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well as the personal and philosophical preferences of the individual clinician. However, objective documentation on the efficacy of these
various prescriptions has been lacking in the
literature, and most of the evidence presented
appears to be anecdotal. Further, a clinician
wishing to test a specific prescription is faced
with the daunting task of having to treat a sample group of patients, over a minimum of 2 to 3
years, to develop an appreciation for the clinical
details manifested by the prescription. This approach is, in our opinion, archaic and cumbersome. Consider this: we routinely design supersonic aircraft and space-age vehicles, and
develop them with CAD-CAM systems, without
ever actually putting the first rivet in a piece of
metal. If a supersonic wing can be designed, and
expected to fly the first time with computer
aided graphics, then it should certainly be possible to design orthodontic appliances utilizing
the same principle. It was our goal, therefore, to
construct a virtual dentition (Graphic A),
progress to the development of a virtual occlusion, and then to test the efficacy of our appliance design on the virtual dentition before applying it on the patient. In addition, this gave us
the ability to compare the effects of different
torques, angulations, and prescriptions in a totally objective manner.
The objective of this process was fairly
straightforward. Instead of trying to extrapolate
the sort of subjective fuzziness that one is likely
to encounter in attempting to compare treatment results on patients, where an effort to measure an outcome is hindered by differences in
patient compliance, variations in morphology,
and a host of other uncontrollable factors, we
Graphic A.
chose to evaluate the impact of certain appliance designs by creating a standardized dentition which would not, by definition, involve having to deal with variations in morphology or
differences due to inconsistencies introduced by
differing levels of patient compliance. In effect,
we could create a standardized virtual dentition,
and then apply standardized virtual appliances
to that dentition to study the outcome of specific
bracket placement, torque, and tip application,
and do so by varying only one factor at a time.
For example, the rest of the dentition and the
appliance could be kept as a constant, and a
single tooth identified for variation of the selected torque in the bracket (Fig 1), so that we
could measure the impact of the one changed
variable on the finished position of the tooth.
Conversely, if we wish to study the impact of a
specific orthodontic prescription on the entire
dental arch, then the dentition could be kept as
a standard, and the entire appliance system
changed, so that the impact on the combined
axial inclinations in all three planes of space
could be studied by rotating the model in each
of those individual planes of space.
In assessing occlusal function and the functional aspects of the occlusion, there continues
to be a significant range of opinions within the
dental profession. On other factors, there is
some degree of unanimity and agreement. For
example, it is widely accepted that balancing
interferences are undesirable during lateral
movements, partly for periodontal reasons and
partly due to concerns about the impact on tem-
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Figure 4. Archwire adjustment to offset the distolingual rotation imposed by selecting a tube with a
distal offset.
Figure 6. Clinical illustration of the contact relationship between the mandibular first and second molars,
achieved by using a molar tube without distal offset.
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Figure 8. Graphic illustration of the difference in expressed lingual crown torque between the maxillary first
and second molars, when a tube with 10 of lingual crown torque is used on both teeth (A). Lateral view of the
same graphically depicted dental arch, with the lingual cusp of the maxillary second molar extruded in to the
occlusal plane, thereby creating an occlusal interference (B).
erupt with a buccal crown inclination and consequent lingual root torque. To study the degree
of torque required in the molar tube to achieve
an adequate buccal root torque, we studied the
problem with the 3D graphic analysis described
earlier. Figure 9 shows an occlusal view of the
maxillary arch with an appliance system that has
10 of torque on the maxillary first molar and
10 of torque on the maxillary second molar. It
is evident that the second molar is not torqued
adequately, with the consequent and undesirable extension of lingual cusps into the occlusal
plane. Figure 10 is a view of the same dental arch
with the second molar tube designed with 17 of
lingual crown torque. It is the authors conclu-
Figure 10. Occlusal view of the same dental arch demonstrated in Figure 9, with a second molar tube that
delivers 17 of lingual crown torque. Note the improvement in the alignment between the maxillary first and
second molars, as well as elimination of occlusal interferences created by the maxillary second molar.
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Figure 19. Diagrammatic representation of a lingually inclined maxillary incisor, as seen in a Class II
Division 2 malocclusion (A). The finished position of
this tooth, with a 016 x 0.022 archwire in a 0.018 x
0.025 slot (B).
tioners using the 0.022 x 0.028 slot have indicated that the finishing wires are rarely larger
than a 0.021 x 0.025. The overwhelming majority
of clinicians who use the 0.018 x 0.025 slot use a
0.016 x 0.022 finishing archwire. Figure 19 A
provides a diagrammatic representation of the
effect that this will have. The pronounced lingual inclination of the maxillary incisor crown is
intended to reflect the starting position in a
significant Class II Division 2 malocclusion. Figure 19 B demonstrates the finished position of
this tooth if a 0.016 x 0.022 archwire is used in a
0.018 x 0.025 slot. Figure 20 demonstrates the
starting and finished position of the same tooth
if a 0.018 x 0.025 archwire is used. Figure 21
shows the effect, utilizing the same bracket and
a 0.016 x 0.022 archwire, in a labially inclined
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References