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Clinical Impressions Vol No

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Clinical Impressions Vol No Powered By Docstoc
Impressions                                  PUBLISHED BY ORMCO   •   VOL. 9, NO. 1, 2000

Dr. Tracey
on the
Page 2

Dr. Bennett on
Intervals.....Page 8
Dr. Hutta on
Herbst Crown
Removal.....Page 14
Dr. LeClerc on the ESLO.....Page 17

Dr. Bagden on Copper Ni-Ti.....Page 18

Dr. Swartz on Impression Trays.....Page 23

Dr. Scott on the Orthos Lip Bumper.....Page 24
Hyper-Aesthetic Orthodontics –
by Stephen Tracey, D.D.S., M.S.
Upland, California

                    s respected author,         of lipstick and 2,055 jars of skin care                   of us who practice in the golden state, one
                    speaker and consultant,     products – sold every minute. According                   out of every five cosmetic surgery patients
                    Dr. Stephen Covey           to numbers provided by Datamonitor                        resides in California.) And lest you think
                    has noted, “The main        Cosmetic and Toiletries Database, over                    cosmetic surgery is only for the rich and
                    thing is to keep the        1,700 new skin-care products were                         famous, the ASPRS reports that 65% of
                    main thing the main         launched in 1996, all in the pursuit of                   those who undergo aesthetic plastic
                    thing.” Well folks, the     beauty. And the U.S. is not alone. In                     surgery have family incomes under
                    main thing, as far as       Brazil, there are more Avon representa-                   $50,000 per year.
                    orthodontic patients        tives than members of the army. In Africa,
                    are concerned, is aes-      Kalahari bushmen continue to use animal                   According to Dr. Nancy Etcoff, practicing
                    thetics. Not efficiency,    fats to moisturize their skin, even in the                psychologist and Harvard professor,
                    and not function.           midst of devastating famine.                              people are spending billions of dollars on
                                                                                                          cosmetics and plastic surgery for a reason:
Don’t get me wrong, I’m not saying              People do extreme things in the name of                   looking good has survival value. From
efficiency and function aren’t important.       beauty. According to a report just released               infancy to adulthood, beautiful people
And I’m certainly not saying quality is         by the American Society of Plastic and                    are treated preferentially and viewed
not important – quite the contrary! What        Reconstructive Surgeons (ASPRS), over                     more positively – true for both men and
I am saying is that, more and more, we          one million people had cosmetic surgery                   women. Beautiful people find sexual
have become increasingly enamored with          in 1998. Of the top five cosmetic proce-                  partners more easily, are more likely to
efficiency, often at the expense of what        dures performed, eyelid surgery, facelift                 find leniency in the courts, and can elicit
patients want more than anything else –         and chemical peel (all procedures                         cooperation from strangers. Beauty
quality orthodontics that places a premium      involving facial aesthetics) trailed only li-             conveys real social and economic
on aesthetics.                                  posuction and breast augmentation in                      advantages; while equally important,
                                                number. Shockingly, teens are a fast-grow-                unattractiveness leads to major social
What makes me so sure about this? Most          ing segment, with nearly 25,000 cosmetic                  disadvantages and discrimination.
patients do not understand the orthodon-        procedures performed on children age 18
tist’s functional and stability goals but are   or under. Since 1992, cosmetic surgery                    Believe it or not, people size up others
intimately aware of aesthetics. The fact        has risen a dramatic 153%, with over a                    within the first three or four seconds of an
is, patients want to look better – that’s it.   50% increase in just the last two years                   encounter. Within 30 seconds at least 11
Once I began to understand this perspec-        (Figure 1). (Of particular interest to those              assumptions are made about the other
tive, the entire tenor of my practice began
to change, bringing along with it increased
patient satisfaction and unexpected prac-       “We expect attractive people to be better
tice growth. Curious about what was
behind all this, I did a little research.       at everything – from relationships to jobs.”
Here’s what I found.

Orthodontics: Beneficiary of a Culture
Obsessed with Aesthetics                           Dr. Stephen Tracey believes in combining innovative yet
                                                   prudent orthodontic mechanics with the seemingly limitless
Whether we like it or not, we are the
                                                   potential of the human spirit to create practice success
beneficiaries of a culture obsessed with           through technology and teamwork. He manages an active
aesthetics. If you have any doubts at all,         practice in Upland, California, and serves as assistant
simply take a look at the facts: In the            professor at Loma Linda University, where he earned his
United States, more money is spent on              D.D.S and M.S. in orthodontics and where he was named
                                                   instructor of the year in 1995. He has written articles for
beauty than on education or social ser-
                                                   numerous publications and has lectured in 13 countries.
vices. The cosmetic industry alone does            His interest in pursuing what’s possible led him to the blis-
over $35 billion worth of business annu-           tering lava fields of the Ironman Triathlon, a climb to the
ally, with tons of makeup – 1,484 tubes            summit of Mt. Rainier and a 110-mile trek in the Amazon.

                                                  Cover photo taken at Norton Simon Museum,
                                                  Pasadena, CA. Bronze sculpture by Rodin.

Giving People What They Want
 person, including social status, economic
 status, educational attainment, occupa-
 tion, marital status, educational status,                COSMETIC SURGERY PROCEDURES
 ancestry, trustworthiness, credibility,
 and likeliness to succeed.
 The process is an unconscious one, yet the
 reason we do it is simple. Ellen Berscheid,          1,000,000
 in Psychological Aspects of Facial Form,
 explains, “In a society in which one can-
 not even count on having the same set of
 parents in our childhood for any length of
 time; the same marriage partner for any                 600,000
 length of time; when one may be thrown
 into the dating and mating market at age                400,000
 30, 40, 50, 60; when it becomes increas-
 ingly unlikely that one will have the same
 workmates, colleagues, or neighbors for                 200,000
 any length of time – in sum, in a society in
 which social fragmentation has proceeded                             0
 to an unprecedented point, people are
 constantly assessed very quickly by others                                         1992                1996               1998
 simply on the basis of their appearance
 rather than their record of actual behavior    Figure 1. Since 1992 cosmetic surgery has risen a dramatic 153%, with over a 50% increase in just the
 and other characteristics.” In the course      last 2 years.
 of one day, we can encounter dozens of
 people and receive hundreds of verbal          report card of a fifth-grade student,                the ages of 14 and 70 about their mating
 and visual messages. In order to process       including grades, evaluation of attitude,            preferences. Around the world, kindness
 all this information quickly, we often form    work habits and attendance. The only                 was a highly valued quality in a mate, but
 our reactions to people based on minimal       variant was the attached photograph of               physical attractiveness and good looks
 knowledge – primarily appearance.              the child – an attractive or unattractive            were on everyone’s top-10 list of desirable
                                                boy or girl. Despite the depth of informa-           qualities. Another study demonstrated
 Appearance constitutes 55% of our first        tion about behavior and performance,                 that the best-looking girls in high school
 impressions of people. In job interviews,      looks swayed opinions. The teachers                  are more than 10 times as likely to get
 about 75% of the decision to hire is based     expected the good-looking children to be             married as the least good looking. And
 on the applicant’s appearance. And for         more intelligent and more sociable and               better-looking girls tend to “marry up;”
 those who have recently been hired, there      popular with their peers. Disturbingly,              that is, marry men with more education
 is likely to be an 8 to 20% variation in       further research indicates good-looking              and income than they have.
 entry-level salary based on personal           students tend to get better grades, but
 appearance. Even Aristotle said, “Beauty       when the subjective aspects of grading               If we do our job correctly, we have the
 is a greater recommendation than any           are removed and grades are based                     power to make a huge contribution to the
 letter of introduction.”                       solely on standardized tests, the advan-             facial aesthetics of an individual. Van
                                                tage disappears.                                     Morrison sang, “I’m in heaven when you
 We expect attractive people to be better                                                            smile,” because without a doubt, a beauti-
 at everything – from relationships to jobs.    Preferences based upon looks turn up                 ful smile is a critical component of attrac-
 And these expectations start early in          from Kansas City to Kuwait. In 1990,                 tiveness. As a matter of fact, according to
 childhood. In one study, teachers in 400       psychologist David Buss interviewed over             a survey released by the Academy of
 classrooms in Missouri were given a            10,000 people from 37 cultures between                                      continued on following page

Dr. Tracey
continued from preceding page

General Dentistry, a person’s smile – not      Myth #2: We give something up
their clothing, hair or eyes – is what         when we focus on aesthetic treatment
others notice first.                           systems. I would agree that at some
                                               earlier point in time, this statement was
So what does all this mean? What it            more true than I would have liked, but
means is that in this new millennium,          things are different today. We now have
orthodontists, along with dentists, cos-       available to us clear brackets that are
metic surgeons, cosmeticians and nutri-        clearer, stronger and more efficient than
tionists, will continue to be in tremendous    ever before. Gone are the days of tie-
demand as purveyors of beauty. If we           wing fractures and mission-impossible
play our cards right and give our patients     debonding. Today’s aesthetic brackets           Figure 2. With the introduction of Ormco’s new
what they really want – the ultimate in        are a far cry from previous versions you        aesthetic bracket, inspire!, we now have the abil-
aesthetics, both during and after treat-       may have tried just a few years ago.            ity to deliver efficient orthodontic treatment that is
                                                                                               more aesthetic than ever before.
ment – we are sure to see unprecedented
growth in our practices. But it also means     With the introduction of Ormco’s new
something else – that we’ll have to be         aesthetic bracket, inspire!, we now have
willing to look at what we do in a totally     the ability to deliver efficient orthodontic
new and different light.                       treatment that is more aesthetic than ever
                                               before (Figure 2). First of all, unlike other
Managing an Aesthetic-Driven Practice –        ceramic brackets that are made of poly-
Seven Myths You Must Give Up to                crystalline alumina, inspire! brackets are
Capitalize on the Importance of                made from single crystal aluminum oxide
Aesthetics in Today’s Culture                  and are the result of a totally new design
Myth #1: The practice of the future            and manufacturing process. Consequently,
will be driven by efficiency. Let’s face it,   they’re not just translucent but crystal
with all the focus on efficiency the past      clear, with strength and aesthetics that are
few years, it would be easy to believe         beyond compare. Bracket dimensions
that the key driver to future practice         have shrunk (now nearly identical to
growth will continue to be efficiency. It is   metal) and reliability and fracture resis-
my belief that the most successful ortho-      tance have been dramatically enhanced,
dontic practices in the next decade will       thanks to improved tie-wing geometry            Figure 3. Clear braces with colored ligature
be driven by the public’s unquenchable         and a perfected heat-treatment process          ties – what gives? Remember the first rule of
thirst for enhanced aesthetics. Time-sav-      that relieves stress by altering the molecu-    aesthetics: Aesthetics is whatever the patient
ings is, indeed, a commodity that people       lar structure of the bracket. And while         says it is.
value highly, and our patients will con-       bond strength is vastly improved due to
tinue to respond favorably to improved         a mechanical ball base, bracket removal         aesthetic appliances. Of course, in the
technologies that add convenience, but         is simple as a result of proven design          old days this made sense – the brackets
for practitioners who want to catapult         features that allow fail-safe atraumatic        cost more and treatment was truly more
the growth of their practices, the evi-        debonding every time. Bottom Line:              difficult. While aesthetic brackets still
dence that “looking good has survival          Today’s aesthetic appliances offer effi-        cost a little more, there is little difference
value” would be foolhardy to ignore. It        ciency, effectiveness and more.                 in actual chairtime involved and, more
only makes sense that people who come                                                          importantly, consumers are weary of
to us to improve their looks (and thereby      Myth #3: It makes sense to put a sur-           being nickeled and dimed when they
their self-image and a greater likelihood      charge on aesthetic treatment. Ever             make big ticket-purchasing decisions.
of acceptance in the world) would want         since introduction of the first clear braces    Don’t get me wrong, people will pay
to look good during treatment as well.         in the early eighties, it has been routine      almost any price for something they
Bottom Line: The practice of the future        and customary for orthodontists to              really want – even if they can’t afford
will be driven by aesthetics.                  charge more for treatment utilizing             it – but they don’t want to feel as if

    Clinical Efficiency…Dependable Debonding
    inspire!™ is the only crystal clear bracket available in ortho-
    dontics. It goes on clear and stays clear throughout treatment.
    Improved heat treatment ensures reliability by maintaining the
    strength of the material, making it highly resistant to fractures.

    Modifications of the tie-wing geometry of inspire! make the
    wings more available for ligation and produce more robust
    wing strength, which significantly reduces the potential for
    wing failure. Greater under-tie-wing space accepts double
    ligatures without increasing the overall dimensions of the
    bracket. Improved tumbling has resulted in better rounding
    of corners and edges, which fosters greater patient comfort
    and minimizes wire binding.
                                                                         Debonding inspire! is simple. Just squeeze the mesial and dis-
    inspire! is a pure A+ Straight-Wire, true twin appliance.
                                                                         tal sides of the bracket and it’s off. Its mechanical ball base is
    That means you can combine it with any other Straight-Wire           designed to leave a clean adhesive layer on the tooth for safety
    bracket within the arch without compromising the precision           and to avoid damage to the enamel.
    of treatment. Its mechanical ball base achieves consistent bond
    strength with a reliability equal to traditional stainless steel     Finally, you have aesthetics and function combined in one
    mesh. No special primers or adhesives are necessary. And             appliance. inspire! is available in 5x5 upper and 3x3 lower,
    inspire! incorporates Ormco’s patented Face Paint™ System,           Roth* prescription. Both .018 and .022 slot sizes are available
    designed to facilitate identification as well as provide             with or without cuspid or bicuspid hooks.
    crosshairs for ease of bracket placement.                            *Does not imply endorsement by doctor.

they’re being sold up. Witness the instant       Myth #4: All aesthetic appliances are                 appliances like Bite Fixers that, when
success of Saturn, the United States             clear. For most of us, the terms aesthetic            combined with clear brackets, make
automobile manufacturer that promises            appliances and clear brackets are synony-             Class II correction beautifully efficient.
a quality product with no-hassle, one-           mous. But are they? In today’s world, far             It’s about clear slipcover retainers and
price shopping.                                  from it. When it comes to braces, beauty              bonded lingual retainers or, if the patient
                                                 is truly in the eye of the beholder, partic-          chooses, brightly colored, custom-designed
For some time now, I have given patients         ularly when put in the context of age,                Hawley-style retainers. It’s about giving
the choice of any bracket they want. That        gender and cultural background. Adults                people what they want (Figure 3).
includes clear, silver, gold and self-ligat-     seem to favor appliances that are as                  Bottom Line: Remember the first rule
ing. And I’ve offered the choice at no           inconspicuous as possible, while kids                 of aesthetics: Aesthetics is whatever the
additional charge. Nearly 90% of my              favor braces that stand out, with rain-               patient says it is…period, end of story.
patients, regardless of age, choose clear        bow-colored ligature ties being almost
brackets. So what’s the real cost to me?         a given. While I can’t seem to give away              Myth #5: Aesthetic orthodontic treat-
Not much, especially in light of the fact        gold braces, a good friend of mine only               ment is about helping patients look
that I have adjusted all my fees ever-so-        25 miles away has a hard time keeping                 good during treatment and nothing
slightly to cover the increased product          up with demand. So what gives?                        more. All right, so patients want to
costs of treating so many patients with                                                                look attractive during treatment and
aesthetic brackets without additional            What gives is that what’s aesthetic is not            are willing to actively seek out those
surcharges. Throw in the fact that, as           up to us – it’s up to our patients, every             practitioners who are willing to give
a result of this policy, my practice has         last one of them. And it’s about a lot more           them what they want. Is there anything
grown significantly, and it’s not hard to        than just different kinds of brackets and             else? Absolutely!
see that I come out ahead…way ahead.             colored ligatures. It’s about Pendulum
Bottom Line: If you want to grow your            appliances and Herbst appliances that                 One often-overlooked benefit of aesthetic
practice, offer aesthetic treatment              allow postponement of bracket placement               orthodontic treatment is increased patient
options at no extra charge.                      for a significant amount of time. It’s about                              continued on following page

Dr. Tracey
continued from preceding page

                                                     Bottom Line: Aesthetic orthodontic treat-      practitioners detail their cases with wires
                                                     ment has a positive effect on patient com-     that do not completely fill the bracket
                                                     pliance and is good for both patient and       slots and often use vertical seating elastics,
                                                     orthodontist.                                  it’s easy to see that finishing mechanics
                                                                                                    alone can result in an unaesthetic linguo-
                                                     Myth #6: Cuspid width is the key to            version of the cuspids. It only makes
                                                     a beautiful, broad smile. I think most         sense to utilize positive lingual root
                                                     practitioners today would agree that a         torque in the upper and lower cuspid
                                                     broad smile is preferable to a narrow          brackets to counteract the negative effect
                                                     one. But, how exactly do we define the         of these force moments. Bottom Line:
                                                     difference? If you look at some of the         First bicuspid width combined with verti-
                                                     most beautiful smiles around – the             cal axial inclinations of both the upper
                                                     Cindy Crawfords, the Claudia Schiffers,        cuspids and upper first bicuspids are two
                                                     the Matt Damons, and the Val Kilmers of        of the most critical components of a
                                                     the world – you will find that the visible     broad, beautiful smile.
                                                     part of their smiles at fullest exposure
Figure 4. Almost everyone who has used a             spans a distance equal to the width –
Herbst appliance has noticed the almost instanta-
neous transformation that takes place in a child’s
                                                     between the irises of their eyes, with             “Research has
                                                     prominent exposure of the first bicuspids
self-image, which often translates to improved
cooperation as well.                                 (Figure 5). There are no black shadows           demonstrated that
                                                     present in the buccal corridor between
compliance. “How’s that?” you ask.                   the facial surfaces of the posterior teeth        people who feel
Research has demonstrated that people                and the inner cheeks and lips. As ortho-
who feel attractive tend to be more at ease
socially, more confident and less likely to
                                                     dontists, our attention is too often
                                                     unduly focused on cuspid width at the
                                                                                                       attractive tend to
fear negative opinions than people who
feel unattractive. They’re also more likely
                                                     expense of bicuspid width. If these inter-
                                                     national icons constitute the current
                                                                                                       be more at ease
to think they are in control of their lives
and not pawns of fate, and they’re more
                                                     standard of beauty, then from an
                                                     aesthetic standpoint the first bicuspid
                                                                                                        socially… than
apt to be assertive. As Dr. Ken Blanchard
noted in his best-selling book, The One-
                                                     should be considered one of the “eight
                                                     anterior teeth.” Additionally, the axial
                                                                                                       people who feel
Minute Manager, people who feel good
about themselves produce good results.
                                                     inclination of the upper first bicuspid
                                                     crown should be parallel with the cuspid
                                                     crown in front of it, with both appearing
For example, I’m sure almost anyone who              to be nearly vertical (Figure 6). With         Myth #7: Straight teeth are what
has used a Herbst appliance has noticed              regards to aesthetics, lingual crown           makes a beautiful smile. I don’t care
the almost instantaneous transformation              inclination of either of these teeth is        how perfect an occlusion you create,
that takes place in a child’s self-image as          typically undesirable.                         if the patient has misshapen and discol-
soon as the appliance is placed in a severe                                                         ored teeth, you will have fallen short
Class II case. Although permanent                    All this brings up a point that is sure to     in your efforts to create hyper-aesthetic
changes may require many months of                   be a bit controversial. In my opinion,         orthodontic results. Aesthetic enamel
appliance wear, changes in facial appear-            upper and lower cuspid brackets should         recontouring should be part of every
ance are immediate, with significant im-             have positive lingual root torque. Why?        debanding procedure. And tooth
provements in profile and lip closure                Because nearly all our mechanics, includ-      bleaching shouldn’t be relegated to
(Figure 4). Suddenly these ugly ducklings            ing space closure and elastic wear, create     an afterthought (Figure 7a-c).
begin to see themselves as beautiful swans           moments of force that result in unaesthet-
and behave as such with better coopera-              ic lingual tipping of these crowns. In fact,   You can’t look anywhere on TV these days
tion and greater attention to hygiene.               if you take into consideration that most       without noticing how brilliantly white

and perfect the teeth of celebrities, movie
stars and models have become. In addi-
tion to the more traditional method of
home bleaching that uses carbamide
peroxide gel placed into custom-fitted
delivery trays, new techniques have
recently been developed that allow you
to whiten your patients’ teeth significantly
in less than a one-hour visit. It’s my belief
that post orthodontic tooth bleaching
should be a standard recommendation
for nearly all patients at their first visit.
Bottom Line: The most beautiful smiles
are composed of teeth that are not only
straight but also artistically contoured
and dazzlingly white.
                                                Figure 5. An accepted standard of beauty across      Figure 7a. The most beautiful smiles are com-
Aesthetics – The Future of Our Profession       many cultures implies that the fullest exposure of   posed of teeth that are not only straight but also
                                                a patient’s smile should be equal to the width       artistically contoured and dazzlingly white.
As the profession of orthodontics contin-       between the irises of their eyes, thus suggesting
ues its journey into the new millennium,        that the first bicuspids be considered one of the
technology will continue to play an ever-       “eight anterior teeth.”
increasing role, with a virtually untapped
market of orthodontic patients being
discovered as a result of efforts to give
people what they really want – quality
treatment that places a premium on aes-
thetics. Lingual orthodontics will make
a resurgence, bracketless systems such as
Invisalign will continue to be researched
and developed, and delivery systems
involving the Internet will become more
commonplace. So, of course, simplify            Figure 6. The axial inclination of the upper first   Figure 7b. Before recontouring and whitening.
your treatment and be as efficient as           bicuspid crown should be parallel with the cuspid
                                                crown in front of it, with both appearing to be
possible, but never lose sight of what
                                                nearly vertical.
your patients want more than anything
else – to look and feel their best, today
and always.

                                                                                                     Figure 7c. After recontouring and whitening.

Extending Treatment Intervals:
by Randall K. Bennett, D.D.S., M.S.
Salt Lake City, Utah

         n 1927 Charles Lindbergh flew           It’s also given us time to grow the practice              common practice. My primary concern
         the Spirit of St. Louis on the first    yet have more time to spend with each                     was quality of care – losing control of
         solo nonstop transatlantic flight.      patient, especially the more complex cases.               cases, compromising treatment results
         The trip took over 33 hours.                                                                      and extending overall treatment times.
         Today, the Concorde makes the           I want to make something very clear.                      Then there were the A/R issues and the
         same trip in 3 hours, a tenth the       If patients in our office are cooperating                 possibility of alienating referring dentists.
         time. Amazingly, in the same time       and if treatment is going well, we will                   Today, however, there are only a few situa-
         it takes the Concorde to cross the      see them every 12 to 13 weeks. This                       tions in which I would ask a patient to
         Atlantic, shuttle astronauts can        does not mean that we see all of our                      visit every 4 or 6 weeks: an extremely
         orbit the globe several times.          patients every 3 months no matter how                     difficult case, a noncooperative patient
                                                 treatment is progressing. Technology                      and, if needed, for finishing the case.
         Decades ago orthodontists were          has advanced to the point where seeing
         crimping and soldering their own        the patient less often is possible if you                 In making this change, we have neither
bands, then cementing them onto every            are careful. Treatment intervals should                   lost control of cases (mechanically or
tooth. Archwires had to be adjusted at           be selected that are specific to each                     compliance-wise) nor extended overall
least every month. This protocol helped          patient’s case. Can you render high-                      treatment times. We have not experienced
create a tradition of monthly visits for         quality treatment and see patients less                   additional A/R problems nor have we
making adjustments, monitoring compli-           often than in the past? Yes. Can cooper-                  alienated patients or referring dentists.
ance and receiving the monthly payment.          ative patients be placed on autopilot                     In fact, we are finishing with high-quality
                                                 for several months at a time? Yes. Does                   results and experiencing more referrals
From Charles Lindbergh’s time until now,         this mean that every patient should be                    from patients and dentists as they learn
orthodontic technology has changed               seen less frequently? No. With today’s                    about our current protocol.
almost as dramatically as aviation technol-      advanced bracket and wire systems,
ogy, yet many of us are resistant to capital-    it is possible to maintain the highest                    The purpose of this article is to offer the
ize on a key aspect of what technology           standards of care without making                          appropriate rationale for implementing
has to offer – extending treatment inter-        most patients visit the office monthly.                   extended treatment intervals for the benefit
vals beyond the traditional monthly visit.                                                                 of your patients and your staff members
While some doctors with whom I have              Getting to 12-week intervals has been                     and to offer you ideas for making the
spoken have pushed treatment intervals           an evolution in our practice – not a revo-                transition a methodical one. Extending
to 6 or 8 weeks, they are reluctant to           lution. We didn’t go from 4- to 12-week                   treatment intervals beyond 6 to 8 weeks
capitalize on the full capabilities of the       intervals overnight nor would I advise                    requires: (1) a systematic application of
new technologies. They purchase all the          anyone to do so. We transitioned cau-                     the most advanced bracket and wire
advanced products but still use those            tiously. I had the same fears as anyone                   systems, (2) trust in that technology to
products in the same old ways.                   else in exploring such a break with                       do the job it was designed to do, (3) staff

Like all of you, I was trained to see patients
every 4 weeks in order to control treat-
ment, monitor cooperation and facilitate            Dr. Randall Bennett received his M.S. in orthodontics
the monthly orthodontic payment.                    from Loma Linda University and then practiced lingual
Several years ago we challenged ourselves           orthodontics exclusively in Beverly Hills, California. During
to explore the full capabilities of the             this time, he was heavily involved in lingual orthodontic
                                                    research, writing and teaching. In 1989 Rand moved
new appliance technologies. We pushed
                                                    with his wife and four children to Utah, renowned for
our conventional 4-week cycle out to a              its world-class family recreation. Currently Dr. Bennett
6- then 8- then 10-week cycle, and now              practices in Salt Lake City and lectures nationally and
we see most patients, after braces are              internationally on practice management and clinical
placed, at 12- to 13-week intervals.                efficiency and effectiveness.
Patients love the convenience and a more
open schedule has lowered our stress.

Letting Technology Do Its Job
 enrollment, (4) planned communications
 with patients, parents and referring den-                               “After Dr. Bennett treated my first two children, we moved quite a distance away from the office, but
 tists and, as importantly, (5) a letting go of                          I decided to make the trips with my next two children because I felt that he is always on the cutting
 the perceived link between quality of care                              edge of what is going on in orthodontics. I could also justify it because there was more time between
 and frequency of visits.                                                appointments – 8 weeks being the closest times that Janelle ever had to go just as she was beginning
                                                                         and finishing treatment, with 12 to 13 weeks being the norm. What I really enjoy is the quietness of
 Skeptics may say that it is unethical or at                             the office and the fact that he and the staff members always have the time to make me feel impor-
 least foolhardy to see patients every 12 to                             tant. They explain things so well – even keeping extra chairs in the clinic so parents feel welcome to
 13 weeks. I have found that carefully doing                             watch. When we had the rare emergency, we got right in. They always seem to have time in the sched-
 so benefits everyone involved and that                                  ule to accommodate such things.”
 patients are ardently enthusiastic about it.
                                                                         Mrs. Teresa Russell, an adult patient of Dr. Bennett’s, had full-banded treatment
 Some of the most important objectives                                   as a teenager and also has had all four of her children treated in his practice.
 of orthodontic treatment are a functional,                              Dana (on left), age 18, ended treatment two years ago and Janelle (on right),
 aesthetic, comfortable, stable occlusion.                               age 15, got her braces off
 I am in no way advocating shortcuts in                                  in December.
 order to treat cases in less time or with
 fewer appointments. We should never
 compromise the quality of the clinical
 result or its long-term stability for the
 sake of efficiency. It is no longer clini-
 cally necessary nor is it respectful of
 our patients’ time to make them come
 to the office more often than necessary.
 There is a better way.

 My Catalyst for Change: Patient Need
 A number of incidents occurred roughly
 at the same time, which dragged me
 kicking and screaming into our new treat-
 ment protocols. With the introduction
 of Orthos™* brackets, buccal tubes and                              parents’ contagious enthusiasm, I reframed               at these longer intervals and requested
 archwire forms, I had made a change in                              the dilemma as an opportunity to put the                 treatment for herself at 3-month intervals
 my appliances and at the same time was                              new technologies to the test, although I                 because of the convenience. Again, treat-
 intrigued with the idea that Copper Ni-Ti®                          still did not think I had an overwhelming                ment progressed beautifully in fewer
 archwires could be thermally reactivated                            chance of being successful. The parents                  appointments at longer intervals (Case 2,
 intraorally without continual tweaking.                             signed a release and we placed brackets.                 on page 12). Having these patients force
                                                                     The patient left for the Far East and                    me into appropriate intervals gave me the
 I had begun to use these new technologies,                          returned 12 weeks later. I was amazed                    confidence I needed to employ a similar
 still keeping to the 4-week treatment                               at the progress she had made. She was                    protocol with more and more patients.
 interval, when the catalyst for change                              further ahead in treatment than she would
 materialized. Parents of a girl who was                             have been had I made archwire adjust-                    Less Can Actually Be More
 moving to the Far East asked me to treat                            ments every month and finished her                       What this globetrotting patient and her
 her on a schedule of 3- to 4-month inter-                           treatment successfully in fewer visits and               cousin helped me realize is this: When I
 vals when she came to visit. The parents                            months than I generally would have ex-                   see a patient, I feel compelled to do some-
 were confident this schedule would be                               pected (Case 1, on page 11). Interestingly,              thing. With only 4 to 6 weeks to work,
 often enough to treat her successfully.                             this patient’s cousin, who lives close to the            many archwires (especially Copper Ni-Ti)
 I was not! However, in response to the                              office, watched her treatment progress                                            continued on following page
 * Products identified as “Orthos” are distributed in Europe as “Ortho-CIS.”

Dr. Bennett
continued from preceding page

have not had the appropriate length of           express when contemplating the exten-
time to express themselves fully. In seeing      sion of treatment intervals from 4 or 6            “In 29 years I have seen a lot of changes take
the patient prematurely, I feel the need to      weeks to 8 weeks is that they will lose            place in how orthodontics is performed. I have
tweak, step and/or replace the archwires         control of the case. If you have this fear,        seen absolutely no decrease in treatment qual-
when what I really need to do is to trust        select several cooperative patients whose          ity as we have evolved to seeing most of our
the technology to do its job. I think it is      treatment is going well and extend their           patients every 12 to 13 weeks. The patients
in our nature to feel guilty if we don’t do      next treatment interval much longer                are happier, their results are excellent and
something to the patient each time.              than your norm. At the subsequent                  they see us far less often with far more
                                                 appointments, examine the patients care-           convenience. Everybody wins. When we first
All of us have had patients who have             fully, evaluate their treatment progress           started going to the new schedule, there were
missed several appointments, returning to        and be prepared to be pleasantly sur-              a few older patients already in treatment
the office months later whereupon we find        prised. To date, I have not met a doctor           who just couldn’t believe that they’d still
that they have progressed further in treat-      who has extended treatment intervals               get done on time and so we kept them on
ment without our supervision than we             from 4 to 6 weeks or from 6 to 8 weeks             an 8- to 10-week schedule. I remember one
would have surmised. In disappearing,            who has had a negative experience.                 gentleman who even had us keep him on a
they had inadvertently allowed the tech-                                                            6- to 8-week schedule, but when he saw how
nology to do what it was designed to do.         My recommendation is to extend cooper-             well the wires worked, he asked us to put him
                                                 ative patients first, from 4 to 6 weeks,           out 12 weeks then joked saying he guessed
Benefits of Extended Treatment Intervals         then from 6 to 8 weeks. When you                   he should have believed us in the first place.
The benefits of extending treatment              become comfortable that you can main-              For the most part, though, as soon as we
adjustment intervals are numerous for            tain control within these time frames,             explained how the new wires worked, most
all involved in the process, patient and         begin transitioning other existing as              patients were eager to go to the new schedule.
parent as well as doctor and staff. These        well as new patients to the same sched-
benefits include (1) enhanced conve-             ule, keeping your few noncooperative               This schedule has really lightened our days,
nience and reduced pain for patients,            patients on a separate, more frequent              so we have more time with each patient.
(2) less cost for patients in traveling to and   track, again bringing them in to address           It’s easy to get the wires into even the most
from the office and in taking time off work,     compliance issues but not making                   malaligned teeth, and we don’t have the wire
etc., (3) increased doctor availability that     wire adjustments.                                  breakage or other emergencies that we used
allows you to spend more time with each                                                             to have. We’re less stressed because we have
patient, (4) additional openings in the          Doctor Scripting at Adjustment Visit to            time to keep up with other duties in the clinic,
schedule for new patients, (5) reduced           Extend Appointment Intervals                       and it’s even given us more time to market
pace for the staff, which enhances their         While looking at the assistant, the                the practice.”
work satisfaction and gives them greater         doctor says something such as: “Sally,
patience to deal with stressful and com-         this advanced wire needs about 12 weeks                                      Judy Huddleston
plex situations and (6) extracting the full      to do its work. That will be perfect timing                                   has 29 years of
value from Copper Ni-Ti, thus decreasing         to have Johnny and his mother come back                                         experience in
expenses and improving net income.               for Johnny’s next adjustment.”                                                  orthodontics
                                                                                                                                as a Clinical
I divide the transition to extended treatment    Staff Scripting at Adjustment Visit to                                         Assistant.
intervals into two categories: (1) going         Extend Appointment Intervals
from 4- or 6-week to 8-week intervals, (2)       “Mrs. Jones, the wire that Dr. Brown just
extending from 8-week to 10- or 12-week          placed is the latest technology. Dr. Brown
intervals. I will address each globally and      wants to let the wire do its work for the
then deal with concerns related to both.         next 12 weeks. Johnny’s treatment will
                                                 progress better if we leave this wire alone
Judicious 4- to 8-Week Transitioning:            for that time period so it can do what it
Overcoming Mechanical Control Fears              was designed to do. ”
The most common concern that doctors                                         continued on page 13

Case 1.
Pretreatment – Female, age 13, moving
to Asia, treated in Salt Lake City, Utah.
Class I with anterior open bite, moderate
crowding and tongue thrust. Appliances:
Orthos brackets with Accent buccal tubes on
bands. Initial wire: .018 Copper Ni-Ti (35˚C)
tied in with Power “O”s. Patient was instructed
to wear 1/4” light vertical elastics (Owl).

First Adjustment Visit – 3 months into treatment.

Posttreatment – 6th visit. Photo taken day braces
removed. Obviously, settling needs to occur in
molar regions. Retention is critical.

Total treatment time: 16 months, 8 visits
(6 adjustment visits). Patient seen every
12-16 weeks.

Case 2.
Pretreatment – Female, age 14. Class II, divi-
sion 2, deep anterior overbite with moderate to
severe crowding. Appliances: Orthos brackets.
Initial archwire: .016 Copper Ni-Ti (35˚C).

First Adjustment Visit – 3 months into treatment.
Second archwire placed: .016 x .022 Copper
Ni-Ti (35˚C) for 2 adjustment visits (6 months).

Final archwire (not shown): .016 x .022 TMA
for 8 months.

Posttreatment – Photos taken at end of 2 years
of retention.

Total treatment time: 17 months, 8 visits
(6 adjustment visits).

Dr. Bennett
continued from page 10

Judicious 8- to 12-Week Transitioning          brushing or better elastic wear from pa-        Overcoming A/R Problem Fears
Extending treatment intervals from 8 to        tients whom we see monthly versus those         Consumers are accustomed to making
10 weeks and from 10 to 12 weeks is a          we see quarterly. Effective patient educa-      monthly payments without making
different matter. Accurate diagnosis,          tion and committed parents are the key,         monthly visits to the car dealership, the
appropriate treatment planning, effective      no matter how often you see patients. The       American Express office, the utility com-
adjustments at each appointment and a          extra time spent before treatment clarify-      pany, etc. We make the initial financial
long-term vision for each case are always      ing expectations and getting agreement          arrangements so that there is no associa-
important. They become crucial at longer       will pay off in the long run. When we be-       tion between the number of office visits
intervals. Some doctors have stated that       gin treatment on a patient with hygiene         and the monthly payments. The Treat-
they have encountered problems in going        concerns, we establish a schedule for hy-       ment Coordinator believes in the process
12 weeks between visits but, upon exami-       giene monitoring separate from mechanics                                      continued on page 30
nation, have found that an inaccurate          monitoring. When compliance issues
diagnosis, inappropriate treatment plan,       arise, we deal with them separately from
ineffective mechanics or lack of patient       mechanics. We establish the schedule              “We don’t tie monthly payments to treatment
cooperation are to blame.                      based on the requirements of the ad-              visits during our consultations so there’s never
                                               vanced appliance systems and the typical          been a link between the two in the patient’s
When you move from 8-week intervals to         compliant patient. Since the majority of          mind. We just don’t get many questions about
10- or 12-week (or longer) intervals, it is    patients do cooperate, we don’t punish            12- to 13-week intervals. I explain that the
imperative that you have a cooperative pa-     them by making them adhere to a more              wires are heat-activated and keep on working
tient, that you know where you are going,      frequent appointment schedule.                    over a long period of time. Patients accept
that you carefully examine the patient at                                                        that. If the patient has good hygiene, there’s
every visit and that you do all that needs     I’ve had doctors tell me that patients            no need to worry them about extended
to be done at each appointment. I also         would become enraged if they were                 treatment intervals. I just point out that
want to emphasize the importance of            told to come in only for a compliance             patients with good hygiene don’t need to visit
using high-quality products. My experience     check. We do not experience this. I               as often. We’ve found that if patients aren’t
with first-generation nickel titanium wires    ensure that patients understand that              going to brush, lecturing them monthly
would not have warranted 12-week inter-        Copper Ni-Ti wires and patient cooper-            doesn’t do any more good than lecturing
vals because the wires were inconsistent       ation make the 12-week appointment                them quarterly, although we will have them
and therefore unreliable. With my current      interval a possibility. Noncompliance is          come in more often for hygiene checks if
wires and bracket system, I see consistent     a choice that results in more frequent            they don’t cooperate.”
performance and that performance has           appointments. I feel confident that we
given me confidence to change my proto-        actually impact compliance positively             Sonja Johnson has 4 years of
col. The same goes for elastomerics. I’m       by offering fewer appointments as a                               experience as a
continually asked to explain why we do         reward for good compliance.                                          Treatment
not use steel ligatures. We tie in archwires                                                                          Coordinator
using a figure-eight configuration that        Script for Giving Compliance                                            and Clinical
keeps the wire engaged in the slot. There      Ownership/Appointment Interval to Patient                                Assistant.
is a vast difference in quality between        “Mrs. Jones, the new titanium wires that we
brands of elastomeric products. We have        use require at least 12 weeks to work effec-
no problems with missing or loose ties         tively, and if we were to change them any
over longer intervals using high-quality       more often, we might actually slow down
elastomeric products.                          treatment. That’s why you’re given the oppor-
                                               tunity to have Johnny come for adjustments
Overcoming Cooperation Control Fears           only every 12 weeks. The only reason we
Many of us have convinced ourselves that       would check Johnny more frequently would
we get more cooperation from patients we       be if his hygiene were inadequate (or some
see more often, but I question the validity    other compliance issue), so the appointment
of that assumption. I do not see better        frequency is really up to him.”

Predictable Herbst Removal
by Lawrence Hutta, D.D.S.
Worthington, Ohio

                  his technique for                high-speed handpiece (usually without
                  removing Herbst*                 water) with a 557 crosscut fissure bur,
                  crowns takes advantage           make a diagonal cut across the occlusal
                  of the morphology of a           surface of the lower crown. The cut
                  natural tooth versus a           should extend from the distal lingual
                  stainless steel crown.           cusp to the mesial buccal cusp (Figure 1).
                  Although the Ormco               (You can clearly delineate tooth structure
                  custom-fit stainless steel       from cement, especially if you have used
                  crowns fit the tooth well        a non-tooth-colored cement.) Extend
                  and have good retention,         this diagonal cut down the cusp tip on
                  there is space between           the buccal surface of the crown to the                 Figure 1. Make diagonal cut across occlusal of
                  the natural tooth and the        gingiva and slightly below the tissue, if              the lower crown.
                  inside of the crown. This        necessary, observing the tooth/cement
space is normally filled with cement, and          interface (Figure 2). Place a small screw-
this technique takes full advantage of the         driver into the occlusal slot that you cut.
buffer the cement provides. It will destroy        Wedge the flat blade of the screwdriver
the crown but is an easy and predictable           head under the crown from the occlusal
way of removing the Herbst appliance.              edge (Figure 3) and twist the screwdriver
It does require a certain level of skill to        1/4 turn back and forth a few times. You

control the depth of cuts using a high-            can also place outward pressure on the
speed handpiece. There is little if any dis-       mesial extension arm. The crown will lift
comfort to the patient and it takes only           easily off the tooth (Figure 4). If there is
about 5 minutes of doctor chair time.              a lingual arch connecting the right and
                                                   left sides of the lower Herbst member,                 Figure 5. Cut from occlusal edge over palatal
Our patients are always excited on the             you can section the arch and remove                    cusp to connect with hole, extending to gingiva.
day we are to remove the Herbst appli-             crowns individually or leave intact and
ance. Most of them have counted down               remove together. Repeat the above steps                occlusal edge between the mesial and
the days for this highly anticipated               for the opposite side.                                 distal buccal cusps. Extend this groove
appointment. I want to make this appoint-                                                                 (or cut) over the palatal cusp, connecting
ment as pleasant as I can for both the             Removing the Upper Herbst Member                       it to the vent hole you cut at delivery.
patient and me, so I have developed what           Move to the upper member of the Herbst                 Extend the cut palatally to the gingival
I think is a fast, predictable and harmless        appliance. Again, using your high-speed                tissue or just below (Figure 5). Rinse
way of removing a custom-fit stainless             handpiece and a 557 crosscut bur, make                 well with your air/water syringe and
steel crown Herbst appliance. It requires          a cut through the crown, starting on the               inspect the cuts, making sure they are
little if any pressure to the first molars,
which are often somewhat sensitive.

Removing the Lower Herbst Member
The first step is to remove the rods from             Dr. Larry Hutta is a cum laude graduate of Ohio
                                                      State University College of Dentistry. He received his
the lower (mandibular) member of the
                                                      certificate in orthodontics from Eastman Dental Center
appliance by removing the Hex-Head                    at the University of Rochester School of Medicine and
screws from the mesial extensions. I                  Dentistry in 1986. Dr. Hutta has a large private practice
recommend leaving the upper member                    located in Worthington, Ohio, where he has used the
tubes attached. You will see why later.               Herbst appliance for over 9 years. He is a diplomate
                                                      of the American Board of Orthodontics. Dr. Hutta has
(If your Herbst appliance design has
                                                      previously lectured on various topics, including the
used rests and you’ve secured them with               Herbst appliance as well as practice management.
composite, remove the composite with                  He is an avid golfer and he and his wife, Kelley,
a high-speed handpiece.) Using your                   have three daughters.
* Herbst is a registered trademark of Dentaurum.

Figure 2. Extend cut down the cusp tip on buccal   Figure 3. Wedge screwdriver under crown from        Figure 4. A lingual arch can be left intact or
surface to gingiva or slightly below.              occlusal edge, making 1/4 turn twists.              sectioned to remove crowns separately.

Figure 6. Wedge screwdriver between cut edges      Figure 7. Reinsert screwdriver from occlusal edge   Figure 8. For greater control, hold Herbst axis on
that extend palatally, making 1/4 turn twists.     and twist until crown is free.                      buccal of crown with Weingart plier.

complete. Once again, use a small screw-           During this procedure small metal frag-
driver to wedge between the cut edges              ments may become airborne. I highly
that extend palatally (Figure 6). Using a          recommend that your patient and your
twisting motion back and forth with 1/4            assistant wear protective eyewear. I wear
turns, you will begin to feel the crown            a clear full-face shield to protect my eyes
loosen. From an occlusal approach,                 as well as my face. High- and low-speed
wedge the screwdriver between the cuts             evacuation suction can minimize the
and twist the screwdriver with 1/4 turns           amount of small metal airborne particles.
(Figure 7). Holding the Herbst tube arm
that is still attached to the crown, you           If you use the technique I described, I
                                                                                                       Figure 9. Use ultrasonic or conventional scaler to
can lift the crown off the tooth. If you           feel you will relieve the stress of Herbst          remove remaining cement.
need more control, you can hold onto               removals. Let’s make this appointment a
the Herbst axis on the buccal of the               positive memory for our Herbst patients
crown with a Weingart plier (Figure 8).            and for ourselves.                                  Armamentarium
Repeat this procedure on other side.                                                                   • High-speed handpiece
                                                   Herbst Delivery Tips That Aid Removal               • SSW FG-557 crosscut fissure bur
Normally, after removing all four crowns,          • Cut small vent holes in cusp tips                 (SS White order #155006)
there is still some cement covering the            of crowns.                                          • Clear face shield
tooth (Figure 9). Ultrasonic or conven-            • Use a non-tooth-colored cement.                   • Eye protection for patient, orthodontic
tional scalers can assist with cement              • Use non-tooth-colored composite for               assistant and doctor
cleanup prior to banding and bonding.              securing rests.                                     • 4142K Craftsman® flathead screwdriver

  Improving Efficiency and
Predictability with the Herbst
                                                Intensive 3-Day
                                               June 22-24, 2000
                                               Office of Dr. Larry Hutta
                                      Worthington, Ohio (just north of Columbus)

                                   Thursday, June 22, 8 a.m.- 1 p.m.
                                   Lecture (includes continental breakfast and lunch)
                                   (Afternoon golf can be coordinated through Dr. Hutta’s office)

                                   Friday, June 23, 8 a.m.- 5 p.m.
                                   Lecture and Hands-on Patient Treatment
                                   (includes continental breakfast and lunch)

                                   Saturday, June 24, 8 a.m.- 1:30 p.m.
                                   Lecture (includes continental breakfast and lunch)
                                   (Afternoon golf can be coordinated through Dr. Hutta’s office)

                                   If you have yet to discover the many clinical advantages of Herbst therapy
                                   or would like to strengthen your knowledge to an intermediate level, join
                                   these two experienced practitioners for an intensive 3-day workshop.
                                   The hands-on clinical experience will include fitting a Herbst on a patient,
                                   troubleshooting cases in progress and removing the Herbst.

                                   Topics include:
                                   • Simplified Treatment Mechanics (STM), a triphasic system of treating
                                     orthodontic malocclusions through noncompliance therapy
                                   • Clinical justification of Herbst therapy
                                   • Case selection criteria
                                   • Efficient delivery
                                   • Communicating the value of Herbst to the patient
                                   • How to fabricate in-house or use an outside lab
                                   • How to integrate with fixed appliances
                                   • Appointment sequencing
                                   • Finishing

                                   Cost: $1,200 per participant (doctor or staff). CEU credit: 17 hours.
                                   To register, contact Paula Allen-Noble (800) 990-3485.

 Dr. Larry Hutta   Dr. Joe Mayes   * Herbst is a registered trademark of Dentaurum.

  4th ESLO Congress:
The Balance of the Smile
          Palais de Congres, Brussels, Belgium – June 1-3, 2000
                An interview with Dr. Jean-Francois LeClerc, president of the European Society of Lingual Orthodontics (ESLO),
                                       which is celebrating its 4th biennial international congress in June.

                                                make presentations from 13 countries,                                 Pre-Congress Course:
                                                representing not only Europe but also                                 May 31, 2000
                                                Asia, Africa, South America and the                                   Didier Fillion, D.D.S.
                                                United States, and at the time of printing,                           “Lingual Orthodontic
                                                we already had over 400 inquiries from                                Advanced Course”
                                                35 countries about attending the congress.
                                                These responses indicate the importance
                                                of the ESLO as a forum for the global
                                                lingual community. Japan held its first
                                                international congress in Tokyo in March
                                                1999 with 260 participants. Some of the
                                                most forward-thinking changes in appli-                               Post-Congress Course:
                                                ance techniques are being generated from                              June 4, 2000
                                                Asia and Europe. The European Congress                                Guiseppe Scuzzo,
       Dr. Jean-Francois LeClerc                provides a platform for sharing such                                  M.D., D.D.S. &
                                                information across many continents.                                   Kyoto Takemoto, D.D.S.

                  linical Impressions                                                                                 “Clinical Problems
                  (CI): Dr. LeClerc, there      CI: What are your objectives for                                      and Solutions in
                  has been a resurgence         the Congress?                                                         Lingual Orthodontics”
                  in interest in lingual        JFL: Our first objective is to ensure that
                  orthodontics in the past      each participant learns something new
                  few years. What role do       and of value. The second is to demon-
                  you see the ESLO play-        strate the strength of the ESLO as a forum
                  ing in this resurgence?       for the exchange of knowledge that                Congress president, one has the duty of
                  Jean Francois LeClerc         furthers the technique. We invite every           giving direction to the meeting so that its
                  (JFL): The annual meet-       orthodontic specialist, regardless of prior       speakers are focused in their messages.
                  ings of the regional and      experience with the lingual technique, as         With the opportunity of being the first
                  national societies in         well as students, assistants and laboratory       president in the new millennium, I
                  Europe, Japan, Korea          technicians. We have not only built a             wanted to develop a theme that is both
and the United States are vitally important     strong program with high standards for            powerful and innovative. The direction is
to provide updates to its members about         those making presentations, we have               exemplified by the theme of the Congress:
issues specific to those geographical           also arranged two courses from highly                                       ®
                                                                                                  The Balance of the Smile. Balance in this
regions. The role of the ESLO is broader        respected practitioners to be linked to the       instance refers to the link between philos-
in scope. Since its creation, the ESLO has      congress. Dr. Fillion will conduct a one-         ophy and science, between aesthetics and
always been admired for its innovative          day course on May 31, and Drs. Scuzzo             function. Those of us who have opted to
meetings in Paris, Venice, Monte Carlo          and Takemoto will conduct a full-day              practice lingual orthodontics have the
and Rome. It provides an overview of            course entitled “Clinical Problems and            great privilege of being able to follow the
what is occurring around the world and          Solutions” after the congress on June 4.          evolution of each patient’s smile from the
offers a central meeting place for the                                                            beginning to the end of treatment. That
cross-pollination of philosophies and           CI: As president, what is the direction           process allows us to keep the artistic
techniques from every corner of the planet.     you set for the Congress?                         element of dentistry prominent in our
We had 65 doctors submit requests to            JFL: When one bears the honor of being                                      continued on page 29

www.copper ni-ti: The World
by M. Alan Bagden, D.M.D.
Springfield, Virginia

                 opper Ni-Ti® has received              periodontal health
                 tremendous attention                   is an issue.
                 since its introduction in              Severely
                 1997. It is a quaternary               malaligned teeth
                 (nickel, titanium, copper              can be engaged
                 and chromium) alloy with               without creating
                 distinct advantages over               damaging or
                 traditional nickel titanium            painful levels of
                 alloys. It can consistently            force or unwanted
                 generate a more constant               side effects.
                 force over longer activa-              • 35°C Thermo-
                 tion periods than nickel               active Copper
                 titanium alloys. It is more            Ni-Ti is the most
resistant to permanent deformation than                 commonly used
nickel titanium wire and exhibits better                temperature-influenced wire. It generates     ates constant unloading forces that can
springback. For small activations,                      mid-range, constant force levels when the     result in sustained tooth movement. It
Copper Ni-Ti generates near-constant                    wire reaches mouth temperature. Early         is thought of as the stiffest of the Copper
force, differentiating it from other alloys.            ligation is easier and unloading forces are   Ni-Ti wires. Engagement force is lower
And it exhibits a smaller drop in tooth-                higher and more sustained than conven-        than with other superelastic wires because
driving force than can be seen with                     tional nickel titanium wires when the wire    of the lower loading forces built into the
nickel titanium alloys.                                 reaches body temperature. To capitalize       copper alloy. The unloading forces are
                                                        on this property, it is recommended that      consistent with other superelastic nickel
What is especially beneficial about                     the patient rinse with cool liquid at least   titanium wires.
Copper Ni-Ti is the fact that due to the                once a day to bring the oral temperature
manufacturing and thermal treatment                     below the activating range, then follow       So why is it that some clinicians report
processes, clinicians can select one of                 the cool liquid with a liquid that exceeds    that they are not seeing the performance
three types based on individual properties              35°C to “reactivate” the wire. By doing so,   from the wire that other practitioners
of these patented wires. These properties               maximum effect is achieved. Because of        claim? It appears that there are two rea-
are related to the specific temperature at              the thermally influenced nature of the        sons for these discrepancies. One reason
which each wire achieves ideal activation:              wire, special ligating procedures should      is unfamiliarity with the proper technique
• 40°C Thermoactive Copper Ni-Ti is the                 be followed to ensure maximum effi-           of engaging the wire in the brackets
lightest of the three types. It provides in-            ciency. (See Ligating Copper Ni-Ti on         (see opposite page). The other and most
termittent light forces for patients                    the opposite page.)                           important reason is that most clinicians
with low pain thresholds and/or where                   • 27°C Superelastic Copper Ni-Ti gener-       do not leave the wire in the mouth long
                                                                                                      enough for it to perform its function. My
                                                                                                      advice is this: put it in and leave it alone
                                                                                                      for 10 to 12 weeks, retying it at your
   Dr. Alan Bagden, currently practicing in Springfield,                                              normal appointment interval but not
   Virginia, received his dental medicine degree from the                                             changing the wire.
   University of Pennsylvania School of Dental Medicine
   and his orthodontic training from the University of                                                An opportunity to demonstrate the validity
   Maryland. A diplomate of the American Board of                                                     of this protocol was offered recently when
   Orthodontics and a fellow of the American College of
   Dentists, Dr. Bagden is past president of the Northern
                                                                                                      a patient, who works for the Chinese
   Virginia Dental Society and past president of the                                                  government in Beijing, presented for
   Virginia Association of Orthodontists. As an advocate                                              comprehensive orthodontic, implant and
   of economical and time-efficient orthodontic treatment,                                            prosthetic needs. Her wanting to have the
   Dr. Bagden has a special interest in clinically evaluating                                         work performed in the Unites States while
   new and progressive orthodontic products.
                                                                                                      living in China dictated infrequent office

Wide Wire

                                                                                                  Case Study:
                                                                                                  Pretreatment. Female, age 30, presented with
                                                                                                  an edge-to-edge Class II malocclusion and a
                                                                                                  moderately deep vertical overbite.
                                                                                                  case continued on following page

 visits. Because appointment intervals were     closing pop in the left temporomandibu-
 to be from 4 to 11 months, Copper Ni-Ti,       lar joint.
 with its inherent properties, was the obvi-                                                         Ligating Copper Ni-Ti
 ous wire of choice. Her case demonstrates      Treatment Plan. Correct the Class II
 the utility and practicality of Copper Ni-Ti   relationship, crowding and rotations.                Copper Ni-Ti wire is ligated in
 wire and Ni-Ti springs in situations where     Establish proper occlusal vertical dimen-            a very definite fashion. Spray the
 long periods of time will elapse between       sion. Open adequate space for implant                wire with “Endo-ice” or use some
 appointments. While I am certainly not         replacement of the maxillary cuspids.                other mechanical product to cool
 advocating appointment intervals of these                                                           it, maximizing its flexibility. Begin
 durations, the case does demonstrate the       Since there was not adequate space to                tying it in by securing the most
 durability of the alloy and its ability to     place an aesthetically pleasing, ideally-            malpositioned tooth first. (In this
 exhibit constant unloading forces over         sized cuspid on either side of the maxil-            case it was the lower right lateral
 long periods of time.                          lary arch, I distalized the first molars by          incisor.) Then, secure the next
                                                placing a compressed Ni-Ti coil spring               most malaligned tooth, followed
 Visit One: Pretreatment                        between the maxillary right first and                by the next most malaligned,
 Female, age 30, presented with an edge-        second molars, while also distalizing the            and so forth. This technique is
 to-edge Class II malocclusion and a            buccal segments with heavy Class II                  effective for two reasons: (1) It
 moderately deep vertical overbite. The         elastics attached to sliding hooks placed            allows for the most complete wire
 arches were moderately to severely             mesial to the maxillary first bicuspids.             engagement in the bracket, and
 crowded. There was an anterior crossbite                                                            (2) It minimizes the potential for
 between the maxillary right lateral incisor    Full Appliances. Ormco .018 Spirit®MB                debonding the bracket during
 and the mandibular right cuspid. Both          brackets on the maxilla, Ormco .018                  tie-in. Patients are then instructed
 maxillary cuspids are congenitally absent.     Mini-Wick brackets on the mandible,                  to rinse with warm to hot liquids
 The primary cuspids were retained with         with Ormco first molar bands and                     at least three times a day to ener-
 insufficient mesiodistal width for ideal       Ormco Washbon second molar bands.                    gize the wire.
 implant placement. There was a late-                               continued on following page

Dr. Bagden
continued from preceding page

Initial Wires. Ormco .016 x .022               Visit Two: 7 Months into Treatment        during the course of each day. What was
Copper Ni-Ti (35°C) with ligature ties.        Following the 7-month interval, the       particularly impressive at this visit was
                                               superb aligning power of Copper Ni-Ti     the superb alignment of the mandibular
Auxiliary Appliances. A bite plate with        is clearly demonstrated. The patient      lateral incisor, exceptional arch form
“C” clasps in the maxilla to increase the      followed all instructions and being an    (especially in the mandible) and appropri-
occlusal vertical dimension and a bumper       avid consumer of tea, had no difficulty   ate torque in the mandibular second
sleeve over the maxillary wire in the cus-     in having warm to hot liquids come in     molar area. Note also the subtle interprox-
pid area to minimize soft tissue irritation.   contact with the wire multiple times      imal rotational correction between the

Visit Two: September 1997 – 7 Months
into Treatment.
case continued from preceding page

Visit Three: February 1998 – 12 Months
into Treatment.

mandibular first and second molars.
The upper lateral was still in rotation, and     “What was particularly impressive at the
had we been able to tie in the wire more
frequently, that rotation would have been        2nd visit was the superb alignment of the
eliminated. Additional time will remedy
that situation. The bite plate had been           mandibular lateral incisor, exceptional
effective in creating an increase in the
occlusal vertical dimension, so it was            arch form (especially in the mandible)
eliminated. The Class II relationship had
not worsened. The compressed Ni-Ti coil               and appropriate torque in the
spring was making space as evidenced
by the space between the maxillary first            mandibular second molar area.”
and second molar.
                                               was improving. The patient was then sent      removal to facilitate cleaning, it would
Visit Three: 12 Months into Treatment          for implant and prosthetic consults. The      also foster healing, minimizing any post-
There was now adequate space for appro-        maxillary right lateral incisor was reposi-   surgical complications. The stent was
priately sized cuspids so we removed the       tioned for aesthetic improvement.             placed at this appointment.
Ni-Ti coil spring between the first and
second molars. The Class II elastics had       Visit Four: 19 Months into Treatment          Visit Five: 23 Months into Treatment
distalized the buccal segments to assist in    The patient underwent implant surgery in      Final detailing of the case was begun at
creating that cuspid area space (note the      the maxillary cuspid area and the primary     this appointment. An .016 round stain-
increase in mesiodistal width in the afore-    cuspids were removed. Typically, the pon-     less steel wire with fixed hooks was
mentioned area), but we continued the          tic of choice is an acrylic tooth bonded      placed in the maxillary arch. The original
Class II elastics (with a stronger elastic     with a bracket and attached to the arch-      .016 x .022 Copper Ni-Ti was still in the
on the left side) to address the Class II      wire. Because the patient was to recover      lower arch. The implants were healing
relationship. An anterior diagonal elastic     unsupervised, the best course of action       well and the pontic/stent was performing
from the maxillary right cuspid to the         was to construct an acrylic stent with the    well. Plans were made with the implantol-
mandibular left cuspid was also directed       pontics placed on it. This would not only     ogist and prosthodontist to coordinate
to correct the midline while the Class II      create improved aesthetics and allow                               continued on following page

                                                                                             Visit Five: January 1999 – 23 Months
                                                                                             into Treatment.
                                                                                             case continued on following page

Dr. Bagden
continued from preceding page

uncovering the implants, removing the      Conclusion                                     its job. All Copper Ni-Ti wires should
orthodontic appliances and placing         Although it can be argued that the need to     be left in for a minimum of 12 weeks.
the temporary crowns.                      treat patients with such long appointment
                                           intervals is rare, this case does serve to     The importance of precise band and
Visits Six, Seven and Eight:               demonstrate several important features         bracket positioning cannot be overem-
28 Months into Treatment                   of the Copper Ni-Ti alloy. First is its        phasized. If the appliance is not well
After removing the bands and brackets,     durability. The lower archwire was never       constructed, the wires cannot deliver
we placed an invisible retainer (with      changed during the entire course of treat-     an ideal result. Inappropriate bracket
pontics in the cuspid area) prior to       ment and delivered constant forces. It         position will result in inaccurate tooth
implant uncovering and temporary           also demonstrates that Copper Ni-Ti is         position. My advice to Copper Ni-Ti
crown placement.                           extremely effective in correcting rotations,   users is to construct the appliance well,
                                           crowding and other alignment issues.           tie in the Copper Ni-Ti as previously
Final Visit: 30 Months into Treatment      When left to do its job, Copper Ni-Ti          outlined and then sit back and watch
After implant uncovering and temporary     works. Again, I believe practitioners who      it work. The results should be more
crown placement, the sutures can be seen   have been frustrated with its performance      than satisfactory.
above the temporary crowns, but they       have been too hasty to change the wire
do not detract from the pleasing result.   before it has had the opportunity to do

Visits Six, Seven and Eight: June 1999 –
28 Months into Treatment.
case continued from preceding page

Final Visit: 30 Months from Beginning
of Treatment.

Product Review: New Impression
Trays Effective for Diagnostics and
Appliance Fabrication
by Michael L. Swartz, D.D.S.
Orange, California

In his capacity as director of clinical affairs for Ormco, Dr. Swartz uses Ormco products in
treating patients. He will, from time to time, offer clinical tips for using these products effectively.

          have always been a big fan of                  the trays with contact adhesive makes
          disposable Styrofoam impression                these same trays perfect for appliance            Figure 1. Although disposable, Bright Trays are
          trays. They are deep, offer good               impressions. You will want to use contact         comfortable, sturdy (to prevent distortion) and
                                                                                                           hold alginate well. They make excellent trays for
          tissue reflection and are comfort-             adhesive spray containing hydrocarbon
                                                                                                           both diagnostics and appliance fabrication.
          able for patients.                             solvents that will dry quickly and adhere
                                                         well to the tray.
         Ormco’s new line of Bright Trays
         are now my impression tray                      Wrap a paper towel around the tray
         preference, providing excellent                 handle and spray the inner tray with a
         tissue reflection for high-quality              thin layer of adhesive (Figure 2). Allow
         diagnostic models and patient                   the adhesive to set for about 1 minute
         comfort (Figure 1). The rim lock                or until it becomes tacky. You can spray
         and perforations hold alginate                  multiple trays in advance and store them
well, and each size is a different color,                in plastic bags or wrap them in house-
making them easy to identify as well as                  hold plastic wrap. Once the adhesive
aesthetically pleasing.                                  has dried (becomes tacky), take the
                                                                                                           Figure 2. To improve alginate retention for appli-
                                                         impression as usual. The retention is
                                                                                                           ance impressions, spray trays with a contact
Improving alginate retention by spraying                 awesome (Figure 3).                               adhesive and let set for 1 minute, then take the
                                                                                                           impressions as usual.

   Dr. Michael Swartz has spent more than 30 years in the
   dental field in a variety of capacities. He began his pro-
   fession as a dental technician and then became a dental
   materials research chemist, later earning his D.D.S. from
   the University of Southern California School of Dentistry.
   While serving as the director of research and develop-
   ment for Ormco, he also developed a practice and began
   lecturing. He returned to school and earned his certificate
   in orthodontics from the University of California at San
   Francisco in 1985 and then opened a private practice in
   Encino, California, while continuing to lecture both in and
   outside the U.S. He currently holds the position of director
   of clinical affairs for Ormco, conducting numerous contin-
   uing education programs. He has given over 300 presen-
   tations around the world and publishes extensively.
                                                                                                           Figure 3. Impression material retention in Bright
                                                                                                           Trays gives excellent results.

The Orthos Lip Bumper:                                                               ™*

by Michael W. Scott, D.D.S., M.S.D.
Longview, Texas

                   rthodontists have                                I solved the last two problems myself by                 and dental anatomy rather than from
                   used lip bumpers for                             soldering hooks on each lip bumper when                  a theoretical concept of an ideal arch
                   years as a usual part                            I received them. The other problems                      shape.) Figure 1 shows the correct fit of
                   of their Phase One                               were just going to be there so I resigned                the Orthos Lip Bumper to the Orthos arch
                   treatment regimen                                myself to dealing with them as we treated                form as compared with the constricted
                   and clinical research                            each patient. While hooks finally became                 arch form of another manufacturer’s lip
                   has repeatedly proven                            commercially available, the other prob-                  bumper (Figure 2).
                   their effectiveness.                             lems persisted.
                   What we have needed
                   is a patient-friendly                            As my experience using lip bumpers grew,
                                                                                                                              “One of the desired
                   lip bumper that is
                   easy to seat, easy to
                                                                    I found that I was going through the same
                                                                    motions, making the same bends every
                                                                                                                                   effects of lip
                   adjust and improves
                   our clinical efficiency.
                                                                    time I seated one. Also, when I observed
                                                                    bumpers at the end of their use, I found                     bumper therapy
Now we have it: the Orthos Lip Bumper.                              they all had a similar look in terms of arch
                                                                    form. It was logical to think that the                    in Phase I treatment
I use hundreds of lip bumpers every year.
When I first got into lip bumper therapy,
                                                                    repetitive bends I was making manually
                                                                    to seat a lip bumper could easily be man-                  is the development
I made the things myself from straight                              ufactured into the product, thereby
lengths of .045 stainless steel wire. When                          making it more clinically efficient; thus,                  of an appropriate
commercial lip bumpers became avail-                                the Orthos Lip Bumper was developed.
able, the same problems I had with my                                                                                               mandibular
homemade versions still existed plus other                          Appropriate Mandibular Arch Form
problems that were manufactured into the                            One of the desired effects of lip bumper                        arch form.  ”
product. Those problems included:                                   therapy in Phase I treatment is the devel-
• Constricted arch form.                                            opment of an appropriate mandibular                      Minimal Tissue Impingement
• Tissue impingement that causes ulcers.                            arch form. The Orthos Lip Bumper is                      Efficiency and profitability demand that
• Inadequate range of sizes.                                        manufactured to fit the Orthos mandibu-                  there be as few emergency visits as possi-
• No way to measure accurately for                                  lar large arch form. The mandibular large                ble throughout treatment. Emergency
correctly sizing individual patients.                               arch form was chosen because the lip                     visits associated with lip bumpers are
• Extensive wire bending needed to seat.                            bumper sits outside the mandibular arch.                 usually due to irritations of the soft tissue.
• Incorrect placement of adjustment                                 (As most everyone using the Orthos arch                  The Orthos Lip Bumper has greatly
loops for patient comfort.                                          forms knows, the Orthos archwire shape                   reduced these problems. Figure 3 shows
• Lack of tie-in hooks.                                             is uniquely derived from actual skeletal                 the smooth, clean edges of the plastic part
   - Without tie in, the lip bumper would
often become passive in the buccal tubes
and slide out, thus creating emergency
visits to reseat it.                                                    Dr. Michael Scott earned his D.D.S. from the University
   - Because the patient could remove the                               of Tennessee School of Dentistry in 1982 and his M.S.D.
lip bumper, patient compliance suffered.                                in orthodontics from Baylor College of Dentistry in 1984.
• Seating challenges.                                                   He has lectured extensively in the United States, Asia,
   - The only way to get a lip bumper to                                Latin America and Europe on the Orthos Appliance
                                                                        System, Copper Ni-Ti,® early treatment, facemask
stay seated for any length of time was to                               therapy and is a proponent of extended treatment
create friction between it and the buccal                               intervals. He maintains a private orthodontic practice
tube either by expanding the lip bumper                                 in Longview, Texas.
(a bad idea) or by toeing in the distal end
of the lip bumper and adversely rotating
the first molar.
* Products identified as “Orthos” are distributed in Europe as “Ortho-CIS.”

Patient-Friendly & Efficient

                  MANDIBULAR                                         MANDIBULAR
                    LARGE                                              LARGE

 Figure 1. Fit of Orthos Lip Bumper to Orthos      Figure 2. Constricted fit of other manufacturer’s     Figure 3. Improved engineering of Orthos Lip
 mandibular large arch form creates adequate       lip bumper on the Orthos arch form.                   Bumper shows smooth, clean plastic edges,
 space for unraveling crowded arches.                                                                    larger ball hook and rounded solder joint.

 Figure 4. Plastic tag, small ball hook and cor-   Figure 5. For tissue impingement, apply light-        Figure 6. Lingual inclination of Orthos Lip Bumper
 nered solder joint of other manufacturer’s lip    cure composite to wire.                               ball hooks minimizes soft tissue problems.
 bumper are all potential tissue irritants.

 of this appliance, the smooth round solder        of composite around the wire. Smooth
 joint where the hook is attached and the          the composite with your wet finger
 large ball on the hook – all of which serve       making sure to keep the hook accessible
 to lessen soft tissue problems. Figure 4          for connecting the power chain. Light
 shows the other manufacturer’s lip                cure for 20 seconds (Figure 5).
 bumper with a small ball hook and the
 solder joint with a corner – both of which        Reduced Appliance Rework
 often cause irritation. This appliance often      One of the repetitive motions that I found
 has a plastic tag that can create ulcerations     myself going through as I seated lip
 as well.                                          bumpers was bending the hooks lingually
                                                   in order to prevent them from sticking                Figure 7. Occlusal view of the other manufactur-
 Pearl. Even with the improved design of           into the buccal soft tissue. Hooks of the             er’s lip bumper shows no lingual inclination, thus
 the Orthos Lip Bumper, there will still be        Orthos Lip Bumper come with a lingual                 requiring chairside adjustment of the ball hooks.
 times when a patient’s soft tissue will wrap      inclination (Figure 6). Figure 7 shows an
 itself around the lip bumper wire and             occlusal view of the same manufacturer’s
 become inflamed and tender. When this             lip bumper shown previously. You cannot
 occurs, I simply cover the wire with a            see the hook because it is directly under
 light-cured composite. To apply the com-          the wire. Notice again the plastic tag that
 posite, moisten your gloved fingers with a        is a potential tissue irritant. Figure 8
 small amount of sealant and shape a mass                                  continued on following page

Dr. Scott
continued from preceding page

                                                                                                          task with previous lip bumpers was
                                                                                                          accentuating the bayonet bend. The
                                                                                                          bayonet bend creates a positive stop to
                                                                                                          prevent the bumper from sliding through
                                                                                                          the buccal tube and impinging on the soft
                                                                                                          tissue distal to the first molar. If the
                                                                                                          bayonet bend does not create a solid stop
                                                                                                          when adjusting the lip bumper, one might
                                                                                                          think the bumper is correctly positioned
                                                                                                          2 to 3 mm in front of the mandibular in-
Figure 8. Comparison of Orthos Lip Bumper            Figure 9. Comparison of Orthos Lip Bumper (top)      cisors, only to discover that it has actually
(right) and other manufacturer’s appliance (left).   and other manufacturer’s appliance (bottom).         slid back through the buccal tube, requir-
Note larger ball hook of Orthos appliance.           Note distinct bayonet bend of Orthos appliance.      ing removal and adjustment. Figure 9
                                                                                                          shows a comparison between the bayonet
                                                                                                          bend of the Orthos Lip Bumper (top) and
                                                                                                          that of a competitor’s (bottom). Figure 10
                                                                                                          shows how the accentuated bayonet bend
                                                                                                          in the Orthos Lip Bumper prevents the
                                                                                                          wire from sliding through the buccal
                                                                                                          tube. Figure 11 shows how an indistinct
                                                                                                          bayonet bend allows the wire to protrude
                                                                                                          through the buccal tube and cause the
                                                                                                          problems previously mentioned.

                                                                                                          Accurate Measurement for Proper Sizing
Figure 10. The accentuated bayonet bend of the       Figure 11. The indistinct bend of the other manu-    With previous lip bumpers, there was no
Orthos Lip Bumper prevents the wire from sliding     facturer’s lip bumper can easily cause the wire to
                                                                                                          accurate way to determine the correct
through the buccal tube.                             protrude past the buccal tube.
                                                                                                          size. Many times our “clinical experience”
                                                                                                          proved wrong. More often than we liked
                                                     shows a side-by-side comparison of the               to admit, we’d work to make a particular
                                                     two lip bumpers.                                     size fit only to discover that we needed a
                                                                                                          different size. We’d then have to sterilize
                                                     You might ask why the hook is in front of            the original, mangled appliance to return
                                                     the adjustment loop. The answer is sim-              it to stock, but with no clue about what
                                                     ple. All adjustments are made from the               size it now was. The Orthos Lip Bumper
                                                     loop distally. The hook is never in the way          completely solves this problem by provid-
                                                     of adjusting the lip bumper. Placing the             ing a ruler and conversion table to deter-
                                                     hook anterior to the loop also allows the            mine the correct size. The measurements
                                                     loop to be positioned to the buccal of the           are printed on both sides of the ruler to
                                                     second bicuspid or second primary molar.             accommodate right and left sides, and the
Figure 12. Place the tooth of the ruler at the
midline. Measure both sides, average and use         This keeps the loop away from the                    conversion table is accurate.
conversion table to find appropriate size.           frenum that attaches to the buccal of the
                                                     first bicuspid. If the hook were distal to           Sizing the Orthos Lip Bumper
Conversion Table                                     the loop, the loop would have to be more             • Place the tooth on the ruler at the
  39 mm or less is a size 1 lip bumper
                                                     mesially positioned and would impinge                midline (Figure 12).
  39 – 43 mm is a size 2 lip bumper
  43 – 46 mm is a size 3 lip bumper                  on that frenum.                                      • Measure to the mesial of the buccal
  46 – 48 mm is a size 4 lip bumper                                                                       tube of the right quadrant.
  48 mm or more is a size 5 lip bumper               Another repetitive and time-consuming                • Flip the ruler and measure to the mesial

Figure 13. Tying in the Orthos Lip Bumper.

Figure 13a. After cementing the bands, connect       Figure 13b. Connect the dual power chains to     Figure 13c. Occlusal view of the lip bumper tied in.
two 3-unit power chains to the lip bumper tube.      the hook.

Figure 14. Follow-Up Lip Bumper Adjustments.

Figure 14a. Hold the anterior leg of the loop as     Figure 14b. Bend the part of the wire with the   Figure 14c. Hold the posterior leg of the adjust-
shown and bend the part of the lip bumper wire       bayonet bend downward (gingivally) 15° as        ment loop as shown and bend the bayonet bend
anterior to the loop upward (occlusally) about 15°
                                                 .   shown.                                           upward (occlusally) about 15°.

of the buccal tube of the left quadrant.             Tying in the Orthos Lip Bumper                   and, by then, the lip bumper will
• Average the two measurements to                    • After cementing the bands, connect two         be touching the lower anterior teeth,
account for midline discrepancy.                     3-unit power chains to the lip bumper            requiring adjustment. Adjustment is
• Use the Conversion Table to find                   tube (Figure 13a). Pearl. Two power chains       easy and chair time is minimal.
the appropriate size (Figure 12). The                substantially reduce emergency visits. Do not
table is printed on each Orthos Lip                  tie with steel ligatures. Doing so is far too    To advance the lip bumper 2 to 3 mm
Bumper Introductory Pack.                            difficult and unnecessary.                       in front of the anterior teeth, hold the
                                                     • Connect the dual power chains to the           anterior leg of the adjustment loop as
You will find that the Orthos Lip Bumper             hook (Figure 13b).                               shown. Bend the part of the lip bumper
virtually seats “right out of the package”                                                            wire anterior to the loop upward
and there is very little chair time needed;          Figure 13c shows an occlusal view of the         (occlusally) about 15° (Figure 14a).
however, your clinical judgment must still           Orthos Lip Bumper tied in. Notice that
enter into the final decision. For example,          the hooks are bent to the lingual of the lip     Bend the part of the wire with the bayo-
an average measurement of 44 mm would                bumper and that the distal ends of the           net bend downward (gingivally)15° as
indicate a size 3 lip bumper, but in a               bumper wire do not protrude past the             shown (Figure 14b). The net effect of
severely crowded case, you might choose              distal end of the molar tubes.                   these two bends is to open the loop.
a size 4 and initially close the adjustment
loop in order to have more room to adjust            Follow-Up Lip Bumper Adjustments                 Hold the posterior leg of the adjustment
the lip bumper as space is created.                  I typically see patients at 9-week intervals                             continued on following page

Dr. Scott
continued from preceding page

loop as shown and bend the bayonet                   I delegate seating and adjusting lip                Case 1 demonstrates the typical use of
bend upward (occlusally) about 15°                   bumpers to my staff. When I check a                 the Orthos Lip Bumper in the late mixed
(Figure 14c). This bend serves to level              lip bumper seating, it is already in place          dentition.
the lip bumper in the mouth so that                  with the power chains ready to be con-
the anterior part is not too low in the              nected to the hooks. I remove one side              Conclusion
vestibule. This bend does NOT negate                 from the buccal tube to see that it is              The goal of this article was to introduce
the second bend. Because the plier is                not constricted or expanded, check to               the reader to the Orthos Lip Bumper
moved to the posterior part of the                   make sure it is advanced the correct                and to show why I consider this product
adjustment loop, the loop stays open                 amount in front of the anterior teeth,              to be superior to any other lip bumper
and the lip bumper stays advanced.                   then use a hemostat to secure the                   now available. I believe the Orthos Lip
This final bend simply gets the lip                  power chains to the hooks. My total                 Bumper will significantly improve
bumper back to the correct horizontal                time involved in the procedure is                   clinical efficiency in Phase I cases.
plane in the mouth.                                  mere seconds.

Case Study: Lip Bumper Therapy in Late Mixed Dentition of Male Patient, Age 11-6

Pretreatment.                                        Pretreatment. Mandibular cuspids in crossbite.      Treatment in Progress: 11 weeks into treatment.

Treatment in Progress: 18 weeks into treatment. Note how the adjustment loops have opened throughout treatment as compared with Figure 13b.

End of Lip Bumper Treatment. Total lip bumper
treatment time: 27 weeks (right).

Lingual arch seated to maintain space (far right).

                                              The Orthos™ * Lip Bumper
                                Wire distal to the          If you have experienced clinical limitations caused by design inadequacies
                                bayonet bend is             or limited size availability when using competitive lip bumpers, you will
                                equal to length of          be pleased with the new Orthos Lip Bumper design. It’s patient friendly,
                                buccal tube to
                                further preclude
                                                            easy to seat and adjust, reducing chairtime and increasing clinical efficiency.
                                impingement                 It is available in 5 patient-specific sizes that cover the entire range of
                                                            patient needs.

                                                            Defined bayonet bend creates a
                                                            positive stop that keeps it from
                                                            sliding through distal end of
                                                            buccal tube

       pink color for

                                                                                                                    Hook bent 25˚ lingually to
                                                                                                                    the axis of the lip bumper
                                                                                                                    to minimize tissue irritation
             Easy-to-use measuring template
                   for accurate sizing                                                    *Products identified as “Orthos” are distributed in Europe as “Ortho-CIS.”

Dr. LeClerc                                          lingual braces are invisible, I feel that we
                                                     can be ever cognizant of building the
                                                                                                             CI: And lastly, what made Brussels your
                                                                                                             choice for the 4th biennial session?
continued from page 17                               smile; for example, of controlling the gum              JFL: We chose Brussels because of its easy
                                                     line, and urging the incisal edges to follow            accessibility from all corners of the globe.
thinking. I like to think that we belong             it, fostering the cuspid-to-cuspid curve.               Within Europe, high-speed trains travel
to a brotherhood of artists. The Balance of          As important to this philosophy is treat-               regularly to this destination. It is a cos-
the Smile represents that essential artistry         ment customization according to each                    mopolitan, multilingual city, renowned for
– the synthesis of science and philosophy.           patient’s personality, sex and tooth shape.             its culture. The social program will take
It projects the idea of facial harmony and                                                                   full advantage of Brussels’ historic, artistic
beauty that transcends mere alignment.               CI: Give us a Congress overview.                        and gastronomical delights. Post-confer-
                                                     JFL: The Congress lasts for three full days.            ence tours have also been arranged to
CI: It seems that you would like to call             Sixty-five speakers will address an expect-             Bruges, Antwerp, Amsterdam, Paris and
attention to overall facial aesthetics in            ed audience of 600 participants on one                  London. It will be a memorable trip for
lingual orthodontic treatment.                       of five general subjects: (1) the smile, its            everyone who attends.
JFL: Yes, for too long the specialty in              analysis and the contribution of video-
general – both labial and lingual – had              imaging systems to analysis and the                     For more information about ESLO2000,
focused narrowly on occlusion. Like many             consultation process, (2) lingual ortho-                consult its Web site:
of the progressive labial practitioners, we          dontics and its aesthetic results, (3) auxil-           or contact the European Congress
who practice lingual have also broadened             iary appliances, (4) implantology, and                  Consultants and Organizers at phone:
our diagnosis and treatment planning to              (5) orthognathic surgery versus osteodis-               32 2 647 8780 or fax: 32 2 640 6697
include the entire face and how the smile            traction. Participants will return home                 or e-mail:
– the composition of the teeth, gums and             with numerous helpful techniques that
lips – relates to its general aspect. Because        they can immediately put to good use.

Dr. Bennett
continued from page 13

and speaks with conviction. We have                 have found the opposite to be true. We            support of your staff. I suggest a well-
neither altered our credit management               conducted an informal survey in our office,       planned staff meeting – perhaps even an
policies nor have our collections                   asking patients two questions. Would              off-site meeting – to present the concept,
suffered because of extended intervals.             you consider your treatment more or               field questions and concerns and develop
                                                    less valuable if you came for 18 visits in        an action plan together. Once educated
Script to Create the Correct                        18 months or for 6 visits in 18 months?           about the new technology, staff members
Payment/Appointment Association                     When the answers came back overwhelm-             are usually eager to extend adjustment
“Mrs. Jones, with this advanced technology          ingly that treatment in fewer visits is more      intervals and become ambassadors of the
you will only need to visit the office quarterly.   valuable than treatment that requires             program, especially when they understand
Our patients love this arrangement because it       more visits, I asked the patients how             the goals and benefits and their role in the
is so much more convenient for them. We will,       much more they would be willing to pay.           process. Staff members are patient advo-
of course, establish a monthly payment sched-       To my surprise, the response was an as-           cates. If you have a conviction about the
ule, ensuring payments fit into your budget.”       tounding 33% increase over my usual fee.          benefits of the process and you and your
                                                                                                      staff implement the initial patient transi-
Patient Perceptions: Overcoming the Fear            In spite of all of our enticements – video        tion together, they will recognize the ben-
that Quantity = Quality                             games, contests, TVs in the ceiling –             efits to the patients as well as to the office.
As orthodontists we have mistakenly                 patients and their parents have less time
connected the idea of frequency of visits           than ever to spend in our offices. Actually,      Conclusion
(quantity) with quality – that patients will        they would love it if we placed braces one        High-quality treatment results are para-
feel that treatment in fewer visits is less         appointment and took them off one visit           mount. No less important is the quality
valuable and may expect a lower fee. I              later, even if that visit were 18 months later.   of your patients’ experience. Treating
                                                                                                      patients well means being respectul of
                                                    Doctor Scripting for the Initial                  their time. I am not recommending that
   “I live a great distance from the office and I   Exam/Consultation                                 you sacrifice treatment effectiveness and
   could work within minutes of my home, but I      “Mrs. Jones, it used to be necessary to see       quality for the sake of treatment efficiency.
   choose to work here because patients love our    patients every 4 weeks in order to do the         What I am suggesting is this: Allow the
   office. Our schedule and convenience for the     proper adjustments. In our office we use          new technologies to fulfill their potential.
   patients is a huge selling point. Most of our    advanced wires that work best if adjusted less    I believe it is a mistake to think that
   prospective patients expect to be seen every     often. This results in less painful and more      somehow we are better orthodontists,
   month and aren’t expecting us to tell them       convenient treatment – with adjustments           that we do better work, or that we
   about 12- to 13-week intervals. When I tell      every 12 to 13 weeks. Of course, if you have      enhance patient cooperation by seeing
   prospective patients that treatment will be      something you want us to look at sooner, we       patients 20 to 30 times during treatment.
   just as effective but that they will have to     are always happy to see you when you want.”       I feel more in control of treatment than
                          visit us less often,                                                        ever before because I have more time
                              they’re ecstatic.”    Overcoming Referring Doctor Resistance            with each patient. I have time to carefully
                                                    Uninformed general dentists may initially         evaluate what has happened since their
                             Ceteka Troxel          feel that extended treatment intervals are        last appointment and anticipate future
                              has 5 years of        somehow less effective. Ultimately, den-          changes more accurately. I have time to
                               experience as        tists want what is best for their patients,       devote additional energy to the complex
                               a Treatment          and once informed about the advances              cases, adolescents who have special needs,
                               Coordinator          in technology, support the added conve-           my staff and my family.
                               and Clinical         nience. Remember, dentists have em-
                              Assistant.            braced dozens of new dental technologies          Some patients need to be seen every 4 to 6
                                                    in the past decade.                               weeks, some patients should probably be
                                                                                                      seen every few days, and many coopera-
                                                    Overcoming Negative Staff Reaction Fears          tive patients can be seen every few
                                                    As with any change in the office, it is           months. The treatment interval should be
                                                    imperative to have the commitment and             specific for each patient and each treat-

   Orthos and Copper Ni-Ti: Efficiency and Predictability
  With Orthos, orthodontists around the globe are realizing               “Before implementing Orthos in my
  the clinical benefits of the first concurrently designed systems        practice, I routinely spent 6 appoint-
  of brackets, buccal tubes and archwire forms. The ideal                 ments or more finishing my cases.
  bracket and buccal tube geometries, archwire shapes and                 With Orthos I have reduced my
  bracket placements – based on analysis of 100 actual cases –            finishing appointments to 2 to 3
  consistently optimize occlusion and compensate for the                  visits, which I attribute to main
  mechanical efficiencies inherent in previous appliances.                factors: improved in/out geometries,
                                                                          resulting in much earlier alignment of the
  The initial objective for developing Copper Ni-Ti was to im-            marginal ridges, and coordinated arch
  prove the performance of nickel titanium archwires. We want-            forms that provide improved
  ed to enhance the tooth-moving force characteristic of high-            interdigitation of the
  quality nickel titanium wires while reducing the loading force          occlusion.”
  required for ligation. The addition of a small percentage of
  copper allows us to set controlled heat transformation tempera-         Joseph Gray,
  tures (+/- 2°C.) that ensure consistent performance, unlike             D.D.S., M.S.
  other temperature transformation wires with widely fluctuating,         Upland, California
  unpredictable activations and correspondingly unpredictable
  results. Proper choice of materials plus tight tolerance stan-
  dards and rigidly controlled manufacturing processes result in
  inherent benefits that perfectly complement the Orthos system.

ment phase. It is no more necessary to see      more-frequent hygiene check appoint-               often during certain phases of their treat-
every patient every 6 weeks than it is to       ments where hygiene is checked and                 ment, especially when finishing. The inter-
have every patient wear Class II elastics.      discussed but no adjustment is made.               val is always dictated by the diagnosis,
Today it is possible to treat many of our                                                          treatment plan, patient cooperation and
cases in far fewer visits without any com-      Q: If a patient wearing elastics is left           treatment progress at each appointment.
promise in treatment quality. Patients will     unmonitored for 12 weeks, isn't there a
appreciate you for making the change.           possibility of overcorrection of the bite?         Q: How do you handle elastics that
                                                A: That’d be a refreshing problem to have.         discolor or do you use steel ligatures?
Frequently Asked Questions                      In reality, most of our patients are just          A: We don’t routinely tie in with wires.
Q: What happens when a patient who              diligent enough in their elastic wear that         Power “O”s™ do just fine. We appoint-
breaks something in week 3, doesn’t             they get the job done without overcorrect-         ment everyone at the appropriate interval
call and is not seen until week 12?             ing. In finishing, we may also be bringing         then recommend that they call if they
A: We spend considerable time educating         certain patients in a little more often – let’s    need to be seen sooner, specifically for
the patient about potential problems,           say at 8-week intervals – so we’d be moni-         elastic changes.
especially in the case of breakage, demon-      toring some cases a little more closely
strating that for the benefit of the fewer      anyway. We spend a great deal of time              Q. When using power chain to close
appointments, they must be diligent about       educating patients so that they are aware          space, do you still run appointments
breakage, less we lengthen the overall          of the changes they should see in the bite.        at 12-week intervals? It is commonly
treatment time. Where we were previously                                                           thought that elastomeric forces quit
spending 10 minutes with each patient,          Q: If a patient wearing elastics does              working after a very short period.
we now spend 15 to 20 minutes. We use           not wear them or runs out and fails                A: You’re right. According to one study,   1

much of that additional time to continue        to call, won’t treatment be extended?              elastomeric chain loses at least 50% of
to educate them. If they don’t cooperate        A: Here again the key is patient education.        its elongation force within hours. The
we see them more often.                         In the case of an uncooperative patient,           remaining force dissipates slowly over
                                                you may want to see them more often.               several weeks. Consolidating small spaces
Q: Do hygiene patients run greater risk         You can book an appointment for an                 with this force is sufficient. In closing
of decalcification if not monitored more        elastic wear check with no adjustment.             extraction sites, I use Ni-Ti coil springs
frequently than 10 to 12 weeks?                                                                    or TMA® closing loops.
A: Patients who don’t brush well always         Q: Do you always see every person at
run the risk of decalcification. We put         10- to 12-week intervals or does it de-            References
                                                                                                   Lu, Tz Chang, Force decay of elastomeric chain:
noncompliant hygiene patients on a              pend on the individual circumstances?              A serial study: Part II. Am. J. Orthod. Dentof. Orthop.,
12-week cycle for adjustments and require       A: Some patients need to be seen more              104:373-377, 1993.

                                                 Lecture/Course Schedule at a Glance
 Date         Lecturer               Location                 Sponsor, Contact and Subject
 3/2          R to R                 Orange, CA               Ormco; Kathi Carpenter (800) 854-1741, Ext. 7272; Residency to Retirement
 3/3-4        Terry Dischinger       Salt Lake City, UT       Utah Ortho. Society; Dr. Paulis (801) 963-3111; Edgewise Herbst Appliance
 3/5-6        Hans Seeholtzer        St. Petersburg, Russia   Ormco Europe; Raissa Veronina 007-812-311-01-77; Modern Management
 3/10-11      Didier Fillion         Campinas, Brazil         Laura Buso Rys 55 19 237 31 31; Lingual Ortho Typodont Course*
 3/12-17      FACES                  Beaver Creek, CO         Ormco & FACES; Dr. Thomas (919) 493-8944; Ski Seminar: Ortho & Cosmetic Surg., Prost. Tx, Mktg.
 3/16-18      Hans Seeholtzer        Erding, Germany          Ormco Europe; Dr. Seeholtzer 49-8122-1683; Modern Management
 3/17         Wick Alexander         Tokyo, Japan             Ormco Japan; Roy Kishi 81-3-3945-0065; Refresher Course - The Alexander Discipline
 3/17         R to R                 Buffalo, NY              (S.U.N.Y.) Ormco; Kathi Carpenter (800) 854-1741, Ext. 7272; Residency to Retirement
 3/20-22      Wick Alexander         Brisbane, Australia      17th Aust. Orth. Cong.; Jayne Hindle 61-7-3846-5858; 4 M’s of Ortho & Final Step in Interdisciplinary Tx
 3/24         R to R                 Nashville, TN            (Vanderbilt U.) Ormco; Kathi Carpenter (800) 854-1741, Ext. 7272; Residency to Retirement
 3/29-30      M. Scott/M. Swartz     Tel Aviv, Israel         Ormco Europe; Dr. Chakir 972-3-9222663; Orthos™ and Archwires
 3/30-4/1     Didier Fillion         Vienna, Austria          Universitat Wein; 43 1 40181 2300; Advanced Lingual Ortho Course
 3/31-4/1     Dirk Wiechmann         Osnabruck, Germany       Ormco Europe; Top Service 49-5472-5062; Lingual Therapy
 4/1          Jim Hilgers            Boston, MA               Tufts U., School of Dental Medicine; Laura Martin (617) 636-6629; Hyperefficient Treatment Mechanics
 4/1-2        M. Scott/M. Swartz     Gdansk, Germany          Ormco Europe; Polorto 48-34-3247-812; Orthos™ and Archwires
 4/6-7        Wick Alexander         Panama                   Latin American U. of Science & Techn.; Dr. Luis Batres (507) 264-3920; Adult & Early Treatment
 4/7          Astrid Heider          Erlangen, Germany        Ormco Europe; Dr. Heider 49-941-944-6095; Alexander Typodont Course*
 4/7-8        M. Scott/M. Swartz     Zagreb, Croatia          Ormco Europe; Dr. Facan 385-1-48-18-010; Orthos™ and Archwires
 4/10         R to R                 Kansas City, MO          (U. of MO) Ormco; Kathi Carpenter (800) 854-1741, Ext. 7272; Residency to Retirement
 4/29         J. Hilgers/S. Tracey   Chicago, IL              AAO Annual Session; Lecture – Y2K – Survival Kit for the New Millennium
 4/29         Wick Alexander         Chicago, IL              AAO Annual Session; Lecture – The Little Things in Orthodontics – Do They Make a Difference?
 4/30         Duane Grummons         Chicago, IL              AAO Annual Session; Lecture – TMD 2000: Do’s and Don’ts During Orthodontics
 4/30 & 5/1   David Sarver           Chicago, IL              AAO Annual Session; Lecture – The Future of Imaging in Orthodontics
 5/1          Frank Cordray          Chicago, IL              AAO Annual Session; Lecture – The Importance of Condylar Position in Diagnosis & Treatment Planning
 5/1          Nigel Harradine        Chicago, IL              AAO Annual Session; Lecture – Self-Ligating Brackets: Efficiency in Practice
 5/1          Richard Boyd           Chicago, IL              AAO Annual Session; Lecture – Enhanced Patient Care: High Tech, High Touch
 5/1          John Smith             Chicago, IL              AAO Annual Session; Lecture – Vision, Computer Technologies & Protocols: Keys to Practice Success
 5/1          Birte Melsen           Chicago, IL              AAO Annual Session; Lecture – Orthodontic Influence on the Periodontal Prognosis
 5/1          Didier Fillion         Chicago, IL              AAO Annual Session; Lecture – The Power of Lingual Orthodontics
 5/2          J. Courtney Gorman     Chicago, IL              AAO Annual Session; Lecture – Lingual Orthodontics – Same Old Game with a Few New Twists
 5/2          Birte Melsen           Chicago, IL              AAO Annual Session; Lecture – Computerized Diagnosis and Treatment Planning
 5/2          Kyoto Takemoto         Chicago, IL              AAO Annual Session; Lecture – Lingual Orthodontics – Present and Future
 5/2          Julia Harfin           Chicago, IL              AAO Annual Session; Lecture – Treatment Considerations in Adult Orthodontic Patients
 5/4-5        Damon/Dischinger       Chicago, IL              Ormco; Meredith Brick (800) 854-1741, Ext. 7573; Ultra-Efficient, Super-Treatment
 5/4-5        Mario Paz              Orange, CA               Ormco; Shelly Boulet (310) 278-1681; Hands-On Lingual Ortho with Typodonts & Patients*
 5/4-5        Wick Alexander         Arlington, TX            Dr. Alexander; Brenda Horton (817) 275-3233; Complications of Eruption
 5/11         R to R                 Ann Arbor, MI            (U. of MI) Ormco; Kathi Carpenter (800) 854-1741, Ext. 7272; Residency to Retirement
 5/12-13      Birte Melsen           Köln, Germany            Ormco Europe; IFG Lübeck 49-451-610-80-20; From Burstone to Melsen
 5/18-20      Hans Seeholtzer        Berlin, Germany          Ormco Europe; Dr. Seeholtzer 49-8122-1683; Modern Management
 5/19-20      Randy Moles            Frankfurt, Germany       Dr. Gross 49 2 0224 5220; TMD Treatment
 5/19-20      Terry Dischinger       Lake Oswego, OR          Dr. Dischinger; Paula Allen-Noble (800) 990-3485; In-Office Comprehensive Hands-On Herbst Training*
 5/25-26      Kyoto Takemoto         Tokyo, Japan             Dr. Takemoto; Roy Kishi 81-3-3945-0065; In-house Lingual Ortho Typodont Course*
 5/28-29      Kyoto Takemoto         Tokyo, Japan             Dr. Takemoto; Roy Kishi 81-3-3945-0065; In-house Lingual Ortho Typodont Course*
 5/31         Didier Fillion         Brussels, Belgium        ESLO; ECCO Fax 32 2 640 66 97; Advanced Lingual Ortho Course

                                                                *Typodonts and/or Participation
  For additional information on any course, please call the contact number shown or (international doctors) Ormco distributor.

  1717 West Collins Avenue
     Orange, CA 92867
      (800) 854-1741
      (714) 516-7400

Print Number 070-5382

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