be where we are headed movement from this force. and the source of the next generation of clinical advances. high-school level geometry. The more force, its moments or its side effects. Dr. Turley: A lot of clinicians find bio- exotic analysis, such as finite element So the first order of business for all ortho- mechanics difficult and too theoretical. analysis, are used more in the engineering dontists should be to take a step back and Why? of appliances than in clinical practice. try to understand from the standpoint of This is changing fast. biomechanics what is working and what Dr. Nanda: This has had a lot to do with is not working and how to fix it. us – educators, researchers and orthodon- One should remember that biomechanics tists active in the area of biomechanics. is not a technique. It is applicable to all With an understanding of biomechanics, We did not describe principles and the orthodontic techniques – any wire, we’ll find that simple loops, cantilevers appliances in a user-friendly way. The spring or loop which delivers a force and a small bend at the right place in terminology associated with learning when ligated into the brackets. So a the wire are all that is necessary to im- biomechanics probably has limited the basic understanding of biomechanics is prove our favorite technique. Simple, clinician’s understanding. Sometimes essential for all orthodontists in order to sound principles of biomechanics can be simple ideas seem complex because of understand what forces we are applying applied to any technique. the language and terms used. Another and what sequelae to expect. We would problem is the quantitative nature of not expect our internist to prescribe a Dr. Turley: Why isn’t biomechanics the field: the mathematics used to drug without telling us the dosage, the a bigger part of all orthodontists’ demonstrate the concepts often seems to frequency and the duration of intake. training? intimidate the learner. But for the most In orthodontics, we apply a force on part, the mathematics is simply based on teeth with only a minimal idea of that continued on following page 3 Illustrations from Biomechanics in Clinical Orthodontics courtesy of W.B. Saunders Company Dr. Nanda continued from preceding page Dr. Nanda: A good question, Pat. Our tooth movements. A given wire may look Dr. Nanda: Orthodontists should care basic problem in this area has been a the same from the standpoint of its shape about specifics of forces and moments. huge gap between the classroom and in the mouth, but a different placement of Orthodontics is little different, let’s say, clinical practice. The students are taught a bend or loop would deliver a completely from driving a car and knowing the all the details of forces, moments and different type of tooth movement. mechanics of an automobile. In our couples, but in the clinic, there is little specialty, we deliver the forces, so it application of biomechanics. Many Dr. Turley: What are the advantages becomes imperative that we must know clinical approaches follow specific wire of using biomechanically oriented what we are doing. sequences or are taught as if there are appliances? “magical” properties incorporated into the I concede that 60 to 70 percent of the bracket. The student becomes more con- Dr. Nanda: The #1 advantage is that you adolescent patients in our practices cerned with the technical aspects of care can go from point A to point B in a probably do not need specialized mech- and forgets about how the appliance is straight line. Let’s take a look at an anics. The problem comes with patients working. There is good news, however. example. In extraction patients with who have complex problems such as Orthodontic departments are spending biomechanically oriented space closure, open bites, deep overbites, midline more time in educating their students you can retract all six anterior teeth into discrepancies, asymmetric molar about biomechanics, and several schools the extraction site with minimal anchor- occlusion, moderate to severe crowding, are moving away form technique-based age loss, excellent root alignment of the critical anchorage, crossbites, etc. A approaches to orthodontics. posterior teeth and ideal axial inclinations simple straight wire and chain elastics are of the incisors. On top of that, you only not going to solve these problems. These I must add that we at the University of have to activate the appliance once patients need a comprehensive treatment Connecticut have contributed signifi- during treatment. The maximum force plan with a mechanics plan to achieve cantly by providing educators in various you need for space closure ranges from results. Use of biomechanically oriented programs who can link biomechanics to 300 to 350 grams, and you lose only 25 appliances in these patients will help clinical practice. Out of our 100+ gradu- to 30 grams of force with each millimeter achieve tooth movement compatible with ates in the last 25 years, 20 are in full-time of tooth movement.
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