pdf | 2mb | clinical impression vol 5 (1996) no 4...american association of orthodontists, the...

PUBLISHED BY ORMCO CORPORATION • VOL. 5, NO. 4, 1996

®CLINICALImpressions

Dr. Roblee on IDTPage 2

Dr. Hilgers on BiosPage 8

Dr. White on Bond/Band Failure5

Dr. Boyd on Missing LateralsPage 18

Dr. Eckhart on Patient NewslettersPage 20

Dr. Roblee

Interdisciplinary DentofacialA Treatment Philosophy for N

by Richard D. Roblee, D.D.S., M.S.Fayetteville, Arkansas

magine for a moment that you are search-ing for a new treatment philosophy. Whatbenefits would you consider important inthe selection process? Most professionalswould rank consistent optimal treatmentresults as the primary benefit.The majorityof us would also want other clinical benefits such as elevating overall clinicaleffectiveness by simplifying complex treatment, minimizing unnecessary procedures, shortening treatment timeand maximizing the long-term prognosisof therapy to reduce maintenance problems. As a spin-off of these clinicalbenefits, most would want a treatmentphilosophy that secondarily producespractice management and marketing benefits. These benefits may include:more efficient time utilization and inter-professional communication; reputationenhancement in both the lay and profes-sional communities; higher levels of patient and referral satisfaction; enhancedinterdisciplinary comprehension and utilization of comprehensive care with resultant stronger team support and professional relationships; greater personal satisfaction for doctor and staff; enhanced patient trust and patient-perceived value of therapy – the list couldgo on and on. If these sound like the benefits you would seek, look no further.The treatment philosophy is calledInterdisciplinary Dentofacial Therapy orIDT. When properly perfomed, IDT canconsistently produce optimal treatment

results while simultaneously producingprofound practice management, timemanagement and marketing benefits forthe practitioner, making IDT an ideal toolfor optimally positioning an orthodonticpractice for the future. This article willbriefly define the concept and philoso-phies of IDT. It will also give insight intothe implementation of IDT and why it isnecessary today as well as in the future.

There has never been a more exciting timeto be part of the dental profession. Exten-sive scientific and technological advancesare being made at an everaccelerating rate,enabling us to help patients in ways neverbefore thought possible. But with theseever-increasing possibilities of treatmentalso come ever-increasing responsibilities.We have to study continuously to keep up with the rapid rates of change in ortho-dontics, as well as in restorative dentistry,periodontics, oral and maxillofacialsurgery, endodontics, and in all other disciplines of dentistry and medicine. The phenomenal increase in information ismaking it more and more difficult to stayabreast in one area, much less in all ofthem. And as a result, we are increasinglyhaving to rely on the other disciplines tohelp us help our patients. The responsibil-ities for our decisions and actions are alsoincreasing, as we routinely perform moreinvasive and/or less forgiving procedures,such as adult orthodontics, orthognathicsurgery and/or the placement of dental implants.

But even the burden of these heavy

Dr. Roblee practiced general restorative dentistry in Dallas, Texas, before going back to study graduate orthodontics at Baylor College ofDentistry. He is known for his work in esthetic dentistry, orthodontic techniques and interdisciplinary therapy, and he lectures nationally andinternationally on these topics. Dr. Roblee is the author of numerous publications and videotapes, including a textbook entitled InterdisciplinaryDentofacial Therapy (Quintessence Publishing Co., Inc., 1994). He is an associate clinical professor at Baylor College of Dentistry in both therestorative department and the orthodontic department. Dr. Roblee is an active member of numerous dental organizations, including theAmerican Association of Orthodontists, the American Academy of Esthetic Dentistry and the American Academy of Fixed Prosthodontics. He

maintains a full-time orthodontic practice in Fayetteville, Arkansas, with an emphasis on esthetic and interdisciplinary therapy.

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responsibilities can be outweighed by theunparalleled professional satisfaction andthe professional camaraderie produced by reaching higher and higher levels ofpatient care through the optimal coordi-nation of knowledge and skills in the various disciplines. Different specialists(such as an orthodontist and an ortho-gnathic surgeon) frequently pair up and enjoy a good working relationship, butbecause of the inherent complexities anddifficulties in developing and maintaininga large team, very few groups practice acomprehensive approach that equally encompasses all the disciplines. Con-sequently, advancing the science of dentistry is not so much the problem today as is employing and orchestratingthe science that already exists.

Multidisciplinary therapy, as it is routinelyperformed, utilizes multiple disciplines,but it is usually performed in a disjointedfashion, where the various providers work

as separate entities rather than as a cohe-sive team. This noncohesive approach can result in disappointing compromisesor failures, which frequently lead to frustration and bad feelings betweenproviders. I feel strongly that many of theproblems that the orthodontic specialtyhas in its relationship with the other disciplines, especially with general practi-tioners or restorative dentists, are a directresult of the shortcomings associated witha typical multidisciplinary approach.

When treatment decisions are left to an individual provider, it is a natural tendency for him or her to characterize apatient’s dental and dentofacial problemsin terms of his or her own backgroundand interest. In fact, some providers develop treatment plans according to theirown capabilities rather than according towhat the patient actually needs and theextensive options that the profession canprovide. Many orthodontists easily see

these problems with their counterparts inrestorative dentistry. But very few ortho-dontists realize that restorative dentists often see them in the same light.

Whenever dentofacial problems are addressed by one provider and not as ateam, shortcomings frequently arise thatcan compromise future providers’ treat-ment. When improperly planned, ortho-dontic therapy can force compromises in restorative procedures that follow. The resulting frustration and disappoint-ment of the restorative dentist often lead him or her to decline referral of asimilar patient the next time. In some instances, general dentists who have theirpatient’s best interest in mind can evenmisinterpret the situation and think that,through some of the short courses that are readily available, they can easily learnto perform orthodontics as well as, or better than, the orthodontist.

Therapy (IDT): Now and the Future

continued on page 4 3

Figure 1A. Initial. Figure 1B. Progress after orthodontic intrusion and gingival recontouring.

Figure 1C. Final result after placement ofall-porcelain anterior restorations.

IDT case utilizing orthodontics, periodontics and restorative therapy. Each therapy was planned and executed to complement other therapiesand produce exceptional results. The IDT approach consistently produces optimal results and many secondary practice management and marketing benefits.

The concept of IDT assists in the ideal coordination of the different disciplines toconsistently provide optimal dentofacialcare (Figures 1 & 2). At the same time,IDT can help overcome some of the prob-lems and shortcomings associated with a less sophisticated, multidisciplinary approach to therapy. An interdisciplinaryapproach is similar to a multidisciplinaryapproach in that it utilizes the multipledisciplines. However, the prefix interrepresents a more highly structured working relationship among the differentdisciplines. The word dentofacial of IDT

signifies that state-of-the-art care requiresthe entire team to diagnose, treatmentplan, and treat from a dentofacial perspec-tive, not only for esthetics, but also forproper long-term dentofacial health andfunction.

But what actually differentiates Inter-disciplinary Dentofacial Therapy from thetypical multidisciplinary therapy? I havefound that it is not the demographics orbackground of a group that determinesthe level of care. Instead, it is the underly-ing principles with which a team practices.

I am referring to the three hallmarksof IDT: common comprehension,

regimental sequencing and extensive communication. The first is common comprehension. To consistently work together as an interdisciplinary team, a group of providers must have a commoncomprehension of treatment. This includes common objectives, common philosophy and common knowledge. An interdisciplinary team should establishcommon objectives in areas such as occlusion, periodontal health and mainte-nance, dentofacial esthetics, etc. Withoutthese common objectives, individual teammembers’ therapies may go in different directions.

Along with common objectives, theremust be a common philosophy for obtain-ing them. There should be commonphilosophies for diagnostic procedures,treatment planning and treatment. Thereshould even be a common philosophy for the way team members talk to theirpatients and the way they motivate themtoward treatment.

The last aspect of common comprehen-sion is common knowledge. As individualteam members, we must be experts in ourown discipline. We must also understandthe other disciplines’ treatments wellenough to know how they can help ushelp our patients, when best to use themand what their limitations are.

But how can a team acquire this commoncomprehension of treatment? Reviewingtapes and reading the available literaturecan be instructive. Continuing educationcourses are helpful, and now there arealso some textbooks available that outlinethe philosophies and objectives of IDT.But experience has shown that there isnothing more effective and exciting thanproblem-based learning with your teammembers. I have found that the most effective way for team members to learnand retain this common information is toproperly work up untreated cases andthen diagnose and treatment plan them asa team. My core team and I get togetherevery Wednesday morning from 7:00 to8:00 for a team conference about interdis-ciplinary cases that are currently in the

treatment-planning stage or that are currently in treatment.

In addition to these smaller meetings, wealso have a larger study group that encom-passes several different teams in our areaand includes multiple providers from eachdiscipline. This group meets regularlyonce a month on a weekday afternoonand discusses, diagnoses, problem solvesand treatment plans untreated cases thatare worked up in a highly structured andcomprehensive format. Also, at thesemeetings each member will periodicallypresent what is new in his or her area ofexpertise, as well as review literature andsummarize continuing education courses.Team meetings in groups such as thesecan provide the most effective environ-ment for the orthodontist to educate theother team members about what he or shecan do to help them. I am certain thatmost orthodontists will be surprised atwhat they can learn from the other teammembers, especially the restorative dentist. The levels of camaraderie and enthusiasm at these meetings are fantastic,because good dentistry is exciting andhighly contagious. The common compre-hension of treatment that develops canhelp optimize the process and results ofteamwork. Secondarily, it teaches teammembers to appreciate what the otherteam members can do to help them, replacing possible disappointment causedby unrealistic expectations.

The second hallmark of IDT is regimentalsequencing of diagnostic, treatment plan-ning, and therapeutic procedures. To consistently obtain optimal results, dentaland dentofacial problems must be analyzed and treatment planned in a highly ordered fashion that ensures thatall necessary expertise has been includedat the most appropriate time and that noproblems or potential solutions have beenoverlooked. It is also important to regi-mentally sequence all aspects of therapyto help maximize the team’s individualand overall results and to minimize thepossibility of one or more members having to make unplanned compromises

Dr. Robleecontinued from page 3

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“IDT can consistentlyproduce optimal treatment resultswhile simultaneouslyproducing profoundpractice management,time management andmarketing benefits for the practitioner.”

Preliminary Therapy: Prelude to IDT

Diagnostics: Phase I of IDT

Treatment Planning: Phase II of IDT

Definitive Therapy: Phase III of IDT

Maintenance: Phase IV of IDT5

Figures 2A & 2B. Initial.

Cephalometric superimposition.

Figures 2C & 2D. Final result after periodontal and restorative therapies.

Case that was diagnosed, treatment plannedand treated with an IDT approach. Note the vertical changes achieved with only periodontal and restorative therapies. Eventhough orthodontic therapy was not neededin this case, these results could not havebeen achieved if the interdisciplinary teamhadn’t utilized orthodontic and orthognathicdiagnostic principles. Cases such as this and in Figure 1 can quickly teach a teamthe benefits of a thorough dentofacial evaluation and comprehensive approacheven when performing only restorative andperiodontal therapies. This educationalprocess can produce many secondary benefits for the orthodontist. When an interdisciplinary team understands the benefits of IDT, orthodontic problems will no longer be overlooked as they frequentlyare in multidisciplinary therapies.

Figure 3. IDT can be divided into five distinct stages. Adetailed flowchart has been developed for each of thesestages. To obtain consistent quality results such as those inFigures 1 and 2, dental and dentofacial problems must beanalyzed, planned and treated in a regimental fashion toensure that all necessary expertise has been included andthat no problems or potential solutions have been over-looked. The IDT flowcharts are instrumental in facilitatingconsistent optimal results in comprehensive therapy.

Figure 4. An example of an IDT Diagnostic and Treatment Planning Summary. To be effective in the IDT diagnostic and treatmentplanning process as well as correspondence, a team should always arrange the problem list in standardized categories and terminol-ogy that give a systematic description of the patient’s problems. The treatment plan should also be arranged in a standardized for-mat and sequence so that it and the problem list are familiar to and functional with the other team members involved. The standard-ization enables the team leader to provide a platform for communication that all team members can easily add to and change whilealso keeping the team focused and going in the same direction. In typical multidisciplinary therapy, the structure of correspondence,when it exists at all, is highly varied between different team members and is usually ineffective, allowing the team and the varioustherapies to become disjointed.6


Figure 5. Example of IDT Specialized Evaluation Summary form. In IDT the team leader performs a standardized general evaluation of the patient and formulates an IDT diagnosticand treatment planning summary (Figure 4) which precedes the patient, along with any existing diagnostic records, to all specialized evaluations with other team members. Teammembers can quickly and easily complete the Specialized Evaluation Summary and add to orchange the team leader’s preliminary problem list and preliminary treatment plan accordingto their specialized findings. This method of correspondence has proven to be highly effectiveand relieves each team member from having to dictate long letters that are often very diffi-cult to combine into one workable problem list and treatment plan.

in their therapy because another teammember performed improper therapyand/or therapy out of proper order. Tomaximize overall treatment and help prevent these problems, detailed IDTflowcharts (Figure 3) have been devel-oped that tell the team the ideal order of various procedures and all the differentstages of treatment. These flowcharts have proven extremely beneficial and actas a blueprint for effectiveness in teamtherapy.

The first two hallmarks of IDT, commoncomprehension and regimental sequencing,lay the foundation of the team and give itdirection. The third hallmark, however –extensive communication – fuels the team,sustains its proper function and promotesits growth. There are three basic types ofcommunication in IDT: team conferencing,correspondence and visual communication.Team conferencing includes any direct interaction between two or more teammembers, whether by telephone, across adesk or at a team meeting. Since time isone of our most valuable commodities,IDT is structured to maximize the effec-tiveness of communication and to mini-mize or negate the time each team mem-ber spends in direct interaction.

The second type of IDT communication,correspondence, entails any written communication between team members.In multidisciplinary therapy, the typicalcorrespondence between team members is disjointed and ineffective, if it exists at all. Correspondence in IDT needs to be thorough yet concise. It needs to reflect a common philosophy and formatso that it can be used effectively and interchangeably by all the different teammembers. Effective team correspon-dence starts out with a team leader composing a detailed initial problem list and preliminary treatment plan in an easily referenced standard format(Figure 4). This serves as a platform thateach additional team member easily builds upon to help keep the team organized, focused and going in thesame direction (Figure 5).


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by James J. Hilgers, D.D.S., M.S.Mission Viejo, California

IntroductionBios™ is a light-wire, higher-torque version of the Orthos™ appliance system.It is designed for the orthodontist whodoesn’t fill the slot and depends on func-tional adaptation more and dominancemechanics less. Just as tooth morphologyand size help determine bracket place-ment and occlusion, wire technology and trends in biomechanics help forgethe need for different torque values. Put simply, the Bios System allows for earlier torque control with lighter wires.Its strength lies in accommodating theright size wire to achieve a specificmechanical objective. This ensurestorque control throughout treatment, creating less dependence on full-sizeedgewise wires. Wires are downsizedwhen torque control is inconsequentialand upsized when torque control is paramount.

The intent with Bios is that when moretorque is desired, it is built into the system; when less torque is needed,wires are downsized to use bracket-slotplay. Years of work tying specific torquevalues to biomechanical principles andphysiological response allow the clinicianwho opts for lighter wires to get the bestof both worlds: Orthos technologyrefined in the Bios light force system.

The Theory Behind BiosBios is an acronym for “Biologic OrthosSystem.” This name implies the focus of this sister bracket system to Orthos. Itis intended to take all the breakthroughtechnology of the Orthos System andapply it to lighter-wire, more-biologicmechanics. Bios is designed for theorthodontist who believes in lighterforces, the use of function throughouttreatment and the selection of wire size and configuration to deliver desiredtorque-control values. Orthos wasdesigned by using a sophisticated computer technology to closely identifyfeatures in tooth morphology and archform that allow a perfect occlusion tooccur. It implies, however, a complete fit of the archwire in the bracket slot tocreate this idealization. It is my beliefthat the need for torque control varieswidely and is dependent on patient facialtype, tooth position objectives and otherclinical and biologic factors. This meansthat one set of torque values does not fitall cases. It’s just an average. Since it isnot very practical (at least at this point)to change the torques on each patientdependent on specific need, the one variable that we do have is the archwires.

By selecting the appropriate archwire toaccomplish a certain objective, we have a great deal of leeway over final position-ing of the teeth. One fact underscoresthis approach. Superelastic archwirescannot be torqued. They are what theyare. If an accentuation of torque is needed, it needs to be in the bracket system. Of course, a stainless steel arch-

Bios…A BracketEvolution, a Systems Revolution

Dr. James J. Hilgers, a well-known proponent of simplified orthodontic mechanotherapy, wasinstrumental in developing the recently introduced Bios™ System. He has published and lec-tured extensively and conducts a semiannual in-office seminar – “The Essence of PracticalOrthodontics.” Dr. Hilgers’ private orthodontic practice is located in Mission Viejo, California.He received his dental education at Loyola of Chicago and graduated from the ortho programat Northwestern University.

continued on page 10

TYPICAL ARCHWIRE PLAY VALUESSlot size .018 x .025

Wire Size Radius Play.016 x .016 .003” +/–17.1˚

.0175 x .0175 .003” +/– 5.2˚.016 x .022 .003” +/– 9.5˚.017 x .025 .003” +/– 4.6˚.018 x .025 .003” +/– 1.5˚

Figure 1. The upper molar erupts down thegrowth (facial) axis. Its normal eruption wouldbe downward and slightly forward, dependingon facial type. In brachyfacial (horizontal)growth patterns, more forward growthoccurs. In dolicofacial (vertical) growth patterns, more downward growth occurs. Itwill continue along this eruptive axis unlesschanged by treatment or functional distur-bance.

Figure 2. The upper incisor erupts on its longaxis. This is referred to as axial or conicalgrowth. It will continue along this axis unlesschanged by treatment or functional distur-bance.

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Table 1. When using an .016 x .016 idealarchwire in an .018 x .025 slot, there is agreat loss of active torque. Bracket play isreduced when using a rectangular archwirewith a wider rectangular dimension. This further fills the bracket slot, reducing bracket play and increasing effective torque.

Table 2. Completely filling the torque slotensures that whatever torque is built into thebracket will eventually work itself out. Thisfinal expression of torque is defined by bothactive torque in the bracket slot and theamount of time it takes for the constrainedwire to express itself.

wire can be actively torqued, but this isgenerally down the road in the treatmentcycle. We wish to choose the appropriatetorque control at the onset of treatment,in the very first archwire, to fulfill thespecific needs of that particular case.This point cannot be emphasizedenough: The bracket system cannot be easily changed on a case-by-case basis. The archwires can. That means the truevariable in the system is the size and config-uration of the archwire. Since true super-elastic archwires cannot be bent, it makessense to have higher torques built intothe system and use archwires accordingto specific need. Decrease bracket-slotplay where torque is needed; increasebracket-slot play where it is not.

I am not arguing that the ideal torquevalues which the Orthos System impliesare not correct. They are. It is just thatthey require filling the slot as much aspossible to allow them to express them-selves. When smaller archwires are used,

there is a great deal of loss oftorque control. When a different

need is there, torquing (or detorquing)the wire is required. That is what we wishto avoid or at least minimize.

.018 Slot Versus .022 SlotClinicians argue ad nauseum about theirchoice of bracket-slot size. It is obviousthat you can do good orthodontics witheither .018 or .022 slots and that themain differences are generally not techni-cal but choice driven. There is no oneright way. In this era of superelastic archwires, the differences between usingan .018 slot and an .022 slot have diminished. The orthodontist whochooses the .022 slot has clear reasonsfor that choice. However, in my view, the smaller slot size has some distinctadvantages:

1. Torque control in smaller wires. Forexample, whereas an .016 x .022 Ni-Tiwould exert virtually no torque controlin .022 slot brackets, it is very effectivein the .018 slot system. For a comparablewire in the .022 system, you would haveto use at least an .018 x .025 wire, whichis considerably less flexible and more dif-ficult to completely engage.

2. Overutilization of round wires. Eventhough you may be using a rectangularor square wire in an .022 slot bracket, ifbracket tolerances are not correct, it isjust like using a round wire, with all itsnegative side effects.

3. Less patient discomfort. The need forheavier torque-control archwires in thefinishing phases of treatment createsproblems both in and out of the office.Placement of the heavier archwires ismore difficult, deflection is decreasedand there is a tendency for increasedpatient discomfort.

4. Less need for defined arch coordination.The heavier the ideal archwires used, thegreater the need for detailed archwirecoordination. Functional control (i.e.,tongue and lip pressure) is minimizedwhen arch form is dictated by rigidity ofthe archwire. Arch form and continuityare more biologic when not overriden.

5. Less stress on the bond. With the use ofnew bonding cements (i.e., Fuji lightcure) which have less retentive strength,stress on the bonds means more loosebrackets. These cements have greatpotential in a wet bonding field and aidin precise bracket placement (because noisolation devices are necessary), but theyare not amenable to heavier forces.Lighter wires that are used throughouttreatment aid bracket stability. We havefound these newer cements to haveexcellent retention characteristics as longas larger archwires are not used.

OvercompensationTorque is controlled in individual teethor segments of teeth in two ways. Eitherthe bracket-archwire slot tolerances aregreatly reduced (i.e., using a larger arch-wire) or the time of torquing activity isincreased (i.e., the archwire is left inlonger). These two variables compel theclinician to decide which size wire to use and how long it should be engaged.The concept of functional finishingimplies that lighter wires be used when-ever possible to allow the muscular pattern of the patient to help in thedetailing process. Torque needs for anindividual case are defined by choosingappropriate archwire sizes and configura-tions (i.e., utility arches, reverse curve T-loop archwires) to accomplish adesired objective. Simply stated, whenmore torque control is needed, thebracket slot is filled. When less torquecontrol is needed, the archwires aredownsized to increase play. Where astrong torquing moment is required, it is available in the higher-torqued Bios bracket system. When reduction or loss of torque is required, round orundersized edgewise wires are used. The cases that commonly call forincreased torque control are Class II,division 2 malocclusions, extractioncases, and adult cases. The cases thatrequire less overall torque control areClass I and Class II, division 1 malocclu-sions. Of course, the need for definedtorque control can vary case by case,upper arch and lower arch.

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Dr. Hilgerscontinued from page 8


“The Bios light wiresystem offers the clinician who is interested in usinglighter forces andwires an entry toOrthos technology.This highly sophisti-cated system affords a clinical efficiencythat is nonpareil.”

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Figure 4. In the Class II, division 2 malocclu-sion, torque in the upper incisors is com-monly created by advancing these teeth.Torque is then maintained or accentuated by reducing bracket slot play by using largearchwires.

Figure 5. Esthetically, the brachyfacial typecan accommodate a fuller dentition with amore acute interincisal angle. In this case, amore acute interincisal angle results in facialharmony with good lip repose, an expressivesmile and no lip strain. Note that the upperincisors are torqued parallel to the growth(facial) axis, resulting in a 112° interincisalangle, ideal for this particular patient’sgrowth pattern.

Figure 6A. Example of developing Class II,division 2 malocclusion with constrictedupper and lower arches.

Figure 6B. When upper molars are growingcloser to upper incisors, the resultant archform shows flaring of the upper laterals, lin-guoversion of the centrals and a constricted,hour-glass shaped arch form. This is typicalof the Class II, division 2 malocclusion.

Figure 7B. Final arch form changes in atreated Class II, division 2 malocclusion.

Figure 7A. Final occlusion demonstratingpositive torque in the upper incisors createdby long duration of edgewise wires with littleplay in a high-torque slot.

Figure 3. In strong growth patterns where theupper molar (a) grows down the facial(growth) axis and the upper incisor (b) growsdown its long axis (axial or conical growth),there is a diminution of space between themolars (c) and incisors (d). This accounts fora pinching, or closing, of the arch, resultingin the typical dental characteristics of theClass II, division 2 malocclusion.

Relation of eruptive pattern of teeth in the development of C1 II, d2 malocclusion

This case demonstrates the occlusion and arch form characteristics that result as aconsequence of the eruptivedirection of teeth. It defineshow the interincisal angle relates to the individualgrowth pattern of this patient.Ideal treatment relates the finalposition of the teeth to theoverall direction of growth.

The Cuspid ConundrumUpper and lower cuspid torque seems tobe the most controversial area of straightwire systems. It can range from -7° to+7° in both arches – in other words, atotal variance of 28°. How is it possiblethat there could be such a divergence ofopinion? To begin with, vertical place-ment of the bracket can greatly affecttorque (due to the convexity of the facialsurface). A gingivally placed bracket can have a torque variance of + or -9°

compared with a bracket placed incisally.However, mechanics are usually theanswer to this conundrum. Almost every mechanical force has a tendency to detorque cuspids. Class II elastics,elastomeric chain, retraction in extractioncases and vertical elastics to seat theocclusion all act to detorque these teeth.This needs to be compensated for withtorque in the bracket. So, although somemight argue that ideal torque would beless than +7°, mechanics mitigate thatsomewhat. In addition, a more naturalsmile occurs when the cuspids supportthe corners of the mouth. This smile line is enhanced when the upper cuspids

(especially) are not undertorqued.It certainly helps avoid the

“orthodontic look” of a narrowed orpinched arch that commonly occurs inextraction cases. First order in-out bendsare markedly affected by torque. Positive lingual root torque on both upper and lowercuspids is instrumental in creating propercontact points between the distal of lateralincisors and the mesial of cuspids (bothupper and lower). This reduces the number of adjustment bends needed in these areas.

Loss in Torque Due to Bracket-Slot PlayThere is a wide variability of torque control in the bracket slot based on theamount of leeway or play between thesize/shape of a rectangular archwire andthe bracket interface. It has been calculated that there is a loss of 6° intorque control for each .001 inch tolerance in bracket fit. For example, an .016 x .022 wire would only exert 9° of torque in a 21° torque bracket.Theoretically it would take an .018 x.025 archwire to allow all of the torquein the bracket to exert itself. With an.016 x .016 archwire, torque is dimin-ished even more due to the shorteneddiagonal size. When one thinks of torquewithin the bracket slot, there is anassumption that torque will ultimately be expressed on the tooth. Not so. Wiresize, bracket tolerance and force momentare major factors in the final placementof the root. By simply choosing to down-size or upsize the edgewise archwire, theclinician is more capable of reaching aspecific goal than by changing specificsin bracket torques. It is more importantthat the tooth-to-tooth in-bracket torquesbe symmetrical and harmonious.

Torque to Facial TypeDetermining the ideal interincisal angleshould not be based on averages.Steiner’s 125° interincisal angle is merelyan average. Growth direction, estheticsand overbite should also be consideredin determining ideal torque in the upperand lower arches.

1. Growth: From the geometric stand-point, the upper molar will follow an

eruptive path that closely aligns to thegrowth direction of the patient. That is, it will erupt down the facial axis. In the more brachyfacial (hypodivergent) patterns, the upper molar will come farther forward due to the more horizon-tal growth pattern. In dolicofacial (hyperdivergent) patterns, the uppermolar will erupt more vertically but nothorizontally, again following the verticaldisposition of the facial axis. Incisorserupt along their vertical axes (axialgrowth). It is apparent that if the uppermolar is coming forward in the stronggrowth pattern and the upper incisorsare erupting more vertically, spacebetween the two is diminishing. Theresult: a Class II, division 2 malocclusionwith crumpling of the arch, labioversionof the upper lateral incisors, linguover-sion of the upper centrals, an hourglasstype narrowing of the upper arch and constriction of the lower arch.Conversely, when the upper incisor isproclined labially and the upper molar is erupting more vertically, the spacebetween them is increasing. The result:Class II, division 1 malocclusion with a V-shaped upper arch, severe overjetand a retruded and flattened lower arch.The answer to this disparity is to torque (or detorque) the upper incisors parallel tothe growth axis of that individual’s facialtype. The interincisal angle in a strongbrachyfacial type could be 110° and still be completely normal for that case. It could be 140° in the dolicofacial typeand also be normal. In addition, one caninfer the anchorage requirements of thedifferent facial types for proper torquingof these teeth.

2. Esthetics: Brachyfacial types can easilyhandle a more protruded denture. Anacute interincisal angle often looks quiteattractive in strong facial patterns. It provides a more youthful, expressiveappearance than if one always attemptsto treat to the average 125° interincisalangle. At the same time, when theincisors are proclined labially in the weak facial pattern, lip strain and facialgrimacing are evident. Retraction and

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“Since true super-elastic archwires cannot be bent,

it makes sense to have higher torquesbuilt into the systemand use archwires

according to specific need.”

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Figure 9. In the Class II, division 1 malocclu-sion, a detorquing moment is created whenretracting the upper incisors by using anundersized rectangular or round wire. Thisavoids both straining anchorage and havingto use higher-torque brackets on upperincisors. When torque is needed, it is builtinto the system and implemented by fillingthe slot. When torque is not needed, simplydownsize the wire.

Figure 8. In vertical growth patterns wherethe upper molars are erupting along thefacial axis (a) and the incisors are eruptingaxially (b), there is an increase in spacebetween the upper molars (c) and incisors(d), resulting in the typical dental character-istics of the Class II, division 1 malocclusion.

Figure 11A. Example of developing Class II,division 1 malocclusion with dental protru-sion, anterior spacing, narrowed arches andsevere overjet.

Figure 12A. Final occlusion demonstratingpositive torque in the upper incisors createdby using undersized edgewise wires withample play in a high-torque slot. Since thearchwires used in retraction of the upperincisors exerted limited active torque, theresult shows backward tipping of the anteriordentition.

Figure 11B. When the upper incisors aregrowing away from the upper molars, theresultant arch form shows labial flaring of theupper incisors, increased overjet, a narrowtapered arch form and a tendency forblocked-out or impacted upper cuspids. This is typical of the Class II, division 1 malocclusion.

Figure 12B. Final arch form changes in thetreated Class II, division 1 malocclusion.

Figure 10. The protruded dentition results infacial grimacing and disharmony. Reducingthe interincisal angle in these cases results ina more pleasing facial profile. Note that theupper incisor is torqued parallel to the growth(facial) axis, resulting in a 123° interincisalangle, ideal for this particular patient’s indi-vidual growth pattern.

Relation of eruptive pattern of teeth in the development of C1 II, d1 malocclusion

This case demonstrates the occlusion and arch form characteristics that result as aconsequence of the eruptivedirection of teeth. It defineshow the interincisal angle relates to the individualgrowth pattern of this patient.Ideal treatment relates the finalposition of the teeth to theoverall direction of growth.

more vertical positioning of the teeth onthe denture base are indicated.

3. Overbite: Holding a “correct” overbitein a strong muscular (brachyfacial) pattern is very difficult when the incisorsare too vertically inclined. The chevronthat is created by a more acute interin-cisal angle enhances the mutual supportof the dentition itself. In addition, ithelps alleviate some of the negativeeffects on the TMJ sometimes caused by a collapsing anterior arch. In thedolicofacial pattern, where overclosure

of the bite is not normally a problem, a more vertical positioning of the teethcan help maintain incisal guidance.

Simplicity By SystemUnquestionably, one of the biggestadvantages of Orthos is the systemsapproach that it brings to arch form andocclusal fit. The highly integrated tubes,brackets and coordinated archwires create a system that allows the clinicianto greatly reduce chairtime and increaseefficiency. For the first time, all the arch-wires, from superelastic through ideal,

are computer designed and fabricated to achieve the most ideal fit of the teeth.If the tubes and brackets are properlyplaced, the clinician’s main responsibilityis to decide which archwire is needed toachieve a desired result.

Buccal Root Torque in theLower Buccal SegmentsResearch in the development of theOrthos System indicated a tendency toleave the lower buccal segments undulylingually inclined, reducing occlusion of



Figure 15. Arch configuration influencestorque control. Reverse Curve TMA® Arch-wires with ‘T’ Loops (.016 x .022) can beadjusted to torque, advance, intrude andretract incisors by simple intraoral adjust-ments and allow the clinician to define

torque and step-ups between incisorsand buccal segments.

Figure 14. From the growth standpoint, idealtorque of the upper incisors (b) would placethe long axis of these teeth parallel to thegrowth (facial) axis of the face (a). Thisresults in a symmetry of growth as the uppermolars (c) grow in harmony with the upperincisors (d). This aids in stability of the occlu-sion and overbite-overjet relationships. It canalso be argued that this is the position of the upper incisors that is more harmonious with normal TMJ function.

Figure 16. Most mechanics have a tendencyto detorque upper and lower canines. Cuspidretraction in extraction cases, buccal spaceclosure with elastomeric chain and verticalseating elastics all have a tendency todetorque these teeth. Lingual root torque on the cuspids helps mitigate this tendency.

Figure 13. When upper incisors are torquedparallel to the growth (facial) axis, there isharmony in arch form and overjet. This con-cept is used when setting up torque objec-tives and determining what, when and wherea certain size of archwire will be used. It isalso a strong determinant of anchorageneeds for each case.

Figure 17. The Orthos™ System is designedfor the use of larger wires to express thebuilt-in torque of the brackets and buccaltubes. When undersized archwires are rou-tinely used in the lower buccal segments,there is a resultant lifting of the lingualcusps with concomitant loss of anchorage.Note that the lower buccal segments havebeen detorqued and expanded with the useof -10° torque along with undersized wires. Proper torque can be achieved by using afull-sized (0° bracket play) archwire. Whenusing undersized torque-control wires (e.g.,.016 x .022), proper lower buccal segmenttorque is achieved by increasing bracketand tube torques up to -27°. Overcompen-sation needs to be part of the clinician’sthinking when using lighter, undersizedarchwires with their resultant loss torquecontrol.

14

by Larry W. White, D.D.S., M.S.D.Hobbs, New Mexico

erb Kelleher, the creativeand highly effectivePresident, Board Chairman and CEO of SouthwestAirlines, has said that hiscompany’s airplanes onlymake money in the airwhile carrying customers

and cargo between cities. Southwest putsKelleher’s fundamental business idea intopractice every day by minimizing groundtime for each of its 234 jets. When aSouthwest plane lands, flight attendantsassist as many as 137 customers off theairplane and quickly tidy the cabin.Almost immediately, local customersbegin to embark. Simultaneously, groundcrews are off-loading baggage, refuelingthe aircraft, servicing lavatory and watersystems, removing trash, replenishingsnack and beverage items and loadingnew cargo and baggage. Remarkably,everything is in place, and the jet is dis-patched within 15-20 minutes – setting

Southwest Airlines (and its consistentprofits) apart from the rest of the airlineindustry.

When you think about it, we are notunlike a highly efficient airline. We areonly earning fees when our patients aretraveling efficiently toward an orthodon-tic destination – with brackets, bandsand wires in place. The breakage ofappliances is the orthodontic equivalentof an extended period of time on theground or a mechanical failure that causes a costly and inconvenient delay.Extending this airline metaphor a bit further, some of my patients have suchchronic problems with breakage that they are spending too much time on the tarmac and only fly infrequently. This is costing money and delaying theirarrival time.

It was clear to me early in my orthodon-tic career that loose bands, broken brack-ets and fractured wires would be a majordeterrent to providing first-class ortho-dontic services for my patients. Over thepast 30 years, broken appliances haveremained my most vexing and chronicclinical problem, and I suspect this istrue for many other orthodontists.Certainly, broken appliances exact aphysical and emotional toll on the ortho-dontic staff, but they also carry a higheconomic tariff as well. My friend J.Barnett discovered a few years agothrough a time-cost computer programthat the recementation of a single bandin his office cost $35.1 That cost has certainly increased by now.

Several years ago, I began to record dailythe number of loose bands and brokenbrackets, so that I could evaluate theeffect different cementation proceduresmight have. I have tried just about every“improvement” dental science has devel-oped and distributed: silicate cements,acrylic cements, Durelon® cement, glassionomer cements, bands with

Keep em Flying

H


Figure 1

Percent of Patients with Broken Brackets/Loose Bands20191817161514131211109876543210

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Year

Per

cen

t

Dr. Larry W. White received his D.D.S. and M.S.D., Orthodontics, from Baylor University Collegeof Dentistry. Dr. White is a diplomate of the American Board of Orthodontics and currentlyserves as editor, Journal of Clinical Orthodontics and as manuscript reviewer, American Journalof Orthodontics and Dentofacial Orthopedics. He is a member and past president of the RockyMountain Society of Orthodontists, the Texas Tweed Study Club and the New Mexico Society ofOrthodontists. Dr. White has been engaged in the private practice of orthodontics in Hobbs, NewMexico, since 1968.

screen mesh, microetched bands, heavily-filled composites, lightly-filled composites, fluoride-filled composites,contact composite, light-cured composite,microetched brackets, direct and indirect bonding techniques, etc.

I even instituted a behavioral reinforce-ment schedule for my patients thatrewarded them for non breakage.2

Nevertheless, over the years there wasscarcely any statistical change. The daily average of patients with brokenbrackets and loose bands typically hadranged from 11 to 15 percent despitewhatever scheme I used to reduce breakages (Figure 1). I began to believethat perhaps this was an example of what W. Edwards Deming labeled “common cause”3– that is, a percentageof appliance breakage that could be considered completely normal and could be statistically expected and predicted.

Others who have kept records ofpatients’ broken appliances maythink that the amount of breakage

is too high in my office. But a factor thatincreases the difficulty of keeping brack-ets and bands in place in my geographicarea is the prevalence of highly-fluorosedwater supplies. Miller recently showedhow impervious fluorosed teeth are toacid-etching and why they need specialmicroetching with aluminum oxide toprovide enough surface area for success-ful bracket bonding (Figure 2A, B, C, D).4

One of the changes I made that did bearsome immediate fruit was the use oflight-cured composites. I noticed amarked reduction in the number ofbrackets that broke with the insertion ofthe first archwire. Apparently, the degreeof cure of chemically-cured adhesives issignificantly lower than that of the visiblelight-cured resins.5 Fewer brackets brokeimmediately at the bonding appoint-ments, but over a longer time even thisimprovement seemed to lose its advan-tage, as the overall statistics did notchange appreciably.

Nevertheless, since beginning to use theOrthos™ appliance about one-and-one-

half years ago, I have noticed a hearten-ing improvement in the breakage statistics. Within a year of the Orthosinstitution, I noticed that on many daysthe percentage of patients with brokenappliances often dropped to single digits – a phenomenon almost unseenpreviously.

I was skeptical about whether a newlydesigned bracket system could reducethe amount of breakage, but the Orthosappliance did have features that weresupposed to limit breakage such as:• thinner and less prominent mandibular

anterior brackets (Figure 3);• offset bicuspid brackets that prevent

subgingival moisture contamination (Figure 4);

• microetched band interiors that increase the surface area for cement adhesion (Figure 5A, B);

• Optimesh™ on the bracket pads that increases adhesion between the bracket mesh and the adhesive. This remains the most sensitive and vulnerable area of the bonding interface.616

Dr. Whitecontinued from page 15

Figure 2. Fluorosed enamel seen under a scanning electron microscope. A – Control; B – Afteracid etching; C – After microetching with aluminum oxide; D – After microetching and acidetching. Note the lack of acid effect on the enamel surface in B and the increased surfacearea after microetching and acid treatment of enamel makes bonding more secure in D.

A B

C D

Conventional Straight Wire

Orthos

Figure 3. Reduced profile of mandibularanterior brackets facilitates placement indeep overbite and crowded cases.*

Figure 4. Theextended bicuspidpad results ingreater bondstrength, since the occlusal thirdof the tooth is easier to etch and less subject to contamination.*

Since patient charts with Orthos appliances are marked in my office, itwas easy to survey the breakage experi-ence with those patients as opposed tothe others. As you can see from thechart, over the past months Orthospatients have had almost three times less breakage than the patients with other preadjusted edgewise appliances(Figure 6). The test period covered allpatients currently in treatment for thepast 18 months. Some patients have been in treatment longer than others.

The number of patients having breakagewas almost equal in the two groups –105 and 106. Of the 262 patients whowore the Orthos appliance, 40 percenthad at least one experience with a broken bracket or band. This contrastswith 61 percent of the 170 patients withnon-Orthos appliances. The breakagewith the Orthos appliance averaged .71breaks/patient, whereas the non-Orthosbreakage averaged 2.02 breaks/patient –almost three times the breakage experi-ence of the Orthos patients. Had thenumber of non-Orthos patients equaled

that of the Orthos group, we would haveexpected around 529 breaks. Not onlydid a larger percentage of the non-Orthospatients experience breakage, but alsomore of them had multiple and repeatedbreaks.

I do not offer this paper as a scientificallyresearched study, rather as an anecdotalexperience. For instance, I did not pairthe patients in each group, nor did I isolate and evaluate the bonding mate-rials used with each patient, types ofcements, types of composites, locationsof failure or time spent in treatment. I have not differentiated between loosebands and the breakage of bondedbrackets. I have simply recorded the kindof breakage that most disrupts my dailyroutine – loose brackets and bands thatmust be replaced.

Despite a statistical analysis that showsOrthos’ complicity in the reduced appli-ance breakage at the 99 percent level ofconfidence, I realize it is possible that theOrthos appliance, per se, has little ornothing to do with this reduction in

breakage. But after failing for so manyyears to improve this statistic, I aminclined to believe the analysis that saysOrthos had something to do with it.

At any rate, to keep my patients air-borne, I intend to continue:• eliminating the use of non-Orthos

appliances;• increasing the use of Orthos appliances;• using light-cured, polymer-reinforced

glass ionomer cements for bands;• microetching all teeth that show any

evidence of fluorosis before bonding them (microetcher available from Danville Engineering, San Ramon, California, 1-510-838-7940) (Figure 7);

• microetching all bracket pads of broken brackets and the teeth involved before reattaching the brackets (Figure 8);

• microetching fluorosed teeth with microetcher and Sand-Trap (available from Clinician’s Choice, Dearborn, Michigan, 1-800-265-3444) (Figure 9);

• using light-cured adhesives;

A

B


Figure 5. A – Inside of metal band beforemicroetching;* B – Note increased surfacearea of inside of band after microetching.*

Figure 7. Microetching in mouth with moist-ened paper towel to protect patient’s facefrom powder scatter.

Figure 9. (Right) Use of the Sand-Trap hasgreatly improved the cleanliness of usingthe microetcher.

Figure 8. Microetching bracket within micro-etching cabinet to prevent powder scatter.

Difference in Breakage Experience(2.84 x More Breakage for Non-Orthos Appliances)

# Patients # Patients % of Patients # of Broken Brokenin Study w/Broken Appl. w/Broken Appl. Appl. Appl./Patient

Orthos 262 106 40% 187 .71Non Orthos 170 105 61% 344 2.02

Figure 6. (Right)

* Illustration courtesy of Ormco Corporation

by Richard E. Boyd, D.M.D., M.S.Columbia, South Carolina

he treatment of congenitally missing teethis a common problem facing the ortho-dontist. Approximately 7 percent of thepopulation has some pattern of missingteeth. Mandibular second premolars arethe most frequently missing teeth whilemaxillary lateral incisors are second-most.Obviously, any anterior tooth presents anesthetic challenge, but a maxillary anteriortooth is especially critical. It is the missingmaxillary lateral incisor(s) that I wouldlike to discuss.

The etiology of missing teeth is unclear.Genetics appears to play a major role,even though only 10 percent of all patients studied have a family history ofmissing teeth.

TreatmentTreatment of congenitally missing maxil-lary lateral incisors varies greatly. The occlusion, facial profile, patient desiresand the treating doctor’s preference determine the final mechanotherapy.Missing teeth present both a functionaland cosmetic concern. As a result, anytreatment decision should be reached bythe team of patient, parent, orthodontistand restorative dentist.

In the past there have been several approaches to treatment. The first is tosubstitute maxillary cuspids for the miss-ing laterals, followed by enameloplastycombined with bonding, to eliminatebridges (Figure 1). Second are traditionalbridges (Figure 2). Third is to makeMaryland bridges with acid-etched metalwings (Figure 3), and fourth, implants toreplace the missing laterals (Figure 4).

Resin-Bonded PonticA recent innovation in restorative treat-ment of missing lateral incisors is theresin-bonded pontic. This method provides a very conservative approach by creating minimal dimpling of the contiguous teeth, barely breaking theenamel-dentin junction. The surface area

Dr. Richard Boyd, in private practice in Columbia, South Carolina, for 12 years, has estab-lished a solid clinical reputation as well as one for applying sound business principles andpractices to the profession of orthodontics. He has lectured throughout the U.S., Europe andCanada and will be a featured speaker at the 1997 AAO meeting.

18

The Resin-Bond

Figure 1A. Cuspid substitution after enam-eloplasty and bonding.

Figure 1B. Final facial photo.


Traditional Cuspid Substitution

ded Pontic

Figure 3B. Facial view.

Figure 3C. (Below) Palatal view.

Figure 2A. Preparation for three-unitbridges.

Figure 2B. Traditional three-unit bridges.

Figure 4A. Panoramic X-ray with implants inplace.

Figure 4B. Implants prepped for crowns. Figure 4C. Final cementation ofcrowns over implants.

Figure 3A. Missing laterals prior to Marylandbridges.

Figure 3D. After cementation of Marylandbridges.

19

Maryland Bridges

Traditional Three-Unit Bridges

Implants with Crowns

by James E. Eckhart, D.D.S.Manhattan Beach, California

get newsletters from a number of specialists (periodontists, oral surgeons, CPAs, speechtherapists), and I quicklydecide whether to savethem for reading or to discard them. The decision

is based upon scanning the articles’ head-lines for interest and pertinency to me.Therefore, I always assume that recipientsof my patient newsletter (both profession-als and patients) receive too much mailand make quick decisions on whether to discard it or not. So it forces me to befocused on my goals with my newsletterand respectful of the reader’s time.

Goals of a NewsletterMy goals are to educate, differentiate, promote, and acknowledge.

• Education – I want my patients to know certain things about dental/orthodontic health.

• Differentiation – I want them aware of our services that distinguish us from our competition, how we are not just another office.

• Promotion – All my patients should be aware of the services and standards of care we provide.

• Acknowledgment – People appreciate seeing their name in print if I get a chance to mention them.

In addition to these four goals, I also needthe newsletter to be producible with mini-mum time and expense. My staff does notproduce it – I do.

FormatWe have averaged two to three newslettersper year. The format is usually two pages,81/2”x 11”, printed on both sides, so that itis really four pages. For printing efficiency,we use a single 11” x 17” sheet printed on both sides, then folded. The layout isdesigned to be both mailable and yet attention-getting in a literature rack. Page 1 has our masthead (including title,logo, address, specialties, office hours, andissue number), the mailing informationsection (bulk mail permit preprint, roomfor address label), and the lead article.

Page 2 has the finish of the lead articleand another article or two, with a joke orsong refrain at the bottom. Pages 3 and 4are similar to page 2.

Article TopicsFor years I have collected articles in print,other people’s newsletters, dental cartoonsand jokes, etc. I keep them in separate envelopes, by topic groupings. The envelope headings are Technical Articles,Administrative and Financial, Patients,General Health, Community, Home Care,Humor, and Ads (products or services Iwant to promote). Within each envelopethere are many topics. For example, with-in the Technical Articles envelope, I have

articles on adult treatment, orthognathics,siblings needing treatment, sterilization,what problems need treatment, snoring,bleaching, physical therapy, nonextractionorthodontics, ages for treatment, fiber-otomies, permanent retention, and so on (I have over 50 topics identified in thisenvelope). I made a list of all the topics ineach envelope and prioritized each topicA, B, or C. Then I eventually include theA’s and B’s in a newsletter.

I have used two approaches for the topiccontents of the newsletters. One approach(learned from Dr. Randy Moles in Racine,Wisconsin) is to have an overall theme foran issue, such as dental care for youngchildren, in which the topics include babyteeth, fluoride, pacifiers, thumb sucking,tooth brushing, tetracycline, diet, firstdental visit, first orthodontic visit, toothavulsion, sealants, mouth breathing, earlyortho vs. serial extraction, etc. This type ofapproach is useful in a marketing programwherein the doctor talks to parent groupsand promotes to pediatric specialists. A similar theme could be used for TMJ,adult orthodontics, snoring, etc.Specialized issues like this require a longernewsletter, so it may be expanded to six or eight pages (from the usual four).

The other approach is to try to balance anissue with one article from each envelope,such as snoring (Technical), prominentpatients by profession (Patients), sportssponsorships we’d like to do (Commun-ity), our punctuality (Administrative),foods to enjoy and foods to avoid (HomeCare), does snoring shake your roof timbers? (Ad), smokeless tobacco(Health), and a cartoon with an ortho-dontic theme (Humor). We have usuallyincluded jokes and/or song refrains from some popular songs as a way tolighten the tone. I have stayed away from recipes and biographical articlesabout myself or my staff, because I would not read them in someone else’snewsletter. Not all authors agree with this opinion.

Dr. James E. Eckhart has lived and practicedin Manhattan Beach, California, since 1975,where he is still in the process of raising threechildren. He completed his orthodontic train-ing at the University of California in 1974.

20

I

Effective Patient N

Preparation of the NewsletterI select topics from the envelopes. I roughout a dummy mockup, deciding which articles to place where. I write the articlesin longhand, using the references in theenvelopes. This usually takes me oneSaturday.

I have a professional typesetter preparethe pages (at $35 per page, using hisMac). I proof and revise the copy, whichhe corrects. The typesetter sometimes provides clip art, and I frequently willprovide illustrations from various materi-als on hand. The printer prints thenewsletter; usually we use black ink onwhite paper. For the special themenewsletters we use two ink colors, and itreally livens the appearance. The printeralso folds the newsletter (and collates if

more than one piece of paper).

DistributionActive patients are given a copy duringtheir appointment, with a brief explana-tion. This encourages them to read it orget it into the hands of someone whoshould read it. It saves the cost of mailing.For retention and observation patients, we print mailing labels, attach them to the newsletters and take them to a localmailing house whose bulk mail permit ispreprinted on the newsletter. They aresent with “Address correction requested”preprinted, so that we can update ourcomputer files if the patient has moved.

We also send the newsletters to our refer-ring dentists, and in the case of specialtheme newsletters, we send selected

dentists several for their reception room,along with an appropriate cover letter.

CostsTypesetting costs around $140 for fourpages. Printing and folding costs around$200 for 1,000. Mailing costs around$130 for 650. The time is around a day-and-a-half of my time.

ResultsDepending on the article contents, we getinquiries regarding TMJ splints, bleaching,snore devices, early exams for children,etc. We manage to examine essentiallyevery sibling of patients in our practice.And we have people talking about us toothers, because we have familiarized themwith what we do and how we aredifferent from other offices. 21

Newsletters


the lingual cusps. This is partially due tothe need for gingival placement of thelower buccal brackets and tubes. This istrue when full-sized edgewise archwiresare used, but with smaller edgewise archwires, bracket tolerances wouldagain indicate the need for higher torquevalues in this region. The loss of corticalanchorage and muscular anchorage inthe lower arch is exacerbated when thelower is undertorqued using undersizededgewise wires. This is simply anotherexample of how static tooth position andmorphology measurements are goodindicators of torque averages but poorindicators of the response to specific

mechanics and bracket-to-wire tolerancesin determining the ultimate position ofthe dentition.

The Extra Goodies1. Gingivally offset bicuspid brackets.The idea that retention is enhanced byplacing a small bracket on a large pad isnot new. Bracket retention and properplacement are greatly enhanced with gingivally offset bicuspid brackets. Iimmediately saw the merit of these onthe second bicuspid, the last tooth toerupt. It makes early direct bond place-ment possible. I have found this to be ofgreat value in both the upper and lower

bicuspid regions. It allows for more uniform bracket placement because therounded edge of the pad is closer to thecusp tip.

2. Gingivally offset cuspid brackets.So often it is impossible to correctlyplace a cuspid bracket on an erupting orpartially blocked cuspid. This problem islargely solved by using gingivally offsetcuspid brackets. Although we don’t usethese on all cuspids, it quite often pre-vents having to place a bonded button(or series of buttons) on an erupting cuspid. When glass ionomer cements are

The Bios Approach…Finesse Over ForceTaking advantage of the unprecedented precision of Orthos’ “ideal” anatomical averages, Dr. Jim Hilgers designed theBios™ System to allow for earlier torque control with lighter wires. This helps ensure torque control throughout treat-ment when needed, lessens dependenceon full-size edgewise wires and facilitatestechniques that use function more anddominance mechanics less. Bios differsfrom the Orthos™ prescription by virtueof its increased torque in upper incisorsand in the mandibular posterior seg-ment, as well as lingual root torque inupper and lower cuspids. Bios also af-fords the distinguishing advantages ofOrthos responsible for its rapidly grow-ing popularity around the world:• Compensation is cut into the slot of the

lower cuspid brackets and the shape of the archwire is adjusted to sweep as close to the tooth surface as practical. The profile of the lower incisor bracket is reduced as is the previous frequent requirement of first order bends mesial to the lower cuspid brackets1.

• Progressive distal tip in all lower anterior brackets achieves uniformity in root spacing.

• Lower bicuspid brackets with distal root tip achieve balanced proximal

contacts and correct root alignment.• Molar tubes are designed so that

molars occupy the least amount of arch space and molar interdigitation is improved2.

• Distal root tip is incorporated into upper 2nd bicuspid brackets.

• Thicker 2nd bicuspid brackets better synchronize with 1st bicuspids and molars.

• Moderately increased buccal root torque on maxillary posterior segments prevents lingual cusps from dangling.

• Arch forms and brackets are computer-derived from skeletal analysis and are integrally designed to coordinate the dental arches3.

• Bicuspids are available gingivally offset with occlusally extended pad to increase the bond area for superior retention. Additionally, the Optimesh™

coating increases bond strength by over 35 percent4.

The Bios System incorporates the rangeof Orthos archwires, including the newTitanium Niobium/FA™ finishing arches,and a wide choice of tubes, including thenew Accent™ tubes that simplify archwireentry and help coordinate both buccalsegment bracket placement and molar

integration. Whether you’re a clinicianwho prefers lighter wires or an Orthosuser seeking an auxiliary appliance foradult deep bite cases or cases with strongmusculature patterns where highertorque values are needed, Bios will benefit your practice. Order informationfor Bios brackets and tubes is providedon Page D of the Center Section.

1 U.S. Patent #5,474,448, 2 U.S. Patent #5,464,3493 U.S. Patent #5,456,600, 4 U.S. Patent #5,295,823

22


Figure 23. When Class III vertical elastics areused, the vertical component of the elastic isalso oriented in the Class III direction, dictat-ed by Hemi Hook position.Table 3. Schematic demonstrating bracket torque and angulation for the Bios Light Wire

System. Note the integration of Accent™ nonconvertible buccal tubes and the absence ofheadgear tubes. Bands with headgear tubes are only utilized in cases where a headgear isbeing used. The clinician can select double buccal tubes on both the upper and lower firstmolars to allow the use of secondary or segmental archwires. Convertible tubes are also available for those who prefer to use them.

+2˚ +4˚ +6˚ +3˚ +3˚

+5˚ +9˚ +10˚ 0˚ +4˚AngTq +22˚ +14˚ +7˚ -6˚ -8˚ -10˚ -10˚

DO +15˚ +15˚

Tq -5˚ -5˚ +7˚ -7˚ -17˚ -27˚ -27˚Ang DO +5˚ +5˚

Bios Rx

Figure 21. Class II elastics (A) are utilizeduntil the cuspid is on the downside incline ofthe lower cuspid (C). This averts bracketinterferences as the brackets interlock. Fromthis point onward, Class II vertical elastics (B)are used to prevent bite opening, to use theinclines of the tooth to aid Class II correctionand to keep the teeth together in the func-tional finishing process.

Figure 22. Straight pull Class II elastics areused until the upper cuspid is on the down-side incline of the lower cuspid. The elastic of choice then becomes a Class II vertical.Note that by correct hook placement eventhe vertical portion of the elastic has a ClassII orientation.

23

Figure 20. Although this is at the discretion of the clinician, the Bios System has HemiHooks on the mesial of upper and lower cuspids and the distal of lower first bicuspids.When Class II elastics are used, it is benefi-cial to have the hook on the mesial of thecuspid to create a longer and more horizon-tal pull of the elastic. The extended horizontalspan helps prevent extrusion of teeth. Thisplacement of Hemi Hooks ensures that allelastics are oriented in the correct direction.Note that even the triangular elastics have astraight vertical pull when this arrangementof hooks is used.

Figure 18. Employing gingivally offset brack-ets on the lower bicuspids allows for (a) amore gingivally-placed bracket where upperbuccal cusps might interfere, (b) an earlierideal bracket placement on erupting bicus-pids, (c) a larger bonding pad for increasedbond strength and (d) more accurate bracketplacement by moving the pad edge closer tothe cusp tips.

Figure 19. Nonconvertible Accent™ tubes,combined with gingivally offset bicuspidbrackets, result in root and contact harmonythat has heretofore been unachievable withmany straight wire appliances. This is due tothe inability of the clinician to place the tubesand brackets accurately because of occlusalinterferences and partially erupted teeth,especially the lower second bicuspids. Ofcourse, the clinician needs to learn a newposition for pad placement for this harmonyto occur. The focus is on pad placement toachieve ideal bracket placement.

Dr. Whitecontinued from page 17

• adding a pad of screen mesh as a surface-area-enhancing shim to all loose bands before recementing them (Figure 10).

George Santayana once said, “The empiri-cist is someone who believes in what hesees, but he is better at believing thanseeing.” At present, I have neither theresources or time to investigate thoroughly the effect the Orthos appli-ance is having on reducing the breakageof brackets and bands. Nevertheless,from what I have seen and measured so far, I must label myself a cautiousempiricist who is finally seeing a measur-able reduction in breakage and whobelieves the Orthos appliance somehowbears a portion of responsibility for it.

1Barnett, J. W.: Personal communication.

2White, L. W.: Behavior modification of orthodontic patients. J. Clin. Orthod. 9: 501-505, September, 1974.

3Deming, W. Edwards: Out of the Crisis. Massachusetts Institute of Technology Center for Advanced Engineering Study. Cambridge, MA 02139.

4Miller, R.A.: Bonding fluorosed teeth: new materials for old problems. J. Clin. Orthod. 24: 424-427, July 1995.

5Elaides, T., Elaides, G., Brantley, W. A., Johnston, W. M.: Polymerization efficiency of chemically-cured and visible light-cured orthodontic adhesives: degree of cure. Am. J. Orthod. and Dentof. Orthop. 108: 294-301, September, 1995.

6Jost-Brinkmann, P. G., Schiffer, A., and Rainer, R. M.: The effect of adhesive-layer thickness on bond strength.J. Clin. Orthod. 26: 718-720, November, 1992.

Figure 10. Increasing bond strength of loosebands by adding a pad of screen mesh before recementing them.

used for bonding. the gingival portion of the pad can actually be placed sub-gingivally and still cured properly.

3. Proper placement of Hemi Hooks.A study showed that 30 percent of theadjustment time while the patient was inthe office was spent doing one simplething – tying on Kobyashi ties for elastics.Small Hemi Hooks can be a great time-saver but they have draw-backs, especiallywhen used on all posterior teeth.Cleaning and tying are more difficult and bracket placement can be somewhatcompromised. These problems are by andlarge alleviated by ordering Hemi Hooksin just the right places. The placements of choice are the mesial of upper andlower cuspids and the distal of lower firstbicuspids.

4. Optimesh bases. Optimesh™ bases onlarger pads significantly improve bondretention. Research reveals a 35 percentimprovement in bracket retention fromOptimesh alone.

5. Accent buccal tubes integrated with Biosbrackets. The use of Accent tubes on bothfirst and second molars simplifies arch-wire placement and molar rotation whileeliminating the need for disarticulating or tying in convertible molar tubes. These unobtrusive tubes (see ClinicalImpressions, Vol. 5, #1, for my article onAccent tubes), with their funneled mesialopening, allow for easy insertion of bothsuperelastic leveling archwires and morerigid ideal archwires further along intreatment.

ConclusionThe Bios light wire system offers the clinician who is interested in using

lighter forces and wires an entry to Orthos technology. This highly sophisticated system affords a

clinical efficiency that is non-pareil. The next article will

focus on the retention proforma.

*Offset cuspid brackets are undergoing clinical trials and are not yet available as

stock itms.

Dragon Slaying 101April 21-26, 1997

Drs. Jim Hilgers and Rand Bennett aregirded up again for their next hands-oncourse on slaying those monsters thattorment your practice. The focus is ondiagnostics, case presentation, mechan-otherapy and management, with anemphasis on noncompliance therapy.“The Essence of Practical Orthodontics”is based on flexible techniques that willarm you to the teeth with good clinicalideas that can be used in any practice,any time, any place. And what betterplace to do battle than the beautifulSouthern California coast in MissionViejo, where the next course will be presented April 21-26, 1997. For course infor-mation, call Kim at (714) 830-4101.


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Figure 24. Gingivally offset cuspid brackets*are useful with incompletely erupted cuspids.The bracket pad can be placed subgingivallyand light cured, the large pad aids in thebracket retention and the edgewise bracketis preferable to a simple button for achievingroot alignment.

Figure 25. Positive lingualroot torque in the upper andlower cuspid counteracts thetendency for detorquing withmost mechanics. Note thetorque change between thelower cuspid and the firstbicuspid. Tooth morphology,contact relationship and support by the lingualplanum alveolare dictate this crossover from positiveto negative.

is equivalent to that of a BB** (Figure 5).In addition to the conservative nature ofthis restoration, the all-porcelain ponticand wings provide for an exceptional esthetic result (Figure 6). Lastly, to add a more natural look, the tissue is “scoopedout” upon placement of the final restora-tion so that the pontic appears to comeright out of the tissue (Figure 7). It is important to do this on the model in thelab prior to construction of the pontic –not in the mouth – before insertion. The healing gingiva recontours nicelyaround the final restoration (Figure 8).

An even newer option is belleGlassHP,™*** a conservative, strong (polymerglass) and esthetic resin-bonded pontic. It is the latest esthetic restorative and provides high flexural strength, affordingthe best of both porcelain and compositerestorations. The superior color depth,light absorption and enamel-like lustermake the belleGlass HP restoration virtually disappear in the mouth. The material is cured under high-pressure nitrogen at 280°F and wears at a rate of only 1.2 micrometers per year, but itwill not destroy natural opposing teeth.

ConclusionWhile there are many options for thepractitioner today, dental materials continue to improve and provide evenmore options for our patients. These conservative, strong, esthetic options offer an alternative to prepping for fullporcelain-fused-to-metal three-unitbridges or the use of implants on an adolescent teen. This advancement indental materials, coupled with goodrestorative work and a team approach to management of this problem, providesthe best option available for our patients.

* IPS Empress is a ceramo-glass material from Ivoclar Williams, Amherst, New York.

** Special thanks to Dr. Malcolm Gordon, Columbia, South Carolina, for providing some of the clinical slides of the restorative process.

*** belleGlass HP is a polymer-glass material from belle de st. claire, Orange, California.

Dr. Boydcontinued from page 18

Figure 5A. Lingual view of BB-size prepsprior to electrosurgery to remove tissue andbefore bonding of pontic.

Figure 5B. Pontic bonded in place.

Figure 6A. Facial view of pontic. Figure 6B. Lingual view of pontic on model.Note wing extensions.

Figure 7. Model preparation of tissue area inlab, an important step for aesthetics.

Figure 6C. Facial view of ceramo-glass pontic.

Figure 8A. Resin-bonded pontic a few weeksfollowing placement.

Figure 8B. Close-up view of pontic. Note appearance of pontic at gingivalmargin.

Resin-Bonded Pontic

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The last form of IDT communication is visual communication. This includes photographs, radiographs, study casts, diagnostic wax-ups, diagnostic provisionalrestorations and other means to provideinformation that is difficult to communi-cate verbally. These sources of visual com-munication can be invaluable in IDT andshould be standardized, organized andreadily accessible to all team members.

One of the most common sources ofbreakdown in multidisciplinary therapy ispoor communication due to the fraction-

alization of patient records and associatedtreatment information among the variousteam members. This can lead to great confusion about what diagnostic recordshave already been performed and as towhere the patient is in the course of his or her treatment. To help prevent thesebreakdowns in communication, an IDTRecord can be utilized which contains allthe diagnostic and treatment records,progress notes and any other associatedinformation in one concise, formatted reference. The IDT Record precedes thepatients to all the different providers and

creates the common thread that keeps theteam organized and going in the same direction while helping to prevent repeti-tion of diagnostic records. The proven effectiveness of the IDT Record can greatlyreduce the amount of correspondence andteam conferencing.

To further focus the team, the history anddiagnostic forms of all the individualmembers can be compiled and standard-ized so that everyone on the team uses thesame forms. This establishes a commonstarting point, and providers can ask

Figure 6. Electronic communication is already having a major impact on the effectiveness of IDT and is greatly reducing the burden it placeson doctors and their staffs. The IDT electronic network illustrated above is designed to allow any dentist or specialist wanting to participate in IDT to utilize the system with as little as a telephone or as much as a full local area network. The IDT electronic network was developed inconjunction with Oasys Imaging.

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questions related to different disciplinesthat help determine who should be on theteam. Copies of these completed formsshould be sent along with the IDT Recordto the other team members before theirspecialized evaluations, so that the patienthas to fill out only one form, even thoughthey may see three or four differentproviders. Little things such as this, theorganization of the IDT Record and the ob-vious effectiveness of the interdisciplinaryteam, can significantly enhance patientconfidence in the team and can help motivate them toward comprehensivecare.

The newest addition to IDT is the imple-mentation of electronic communication and it is already having a major impact.Electronic communication uses fax machines, voice mail, word processing,electronic patient-records storage, imagemanipulation and computer networking,and now, even the Internet to reduce theburden IDT places on its providers andtheir staffs (Figure 6). An example is theuse of voice mail or e-mail for conferenc-ing with other providers in their offices.We are all familiar with the frustration ofplaying phone tag with other doctors todiscuss patients and the overall interrup-tions that phone calls make on our dailyschedule. A centralized team voice mail ore-mail system almost completely alleviatesthis by allowing concise messages to beleft by one provider and then reviewed,answered or hard copied by the other athis or her leisure. Soon providers, in theiroffices or homes, will be able to effectivelyconduct video conferences over theInternet with the patients’ records and livevideo images of the team members beingdisplayed on their computer monitors.Word processing with sophisticated IDTdatabases and question/answer streamsnow empower all team members to easilytake part in highly structured and efficientIDT correspondence at chairside withoutwriting or dictating.

But probably the most useful and excitingarea of electronic communications is thatof electronically storing and managing patient records. These records include all

correspondence, progress notes, patientforms and visual information such as radiographs and patient images. These can be recorded easily and stored at onesite, then shared and utilized by any authorized team members in their officesor homes through the use of modems,storage medium, the Internet, fax machines and even inexpensive hardcopies. With electronic communication,the team no longer has to worry aboutsharing and manually transferring one setof records. Instead, every team memberhas immediate electronic access to all patient records and the exact status of patient treatment.

When performed properly, IDT can buildand strengthen professional and patientreferral sources, increase practice effective-ness and profit, lower provider stress andelevate the patient’s perceived value oftherapy and the providers’ reputations.The three hallmarks of IDT – commoncomprehension, regimental sequencing andextensive communication – and the recentaddition of electronic communication havebeen instrumental in elevating my team’slevel of interdisciplinary care, as well asthe overall enjoyment of our profession. I hope they will do the same for yours.The long-term primary and secondary effects of IDT can make it a highly effective and professional means for positioning your practice for both nowand in the future. The bottom line aboutIDT is that even though all the disciplinesand all the individual providers havemuch to gain from an interdisciplinarydentofacial approach, the most importantand greatest benefactors of all are our patients.

For more information on InterdisciplinaryDentofacial Therapy (IDT), setting up anIDT study group, IDT forms, upcomingIDT lectures, etc., contact:

IDT Systems1915 Green Acres RoadFayetteville, AR 72703Fax (501) 521-6141

orwww.Dental-IDT.com

InterdisciplinaryDentofacial Therapy:A ComprehensiveApproach to OptimalPatient CareRichard Roblee, D.D.S., M.S.with a foreword by Peter E.Dawson, D.D.S.

The IDT approach affords today’s ortho-dontist the clinical, practice manage-ment, time management and marketingbenefits critical to properly positioningthe practice to meet the challenges of thefuture. From diagnosis to maintenance,Interdisciplinary Dentofacial Therapyprovides the concepts and methods that allow dental practitioners in all disciplines to create professionally integrated teams that consistently maximize treatment outcomes. Richly illustrated, the book presents cases inwhich IDT provides optimum outcomesfor complex dentofacial problems and a detailed model, as well as practical suggestions, for establishing and coordi-nating an interdisciplinary team. It alsoincludes extensive material on communi-cation and documentation using the latest technologies.

Interdisciplinary Dentofacial Therapyis the most complete text available onIDT, with 236 pages and 473 illustrations (442 color). It is available for $128 from Ormco (see order information onPage D of the Center Section) or fromQuintessence Publishing Co., Inc., 551 North Kimberly Drive, Carol Stream,IL 60188-1881; Tel: (800) 621-0387 or (708) 682-3223; Fax: (708) 682-3288.

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