Hard-Core Orthodontics©

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Observations from over thirty five years of orthodontic practice:

Diagnosis:

1. Most of us diagnose by what we think we can do with the appliance we use. Nothing is wrong with this as long as we do no harm. I was taught in ortho school that most orthodontics could be done without extraction. Wow, did I have a revelation when I got into practice. From what I have seen, there is only so much space that is gained by expansion. Most of the space gained is by proclination of the incisors. This is why practitioners who don't extract when they should must use three to three bonded retainers. I have seen what happens down the line. It isn't nice.

2. Always recognize tongue thrust and temperomandibular dysfunction problems. Tongue thrust may cause anterior root resorption as well as treatment and retention difficulties. TMJ problems must be found before starting. Possible problems with the joint may be exacerbated by treatment. Or, treatment may ameliorate joint problems. Make sure the patient is not a thumb sucker. Neither Class II nor open bite treatment will work until this habit is corrected. Some teenage and older patients will have this habit.

3. If you want to know occlusion, take Dr. Pete Dawson's course. It is the best I have taken. I took it the days before the ABO oral exam. It helped me pass the exam.

4. Some people get so tied up with measuring their cephs that they lose sight of what is important. Many ceph measurements amount to measuring the immeasurable. I don't think that we can measure to the accuracy of 1/2 a millimeter or degree. But that's what you read in the literature.

5. Mounting models is often unnecessary. The University of Alabama Orthodontic School (Dr. Sadowsky) doesn't do it anymore. If you know how to position the jaw in its proper position, you can write on the chart what happens. I do mount an occasional case, particularly if I think I will show it to someone else. If you have trouble breaking the habitual bite pattern, centric occlusion, a flat plane splint will help determine where the jaw should be placed, centric relation. I use this only if it will influence treatment. I try to finish so that CO=CR.

Treatment:

1. The appliance I use now is a differential anchorage appliance. This is, without a doubt, the appliance of the future. But, not many orthodontist use it now because they have been taught that tipping is not to be done. If you haven't been taught how to handle a tipped tooth, it is very difficult to be brave enough to attempt to do so. As we all know, it is easier to move a tooth by tipping than by bodily movement. Extrusion is more easily done than intrusion. If I want a tooth to move mesially or distally, I use the tipping slot. If I want a tooth or teeth to stay put or to be used as anchorage, I place the wire in the edgewise slot where the most friction and resistance to all but bodily movement, the most difficult movement, lies. I use Lancer's Spectrum® bracket. It has four usable slots. I can make a tooth do almost anything with this bracket.

2. Interproximal stripping is the best new method in years. Some Class I cases will treat in less than a year. I use a brass separating .032" to go beneath the embrasure. I take off enough enamel to allow the wire to come through the embrasure. I use a small tapered diamond burr. After stripping is done, I round off any sharp edges, check with a scaler that there are no ledges, then, take bitewings to be sure interproximal sides are parallel, etc. I finish with a fluoride treatment after brackets are placed. Try to bond rather than band the molars on a stripped case.

3. If mandibular canine interdental distance is so important, why do most orthodontists ignore it? Or place a three to three bonded retainer to hold the expanded distance.

Finishing:

1. Before you spend an extra six months getting all the marginal ridges exact, all the roots perfectly aligned, etc., ask the patient how important it is to him. If the patient is paying extra for this as in overtime charges, he should have some input. If the error from perfect is only slight, Mother Nature may help with the final alignment. Of course, if you are readying the case for an ABO exam?

2. Before I began to use Straight-Wire, I didn't use many retainers of any kind. I took the Roth course. Now, I do. I think that anterior root paralleling is more difficult than with Begg. I think that with Straight Wire there is a tendency to lose anchorage and procline the mandibular anteriors. You will definitely need permanent three to three retention. Most, not all, of the criticism of the Begg appliance is unfounded.

3. Take a pan and ceph before appliance removal.

4. My major criteria for finishing involves the following: A. All roots parallel, with the upper and lower lateral roots a little distally inclined. There are cases that have teeth with aberrant or crooked roots. If they are made parallel, the crown will be significantly out of alignment. These are exceptions to the root paralleling rule. B. Parallelism involves bucco-lingual axes, particularly of the lower incisors. I feel the buccal and lingual aspects carefully before appliance removal. C. Make sure that the maxillary lateral roots are properly torqued. Usually, they will need some buccal root torque. D. Over rotate all rotated teeth! C. At appliance removal, flatten the contacts of the lower incisors. Keystoning is even better. This involves doing the interproximal stripping so that it will help hold the over rotated position or prevent relapse. E. To make sure you have the Class II corrected, check the second molars. F. Try to have the mandibular incisors around 90º to the mandibular plane in Caucasians, 100º , in African Americans. Torque the maxillary anteriors to meet them at around 125º/150º . G. Have the A-P line close to the mandibular incisor edge. In African Americans, lower incisor edge in 3-5+ mm., in front of the AP line.

5. You will be often be surprised to find that upon finishing a case that looks good that there are interferences in protrusive or lateral. These interferences are enough to cause some of the incisors to loosen. Place your index finger across the maxillary incisors and get the patient to tap in in centric ( CO should equal CR) and then slide the mandible into a protrusive end on position. Relieve any excessive contact that is causing loose teeth by holding or pressing on the incisors during these movements. Many times there is no incisor contact in protrusive due to interference from the mandibular cuspid or first bicuspid. Sometimes, a molar will prevent protrusive incisor contact. If the anterior teeth are to firm up, all excessive interferences must be relieved. You could be setting the patient up for root resorption or gum recession if you do not. Check for balancing contacts in lateral excursion. Relieve these, also. I want a cuspid rise rather that group function, if I can get it. Hanging maxillary palatal cusps are not good but are of little consequence if they do not produce balancing contacts. A good cuspid rise will eliminate most balancing contacts. Excessive cuspid contact force will cause a stripping of the gingiva on the cuspid. Maxillary anterior occlusal alignment may contribute to interferences. The maxillary cuspids should be the relatively longest tooth. The centrals the next longest by half a millimeter. The shortest, the laterals by yet another one half a millimeter. The mandibular cuspids should be slightly higher occlusally than the incisors. They should not cause interference with the maxillary laterals on protrusion.

Money:

1. The best orthodontists don't necessarily make the most money. The best con men do. Don't ask me if there are any con men doing orthodontics. There are a lot of good orthodontist out there. Some do quite well financially. The orthos who make their patients feel important, do well.

2. I have been charging a monthly fee that I let run for 30 months rather that 24. This way, the patient doesn't have to come up with a lot of money to start. I explain to the patient/responsible party that the payments will run longer that the treatment. A credit check is done on all starts. The first payment is due when we take records, the second, at bonding, then thirty more over the next thirty months. This way, the orthodontic fee is the same or more than that of other orthodontists in the area. I don't feel as pressured to finish the case, either. If treatment time is longer, a per visit fee kicks in. Simpler cases are charged less. But, I make sure the fee is predicted to run longer than the treatment, because I am behind, money wise, for the first few months. I HAVE DISCONTINUED THIS BECAUSE IT GOT ME INTO THE COLLECTION BUSINESS MORE THAT I WANTED TO BE. IT GOT ME A LOT OF PATIENTS AND MORE INCOME, BUT...............

More:

1. The orthodontists that should go to Continuing Education courses, don't.

2. Though some general dentists can do acceptable orthodontics, why do they bother. It looks easy to the dilettante or orthodontic dabbler. So does playing the piano. If the dentist doesn't know what to look for in a "completed" case, he sure won't find it. The patient may not find out what kind of orthodontic job that was done for years. Believe me, I have seen the results of poor orthodontics over and over. The dentist who does orthodontics without proper training is just asking for trouble. And now Invisalign.

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