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J Ind Orthod Soc 2005 ; 38:68-78
INTERVIEW
Dr. Ravindra Nanda on his treatment philosophy
Part - I
International consultant Editor Dr. Ramesh Sabhlok interviews
Dr. Ravindra Nanda on his treatment philosophy.
Dr. Ravindra N and a is at present UConn A lumni Endowed Chair, and Professor and Head
of the Department of Orthodontics, Ora l and M ax ill ofacia l Surgery, Pediatric Dentistry
and Adva nced Education in Genera l Dentistry at the University of Connecticut, Farmington,
Co nn ecti cut, U.S.A. Dr. N and a has been author and co-a uthor of three o rthodo nti c
books and more than o ne hundred scie nti fic and clinical artic les in majo r jou rn als. H e is
on the editorial board of severa l journals. He is an active member of various organ izations,
including the American Association of Orthodontics, European Orthodontic Society and
Edward H . Angle Society. Dr. Nanda is a Diplomate of the American Board of Orthodontics.
Ramesh Sabhlok: On behalf of the Editor-In-Chief of
the JIOS and members of the Indi an Orthodontic
Society, I exte nd greetings to you from Indi a. You have
very diversified postgraduate tra ining in Indi a, H o ll and
and in USA. Could you give us a brief background of
the treatment philosophies and the app li ance systems
you have been exposed to and you are makin g use of
them in your practice?
Ravindra Nanda : Indeed, well First of all , I want to
thank Indi an Orthodontic Society for giving me this
opport unity to have a co nv ersat io n
abo ut my
treatment Philosophy to be published in the Journal.
As fa r as your question is conce rn ed, indeed w hat I do
now, is a cu lmin at ion of. al l th e different treatment
Philosophies, I have been exposed to. My first exposure
to Orthodonti cs was in Indi a in Lu ckn ow, w hen I was a
stude n t w ith my brother Ram. H e h ad started
orthodontic program. I was in hi s first c lass, Predeep
Jayna and myself were together in Dental schoo l and
also in the Orthodo nti c Program. Ram was a stud ent of
Jarabak and he was also a student of Tw eed. So during
our two years fro m 1965 and 1966, I was exposed to
Tweed and Jarabak treatment philosophy and then I
moved to Holland and I had the opportu nity to work
there w ith Alan Brodie w ho was doing his sabbat ica l
there as a Fulbright Scholar for o ne year. So, then I
was exposed to Brodie's Philosophy of No n-ext raction
treatment more like univers ity of Illinois co ncept and
then w hen he left afte r hi s first year, next two and half
to three years I was exposed to w hat Vander Linden
was teaching at that time w hi c h was University of
68
Washington Seattle. I moved to Loyala University in
1970 where I was th ere for two years and that's wh ere
my first exposure to Bioprogressive treatment started
and in the mea ntime, I started teaching students sort
of a co nglomeration ofTweed Edgewise Boiprogressive.
Th en I got a ca ll to join the new sc hoo l at th e university
of Connecticut w ith Charles Burrstone and that's where
my first seriou s exposure to Biomechanics sta rted. So,
over the l ast thirty three years, I h ave been in
Connecticut so what I teach right now is, w hat I would
ca ll Biomechanics Sensitive Orthodontics, which is not
a technique oriented Orthodontics. It is Orthodontics
w hi c h Orthodontist i s in contro l of, becaus e
Orthodontist understa nds the diagnosis, treatment plan
and wh at patient needs and w hat sort of mechanics he
ca n use in hi s app li ance system.
Ramesh Sabhlok: Before we start further into the
Biomec hani cs, let m e sta rt about the Diagnosti cs
criteria you use, when you look at a case and w here
do yo u keep yo ur In c i sors? Wh at i s the role of
comp uteri zed planning in your practice like Dolphin
imag ing system in your sc hool?
Ravindra Nanda: First of all , ove r the years I have
moved away in my teac hing philosophy fro m ske leta l
tissues as a primary diagnostic criter io n to the soft
tissues. So these days, I would probably look at the
soft tissues first and then I would look at the ske leta l
tissues. Peop le are lot more co nsc ious abo ut their
esthet ics and I want to see what type of smil e cha nges
I ca n create, what type of fac ial esthet ic improvements
Rav indra Na nda
I ca n create and then on that basis, I dec ide w here I
am go ing to place my upper incisors and w here I am
going to place my lower inciso rs. We have moved away
from those days of lowe r inc iso rs 90 degrees to 95
degrees or FMA of 25 degrees. We think all those
numbers are basica ll y averages and eve ry patient sort
of demands ow n diagnostic criteria so I am into soft
tissue and then the ske leta l tissues.
As fa r as our diagnostic criterion is co nce rned, over
the yea rs we have evo lved, we used to have our ow n
orthodont ic treatment p lan set up. We w ere probably
the first o ne to start computerized orthodo ntics in 1973
but th ese days we are usi ng more and more Do lphin
System becau se we are a lm ost paperless in o ur
department, everything is digital into the laptop. W e
don 't take study model s. W e are into E-models, Di gital
X-rays, computerized trea tm ent plan of the pati ent,
communication w ith the computers so we are more
into, what I ca ll 21st ce ntury type of Orthodontics thi s
time.
Example of diagnosis and treatment planning at the University of Connecticut, Orthodontic Department
Diagnosis
Database ~------------------------------------,
Models
(plaster
3D digital)
Problems
PhotographsExtraoral
Frontal
Lips lightly touching
Lips relaxed
Smiling
Profile
Lips lightly touching
Lips relaxed
45° angle
~pr
Intraoral
Upper occlusal
Lower occlusal
Right buccal
Left buccal
Frontal
1ms
obe
Clinical examination
Chief complaint
Medical history
Dental history
Extraoral exam
Intraoral exam
Functional exam
,
...
~
Problems
...
Radiographic imaging
Panoramic X ray
Lateral cephalometric X ray
~
Prob lems
Problem list
Treatment
Synthesis and - . . Treatment - . . Mechanics - . . Treatment - . . Treatment - . . re-evaluation
diagnosis
objectives
plan
sequence
69
J Ind Orthod Soc 200 5; 38:68-78
Normofacia l w ith ovo id fac ial form
Large interca nthal distance.
Wid e alar base.
Nose and cupid's bow co in cident.
Chin is o n w ith fac ial ML.
ILG @ Rest: 2.S mm
Incisor Show @ Rest: 3m m
Li p competent
Asymmetri c fac ial proportion s.
Convex ST profil e w ith stro ng
soft tissu e Pogoni o n.
Protrusive upper lip
Sn-Pg lin e and Esthetic pl ane.
Everted lowe r lip .
LFH : Th roat Depth » 1.2: 1
UL:LL-1 :2
Obtu se NLA.
Deep mentolabia l fold
• Incisor Show: 100% of upper
incisor and 3.5 mm of gingiva.
• Unconsonant smile, lowe r lip
does not follow the in cisa l line.
• No darkness in bu cca l
corridors.
Adeq uate mal ar promin ences .
Max.R 1 obstructing lip c losure.
Posteri or gingiva l displ ay
M x M L is on w ith fac ial and Md midlin e.
100% deepbite
Flared and protrusive 1
Uprighted 1
M x. Peg latera ls.
White spot lesio ns o n M x,
and Md premol ars.
Uneven gin gival heights.
No gingival infl ammation
Good attac hed/ keratinized tissue in Md anteri o r
Good OH
70
JL
Rav indra N anda
7654321-12 34567 present.
U-shaped arch.
Flared upper right 1 and uprighted upper
Left 1.
Peg laterals.
5 mm of spaci ng
7654 32 1- 12 34e67 present
U-shaped arch.
Right 6 tipped forward.
Flared ce ntral incisors.
Class II Mol ar relation ship
Class II ca nine.
Problem List
1-Pathology and other
a. Family history of congenitally missing lateral
incisors, and impacted canines.
b. Trauma on 1
c. Peg shaped mx. laterals.
d. Radiolucency on mx left lateral.
e. Mandibular e left still present.
f. White spot lesions on upper and lower
premolars.
g.
Mx 8's absent, Mandibular 8's impacted.
2- Antero-Posterior
a. Skeletal : Retrognathic mandible, with strong
hard tissue Pg.
b. Dental:
I. Class II molar relationship.
II. Class II can i ne relationsh i p.
III. Flared 1 incisor and uprighted 1.
IV. 10 mm overjet on right central incisor.
V. 2 mm overjet on left central incisor.
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J Ind Orthod Soc 2005; 38 :68-78
3-Vertica l
a.
Skeletal:
I. Normal mi dd le facial height (46%) and
II. Relatively sho rt lower facial height (54%)
II I. Tip Up pa latal p lane.
b
Denta l:
I.
100 % Deepbite
II.
Uneven gingiva l heights.
III .
Extruded upper inciso rs
IV.
Extruded lower incisors
V.
Deep cu rve of Spee
V I. In c iso r sho w at smil e: 100 %. + 4 mm of
gi ngiva .
V II. Redunda nt li ps.
V III. Deep mento labial fo ld.
4- A li gnment
• 3 mm of m x . Crowdin g and no mandib ul ar
crowd ing.
5-Tra nsverse
• U ppe r and lowe r m idlin e i s o n w ith fac i al
mi d line.
Treatment Objectives
1-Patho logy/Other
a. M o nitor 1. and mx. Left late ral.
b. Restore peg laterals.
c . M o nitor eruption of 8' s.
d . Di sc uss treatment options.
2-Skeleto fac ial:
a. Decrease co nvex ity.
3-Soft Ti ssue Profil e
a. Dec rease soft ti ssue convexity.
4-0cc lu sa l p lane.
a. M aintain the occlu sa l plane.
5-Midlin es
a. Upper: M aintain the upper midline.
b. Lower: M aintain the lowe r mi d line.
6-Transverse/Arch Width
a. M aintain max ill ary and mandi bul ar arch width.
7-A-P/ Incisors:
a. Improve overj et. Fl arin g of th e 1 and uprighting
th e 1 and fl aring the mandi bul ar incisors.
A-P M olars:
a. M ainta in upper 6's.
b. M ove th e m a ndibul ar m o l ar b y u sin g
dentoa lveo lar effect.
8-Verti ca l/I ncisors:
a. M x- Intrude
b. Md. Intrude.
72
Vert ica l/M o lars:
a. M x. Extru de.
b. M d.- Extrude.
Ramesh Sabhlok: How do you find Do lphin Imaging
as compared to other systems ava i lab le?
Rav ind ra Nanda: Well , No system is a perfect system .
Wh at w e have done is we have used Do lphin system
we have c reated so me ch anges, we have sort of
tailo red it to our use and it works very w ell . Being an
educat ional in stitution taking ca re of th e res idents and
large number of patients it works very nice ly fo r us.
Ram esh Sabhlok : Wh at is yo ur m ain criterio n of
selection regard ing th e extracti o n and non extractio n
cases? Because over the number of yea rs the pendulum
is sw inging thi s side and th at side. Wh at are the most
important factors you w ill base your dec isio n regard ing
extracti on/ Non-extraction cho ice?
Ravindra Nanda : Aga in, it is tru e w e have changed
our criteri a for extracti o n and no n-extraction. I always
start at Esthetics first. Th ere was a time w hen w e would
extract fo r 4 to 5mm of space sho rtage but, these days
o ur criteria is more based on mo lar relati onshi p. If a
pati ent is adult and has a full class II mol ar relat io nship
most probab ly I w ill extract in a pati ent li ke that to
accommodate all the teeth into th e arch because I do
not wa nt to subj ect an adult pati ent into headgears or
c l ass II e l as ti cs or o th er appli ances w hi c h nee d
compli ance and not as comfo rtable. So, I loo k at the
Orthodo nti c Treatment Sequence
MAXILLA
MANDIBLE
Consult with prosand endo
Consult and Seps
Band 6's
Band 6's
Bond 5 t05
Bond 5 t05
Align mx. Teeth
Align md. teeth
Intrude upper incisors.
Intru de lower incisors.
Use -6 degrees torque
brackets.
Get into a heavy wi re 21x2 5
Get into a heavy wire 19X25
Place TFBC
Place Twin Force Bite Corrector
Class II elastics
Class II elastics
Finishing
Finishing
Retention with a wrap around
Retention with fixed 3 to 3..
)L
Esthetics first, then I am going to look at the amount of
the crowding, then I am going to look at whether I am
going to extract in the lower or in the upper. So, as a
rule in children now our extraction percentage has
dropped down to may be to 15 to 20 percentage. In
adults extraction percentage is still very high because
of the absence of the growth factor.
Ramesh Sabhlok: What is your criterion In Border line
cases?
Ravindra Nanda: There are no more border line cases
anymore. That terminology has gone down the river
because borderline cases are all non extraction cases.
Ramesh Sabhlok: Biomechanics in Orthodontics has
been forgotten for years. Recently the Orthodontists have
started payi ng attention to it. What are your perceptions
about this? A lot of clinicians find biomechanics very
difficult and too theoretical. Why is it so? Why is not
biomechanics a bigger part of all Orthodontists training?
Dr. Ravindra Nanda: See!
I think We started
Biomechanics on a wrong footing because the people
who were teaching Biomechanics in the past were
very, what I will call it puritanical , in other words
everything had to be pure, there was no compromise,
there was no meeting of minds and there were systems
devised, there were techniques used, which were very
difficult to use, very difficult to execute on the patients
and the net result was that they were not very practical
in a busy office. One of the things over the years which
I have done is I have made Biomechanics what we
call user friendly. So, Biomechanics does not have to
be difficult Biomechanics and the example I always
give of pharmacology. Like in Medicine, you can not
think of giving a medication to a patient without
knowing what dose to give, how long to give, what are
going to be the side effects. Similarly, force in orthodontics
is our pharmacological medicine because we got to know
what type of force to give, how much, for how long,
what direction, what is the centre of resistance and
then. what are the side effects going to be.
So, why it is not being taught in Orthodontic schools is
because of the ignorance of the teachers, because the
teachers were not exposed so they do not want to show
what they do not know to their students. So, the net
resu It is it conti nues on and on and on. It is not a problem
in India it is a problem all over the world because I
travel all over the world same question is asked all
over the place . So, university of Connecticut has done
Ravindra N anda
a great like thirty three full time teachers, five to six
Orthodontic Chairman, couple of deans were teaching.
We were trying to tell people th at Biomechanics is
important. Biomechanics is not a treatment philosophy.
Biomechanics is th e basis of Orthodontics. It could be
a part of straight wire, it could be a part of Bio-progressive
it could be part of any technique. So all we have to do
is to understand how a force system works. So all I wish
is that one day all the orthodontic professors and
instructors should get together in a room and for three
to five days all the basics done so that they can go
back and start their students and telling them how
important the biomechanics is. That is the only way to
do it because you can not teach the students even the
professors do not know about it.
Ramesh Sabhlok: What are some examples of
biomechanically oriented appliances? And what are the
advantages of using biomechanically oriented
appliances?
Ravindra Nanda: There are many biomechanically
oriented appliances as you probably heard today. I
talked about, what I call in Orthodontic smart wi res.
Intrusion Arch
Fig. 1: Schematic diagram of the moments and forces
created by an intrusion arch
73
J Ind Orthod Soc 2005; 38:68-78
Fig.2(a): Patient with a deep bite and a CI II maloccl usion at th e initi ation of the treatment
Fig 2 (b): Intrusion arch in place, is correctin g the deep bite and tipping back the max ill ary molar
Fig.2 (c) : Patient at the end of the treatment with and id ea l overbite and correction of the Class II malocclusion
74
Rav ind ra Nanda
7~
-
,-~.-
,..
These are the w ires w hi ch use spec ial memo ry all oys,
th ey use specia l o rth odo nti c bends, un derstanding of
moments and fo rces and we ca n deve lop w ires such as
intru sio n w ires. We ca n use intrusio n w ires (see figure 1
and 2), but they ca n do extru sio n for us, th ey ca n do
space closure fo r us, they can co rrect the mi d lines for
us, th ey ca n correct the occ lu sa l planes . So, o ne w ire
has the ab ility to do va ri ous fun cti o ns th at is the smart
w ire. I ca n have a space closure loop w hi ch w ill deliver
a contro lled tipping, translati o n as well as root upri ghting
over a five mo nth peri od o r a fo ur mo nth peri od. All
th ree movements will take pl ace w ith o ne activati o n.
So th ere are w ires w hi ch are much easier to use th ese
days and lot of these th ings you are go ing to see in my
fo rth coming boo k w hi ch is coming up.
Ramesh Sabhlok: Wh at is the name of th e book?
Ravindra Nanda : Th e boo k w hi ch 'is go in g to be
publi shed w ill be in my hand is go ing to be in A pril of
thi s year in coup le of mo nths. Th e titl e of th e book is
Bi o mec h ani c and Esth et i c St rateg i es in C l i ni ca l
Orthodo ntics and so fa r I have bee n very lu cky to have
some ve ry nice peo pl e p art ic ipate in co ntribu t in g
chapters w ith me.
Ramesh Sabhlok: So it wi ll be d iffere nt from th e ea rl ie r
book?
It w ill be very d ifferent th an the earli er book. It is very
clinica l. It talks abo ut O rthodo nti sts using impl ants to
move the teeth. It talks about using impl ants to how to
correct th e non - surgica l open bi te. It has three chapters
on class three pat ients. It has chapters o n space cl osure,
new smart wires, new Intru sio n w ires. It has chapters
by Vi ncent Ko ki ch, Bjorn Zac hri son, Sunil Kapil a, H arry
Legan. So, I have inv ited six to seve n chapte rs by my
fri ends and ba lance o f the chapte rs by myse lf and by
my co ll eagues fro m unive rsity of Connecti cut.
Ramesh Sabhlok: In your book o n "B iomec hani cs in
Clini ca l Ort hodo ntics" edi ted by you, Class II treatment
gets lot of atte ntio n. Wh y?
Ravindra Nanda: Yes, In the last boo k there was lot of
emphasis was o n class II. Th at is W hy as I have j ust
mentioned that in the forth coming book we w ill have
th ree chapters o n class III. O ne is w ritten by my fri end
Frank Chang fro m Taiwa n, o ne is by o ne o f m yo id
stud ent Gingi Su guwa ra fro m Japan and one chapter is
w ri tte n by me. So, we are cove rin g w hat I would ca ll
Pseudo class III patients, protract io n H eadgea r and the
cu rrent protoco ls of co rrecting c lass III , im p lants and
th en all the clini ca l problems in a seq uenti al manner
in thi s boo k.
Ramesh Sabhlok: D o b io mec hani ca ll y orie nted
app li ances give a mo re opt imal b io logic respo nse for
tooth movement th an oth er types of appli ances?
Ravindra Nanda : O ne hun dred pe rce nt. Thi s is a
correct statement. Th e reaso n for th at is th at, a biomec h ani ca ll y correct app li ance system de li vers a
optimal fo rce, a force whi ch is very low because you
are usin g a low load -d eflec ti o n rate, fo rce is not
acti vated eve ry time. You acti vate the fo rce fo r a lo ng
dista nce, fo rce di ss ipates very slow ly, and decay is very
slow, the tooth movement is much bette r. So, all th ese
app lia nces w here you are acti vatin g fo rce all the time,
you are putting in too mu ch of fo rce and I do not thin k
you are gettin g very good orthodonti c tissue respo nse
and the defini tio n of a good ti ssue respo nse is no root
reso rpti o n, treatm ent fini sh in pro per time and no side
effects. So, if you are not go ing to have side effects
then you are go ing to have not treatm ent w here you
move crown o n o ne side and then spend tim e to move
the roots o n the oth er side. So, we are do ing sho rter
treatment time, lo nger v isits, lowe r force va lues and
mo re w h at I wo ul d ca l l pred i c t ab le orth o d o nt i c
treatment.
Ramesh Sabhlok: Yo u have rece ntl y introd uce d
Nanda's Biomechani ca l App li ance System ? Wh at are
the m aj o r adva nt ages over the o th er pre-adju sted
syste m s? Ca n yo u te ll u s so m ethin g abo ut yo ur
prefe rence about slot size?
Ravindra Nanda: W ell, you may say I have introd uced
a N ew System . It is not rea ll y a new system . It has
been pac kaged into a new system because lots of time
peop le get very confused. Ove r the yea rs, I give about
14 to 15 courses all over th e wo rl d . I v isit may be about
12 to 13 countri es and every tim e I go, peop le always
say, Ca n you give me seq uentiall y how to correct it?
w hat is the w ire sequence? how you correct it? So, we
went ahead and said o kay, we woul d like to have a
bio mec hani ca l system w here the brac kets w ires are
cohesive ly tied together and the tooth respo nse is tied
together to w hat you are trying to ac hieve and that is
w hy we ca ll thi s app lia nce system. So, you ca n not
com pa re thi s w ith any oth er Pre-adju sted app lia nce
system because in our app li ance system we have the
brac kets, we h ave the w i res and th ese w i res are
spec iall y designed w ires, spec ial loops, specia l be nds.
75
J Ind Orthod Soc 2005; 38:68-78
So, we are gettin g more predi ctabl e Orthodontic
response.
As far as our brackets are co nce rn ed we spent lot of
time designing our brackets. W e beli eve in a torqu e
system of 1 7 degrees for centra l in cisors, 11 degrees f?r
the lateral incisors and so on. We feel that a Orthodontist
should dec ide what wire bracket interface is go ing to
be needed to finish a pati ent rath er th an a bracket to
decide what type of wire one ca n put in at the end of
the treatment. So, W e are not in favor of using a lower
torqu e brackets because 9 degrees 11 degrees you wi II
have to put in 0215X025 w ire to exp ress th at torque
while in 17 degrees I ca n put a mu ch lower dimension
wire to express th at amount of to rqu e in my wires. So,
as far as the other things of th e bracket, we designed
th ese brackets with the help of engin ee rs, who are very
versed with the aircraft industry w here you are go ing to
use N atos which are go in g to be fatigue res istance
because of changes in the temperatu re o f the ai rcraft
engines. So, what we are using is a spec ial mim system
and we got rid of th ese bonding base which people
have used over the years and we have cut down th e
amo unt of th e thi ck ness of th e bracket by usin g a
specially designed mec hani ca l lockin g system, So th at
w hen we are bonding, our brea kage rate of the brac kets
or loose brac kets is extremely low. Th e brackets are
very low profile they are angul ated alo ng th e lo ng ax is
of the teeth so that th ey are close r to the centre of the
resistance when w e are placing arch wires in th ere. So,
these brac kets have what we like them but as I always
say that brackets do not make a patient good o r bad.
Brac kets o nly help us attach the w ires If the brackets
have certain characte ri st ics w hi ch are good it helps
you to fini sh a pa ti ent better so, how and w hat you. p.ut
into a bracket is finally go ing to determin e w hat It IS.
SO, N and a Biomec hani ca l system is mo re dependant
upo n the w ires less o n th e brac kets
Ramesh 5abhlok: Yo u have in co rporated minu s 7
degree torqu e in th e upper ca nine brackets and there
are many prescriptions like Ri cketts, Hilgers and So ndhi
incorpo rate plus torque in the upper ca nine brackets,
these days more and more peopl e like fuller smiles.
Sometimes th ere are buccal corridors and dark areas .
Some of the prescriptions in corpo rate plus torque in th e
ca nine brackets. Wh at do you think about this?
Ravindra Nanda: Th ere is a resea rch, w hi ch we are
fini shing at this tim e which basically corrobora tes our
wo rk . What we did is we looked at severa l hundred
patients, their smil es, espec ially using mov ie ca meras
76
and different types of treatments th ese individu al patients
have go ne throu gh. Wh at we find is that ca nine is not
th e pil lar, which defines a smile or which defines th e
co rn ers of a mouth, because our resea rch is showing
th at 40% of th e patients in th eir smil e are go ing to
show their first pre-mol ars, the other 38 to 39% of the
patients show the second pre-molars and there are.anly
very small number of patients will show th e mes ial of
the first mol ars o r th e second molars and th e ve ry smal!
percentage of th e pat ients who only show ~a nin es
when they smile. So, th e ca nine does not enter Into the
estheti c aspect or enter into the dark corn ers o r all those
aspects. Those are the posterior teeth which are .goi n.g
down i nto the co rners . Now, as far as ca nin e IS
co ncern ed one of the bi g problems not hav in g mu ch
large r negat ive to rqu e is that you leave these cuspid s
hanging down while th e lower cuspids are basically
not following th e arc h form of th e pre-mol ars. Lowe r
pre-molars buccal inclination is linguall y in clined. So
you must have lower ca nine follow th e pre-molars. When
you do th at you end up having about 3 to 4 mm of
overjet in the ca nine area. W e do not like th at, W e
think that a ca nine which is sli ghtly tu cked in gives
o nl y 1 mm. or so of overjet in the ca nine area gives a
mu ch better smil e and as you probab ly saw in all our
finished patients when I give th e esth eti c lecture day
after tomorrow you will see I will further expa nd o n
this o ne th ere.
Ramesh 5abhlok: Wh at is your usual Protocol in
Orthodontics w hen you start a new case?
Ravindra Nanda: W ell , our message always is th at
every patient is an individual and no patient is go ing to
fit into averages o r numbers o r any thing. 50, w henever
you look at a patient, see that is the first p a tie~t yo.u
have ever see n in your life and th e problem patient IS
presenting is th e first problem you have ever seen in
your li fe. So this way you are lookin g at a patient w ith
very fres h eyes beca use when you look at a patient
w ith fres h eyes you will see lot of thin gs w hi ch no rm all y
you do not. If you are ju st classifyi ng patients into say i ng
like he is class II Division II, then you are go in g to mi ss
out lot of things. So, for us the clini ca l exa min atio n is
o ne of th e most important parts, facial exa min at io n,
intra-o ral exa min at ion lateral fac ial photographs are
extremely impo rtant for us. W e take lateral views, frontal
v iews, 45 degree views we take what we ca ll posed
smil e, we take smile in happiness, we take re laxed lip
position. So a full analysis of pati ent's face is very
important. Cep halometri cs- we will use cep halo metic
Ravindra Nanda
Mushroom Loop
Fi g.3: Schematic diagram
showi ng the moments and
fo rces on the mushroom
loop.
Fig.4: Extra oral activation of mushroom loop prior to insertion
Fig. 5 : Patient with a mushroom loop placed to achi eve retract ion of the max ill ary ante ri ors
analysis to understa nd the patient's skeletal relati o nshi p
pattern . But everything has to sort of tie in and th en
o ne of th e most important thing is w hy th e patient is
th ere, w hat the pa ti ent is looking fo r, w hat is the
patient's comp laint and that should never be ignored.
II occ lu sio n, your bite is closed". After all that th e
patient w ill say, "docto r, w hat about my inciso r because
you never mentio ned th at I w ill co rrect your incisor
also?" So, it is very impo rtant for the patient to li sten
about the main compl aint.
Ramesh 5abhlok : 50 the pat ient's chi ef com p laint
should be taken into co nsiderati o n
Ramesh 5abhlok : So, over th e num ber of yea rs we are
going away fro m the A ngle's classificatio n. Now we
are looking at th e faces, at the soft tissues analysis. So,
our thinkin g has changed more towa rd s soft tiss ue
analysis? Wh at is your pe rceptio n?
Ravindra Nanda: Al ways, because a pati ent may come
to you to get the lateral in ciso r corrected and you are
ta lking to the pati ent abo ut the bu cca l occ lu sio n or
cross bi te but, te ll the patient th at you are go i ng to
take care of the lateral inc iso r. It is very impo rta nt fo r
the pati ent to hea r, because lot of the ti me, my residents
are ta lking w ith th e pati ent, "Oh, you are having c lass
Ravindra Nanda: Extremely im po rta nt, I always tell
my students th at the most important thing is re lati o nship
of th e anteri o r teeth to the smi Ie, to the li ps, the verti ca l
dimensio n and the ca nine relatio nshi p. Wh at goes o n
77
J Ind Orthod Soc 2005; 38:68-78
in the bac k, depe nds on w hat your trea tm ent plan is. If
you have extracted o nl y in the upper you may have a
c lass II mo lar, if you have not extracted you sho uld
have a class I mol ar, if you have extracted ra rely in th e
lower arch you may have a class III mo lar relationship .
So, th e q uestion always is anteri or teeth are quite
sepa rate tha n the posterior teeth. You have to ali gn
them toget her but you look at th e anterior teeth quite
d iffere nt th an you look at th e posterior teeth.
Ramesh Sabhlok: Wh at will you lik e to tell u s
somethi ng about the Anchorage preparation in different
c lini ca l situ at io ns, espec i ally in m ax imum and
minimum anchorage cases?
Ravindra Nanda: Yo u see, our concept of anchorage
is very different. In my last book, I had covered thi s
concept in detail but in the new book I left that part
there. W e thi nk anchorage as four sepa rate concepts.
M ost of the time people always stop at th e first co ncept
and the first co ncept always is to increase th e anchor
units, use additional anchorage with headgear, cl ass II
Elastics, Lip Bumpers, palatal arc hes, thin gs like that.
For us that is a tradition al anchorage. But, the second
concept is very important that is, what we ca ll the
magnitude of force, diffe renti al fo rce, so we use that in
favo r, different force in the posterior region, different in
the anterio r region. Th e third co ncept is differenti al
moment-to-force ratios. W e can use differe nt momentto-fo rce ratio in the back as well as in front so th at we
can pit them against each other. And the fourth concept
always is the Biologi ca l. You know that means that
how the bone is, how th e tissues are, whether you are
treating adult, whether you are treating young. So, these
are all concepts of anchorage which are quite different
than other people.
Ramesh Sabhlok: I b e lieve that you believe in
Segmental arch techniqu e in Connecticut over the
number of years when Charles Burstone introdu ced?
What is your retraction mechanics in extraction cases?
How do you preserve the anchorage in different clinical
situations?
Ravindra Nanda: Dr. Charlie Burstone retired in 1992.
We have not used segmental arch philosophy since that
time. University of Connecti cut was never 100%
78
segmented arch. Segmented arch was o nl y may be
15% of the trea tm ent w hi ch w as done. So th e majority
of t he tr ea tm en t was done what we wou Id ca ll
Biomechan ica l approach in co nventi ona l Ed gew ise
Orthodonti cs. So, we do not use segmenta l mec hani cs
fo r retraction at al l any more. Our concept is mainly
makin g orthodontics user friendl y. So, incorporating the
concepts of Biomechani cs, Segmental philosophy into
th e conventi onal Edgew ise because people want to treat
more patie nts, peopl e wa nt to treat faster, people want
to treat with th e app li ance system which looks good in
the book but th ey also wa nt to look good in th e patient's
mouth.
Ramesh Sabhlok : In maxi mum anchorage cases w ill
you retract the ca nine individu all y first, fo ll owed by
retractio n of the incisors to preserve the anchorage or
you wi II retract en-m ass?
Dr. Ravindra Nanda : W ell , it does not m ake the
difference to us whether you retract individu ally o r enmass because the fo rce values are almost the same for
us. So, someti me we retract enmass sometim es w e do
not. But, if I am using sliding mechani cs, I usua ll y use
my intru sion arch as a pi ggyback top wire in the mo uth
to give a moment o n th e posterior teeth to keep them
back, use intrusion wire in th e fro nt so that the bite
does not get deepen and I ca n use even 016x022 or
017x025 55 wires to retract the ca nines or I ca n use my
new CNA wires which is our new Beta titanium wire
which we use to makeour Mushroom loops (see Fi gure
3, 4,5). And mushroom loops w e are using more over
the T-Ioop beca use the probl em with the T-I oop is th e
horizontal part was very large and it was always di gging
into th e tissues so we wanted to make it more user
friendly So, we made the T-shape into a mushroom shape
by shaving off th e co rn ers and the then loop also
becomes little bit more biomechanically nice because
now it has a archial shape. So, when you open the loop
the spring wants to close at the same time the horizontal
part is very small and the loop is more efficient.
(To be continued in next issue)
Communications
Dr. Ravindra Nanda - [email protected]
Dr. Ramesh Sabhlok - [email protected]
I
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