RECENT ADVANCES IN ORTHODONTICS

Contents:

• Introduction
• Advances in bonding materials
• Advances in brackets
• Advances in wires
• Advances in anchorage
• Advances in soft wares
• Future scope
• References

Introduction:
There has been tremendous progress in orthodontics since E.H.Angle first popularised the
fixed orthodontic appliance. Recent years have seen an increased demand for orthodontic
treatment in both adolescents and adults, in addition patient and clinician expectations of
treatment outcomes continue to rise.
A desire for aesthetic materials have resulted in both smaller and tooth-colored
appliances. Improvements in technology, have also led to development of new materials.
The best example was the development of nickel titanium alloy by NASA space
programme, which was subsequently adapted for use in orthodontics including magnets,
computerised imaging system and distraction osteogenesis.
Bonding materials:
Bonding in orthodontics is semi-permanent in nature, bond strength should be high
enough to resist accidental debonding during whole treatment but also less force to be applied
during debonding.
With increased demand for adult orthodontics, the clinician is often faced problems of
luting brackets on the tooth surfaces.
To overcome, the 6th & 7th generation cements are being introduced by which it is
possible to bond orthodontic materials to gold, amalgam & porcelain.
6th generation cement:
The history of bonding is quite remarkable and productive.
 The self-etching adhesives involve a mechanism in which as soon as the decalcification
process is initiated, the infusion of evacuated spaces by dentin bonding agent is begun.
As the result the potential for residual vacancies amongst the collagenous fibres id
dramatically reduced or eliminated.
Light cure bonding cement capsules:
It is a 6th generation cement.
Band cement in disposable capsules is a no-mix, light activated, glass ionomer cement
that contains fluoride to control decalcification under the bands during extensive treatment.
It eliminates excessive ware and cross-contamination b/w patients.
The narrow-tipped design helps accurately dispense adhesive directly into the molar
bands.
New light cures GIC (silverman -AJO):
A new light cured gic exhibited all the necessary qualities needed to bond
brackets,without any etching and in the presence of salive.
The debonding procedures were also completely undamaging to the underlying enamel.
On removal no decalcification was observed on any teeth because of fluoride release by
the cement.
Advantages:
The new LC resin-reinforced gic possesses the following advantages over composite resins for
bonding orthodontic brackets:
- Time saving
- No need of dry working field
- No need of etching and priming of enamel surface.
- Fluoride release helps in preventing decalcification.
- Patient & operator comfort.
L-pop bonding agent:
Prompt L-pop is a water based,two-liquid, light activated dentin bonding agent marketed
by ESPE America.
It is recommended for bonding directly-placed,light activated resin composites and
copomers to enamel & dentin.
It is the only product containine all bonding agent components in one solution.
 It has several important advantages compared to currently available 5th generation
bonding agent.
It is applied to enamel for 15seconds.
Directions to use:
• Apply L-pop bonding agent to the tooth surface.
• Applty gentle air blow makes the agent evaporate.
• Then the restorative material applied and is light cured.
• The bonding agent can also be cured for 10s before applying restorative material.
The main disadvantage is its LOW BOND STRENGTH.
7th generation:
It is a fluoride releasing composite formed to over come the problems faced by 6 th
generation.
• No-mix property.
• It provides superior bond strength and dirt proof bracket placement.
Brackets:
Composition of brackets:
Due to allergy in brackets non-nickel and low nickel SS brackets are introduced.
Newer alloys like 2205 alloy demonstrates less crevice corrosion than 316 & 318 alloy
when coupled with nickel titanium, beta-titanium.
Titanium brackets has hardness compared to Niti wires but has hardness of almost S.S
wires.
The new titanium brackets have low friction.
CAD-CAM system:
It is an orthodontic care system incorporating a hand-held scanner and treatment planning
software.
The scanner is used by the orthodontist to acquire three dimensional information of the
dentition and associated anatomical structures of a patient and provide a basic information for
interactive, software based diagnosis, appliance design and treatment planning for the patient.
This scanner is suitable for in-vivo scanning, plaster models, impressions or any
combinations.
Manufacturing:
The metal injection molding technique involves mixing metal powders with particle sizes
of a few microns with organic binders, lubricants and dispersants to obtain homogenous mixture.
The MIM manufactured products are having the density of more than 97%.
The main disadvantage if MIM technique is porosity and corrosion of the bracket.
Welding:
Latest technique in welding of appliances is Laser welding.
It used Nd:YAG type laser to weld the metals.
At the wavelength of 1064nm with pulse energy of 60 joules.
Esthetic brackets:
Zirconia, polycrystalline or single single crystal alimina and plastics are the material from
which esthetic brackets are derrived.
Despite the poor hardness and associated more distortion on force application there is
even release of formaldehyde.
New generations have improved debonding characteristics and hence less of enamel
fracture.
The ceramic brackets have superior mechanical properties, increased transparency,
decreased reactivity in oral environment and inert biological character.
Speed brackets:
What is SPEED?
The speed appliance is miniature of self-ligating appliance which offers overlapping
benefits to patients and the doctor by improving aesthics,oral hygiene,comfort for patient and
increased efficiency, less chair side time and precision for the dentist.
One of the major disadvantage of speed brackets were, they require heavy forces to slide
the clip open during subsequent visits.
To overcome this there is a new development known as TIME brackets.
Advantages:
• Easy to open throughout the treatment.
• Controlled delivery of forces.
• More hygiene in patients.
Damon III:
Damon III a new type of Damon bracket, which is a part is ceramic and part is metal.
Smaller and comfortable for the patients.
Smart clip brackets:
Another type of self-ligating system, smart clips brackets do not have a sliding door or
separate clip.
The arch wire is held in place with a speciality designed clip built into the bracket.
Synergy brackets:
This system is better than damon III because o
• Low friction
• More control throughout the treatment process.
• Synergy brackets are problem-free.
• No sides or clips to deform, break or clog unlike self-ligating brackets, outstanding bond
strength and no food traps.
• Easy to position.
• Synergy is the only brackets that takes advantage of today’s super elastic wires.
• The synergy system gives greater patient comfort. Synergy brackets are much smaller
and have a significantly lower profile. Bulku self-ligating brackets are prone to bond
failures.

• Synergy has greater practice profit potential. A 6-8 weeks of interval, fast treatment time,
low cost.

APC:

Now a days brackets are available with bonding agent already placed for

Pick,

Position,

Cure.

APC- adhesive coated appliance system:

The APC system is the only orthodontic bonding system that coats the bracket with
adhesive.
 No messy mixing problem is here.

No bracket handling problems with each individual bracket clearly identified and pre-
oriented on a special foam liner that virtually eliminates the bracket rotation transist.

Fewer steps, less time

Indirect bonding:

Given by H.Stuart in 2003

In this technique flowable composites are used which is applied to the brackets.

Then this tray is placed in patients mouth and cured.

Technique allows precision placement and is less time consuming.

New coating around brackets:

Early test on a new coating for orthodontic brackets and wires developed by researches
suggest that it could inhibit plaque growth and decalcification common in patients wearing fixed
appliances without decreasing the bond strength b/w brackets and tooth.

The coating is made from a calcium phosphate base that release zinc onto braces and
surroundig teeth – inhibits acid producing bacteria that demineralizes teeth and minimizes
calculus formation.

InvisAlign:

A new technology that allows tooth alingment without brackets has been recently
introduced is InvisAlign.

This system offers the first true alternative, by using advances in 3D imaging technology
to create a series of customized plastic aligners.

This uses computer technology to create a sequence of finely caliberated clear plastic
aligners as few as 12 or more as 48 trays depending on the severity.

Patient will wear each aligner for 2 weeks, removing them only to eat and brush.

As patient replace each aligner with the next the teeth will move little by little until they
reach final alingment.

Lingual orthodontics:

Lingual orthodontics as we understanding today (a full,multi bracket appliance) begin in

the 1970s.
 The lingual appliance was not the consequence of an aestic demand, but it was started in
japan by Kinja Fujita to satisfy the orthodontic need of patients who practised martial arts, to
protect the soft tissues(lips&cheeks) from the possible impacts against brackets.

He submitted his concepts on lingual orthodontics in 1967, began his research in 1971, and
published the fujita method in 1978, treating class 1 and class 2 cases with extraction of all 4
premolars.

Fujita bracket had 3 slots

1. Occlusal

2. Horizontal

3. Vertical.

Generations of lingual orthodontics:

In the second generation (1980) hooks were added to canine brackets.

In the 3rd generation 1981 hooks were added to all brackets and to molar tubes.

The 4th generation 1982-84 included a lower profile facilitating insertion of the arch wire.

With the 5th generation 1985-86 the bite plane became more pronounced, the torque
increased, and the molar brackets included an accesory tube for a transpalatal bar.

For 6th generation 1987-90 the hooks were elongated, the transpalatal bar attachment was
optional, and the hinge cap tube for the second molar was developed(self-ligated bracket)

With the 6th generation 1990 the square bite plane became rhomboid shaped, increasing
the inter-bracket distance and the premolar brackets were widened mesio-distally for better
rotational control.

Favourable cases:

• Cases with mild incisor crowding and anterior deep bite.

• Long and uniform lingual tooth surfaces without fillings, crowns or bridges.

• Good gingival and periodontal health.

• Keen, complaint patient.

• Skeletal class 1 pattern.

• Mesocephalic or mild /moderate brachycephalic head.

 • Patients who are able to adequately open their mouth and extend their neck.

Unfavourable cases:

• Dolicocephalic head.

• Maximum anchorage cases, and unless treated with micro implants.

• Short, abraded and irregular lingual tooth surfaces.

• Presence of multiple crowns, bridges and large restorations.

• Patients with low lwvel of compliance.

• Patient with limited ability to open the mouth(trismus)

• Patient with cervical ankylosis or other neck injuries that prevent neck extension.

Future advances in lingual:

Self ligating brackets have a great appeal but to be sucessful as a lingual bracket, they
must have a robust, durable opening/closing mechanish.

In a malocclusion with crowded lower incisors, the bracket width encroaches on the inter-
bracket space to the extent that the physical diameter of the arch wire.

Even width “spider web” niti wires, may prevent closure of the bracket’s mechanism
thus reducing initial efficiency.

This appliance is designed to accept auxillary springs for extra torque and tip controll
when necessary.

Incognito appliance:

• It’s a custom made, cast gold appliance.

• Incognito appliances are manufactured with the latest state of the art CAD-CAM
technology.

• Each gold alloy bracket (anti-alleigic) is manufactured using the latest rapid prototyping
machines.

• The arch wires are precisely made by wire bending robots.

Archwires:

After introduction of thermoelastic and nobium nickel titanium archwires a break through
in archwires no major development has emerged in the past decade.
 Technology such as NiTi wires have replaced the traditional S.S wires of past, providing
patients with a temperature-sensitive wire that allow for contineous movement of teeth over
longer periods of time.

Decreases time and increased comfort.

Thermal-activated archwires:

It was introduced by Evans & Danning in 1996.

In these wires desired shape of arch was incorporated using heat.

These wires are ligated in the patient’s mouth and get activated to return to its original
shape due to heat present in the oral cavity.

Advantages:

 Desired arch form could be achieved.

 A gentle contineous force for tooth movement.
 Excellent for initial leveling and aligning.
 Provides maximum and shape memory with minimum friction.

Nickel free titanim beta III arch wires.:

It was given by Dr.Burstone and Goldberg.Beta 3 is a comparable nickel free titanium

arch wire,that provides strngt and versatility of s.s along with resiliency of niti.Beta 3 offers a
smooth surface for excellent sliding mechanics and superior bend performance. It probides twice
the bend and deflection of s.s. without permanent deformation.

CNA:

• Due to problems associated with niti of not withstanding cold bending,not fabricating
loops,not being weldable or solderablr.

• CAN came to origin.

• 3- nitro aniline -2-chloro-4-nitro aniline alloy(CNA)

Super elastic composite wires:

• Since mid 1990, the research teams working in U.S & japan presented extensive
evidences on feasibilty of esthetic polymeric wires.

• Super elastic composites have the potential to be used in orthodintics.

 • Super elastic SMA-polymer composites have the potential to substantialy reduce those
forces.

• The design of these composites is based on a soft polymeric core and a super elastic
shape memory metal.

Opti-flex wires:

These are new orthodontic archwire that is designed to combine unique mechanical properties
with highly esthetic appearance.

Made of clear optical fibre and comprises of three layers.

1. Silicon dioxide core that provides the force for moving teeth.

2. Silico resin middle layer that protects the core from moisture and adds strength.

3. Stain resistant nylon outer later that prevents damage to the wire and further increases its
strength.

4. The wire can be either round or rectangular and is manufactured in various sizes.

5. Its mechanical properties include a wide range of action and the ability to apply light
contineous force.

6. Sharp bends must be avoided since they could fracture the core.

7. It is highly resilient arch wire, especially effective in alingment of crowded teeth.

Shape memory plastic wires:

Polynorbonen, a shape memory plastic developed in japan in 1991.

Has a glass transitional point of 35°C.

Once the environmental temperature exceeds the critical point,this plastic will begin to
display an elastic property, then return to its original shape if deformed.

This shape memory plastic wire of 1mm in diameter can be stretched to two or three
times of its original length at a temperature of 50°C and exert a relatively stable contineous light
force of 119-156gms to move the teeth.

This new material compared with conventional elastic modules used in orthodontic
therapy.

This exhibited a less degree of force degradation at a body temperature of 37°C for a long
period, and can be manufactured to near the toth color required.
 These advantages make feasible clinical application of the shape momory plastic in
orthodontics.

Appliances:

Bite-jumping screw:

Introduced by Marc Geserick in 2006.

A new method has been developed to simplify the progressive bite advancement in twin block.

A screw is incorporated longitudinally in upper bites blocks with a screw heads at 70degree
angle to lower bite block. 6mm of antero-posterior correction in either class 2 or class 3 cases
can be done.

Transforce arch developing appliance:

Given by Dr.W.Clark in 2004.

This contains niti springs which generates force.

It has a malleable arms parellel to the incisal edge for easy adjustments.

It has many advantages over the previously developed appliances used for arch expansion.

-invisible for adult arch development

-less bulky.

-can be given in lower arch

-also helps in expansion of arch in saggital direction.

Flip lock herbst appliance:

Miller R 1996 – offers several advantages over conventional herbst design.

-improved patient comfort and acceptance

-fewer clinical problems compared to screw or pin attachments.

-less chair time for reactivation.

-less frequent emergency appointments.

They are divided into

 • First generation

• Second generation

• Third generation.

First generation:

It was made from a dense polysulfone plastic but breakage occurred because of the forces
generated within the ball joint attachment.

Second generation:

In these flip lock appliance the plastic was replaced however fracture probles remains
unchanged.

Third generation:

This is made of a horse shoe ball joint.

This system has prooved to be more efficient than the previous models , both in terms of
application as well as its resistance to fracture.

MALU herbst appliance:

The mandibular advancement locking unit is a recently developed attachment device for the
herbst.

It consist of two tubes two plungers,two upper “Mobee” hinges with ball pins and two lower key
hinges with brass pins.

The major advantage are the lower cost, no laboratory needed, flexibility and the possibility of
using combined with edgewise therapy.

Each upper mobee hinge is inserted into the hole at the end of the MALU tube and
secured to the first molar hear gear tube with ball pin.

Each lower key hinge is inserted into the hole at the end of the plunger and locked into
the base arch, distal to the cuspid,with the brass pin.

Magnetic telescopic device:

This consist of two tubes and two plungers,with a semi-circular and with
(Nd,Fe,B)magnets placed in such a manner thaat arepelling force is exerted.

It is fixed using the MALU system.

 This appliance has the advantage of linking a magnetic field to the functional appliance,
itsmain advantage are its thickness,laboratory work necessary to prepare it and the covering of
the magnets.

Forsus:

Fatigue resistant device given by Willian Vogt in 2004.

This is an innovative three telescopic appliance with a coil spring in its exterior part.
This feature maxes it resemble some flexible functional appliances(AFF).

In comparison with AFF its great advantage lies in coil spring which is resistance to
breaking. The coil spring is applied by sliding it on a rigid surface avoiding angulations at the
fixed points.

Softwares:

Insignia :

It is a fully interactive software designed to incorporate treatment plan into a virtual 3d model.

It gives a

- Patient specific brackets

- Computer assisted bracket placement

- Custom wire

- All phases of treatment adjustments.

Digital imaging software:

Now we can

- Create a treatment plan with just a few mouse movements.

- Quickly teach our ideas to patients, surgeons, students.

- Concentrate on facial structures and beauty rather than on holding protracters to measure
angles and distances.

- Let the computer generate numerous analysis,super impositions,measurement

tables,growth and treatment predictions.

- Print, store or e-mail our results.

Paper less operations:

Whether we realise or not within next few years our records would all be digitalized.

Features

- Computarization of patient records.

- Internet access to every part of the world

Requirements:

- Software

- Computer

- Patient info delivery system.

Photographic ‘kesling setup’:

• Kesling described the concept of planning individual orthodontic tooth movement in

1945.

• It is a visual aid to communication b/w clinician and patient at the treatment planning
stage.

• It helps the clinician to plan the stages.

• Type of orthodontic treatment required.

• Gives the patient an idea of what is achievable and what is involved.

• It can also highlight the limitation of tooth movement alone, indicating the need for
surgical intervention.

Future advances:

A novel concept under development are Brackets using so called smart brackets. The
smart bracket concept consists of a bracket containing micro-chip capable of measuring forces
applied to the bracket or tooth interface.

The goal of this sucessfully demonstrated concept is to significantly reduce the duration
of orthodontic therapy and to set the applied forces in non-harmful,optimal ranges.

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