Impressions PUBLISHED BY ORMCO • VOL. 9, NO. 1, 2000
Dr. Bennett on
Dr. Hutta on
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.
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
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
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
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
your patients want more than anything
else – to look and feel their best, today
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.”
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
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
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
Total treatment time: 17 months, 8 visits
(6 adjustment visits).
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.
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
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.
• 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
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.
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
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
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
case continued from preceding page
Visit Three: February 1998 – 12 Months
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
case continued on following page
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
Product Review: New Impression
Trays Effective for Diagnostics and
by Michael L. Swartz, D.D.S.
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.
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
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
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
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
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
Defined bayonet bend creates a
positive stop that keeps it from
sliding through distal end of
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: www.eslo2000.com
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: email@example.com
– 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.
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, et.al.: 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
Print Number 070-5382