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Clinical Impression Vol 5 (1996)

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Clinical Impression Vol 5 (1996) CLINICAL ® ImpressionsPUBLISHED BY ORMCO CORPORATION • VOL. 5, NO. 1, 1996 Dr. Smith on Treatment Efficiency Page 2 Dr. Mayes on STM, Part 2 Page 6 Dr. Hilgers Takes a Step Backward Page 12 Dr. Scott on the Lokar Appliance Page 16 Dr. Smith A Treatment Efficiency Philo by John R. “Bob” Smith, D.D.S., M.S.D. Winter Springs, Florida ave you ever looked at one of your facing the orthodontist: patients’ charts and noticed that the 1. Noncompliance with orthodontic treatment record was as thick as an appliances (i.e., headgear, functional unabridged version of War and Peace? appliances, elastics). Then you saw a thin chart – one of your 2. Emergencies – broken or loose favorite patients, where the treatment appliances. Emergencies related to went smoothly with few office visits. Why improper management of archwire was there such a big difference? Usually, ends, protruding ligature ties and we are quick to blame the patient for the improperly contoured or activated extra visits and hassles. In some cases this wires or appliances are preventable. attitude is justified; however, many times 3. Poor oral hygiene and associated the responsibility for problems during decalcification, decay and periodontal treatment is due to the orthodontist’s complications. decisions on timing of treatment and 4. Root resorption. selection of orthodontic appliances. To minimize these problems, we must There has been a general trend in ortho- create positive changes by focusing on dontics to begin treatment at an earlier efficiency, quality control and profitability. age. The objectives of early treatment The most significant changes I made to H have been expanded to include manage- improve the quality of life, efficiency and ment of arch-length deficiencies and profitability in my practice were the use of skeletal malalignments. While it is noncompliance appliances and properly essential to correct these discrepancies, timed phases of treatment. the timing of initial treatment and the choice of appliance are critical for optimal Noncompliance Appliances efficiency and profitability. The decision Headgears, Bionators, Frankels, sagittals, to start treatment too early or use an Jones Jigs, Class II elastics and other appliance that demands high patient removable appliances, while effective with compliance can extend treatment and the compliant patient, are ineffective frustrate patients, parents and the ortho- with the less-than-motivated patient. The dontic team. The first step toward reduc- amount of time, energy and additional ing these difficult situations is to develop visits needed to treat these patients will a philosophy of treatment that is based on certainly stress a busy practice. Constant addressing the most common problems discussions on compliance issues can compromise the office’s relationships with patients and parents. Dr. John R. (Bob) Smith received his D.D.S. from Emory University in 1975 and his M.S.D. The two most effective noncompliance from the University of Washington in 1977. He devices are the Herbst* and Pendex™ received the Milo Hellman Research Award for appliances. Both possess the ability to his graduate thesis. An original member of the simultaneously correct both transverse “Lingual Task Force,” Dr. Smith has lectured and published extensively on lingual orthodon- and anteroposterior discrepancies. The tics as well as practice management, diagnosis Herbst, combined with a rapid palatal and treatment planning, and early intervention. expander or quad helix, is used to correct He maintains a full-time practice in Winter the typical Class II skeletal and dental Springs, Florida. malocclusion, while the Pendex is used for the skeletal Class I with a Class II * Herbst is registered trademark of Dentaurum, Inc. 2 sophy…That Really Works dental malocclusion (see the article by rected, the patient was maintained with unable to accomplish my treatment goals, Drs. Bennett & Hilgers on the “noncom- partial braces and headgear until cuspids frequently producing a compromised pliance appliance” in Clinical Impressions, and bicuspids erupted into position. I result. Vol. 3, No. 3, 1994). usually did not wait for the eruption of second molars before bonding the remain- Have you ever produced a beautiful case The major advantages to both of these are: ing teeth and continuing treatment. I call only to have the second molars erupt into 1. Fixed with continuous force this process progressive bonding, where poor position? What did you do next? application and direction. Phase I treatment blends into Phase II You had to band or bond the second 2. Easily adjusted. treatment with no rest period between the molars and go back through your arch- 3. Reduce the need for other bonded phases. Treatment would range from 20 to wire sequence to reestablish the occlusion. appliances while in use. (With the This adds four to twelve months to Herbst, it is occasionally necessary to the overall treatment time, consumes place brackets on the incisors to more supplies, increases labor costs and establish torque and/or increase arch contributes to reduced profitability. Also, length.) “The most signifi- it is very disheartening to the patient to 4. Patients are seen at 10-to 12-week suffer additional delays in treatment. intervals. cant changes I 5. Because of the noncompliance made to improve Doesn’t it make sense to wait until second nature of the appliances, visits are molars have erupted before placing full short and positive. the quality of life, orthodontic appliances? Many doctors argue that some patients who are nearing Emergencies, Poor Oral Hygiene efficiency and high school age will not tolerate braces. I and Root Resorption agree that this can be a challenge. In those One thing these problems all have in com- profitability in my few cases, it is best to inform the patients mon is their tendency to occur with fixed of their options. First, waiting will be more orthodontic bands and brackets. There- practice were the efficient and will ensure proper molar fore, to reduce their deleterious effects in position. Second, braces can be placed the noncompliant patient, every effort use of noncompli- early, but if second molars erupt into poor should be made to keep the active position, additional time in braces will orthodontic phase with full braces to a ance appliances be necessary. Third, they can choose to minimum. How can this be done with the accept some malalignment of the molars difficult Class II skeletal and dental maloc- and properly if they are left untreated. I prefer the clusions? Before I describe my current first option whenever possible. The wise protocol for treatment, let’s look at what timed phases of orthodontist would realize that the second happened in my practice before I routinely option would require additional fees to used the Herbst and Pendex for Class II treatment.” compensate for the extra work. corrections. When bonded brackets and bands are When I started my practice 18 years ago, worn for extended periods of time, there the typical nonextraction Class II case was 40 months, depending on the eruption is greater potential for decalcification, treated in the late mixed dentition with of cuspids and bicuspids. When patients periodontal disorders and root resorption. bonded brackets on the upper and lower cooperated and wore their headgear and If a treatment protocol that minimizes the incisors, bands on all first molars and elastics, it did not take long to develop duration of fixed therapy can be used, it utility archwires. The driving force for A-P a nice occlusion from the first molars will greatly reduce these serious problems. correction was headgear of various types mesially. However, with many cases, It is always difficult and time consuming and Class II elastics. Once incisor torque, I struggled with the Class II correction to explain these various problems to arch length and dental midlines were cor- due to poor patient compliance and was continued on following page 3 Dr. Smith continued from preceding page patients, parents and referring doctors. patients with crossbites, digital habits or primary cuspids does not adversely affect To develop a community image of high midface deficiencies that need maxillary my ability to expand later and achieve a service and quality care, it is essential to protraction. If I am supervising a seven- nice nonextraction result. Also, if active minimize these unpleasant explanations. year-old with a Class II crowded condi- treatment can be stalled until just prior to Implementing a new treatment philoso- tion, I will generally recommend removal the eruption of the cuspids and bicuspids, phy, especially the use of noncompliance of primary canines to allow the incisors there is a reduction of the overall supervi- appliances and properly timed treatment to erupt into better alignment rather than sorial time. Treatment can still be accom- phases, enables you to do just that. performing early expansion. Why? There plished with a two-phase approach, but are many mild-to-moderately crowded the retention period (resting period) Current Treatment Philosophy Class II cases that I will treat on a nonex- between phases is greatly reduced. In cases (Ages 5 – 8) traction (permanent teeth) basis with ex- with severe crowding, I can continue with I typically avoid early treatment except in panders, Herbst or Pendex. Extraction of continued on page 22 CASE I: N.H. – Class II, Div. I Skeletal and Dental Malocclusion. Pretreatment. 4 Simultaneous treatment of transverse, A-P and arch length. Full-banded and bonded therapy. Final result after 22 months of treatment and 19 office visits. 5 Simplified Treatment Mech Or How to Look Just as Forward to art I of “Simplified Treatment Mechanics” If Simplified Treatment Mechanics are (STM) covered treatment goals and keys used, the 600 active patients will be seen to achieving them. In this installment, I every eight weeks, and this means 300 ac- will describe the appliances I use and how tive patients a month.
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