FIXED/ FUNCTIONAL/ SPLINT ORTHODONTICS By Michael C. Alpern, D.D.S., M.S. Adjunct Professor of Orthodontics, Marquette University, School of Dentistry; Adjunct Professor of Orthodontics, University of Louisville, School of Dentistry.

I. INTRODUCTION

Dental Consultant Harry Schader introduces new subjects by stating, "In order for you to grasp these new concepts, please take every thing you have learned, with all your previous prejudices and pack them up in a ball and place out the door. Open your mind and consider something new! You can pick up your old knowledge when you leave."

Economic consultant Peter Lynch suggests investing funds in those companies that focus on new knowledge and new technology.

World famous hockey player Wayne Gretsky was interviewed and asked what is the secret of his success, since he is not the biggest, fastest, nor most agile skater. Gretsky smiled and responded, "I thought you all would have figured it out by now. You see, everyone else skates to where the puck is. I skate to where the puck is going to be!"

Combining these three new sources of information could lead to constant change and potential improvement in all phases of orthodontics. If you open your mind to new ideas and new information. If you invest in new knowledge and new technology, the results may permit a unique level of orthodontic treatment which may permit functional, esthetic and stable results, superior to previous techniques.

Where is it written that you must confine orthodontic treatment to placing bonds and brackets on maloccluded teeth and, using traditional stainless steel arch wires, attempt to move the teeth within their existing alveolar trough and expect to achieve functional, esthetic and stable results? You can continue to use these established techniques. You may also expect periodic relapse problems, which truly displeases patients and families. You can possibly expect to find growth, functional and TMJ problems, regardless of the skill of the diagnosis and treatment. You may also expect esthetic compromises that may not please the patient.

As we enter the next millennium, fixed orthodontics has undergone changes. Bonded brackets are more common. New metallurgy has produced new arch wires with more flexibility and better memory. Functional appliances have proven that orthopaedic and orthodontic changes can be completed with and without the use of bands, bonds and brackets in growing patients. TMJ arthroscopic surgery from an Orthopaedic Surgeon's standpoint (not traditional dental knowledge) ^1,2,3,4,5,6 has introduced new knowledge and resulting new technology, which has changed nearly every aspect of orthodontics from diagnosis to retention.

If we combine all three of these new developments into a single technique, the results appear worth consideration in orthodontic success and the continued success of the orthodontic specialty.

New knowledge can be disconcerting. It can make you uncomfortable. However, the only method of improving it is—to consider new knowledge. Judge it not by previous prejudice or dogma. Your patients' teeth affect their TMJ’s. Your patients' TMJ’s affect their teeth,—and orthodontics affects both! Considering current knowledge of the TMJ, these previous statements are a given; they are factual and indisputable.

Therefore, it would appear prudent to incorporate the most current TMJ knowledge and technology into orthodontic treatment, especially if this incorporation accelerates the rate of orthodontic correction, while simultaneously preventing and/or treating TMJ symptoms.

Similarly, functional orthodontic treatment can redirect, and potentially encourage, required growth correction. Functional treatment has traditionally utilized removable appliances. What if functional treatment could be constructed in a new fixed manner, potentially eliminating the patient cooperation requirements of removable appliances?

Combining all of these concepts into one treatment system is the essence of this paper.

II. NEW FACTUAL KNOWLEDGE

TMJ arthroscopic surgery, from an orthopaedic surgeon's standpoint, has yielded the following new considerations for orthodontic treatment.

1. Cartilage: There are two types of human cartilage: hyaline or load bearing cartilage; and fibrocartilage which is lining cartilage. The two differ in the percentage of proteoglycans, which permits loading without cartilage destruction and death. The cartilage lining the human TMJ condylar fossa, eminence, disc and capsule is fibrocartilage. As such, repetitive loading of this fibrocartilage could, potentially, overload this (limited life-span) important TMJ component, producing irreversible damage. TMJ fibrocartilage lacks blood and nerve supply. Thus, no healing, remodeling or true regeneration is possible. The absence of pain perception allows for no notification of possible damage that may be occurring. Conclusion: Orthodontics must protect and/or vertically unload this cartilage during occlusal correction.

2. The human TMJ is a joint created for unencumbered movement. When unencumbered movement occurs, there is usually almost no overt TMJ symptoms. Only when encumbrances to TMJ freedom of motion occurs do TMJ symptoms occur. This is done by the stretching of the pericapsular tissues which do have pain fibers. Conclusion: Orthodontics must strive to provide unencumbered freedom of TMJ motion during treatment, and free up any pre-existing encumbrances, should they exist.

3. According to multiple authors, Posselt ⁷, Sondhi ⁸, and Williams ⁹ the first movement of the mandible from centric occlusion or centric relation to the rest position, and then to all other positions, is a straight vertical drop. The final movement during closure is a straight vertical rise. Once the condyles clear the initial vertical drop, each condyle is capable of multiple attack paths. There are hundreds and hundreds of individually unique right to left mandibular and concurrent dental pathways, or attack paths, during normal chewing, talking and swallowing. Conclusion: Orthodontics must strive to create an occlusion which is compatible with each right and left mandibular condylar movements, including opening and closing.

4. Disclusion? Since there is clear scientific evidence of the initial vertical drop of each condyle, this mandibular movement unlocks and discludes the molars and bicuspids. Why should we follow previous knowledge instructing us to place the cuspids and incisors in such a position as to "disclude" the molars? New knowledge concludes that, rather than initial unlocking of the molars, the position of the cuspids and incisors primary role is to act as "proprioceptive sensors or markers," to inform the mandible of it’s relative position, and assist in guiding the mandible as it strives to reach it’s positions.

5. Closure: This is an orthopaedic surgical term referring to the speed and angulation in which human body parts come together. Dentally, this refers to the speed and angulation that the mandibular cuspids and incisors occlude. Nuelle ¹⁰ first introduced the idea that both mandibular condyles may not necessarily move at the same speed, depending on their condylar angle, as viewed from a sub mento-vertex radiograph. If you have one condyle positioned at a low angle and the opposite condyle positioned at a very high angle; the condyle with the higher angle will move at a higher angular and linear speed. New evidence, based on a thesis by Watson ¹¹, found in a human skull study that the teeth on the contralateral side of a condyle, with a high angle, exhibited excessive wear compared to the teeth opposite a condyle with a low angle. Conclusion: Incisal guidance and cuspid disclusion must be individualized right and left based on a submento-vertex radiograph. This follows Posselt’s original 1952 treatise which continually stressed individual variation requiring individual treatment. Treating all patients to a generic formula would appear to be inappropriate.

III. THEORY BEHIND THE APPLIANCE

1. Given the initial opening and closing movement of each condyle to be a straight vertical drop and rise; orthodontic treatment will be based on the orthopaedic surgical philosophy of "vertical unloading." From the initiation of orthopaedic functional movement or tooth movement, the occlusion (and thus the condyles) will have bonded composite or acrylic material on the molars, preventing the final vertical movement from rest to final centric.

2. This "vertical unloading" will attempt to free up the mandible, to permit unencumbered movement. If the mandible is free from encumbrances, with freedom of motion, and free from dental contacts (via the posterior vertical unloading), then the TMJ’s should not be traumatized and any inflammation should resolve, permitting all muscles to become neutral. This normalization of the entire TMJ complex permits the patient to demonstrate Individualized Patient Selected Centric. This IPSC position is patient selected. No doctor is smart enough to push, "romance," or use any other modality that yields a "doctor selected" centric. Once IPSC position is found, it is the orthodontists' job to attempt to position all the teeth in harmony with that IPSC position, plus giving proper attention to individualized right to left cuspid and incisal positions.

3. Vertical Unloading of the TMJ implies that the condyles will be held, stopped or supported at the rest position. This unloading must be accomplished using the principles of a full arch flat plane bite splint. It is critical to understand that vertical unloading implies condylar support. That is why the posterior support is the foundation of vertical unloading.

Great care and caution is urged when just using anterior bite splints. In fact, the author advises that one almost never utlize anterior bite splints alone.

Anterior bite splinting alone, without posterior support could, under the correct set of circumstances, cause posterior vertical loading of the TMJ’s and the resulting cartilage death may be irreversible. Anterior bite splinting alone, without posterior support, is similar to patients who lose molar teeth and do not have them replaced with prostheses. Without the molar posterior support, the strong masseter and medial pterygoid muscles continue to exert strong vertical forces (estimated to be 250-350 pounds per square inch), which compress the cartilage under heavy crushing forces yielding cartilage cellular matrix degeneration and death. Again, since human TMJ fibrocartilage has no blood supply or nerve supply, the cartilage is unable to inform the patient of the impending cartilage death and no blood supply to permit it to heal.

We only advise anterior bite splinting (using a removable Bite Plane Headgear Tubes Appliance) in brachycephalic, deep bite cases and we stress this anterior bite splinting must always be accompanied with posterior vertical splinting using composites bonded to the molar buccal cusps.

4. Vertical control will utilize Pearson’s ¹² techniques. Pearson found that patients, exhibiting a large vertical component to their growth, can be restrained from severe vertical growth via placing large acrylic bite splints on the posterior teeth. Previous vertical control used high pull head gear, which depended on patient cooperation and was intermittent at best. Large interocclusal splinting permits full-time orthopaedic forces, where they are most needed. These forces apply the required forces to prevent vertical growth, as described by Schudy ¹³.

5. Vertical unloading of the interocclusal forces (250-350 pounds per square inch) frees up the orthodontic appliances to function unencumbered. This speeds tooth movement, potentially reduces discomfort, root resorption and periodontal trauma.

6. The use of nickel titanium wires, with individualized forces throughout the arch wire, and reduced surface friction will be augmented by very small "micro"sized brackets with maximum inter bracket width freeing up the true elasticity of these space age wires.

7. Apical base expansion of the maxillary and mandibular arches permits changing the entire oral environment. Apical expansion moves muscles laterally, potentially increasing the functional tongue space and potentially increasing or improving the nasal airway. This complete oral environmental change may obviate previous extraction requirements and, potentially, improve esthetics.

8. Rapid Palatal Expansion secondarily causes movement at the suture uniting the palate with the lateral pterygoid plates. A potential lateral movement of the lateral pterygoid plate may occur. HYPOTHESIS: orthopaedic surgeons have found that many true internal derangements of joints can only be reduced by repositioning or altering the muscle length or muscle tension of muscles involved in the joint function¹⁴. The lateral pterygoid muscle is a key muscle in TMJ movement. We have stated since 1985 ¹⁵ that the superior head of the lateral pterygoid muscle becomes a tendon which becomes the TMJ disc which attaches circumferentially around the head of the mandibular condyle. The origin of the lateral pterygoid muscle is the lateral pterygoid plate. Potentially changing the length or tension of the lateral pterygoid muscle could permit improved TMJ function and thereby reduce or eliminate TMJ symptoms. In a fifteen year retrospective study, we have found that patients whose treatment included rapid palatal expansion tended to have little to no TMJ symptoms at the end of treatment, regardless of their initial TMJ status.

9. A re-orientation of orthodontic thought processes needs consideration with regard to mandibular protraction functional appliances. Nearly all fixed, flexible, spring loaded or removable functional appliances, are based on taking a "construction" bite from the patient, in which the patient is asked to move their mandible downward and forward. Appliances are then constructed to force the patient to function in this downward and forward position. Nuelle and the author have long been concerned about the forward movement aspect of this action. Downward movement is no problem, as that is essentially vertical unloading. The forward component of movement is the great risk. Consider that the construction bite procedure is a "blind" procedure. The orthodontist can not see where the condyles and discs are located. In patients with unknown, "silent" or previously asymptomatic true TMJ internal derangements, such as adhesions, anatomical aberrations, perforations, loose bodies, congenital plica, steep and long articular eminences---- forced forward condylar movement without marked vertical movement could result in severe TMJ cartilage damage, which is irreversible. TMJ cartilage has no nerve supply to inform the brain of trauma. TMJ cartilage has no blood supply to permit healing. The author has for years advised that for each millimeter of forward movement it must be accompanied by three millimeters of vertical movement, to attempt to provide a degree of safety.

Consider a potentially more effective functional alternative. Nearly all forward mandibular movement occurs from two sources: periosteal stretching of the entire TMJ complex, including the capsule, ligaments and disc results in growth at the head of condyle, effectively lengthening the mandible. Periosteal stretching occurs when you place acrylic bite planes in the molar and bicuspid regions, which prevent the final closure of the mandible from rest to IPSCR or centric. In growing patients, exceeding the vertical opening of rest slightly may even produce more physiologic stretching, which would potentially stimulate more periosteal stretching, stimulating more growth.

Effective mandibular growth only occurs if the vertical growth of the posterior portions of the mandible and maxilla are controlled. No matter how much condylar growth occurs, if the posterior portions of the maxillae and the related alveolar bone and teeth grow excessively downward; mandibular growth is deflected downward. Additionally, if excessive vertical growth of the posterior mandibular alveolar process occurs, then the upward growing mandibular posterior teeth prematurely strike the downward growing maxillary molars, resulting in severe or marked vertical deflection of any condylar growth. Thus vertical growth can obviate mandibular lengthening. The obvious answer is that if the orthodontist truly needs Class II retrognathic mandibular forward growth (forward, horizontal growth of the chin), then posterior maxillary and mandibular vertical control is critical to success.

Consider that if effective periosteal condylar stretching and effective posterior vertical control are truly effective,—then no anterior protractive forces may be required. This would eliminate the potential risks associated with anterior directed forces.

The following techniques are based on all of the previous new scientific facts:

III. THE APPLIANCES AND PROCEDURES.

To accomplish all of the previous objectives and utilize the new scientific knowledge now available, we begin with a total revamping of orthodontic treatment.

Since most Class II, Class III and Class I crowded problems may involve deficient maxillary and or mandibular width, a new bonded Rapid Palatal Expansion Bite Plane System was developed to work concurrently with a new micro sized banded and bonded mandibular fixed orthodontic appliance. The new bonded RPE-BP appliance has been redesigned to be easily inserted and easily removed. Vertically mounted band material, occlusal micro expansion screws, pink base plate wax, a new wire re-design all accomplish what has been previously a difficult and potentially traumatic experience; that of removing the bonded palatal expander. This process has been published previously. Crossbite hooks, Cl II hooks, Cl III protraction hooks, lip bumper tubes, orthodontic molar tubes, various thicknesses of bite planes and unilateral wedge bite planes have all significantly changed the design and function of traditional palatal expansion.

Above: Occlusal micro expansion screws and pink base plate wax		Above: Crossibite hooks

	Above: RPE-BP with lower fixed appliance.
Above: RPE-BP with lower lip bumper.

Once maxillary palatal expansion has successfully been completed (4-6 weeks, turning once per day), the expansion screw is wire ligated to prevent voice vibration from rotating the screw closed. The ligated RPE-BP appliance now becomes a "disposable anchorage" for other required orthopaedic and orthodontic procedures, while 4 months of palatal suture stabilization occurs to permit calcification of the new bone created by the sutural expansion. Here bite plane thickness can exhibit a functional role. Thick bite planes continue to exert condylar periosteal stretch stimulating condylar lengthening. Thick bite planes simultaneously markedly restrain posterior vertical growth of the maxilla and mandible. This results in pronounced forward functional growth of the mandible. Unilateral expansion is controlled by shaping one side as a wedge, simulating an extension of the lingual cusps of maxillary molars and bicuspids; to prevent expansion on one side while a minimal (flat plane) contact on the opposite side permits needed expansion. Thin bite planes minimize vertical forces, which can permit normal vertical growth, while still vertically unloading the TMJ complex, freeing up unencumbered motion.

Once palatal expansion has been completed, the crossbite hooks can be used to connect elastics from lingual cleats on the mandibular molar bands. The mandibular dental arch has had bands placed on both first molars and bonds placed on second molars, and all other mandibular teeth. A rectangular full slot size wire has been placed. We use a Bio-Force Sentalloy nickel titanium wire with Ion Guard in an Accu-arch form. The Bio-Force Sentalloy wire is unique in that it is temperature sensitive, yet has individual forces throughout the same arch wire. Incisors receive approximately 90-100 grams of force. Cuspids receive approximately 150 grams of force and molars approximately 250-350 grams of force,—all in the same wire. This temperature sensitive wire can usually be easily placed with near full bracket engagement in nearly all teeth on initial insertion. An .018 x .025 wire in an .018 x .028 rectangular slot gives full three dimensional control and permits alveolar apical base uprighting of lingually tipped buccal segments, without any back and forth (apical wiggling) or excessive buccal tipping or flaring, when simultaneously using the crossbite elastics to the expanded RPE-BP. A five year retrospective study of this technique has verified no root resorption or adverse effects ^{16 (unpublished)} in my office.

Using crossbite elastics, stretching from the lingual cleats of mandibular molar bands (connected to a near full channel engaged rectangular arch wire), are directionally secured to crossbite or Cl II hooks attached to the ligated RPE-BP. This disposable anchorage is strong, stable and easily used. The resulting effect appears to be an uprighting of the mandibular alveolar process and the mandibular teeth. A five year study, supervised by a board certified periodontist, verifies the apical base and alveolar uprighting, versus molar tipping and alveolar perforation noted for previous round wire techniques. ^{16 (unpublished)}

RPE-BP with crossbite elastics and first molar extraction space closing elasitics.

A major part of this success is the bite plane effect. Every time a patient clenches, in centric occlusion, the maxillary teeth surround and compress the mandibular arch and teeth, with what has been estimated at 250 to 350 pounds per square inch of biting pressure. This occluding pressure can prevent verticalizing of lingually tipped molars and bicuspids, which must depend on 6-8 ounces of elastic force and/or 350 grams of force from a full sized .016 x .022 stainless steel arch wire. Pitting 350 grams of force or 6-8 ounces of force against 250-350 pounds per square inch is no contest. It is like trying to move an ocean liner with an outboard engine on a small fishing boat.

The author is convinced that a significant delay in the speed of tooth movement; a significant part of perceived or reported orthodontic pain, root shortening and other risks associated with orthodontic movement,—can all be reduced if orthodontic movement is permitted via unencumbered freedom of directional movement of the teeth involved. Nearly all orthodontic mechanics can be simultaneously performed with flat plane bite planes.

Similarly, Class II skeletal and dental correction can be assisted with bite planes. Skeletal Class II correction is assisted with thick bite planes on the RPE-BP appliance, which simultaneously permit periosteal condylar stretching and strong vertical growth restraint in the molar and maxillary tuberosity area. The five months of RPE-BP orthopaedic effect is full-time, exerting significant, yet physiologic forces. The flat plane bite plane effect frees up any forward growth encumbrances, which may be present. A strong caution must be mentioned here. Multiple, inadvertent destructive forces by the patient can obviate any correction. Should the patient chronically lean on their jaw during the day and sleep on their jaw during the night—then 15-25 pounds of reverse force can override the intended corrective designs. Heavy posterior forces placed by the patient against any flat plane bite plane frees the jaw to stretch the now unprotected TMJ complex, resulting in ligament tearing and cartilage death. As part of this technique, extensive patient training and parent follow-up is required to prevent a potential TMJ crisis or a poor result.

Only when the RPE-BP is removed is the true effect of the skeletal Class II correction visualized. The dental Class II correction can be assisted with crossbite Cl II elastics, which simultaneously upright the lingually inclined molars and bicuspids. But, can also exert a forward Class II movement, which more easily moves mandibular buccal dental segments forward, under the fixated maxillary buccal segments, without the dental occluding interference previously mentioned. Many full step Class II, Division 1 or 2 severe occlusions can be reduced to Class I during the five months of RPE-BP treatment. What was previously a severe overjet and overbite patient can now be re-evaluated as a simple case after only five months of treatment.

If the patient is a Class II Division 1 open bite, the thick, active posterior bite planes have restrained vertical growth and intruded posterior teeth, while permitting (if desired) vertical growth of the maxillary incisors. An anterior open bite turns into a posterior open bite in five months because orthodontic and/or orthopaedic forces are working full-time. Many open bites are due to a deficient amount of functional tongue space. In five months, not only the maxillary apical base, but also the mandibular apical base is laterally expanded, yielding a potentially significant increase in functional tongue room. Post RPE-BP therapy must include muscular reposturing training of the tongue muscles (myofunctional therapy) to this new skeletal morphology in order to preserve this new result and to prevent anterior tongue thrusting.

If the patient is a Class II Division 2 deep bite, the RPE-BP appliance system includes right and left molar tubes. Bonding of the RPE-BP appliance is accompanied by orthodontic bracket bonding of incisors. As soon as the RPE-BP expansion has been completed, a sectional rectangular Bio Force arch wire is inserted from cuspid to cuspid or lateral incisor to lateral incisor. An .018 x .025 Bio Force wire is constructed, which exits the molar tubes. Double helical coils and intrusion bends are formed, and the arch wire then "piggy backs" under the incisal edge of the incisor orthodontic brackets, and is secured with an elastic thread or ligature. This wire is periodically activated (every 6-8 weeks). The four months of RPE-BP stabilization permits adequate time for significant incisor intrusion to occur. Here again, the stabilized RPE-BP appliance gives marked "disposable" anchorage for incisor intrusion, with no apparent detrimental dental or skeletal effects. Credit for this significant advancement must be given to Dr. Lloyd Pearson of Minneapolis for this suggestion.

While orthodontic intrusion of the incisors is proceeding, unencumbered skeletal and dental Class II correction can proceed without interfering or affecting the incisor intrusion.

Class III skeletal and dental corrective treatment is enhanced by this new system. Many Class III dental malocclusions have lingually tipped maxillary incisors. Advancing springs can be added to the RPE-BP appliance (soldered to the anterior arms), which can gently tip the maxillary incisors forward during the four month stabilization phase of the RPE-BP appliance. The posterior bite planes free the maxillary incisors to move unencumbered and forward because the mandibular incisors do not interfere with their forward movement.

Class III skeletal correction can also be achieved if an open mind is used. Multiple authors have attempted maxillary protraction via so called "facial masks" or "reverse pull headgears." The problem with these appliances lies in the TMJ risk to using the chin as anchorage, which transmits chin forces directly to the unprotected TMJ cartilage, which has no nerve supply to notify the patient of the cartilage death and destruction; and no blood supply for healing. Recent radiographic evidence of condylar fossa enlargement or remodeling is nothing more than degenerative changes of the cartilage finally reaching and perforating the periosteum, causing cortical marginal integrity to degenerate, yielding observable skeletal changes. Any medical radiologist will tell you that bony joint changes only occur after significant cartilage death has already occurred.

The author worked for nearly ten years to find a helmet which would permit significant protraction forces with no detrimental anchorage effects. The author is indebted to the Riddell Company, which makes football helmets for nearly all NFL and NCAA football teams, for assistance and construction of the Maxillary Protractor ¹⁷. This device, with a little training, supplies a reasonably comfortable, light, yet functional helmet which permits directional use of elastics to Class III hooks on the RPE-BP. The Maxillary Protractor helmet must never be used for contact sports. The external shell is too light and fragile for this kind of use. This shell is from "symbolic" helmets. However, the inside is strictly NFL, with two air bladders and a unique patient adjustable forehead "pouch" and a strong multiple arch facial grid, which permits directional application of strong removable hooks.

The unique part of the Maxillary Protractor is the time period required. Many orthodontists have found the only time you can effectively protract the maxilla is during the sutural expansion or while you are activating the expansion screw. The author advises turning the expansion screw appliance once per day, which equates into approximately four to five weeks of activation time. If you assume that the maxilla may be slightly loose for three weeks following the activation,—a time window of opportunity of eight weeks becomes critical for helmet protraction. Most patients can be convinced to wear a Maxillary Protractor fourteen hours per day, full-time on week ends or during school vacations for only two months! The major mental block appears to be in the orthodontists' fear of alienating patients with such a suggestion. Give the patient and parents the choice. At least offer them the opportunity. You may be surprised at how easily they can understand the mechanics, and the opportunity to avoid surgery this simple appliance system offers.

The elastics used with the Maxillary Protractor supply approximately one pound of force to the right and left hooks during the day. However, at night, the patients sleep on their back, using the helmet instead of a pillow. With the weight of the head pressing on the back of the helmet, additional forces of two pounds per side can be added without forehead impingement.

After 8 weeks of either fourteen hours per day or full-time, wear is then reduced to night time only for an additional 8 weeks. Periodically, when only a small amount of orthodontic Class III correction is required, some patients who encounter TMJ symptoms using Cl III elastics, may find that the Maxillary Protractor using orthodontic forces from the Retractor’s hooks to molars band hooks can quickly achieve a functional result.

	Combining upper lip bumper with the RPE-BP.
Above: Upper lip bumber tube incorporated in RPE-BP.

RPW-BP in combination with lower lip bumper.

IV. FOLLOW-UP TREATMENT.

Prior to taking the impression for the RPE-BP appliance, maxillary and mandibular separators have been previously inserted for one week for pediatric and adolescent patients and for two weeks for adult patients. Thus, when the impression for the RPE-BP appliance is made, the separators have successfully created band space and are removed just before the impression procedure. Post impression, the maxillary separators are immediately replaced. One or two days later, with the patient pre-medicated, maxillary and mandibular separators are removed and all first molars have tube bands fitted, removed and individually contoured. The mandibular orthodontic bonds are bonded to place without the first molar bands in place. The author has found that this procedure facilitates unencumbered access to bonding the mandibular second molars. It is difficult enough attempting to bond or band second molars without the presence of the first molars. So, bond the second molars and all other teeth first. Then cement the mandibular first molar bands, and later place the mandibular Bio-Force wire. Lastly, bond the RPE-BP into place. This bonds the RPE-BP into place, preserving the band space for the maxillary first molars.

On the day the RPE-BP is removed, the maxillary first molar bands can easily be cemented (here again, only after the maxillary second molar bonds and all other bonds have been bonded). Immediate cementation of the maxillary first molar bands is important, because the author believes it is not only important for treatment efficiency, but more importantly, a Cetlin Palatal Bar system can immediately be placed on removal of the palatal expander. The prompt placement of the Cetlin Palatal Bar System further preserves palatal expansion, permits maxillary molar and bicuspid torque control and arch form alignment to begin immediately.

Needless to say, the Cetlin Palatal Bar System also permits molar rotation, even molar distalization to begin immediately after palatal expansion. Clearly, the author believes that all palatal expansion by the RPE-BP System must be immediately followed by Cetlin Palatal Bar retention. This minimizes and controls relapse and accelerates treatment.

FOLLOW-UP ORTHODONTIC TREATMENT

When the RPE-BP appliance has been removed, the maxillary molar bands are cemented, the remaining maxillary teeth are completely bonded, including second molars, which also have posterior composite over the bracket and extending occlusally to occlude with the mandibular composite. Then, a unique form of orthodontic treatment begins.

The orthodontist should carefully evaluate the contacting occlusion. It is important that some form of posterior vertical unloading still be maintained. The patient is asked to close. If the resulting occlusion does not exhibit posterior vertical unloading, and only anterior contact remains, then additional composite should be added to permit posterior contact. This can easily be accomplished. The right and left mandibular first and second molars are isolated with suction and cotton rolls or triangles. Any remaining mandibular or maxillary composite that could be used is slightly roughened with a fluted bur using a high speed hand piece. The debris is rinsed, re-isolated suctioned and dried. Acid etch is applied to the mandibular buccal cusps and the buccal and lingual surfaces for 15-20 seconds, and rinsed for 20 seconds with a profuse air/water spray, then suctioned dry. A fluoride releasing sealant is applied and the composite material is applied and shaped as an extension of the mandibular buccal cusps. The composite is set using ultraviolet light. The resulting bond buildup is examined with articulating paper to assure equal right and left contact.

As time passes and the arches align, rotations are corrected, and all space requirements are completed,—the composite wears and/or is gradually reduced by the orthodontist so that the teeth are permitted to gently come together. You gently "land" the airplane. As the teeth gently occlude, the orthodontist should carefully look for prematurities or excessive tooth contact. For example, should the cuspids prematurely contact on one side,—the orthodontist should evaluate whether this prematurity is due to inappropriate bracket placement or whether too much cuspid guidance is present. The stainless steel wires can then be torqued to reposition or individualize (as Posselt advised) to permit unencumbered mandibular freedom of motion in all multiple attack paths and in all areas of closure. This unique occlusal individualization occurs during the "landing" process. This process assures the orthodontist that the resulting occlusion will be compatible with both TMJ's, in the individualized patient's selected centric relation position.

V. RETROSPECTIVE ADDITIONS.

The author has seen many orthodontic groups approach American Board or Angle Orthodontic case displays. One leader of the group will skip all radiographs and other records. This individual will pick up only the initial mandibular model. After careful study, this orthodontist will turn to the group and expound on how he would treat the case, especially regarding extraction or non extraction. Can you truly diagnose and then treat based on the existing malocclusion? Is not the existing mandibular model simply a static, one time, example of this patients teeth? If the entire oral anatomy, physiology and function could be effectively and simply changed, is it possible that a different mandibular model would result, which would drastically change the diagnosis and proposed treatment plan?

Performing a Rapid Palatal Expansion Bite Plane System procedure, with associated mandibular orthodontic therapy (such as proposed with this paper), can and will (when properly diagnosed and treated) significantly change the entire presenting records. The skeletal, dental, and functional changes that accompany a maxillary and mandibular RPE-BP System procedure will, potentially, on a significant number of patients, alter the dental changes required. Apical base expansion of the maxilla and mandible can move origin and insertion of associated musculature laterally. Increase in functional tongue room can occur, altering swallowing habits. Potential improvement in nasal airway efficiency can diminish mouth breathing, altering muscle tonus and functional effect. Apical base expansion and uprighting of lingually proclined alveolar processes can significantly increase arch length.

What may have been an obvious arch length inadequacy, requiring dental extraction, may now become a simple non extraction procedure. Selected unique cases have transformed from a crowded case to one requiring space closure procedures without extraction! Imagine what would have happened if extraction had been performed without giving the patient the opportunities to express their potentials?

Clearly, the author does not want to be misinterpreted here. There are many cases which require extractions with the RPE-BP System treatment. Indeed, many severe vertically growing patients or adults can be carefully treated combining extraction of second bicuspids or first molars with this technique. However, in a borderline case, a case that might be treated either way, why not give the patient the choice? You can always try the above system and, at the removal of the RPE-BP appliance—tube, band the maxillary first molars and fully bond the remaining teeth. Place a Bio-Force wire and then in three months—re-diagnose the case. It is critical that the patient be fully and completely informed of this, and any other approaches. Fully informed patients appreciate these attempts and their active participation assists in successful treatment.

Retrospectively, this RPE-BP System potentially permits very rapid resolution of the mandibular orthodontic problem. Many times the five months of RPE-BP treatment are all that is required to nearly complete correction of rotations, spaces or crowding and other alignment problems. The author has found, in extraction cases, that often near complete closure of the extraction space can be accomplished (including first molar extractions) during the five months of RPE-BP treatment. The mandibular arch has always been the most difficult to correct, due to the heavy layers of cortical bone not found in the maxilla. Mandibular orthodontic movement has usually been encumbered and slowed down by the 230-350 pounds of compression by the maxillary teeth. The RPE-BP system nearly eliminates this compression and frees mandibular orthodontic tooth movement to occur in an unencumbered manner. The mandibular arch form can be assisted by the strong lingual forces applied from the crossbite elastics attaching from the lingual cleats on mandibular first molar bands to the crossbite or Class II hooks on the disposable anchorage of the RPE-BP appliance.

BIBLIOGRAPHIC REFERENCES

Copyright, Michael C. Alpern, D.D.S., M.S., Port Charlotte, Florida, January, 1999