COrthodonticLINICAL

DIAGNOSIS DIAGNOSIS DIAGNOSIS A Comprehensive

FAQ - e-ceph® Web RMODS® THE FUNCTIONAL MATRIX a practical solution using THE MULTI - FAMILY Synergy R® a clinical pearl Table of Contents

A Road Map 4 low friction: traditional mechanics: to the Future A perfect fit By Gary Holt D.D.S. Rocky Mountain® located in RMO® is proud to Denver Colorado, is The World’s Oldest be recognized as 9 Synergy r: a clinical pearl ® Synergistic, Bioprogressive , Breathing the longest-running By Travis Barr B.S. and Gary Holt D.D.S. Enhancement Orthodontic Company®. exhibitor at the AAO. Since the ® 12 Diagnosis diagnosis diagnosis: RMO was founded in 1933 by Colorado company’s inception, A comprehensive cephalometric analysis orthodontist Dr. Archie Brusse. The Rocky Mountain® By Bradford N. Edgren D.D.S., M.S. last 55 years was led by Martin Brusse O r t h o d o n t i c s to enhance and expand clinicians’ whose vision was dedicated to developing has pioneered numerous orthodontic knowledge of various systems, appliances, continued education and future appliance breakthroughs such as pre-formed molar and biomechanics. RMO® Seminars are 32 RMODS / e-ceph systems in pursuit of promoting vital oral bands and the metal-injection-molding conducted throughout the year and around Q & A with Dr. Budi Kusnoto health for every patient. RMO® remains process. the world with lecture specialists trained in privately owned and maintains a rich multiple disciplines. history deeply rooted in Denver culture. RMO®’s innovations have continued 35 the functional matrix: A practical solution using The multi Family with orthodontic advancements such as With a world-wide distribution network, a ® ® By Dr. Franco Bruno Martin Brusse realized his goals in two very RMODS and e-Ceph computer aided subsidiary division in Europe, and a joint special and capable people he confidently diagnostic services, interceptive pediatric ® ® venture operation in Japan, RMO is truly selected to continue guiding RMO into appliances, and the Straight Wire Low a global manufacturer. Rocky Mountain® ® the future, Tony Zakhem and Jody Hardy. Friction system which includes RMO ’s Orthodontics has been awarded twice ® patented Synergy bracket line, the Dual- with The President’s distinguished “E-Star Rocky Mountain® Orthodontics proudly Top temporary device system, Award for Exports” by the U.S. Secretary supports the local community and is honored ® and the RMbond Indirect Bonding of Commerce “For continued outstanding to design, engineer, and manufacture its system. contributions to the Export Expansion premium quality orthodontic products with Program of the United States of America”. pride in the U.S.A. ® RMO is dedicated to developing In addition, in 2008 RMO® was awarded Continuing Education programs designed the Governor Award for Excellence in Exporting.

Many of RMO®’s great developmental strengths come from valued relationships and the exchange of oral health concepts, innovations, and educational information. Combined, this process allows RMO® to service customers around the world with progressive Synergistic System treatment solutions.

“RMO® is proud of our heritage, history, and legacy. Tony and Jody have recently completed the formation of an entirely new executive management team that will guide the next generation as we move towards the future.”

Back Row: (Left to Right) Frank Augustine, Jeff Smith, Adam Pollack, Hugh Carr Front Row: Jody Hardy, Tony Zakhem

2 Clinical Review Clinical Review 3 lateral incisor brackets (Synergy® brackets) lower frictional resistance (FR) values have a unique passive ligation system when than conventional brackets when coupled an elastomeric tie is used, but the tie has with small round arch wires.11,12 To reduce minimal contact with the wire due to an friction in the mouth some authors have Low Friction: intelligent design. Clearly, the Synergy R® recommended the use of low friction By Gary Holt bracket is the most versatile, active bracket brackets, small initial wires, and less stiff 13 FSC traditional mechanics: ever. It gives complete control to the doctor wires. The benefit of lower friction is more D.D.S. FRICTION SELECTION CONTROL to dictate active vs. passive forces, reduces rapid alignment of teeth, quicker leveling Figure “FSC” a perfect fit Denver, CO friction dramatically, and total treatment of arches, and progression into bigger arch time duration. Some of the highlights of wires sooner in treatment. This allows the the system include rounded arch slot walls doctor to start anterior-posterior changes to reduce binding and friction, and offers sooner, i.e., start using Class II . graduated ® Dr. Gary Holt multiple ligation options—minimal friction The Synergy system is unique in that it Magna Cum Laude from ligation or conventional ligation, maximum can be used with your current anterior- the University of Maryland rotation ligation or minimal rotation posterior mechanics: you can use a Wilson® Dental School and then ligation.8 The bracket has rounded slot Distalizing Arch, Pendulum, or any other completed his orthodontic walls and bosses on the bracket tie wings to distalizing arch. You can use other inter- REDUCED FRICTION residency at the University of minimize the possible contact surface with arch mechanics such as a Forsus, Herbst, Missouri-Kansas City. He has the arch wire and prevent the ligation force AdvanSync, etc. We have noted rapid 9 treatment times for Class II cases when we completed the training to be the market that is truly passive and acts like from exertion on the arch wire. ® couple the leveling and alignment efficiency Dawson Level I certified. His a buccal tube—Synergy R from Rocky ® ® of the Synergy R with the concurrent Class interests are efficient treatment Mountain Orthodontics. This novel II correction using AdvanSync. The point with attention to detailed bracket system has a removable cover over is you’re in complete control and don’t need occlusion, the use of TADs to the arch slot on the cuspids, first bicuspids, to change bio-mechanics to conform to the and second bicuspids that enable the bracket MODERATE ROTATION improve treatment time and Friction is typically the enemy in two areas bracket, but rather the bracket will support to function similar to a buccal tube during effectiveness, and the use of of orthodontic treatment—leveling and your current mechanics. Diode Lasers in the orthodontic the initial leveling and aligning treatment aligning as well as space closure because stages. However, Synergy R® differs from practice. He has completed frictional forces generated between bracket With lower frictional forces, the space every passive self-ligating bracket currently three Ironman races and lives in and arch wire have a significant effect on closing phase of orthodontic treatment on the market because it converts, while 10 Littleton, CO with his wife and tooth movement. The low friction bracket can be accomplished quite quickly. The bonded to the tooth, to a traditional active ® systems seek to reduce friction compared to Synergy R bracket supports your current three children. bracket with full ligation capabilities for conventional orthodontic bracket systems. space closing technique. If you prefer to space closure and finishing during the later There is evidence that these brackets offer distalize canines into Class I with Energy MAXIMUM ROTATION treatment stages.

Why the interest in low friction brackets? “The point is you are in The orthodontic profession has three Orthodontists are trying to minimize total complete control and don’t need major technologies or trends that are treatment time, reduce the patient burden, to change your bio-mechanics to evolving and offering new and exciting ways expedite each adjustment appointment, conform to the bracket, but rather to practice according to the editor of the increase appointment intervals while 1 the bracket will support your Journal of Clinical Orthodontics. These providing superior results and many are 3-D cone beam computed tomography doctors are examining the bracket system current mechanics.” CONVENTIONAL CONTROL (CBCT), mini implants or temporary as a means to achieve these goals. This anchorage devices (TADs) and low friction is nothing new. In the 1930s the Russell Note the novel 6 tie wing design and hook.

bracket systems. At the forefront of the bracket was introduced and reported to do Note the rounded walls and funnel shape orthodontic profession right now is the just that. This bracket would produce more tube for easy entry of wire. question of low friction systems or passive comfort, fewer office visits, and shorter The wire is simply thread through the self-ligating bracket systems and how they overall treatment time.4 Other examples tubes on the 3s, 4s, and 5s. The central and may benefit the orthodontist. One needs of the early self-ligation brackets were the to look no further than a recent issue of Ormco Edgelok (1972), Forestadent Mobil- American Journal of Orthodontics to Lock (1980), Orec SPEED (1980), and A MAXIMUM CONTROL discover that low friction brackets are a Company Activa (1986).5 The self- ligation 2 hot button topic. In this particular issue concept was given a big boost when Dr. there were two impassioned letters to the Dwight Damon entered his namesake editor expressing polar views on the topic. bracket in 1998 and has continued to enjoy In fact, the editor of AJO, Dr. David a resurgence in popularity since that time.6,7 Turpin, recently penned an editorial urging The Damon system was interesting because more in-vivo studies of self-ligation, low it was a passive bracket that had a “fourth friction brackets and urged prudence when wall” (door) that was comparable to a 3 investigating these brackets. buccal tube. There is another bracket on

4 Clinical Review Clinical Review 5 ChainTM, then that is exactly what you do bracket or placing bends into the arch CASE 2 with Synergy R®. The Energy ChainTM is wire. Synergy R® supports both methods. placed in the same manner as you place it The bracket is very durable because it is Patient presented as Class I crowded with blocked out maxillary right cuspid and severe with a conventional bracket. If you like to manufactured using the Metal Injection Synergy R® Cap crowding in mandibular arch. Treatment distalize the canines into Class I using a Molding (MIM) process and gives the Remover Pliers - T01200 Ni-Ti coil spring then that is exactly what strongest appliance available. Thus, you plan was to open space for UR3 and level you do with Synergy R®. The brackets have can simply debond the bracket, clean the ► Uses joint plier transer to shear off convertible and align the lower arch. caps effortlessly a hook in the middle of the bracket for tooth, clean the bracket pad and rebond the easy access and bio-mechanic advantage. same bracket into the desired position. If ► Easy access the buccal region with little obstruction Once the canines are Class I and you want you prefer to bend the arch wire to finish complete space closure you can chain 6-6 and detail the case then you place the ► Can be used on any convertible buccal tubes and At initial bonding note the blocked out maxillary cuspid and high irregularity in the lower arch. or you can place a crimpable hook on desired bend into the arch wire convertible brackets the arch wire and slide with a Ni-Ti coil and you simply convert the 3, 4, spring. The low friction system lends itself or 5 brackets by removing the cap. to sliding mechanics and space closure is You don’t have to convert all the accomplished very quickly. brackets, just the teeth where the bend is placed. After converting One concern with self-ligating systems is the bracket, the arch wire is tied the loss of torque control, especially in the in with an elastomeric ligature maxillary anterior. To many orthodontists, or steel ligature. In this manner the desire to maintain careful 3D control you can utilize the passive, low of the maxillary incisors is a very important friction benefits during the initial After 12 weeks of treatment space had been created for the upper right cuspid and the lower arch aspect of orthodontic treatment.14 Enter leveling and alignment phase alignment had improved dramatically. ® the Synergy R bracket. This bracket has and then you can finish the case the ability to allow the doctor to dictate with the detail you desire. This is a big the necessary friction in the maxillary and ® CASE 3 advantage of the Synergy R system. Patient presented with a Class II . The treatment plan was to bring the cuspid into the maxillary arch as quickly as possible. Then mandibular incisors. The clinician can dial proceed into the working wires and initiate Class II mechanics. The low friction brackets aided in the vertical alignment of the high cuspid without in the bracket / arch wire friction to fit his / impact to the other anterior segments. her specific treatment needs. If the doctor CASE 1 wants passive ligation in the anterior, that Patient presented with Class II division 2, deep bite, and retroclined incisors. The treatment plan can be accomplished with the use of an was to level the Curve of Spee, align the teeth, followed by Class II elastics. elastomeric tie just around the center tie wings. If he / she desires more detailed rotation control, then he / she can tie only the mesial or distal tie wings. If the doctor wants complete 3D control of the bracket then the doctor can place the ligatures around all wings. This bracket system After 12 weeks of treatment the vertical correction of the cuspid was almost completed without affecting other aspects of the arch form. takes advantage of a completely passive system from the cuspids to the molars, but CASE 4 CASE 5 allows for more control in the anterior. Patient presented with a Class II deep bite, posterior cross-bite, and rotations in Patient presented with a Class III tendency, open bite, and high This bracket offers some of the same the lower arch. The treatment plan was to correct the cross-bite with an RPE maxillary left cuspid. The treatment plan was to bring the ® advantages as a Giannelly bidimensional Note: Maxillary bicuspids Note: Mandibular rotations incisors and then level and align the arches with Synergy R. cuspid into occlusion without impact to the anterior segment. system without the bracket dimensions Maxillary retroclined incisors Mandibular rotations biscuspids needing to be different. The bracket can Maxillary left lateral be passive early in treatment, but can be made to have complete 3D control at any point in time.

As many orthodontists say, “It is not how you start the case, but how you finish the case.” That is indeed the truth. The attention to detail in the finished cases is what separates us as specialists. Another concern with low friction systems is the inability to finish cases as desired. The Synergy R® has overcome this weakness of other bracket systems. Detailing and After 15 weeks of using a low friction bracket, the cuspid was in 13 week follow up photos aligned with .018 x .018 arch wires. The patient was ready to proceed occlusion, and the anterior segment 2-2 had not been negatively finishing of the orthodontic case is usually into the working mechanics phase of treatment. accomplished by either repositioning the affected. After 12 weeks of treatment and expansion the mandibular bicuspids were 6 Clinical Review improved. Clinical Review 7 ® References “Synergy R can make 1. Keim RG. Editor’s corner: orthodontic megatrends. J Clin Orthod Step 1. Push the wire through the bracket until you can all these things easier... 2005;39:345-6. ® see it coming out the distal part of the bracket. ” 2. Am J Orthod Dentofacial Orthop 2009;136:756-8.

3. Turpin DL. In-vivo studies offer best measure of self-ligation. Am In conclusion, I would like to comment on Why do I bring this up? Because the J Orthod Dentofacial Orthop 2009;136:141-2. Synergy R a patient that re-visited the practice recently bracket is not the doctor. The bracket 4. Stolzenberg J. The Russell attachment and its improved and caused me to reflect on brackets. My can’t diagnose, can’t treatment plan, and advantages. Int J Orthod Dent Child 1935;21:837-40. office had seen this patient several years can’t treat the case. The patient should not 5. Rinchuse DJ, Miles PG. Self-ligating backets: Present and future. a clinical pearl ago for an initial orthodontic consultation be asking for a specific bracket, nor should Am J Orthod Dentofacial Orthop 2007;132:216-22. and the family elected to go with another the marketing of a specific bracket be the Article written in by Travis Barr B.S. and 6. Rinchuse Daniel J, Rinchuse Donald J. Developmental occlusion, orthodontist in the area. I had thought place of any practice. Even a fantastic orthodontic interventions, and orthognathic surgery for adolescents. Gary Holt D.D.S. nothing more about the case until they bracket is worth little if the doctor lacks Dent Clin N Am 2006;50:69-86. recently showed up at my practice. The the knowledge or skill to treat the case. Step 2. Place a scalar on the distal part of the bracket 7. Damon DH. The Damon low-friction bracket: a biologically behind the wire and grab an anterior part of the wire with patient has been in appliances for over two The bracket should be a tool to aid the compatible straight-wire system. J Clin Orthod 1998;32:670-80. a Hemostat. years and there has been little progress. doctor in accomplishing the goal of 8. RMO (Rocky Mountain Orthodontics) Product Catalog 2009; p. ® ® . The patient was bonded with a leading 95: www.rmortho.com. Figure 1 Shows the slot and slot cover for the moving the teeth in a faster, easier, and RMO ’s Synergy R bracket System ® self-ligating bracket and as you can see more comfortable and convenient way. is a new and unique frictionless bracket RMO Synerg y R bracket. 9. Thorstenson GA, Kusy RP. Effects of ligation type and method there has been minimal progress over the That is our job. We are still the doctor. on the resistance to sliding of novel orthodontic brackets with system utilizing covered slots on all course of a two year treatment. ® second-order angulation in the dry and wet states. Angle Orthod cuspids and bicuspids (figure 1) as well as a Synergy R can make all these things easier 2003;73:418-30. and can help treatment progress faster. frictionless anterior ligature tie setup using ® 10. Tidy DC. Frictional forces in fixed appliances. Am J Orthod ® ® Synergy R can aid in the A-P, vertical, Dentofacial Orthop 1989;96:249-54. Synergy R brackets (figure 2). Synergy R Two years of treatment- self ligating and transverse correction and Synergy R® brackets offer a frictionless design without 11. Henao SP, Kusy RP. Evaluation of the frictional resistance of the hassle of doors while still providing can aid in the detailing and finishing of conventional and self-ligating bracket designs using standardized the case, but remember that you are still archwires and dental typodonts. Angle Orthod 2004;74:202-11. patients with the much loved ligature colors the doctor and every case still deserves at the later treatment stages. However, as 12. Redlich M, Mayer Y, Harari D, Lewinstein I. In vitro study of the personalized attention to detail that frictional forces during sliding mechanics of “reduced-friction” with all new and improved technology Step 3. Push the wire buccally with the scalar while Synergy R® can provide. brackets. Am J Orthod Dentofacial Orthop. 2003;124:69-73. come challenges. With the Synergy R® Figure 2 simultaneously pushing distally on the wire with the . Example of full arch wire engagement Hemostat. This will allow the wire to come through the ® 13. Materese G, et al. Evaluation of frictional forces during dental bracket the challenge is presented at the using Synerg y R brackets. Also shows the slotted slot. Push an ample amount of wire through; this will be alignment: An experimental model with 3 nonleveled brackets. Am your working wire. Usually the length of two bicuspids J Orthod Dentofacial Orthop 2008;133:708-15. initial bonding, when placing the first cover on cuspids/biscupid brackets as well as the CASE 6 archwire. As with most orthodontic cases, frictionless anterior lateral to lateral setup. is enough. Patient presented with a Class II, division 2 malocclusion, deep bite, rotations, and a poor arch 14. Sinclair PM. Reader’s corner. J Clinic Orthod 1993;27:221-23. the interbracket mesial to distal distance form. The treatment plan was to open the bite by leveling the Curve of Spee, improve the arch form can be very small, and/or have rotational using Synergy R, and then move into Class II elastics. angles that exceed 45 degrees, and/or have “The bracket should be a a height difference of several millimeters tool to aid the doctor in (figure 2). Using Synergy R® brackets to treat these cases works well when full accomplishing the goal of wire engagement in the brackets occurs. moving the teeth in a faster, Complete wire engagement in Synergy R® brackets requires the “threading” of the Step 4. Grab the wire with the Hemostat and thread it easier, and more comfortable wire between and through each bracket through the next tube. The wire will curl back around and convenient way... (figure 2). on itself. The extra wire allows for flexibility and if ” the wire is damaged during this step you can remove the damaged area. In this article we describe a technique that Procedure utilizes the natural flexibility of Ni-Ti to fully engage the archwire. This technique Starting the wire sequence with a .014 results in complete expression of the wire Thermaloy® Plus archwire is preferred for and best utilizes the frictionless environment ® the material property benefits. The .014 provided by Synergy R brackets. Thermaloy® Plus wire works well due to its flexibility, ability to regain its initial shape ® after placement, and adequate force level. “Synergy R The focus of this technique is wire insertion/threading through cuspid and brackets offer a bicuspid brackets, because the greatest After 16 weeks of treatment, the arch forms were significantly improved and the patient was ready challenge is to “thread” the wire from 1st to move into working wires and Class II mechanics. frictionless design” to 2nd bicuspid, and/or from 2nd bicuspid to 1st molar. The following four-step sequence describes this process:

8 Clinical Review Clinical Review 9 SWLF SYNERGY R ®

THE BEST JUST GOT BETTER

RMO®’s SWLF (Straight Wire Low Friction) Synergy R® bracket SWLF Synergy R® provides minimal friction and rapid wire change- represents the latest development in Conver Technology: Passive out, with cuspid and bicuspid brackets that can be converted into when you want it, total control when you need it. No clips, no doors, traditional Synergy®-style brackets at any time during treatment. and no failures. SWLF Synergy R® combines the simplicity and ease Clinically tested and proven effective, SWLF Synergy R® is designed, of self-ligating bracket design with the flexibility and advanced engineered, and manufactured with pride in the USA. performance of Synergy®’s Friction Selection Control® (FSC®) modes. Figure 3. Instrumentation used for wire placement; Clinical photo showing the rotational challenges often encountered.

Another challenge that occurs at initial Discussion Features and benefits include: bonding is when the distal bracket slot This simple four-step procedure works is pressed against the adjacent tooth, not • cuspid and bicuspid brackets feature an integrated convertible cap well in most cases to allow full wire allowing room for the wire to slide through engagement in the most difficult bracket the slot. This can easily be overcome with • can reduce treatment time and appointment intervals placements (figure 3). However, if there bracket placement and a reposition later in is less than 2 mm interbracket distance, treatment. • no moving parts—no broken clips, doors, or slides the technique is not as effective. This Conclusion is due to either not having enough wire Figure 4. Demonstration of a curled wire that was • large flared lead-ins reduce kinking and binding flexibility to complete the threading or not unable to release the torque build-up until further room was By following a simple procedure, full arch having enough free movement to allow made between the brackets. wire engagement is achieved in Synergy • low profile—comfortable for your patient the torque built up in the wire twisting R® brackets unless there is an extreme to be released. A semi-permanent curl ® case of anatomy misalignment. The full • convert to a standard Synergy -style bracket at can result in the wire (figure 4) until more ® functionality of the frictionless Synergy R® any time for advanced FSC modes room is available. bracket system is expressed at the initial bonding.

energy chai n ™ ® ™ Move teeth rapidly and efficiently with RMO 's Energy Chain

Patented formula provides light continuous Stain resistant and latex-free forces for weeks Light-protective spool containers can extend Independently tested and clinically proven shelf-life, and snap together for stacking and Take control of your treatment with FSC®. Combined with SWLF Synergy R®’s integrated convertible cap, FSC® modes performance may reduce appointment intervals storage efficiency ® and save valuable chair time Available in 4 sizes and a variety of colors – deliver maximum tooth-by-tooth control throughout the entire course of treatment. Plus, clinicians can still satisfy color Less stress decay and less elongation over plus Gray and Clear requests even during unconverted bracket stages by ligating the center wings without compromising performance. time compared to virtually all other elastic ™ FSC ® ® All Energy Chain colors perform similarly to FRICTION SELECTION CONTROL (Ligatures illustrated using original Synergy bracket.) chains available Gray and Clear

Closed Reduced Narrow Medium

REDUCED FRICTION MODERATE ROTATION MAXIMUM ROTATION CONVENTIONAL CONTROL MAXIMUM CONTROL

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The World’s Oldest Synergistic, Bioprogressive®, For more information Breathing Enhancement ® To order, please contact your RMO Sales Representative or call 800.525.6375 Orthodontic Company.® or to order call: ® ® The World’s Oldest Synergistic , Bioprogressive , 1.800.525.6375 Breathing Enhancement Orthodontic Company.™ 10 Clinical Review Clinical Review 11 By Bradford N. Edgren RMODS Each of my patients receives a comprehensive cephalometric analysis prior Dr. Bradford Newhall Edgren was D.D.S., M.S. Rocky Mountain Orthodontics Data to any treatment. When taking progress awarded his D.D.S. (valedictorian), Diagnosis Greeley, CO Services® (RMODS®) has been providing records, prior to second phase treatment, I M.S., and Certificate in Orthodontics comprehensive cephalometric analyses of have RMODS® perform a comprehensive from University of Iowa College of lateral and frontal cephalograms since 1969. cephalometric analysis to evaluate the results Dentistry. His academic experience With over 600,000 cases analyzed, RMODS® of Phase I treatment as well as to determine yielded numerous honors and Diagnosis has helped thousands of orthodontists changes in dentofacial relationships due to awards such as Magna Cum Laude ® determine the best, individualized treatment growth. RMODS comprehensive analyses (undergraduate) and National Dean’s ® have aided me in diagnosing upper airway plans for their patients. RMODS provides List (both undergraduate and D.D.S. not only the Ricketts comprehensive analysis obstructions, abhorrent growth patterns, and Diagnosis studies). Dr. Edgren is a Diplomate of but also Steiner, Jarabak, Downs, and Sassouni endochronological problems. Long range the American Board of Orthodontics, Plus. Upper Airway obstruction is evaluated growth simulations have also helped me to and has presented to numerous utilizing six different measurements devised inform my patients and their parents about a comprehensive organizations. His articles have by Handelman and Osborne8, Linder- the probability of orthognathic surgery. been published in both the AJO and Aronson and Hendrickson9, and Schulhof.10 cephalometric American Journal of Dentistry, and Conclusion he is an active member of the AAO, Individualized norms are provided not A thorough and proper orthodontic diagnosis COF, ADA, CDA, and Angle Society. only based upon age and gender, but also analysis including lateral and frontal cephalometric upon ethnic heritage. Utilizing the Visual analyses will only improve treatment Importance of Cephalometric lateral radiographs on his patients to evaluate Treatment Objective (VTO) (short and planning. RMODS® has been providing Diagnosis the craniofacial skeleton. In 1937, Broadbent long term) with arch analysis of upper me with comprehensive cephalometric 3 offered a mean facial pattern. and lower dentition, assists in orthodontic analyses of my patients for almost 20 years. ® Orthodontic treatment faces many obstacles treatment planning. The RMODS Remember, the orthodontist’s treatment plan that can be directly related to existing Growth pattern studies from the third system provides a visual blueprint of will only be as good as the thoroughness of excessive disharmonies of the dental and month of life until eight years of age were recommended dental and skeletal changes 6 4 the diagnosis. skeletal components. These disharmonies analyzed by Allan G. Brodie in 1941. specific to each patient. can be further compounded by aberrant In 1948, William B. Downs developed a dento-facial growth. Diagnosis of such system of measurements in an effort to Each work-up is designed with the discrepancies, as well as forecasting facial define craniofacial dysplasias. Downs only orthodontist’s treatment preferences growth, prior to initiating treatment can utilized a total of ten measurements for his concerning extraction, convexity change, 1 alert the orthodontist of what problems to analysis of lateral cephalograms. In 1953, esthetics, limits of tooth movement, and 5 expect during treatment. Cecil Steiner developed the Steiner method. mechanics. Long range growth simulation The Steiner method became popular to maturity with and without treatment The orthodontist’s treatment plan is only as because it demonstrated an interrelationship aids the orthodontist in predicting the good as the quality of information derived between measurements and gave specific treatment outcomes. Because of the from the diagnostic records.1 Performing guides to treatment planning.6 Sassouni method of long-range growth prediction, a proper diagnosis is essential to good utilized various arcs and planes through the the probability of third molar eruption can treatment planning. Without a proper and craniofacial complex to describe dysplasias. be predicted within 90% accuracy and can thorough diagnosis, treatment planning is at prepare the patient for future removal.7,11 best a guess. Only the naïve clinician utilizes Taking what he felt were the strengths a handful of cephalometric measures or a of the above cephalometric methods; single appliance to correct all .2 Ricketts developed a comprehensive ® Diagnosis is derived from the Greek word for analysis utilizing a combination of over “RMODS comprehensive analyses knowledge. We can only diagnose from what 80 different measurements. Other than we have learned. We must understand the Broadbent, the Ricketts analysis was the have aided me in diagnosing upper airway dentofacial skeleton, recognize normal from only approach that tied together both the 7,2 abnormal, and the limitations of treatment lateral and frontal views into one system. obstructions, abhorrent growth patterns, to develop an appropriate treatment plan.2 Cephalometrics initially was a static system; Cephalometrics is the measurement of the craniofacial growth was not even considered. and endochronological problems. Long dentofacial complex utilizing lateral and The growing patient’s face is constantly posteroanterior radiographs. Properly used, changing. By incorporating the prediction range growth simulations have also cephalometrics can significantly improve the of growth, treatment planning for children orthodontic diagnosis and treatment plan. and adolescents could be improved. In 1970, helped me to inform my patients and Originally, cephalometric radiographs were Ricketts incorporated the arcial growth taken as a research tools to evaluate craniofacial of the mandible into his cephalometric growth. B. Holly Broadbent is credited with analysis. This method of growth prediction their parents about the probability of developing the cephalometric procedure in proved to be reliable for predicting long- 7 1931. He simultaneously took frontal and range growth and occlusal development. orthognathic surgery.”

12 Clinical Review Clinical Review 13 This case is a good example of upper airway Case Study I obstruction and a poor facial growth pattern.

Airway Obstruction and Poor Facial ► Unilateral or bilateral posterior cross-bites She had a history of snoring, , Growth Patterns food allergies, and asthma. Her comprehensive ► Tonsil or adenoids present or history of cephalometric analysis demonstrated the following: Mouth breathing has been identified respiratory problems as a cause for a number of orthodontic 1. Class II canine problems including cross bites, ► Open-bite low tongue positions, and vertical 2. Severe skeletal Class II due to both jaws dysplasias.12-15 Children who have ► Tongue thrust upon swallowing a genetic predisposition towards a 3. Skeletal open bite due to the Mandible narrow, dolichocephalic facial pattern, ► Mouth breathing and having airway compromise are 4. Possible excessive mandibular growth ► particularly at risk to developing long Functional cross-bite with deflection of face syndrome. Moreover, children the mandible to one side or possibly deflected 5. Adenoid blockage of the airway with a genetic propensity to developing anteriorly producing a pseudo-Class I 6. Skeletal buccal cross bite pattern due to the mandible Diagnostic Panoramic Radiograph mandibular , possessing condition. tonsillar hypertrophy and who are Many orthodontists are surprised to learn 7. Mandibular arch wide compared to jaw chronic mouth-breathers are at that the size of the adenoid, tonsil, and particular risk for developing advanced nasopharyngeal airway can be evaluated on 8. Possible low tongue position mandibular prognathism.16 the lateral cephalogram. Linder-Aronson 9 10 Because of her short porion location, high Mouth breathing should also be and Henrickson , Schulhof , Handelman 8 19 cranial base deflection and forward ramus regarded as an obstacle to successful and Osborne , and Ricketts have all devised airway measurements of adenoidal position, she is more likely to grow a lower jaw orthodontic treatment and is likely that is too large relative to the upper face. As a to result in orthodontic relapse if enlargement relative to the nasopharyngeal airway. Radiographic analysis in the lateral result of the upper airway obstruction and poor not treated. It is imperative that the growth characteristics, this patient was referred existence of mouth breathing, as and posteroanterior aspects provides a systematic means of evaluating airway to an Otolaryngologist for evaluation of upper well as its etiology, be recognized as airway obstruction. The tonsils and adenoids soon as possible and ideally before dimensions, the morphogenetic factors affecting lower facial heights, bimaxillary were removed prior to the start of orthodontic orthodontic treatment has been treatment. Following maxillary expansion attempted.7 Since anteroposterior and morphology and dentofacial growth in mouth breathers. Individuals with inherent with a bonded RME (Rapid Maxillary vertical dentofacial discrepancies are Expander), the upper and lower arches were linked to growth, interceptive measures vertical facial growth characteristics are the most significantly impacted by leveled and aligned. should be initiated around age seven. 20 To wait until age 12, when 90% of mouthbreathing. a dentofacial deformity has already RMODS® uses the Schulhof10 analysis of been established, before instituting adenoid enlargement which includes the two orthodontic treatment is not consistent linear measurements by Linder-Aronson with today’s preventative philosophy.17 and Hendrickson9, a linear measurement The earlier the re-establishment of by Ricketts19, the airway percentage in an normal oropharyngeal function and epipharyngeal trapezoidal area described nasal respiration, the more likely by Handelman and Osborne9, and the normal dentofacial development will craniofacial angles N-S-Ba and BA-S- RMODS ® Mandibular Growth Awareness Form alerts the occur. Oral breathing may persist for a PNS. RMODS® analyzes each case for orthodontist to possible abhorrent dentofacial growth. year or more after the airway has been the potential adenoid obstruction of the restored while the original chronic mesopharyngeal airway. Adenoid blockage mouth-breathing habit is “unlearned”.18 of the mesopharyngeal airway is deemed to Ricketts described a condition be present if three or more measurements are one or more standard deviations from associated with upper airway 10 obstruction; he labeled it the the norm. If the patient is a mouth breather 18 and the analysis indicates that the adenoid is Respiratory Obstruction Syndrome. 21 Clinically, Ricketts found the following too large for the airway , the orthodontist characteristics generally associated can make a referral to an otolaryngologist with the presence of enlarged adenoids for further evaluation and appropriate treatment. and tonsils: Diagnostic Intraoral Photographs

14 Clinical Review Clinical Review 15 Case Study II Case Study I continued Frontal Analysis The following progress records were The frontal cephalometric analysis is taken after 24 months of treatment, often overlooked by most orthodontists. prior to banding the second molars and Asymmetries, dental cross bites, skeletal Class II correction. This patient no cross bites, maxillary and mandibular longer snores and her respiration is dental arch widths, nasal widths, now nasal. Note that her low tongue turbinate enlargement, deviated nasal position and forward head posture to septums, and facial proportions can all open her airway has improved. Her be evaluated from the posteroanterior dental has been maintained. cephalogram. Many orthodontists think of the maxilla as being the only culprit of dental or skeletal lingual cross bite patterns. However, many times the width of the mandible can be the major contributor to skeletal lingual cross bite patterns.

Dental compensations can hide overt hypo-plastic maxillary and hyper-plastic mandibular transverse discrepancies. Rapid maxillary expansion can improve skeletal lingual cross bite patterns, but without a posteroanterior cephalogram, it is impossible to diagnose them. The affect of the excessive mandibular width may not be clinically evident until late adolescence, when rapid maxillary expansion may be more difficult. Taking a posteroanterior cephalogram on patients is simple and the benefits to the patient are immeasurable. Furthermore, with the development of cone beam computed tomography, all patients that have a CBCT scan will have both lateral Progress Intraoral Photos and frontal images readily available for analysis with a single scan. This patient presented with a Class I malocclusion, a tendency for a skeletal open bite, possible excessive lower jaw growth and a significant arch length discrepancy with ectopic maxillary Progress RMODS ® Tracing canines. Cephalometric analysis also revealed a skeletal lingual cross bite pattern due to both the maxilla and mandible; as well as “This patient no possible excessive mandibular growth. longer snores and her This patient’s treatment plan included rapid maxillary expansion and fixed Progress i-CAT ® panoramic report respiration is now nasal.” appliances. The result was a nicely Diagnostic Panoramic Radiograph treated Class I occlusion.

16 Clinical Review Clinical Review 17 Superimposition of the initial vs. the final lateral cephalometric analysis Long Range Growth Forecasting (CASE III, CASE IV, CASE V, CASE VI) Case Study III demonstrates both significant horizontal and vertical mandibular growth, as This patient presented with the following predicted in RMODS® initial comprehensive analysis. As previously stated, the ability to forecast problems: the facial growth of a patient to maturity is of 4. Open Bite great benefit. Regardless of how thorough a 1. Class II malocclusion due to the upper right first molar 5. Tendency for Skeletal Open bite due to cephalometric analysis is devised to evaluate the mandible and maxilla a growing patient’s present state, that 2. Severe Overjet technique will be insufficient for treatment 6. Wide mandibular arch compared to jaw planning because of future growth and 3. Severe Class II Skeletal Malocclusion dentofacial development. Incorporation due to the mandible and maxilla 7. Midline asymmetry of craniofacial growth into the method of diagnosis can only result in improved treatment planning. The craniofacial relationships seen even two years after the start of treatment in a growing child may not be the same at maturity. A case treated to suitable balance at age 12 may prove to be a failed result at age 25 due to continued growth. This is especially true in those Superimposition of the current Diagnostic Intraoral Photographs patients that demonstrate abnormally large lateral cephalometric tracing amounts of lower jaw growth during their 22 over the growth to maturity Superimposition of the initial cephalometric vs. the final frontal cephalometric late teenage years and early twenties. without treatment demonstrates analysis on the occlusal plane shows improvement in the cant of the maxilla. ® probable significant growth Rapid maxillary expansion of the maxilla has also successfully corrected RMODS computer performs growth of both jaws, especially the the skeletal lingual cross bite pattern and eliminated dental crowding, simulations by combining the following four growth curves with individual average mandible. However, despite demonstrating the logic in a non-extraction treatment plan. directions and amounts of change per year for the mandibular growth, the approximately 200 cephalometric landmarks. class II molar relationship does not improve without treatment. These four different growth curves are: Treatment designed to take ► Total body height advantage of the remaining ► Soft tissue mandibular growth, while maintaining upper molar position would be of ► Cranial base advantage to improve the class II malocclusion. ► Mandibular growth An orthodontist has more control over the dentition than the skeletal component.7 Each curve is subdivided by race, gender, and skeletal age (this final subdivision is used to classify which patients are normal growers vs. late and advanced growth categories). When treatment planning for a growing patient, it is important to consider how much growth will or will not occur within the treatment time. Skeletal age can be extremely valuable in determining remaining growth in late adolescence. Moreover, the most significant factor in evaluating growth is not absolute amount, but relative amount. It is important, that the relative growth of the maxilla and mandible be normal. Deviations of growth between the jaws within 20% can generally be tolerated, but those deviations greater than 50% will result in a considerable deformity.22 Superimposition of the initial frontal Diagnostic Panoramic Radiograph analysis upon the visual norm

18 Clinical Review Clinical Review 19 Case Study III continued Superimposition of the retention frontal analysis upon the visual norm demonstrates that rapid maxillary expansion during Phase I treatment reduced the probable skeletal lingual cross bite pattern due to additional mandibular transverse growth.

Progress Intraoral Photographs

This patient was treated with rapid maxillary expansion, straight- pull headgear and fixed appliances during Phase I treatment. Superimposition of the initial lateral cephalometric analysis upon the progress cephalometric analysis, prior to initiation of Phase II treatment, shows significant improvement to a Class I molar relationship. The upper molar position was maintained within the maxilla, forward movement of the lower molar and growth of the mandible helped in the correction of the class II malocclusion.

Final superimposition of the initial and retention cephalometric analyses demonstrates the Class II to Retention i-CAT ® Panoramic Report Class I correction. Taking advantage of the mandibular growth as forecasted at the beginning treatment resulted in a nice Class I result for this patient.

These four different “The RMODS ® computer growth curves are: performs growth ► simulations by combining Total body height ► the following four Soft tissue growth curves.” ► Cranial base ► Mandibular growth Retention Intraoral Photographs

20 Clinical Review Clinical Review 21 ®

Case Study IV Superimposition of the initial cephalometric Superimposition of the initial frontal e ceph analysis upon the progress cephalometric analysis upon the progress frontal analysis. This is the case of a Class II malocclusion The frontal cephalometric analysis reveals a analysis demonstrates forward growth of the with the potential for excessive lower skeletal lingual cross bite pattern due to the mandible, as forecasted. jaw growth. Superimposition of the maxilla and the mandible. lateral cephalometric upon the growth Until recently, most diagnostic to maturity forecast shows the potential systems were located and for significant lower jaw growth. maintained in- office and the practitioner was responsible for upgrades, upkeep and maintenance.

Today, ® can delivere-Ceph the latest orthodontic Web diagnostics right to your web browser!

e-Ceph® Web provides an easy two step process for sending patient data and getting diagnostic results. Step one enables users to digitize x-rays directly through their web browser, or to submit files of patient records to our analysts for evaluation. Step two allows Growth to Maturity without Treatment you to receive your results The growth forecast also illustrates no through the same web interface. improvement in the Class II malocclusion, further upright of the lower incisors and So now you can enjoy the deepening of the bite without orthodontic thoroughness and accuracy of treatment. Maintaining upper molar position the RMO Data Service combined with the convenience and and taking advantage of future mandibular Retention lateral cephalometric flexibility of an in-office system. growth will aid in orthodontic correction. analysis

The e-Ceph® Web diagnostic workup delivers the same quality you’ve come to expect from us.

This patient now has a nice final Class I occlusion with the help of the growth prediction.

Diagnostic Intraoral Photos

22 Clinical Review Clinical Review 23

Case Study V This patient presented with a Class II malocclusion. The Wilson® 3D® growth forecast to maturity demonstrated strong lower jaw The Wilson® 3D® system comprises a series of interrelated fixed/removable intraoral modules that simplify growth in a horizontal direction. Maintaining the upper and improve treatment. Wilson® 3D® appliances can be used to supplement all techniques while delivering molar position and allowing for the forecasted lower jaw practical and simple solutions to both typical and extraordinary movement challenges. RMO® sponsors growth will help in correcting the class II malocclusion. numerous CE events that teach the skills needed to incorporate Wilson® 3D® concepts and materials into your present technique. Please call RMO® or visit our website for additional information about the legendary Wilson® 3D® system.

Diagnostic Intraoral Photos

• Time tested and proven

• Over 100 different movements possible, including: expansion, contraction, distalization, space maintenance, bilateral, and unilateral

• Does not replace your current technique – the Wilson® system simply complements your current system

• First phase, early treatment, mixed dentition, and adults

Retention records demonstrating • Preconfigured sizes to fit all patient dental ranges Class II to a solid Class I correction. • Fixed for the patient and easily removable by the clinician for rapid chairside adjustments

For more information, please call 800.525.6375 or visit our website at www.rmortho.com. Retention panelipse Retention Intraoral Photos The World’s Oldest Synergistic, Bioprogressive®, Breathing Enhancement Orthodontic Company.® 24 Clinical Review Clinical Review 25 Case Study VI

The following patient had a severe Class III malocclusion. Superimposition of the lateral cephalometric analysis upon the visual norm illustrates the significant mandibular prognathism.

Superimposition of the initial lateral Superimposition of the cephalometric analysis upon the growth initial frontal analysis to maturity forecast demonstrates the upon the visual norm potential for significant additional mandibular growth. Treatment designed to address this possible excessive growth will improve overall treatment success.

Diagnostic intraoral photos

Superimposition of the progress lateral cephalometric analysis upon the initial cephalometric analysis demonstrating how early treatment involving fixed appliances along with the growth forecast aided in improving this patient’s malocclucion.

Progress Panelipse

Progress photos

26 Clinical Review Clinical Review 27 References 1. Downs WB: Variations in facial relationship. Their significance in treatment and prognosis. Am J Orthod. 1948;34:812-40 Retention i-CAT ® panoramic report 2. Moyers RE: Handbook of Orthodontics 4th Ed. Chicago, Year Book Medical Publishers, 1988

3. Broadbent BH: The Face of the Normal Child. Angle Orthodontist 1937;7:183-204

4. Brodie AG: On the Growth of the Human Head From the Third Month to the Eighth Year of Life. Am. J. Anat. 1941;68:209

Final lateral cephalogram and lateral 5. Steiner C: Cephalometrics for you and me. Am J Orthod cephalometric analysis 39:720-755, 1953 6. Profitt WR: Contemporary Orthodontics St. Louis, C.V. Mosby Co., 1986

7. Ricketts RM: Provocations And Perceptions In Cranio- Facial Orthopedics. Dental Science and Facial Art. Vol. 1 Book 1 Part 2. United States, Jostens, 1989

8. Handelmann CS, Osborne G: Growth of the nasopharynx and adenoid development from one to eighteen years. Angle Orthodont. 46(3):243-259, 1976

9. Linder-Aronson S, Henrickson CO: Radiocephalometric analysis of anteroposterior nasopharyngeal dimensions in 6 to 12 year old mouth breathers compared with nose breathers. Practica-Otorhinolaryngologica, 212, Swiss, 1973

10. Schulhof RJ: Consideration of airway in orthodontics. J Clin Orthodont 12:440-444, 1978

11. Ricketts RM, Turley P, Chacomas S, Schulhof RJ: Third molar enucleation: Diagnosis and technique. J Calif Dent Assoc 4:52-57, 1976

12. Subtelny JD: The significance of adenoid tissue in orthodontia. Angle Orthod 24:59-69, 1954

13. Ricketts RM: Respiratory obstructions and their relation to tongue posture. Cleft Palate Bull 8:3-6, 1958

14. Linder-Aronson S, Woodside D: The channelization of upper and lower anterior face heights compared to population standards in males between ages 6 to 20 yrs.. Eur J Orthod 1:25-40, 1979

15. Quinn GW: Airway interference and its effect upon the growth and development of the face, jaws, dentition and associated parts. NC Dent J 60:28-31, 1978

16. Meredith GM: Airway and Dentofacial Development. Upper Airway Compromise Dentofacial Development Symposium, 1986

17. Rubin RM: The effects of nasal airway obstruction on facial growth. Upper airway compromise dentofacial development symposium. 1986

18. Ricketts RM: Respiratory obstruction syndrome. Am J Superimposition of the initial cephalometric Orthod 54:495 – 507, 1968

analysis with the retention analysis shows 19. Ricketts RM: The Cranial Base and Soft Structures in Cleft Palate Speech and Breathing. Plast Reconstr Surg 14:47- good control of growth with treatment. The 61, 1954 final result was a Class I occlusion. Superimposition of the initial 20. Bushey RS: Adenoid obstruction of the nasopharynx. In: frontal analysis upon the Naso-respiratory Function and Craniofacial Growth. J.A. retention frontal analysis McNamara, Jr. (ed.), Monograph 9, Craniofacial Growth Series, Center for Human Growth and Development, The University of Michigan, Ann Arbor, 1979

21. Poole MN, Engel GA, Chacomas SJ: Nasopharyngeal Retention Photos Cephalometrics. Oral Surg 49:266-271, 1980

22. RMODS Course Syllabus. 1989

28 Clinical Review Clinical Review 29 Why Indirect Bonding? System Highlights

RMO®’s RMBond® Indirect Bonding system provides clinicians a simple and • Reduces chair time consistent solution for maximizing practice efficiency. The RMBond® Indirect Bonding (IDB) system delivers a step-by-step process that • Significantly more comfortable bonding experience for patient allows doctors to fundamentally reduce the amount of chair time involved when bonding appliances to a patient. This • Convenient and more precise final appliance placement on a study model at doctor’s leisure results in a greatly improved patient experience also, as the IDB process significantly reduces the patient’s chair time Inner Tray Material • Reduces clinician neck and back pain by minimizing and discomfort during bonding. The RMbond® system time bent over a patient during bonding procedure allows for extremely accurate bracket placement • No need for two models – study model also under convenient setup conditions working on a functions as IDB model study model, and most of the procedures can be conducted by staff persons with modest Dispensing Gun Tray Finish training. The RMbond® start-up kit is a turnkey system that includes all of the materials necessary to begin Indirect Bonding your patients immediately. unique components in The RMbond® Indirect bonding system include: Round Rope Wax LC Bonding Resin Precise bracket placement on a study model

RMbond® Inner Tray Material:

• Provides predictable and reliable working time, with excellent flow characteristics for complete encapsulation of appliances

• Clear material visibility during bracket transfer assures accurate seating and rapid light curing

• Provides an ideal tear strength LC Turbo Material when removing Inner Tray Material – LC Flowable Adhesive no debonds and minimal cleanup Transfer tray fabrication - Inner Tray Material fully encapsulates all appliances • Eliminates the need for block outs around hooks and undercuts

RMbond® LC Flowable Adhesive:

• Precise dispensing system with needle tip

• Ideal viscosity Model Storage Box • Reduces flash Separating Medium

• Excellent bond strength Rapid patient bonding process - light curing directly through transfer tray

30 Clinical Review Clinical Review 31 Dr. Budi Kusnoto is a tenured full time associate professor in the Department of Budi Kusnoto, Orthodontics, University of Illinois at Chicago. D.D.S., M.S. Q: How long does it take Q: Why do I digitize the Q: What is a Visual His computer science background and knowledge for me to receive my results? upper arch and what Treatment Objective (VTO) in biomechanics as well as management of Department of kind of information will and how does it help me craniofacial deformities are complimentary A: On average results will be returned within it supply me? in my diagnostics? to his teaching in the field of orthodontic Orthodontics 3-5 minutes, depending on the complexity of diagnosis and treatment planning. He also the analysis requested and Internet speed. If ® A: By adding the upper arch you will be A: By using the VTO, we can map our has been actively involved in clinical research University of Illinois you have submitted your records to RMODS provided with the as well as treatment into a moving target (in a growing in the area of temporary anchorage devices, at Chicago for the analysts to digitize, results should be a more complete view of the patient’s current individuals) as well as graphically represent invisible orthodontic appliances, computerized returned within 3 days. situation. our treatment goal in terms of where should orthognathic-craniofacial surgical imaging, 3D we position the teeth at the end of treatment. imaging-computerized treatment simulation, and Clinicians can also utilize the VTO to improve longitudinal digital data mining project. Currently the accuracy of their treatment. We have the Dr. Kusnoto also maintains a private practice A: It is the only cephalometric analysis software in the market that can actually Q: Is there tech support Q: What is a Visual Norm? ability to design how much certain parts of and clinic directorship at the Department of available? the occlusion should be moved, whether it Orthodontics, College of Dentistry University produce interpretation of the cephalometric Where does it come from? numbers and its parameters which can lead is dental or skeletal, in order to achieve the of Illinois at Chicago. He is an active member of : Yes, well trained analysts and technical ® optimal stable occlusion for the patient. American Dental Association, Illinois Society of to formulating treatment objectives, thus A A: e-ceph Web is one of the extremely few coming up with suggested treatment plans support is available Monday through Friday cephalometric software programs currently Orthodontists, Chicago Dental Society, American during business hours. Association of Orthodontists, and is a Diplomate and treatment mechanics including treatment available in the market that has the ability to accurately produce a Visual Norm (graphical of American Board of Orthodontics. sequence and timing. representation of a NORM) which can be Q: Can I get just a height used as a template while treating the case (to prediction? What ® Q: Why would I want to guide clinicians in designing their orthodontic information is required Q: What different types of digitize a frontal? mechanics to move teeth/bone in space). for this? RMODS / analyses does e-ceph ® ® Web offer? A: Much more data, that can influence our A: Yes, all that is required is the patient’s date treatment objectives and eventually treatment of birth and their present height. If you would A: e-ceph® Web offers the same mechanics, can be gathered by simply adding like improved accuracy you can include the cephalometric tools and analyses as the frontal analysis. Often clinicians tend to skeletal age from the current hand wrist film. e ceph ® skip looking at skeletal/dental asymmetry in Q & A with Dr. Budi Kusnoto RMODS service; Ricketts, Downs, Steiner, Sassouni Plus, and Jarabak. the transverse dimension or possible airway ® obstruction which can be quantified using the Dr. Kusnoto has been using RMODS ® services for the past 5 years for his research in validating computerized frontal analysis. cephalometric prediction treatment outcome, he is also constantly involved in evaluating many other cephalometric imaging software in the market.

® ® Q: Is any special equipment through the e-ceph Web RMODS server. All required? Q: Can you provide us with ® : Why do I need to ® data can be securely stored in the RMODS server Q an overview of RMODS facilities and are easily accessible from anywhere on digitize the lower ® A: A computer with standard high speed and e-ceph Web? the planet with a high speed Internet connection. Internet (such as DSL or cable) running arch and what

® standard web-browser will be sufficient to kind of information A: e-ceph Web can be summarized as a run e-ceph® Web application. will it provide me? web-portal (Internet virtual meeting place) to various cephalometric analyses, growth Q: What is the benefit of A: Digitizing the lower dental arch will simulations, data/image management, and e-ceph ® Web? give the clinician much more information case management tools to aid in developing Q: What if I don’t have (about occlusion, tooth size discrepancy, excellent treatment objectives/plans. It can A: e-ceph® Web functions as time to digitize my case? dental development) as it relates to the also be a web-portal for potential inter- cephalometric digitizing software, and skeletal and facial structures which institutional as well as inter-clinician world ® were derived from lateral and frontal also gives you the flexibility of being able : If you would like the RMODS analysts wide exchange of study cases. ® A cephalometric radiographs. The digitized to send your records directly to RMODS to digitize your case, you can simply click on ® information from the lower arch is required where well trained and highly experienced the “PROCESS by RMODS ” option after by the RMODS® program to produce the personnel will digitize them and return the uploading all the necessary radiographs/ treatment planning segments of the results. ® results to you. digital images and patient information into : Why use e-ceph Web? It provides a 3rd dimension of the view of Q the e-ceph® Web system. The final result will the patient. ® be sent back to you by email. A: e-ceph Web is purely web based, meaning it is not installed on a computer. It is ® Q: How is e-ceph Web ® easily accessible through any terminal connected better than the software to the Internet. No updates or maintenance will ever be needed, as this is done automatically that I would have in my office? 32 Clinical Review e ceph Clinical Review 33 Multi-Family Appliances Dr. Franco Bruno received his Medical Degree from the University of Pavia, Italy. His Orthodontic Specialty degree was awarded at the University of Cagliari, Italy. The Multi-Family Appliances Postgraduate Degrees include Straight Wire Therapy and and TMJ Therapy from the are an integrated system of University of Milan and Lingual Orthodontics from the University of Varese. appliances that allow the Dr. Bruno completed the 2 year Zerobase Bioprogressive Course and is the Chair Multi-Family of Bioprogressive Philosophy at the University of Cagliari. He is also Head of the orthodontists to choose the Bioprogressive Department, Dental Clinic, at the same institution. n atio ideal appliance according to Dr. Bruno has a Private Practice Limited to Orthodontics, which he opened in 1986. l Educ Functiona the age and the malocclusion of the patient. The Buccal Midline correction Bumper functional By Dr. Franco Bruno diminishes the acts to insure matrix: Italy effect of the correct labial forces positioning of a practical solution the midline Defined tooth channels using The Multi-Family

The philosophy of “Self Confident This approach is based on simple INTRODUCTION Orthodontics” views the interaction between considerations. If alterations of the the Functional Matrix and malocclusion as a Functional Matrix are the cause of A long-term goal in orthodontics has continuous exchange of information between malocclusions, its neutralization guarantees been to understand the interaction between the two components and, therefore, foresees simpler active treatment. If, however, the the Functional Matrix and malocclusion. a therapeutic protocol that aims at correcting dysfunctions are the result of a malocclusion Research in this area began in the early both parts of the system in order to find its treatment will be more complex; therefore, 19th century and, to date, there is no the most appropriate solution for long-term neutralization of the Functional Matrix definitive understanding. Contemporary stability. The main therapeutic idea is to work would allow faster and more simplified orthodontics recognizes two opposing on each component at different treatment treatment. Lastly, if the resolution of the Can be sterilized and views. The “functionalists” believe that times. In the absence of definitive scientific malocclusion is decisive for correction of the and/or disinfected the Functional Matrix, especially that of a evidence, the clinician must develop his/her dysfunction, control during active treatment Raised Occlusal repositions the muscular nature, is the determinant principle own viewpoint and objectives to best resolve allows a quicker adaptation of the Functional Plane tongue in of malocclusion. Contrary to this belief is the patient’s problems and reach a clinical Matrix to the new occlusion. Therefore, the maxilla the “mechanistics” view, whose proponents outcome that will be stable over time. the guideline is to act on both components say that muscular dysfunctions are a result without certain knowledge of which is the of malocclusion. Unfortunately, the latter Our therapeutic protocol calls for a three- cause and effect. Simplified therapeutic ® Multi-T have yet to submit a theory on the etiology step treatment sequence to address the protocols will produce a better and more e r Lingual of malocclusion. There are various positions Functional Matrix: stable result. r a i n M u l t i T envelope between these two extremes that, to a greater or lesser degree, recognize the influence of 1. Preparation Stage: use myofunctional Based on these concepts we have tried to find the functional matrix on malocclusion. orthodontics at an early age, from 4-5 up a solution to patient treatment with a simple, It is difficult for the clinician to address to 10-12 years of age, while waiting for the economical, and easy to use myofunctional malocclusion both in etiological terms and appropriate time to start treatment with approach that can be utilized at any age and ™ ® Multi-S Multi-T Multi-P ® Multi-TB™ long-term stability. A primary issue is the conventional orthodontic mechanics. at all stages of orthodontic treatment. es probability of relapse after orthodontic t e r ac Star a i n ose r Br Mul ti u l t i T r Purp er fo treatment. If the Functional Matrix is Treatment Stage: use myofunctional The appliances of the MULTI SYSTEM M Multi Multi Tr ain 2. the cause of malocclusion, and it is not appliances in association with conventional respond very well to these characteristics and neutralized during treatment, there will be a fixed appliance therapy. therefore are included in the “Self Confident greater possibility of relapse. However, if the Orthodontics” philosophy of treatment. dysfunction is a result of the malocclusion, 3. Retention Stage: use myofunctional only its complete resolution will guarantee orthodontics at the end of treatment to stability of the case. From our perspective, promote adaptation of the Functional Matrix this ideological dualism is irrelevant. to the new occlusion.

34 Clinical Review Clinical Review 35 THE MULTI SYSTEM BASIC INSTRUCTIONS When should the MULTI series of appliances 4: Felicio CM, Ferreira CL. Protocol of orofacial coarticulation therapy. Int J Orofacial Myology. 1997;23:3-9. myofunctional evaluation with scores. Int J Pediatr Review. PubMed PMID: 9487825. OF ORTHODONTICS FOR USE be used? As previously discussed, these are Otorhinolaryngol. 2008 Mar;72(3):367-75. Epub 2008 Jan 9. primarily myofunctional devices. They PubMed PMID: 18187209. 21: Thiele E. Timing in myofunctional training. Int J SPECIFIC CHARACTERISTICS OF THE The MULTI SYSTEM of Orthodontics Based on the specific characteristics of are designed to stretch the lateral and Orofacial Myology. 1996 Nov;22:28-31. PubMed PMID: MULTI SYSTEM APPLIANCES 5: Grabowski R, Kundt G, Stahl F. Interrelation between 9487823. represents an integrated series of the malocclusions, it is relatively easy for periodontal muscles to generate strength in occlusal findings and orofacial myofunctional status in myofunctional appliances that allow the The MULTI appliances, MULTI-S, the orthodontist to make an accurate order to modify the skeletal and/or dental primary and mixed dentition: Part III: Interrelation between 22: Marchesan IQ, Krakauer LR. The importance of malocclusions and orofacial dysfunctions. J Orofac Orthop. respiratory activity in myofunctional therapy. Int J Orofacial orthodontist to utilize the device that is most MULTI-T, MULTI-P, are designed to be used determination as to what appliance is relationship. As per classical myofunctional 2007 Nov;68(6):462-76. English, German. PubMed PMID: Myology. 1996 Nov;22:23-7. PubMed PMID:9487822. suitable based on the age and characteristics independent of other orthodontic devices. As appropriate for the case at hand. therapy, their main use is in Class II and 18034287. of the patient’s malocclusion. part of their design, dental tooth eruption/ certain Class I cases and they possess three 23: Annunciato NF. Plasticity of the nervous system. Int J 6: Verrastro AP, Stefani FM, Rodrigues CR, Wanderley MT. Orofacial Myology. 1995 Nov;21:53-60. Review. PubMed positioning guides are included as innovative MULTI-S is indicated for younger patients principal functions: Occlusal and orofacial myofunctional evaluation in children PMID: 9055672. with anterior open bite before and after removal of pacifier The MULTI series of appliances are primarily additions to myofunctional therapy. The and is applicable starting from 5 up to 7-8 sucking habit. Int J Orthod Milwaukee. 2007 Fall;18(3):19- myofunctional in nature and, as such, each years of age. a. UPPER RIDGE: Dental tipping and 25.PubMed PMID: 17958262. 24: Gommerman SL, Hodge MM. Effects of oral extent of the guides vary among the appliances myofunctional therapy on swallowing and sibilant appliance is designed for specific functions. to follow the development of tooth eruption Multi-S guide for tooth eruption. production. Int J Orofacial Myology. 1995 Nov;21:9-22. 7: Stahl F, Grabowski R, Gaebel M, Kundt G. Relationship PubMed PMID: 9055666. All appliances in the series have various with age. MULTI-S contains a guide only between occlusal findings and orofacial myofunctional b. SKELETAL: Possible interference with status in primary and mixed dentition. Part characteristics in common, although each has for the incisors; MULTI-T contains guides 25: Sergl HG, Zentner A. Theoretical approaches to behavior unique features rendering them case specific for the incisors and canines; MULTI-P has the growth of the jaw bone; increase of lower change in myofunctional therapy. Int J Orofacial Myology. jaw growth; remodelling and modification of II: Prevalence of orofacial dysfunctions. J Orofac Orthop. 1994 Nov;20:32-9. Review. PubMed PMID: 9055662. for various stages of treatment. additional guides for premolars. MULTI- 2007 Mar;68(2):74-90. English, German. PubMed PMID: the TMJ. 17372707. Type Age Sizes Holes Lip-Bumper Effect TB, was designed to be used in 26: Seminara R, Seminara G. Cephalometrics and oral combination with conventional myofunctional impairment. N Y State Dent J. 1994 Multi- S 5-8 1 yes yes c. MODIFICATION OF THE 8: Fraser C. Tongue thrust and its influence in orthodontics. Oct;60(8):53-7. PubMed PMID: 7970420. Multi-T 6-10 1 yes yes orthodontic treatment, and Int J Orthod Milwaukee. 2006 Spring;17(1):9-18. PubMed FUNCTIONAL MATRIX ACTIVITY: PMID: 16617883. Multi-P 9-13 multiple yes no therefore does not have any 27: Stavridi R, Ahlgren J. Muscle response to the oral-screen Following eruption of the first permanent MULTI family appliances do not require activator. An EMG study of the masseter, buccinator, and Multi-TB all 1 no yes dental guides. 9: Korbmacher HM, Schwan M, Berndsen S, Bull J, Kahl- molars it is often preferable to utilize impressions or the need for a dental mentalis muscles. Eur J Orthod. 1992 Oct;14(5):339-49. Nieke B. Evaluation of a new concept of myofunctional PubMed PMID: 1397072. THE COMMON CHARACTERISTICS Type Guidance MULTI-T that is applicable from 6 to 9-10 laboratory. This is very important because therapy in children. Int J Orofacial Myology. 2004 Multi- S Incisors Nov;30:39-52. PubMed PMID: 15832861. OF MULTI SYSTEM APPLIANCES years of age. most patients would prefer to avoid having 28: Winchell B. Orofacial myofunctional therapy for adult Multi-T Incisors and Canines Multi-T patients. Int J Orofacial Myology. 1989 Mar;15(1):14-8. impressions taken, and initiating orthodontic 10: Usumez S, Uysal T, Sari Z, Basciftci FA, Karaman Multi-P Incisors, Canines and Bicuspids PubMed PMID: 2599777. treatment without the need for impressions AI, Guray E. The effects of early preorthodontic trainer Like all myofunctional devices, these Multi-TB No guidance treatment on Class II, division 1 patients. Angle Orthod. appliances have a monoblock shape in may incline the patient and parents to be 2004 Oct;74(5):605-9. PubMed PMID: 15529493. 29: Bergersen EO. The eruption guidance myofunctional appliance in the consecutive treatment of malocclusion. Gen order to simultaneously work on both dental more comfortable with their orthodontist. Dent. 1986 Jan-Feb;34(1):24-9. PubMed PMID: 3456331. All of the appliances, with the exception of 11: Jefferson Y. Orthodontic diagnosis in young children: arches. The mandibular position protrudes In addition, when the dental laboratory is beyond dental malocclusions. Gen Dent. 2003 Mar- the MULTI-TB, have 3 holes in the front by-passed, the MULTI SYSTEM becomes Apr;51(2):104-11. Review. PubMed PMID: 15055681. 30: Garliner D. The current status of myofunctional therapy with respect to a edge to edge incisor position. in dental medicine. Int J Orthod. 1982 Mar;20(1):21-5. of the appliance to allow for partial oral exclusively an in-office procedure without a Moreover, the appliances have a raised MULTI-P is used after the exchange of PubMed PMID: 6953051. respiration. These holes, which have the costly laboratory fee. 12: Zardetto CG, Rodrigues CR, Stefani FM. Effects occlusal plane. This positioning promotes an the lower canines or first upper bicuspids of different pacifiers on the primary dentition and oral effect of increasing the elasticity of the frontal myofunctional strutures of preschool children. Pediatr Dent. 31: Garliner D. The modern myofunctional therapeutic immediate mechanical unlocking of the TMJ (depending on the patient’s pattern of concept. Int J Orthod. 1980 Jun;18(2):21-3. PubMed PMID: plane, permit a greater elastic response during 2002 Nov-Dec;24(6):552-60. PubMed PMID: 12528948. in association with the functional unlocking exchange) up to 13-14 years of age with 6930367. closing exercises and, therefore, a more of muscles. braces/myofunctional orthodontics. 13: Meyer PG. Tongue lip and jaw differentiation and its effective intervention on anterior teeth in relationship to orofacial myofunctional treatment. Int J 32: Hanson ML. Oral myofunctional therapy. Am J Orthod. 1978 Jan;73(1):59-67. PubMed PMID: 271473. cases of deep-bite. Orofacial Myology. 2000 Nov;26:44-52. Review. PubMed In addition, all of the appliances have a large MULTI-P has specific indications for use for PMID: 11307348. 33: Leone KJ. Myofunctional therapy in specialty as well as vestibular shield which serves to activate each of its two models. The low volume model MULTI-S, MULTI-T and MULTI-TB 14: Bacha SM, R√¨spoli CF. Myofunctional therapy: brief general practice. Int J Orthod. 1977 Sep-Dec;15(3-4):10-32. the perioral muscles; the shield is adequately is designed for mesofacial or brachyfacial intervention. Int J Orofacial Myology. 1999 Nov;25:37-47. PubMed PMID: 271634. utilize the shield to create a thickening in the extended in order to provoke stretching patients; the high volume method is designed PubMed PMID: 10863453. and activation of the musculature although anterior segment designed to increase the 34: Haas AJ. Let’s take a rational look at myofunctional for a dolichofacial patients. therapy. Int J Oral Myol. 1977 Jul;3(3):24-7. PubMed PMID: effect of the lip-bumper. 15: Klocke A, Korbmacher H, Kahl-Nieke B. Influence of not arriving up to the fornix given that it Multi-P orthodontic appliances on myofunctional therapy. J Orofac 275226. is preformed and not customized for the Orthop. 2000;61(6):414-20. English, German. PubMed patient. Lingually, the appliance has a frontal MULTI-S, MULTI-T and MULTI-TB are PMID: 11126016. 35: Gottlieb EL. Orthodontics vs myofunctional therapy. J available only in one size. Clin Orthod. 1977 Feb;11(2):83-5. PubMed PMID: 273609. lingual ramp for the re-teaching of lingual 16: Reinicke C, Obijou N, Tr√§nkmann J. The palatal shape posture and two lateral wings which increase of upper removable appliances. Influence on the tongue 36: Proffit WR, Brandt S. Dr. William R. Proffit on the MULTI-P is available in two models: low and position in swallowing. J Orofac Orthop. 1998;59(4):202-7. proper role of myofunctional therapy. J Clin Orthod. 1977 the re-education effect of the frontal elevator. high volume, that is, with a different frontal English, German. PubMed PMID: 9713176. Feb;11(2):101-5. PubMed PMID: 273603. In summary, the specific design characteristics thickness of the occlusal lift. References 17: Tallgren A, Christiansen RL, Ash M Jr, Miller RL. 37: Wildman AJ. The motor system: a clinical appraisal. Dent Effects of a myofunctional appliance on orofacial muscle Clin North Am. 1976 Oct;20(4):691-705. PubMed PMID: of the MULTI SYSTEM are: 1: Meyer PG. Tongue lip and jaw differentiation and activity and structures. Angle Orthod. 1998 Jun;68(3):249- 1067201. The low volume MULTI-P is available in 13 Beyond age 13-14, it is advisable to use its relationship to orofacial myofunctional treatment. 58. PubMed PMID: 9622762. different sizes. Int J Orofacial Myology. 2008 Nov;34:36-45. PubMed a. Vestibular Shield MULTI-TB in association with conventional PMID:19545089. 38: Kaye SR. A rational approach to myofunctional therapy. 18: Pierce RB. The effectiveness of oral myofunctional Quintessence Int Dent Dig. 1976 Aug;7(8):51-4. PubMed orthodontics. The high volume MULTI-P is available in 11 therapy in improving patients’ ability to swallow pills. Int J PMID: 1076571. b. Lingual Elevator Multi-TB 2: Paskay LC. Instrumentation and measurement procedures Orofacial Myology. 1997;23:50-1. PubMed PMID: 9487830. different sizes. in orofacial myology. Int J Orofacial Myology. 2008 Nov;34:15-35. PubMed PMID: 19545088. 39: Cottingham LL. Myofunctional therapy. Orthodontics- c. Lateral Wings 19: Benkert KK. The effectiveness of orofacial myofunctional -tongue thrusting--speech therapy. Am J Orthod. 1976 therapy in improving dental occlusion. Int J Orofacial Jun;69(6):679-87. PubMed PMID: 775999. The sizes, easily identified by a special 3: Giuca MR, Pasini M, Pagano A, Mummolo S, Vanni Myology. 1997;23:35-46. PubMed PMID: 9487828. d. Occlusal Plane measuring instrument, differ in the mesial A. Longitudinal study on a rehabilitative model for correction of atypical swallowing. Eur J Paediatr Dent. 2008 thickness of the incisors. Dec;9(4):170-4. PubMed PMID: 19072004. 20: Umberger FG, Johnston RG. The efficacy of oral e. Mandibular Protrusion myofunctional and

36 Clinical Review Clinical Review 37 Cephalometric Tracing CASE # 1: Roberto; age 7 AFTER Class 1, Crowding upper and lower, Cross-Bite, Deep-Bite

Treatment Plan: Multi-T for correcting the cross-bite, reshaping the arches, and correcting the deep-bite. Quad-Helix for gaining space and mesio-distal rotation of upper first molars.

Fig. 1

After 7 months of Multi-T, ready for Quad-Helix phase BEFORE In summary, the specific design characteristics of the MULTI SYSTEM are: a. Vestibular Shield b. Lingual Elevator Before treatment c. Lateral Wings d. Occlusal Plane e. Mandibular Protrusion

38 Clinical Review Clinical Review 39 CASE # 2: Ivan; age 6 Treatment Plan: 2 Phase Class II, Open-Bite, Thumb Sucking Treatment Phase # 1: Habit correction, BEFORE Facial Axis Control: Multi-S and Re-education Phase #2: Class II Correction, smile analysis and gummy smile correction: Fixed Appliances

After phase 1 treatment

Superimposition before and after: Xi-Pm on Pm mandible unlocked, over-jet correction with lower Figure 1 incisor movement to lingual

AFTER

Superimposition before and after: Ba-Na on CC Facial Axis controlled

Before treatment

Our therapeutic protocol calls for a three-step treatment sequence to address the Functional Matrix: 1. Preparation Stage: use myofunctional orthodontics at an early age, from 4-5 up to 10-12 years of age, while waiting for the appropriate time to start treatment with conventional mechanical orthodontics. 2. Mechanical Stage: use myofunctional appliances in association with conventional fixed appliance therapy. 3. Retentive Stage: use myofunctional orthodontics at the end of mechanical treatment to promote adaptation of the Functional Matrix to the new occlusion.

40 Clinical Review Clinical Review 41 CASE # 3 : Erica; age 7 Class II, Upper and Lower anterior crowding, Deep-Bite 10 Months after treatment without any retention: the case is Treatment Plan: 2 Phase Treatment stable Phase # 1: Deep-Bite correction, crowding correction, Facial Axis control: Multi-P Low Volume for 13 months Phase #2: Class II correction, Occlusal Plane inclination correction: Fixed Appliances AFTER

Superimposition Palatal Plane on Superimposition Xi-Pm on Pm ANE No advancement or inclination of Real of upper incisors the lower incisors BEFORE

Before treatment

Before treatment

After treatment AFTER

42 Clinical Review Clinical Review 43 TM APPENDIX I BUCCAL

Orthodontic Literature Review: Muscular Function

We have searched the Pubmed index from 1960 to 2008 to analyze interest in muscle FLI action/interaction in orthodontics over this SERIES time period. TUBES Papers (110) were divided into two groups:

Group A, Meta analysis or Theories ® Graph 1 An increasing interest on muscular function Group B: Clinical Trials and muscle interaction in orthodontics RMO’’’’’’ s NEW supports our analyzing the effects of FLI Series Buccal Tubes Color recess for simple As shown in Graph 1, interest in the study of Green: number of papers in Group A myofunctional appliances in our patients. The quadrant identification muscular function in orthodontics increased MULTI Appliances represent a modern and deliver superior performance in an Red: number of papers in Group B during this time period. complete system to apply the increased focus extremely small package. With Metal- Instrument notches on muscular function to clinical orthodontics. Injection-Molded (MIM) construction for secure grip and for smooth comfortable contours, easy positioning the ultra-low profile design features enhanced mesial openings that make Expanded exit port wire insertion a snap. ® reduces friction and Combined with RMO ’s wire impingement anatomical bases, the FLI Series is ideal for both direct bond and molar Dual-Top band applications. TAD System RMO’s Dual-Top Temporary Anchorage Device (TAD) system provides efficient and flexible biomechanics. Dual-Top TADs significantly enhance treatment capabilities and can be extremely effective in reducing treatment time, surgeries, and extractions. Appliances can be inserted chairside by the doctor and loaded immediately. Experience the next generation of appliances: RMO’s Dual-Top TADs.

• Self drilling and self tapping • Low profile - comfortable for your patient • no pilot hole, tissue punch, incision, or flap necessary • Force loads rated up to 500 grams • 100% Biocompatible - Titanium Alloy • Available in 1.4mm, 1.6mm, and 2.0mm diameters with 6mm, 8mm, and 10mm lengths

TAD System Hand Driver & Ni-Ti Crimpable Crimpable Wilson® Storage Block Attachments Coil Springs Hooks Hook Pliers Accessories Anatomical notch Enhanced opening provides optimum orientation simplifies wire insertion and positioning For More Information Or To Order, Please Contact Your RMO Representative Or Call 800.525.6044

The World’s Oldest Synergistic, Bioprogressive,® Breathing Enhancement Orthodontic Company.™ RMO®’s FLI Series Buccal Tubes are designed, engineered, and manufactured with pride in the USA. Anchorage where and when you need it.

44 Clinical Review Clinical Review 45 CARE AND MAINTENANCE / STERILIZATION / WARRANTY TM Needle Holder Small (Mathieu) Band Pusher/Scaler (Guequierre) • Extra hard stainless steel CARE AND MAINTENANCE • Clean in an ultrasonic unit for 10 minutes with a no-rinse general purpose • Precision made ligating instrument lip-safe beaks ® ® LUBRICATION (RMO Instrument Lubricant - #J00201) – RMO recommends weekly solution that includes a rust inhibitor. Keep tips open during cleaning. • With ratchet lock handle • Dual scaling surface lubrication of all instruments (depending on use). • Dry or drain instruments and dip in instrument milk. • Free sliding inner spring opens beaks when lock is released • One end has sharp curved scaling head, and serrated tip on the other ® • Tips are serrated and carbide coated for positive gripping RMO has chosen a hi-tech material for its standard plier tip inserts which provides the most • Load pliers on tray. Loading method should allow plier tips to remain open of ligature wires and modules; also to reduce wear superior properties for orthodontic applications. This ferrous material is extremely strong, during sterilization cycle. i00358 resistant to abrasion, flexible without fracturing in thin cross sections, and exceptionally • 5 1/4” (13cm) long durable. These materials combined with box-jointed stainless steel forgings give you • Sterilize according to manufacturer’s instructions. schweickhardt excellent value for your instrument dollar. The materials require your participation in proper • Ligature wire up to .016" (0.406mm) • After sterilization cycle is complete, depressurize equipment and care however, in order to provide maximum potential to your practice. allow pliers to cool. i00030 SPECIALIZED H2O - One of the most important factors in the safe and effective cleaning and sterilization of • Remove instruments and make sure they are dry prior to storage. your valuable instrument investment is water quality. Mosquito Hemostat INSTRUMENTS • Lubricate pliers with a silicon (non-petroleum) lubricant. DO NOT USE TAP SUPERIOR QUALITY • 4.75” (12cm) long Water in many municipal supplies can contain high levels of chlorine, chloramines, iron, sulfur, WATER during any sterilization process and always dry instruments whenever MAXIMIZES SATISFACTION. plus other trace elements that can damage your pliers. Tap water used to dilute cleaning they are rinsed. Design Extremely low profile ensures maximum patient comfort • With locking handle solutions and for rinsing pliers prior to sterilization can cause severe damage. Chemicals in ® • Serrated tips for positive gripping tap water can also neutralize rust inhibitors, causing a corrosive effect on plier tips even when COLD STERILIZATION RMO ’s premium Schweickhardt instruments represent the • All Schweickhardt beaks and inserts are milled on high precision Finish Cap Removal Instrument you are spending the time and money to use the right materials. We highly recommend that CDC and ADA guidelines federally mandate the use of heat sterilization for instruments used finest quality available at any price. Each Schweickhardt instrument machines and finished by hand by expert craftsmen. In addition, in dental care. Many professional offices use cold sterilization/high level disinfectants for Fully transparent for unmatched • To remove caps from convertible tubes your office use distilled, R/O, or filtered water for mixing your cleaning solutions, combined is precisely manufactured to our specifications in Germany with all beaks are protected with a tungsten carbine coating for with a no-rinse formula for cleaning solutions. holding solutions and processing of heat sensitive items. If your office uses these types of hardened inserts that can be sharpened or replaced, resulting in a Ligation aesthetics without glare or reflections improved wire grip and maximum reliability. i00124 • Replaceable blade provides leverage when removing cap products, please observe the following recommendations for avoiding damage to your pliers: more economical product over time than disposable instruments. Tie wings incorporate • Tip of blade fits securely in arch slot of tube STERILIZATION • All box locks and screw joints are produced with exacting care to undercuts and downdraft for ® • Always ultrasonically clean prior to immersion in high level disinfectants All Schweickhardt instruments are crafted of 100% surgical stainless RMO STRONGLY RECOMMENDS DRY HEAT STERILIZATION FOR INSERTED ensure a smooth and precise action throughout the entire working • With 10 blades and cold sterile solutions using the same guidelines as specified in heat steel, are forged, finished by hand, and carry a superb warranty. easy and secure ligation ORTHODONTIC PLIERS AS THE OPTIMUM METHOD OF INFECTION CONTROL. Other sterilization methods. angle. BAND AND BRACKET • Stainless steel handle and blade methods of sterilization can be adapted to the non-stainless materials used in many inserted • Premium quality instruments result in a more satisfying experience i00557 orthodontic pliers, but the following guidelines must be followed carefully. • If using glutaraldehyde solutions, use only those that are non-acidic in because they allow for a more precise and ergonomic work process • All edges are carefully chamfered for increased safety - (no pinching or wounding of soft tissue). REMOVAL/SCALERS Replacement blades (pkg of 5) i00559 composition and include a rust inhibitor. day to day, year over year. DRY HEAT STERILIZATION • Because the instruments are not chrome plated, they can be Because of the non-stainless characteristics of a vast majority of orthodontic plier tip materials, • Avoid contact with quarternary ammonium compounds and iodophors. • RMO® Schweickhardt inserts are made from a special alloy and are Rapid Dry Heat Sterilization became the most widely used method of infection control in this subjected to a variety of sterilization methods such as ultrasonic, dry • Keep plier tips open in liquid. Avoid immersion overnight in these applied to the plier with a highly sophisticated soldering technique. dental specialty. Between rapid cycle turn-around and large load capacity, it was the logical heat, chemclave, autoclave, and cold sterilization. chemical solutions. Schweickhardt insert alloy combines hardness (around 62 HRc) Posterior Band choice for clinicians seeking to protect their substantial instrument investment. Despite with high corrosion resistance. Removing Plier advances in materials technology, Dry Heat remains one of the most sensible choices for • If solutions require dilution, DO NOT USE TAP WATER. Use distilled, R/O, or ® • Long chisel tip with carbide insert Modular Omega Plier (RMO ) safety and efficacy in a busy orthodontic practice. filtered water free of errant chemicals. • For adjusting the expansion or contraction of the Omega • Facilitates removal of posterior bands • Clean in an ultrasonic unit for 10 minutes, with a no-rinse general purpose • Dry instruments immediately after rinsing. loop on the Bimetric Distalizing Arch (Wilson®) • With replaceable occlusal nylon pads solution that includes a rust inhibitor. Keep tips open during cleaning. • Hook on round end to hold Omega loop • Lubricate frequently with a silicon (non-petroleum) lubricant. • Stainless steel • Dry instruments with a compressed air blast, towel, or allow to drain for Reduced Friction • Will stay sharp 5 minutes if using a no-rinse solution. Finish i00548 W Extremely accurate precision beaks Smooth rounded flared archslot Smooth rounded • Box joint Replacement tips (pkg of 2) • Place pliers on rack or cassette and load sterilizer according to guarantee perfect holding, bending, lead-ins for reduced friction and i00549 W WARRANTY INFORMATION surface is fully polished for manufacturer’s instructions. Loading method should allow plier tips and cutting results improved sliding mechanics to remain open during sterilization cycle. exceptional patient comfort i00347 ® • All RMO SCHWEICKHARDT Instruments are fully guaranteed against corrosion and Replacement pads (pkg of 10) • After sterilization cycle is complete, lubricate pliers with a silicon i00357 separation of cutting inserts from the instruments for 5 years from the purchase date. (non-petroleum) lubricant. DO NOT USE TAP WATER during any sterilization process, and always dry instruments whenever they are rinsed. • All RMO® SCHWEICKHARDT Instruments are fully guaranteed for the life of the instrument Optimum guidance of working ends Crimpable Hook Plier Base Direct Bond Removing Plier CHEMCLAVE – (Unsaturated Chemical Vapor) to be free of defects in materials and workmanship. through precision box locks and screw • For attaching crimpable hooks securely to arch wires with • Clean in an ultrasonic unit for 10 minutes with a no-rinse general purpose joints provide consistent action over time Patented mushroom-style base Contoured base design • Wedges between both edges of the base and the tooth minimum pressure solution that includes a rust inhibitor. Keep tips open during cleaning. • Any Instruments subjected to misuse, abuse, or improper care and/or maintenance rails deliver superior mechanical provides optimum adaptation to surface and lifts off with virtually no stress • Stainless steel will void all warranty claims bonding with reliable and tooth surfaces • Grips firmly for occlusal-gingival or mesial-distal use • Dry instruments with a compressed air blast, towel, or allow to drain for 5 minutes if using a no-rinse solution. consistent debonding • Hard tool steel insert RETURN ® • Load pliers on tray, placing layers of paper towels between instruments. • All RMO SCHWEICKHARDT Instruments which are unused, unopened, and in the original Loading method should allow plier tips to remain open during sterilization cycle. Narrow i00545 i00129 package may be returned for full credit of the purchase price within 90 days of invoice. • Sterilize according to manufacturer’s instructions. Ergonomic design delivers safety Wide i00546 ® • All RMO SCHWEICKHARDT Instruments, if defective and not misused or abused in any and comfort through careful High corrosion resistance without Material • After sterilization cycle is complete, depressurize equipment and allow pliers manner may be return to RMO® within 90 days for repair, replacement, or refund of the chamfering of all edges to cool. chrome plating Polycrystalline ceramic - INSTRUMENT LUBRICATION purchase price. 99.99% pure alumina oxide • Remove instruments and make sure they are dry prior to storage. REPAIR for maximum strength Utility Scaling and Band Seating Instrument ® ® • Lubricate pliers with a silicon (non-petroleum) lubricant. DO NOT USE TAP For RMO SCHWEICKHARDT Instruments outside the warranty, please contact RMO (Schure) WATER during any sterilization process and always dry instruments whenever RMO Instrument Lubricant customer service or your sales representative fro repair recommendations. • Extra hard stainless steel • Technical grade white oil that can be applied after drying they are rinsed. Technology • Precision knurled handle and prior to sterilization AUTOCLAVE Utilization of CAD / CAM • Sharp scaling shape on one end and serrated band seating • Improves the life of the instrument Because of the high levels of moisture in the autoclave process, this method can be damaging tip on the other • Proves a fast and economical solution for preventing rust to ferrous plier tips and is not generally recommended unless instruments are 100% stainless simulations resulting in • Tips are heat-treated to maintain sharp edge for extended use and protecting cutting edges steel or tungsten carbide inserted. 50% improved fracture strength The World’s Oldest • New narrower scaller tip • Regular treatment reduces the danger of oxidation Synergistic, Bioprogressive®, The World’s Oldest Breathing Enhancement Synergistic, Bioprogressive®, The World’s Oldest i00349 Breathing Enhancement Orthodontic Company.® Synergistic, Bioprogressive®, Orthodontic Company.® J00201 Breathing Enhancement Orthodontic Company.® ® P00695 Rev. B To order, please contact your RMO Sales Representative or call 800.525.6375 P00748 Rev. - ® 46 Clinical Review To order, please contact your RMO Sales Representative or call 800.525.6375 P.O. Box 17085 Denver, Colorado 80217-0085

The World’s Oldest Synergistic, Bioprogressive®, Breathing Enhancement Orthodontic Company.®

Rocky Mountain Orthodontics http://www.rmortho.com/

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