The future of orthodontic materials: The long-term view

Robert P. Kusy, MS, PhD [MEDLINE LOOKUP] • Previous article in Issue

 • Next article in Issue
Chapel Hill, N.C. • View print version (PDF)
• Drug links from Mosby's DrugConsult
Sections • Genetic information from OMIM
 Past And Present • Citation of this Article
 The Short-Term View    • View on PubMed
 The Long-Term View    • Download in citation manager format
 The Calling    • Download in Medlars format
 References • Related articles in PubMed
 Publishing and Reprint Information

 Articles with References to this Article

   Past And Present  TOP 

Today orthodontists move teeth using fixed appliances fashioned from metals, ceramics, and
polymers. Stainless steel, cobalt-chromium, nickel-titanium, and -titanium are the main alloys used
to fashion arch wires.1 Stainless steel has been the workhorse for generations; despite its heat-
treatment capabilities, cobalt-chromium has remained a distant competitor. The two titanium-based
alloys have found their market niches as well: nickel-titanium in the early stages of treatment and -
titanium in the intermediate stages of treatment. None of these materials is ideal, however. The first
three alloys contain nickel, which is regarded by some as an allergen. 2 Anecdotal reports ranging
from edema of the tongue, lips, and mouth lining to anaphylaxis reach this laboratory some half-
dozen times a year. Although -titanium contains no nickel, this alloy tends to cause galling,
fretting,3 and high friction,4 thereby making sliding mechanics more problematic. Ligatures are
manufactured as 0.010 inch (0.25 mm) stainless-steel wires or as O-rings from polyester or
polyether urethanes. Although stainless steel is quite serviceable, all polymeric O-rings,
unfortunately, undergo force degradation,5 are prone to staining, and host odor-forming bacteria. 6
Brackets have been manufactured from metals such as stainless steel and titanium; 7 from ceramics
such as single-crystal sapphire,8 polycrystalline alumina,9 and zirconia;10 and from polymers such as
polycarbonate.11 With regard to brackets, stainless steel and titanium are comparable in the passive
state, which includes the 0° pretorque, 0° preangulation condition. Although the transparent or
translucent appearance of the single-crystal sapphire and polycrystalline alumina makes these
materials esthetically pleasing, all three of the aforementioned ceramics are abrasive when they
bear against opposing enamel. Polymers are esthetically pleasing as well, but they lack strength
and rigidity—problems common to all unreinforced polymers.

   The Short-Term View  TOP 

Each of the aforementioned appliances makes use of only one class of engineering material
at a time (Fig. 1).
Figure 1. Different classes of materials available to the orthodontist.
Only metals, ceramics, and polymers are useful; hence the
semiconductors are placed in parentheses. When any two or more
of these classes are combined, composite materials result.

Click on Image to view full size

In the short term, however, composites will play an increasing important role in orthodontic
treatment as two or more classes of engineering materials are combined at a time. For example,
polymers and metals, metals and ceramics, or ceramics and polymers may be combined in such a
way that the advantages of each class of material may be realized and the disadvantages
minimized, thereby yielding a unique final product that is superior to either of its principal
components alone. Nature makes use of this concept in the engineering of wood, and this approach
in has been adopted by humankind in the design of jet aircraft, pleasure boats, and sports
equipment incorporating fiberglass, which is a composite of glass fibers (a ceramic) and polyester
resin (a polymer). In orthodontics, composite prototypes of arch wires, ligatures, and brackets have
been made from S-2 glass fibers and acrylic resins. Such composites are esthetically pleasing
because their translucent qualities tend to transmit the color of the host teeth. More important, they
are functional, unlike their plastic-coated optical-glass predecessors, being quite strong and
springy.12-14

With the use of a patented process called photopultrusion, 15 arch wire prototypes have been
constructed with stiffness ranging from that of nickel-titanium to that of -titanium wires.1 This
variability can be achieved without a change in the overall cross-sectional dimensions and hence
wire-bracket engagement.12 When the fiber and resin contents are equal, springback is greater than
95%,16 so that the energy applied at wire insertion may be retrieved months later without significant
loss. At this same fiber-resin content the total water sorption is only 1.5% by weight, 14 so that
dimensional stability is good and stains and odors are minimized. Reformation of the cross-
sectional dimension from round to rectangular and from straight length to preformed arches is
possible, as well.17

Ligature prototypes made from a polyethylene fiber and acrylic resin through the use of the
photopultrusion process have been shown to be two-and-a-half times stronger than stainless-steel
ligatures and yet lose most of their tying force in less than 3 hours. 18 Therefore these ligatures can
retain the arch wire in the bracket slot without producing unwanted forces that will change the
moment-to-force ratio and hence the motion on a tooth. Only the lack of an adequate means of
tying, welding, or otherwise securing the ligature stops it from progressing from a prototype to a
product.

Unlike arch wires and ligatures, adequate prototypes of composite brackets have been difficult to
achieve because photopultrusion does not effectively align the fibers in the critical directions to
prevent tie-wing failure. Hand layups, which used woven mats in the same way as the fiber-glass
industry, did not solve the problem. Although torsional measurements indicated that tie-wing failure
occurred at 150 to 200 g-cm of torque (Zufall SW, Chen T, Kay RP, unpublished data), such values
were, at most, only half that of single-crystal sapphire and polycrystalline alumina, which were
comparably tested. Clearly a better methodology must be identified. Perhaps filament-winding will
provide that solution.

   The Long-Term View  TOP 

Up to this juncture and, indeed, in the near future, orthodontists have used and will continue to use
materials that apply forces to stimulate bone changes and to move teeth. This traditional paradigm,
of using appliances as biologic antagonists, must make way for a more sophisticated future
paradigm in which appliances will exercise their effects in a passive fashion. Today, retainers are
prime examples of such appliances, in that they only prevent unwanted displacements. Similarly,
the composite ligatures described here will be purposefully designed to exercise their effect in a
passive fashion. Short of finding the “crooked-tooth gene,” this future paradigm of using proteins,
factors, variants, or all three as drugs to create bone changes and move teeth must be identified so
teeth can move at the biologic optimum rate. Circumstantial evidence supporting the use of this
paradigm is seen every day in private practice and underscored all around us in the case studies
presented at conferences and in the literature. The traditional orthodontist (a category, in this
context, comprising everyone who has ever banded a patient) makes the tacit assumption that he or
she knows the optimal force and proper velocity of each patient's tooth. The fact is, we don't—but
the cells do. Future orthodontists (probably meaning practitioners who are not even born yet!) will
move teeth at their optimal speed with no unwanted round-tripping, resorption, hyalinization, or
pain. How that long-term view of the orthodontic future was adduced consumes the balance of this
presentation.

The physical sciences not only concern themselves with single phenomena—optical,
thermal, electrical, magnetic, mechanical, and chemical—but with coupled phenomena
(Fig. 2).

Figure 2. Single and coupled phenomena of nature that are

routinely studied in the physical sciences. Along each path both the
as-stated and reverse effects are possible. Here the paths of the
piezoelectric and reverse piezoelectric effects are only highlighted.

Click on Image to view full size

Some are apparent to us in everyday living—for example, the thermal-electrical (a.k.a.

thermoelectric) devices that convert electricity into a decrease in temperature, for which the term
“cold plate” has been coined, or the electrical-optical devices that use light to excite electrons out of
their stable positions, thereby creating a change in dark level in those variable-tint sunglasses that
so many of us enjoy. However, note that each coupled phenomenon has an as-stated effect and a
reverse effect.19 For example, for the coupled mechanical-electrical phenomena there are a
piezoelectric and a so-called reverse piezoelectric effect (Fig. 2 ). When in a piezoelectric material
(Fig. 3, A) the application of a force changes the shape of a material (Fig.
Figure 3. Illustration of one coupled phenomenon, the piezoelectric
effect. Here a piezoelectric material (a) has a force (F) applied that
changes the shape (d) of the material (b) as a current is generated
(c). When a piezoelectric material (a) is connected to a battery and
has a current passed through it (d), the reverse effect occurs,
accompanied by a change in shape. Adapted with permission from
Van Vlack LH: Elements of materials science and engineering. 6th
ed. Copyright 1989 by Addison-Wesley.

Click on Image to view full size

3, B ) and subsequently induces an electric current (Fig. 3, C ), the as-stated effect occurs. When
an electric field induces a force and hence a change in shape (Fig. 3, D ), the reverse effect occurs.
It is known that in dry bone an electric field will induce a force and hence a change in shape of the
bone (the so-called reverse effect); therefore the application of a force will change the shape of
bone and subsequently induce an electric current (the as-stated effect). 20 Thus such observations
establish the basis for a parallel situation in orthodontics.

In pursuing a futuristic approach, Barnett, at the American Association for Dental Research
Symposium on New Molecular Approaches to Oral Therapeutics, fortuitously highlighted the
traditional mechanical-surgical paradigm of general dental practice. 21 He predicted that this
paradigm would be transmuted to a pharmacologic-regenerative paradigm as bone
morphogenetic proteins would be used to restore dentin, growth factors would be used to
regenerate tissue, and molecular variants would be used to modulate microbial
colonization. If these paradigms are drawn in the same manner as the physical sciences
(Fig. 4), single phenomena and coupled phenomena—the latter comprising as-stated and
reverse effects—might be inferred.

Figure 4. Dental paradigms and their associated paths, which that

imply coupled phenomena in which as-stated and reverse effects
are possible. The mechanical-surgical paradigm and the
pharmacologic-regenerative paradigm represent the traditional and
future paradigms of general dentistry that were recently discussed
by Barnett.21
 Click on Image to view full size

In that context we can now acknowledge the presence of the traditional mechanical-regenerative
paradigm that dominates orthodontic practices today. Take, for example, the force system on a
bracket of a central incisor consisting of a labial-lingual force (F) and a countervailing torque (M)
such that the moment-to-force ratio (M/F) equals 10 (Fig. 5, A).
Figure 5. Force system on a bracket required to bodily move (i.e.,
translate) a, a central incisor; b, its idealized distribution of
compressive and tensile forces on the alveolar bone; and c, its
biological response by way of osteoclastic and osteoblastic activity.
Because the moment-to-force ratio (M/F) equals 10, the distance
from the bracket to the center of resistance (CR) of the tooth must
also equal 10 mm.

Click on Image to view full size

By inference, the distance from the bracket to the center of resistance of the tooth must be 10 mm. 22
Such a force system will produce bodily movement, otherwise known as translation, once the cells
acknowledge a rather uniform tensile force on the labial surface of the tooth and a rather uniform
compressive force on the lingual surface of the tooth (Fig. 5, B ).23 As a result of the mechanical
forces, osteoblastic and osteoclastic activities ensue in the alveolar regions near the labial and
lingual surfaces of the tooth, respectively, the former regenerating new bone and the latter
resorbing old bone (Fig. 5, C ). And so the tooth moves. Of course, force is active in all bone-tooth
interactions.
If this scenario is possible, what about the reverse effect? That is, can regenerative changes cause
mechanical forces (Fig. 4 )? And, for that matter, can pharmacologic changes prompt regenerative
changes that, in turn, cause mechanical changes? In principle these pathways should be possible;
in the physical sciences a chemical change can prompt an electrical current to flow, in turn resulting
in a mechanical force (Fig. 3 ). This happens each time we turn the ignition keys of our cars. At that
moment a chemical reaction in the battery produces the electricity that excites the solenoid coil and
ultimately produces forces that turn the wheels, thereby carrying us to our daily destinations. Thus,
as in the physical sciences, the future paradigms of orthodontics can act individually or in couples
by way of the stated or reverse effects. All pathways should be possible.

If this deduction is indeed correct, the long-term view of moving teeth in orthodontics might
alternatively occur as follows (Figs. 4 and 5 ): Using the central incisor illustrated earlier,
pharmacologic stimulation by way of proteins, factors, variants, or all three would somehow be
directed to the labial tissue at the interface between the periodontium and the alveolar bone.
Ultimately, regenerative processes would be initiated that would cause osteoblasts to lay down new
bone, thereby creating a mechanical force on the lingual surface of the tooth. This mechanical force
would generate an electric signal in that tissue that would prompt the resorption of bone cells
through osteoclastic activity. Bone changes would thereby occur to move teeth, but the appliances
would have their effects in a passive fashion. That is, the materials from which the appliances are
constructed would not be initiating the mechanical forces but, rather, responding to biologically
induced forces and merely ensuring that the teeth could proceed to their proper anatomical
positions. Therefore the cells would be moving the teeth in response to stimuli, the appliance would
be policing or stabilizing the proceedings, and the orthodontist would be directing both aspects of
the procedure. Instead of designing appliances that would actively deliver an anticipated number of
grams per millimeter (i.e., a force per unit of deactivation) in a particular direction, the dose, its
placement in the tissue, and its duration would be chosen along with the passive appliance. The
mechanical delivery of care through materials would become subordinate to biotechnology.

   The Calling  TOP 

The long-term view of orthodontics presumes an enhanced understanding of tooth motion and its
associated biologic processes. Because much of that knowledge is still a distant reality on the
technologic horizon, innovative materials will dominate orthodontic therapy for some years to come.
In that interim the last great frontier for orthodontic materials—composites—will increasingly
encroach on the use of metals, ceramics, and polymers as functional and esthetically pleasing
appliances become popular as part of the short-term view of the future. In this regard industries
must shed those expedient solutions of “inserts” and “bumps” and start to pursue composite
materials. And while industry pursues this short-term view for the next generation of practitioners,
the rest of the community should support the scientific innovation that will be required to make
biologic manipulation a long-term reality, with good fortune, in the next century.

The author thanks Dr. William R. Proffit for kindly critiquing this manuscript and Mr. John Q. Whitley
for skillfully preparing the artwork.