Fred Marconi
Close to 30 years ago Larry Andrews supposedly revolutionized orthodontics with his straight wire appliance. I visited Dr. Andrews' office and spent some time looking at his pretorqued, preangulated brackets. What I found most interesting was that Dr. Andrews' final wire was a 0.18x0.25 inch in a 0.22x0.27 inch slot. As you all know, this allows for a great deal of "play" in the bracket slot. I wondered what the purpose of a preangulated, pretorqued appliance was when the wire did not have the ability to fully express its third order control due to the size differential between wire and slot. Furthermore, this appliance was touted as potentially eliminating the need for wire bending. However, 30 years after Andrews presented his appliance, in my view it has been the orthodontic supply companies which have benefited most by the appearance of this appliance on the market. The new appliances cost more but have not improved mechanics. We still have to bend wires and cases still take the same amount of time to treat. Much has been written about this in the literature.
However, we must recognize that advances in material sciences (i.e. space age alloys), have improved our treatment and have economized chairtime. In addition, the re-emergence of self-ligating appliances, which existed prior to pretorqued preangulated brackets also offer certain advantages. I will state that not barring the use of and appreciating the advantages of the modern edgewise appliance, the finishing of every case in my practice is accomplished with stainless steel custom bent wires that I fabricate for each individual arch form.
Do any of you remember the Edgelock bracket from Ormco? This was Dr. Gorman's labial bracket 30 years ago.
For those that have used indirect bonding techniques with the lingual appliance, I am sure the story is the same. That no matter how much we program the placement of these brackets, in an ideal situation we are clinically presented with issues that require our wire bending expertise to resolve the problem at hand to correct the malocclusion.
The other day, I received yet another mailing from Lingualcare. In this latest flyer they claim to provide clinician an indirect bonding system along with a "sequence of robotically bent arch wires, that "in most cases", do not require adjustment during treatment. The laboratories and manufacturers are playing to the fantasy that averages apply to all patients and that individualizing treatment is not necessary. Rather, that all we have to do is show up in our offices and let a machine treat our patients.
I have a problem with this concept. For one thing, the treatment of malocclusions involves the synthesis of numerous factors, making such simplistic claims unrealistic. Maybe a Class I mild crowded case with a good skeletal pattern might demand little from the treating professional. For these cases there are other systems on the market that can achieve the same results at a lower cost to the practice.
The other problem that I have with this concept involves the removal of the "art" aspect of orthodontic treatment. If we give over our "creative" abilites to the companies that market their products along the lines mentioned above, this is exactly what will happen. With all due respect to the work of Dr. Wiechmann and others, theirs is a business that will cripple professionals and yield them dependent on a system they do not control.
I went to school and paid a great deal of money for my education to have a company control my profession. Pharmacists once were their own boss. Today they work for Walgreen's, Wallmart, Target and so on. In the USA, orthodontic care is moving in this direction as well, and we have no one but ourselves to blame. As for me, I have a few years of clinical practice remaining, so what may happen in the future will not affect me to any great extent. This is your future, make the right decision.
Rafi Romano
Dear Fred
One of the nicest and most honest words I have read lately!
It reflects much of my own point of view, although I am sure that without the contributions granted us by technology we would not have made the advances we have in our field. These advances brought about by the work done by our colleagues (which obviously- they need to market to cover their expenses) contribute to our knowledge. Nevertheless, it will always be the DOCTOR who really controls the treatment and not the appliance.
Pablo Echarri
I agree with Fred about maintaining the control of our work and controlling the relationship between our fees (in order to go on being competitive in our community) and our expenses to different companies. There are much more.
Anyway, I agree Rafi because we need technology but we need to maintain our independence. If not we will finish like 2001: A Space Odyssey. Warm regards,
Courtney Gorman
Fred
Nothing is ever as easy as it sounds. I have no doubts that we will be bending wires for years to come. As you said orthodontics is part art and the Mona Lisa was not painted by a robot.
Kim Mizrahi
Dear Dr Fred Marconi,
I endorse your views wholeheartedly. I expressed similar sentiments in the introduction to my book, "Orthodontic Pearls"
Craig Andreiko
My name is Craig Andreiko. I am an orthodontist, and I have been involved with lingual since day one. I respectfully take the opposite viewpoint on this topic. Just like fuel injection replaced the carburettor, and the typewriter by the word processor, computer designed appliances and occlusions will one day be the standard of care. Although current systems (mine included) are not perfect they are getting better every day. I feel that this will allow the clinician to treat to new levels of excellence and efficiency. I would like to remind you that lingual once had the same stigma. To quote an old saying: "lead, follow, or get out of the way"
Silvia Geron
Dear friends
My opinion is that we have to welcome any technological and computerized improvements which may simplify our treatment and improve the level of treatment and results. If the new computerized systems will prove themselves in the clinical setting, they will have a significant contribution to make for the benefit of our patients as well as ourselves. If not, they will not survive. If the cost will not justify the improvement and we will have to bend wires anyway, or delay the treatment each time a wire breaks, then it will not be convenient and the new system will not survive.
If we compare the new systems to the Straight wire revolution, of course we have to bend wires even if we use so-called straight wire appliances. However, it is not in question that this is needed far less than with the standard appliances. This is what has caused the preadjusted appliances to be the most popular fixed appliance system in use today.
It does not mean that we will stop being orthodontists, and be dependent on big companies. Orthodontics is not only about bracket positioning. We still have to use our professional knowledge and personal esthetic eye to achieve good results. We still have to know mechanics. We have to refer to the new bracket positioning systems as a tool used to facilitate this technical aspect of treatment. If bracket positioning will be easier we can concentrate on other problems of treatment and achieve better results. On the other hand if we think that the appliance will do everything for us and we do not have to think or do anything besides bonding the brackets, then we will not achieve excellence as desired but the level of results will be reduced, and orthodontists will be totally dependent on computer companies.
Fred Marconi
Dear Sylvia
Thank you all for your well taken observations, I for one would not be using lingual braces if I had not embraced a new technology.
There is no doubt that technological improvements are important. For example, in the field of aviation in which I am also very involved, computers have definitely changed the way we fly making it safer. Interpreting we are spending more time in the cockpit looking at the instruments than observing the scenery. In the end result it's the pilot, the control stick and his judgment that makes the difference.
No doubt bonding has been a tremendous step forward as well as, nickel titanium wires, micro implants and so many other innovations. However, I have yet to understand the impact of pretorqued, preangulated brackets. I still add torque to the wire from 3-3 upper and progressive posteriorly. What is in the formulas sometimes is not enough. Look at Dr. Takemoto's wires.
By the way, the straight wire concept is not new. The idea and application precedes Larry Andrews, except that the second time around it took hold. Good marketing and timing. I ask you: What has straight wire really contributed to improve our mechanics or make life easier for us in the clinic? If the contribution has been minor at best, are we to consider that these new computerized systems of placing brackets will. Will this be cost effective? If we embrace the concept of computerized bracket placement and wire bending then we should embrace Invisalign as well. Craig, the straight wire concept now has close to 30 years in the field, and C.L.A.S.S. close to 18, we have already put a man in the moon. Are we spinning our wheels?
Lets talk about Invisalign. This system was developed by a group of entrepreneurs. They invested a great deal of money and wanted a return on their investment. The rest is history. From this perspective, we as specialist have lost control. This company presents treated cases in our association meeting as if the cases were board certified cases. What I have seen does not meet the requirements, but maybe they have not shown their best cases.
In today's world, where whoever has the power to mass market, wins, regardless of what is been sold, we have lots to loose if we are not careful. The public is too busy to inform itself of what is good so they take the route of that which they hear most about. Take for instance the USA and it's problem with obesity. Obesity in this country has its roots in the heavy marketing that is done by the food industry. Watch two hours of television and notice the amount of "food" that it has fed to the public or perhaps more importantly, the kinds of food. They just eat and eat and can't figure out why they have these cravings. Look at the types of crimes committed, I feel due to the irresponsibility of the film industry. A psychologist once told me that when a child has seen three or four of the types of murders shown on television it's the same as seen an actual murder. In the USA love and peace is not what is taught to the masses. In this country Pope John Paul II message has not arrived. The public is not even aware of how they are programmed. These are just a few of the examples of the power of mass marketing and big business has that power. In Barcelona our president Dr. Paz made the statement in his presentation that Invisalign was becoming an economically powerful company. You figure out the rest.
Let me share something that was taught to me many years ago by my teachers: It's not the bracket or the system of application that makes the difference. When it comes to the practice of orthodontics, it's sticking to one system and not changing that makes the difference in a busy practice. The reason is that each system brings with it unique considerations. We must first understand the system. It takes years of seeing the results to understand what is happening. This is the reason why orthodontic programs went from two to three year programs. Students needed to see their end result and analyze them so as to fully appreciate the result of each case in order to self criticize themselves.
When I started back in practice in 1995, after a short sabbatical, because of a disagreement with Ormco I changed to the American lingual brackets. After years of experience with Ormco I changed, new technology. It has taken me five to six years to finish some of these cases. Many I had to change back to Ormco. Finally, I decided to return to Ormco and my cases started to progress as expected and finish on time. I have paid a dear price in my 30 years of practice for always trying to stay abreast of new technological advances. I pass on my experiences to you for what they are worth.
Silvia Geron
Dear Fred
Thank you for your reply. I agree with you in many ways, I think that we have to be careful not to loose control on our profession by becoming dependent on big companies. This is exactly why I developed the Lingual Bracket Jig, which I am still using very gladly for all my cases since I developed it in 1998. I use it for different types of brackets, like American Orthodontics and STb and others. I think that no matter which technique you use for bracket positioning, you will need wire bending for the finishing. Even if you use a computerized wire bending system, you will need wire bending. In my opinion it is much more difficult to bend the computerized wire which is already bent in three dimensions.
On the other hand I am looking forward to new technologies that may simplify my treatments. Of course I try to evaluate each one as to cost effectiveness. For example, I think that I learned a lot from the Invisalign technique, and I am utilizing some interesting ideas from this technique in my practice. Still, I do not like this technique as it is presented now, and I think that this is a matter of freakish circumstance that they succeeded to promote this technique for full treatment. We can see that based on the idea of Invisalign there are much better and cheeper techniques in the market, (like the Clear Aligner developed by TaeWeon Kim from Korea, or some laboratories, like AOA or Ortholine in Israel). These techniques are suggested for minor treatments, for small corrections of relapse cases, and this is much more suitable for the limited possibilities of the aligners technique.
Computerized bracket positioning and wire bending is only another way of bracket positioning. It can be a good solution if it is cost effective, since bracket positioning is just one aspect of the orthodontic treatment; it is not the only thing that is responsible for successful treatment. Exactly as Straight Wire brackets have improving our technique but have not make a revolutionary change.
I think that this discussion is very important to our profession, and I would like to publish it in the new issue of www.lingualnews.com
Fred Marconi
Sylivia:
When I began using lingual braces, back is 1982, direct bonding and then Targ was the only thing we had available. Then the C.L.A.S.S. method of indirect bracket placement came into use and I thought I was in heaven. After several years of using C.L.A.S.S. I found that it was not such a great thing. In a lingual meeting in Paris I spoke with Jack Gorman, my mentor, and asked him how he was bonding his cases. His response was that he had gone back to using in many cases the Targ approach to indirect bonding. To me there was not much difference between the placement of brackets with the old Targ machine and direct bonding. So I decided to start direct bonding my cases. After a while it became second hand and the rest is history. Your system of bonding was not in existence then so I just got used to the direct method. I do have to say that I find your system and Dr. Hiro's system of indirect bonding excellent tools to use.
In my presentation in Barcelona, I showed a 20 year perspective of cases showing tooth alignment using the direct bonding technique. I had hoped that the audience could see that direct bonding was a viable, easy way of treating patients lingually. My interest is to have clinicians understand that it's not that complicated that all that is needed is some time and practice. The sophisticated systems that are presently being promoted are not providing us with that much of the benefits they claim, and additionally we have the control issue.
Dear Colleagues:
I wrote the message previous to this one as I was hurrying to fly in my plane to the State Capital to spend a day with a group of dentists and the legislators of the state of Florida. I am involved in organized dentistry and take an active role in ensuring that the legislators do not pass laws that may have long term negative effects on our profession. For your information, this year I am the president of the North Dade and Miami Beach Dental Society and I have for the last ten years served on the executive board of our constituents societies in one capacity or another.
It is said that when legislators are in session no one's belongings or personal life is safe. Our Florida Governor, Jeff Bush the brother of our president, just passed a law that some consider will make Florida the wild west in reference as to the use of guns and right to kill.
In Florida we have this year several issues to deal with. Hygienists have convinced several legislators that they can offer a better service to the population of Florida if allowed to work independently, groups that wish to lower our testing and licensing standards, groups that are using dentists that sell their licenses so investors can open dental centers and hire dentist at 10% of the gross revenues produced. These are just a few of the issues. Perhaps this might explain some of my concerns.
It is not that unlike many, I do not embrace new technology. I built my own plane and put my life on the line because I felt that conventional plane production was not offering the latest to pilots. In other words, I have been a test pilot. Interestingly, in the last five years there have been phenomenal changes in aviation, plane design, and instrumentation. Dr. Creekmore, a good friend of mine, sadly died in one of those experimental airplanes. His mistake, I feel, was that where I built my plane, he let someone else build his and did not closely supervise its construction. I had a conversation with him about this at the AAO meeting in Pennsylvania the year before the accident and told him I felt it was not prudent to not be on top of the construction. On approach, the vertical stabilizer tore off and the rest is a sad experience. Dr. Creekmore was a much better pilot than I with many many more hours of flying experience.
The same can happen to us if we give over our responsibility of treatment progress and, or outcome on other's. This is our business and profession and we must be careful. Technology can take a nasty turn and bite us in the butt if we are not vigilant. We are our own worst enemy and some of our colleagues are more interested in their financial well being than the well being of the profession as a whole.
One of my friends, and president of our constituent specialty society, I have come to learn, has supported and is now working with one of these mass clinics. Dr. Moshuri, once chairman of a department of orthodontics, once testified in a court of law accusing orthodontist as a group of collusion because the stand that the AAO had taken concerning the relationship between TMJ and Orthodontics was a smoke screen design to protect us. I have Dr. Moshuri's statements on tape. Today he appears on the covers of several AAO brochures.
Hope you have a better understanding of why I have the opinions that I do.
Sincerely,
Dr. Fred Marconi
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