One Easy Way to Reduce Treatment Time and Broken Braces

In a previous posting, I talked about controlling vertical growth problems by placing composite resin or glass ionomer cement on the occlusal surface of terminal molars.  You can also place composite on the lingual of upper anterior teeth.  How do you decide which to do? If you want to intrude molars (think open bite), use posterior turbos.  If you want to extrude molars (think deep bite) use anterior turbos.

The best way to do anterior turbos to extrude molars is with custom turbos from Kelley Incisal Blocks Laboratory.  You merely obtain an anterior alginate impression and, on the lab sheet, you specify how much overbite you want to finish with.  I usually ask for 4 mm.  You also have to specify the length of the block.  This means how much overjet there is between the incisors when there is 4 mm of overbite.  This must be determined clinically but I usually just ask for 9 mm and cut away what I don’t need.  Almost always they are placed on the central incisors but can be placed on the lateral incisors if appropriate.

To bond these into place, you merely micro etch or pumice the lingual of the upper central incisors and then either traditional etch for 30 seconds or use a L-pop for 5 seconds.  Place  a generous amount of flowable composite on the custom turbo surface that faces the tooth.  No bonding resin required.*  Then place the custom turbo on the tooth.  The cap insures that it is at the proper height.  Do not etch the incisal 1 mm of the tooth so that the cap will be easy to remove.

*No sealant makes it easier to remove the cap at the end of this phase of treatment.  If you are dealing with a deep bite particularly in a teenage male carnivore, use Assure or something similar to enhance bond strength.

Light cure for 30 seconds.  Then use a #8 round bur in a slow speed to remove the cap and to smooth out the lingual anatomy as necessary.  You can advise light chewing for the next 24 hours but these things are pretty rugged and they rarely come off.  Depending on your state laws, all of the above can be delegated.  Finally, mark with blue paper and decide whether you need to full 9 mm or you can remove the excess with a straight diamond in a high speed.

In the photo below right, you can see I cut back on the length of the block.  I usually leave the turbos in until I am in a full size lower working wire.  For me that is a 19x25 in a 22 slot.  So that usually means 6 months.  You only have to grab the sides of the turbo with a How plier and squeeze once or twice to remove it.  Typically this fractures the cement and the turbo comes off.

Some people like to put these on during space closure if extractions were done or even in a deep bite non extraction case.  By opening the bite, you facilitate tooth movement.

                                                                           

Please make any comments or ask any questions below.

                                                                                                          

Modifying a Nance Button To Use As a Bite Plane

While I use turbos of all sizes and locations, sometimes using a bite plate is the way to go.  Unfortunately, patients don’t seem to like removable bite plates as much as orthodontists like them.  So following the lead of my restorative colleagues (“I do fixed everything if possible, nothing removable”), I started doing fixed bite plates quite some time ago.

You start with a Nance button (see my post of October 11, 2014) and then extend the acrylic up on the lingual of the central and lateral incisors. (see the first image)

After curing the acrylic and removing the Nance from the model, you will notice that the underside of the acrylic that touches the central and lateral incisors has the images of those teeth.  You need to polish the images of those teeth away.  (see the 2nd and 3rd images)  If the acrylic does not actually touch the lingual of the upper incisors, you have nothing to worry about as far as decals go.  Please note that I did not trim the acrylic on the lingual of the laterals since I had planned to grind away that entire area.

Please make any comments or ask any questions below.

In my next post, I will discuss several different approaches to posterior and anterior turbos.

Improving Nance Button Use

Now that many of us have migrated our anchorage needs to miniscrews, there is less call for Nance buttons as anchorage enhancers.  They still have a use though.  Here are some ideas on optimizing the use of Nance buttons as well as reducing patient problems:

1. Keep the acrylic portion as large as possible.  Think half dollar not nickel sized acrylic.  The use of larger acrylic buttons reduces the pressure in any particular area.
2. Don’t impinge on the incisal papilla.
3. Ask your lab to use Triad gel for the acrylic portion and not to treat the tissue side of the acrylic with any type of oxygen barrier to eliminate the oxygen inhibition layer.
4. When delivering the appliance, place a thin layer of Triad gel on the entire tissue surface and seat the appliance to the same degree you would if cementing it.  This can be delegated.
5. Light cure the Triad gel in the mouth for 15 seconds.  It gets very warm so don’t overdue the curing time.  This can be delegated.
6. Continue to light cure out of the mouth and trim the excess.  This can also be delegated.
7. Cement the appliance as your normally would.

The Triad gel addition before cementation creates a truly customized appliance with a very intimate adaptation to the patients soft tissue.  This will virtually eliminate emergencies since nothing will be able to lodge underneath the acrylic and cause discomfort.  Also, by having a custom surface, you reduce any pressure points during the use of the Nance button.  When you remove the appliance, you will be amazed at how healthy the tissue looks.

Please feel free to comment or ask questions below.

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.