How to Control Open Bite Tendencies with Fixed Appliance Therapy

In the old days of orthodontics, the rule for patients who were vertically challenged was to not bracket the second molars.  Bracketing the lower 7s especially was viewed as a way to open the wedge and create a true open bite in a susceptible patient.  This approach was clearly a compromise since not bracketing the 7s allowed them to "wander" and sometimes resulted in a weird final occlusion.

The current approach is the opposite.  In general, you want to bracket the lower 7s as soon as possible.  Uppers also if they are available.  Then if you fear opening the bite is a possibility, you place a bonded bite turbo on the buccal cusps of the lower second molars.  If the lower 7s are not available, you can do the same thing with the last tooth in the lower strap up, the first molar, and then duplicate this when the lower 7s erupt.

At the same time (first or second visit) you ask the patient to wear vertical elastics (deltas) from the upper 3s to the lower 3s and 4s.

The idea is to prevent bite opening by keeping the molars intruded and supplementing the action of the masticatory muscles with elastics.

Finally, when bracketing the upper second molars, be very careful about accidentally extruding the 7s.  This is best accomplished by setting the bracket height to no more than 2 mm below the cusp tip. Rick McLaughlin calls this approach "hanging the bracket in space" since it seems that it is barely on the tooth.

Please feel free to comment or ask questions below.

TAD Procedures to Increase Success

Recently, I was chatting with a resident and he stated that he had recently lost 60% of the TADs he had placed and was wondering what he was doing wrong.  Not just residents relate these kinds of frustrations.   An experienced orthodontist was also telling me that he could not understand the hoopla about TADs since he has lost 80% of the ones he has inserted.  He then answered my next question on who was placing the screws and he told me an OS and a periodontist.  That is a mistake.  You must place your own.

I've placed 800 TADs but certainly I lost a lot of them in the beginning.  On the other hand, I’ve lost only one since September in my office. Here is a short list of things to be aware of when you’re doing TADs:
 1. Generally, TADs work best if you use them as part of your original treatment plan and not as a bail out when something goes wrong. They can be used for that but generally they don’t work as well
2. before inserting a TAD, have the patient rinse with Peridex for one minute
3. you should insert the TAD slowly. Some people have said that it should take you a minute to fully insert a single TAD 4. if I am inserting a TAD between the roots of the maxillary second bicuspid and maxillary first molars, I almost always diverge the roots first using a Z bend on a 14 steel (Australian) wire.  Depending on the case, I might not even worry about levelling the rest of the teeth until the second bicuspid root is diverged.
5. I may also do this in the mandible but it seems less necessary as a routine recommendation.  It’s generally always a good idea in the maxilla
6. there are certain locations in which TADs work best and I almost always use those locations. If you choose to use a different location you can expect to have a higher failure rate. Those locations are as follows: (1) The only real location that is predictably successful on the buccal of the maxilla is the surface between the five and the six.
(2) There are four locations on the palate.  (2a) inter-radicular between the 5 & 6.  (2b) inter-radciular between the 6 & 7 (2c) mid palatal at the level of the mesial of the first molar and (2d) mid palatal at the level of the mesial of the first bicuspid.  This is also just about where the third rugae if located.
Anyplace else you can expect a higher failure rate.  Learn to adapt your mechanics to these predictably successful insertion areas.

Finally, I use three TAD systems in my office.  On the buccal surface in the maxilla or mandible, I only use C-implants unless there is some special reason not to.  What I really like is the C-Implant comes in two pieces and it is designed to partially osseointegrate.  You insert the first part of the C-implant flush with the gingiva and allow it to rest unloaded for 6 weeks.  It partially integrates during those six weeks.  And  since nothing protrudes from the gingiva, there are no occlusal forces on the TAD during those initial six weeks.  After six weeks, you attach the second piece and load it.  I rarely lose these TADs.
On the palate, I really like the IMTEC implant system from Unitek.  I use the 6mm anteriorly in the palatal midline and the 8 mm between the roots of the 5-6 area.  The 10mm goes between the 6-7 roots.   The IMTEC comes with a stainless steel cap that allows me to solder an auxiliary.  This auxiliary typically is used to stabilize the adjacent tooth for indirect anchorage.  You can do the same thing by bonding a wire from the adjacent tooth to say a Vector TAD but my staff does not like me “fiddling” with that and using valuable chair time.  Using the IMTEC system requires an alginate impression and then some lab work.  When the patient returns, the DA can bond the wire to the tooth and therefore I am not tied up at one chair for an extended time perio.
 Finally, to close open bites, I place the OrthoTechnology Spider screw in the mid palatal area at the level of the mesial of the first molar and connect a niti spring from a TPA to the TAD. Have the TPA made first and then you can use it as a guide where to place the TAD.  I like the 1.9mm diameter and 5mm long screw .  Bigger is better as we all know and the larger diamter really seems to stabilize things.  Using a length of 5 mm prevents inadvertent insertion into the nasal floor.

Continuing Education

Here is a recent sports headline.  It describes the Minnesota Wild acquiring two free agents and the fact that the season ticket sales went "Wild."  Nice play on words.

One of the things I've seen for years is the lack of commitment by recent grads to continue their education.  Think about how much you've already spent and it was not deductible.  Now every dollar you spend on CE is reduced by your overall Federal and State tax rates.  For instance, spending $2000 on a course and travel seems like a big investment when not much is coming in.  If, however, you don't spend the money, you will pay taxes on that full amount.  If your overall tax rate is 40% now, that means you will keep at the end of the year $1200 of the $2000.  Spend the $2000 on a course and you don't pay taxes on that money since you no longer have it.  So the course costs you $1200 in real money not the $2000 it seems to cost at first glance.  Talk to your accountant if this does not seem perfectly clear.  Spend it or lose it.  Up to you.

Now back to the headline.  I see new residents build a new office and feel they have to compete in esthetics with the guy down the street so they max their buildout and have nothing left for CE.  Big mistake. Business people like the Krafts who own the Patriots don't say "I can't afford to buy new free agents.  I'll wait until I earn some more money."  They say "Let me put a winning team on the field and the money will come."  And that is what happened to the Wild.  They ramped up their team and ticket sales exploded.

Now there is a lot of CE on the web.  I would encourage you to look at Ormco, Unitek, Invisalign, etc for economical ways to enhance your skills.  When you travel for a course, do your due diligence and find out the best courses to take.  Usually, this mean two days with one doc not two days at a national meeting.  Those meetings are for socialization.

Things to consider:

McLaughlin's in office course

Warshawsky's Incognito in office course.

Cope TAD in office course

if you like 18 slot, Wick Alexander's in office course

if you want more on TADs, 2 days with Ludwig in Germany

3 days with Tim Tremont in  Pittsburgh for Dx and Tx Planning

You Wear Those Things in the Office?

About five years ago, at one of my orthodontic study club meetings, the topic was "Pearls."  Each member was supposed to speak for 20 minutes on either a clinical pearl or a management pearl.  One of the things I talked about was loupes.  One of the members looked at me like I was crazy and said, "You wear those things in the office?"  I explained to him that I wear them for everything I do except greeting new patients.  I'm sure he thought I had gone around the bend.  Interestingly, though, I was in his office two years later and he was wearing loupes.

Last Monday, our Waterville dentist lunch group met and the endodontist was asked about loupes versus an operating microscope.  He said that he had microscopes in each operatory but usually his loupes were enough.  One of the gp's mentioned that if his loupes were broken, he would just stay home until he had a new pair.  Of course, he said, that was why he had two pair.

So the last time I was at Tufts, Doug asked if he could try my loupes on since the ones he had from school were had too narrow a field of vision.  Mine are Oroscoptic 2.6 and he thought the field of vision was much better for orthodontic purposes than what he used in dental school.

As this was going on, a second year resident asked "Why do you wear those things?"  Sound familiar?  I explained that everything I do is easier with loupes.  For instance, when I cement a band, I don't try hard to have it super tight.  I want it finger tight and then I rely on the Unitek Multicure to keep it where I place it.  I use How pliers and loupes to position it exactly.  Believe me, looking at it through loupes is a whole different thing than looking at it with naked eyes.

A little while later, the same resident asked me for my help removing a rectangular AW.  It seems that the resident could not pull the wire out on the right side.  I looked and saw a very slight bend in the wire distal of the LR7 tube.  The resident did not see this.  As soon as I straightened the wire, it came right out.

If you have loupes, give them a try for orthodontics.  You won't regret it.  Remember anything that helps you work better and faster, means more profit.

The Key to Non Extraction Orthodontics

If you want to do more cases non extraction (at least in the lower arch), you need to see patients as the first bicuspids are erupting.  In my practice I call this point in time a “decision point.”  The patient may or may not be ready for braces but at this point it is possible to treatment plan the patient to know in which direction you should go for successful treatment.

According to the late Dr. Gianelly, 75-80% of patients can be treated non extraction in the lower arch if all you do is to maintain “e” space.  I’ve followed Dr. Gianelly’s teachings in this regard for over 25 years and it has greatly simplified things for me and allowed me to achieve more predictable, high quality results.

No need to expand the arches, no need to extract lower second molars, no need to do Damon.  Just straight forward, good quality orthodontics and you have 4 chances in 5 of a simple non extraction treatment plan.

Also consider that 40% of our patients have small maxillary laterals.  This usually means that the lower anterior teeth need a little IPR.  Let’s say 2 mm is about right.  If you add that into what you gain in preserving “e” space, I think that takes you into the realm of 90% non extraction as long as you see the patient as the lower first bicuspids are erupting.

The mistake that some make is to look at an eight year old and see that they’ve lost “5 to get 4” or 4 deciduous incisors and a deciduous cuspid.  This looks like 8 mm of crowding so they start thinking about extracting 4s.  If you take the “e’s” into account though, it becomes 3 mm of crowding which might be handled by IPR or at worst the extraction of lower 5s not 4s.  Extracting a lower incisor also might work well if the upper 2s are small.

Palatal Anesthesia

Palatal Anesthesia

One of the things that really stands in the way of a fuller utilization of TADs is the need for anesthesia.  Since many orthodontists have never practiced general dentistry, they are especially fearful of of “the needle” maybe even more fearful than some of their patients.  Compounding this fear is that the palate is a better location than the maxillary buccal surfaces for miniscrews in many situations.  I once heard an idiot at an orthodontic meeting state that he did not believe in miniscrews because he had an office policy not to hurt patients.

Probably, the thing you don’t want to use is the traditional syringe.  The sight of that upsets a good number of patients and I find that it is hard for me to control the amount of anesthesia I try to deliver so I probably over do it which makes it painful.

My personal preference for palatal anesthesia is to use TAC Alternate 20% topical anesthesia from Professional Arts Pharmacy* followed by injection with Septocaine or lidocaine using a Septodont Paroject intraligamentary syringe.  This syringe looks like a pen and is less threatening than the traditional syringe.  I also use a 33 gauge needle.  The lever arm on this syringe makes the use of the 33 gauge needle feasible by easily overcoming back pressure.

Protocol:  Dry the area to be anesthetized and place the TAC Alternate 20% for 5 minutes.  Keep as dry as feasible while waiting.  Wash off and wait 3 more minutes.  Using the technique described by Dr S Malamed in his text, very, very slowly inject a small amount of Septocaine.  Usually 1/10 of a carpule is plenty.  That is three activations of the lever arm.  Go as slow as you can.  It should take at least one minute or longer.  If you place the anesthesia directly in the area of screw placement, you can begin to insert the miniscrew immediately.  This works very well.

Alternatives: Baumgaertel feels that the TAC Alternate 20% topical is enough without resorting to the any injection.  He would follow my protocol for 5 minutes and then 3 minutes and then insert the miniscrew.  If the patient feels uncomfortable at that point, you can reapply the TAC or resort to an injection.  I feel that, if Baumgaertel is right, then they should not feel the Paroject injection and that assures me that they will be comfortable for the screw insertion.

Razavi, who teaches with Baumgaertel at Case Western and speaks for Unitek on the IMTEC miniscrew system, tends to agree with Baumgaertel unless the tissue is more than 2 mm thick.  He feels that is the limit of topical anesthesia.  He will use a MadajetXL in areas of thicker tissue.  As a general rule, the tissue is 2 mm or less in most areas we would choose anterior to the mesial of the maxillary first molar in the palate.  Perhaps if you were more than 8 mm from the gingival margin of the first molar, tissue would be thicker than 2 mm.




Speaking of the MadajetXL, that is part of Jason Cope’s protocol.  He will use DepBlu** which is a variation of TAC Alternate.  After the DepBlu sits for 5 minutes + 3 minutes, he uses a MadajetXL routinely.  For those not familiar with a MAdajectXL, it is like a water pistol for local anesthesia.  It uses pressure but no needle to insert the local anesthesia under the tissue.  By doing that, the deeper tissues can be anesthetized although this might take several applications of the MadadjetXL.

*TAC Alternate 20% is available from Professional Arts Pharmacy in Lafayette, LA.
http://www.professionalarts.com/

**DepBlu is available from Stevens Pharmacy of Costa Mesa, CA.  There is a name change.  The dbg ( formarly depblu ) has lidocaine 10% prilocaine 10% tetracaine 4% and phenylephrine 2% sweetened with Stevia.
http://stevensrx.com/

The syringe I use is from Septodont.  It is called a Paroject.
http://www.septodontusa.com/products/paroject?from=10&cat=4

The Madajet XL is from Mada Medical.  It costs $600 but that compares very favorably with a Syrijet II which is $1800 and is similar.
http://www.madamedical.com/merchant.mv?Screen=CTGY&Store_Code=MM&Category_Code=MXD

Handling Post Treatment Relapse

Recently, Dr. Cartsos asked me about using Invisalign express to treat some simple orthodontic problems or some relapse orthodontic problems. After explaining to her that I didn't believe in Invisalign express because it was too limiting, I turned to one of the residents listening in, and asked him what he would do if he had a relapse problem after braces removal.

His response was the response I expected which was to use some type of removable retainer like a “spring clip” Hawley retainer. It's important to understand your orthodontic history in understanding why the spring clip Hawley retainer still exists as a choice in our armamentarium. Not only should it be your last choice but it should be no choice.

In the old days, as some of you know, it was necessary to construct braces from scratch. That was orthodontist and staff intensive as far as work. That isn't done anymore nor do we even do anything as labor-intensive as fitting lower incisor bands. When it was necessary to construct bands, figuring out a simpler way with the Hawley retainer seemed like a good idea. Additionally, I think it was much more common for patients to be prepared to wear a removable retainer as part of their orthodontic treatment. Recently, Georgios Kanavakis asked me what kind of removable appliances I used in my orthodontic practice. My response was, after some thought, that the only removable appliance I used was an upper retainer after the braces were removed.  To ask a teenagr girl to wear a spring clip Hawley 24/7 is a nonstarter.

So if I was in a situation where I had some minor tooth movement during the retainer phase of treatment, I would think of several options that I might use:

1. My 1st choice would be braces. It is so simple and it works so well. We have the most sophisticated braces available now so why use something as primitive as a removable retainer. If you had to use a removable retainer, the orthodontist would then spend a fair amount of his or her time adjusting it at subsequent visits. I don't want to do that. So I would rather take an indirect impression (done by a dental assistant), do a small amount of lab work (done mostly by a dental assistant with only a small amount done by me), deliver the indirect set up (all done by a dental assistant) place an 18 super elastic arch wire (done by a dental assistant) and then retie this arch wire at each subsequent visit (done by a dental assistant). This way there is virtually no work required by the orthodontist other than what we normally do by monitoring treatment. If the patient had been a good patient during the active phase of treatment, I would do this for no fee and consider it part of my marketing especially if the patient’s mom had referred her friends. By using lower braces I'm also testing the patient's commitment to really fixing the problem. If they are not willing to wear braces, it's not that big a deal to them

2. If I suggested braces and the patient really didn't want to wear braces again but I sensed that it was important to her and to mom especially to mom, I would then suggest Invisalign. I would tell mom that I would do Invisalign for the lab fee and then add 10% to the lab fee for impressions, handling and odds and ends (all done by a dental assistant). I think that's a very fair way to handle a problem like this if braces were not an option.

3. The last way I might do this would be if the problem was a very minor one involving a single tooth. I would take an alginate impression and construct a Essix retainer with pressure on the appropriate tooth.