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JANUARY 1980, VOL. 14 / ISSUE 1
Behavior of Erupting Crowded Lower Incisors
Surgical-Orthodontic Cephalometric Prediction Tracing
Common Sense Mechanics Part 5
Cephalometric VTO
Technique Clinic - Preventing Decalcification on Banded Teeth
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jan(9 - 12): THE EDITOR'S CORNER
Most orthodontists survived the Seventies more or less intact, but worried about what the future
may bring. What can we expect from the Eighties?
While a substantial number of orthodontists can be expected to continue to practice in a more or
less traditional manner through the Eighties, it seems obvious that we have lost control of a major
portion of those factors that influence our destiny with regard to economic, social, and political
events, and that we will be carried along on a tide of consumerism, traditionalism,
anti-professionalism, experimentation, and change. The Eighties will undoubtedly see growth of
advertising, merchandising, and marketing in orthodontics. We will see more closed panel health
care facilities, some of which will have an orthodontic department. We will see more vertical and
horizontal group practices, and associations of practices in franchises and consortia. We will see
many referral relationships between specialty practices and closed panel clinics, open panel clinics,
unions, corporations, and retail dental facilities. Many more practices will be located in stores, in
clinics owned and operated by the store or as concessions leased out to individuals, groups, or dental
chains, each of which may not necessarily be owned by a dentist or dentists.
Orthodontists have been in the forefront of training and using expanded duty auxiliaries and can
be expected to relinquish mechanical tasks to an increasing extent in the Eighties and to assume the
role of diagnostician and supervisor of the tooth-straightening process, while paying much more
attention to those factors which will enhance the success of the treatment and the value of successful
treatment to the whole person and to his well-being.
On the technical side, one can see the Eighties as a time of consolidation and perfection of what
we now have. This could mean more accurate methods of bracket placement, less visible appliances,
more use of bonding and better methods of debonding; more understanding of forces and more
precise control of forces. We can expect more attention to be paid to the human side of treatment—
patient profiling and patient management for the side problems that could interfere with the efficient
completion of optimum treatment. It would not be rash to predict that by the end of this decade,
most orthodontic offices will have one or more computers and that these will be used for diagnosis,
practice management, practice research, monitoring of treatment, storing a great deal more data than
we are accustomed to think we need or want.
On the economic side, the trends that contributed to the decline in patient starts in the average
practice are still with us as we enter the Eighties. Any increase in birth rate that we are now seeing
will not appreciably affect child patient case starts in the Eighties. We will definitely see an increase
in the number of adult patients.
We also will have the impetus on the part of single working adults and, especially, married and
unmarried women in the work force, to seek improvement in their appearance and self-image, and in
their sense of wholeness. Nevertheless, a good part of the increase in adult interest in orthodontic
Article Text
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jan(9 - 12): THE EDITOR'S CORNER
treatment will be balanced by a steady decline in the numbers of 7-17-year-olds in the next decade.
The economics of orthodontic practice should be helped by this shift, however, because adult
orthodontic treatment should command fees that are one-third to one-half higher than child patient
fees, and orthodontists are paying more attention to raising child patient fees on a regular basis to
keep up with increased costs and inflation. At the same time, the presence of larger numbers of
adults may cause changes in treatment and adminstrative procedures.
Increased costs and inflation are continuing at a rate that is not encouraging for the economy in
general and for orthodontists.
It is important for orthodontists to understand the rationale of the consumerists, legislators,
Sunset committees, public health officials, educators, and various bureaucratic agencies (FTC,
HEW, Council of State Governments) who are moving dentistry away from traditional care and
delivery of care. Their view is that a majority of people are not receiving adequate dental care and
that the chief barrier is price. Dentists point in vain to the fact that dental fees have not gone up to
the extent of other goods and services and, indeed, have not kept up with inflation. The adversary
group believes that dental fees ought to be lower than they are and that they have been held
artificially high by lack of competition, by monopolistic control of entry into the profession, and by
the fact that dentists are overtrained for the mechanical tasks that they perform. They believe that
dentists for the most part only want to do the finest quality work for people who can afford it.
How would they solve all the problems? To create the competition that will lower the price,
rescind the ADA Principle of Ethics which prohibited advertising. To break the monopolistic
control over entry into the profession, change dental practice acts to permit ownership of dental
practices by non-dentists, and move to federalize dental practice acts and controls. To replace
dentists in tasks for which they are deemed to be overtrained, promote the use of expanded duty
auxiliaries for most of the mechanical tasks in dentistry, to some extent without dentist supervision.
To get dentists to substitute minimum satisfactory alternatives to the highest quality choices of
treatment, depend on price competition, the alternative work force of auxiliaries, and alternate forms
of delivery of care.
It would be an apt metaphor to describe the dentist as a peach tree from whom the government
and others would like to get apples. Failing that, they will plant their own apple trees.
How many dentists survive under these circumstances depends on how many people prefer
peaches to apples and are willing to pay the price. Most people who cannot afford peaches also will
be unable to afford apples. Ultimately, it may be found that apples cost just as much as peaches, and
then you will see the government move to socialize dentistry completely. Even then, there will be
some people who prefer private practice and are willing to pay the price.
How long do you think it will be before the same forces that are changing dentistry in general
today turn their attention to specialty dental services?
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jan(9 - 12): THE EDITOR'S CORNER
The same reasoning which was applied to dentistry in general will be applied to specialties. The
price is too high. Less well paid professionals can perform satisfactory lower quality treatment for
more people at a lower price. In addition to extensive use of auxiliary personnel, we will see
advocacy of the supergeneralist. General practitioners whose traditional role will largely be handed
to expanded duty dental auxiliaries will be encouraged to assume the role that traditionally has been
served by specialists. How many specialists survive under these circumstances again will depend on
how many people prefer high quality treatment and are willing to pay for it.
Traditionalists like ourselves are angered by external forces which are contrary to our beliefs and
value systems, and occasionally we cry out that "someone ought to be fighting against these
wrongful changes". We hope that somehow people will see the light and return to the old values and
the old ways. From evidences that we have seen in other areas such as education, professions are
weak institutions and do not have the ways and means to withstand external change and, while
dissatisfactions may arise even in the minds of the protagonists of change, questioning the wisdom
or effectiveness of the changes, this process may take 30 to 50 years and in the end, the environment
may no longer be relevent to the past or served by a return to it.
This does not mean that the individual orthodontist who desires to continue in private practice is
doomed. Certainly he should be able to do so in the Eighties, but how successful he is will depend to
a much greater extent than in the past on how well he is able to offer a service which enough people
perceive to be beyond the ordinary.
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jan(24 - 33): Behavior of Erupting Crowded Lower Incisors
Over the past 13 years the author has been observing the behavior of erupting permanent incisors.
A definite pattern has been noticed which could have clinical significance. The author, being a full
time clinical orthodontist in private practice and not a research worker in the strict sense, did not
feel justified in taking lateral head films of the cases. Routine lateral head films besides being two
dimensional, do not provide any information on arch width development. It is felt that there has
been too much emphasis placed on measuring, rather than on studying the patients. In all of the
cases shown, no extraction of primary or permanent teeth nor any form of orthodontic treatment was
performed in the mandibular arch.
Case K.L. A female, age 7 years 7
months at the initial visit. A Class 1 type of occlusion with all teeth present. The partly erupted
lower left lateral incisor was severely crowded lingually (A). 2½ years later the position of the lower
left lateral incisor improved considerably (B). No extraction of primary or permanent teeth nor any
form of orthodontic treatment was carried out.
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jan(24 - 33): Behavior of Erupting Crowded Lower Incisors
Case W.D. A female, age 7 years
3 months at the initial visit. A Class 1 type of occlusion. Except for the upper left lateral incisor
which was congenitally absent, all other teeth were present. The lower right lateral incisor was just
erupting. The lower left lateral was unerupted, but palpable lingually. There were obvious signs of
severe crowding of the lower incisors. In (A) the spaces between the lower right central incisor and
deciduous cuspid and the lower left central incisor and deciduous cuspid were 6mm and 2.5mm
respectively. In (B), one year later, the space for the lower left lateral incisor had increased to
5.5mm, a gain of 3 mm. The lower right lateral incisor was in correct alignment by then. In (E) 12
years 7 months later, the lower incisors are in very good alignment. No extraction of primary or
permanent teeth nor any form of orthodontic treatment was carried out on the mandibular arch.
Some minor orthodontic treatment was carried out on the maxillary arch, so that the congenitally
missing upper left lateral incisor could be replaced with a prosthesis.
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jan(24 - 33): Behavior of Erupting Crowded Lower Incisors
Case A.C. A female, age 7 years 10
months when first presented for consultation. A Class 1 type of occlusion with all teeth present. The
partly erupted lower right lateral incisor was crowded lingually. The lower left lateral incisor was
close to erupting; it was palpable lingual to the deciduous lower left lateral incisor, which was loose
and exfoliated by natural means soon after the first appointment. The available spaces for the lower
right and left lateral incisors in (A) were 5mm and 5mm respectively. In (B) the space for the lower
right lateral incisor increased to 6mm; the space for the lower left lateral incisor remained
unchanged at 5mm. In (C), another 12 months later, both the spaces measured 6mm each; i.e. the
spaces for both lower lateral incisors had increased 1 mm. In (E), at the age of 18 years 11 months,
there was a slight degree of imbrication of the lower incisors. As with the previous cases, no
extractions of primary or permanent teeth nor any form of orthodontic treatment were carried out.
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jan(24 - 33): Behavior of Erupting Crowded Lower Incisors
Case B.V-H A male, age 6 years
7 months when first presented. A Class 2 division 1 type of occlusion. All teeth were present. The
partly erupted and rotated lower right lateral incisor was severely crowded lingually, with 2mm
available space between the central incisor and deciduous cuspid. In (B), 21 months later, the space
increased to 4mm with obvious improvement in the position of the lower right lateral incisor. The
rotation, which was present originally was hardly noticeable now. Once again, no extraction or
orthodontic treatment was carried out to achieve the result in (D). However, a short while later he
did receive orthodontic treatment for correction of the Class 2 division 1 type of occlusion.
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jan(24 - 33): Behavior of Erupting Crowded Lower Incisors
Case J.S. A female, age 8 years
3 months at the initial visit. A Class 2 division 2 type of occlusion with all teeth present. Both the
lower lateral incisors were crowded lingually as seen in (A), and the available spaces for the right
and left lateral incisors were 4mm and 5mm respectively. As can be seen in (B) and (C) the
alignment of the lower incisors improved by natural means without the need of extractions or
orthodontic treatment. The patient had orthodontic treatment later for the Class 2 division 2 type of
occlusion .
Case V.P . A female, age 8 years 1 month
at her initial visit. A Class 2 division 1 type of occlusion with all teeth present. Both the partly
erupted lower lateral incisors were crowded. The lower left lateral incisor was rotated
mesiolingually. Marked improvement in the alignment of the lower incisors by natural means can be
seen in (B), (C), (D). The diastema between the upper central incisors closed without orthodontic
treatment, nor was the frenum removed.
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jan(24 - 33): Behavior of Erupting Crowded Lower Incisors
Case S.V-B. A female, age 8 years 2
months when she first presented. A Class 1 type of occlusion with all teeth present. The lower right
lateral incisor was erupting lingually (B) with the available space between the right deciduous
cuspid and central incisor being 3.5mm. Once again no extractions or orthodontic treatment was
carried out to align the lower incisors. The only orthodontic treatment carried out on this case was
with an upper removable Hawley type of appliance to reduce the overjet and this took three months
to accomplish.
In all the cases presented, no orthodontic treatment was carried out to the lower incisors. The
most interesting and important feature is that no primary lower cuspids or any other primary teeth
were extracted, nor was there any proximal stripping done to the primary teeth.
This problem of erupting crowded lower permanent incisors has prompted various authors to
suggest treatment procedures such as "Serial Extractions" (Kjellgren), "Guidance of Dental Eruption
by Means of Extraction" (Hotz) and "Timed Extractions" (Musselman and Chadha). This treatment
procedure, though it is known by various terms, is basically the extraction of deciduous teeth
prematurely to correct the alignment of the permanent incisors. This is done under the assumption
that it is possible to predict at a very early age that the alveolar ridge will not develop sufficiently to
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jan(24 - 33): Behavior of Erupting Crowded Lower Incisors
accommodate all the permanent teeth. Stripping the proximal surfaces of deciduous teeth instead of
extractions is also based on the same assumption.
This assumption is extremely precarious since there does not exist any growth prediction system
that can be considered accurate in regard to the amount of growth to take place.
Joseph Fox (1814) wrote: "In any of these (discrepancy) cases the removal of the temporary
cuspids is absolutely necessary, and unless the operation be timely performed, the irregularity is
with difficulty remedied."
Some orthodontists believe that if the deciduous cuspids are not extracted at the appropriate time,
the crowding of the lower permanent incisors will become so severe that multiband therapy will be
necessary. This premise is questionable from the evidence presented. In fact, it can be said that
multiband therapy is usually needed after initiating serial extractions. It is generally agreed that once
serial extraction is initiated (i.e. deciduous teeth have been extracted prematurely), more often than
not premolars will have to be extracted due to a deficiency in arch length, which probably is the
direct result of the premature extraction of the primary teeth. Extraction of mandibular premolars, or
any other mandibular teeth (but not so with maxillary teeth) will usually result in unfavorable axial
angulation of the teeth adjacent to the extraction site. Uprighting of these teeth will require
multiband therapy. In the available literature on serial extractions, arch length deficiency seems to
be the deciding factor in recommending extractions. To gain good alignment of the permanent lower
incisors, depends more on arch width (intercanine width) rather than on arch length. This aspect of
arch development is made conspicuous by its absence in the analysis of cases prior to initiating
serial extractions. Ricketts has shown there can be a decrease in arch length, but an increase in arch
width. This is consistent with the uprighting of the lower incisors in many adolescents without
orthodontic treatment as noted by Enlow, Bjork, and Moore.
It appears that the deciduous cuspids have a significant influence on the development of the
alveolar arches by maintaining integrity of contact from the permanent molars forward. Extractions
of the deciduous cuspids will cause a break in the contact with apparent adverse influence on the
development of the alveolar arch. Lingually erupting lower lateral incisors are often referred to as
ectopic eruptions. This should not be so because as can be seen in Figure 1, the embryonic position
of the lower lateral incisors is to the lingual. Lower lateral incisors erupting lingually should as a
matter of fact be known as anatomically correct. On the other hand, labially erupting lower lateral
incisors should be considered ectopic.
If lingually erupting lower lateral incisors are anatomically correct, then there must be an inherent
force for the lateral incisors to move labially. In the same way, there is an inherent force of mesial
migration. As the lateral incisors move labially, the deciduous cuspids will be made to move
sideways. This movement of the deciduous cuspids is probably checked by the mesial migration of
the posterior teeth, thus causing the deciduous cuspids to move obliquely (Fig. 2). The intercanine
width (b) will be greater than (a), thus allowing the incisors to improve in alignment. This may be
the explanation for Ricketts' findings of an increase in arch width while there is a decrease in arch
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jan(24 - 33): Behavior of Erupting Crowded Lower Incisors
The author believes that the deciduous cuspids with their periodontal structures act as
proprioceptors to the forces of mesial migration and also the labial moving force of the lateral
incisors, thus stimulating growth in the region of the cuspids. The V-shaped morphology of the
lingual surfaces of the deciduous cuspids and incisors is the ideal shape to allow the lateral incisors
to move labially, thus transmitting forces to the deciduous cuspids to encourage the mandible to
develop to its optimal shape and size as dictated by the genetic blue-print of that individual. This
hypothesis of mandibular bone growth would be consistent with Moss's idea of the functional matrix
growth concept. Extraction of the deciduous cuspids would rob the functional matrix of an
important proprioceptor.
It is felt that lateral incisors erupting labially in a crowded state (Fig. 3) will not have as favorable
a prognosis for resolution by natural means as with lingually erupting lower lateral incisors. This
may be due to the fact that the forces acting on the deciduous cuspids by the labially positioned
lower lateral incisors are not as conducive to bone development. At the moment, the author is not
able to substantiate this belief because of the lack of clinical material. This investigation is being
As with other bones of the body, the size and shape of the mandible are determined by the
complex and often obscure interaction of two agents, heredity and environment. Every individual
inherits the genetic blueprint that specifies how much bones will grow. The environment where the
individual lives has an effect on the genetic possibilities, encouraging some and prohibiting others.
The same could be said for the growth process of the mandible. The environment would consist of
the presence or absence of deciduous cuspids, the forces of mesial migration, including the inherent
labial migration of the lower lateral incisors, eating habits of the individual, the arrangement of the
erupting teeth, and the morphology of the teeth.
It appears that the presence of deciduous cuspids encourages optimal development of the
mandible in the intercanine area, which is important for the arrangement of the lower incisors.
Based on the existing evidence, the rationale for extracting primary cuspids to alleviate crowding of
lower incisors could be said to be questionable. It would be appropriate to conclude with a quotation
by Oliver Wendell Holmes:
"Let the eye go before the hand, and the mind before the eye."
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jan(24 - 33): Behavior of Erupting Crowded Lower Incisors
Fig. 1
Fig. 1 Lower lateral Incisors are positioned lingually prior to eruption. (Courtesy of Prof. Dr. Frans Van Der Linden and
Harper and Row Publishers, Inc.)
Fig. 2
Fig. 2 Typical arrangement of mandibular teeth at the age of 7 years. Forces of mesial migration and labial migration
cause deciduous cuspids to move obliquely.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jan(24 - 33): Behavior of Erupting Crowded Lower Incisors
Fig. 3
Fig. 3 Ectopic (labially positioned) eruption of lower lateral Incisors.
1. Bjork, A.: Variations in the growth pattern of the human mandible, longitudinal radiographic study by the implant
method. J. Dent. Res. 42,400, 1963.
2. Enlow, D. H.: Handbook of facial growth. W. B. Saunders. 1975.
3. Hotz, R.: Active supervision of the eruption of teeth by extractions. Trans. Eur. Orthod. Soc. 1947.
4. Kjellgren, B.: Serial extraction as a corrective procedure in dental orthopedic therapy. Trans. Eur. Orthod. Soc. 1947.
5. Moore, A.W.: Observations on facial growth and its clinical significance. Am. J. Ortho. 45, 6, June 1959.
6. Musselman, J. J. and Chadha, J. M.: Timed extractions. Dent. CI. Nth. Am. October 1978.
7. Rabine, M.: The role of uninhibited occlusal development. Am. J. Ortho. 74,1. July 1978.
8. Ricketts. R.M.: Growth prediction. JCO 9,5. May 1975.
9. Salzmann, J. A.: Orthodontics in daily practice. J. B. Lippincott Co. 1974.
10. Van Der Linden, F.P.G.M. and Duterloo H.S.: Development of the human dentition. Harper and Row. 1976.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jan(36 - 52): Surgical-Orthodontic Cephalometric Prediction Tracing
Much of the recent literature has emphasized the use of combined surgical-orthodontic treatment
of dentofacial and craniofacial deformities with specific emphasis placed upon the results of such
treatment. However, little has been written about the mechanics involved in surgical-orthodontic
treatment planning. A specific discussion of surgical-orthodontic cephalometric prediction tracing as
it relates to the correction of dentofacial deformities does not exist in the literature. The purpose of
this paper is twofold: 1) to illustrate the mechanics involved in performing a prediction tracing for
cases involving both surgery and orthodontics and 2) to demonstrate the necessity for doing
cephalometric prediction tracings so that both the orthodontist and the surgeon can properly plan
combined surgical-orthodontic treatment.
Because of the extreme diversity of orthodontic and surgical procedures employed in the
surgical-orthodontic correction of facial deformities, it is impossible to illustrate the method of
developing a prediction tracing for each possible deformity. We will, therefore, discuss and
illustrate the method employed for mandibular advancement, maxillary superior repositioning and
combined maxillary and mandibular surgery. With the exception of those methods employed in the
treatment planning for the correction of asymmetries, all surgical-orthodontic corrections are
basically the same as, the reverse of, or a combination of these procedures. Thus, once one is
thoroughly familiar with the techniques involved for these predictions, the principles can be easily
applied to other types of deformities.
The techniques discussed herein were adopted in part from the mechanics developed by Ricketts
for cephalometric analysis, growth prediction and visual treatment objective construction as
presented by Bench, Gugino, and Hilgers. 1,2 A thorough understanding of these principles will aid
in ones ability to understand and apply the material presented in this paper. Whereas, in constructing
the VTO, the skeleton is altered by growth and treatment, we alter the skeleton surgically and finish
the tracing just as is done in constructing the VTO.
Finally, it is emphasized that this paper is not intended to discuss treatment planning in its broad
sense. As we have previously discussed, this involves a detailed systematic patient evaluation,
decision about the indicated surgery, model surgery, and decision about surgical-orthodontic
sequencing.3,4,5,10,12 Furthermore, this paper assumes that the cephalometric x-ray from which the
prediction tracing is to be done was taken with the patient's lips in repose.
I. Cephalometric Prediction Tracing for Mandibular Advancements.
Why do prediction tracings for mandibular surgery? The basic reasons for doing predictions for
isolated mandibular surgery (advancement or set-back) are: 1 ) to accurately assess the profile
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jan(36 - 52): Surgical-Orthodontic Cephalometric Prediction Tracing
esthetic results which will result from the proposed surgery, 2) to consider the desirability of
simultaneous adjunctive procedures such as genioplasty, suprahyoid myotomy, etc., 3) to help
determine the sequencing of surgery and orthodontics (i.e., if the surgery is done first will it be more
difficult or easier to do the indicated orthodontics), 4) to help decide what type of orthodontics
might best be employed (i.e., extraction versus non-extraction) and 5) to determine the anchorage
requirements should extraction treatment be chosen.
The original records of a patient that was treatment-planned for mandibular advancement in
concert with orthodontics are seen in Figure 1. The patient has a prominent nose, a short lower face
height, a deep labiomental fold and a recessive chin. The decision was made to advance the
mandible primarily on the basis of facial appearance. Thus one basic treatment decision has been
made, but we do not know how far we wish to advance it, nor do we know what orthodontic tooth
movement will be necessary to allow the desired advancement. These questions can effectively be
answered by an accurate prediction tracing.
Step 1 - Trace the Stable Structures.
The first step in producing a prediction tracing is to overlay a piece of acetate paper on the
original cephalometric tracing and trace all structures which will not be significantly altered by the
surgery and/or orthodontics. For mandibular surgery, these structures will include the deep cranial
features, the maxilla, the maxillary occlusal plane, the mandibular ramus and the profile to the base
of the nose. Draw in Frankfort Horizontal and a line from nasion to indicate the optimum facial
depth, i.e., 89° in females, 90° in males (Fig. 2A).
We do not advocate treating patients "to the numbers", however optimum facial depth is a
convenient guide for beginning a prediction for either mandibular advancement or set-back surgery.
Nasal esthetics and sex have a direct influence on optimum chin prominence. Furthermore,
mandibular anatomy has an influence on desired chin prominence as the squar-ejawed (Mandibular
Deficiency Syndrome, Type I) 9 individual may appear too strong with the chin in this position while
those with a tapering lower face (Mandibular Deficiency Syndrome, Type III) 9 may still appear too
Step 2 - Add Skeletal Portion Changed by Surgery
Slide the prediction tracing to the left and rotate it slightly to position bony pogonion at the
optimum facial depth, keeping the mandibular occlusal plane in proper relation to the maxillary
occlusal plane. Once a satisfactory position is achieved, trace the distal portion of the mandible, the
corpus axis, and the soft tissue chin in this position (Fig. 2B). There is little change in soft tissue
chin thickness, so the soft tissue chin may be drawn in just as it was originally. 6,7 However, this is
so only if the original cephalometric radiograph is taken with the lips in repose. 8
Step 3 - New A-Po Line.
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jan(36 - 52): Surgical-Orthodontic Cephalometric Prediction Tracing
Construct a new line from Point A to pogonion. If a genioplasty is to be included in the
procedure, the anterior portion of this altered chin, be it bone or alloplast, is now construed to be
pogonion for purposes of placing the teeth. The tracing in Figure 2C illustrates the skeletal
correction. (Note: Frankfort Horizontal and the Facial Plane have been omitted for clarity of
Step 4 - Placing the Teeth.
The teeth are placed exactly as described by Bench, et al 2. First the lower incisor is placed in its
optimum position 1 millimeter ahead of the A-Po line, 1 millimeter above the occlusal plane, and at
22 degrees to the A-Po line.
Old and new mandibles are then superimposed on Corpus Axis at PM and the change in lower
incisor position is noted. Arithmetically adding twice this change to the crowding already present
allows calculation of the arch length deficiency or excess. Thus, the anterior-posterior position of
the lower first molar can be determined and the molar is traced in this position.
The upper first molar is then placed in the desired occlusion and the upper incisor is likewise
placed in the optimum position with its long axis 5 degrees more upright than the new facial axis
(dotted line on the prediction tracing) .
Step 5 - Tracing the New Lip Contours.
Once the teeth are placed, the lip contours are traced to correspond to the new incisor positions.
Unlike Bench, et al2, note that very little change in lip thickness is expected, because the original
film was taken with the lips in repose. Where the lower lip is severely everted due to the upper
incisor, as in our example, the rule of bisecting the overjet as suggested by Bench, et al 2 will prove
useful in locating the vermillion of the lower lip. The result of Steps 4 and 5 are shown in Figure 2D
which is the completed prediction tracing.
Once completed, the prediction tracing must be viewed as a goal toward which one is working. If
the completed tracing represents what you believe is an optimum result, then all is well. However, if
there is something that you do not like about it, i.e., chin contour poor, lips too protrusive or too
recessive, then the prediction tracing should be modified to correct this problem. Once the
prediction tracing is as you like it, the prediction tracing can be superimposed upon the original
tracings, registering on the structures not significantly altered by the surgery and/or orthodontics,
and the previously stated five basic reasons to do prediction tracings for mandibular surgery can be
deliberately and intelligently assessed (Fig. 2E).
II. Cephalometric Prediction for Maxillary Superior Repositioning.
Why do prediction tracings for maxillary surgery cases? It is even more important to do
prediction tracings for maxillary surgery cases, especially when the primary direction of movement
is vertical, to ascertain the effects of the prescribed surgery on the mandible. Specifically, the
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jan(36 - 52): Surgical-Orthodontic Cephalometric Prediction Tracing
mandible may require simultaneous surgical repositioning, and by doing the prediction tracing a
deliberate decision as to what if anything must be done with it can be made. 10 In addition, the
prediction tracing permits one to answer the same basic questions as discussed under mandibular
The original records of a patient are seen in Figure 3. This typical Long Face Syndrome patient
has narrow alar bases, a long lower third face, excessive interlabial gap, excessive exposure of the
upper incisor teeth, a "gummy" smile, a dorsal nasal hump, an obtuse nasolabial angle and a
contour-deficient chin. 11 The decision to superiorly reposition the maxilla is made primarily from
these esthetic features. The amount of superior repositioning is based upon the upper tooth to lip
measurement which is made clinically. Still, we need to know if the maxilla should be moved
posteriorly or anteriorly along with the upward movement and we need to know what orthodontics
will be necessary. Furthermore, we need to know if autorotation alone will produce an adequate chin
or if we will wish to add a genioplasty or consider simultaneous mandibular advancement. These
questions can be answered from a prediction tracing.
Step 1 - Trace the Stable Structures.
As is the case with all prediction tracings, we again begin by tracing the structures which will not
be modified either surgically or orthodontically (Fig. 4A). This should include point A as will be
discussed later.
Step 2 - Determination of Ideal Vertical Position for the Upper Incisor.
Regardless of how accurate your cephalometric technique, we recommend that the measurement
of the amount of upper central incisor exposed, i.e., that from stomion of the upper lip to incisal
edge, be made clinically with the patient standing in a relaxed posture. This is the single most
important measurement in preparation for superior repositioning of the maxilla and can be
confirmed cephalometrically. Once the amount of incisor exposed beneath the upper lip is
determined, the "ideal" amount of superior repositioning of the upper incisor can be determined by
the formula:
X 
0. 8
where X is the amount of superior repositioning necessary and Y is the amount of upper incisor
showing. This formula is used because the upper lip tends to shorten approximately 20% of the
amount of superior surgical repositioning; thus, a 1:1 relationship between the amount of tooth
showing and the amount of repositioning necessary does not exist. 12 Furthermore, if the superior
movement is to be accompanied by posterior movement of the incisors and an acute nasolabial angle
is present, the lip will not shorten quite as much as predicted. Conversely, with an obtuse nasolabial
angle and anterior movement of the incisor, the lip will tend to shorten slightly more. These slight
variations may be disregarded, unless the anterior-posterior change is more than 6 millimeters.
Once the desired amount of vertical incisor repositioning is determined, draw a line parallel to
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Frankfort horizontal on the prediction tracing to represent the desired vertical position (Fig. 4B).
Step 3 - Autorotation of the Mandible.
Superimpose the original and prediction tracings and, keeping the mandibular condyle in the
same position, rotate the prediction tracing clockwise until the occlusal plane is 1 mm above the
line indicating the desired position of the upper incisor. Trace the mandible in this position. The
corpus axis and the occlusal plane are also traced in at this time (Fig. 4C).
The change in point A and the soft tissue chin contour must be carefully studied at this time. To
allow easier observation of these features, one may wish to trace, with dotted lines, the soft tissue
chin, the lower incisor, and Point A.
The first feature that must be noted is the change in Point A. If this point moves posteriorly as it
often will in order to correct an existing Class II occlusion, we then use old Point A in determining
the A-Po relationship for the lower incisor. This point is frequently obliterated by the surgery and
furthermore the soft tissues of the midface, relatively unaffected by the surgery, still retain the same
basic relationship with old Point A making the physiologic basis for the A-Po line valid while using
the old Point A. Conversely, if point A moves anteriorly the soft tissue will be moved forward and
the new Point A is used to construct the A-Po line.
Step 4 - Genioplasty Determination.
The second feature which must be noted is the new soft tissue chin position. (This is where the
chin autorotates to.) Several methods are available to assess chin position, but the authors find those
illustrated in Figure 5 to be the most helpful. If the chin is adequate, then genioplasty is not
necessary. However, if the chin is still weak, as in our example either mandibular advancement or
some type of genioplasty must be added to the treatment plan for optimum esthetics. Conversely, if
the chin is too strong, then some procedure to reduce it may be required.
Ideally, we would like to determine the "normal" position for the soft tissue chin and then plan
our genioplasty to produce this desired result. For bony genioplasties, the ratio of anterior-posterior
soft tissue change to bony change is about 0.6:1, thus, if 5 millimeters more chin is desired, a bony
advancement of 8 millimeters will be required. If alloplastic material is to be added, this ratio
approaches 1:1 thus 5 millimeters of alloplast will produce 5 millimeters more soft tissue chin. 8
For patients who are not to undergo orthodontic treatment or where the lower incisors cannot be
retracted sufficiently, best chin-lip-nose balance is usually attained by placing an alloplastic
genioplasty thick enough to bring the material to a line from Point A and passing 1 to 3 millimeters
lingual to the lower incisor tip, thus producing a "normal" A-Po relationship for the lower incisor.
Figure 4D shows our patient with the projected genioplasty necessary to produce the optimum
chin projection. Once the amount of genioplasty has been determined, the new A-Po line can be
constructed using the genioplasty as a new pognonion and either the old Point A or new Point A as
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discussed previously.
Step 5 - Placement of Teeth In Ideal Positions.
This step is carried out exactly as described by Bench, et al. 2 After placing the teeth in their ideal
position (Fig. 4E), we are now ready to trace the new profile. (The excessive overjet in this patient is
produced by a missing lower incisor. )
Step 6 - Nasal Outline.
With superior repositioning of the maxilla, the nasal tip is generally elevated slightly. This is
more pronounced if the maxilla is moved upward and forward, less pronounced if upward and
backward. The lower border of the nose is relatively unchanged though it too may be elevated a
small amount. Accordingly, the prediction tracing should be placed on the original with the fixed
landmarks superimposed and the nasal outline traced with the aforementioned alterations (Fig. 4F).
Step 7 - Upper Lip.
The upper lip reacts to superior repositioning in the following ways: 1) the length from subnasale
to upper lip stomion shortens 1/5 of the amount of superior repositioning, 2) the thickness increases
by 1/3 of the amount of incisor retraction, and 3) the lip thins out slightly if the upper incisor is
moved forward, but in all but the most extreme instances this is unnoticeable. To trace the new
upper lip one should superimpose on the fixed cranial structures and study the change in incisor
position. If the upper incisor is retracted such that it lies posterior to an imaginary line from the
labial surface to Point A on the original tracing, then lip support has been reduced and one should
trace the new lip in the following manner:
Divide the vertical distance from old incisor tip to new incisor tip into fifths and the
anterior-posteriordistance into thirds. Move the prediction tracing down 1/5 and forward 2/3 and
draw in the new lip vermillion. Connect the new lip vermillion to the previously traced subnasale
in an artistic manner. Subnasale is affected so little by superior repositioning that for prediction it
can be considered a fixed point.
If the upper incisor has moved directly up the line from the labial surface to Point A of the
original tracing, then lip support is unchanged and one should trace the new lip in the following
Divide the vertical distance from old incisor tip to new incisor tip into fifths. Move the prediction
tracing down 1/5 and trace the new lip, connecting it to subnasale as above.
If, as in our illustration, the upper incisor is forward of the line from labial surface to Point A of
the original tracing, then lip support has been increased and the new lip is traced as follows:
Divide the vertical distance from old incisor tip to new incisor tip into fifths. Move the prediction
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tracing down 1/5. Then, while maintaining this vertical position, rotate and slide the prediction
tracing such that the long axis of the upper incisor in the prediction tracing is parallel to, and the
labial surface is flush with, the line from the labial surface to Point A of the original tracing.
Trace the new lip in this position (Fig. 4G). This effectively maintains the original lip thickness.
Step 8 - Lower Lip.
In most instances the lower lip vermillion is traced in the same relation to the lower incisors as
existed prior to treatment. Superimpose the lower incisor on the prediction tracing over that on the
original and trace the lower lip.
Where the lower incisors are retracted 5 millimeters or more, we find that the lip tends to thicken
slightly. Thus the lower incisors are not exactly superimposed, but the prediction tracing is moved
slightly to the lingual of an exact superimposition (i.e., the lip thickens slightly) and the lip traced in
this position (Fig. 4H). Some artistic freedom must be employed when dealing with a hypotonic lip.
In our experience, the hypotonic lip may increase mildly in tonicity following production of lip
competence and added support for the lip via augmentation genioplasty. If one feels that such a
result is likely, then the lip would be traced slightly thinner for purposes of prediction.
Step 9 - Chin.
If no genioplasty is projected, the soft tissue chin will be relatively unaffected by treatment and
should be traced by simply superimposing on the mandibular symphysis. If a sliding genioplasty is
done, the chin is traced by first superimposing on the original symphysis and then sliding the
prediction tracing back 6/10 of the amount of the genioplasty and tracing the new chin contour. If an
alloplastic implant is added, the new chin contour can be determined by simply superimposing the
alloplastic implant on the original symphysis and tracing the chin (Fig. 4I)
Once the tracing is completed, we again must study it to determine if indeed we have achieved a
satisfactory result. To once again gain optimum appreciation for the proposed changes
superimposition of the original and prediction tracing is done (Fig. 4J), again superimposing on the
structures not significantly altered by the surgery and/or orthodontics.
Frequently, it is necessary to do several prediction tracings, trying different surgical approaches
to a problem (i.e., superior repositioning vs. superior repositioning with genioplasty vs. superior
repositioning with mandibular advancement) before one can determine which result is best.
Certainly it is better to retreat a patient on paper than to wish that a different surgical approach
had been employed after the fact.
III. Cephalometric prediction tracing for combined maxillary and mandibular cases.
Once the techniques for prediction tracing involving the mandible alone or the maxilla alone are
mastered, it is a simple step to combine the two when surgery in both jaws is indicated. The basic
technique involved is to trace the stable structures, place the maxilla in the desired position both
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jan(36 - 52): Surgical-Orthodontic Cephalometric Prediction Tracing
vertically and anterior-posteriorly and then place the mandible in its desired position .
The records of a patient are seen in Figure 6. The patient exhibits narrow alar bases, an excessive
interlabial gap and a long appearance to the lower third of the face. In profile the severity of the
problem is better appreciated, as the nasolabial angle is obtuse and the chin extremely recessive.
Because of the obtuse nasolabial angle, the maxilla would optimally be moved superiorly and
anteriorly. Since a severe Class II malocclusion exists and the chin is so recessive, autorotation
alone will not correct these problems, even if the maxilla is moved straight superiorly. Therefore, a
simultaneous mandibular advancement must be considered. With this in mind, the prediction tracing
is done as follows:
Step 1 - Trace the Stable Structures ( Fig. 7A).
Step 2 - Determine the Ideal Vertical Position for the Upper Incisor.
Some care must be taken here, as the use of the aforementioned formula may not be entirely
accurate. In the patient with an obtuse nasolabial angle, where the maxilla will come forward to
increase lip support, slightly more shortening of the lip will be produced than might otherwise be
expected. Thus, slightly more superior movement of the incisor will be desirable. Superimpose the
original and the prediction tracings and draw a line parallel with Frankfort horizontal to indicate the
desired vertical position of the upper incisor. Trace a line from original point A tangent to the labial
of the upper incisor as a reference for the original upper lip support (Fig. 7B).
Step 3 - Autorotation of the Occlusal Plane.
Keeping the condyle in the same position, rotate the prediction tracing clockwise until the
occlusal plane is 1mm above the line indicating the desired position of the upper incisor. Trace the
occlusal plane and the mandibular ramus in this position.
Without moving the drawings, one should now assess the anterior-posterior change of the maxilla
by such rotation. This is done by comparing the new Point A-incisor line to the one made to show
the position prior to rotation. Frequently, enough anterior movement has been effected by the
rotation alone and the anterior maxilla can be traced at this point. If, however, more anterior
movement is desired, then the maxilla is moved anteriorly along the occlusal plane by sliding the
tracing posteriorly until the desired amount of forward movement (i.e., increase in lip support) is
With the desired anterior-posterior maxillary position attained, point A should be drawn in. The
upper incisor and molar position are marked for future reference. By adding Frankfort Horizontal
and the optimum facial depth line we now have a tracing which should look like that made of the
fixed skeletal landmarks drawn in the first step of the mandibular advancement procedure, except
that the nose has not yet been traced (Fig. 7C).
Step 4 - Mandibular Movement.
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This is done exactly as was done in Step 2 under mandibular advancement (Fig. 7D).
Steps 5-10 - Completing the Tracing.
Once the new position of the mandible has been traced, the balance of the tracing is done as
outlined in Steps 4-9 under Maxillary Superior Repositioning. The finished prediction tracing is
seen in Figure 7E.
In Figure 7F the superimposed tracings are illustrated.
Utilizing the Prediction Tracing The Surgeon's View
The primary concern of any proposed surgical-orthodontic procedure is that facial esthetics is
improved and never worsened. In this respect, it is important to appreciate that the discussion on
cephalometric prediction tracings included herein related entirely to planning for optimum profile
results. Nonetheless, the full face changes must be kept in mind, and if optimization of full face
esthetics results in mild compromises in profile results, this is acceptable. Such an instance would
occur where superior maxillary repositioning is planned and the prediction tracing reveals that with
the proposed amount of superior maxillary repositioning the maxilla will need to be simultaneously
repositioned posteriorly 4 millimeters. The patient, however, has a 110° nasolabial angle and "ideal"
prediction tracing placement of the maxilla tells us it must therefore not be posteriorly repositioned.
The decision must then be either 1) to obtain ideal profile results, which will necessitate a
simultaneous mandibular advancement of 2 to 3 millimeters, or 2) to "compromise" and move the
maxilla back 4 millimeters and thereby avoid the additional surgery. What does one do? Optimize
full face results and compromise. However, in the same situation, when the maxilla has to be
excessively repositioned posteriorly (6mm), it is warranted to do surgery in both jaws. The point—
use clinical judgment and do not always treat to numbers.
Finally, prediction tracings permit the surgeon to accurately plan for augmentation genioplasty,
reduction genioplasty, suprahyoid myotomy, etc., as discussed herein and elsewhere, which he is
unable to do otherwise except by "Kentucky windage" 7,8,10,13
Utilizing the Prediction Tracing-The Orthodontist's View
An accurate cephalometric prediction tracing is a necessary tool for the orthodontist because it
allows him to discern the anterior-posterior dental compensations present in a given malocclusion,
and plan orthodontic treatment which will effectively eliminate these compensations, thus allowing
the surgeon to effect the desired esthetic result.
In studying the desired orthodontic changes for the mandibular advancement patient presented
(Figs. 1 and 2), we use two superimpositions suggested by Bench. 14 The first superimposition,
corpus axis at PM, shows the orthodontic change necessary in the mandible (Fig. 8A). Here we can
see that the lower arch will require extraction of the lower first premolars and maximum anchorage
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jan(36 - 52): Surgical-Orthodontic Cephalometric Prediction Tracing
in order to retract the lower canine and incisors to the desired position. The second superimposition,
ANS-PNS at ANS, shows the necessary changes in the maxilla (Fig. 8B). Here we see quite a
different situation with the upper incisors staying relatively where they are, but the upper molar
being brought forward nearly a full premolar width. Thus, in the upper arch we would elect to
remove the second premolars and attempt to bring the upper molars forward. Carried one step
further, if we superimpose the treated arches on the Original tracing, we can see the magnitude of
the Class II malocclusion which we wish to achieve prior to surgery to allow the patient's lower jaw
to be advanced into the optimum position (Fig. 8C).
In the second patient presented (Figs. 3 and 4), this type of prediction was of less advantage to
the orthodontist, as the occlusion was basically Class I and the surgery was done first. It does,
however, alert us to the fact that following surgery we will be treating a maximum anchorage case
and thus our mechanics can be planned accordingly (Fig. 8D). Because the prediction tracing in this
particular case was of no value presurgically, one must not feel that this is always the case. In many
Class II cases which are planned for maxillary surgery, the lower arch needs to be "set up"
orthodontically to allow an accurate assessment of the orthodontic mechanics necessary to produce
the desired lower arch upon which the maxilla can be set at surgery. The maxillary superimposition
in such a case will not be meaningful, as the surgeon can effect the anterior-posterior changes
desired and these are more effectively studied via model surgery done immediately prior to the
surgery itself.
One last benefit can be derived from these detailed prediction tracings and this is in the area of
consultation. With an accurate tracing, one can, in effect, show patients and their parents the
proposed treatment results, at least in profile, which should allow them to better understand and
more readily accept the proposed treatment.
Orthodontist, Center for the Correction of Dentofacial
Deformities, John Peter Smith Hospital, Fort Worth, Texas
Director, Center for the Correction of Dentofacial
Deformities, John Peter Smith Hospital, Fort Worth, Texas
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume Jan
In many cases of mandibular advancement the patient can
protrude the jaw into a Class I occlusion and these questions
can be answered by direct observation of the patient and a
cephalometric x-ray taken with the lower jaw protruded.
However, because at the dental compensations existing in
most cases of mandibular retrognathia, merely achieving a
Class I molar and canine occlusion will not necessarily
produce the optimal facial appearance.
Fig. 1
Fig. 1 Case 1. Pretreatment records.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jan(36 - 52): Surgical-Orthodontic Cephalometric Prediction Tracing
Fig. 2
Fig. 2 Cephalometric prediction tracing for mandibular advancement. A. Tracing of structures which will not be altered
with surgery or orthodontics. B. Placement of distal mandible into optimum relation with remainder of skeleton. C.
Addition of new A-Po line and corpus axis. D. Ideal placement of upper and lower incisors calculated position of molars
and lips traced. E. Superimposed original and prediction tracing to evaluate overall treatment objectives and results.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jan(36 - 52): Surgical-Orthodontic Cephalometric Prediction Tracing
Fig. 3
Fig. 3 Case 2. Pretreatment records.
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Fig. 4
Fig. 4 Cephalometric prediction tracing for maxillary superior repositioning. A. Tracing of structures which will not be
altered with surgery or orthodontics. B. Line parallel to the Frankfort horizontal at desired vertical level of maxillary
central incisors. C. Autorotation of mandible around condyle as it will occur with the proposed amount of superior
repositioning of the maxilla. D. Having added the proposed amount of genioplasty, a new A-Po line is drawn to the new
Po as determined by the genioplasty. E. Placement of teeth as described.
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Fig. 4cont
Fig. 4 (Continued) F. Tracing of new nasal profile. G. Tracing of new upper lip position. H. Tracing of new lower lip
position. I. Tracing of new soft-tissue chin. J. Superimposed original cephalometric tracing and prediction tracing.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jan(36 - 52): Surgical-Orthodontic Cephalometric Prediction Tracing
Fig. 5
Fig. 5 Cephalometric criteria which may be us d to help determine optimum anteroposterior soft-tissue chin position.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jan(36 - 52): Surgical-Orthodontic Cephalometric Prediction Tracing
Fig. 6
Fig. 6 Case 3. Pretreatment records.
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Fig. 7
Fig. 7 Cephalometric prediction tracing for combined maxillary and mandibular cases. A. Tracing of structures which
will not be altered with surgery or orthodontics. B. Vertical referent parallel to Frankfort horizontal to determine new
upper incisor position. C. Determination of anteroposterior position of maxilla and upper teeth. D. Placement of
mandible into optimum position wlth maxilla. E. Finished prediction tracing. F. Superimposed original cephalometric
tracing and prediction tracing.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jan(36 - 52): Surgical-Orthodontic Cephalometric Prediction Tracing
Fig. 8
Fig. 8 Utilizing the prediction tracing. A. Desired orthodontic change in the mandible. B. Desired orthodontic change in
the maxilla. C. Desired position of the teeth prior to surgery to allow desired anteroposterior change at surgery. D.
Superimposition showing desired orthodontic change following surgery.
1. Bench, R.W.; Gugino, C.F. and Hilgers, J.J.: Bioprogressive Therapy: Part 2— Principles of the Bioprogressive
Therapy, J. Clin. Ortho., [11:661, 1977.]
2. Bench, R.W.; Gugino, C.F.; and Hilgers, J.J.: Bioprogressive Therapy: Part 3— Visual Treatment Objective, J. Clin.
Ortho., [11:744, 1977.]
3. Epker, B.N. and Wolford, L.M.: Middle Third Face Ostectomies: Their Use in the Correction of Acquired and
Developmental Dentofacial and Craniofacial Deformities,J. Oral Surg., [33:491, 1975.]
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jan(36 - 52): Surgical-Orthodontic Cephalometric Prediction Tracing
4. Epker, B.N. and Fish, L.C.: Surgical Orthodontic Correction of Open Bite Deformity, Am. J. Ortho., [71:278, 1977.]
5. Epker, B.N.; Fish, L.C.; and Paulus, P.J.: Surgical Orthodontic Correction of Maxillary Deficiency, Oral Surg.,
[46:171, 1978.]
6. Epker, B.N.; Fish, L.C.; and Wolford, L.M.: Mandibular Deficiency Syndrome, Part II— Surgical Considerations for
Mandibular Advancement, Oral Surg., [45:349, 1978.]
7. Schendel, S.A.; Wolford, L.M., and Epker, B.N.: Mandibular Deficiency Syndrome, Part III— Surgical Advancement
of the Deficient Mandible in Growing Children: Treatment Results in Twelve Patients, Oral Surg., [45:364, 1978.]
8. Dann, J.A. and Epker, B.N.: Proplast Genioplasty: A Retrospective Study of Treatment Results, Angle Orthodontist,
[47:173, 1977.]
9. Wolford, L.M.; Walker, G.; Schendel, S.A.; Fish, L.C.; and Epker, B.N: Mandibular Deficiency Syndrome, Part I—
Clinical Deliniation and Therapeutic Significance, Oral Surg., [45:329, 1978.]
10. Fish, L.C. and Epker, B.N.: Superior Repositioning the Maxilla: What to do with the Mandible, J. Oral Surg., [In
press, 1979.]
11.Schendrel, S.A.; Eisenfeld, J.; Bell, WH.; Epker, B.N.; and Mishelevech, D.J.: The Long Face Syndrome: Vertical
Maxillary Excess,Am. J. Ortho., [70:398, 1976.]
12. Fish, L.C.; Wolford, L.M.; and Epker, B.N.: Surgical-Orthodontic Correction of Vertical Maxillary Excess, Am. J.
Ortho., [73:241, 1978.]
13.Hohl, T. and Epker, B.N.: Macrogenia: A Study of Tissue Changes with Surgical Recommendations, Oral Surg., [41
:545, 1976.]
14. Bench, R.W.: Seven Position Serial Cephalometric Appraisal, Proceedings— Foundation for Orthodontic Research,
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jan(53 - 57): Common Sense Mechanics Part 5
Common Sense Mechanics
Controlling Vertical Forces Intraorally
Much has been said and written about vertical dimension and the problems involved with steep
mandibular plane angles and extrusive forces, particularly on the molar teeth. Likewise, a number of
solutions have been offered, including the use of various types of high pull headgear. But little has
been said in terms of controlling vertical dimension problems by controlling magnitudes of force
intraorally in the vertical plane of space. Since certain appliance techniques become almost routine
or "cookbook" in nature, certain potential advantages of force control are lost. For the most part, the
attempt is to prevent overeruption of teeth rather than actually intruding posterior segments.
Whether the latter should be done may be argued, but in my practice no high pull headgear is
used to intrude posterior teeth. The force MAGNITUDES are controlled so that posterior teeth are
only allowed to erupt to the extent of vertical growth within a given patient, in which case the teeth
would erupt anyway, even without orthodontic treatment. There is the advantage, also, of allowing
the teeth of choice to erupt. For example, maxillary molars can be permitted to take up most of the
vertical increase or, if desired, the lower molars can be permitted to take up part of the space.
Understand, we are only talking about the total vertical eruption of teeth that would occur without
treatment. We are not talking about additional vertical resulting from the overeruption of teeth due
to the forces of mechanics.
The Diving Board Concept
In an attempt to continue to use examples with which we are familiar, I would like to discuss
what I call "The Diving Board Concept". It is not that we use the diving board in force control, but
the mental image should permit us to recall more vividly the advantages involved in utilizing the
factor of "length" in our archwires. There is a formula that says that stiffness— or load/deflection
rate— is inversely proportional to the cube of the length. Formulas of this kind often seem
confusing and of little use to the orthodontist, as well as difficult to remember.
To make all of this useful and a little easier, let us analyze the situation more closely. First of all,
stiffness is the amount of deflection we get from a given load (force). The formula tells us that if we
are dealing with a cantilever (such as a diving board), by doubling the length stiffness is reduced to
one-eighth. By doubling the length, only one-eighth the force will be required to produce the same
deflection or the same force acting at double the length will produce eight times as much deflection
(Fig. 61).
Looking at a diving board, we can see that one end is attached and the other end free. If a person
were to walk out only halfway on the diving board, the board would bend or deflect a given
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distance. Also, the weight (force) of the individual standing at this halfway point times the
perpendicular distance to the point of attachment of the board produces a moment at the point of
attachment (Fig. 62). In orthodontics, we often refer to this moment as the "critical moment", as it is
the largest moment involved and is often responsible for breakage in an archwire at that particular
Since moments are products of force times distance, as stated so frequently thus far, you will
notice that the moment keeps decreasing along the diving board and finally reaches zero directly
underneath the individual (load) standing on the board (Fig. 63). This is because the distance at that
point is zero. Now, as the load moves forward to the end of the diving board, the critical moment
doubles due to the fact that the distance has doubled (Fig. 64). The load is still the same, but force
times twice the original distance produces twice the moment (critical moment). Again, note that the
individual produces only a pure force acting through the point at which the load is positioned. There
is no moment at this point, since there is no distance left in relationship to the applied force.
Cantilever Principle
What we have just discussed is known as a cantilever system, characterized by a pure force acting
at one end, and an equal and opposite force at the other end accompanied by a moment. We can
utilize this system in orthodontics and make modifications for practical purposes. The pure force can
be used for overbite correction while the differential torque can be utilized for intraoral anchorage
control. The latter and its application will be discussed later.
To demonstrate the relationship of wire length to load/deflection (stiffness), fabricate a
rectangular segment of wire with a tipback bend (Fig. 65). On your typodont, insert it into the molar
tube and measure the force at the anterior necessary to raise the wire to bracket level (Fig. 66A).
Note the force required and then move half the distance to the molar and again measure the force
necessary to bring the wire to bracket level (Fig. 66B). This visual demonstration should help you to
remember the significance of "bypassing" teeth as one dramatic means of controlling force levels.
Thus far, we have discussed loads (forces) and deflections as related to a diving board. This was
done only to permit an easier reflection on some of the points discussed, as learning by formulas
alone can sometimes be monotonous at best. Next, we will take this "Diving Board Concept" to the
patient and apply it in a simple and effective manner. But, first, I would like to conclude this portion
with a discussion regarding constancy of loads and deflections.
Constant Load versus Constant Deflection
There are those orthodontists who are concerned about precise force levels for certain types of
tooth movement, for various reasons which need not be discussed. On the other hand, there are those
who almost totally disregard the force levels involved in tooth movement. I would like to discuss,
briefly, my personal concept.
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To seek an exact force level requires varying the deflection of the archwire ( Fig. 67). This means
that when we place a given bend, we must determine what angle is necessary to produce the desired
load (force). It also requires that we must know the length of wire between brackets and tubes. We
can resort to reference tables or we can go through "trial and error" until we arrive at the bend which
gives us the force we want. If, instead, we choose to place a "constant" bend (angle), we find that
we create variable loads (forces) (Fig. 68). The problem now, of course, is that some of these loads
might be biologically and physiologically acceptable, while others might be much too high and
introduce additional problems into our treatment procedures, particularly those cases involving
vertical dimension problems.
With all of this in mind, I prefer the application of constant bends (angular) because they are easy
to do, readily reproducible, intraorally activated (light wires only), and offer low force ranges when
the orthodontist is familiar with the "by-pass" approach to force control. It is necessary to get rid of
the idea that "light" wires, by themselves, produce "light" forces. As we know, small interbracket
distances can produce very high magnitudes of force with the so called "light wires". Bypassing
teeth is one method of increasing interbracket distance. Individuals often use single wing brackets
for this purpose, but when all teeth are banded all of the time and an archwire engaged in every
bracket automatically, there is little alternative for reducing force levels.
In short, constant bends are VERY practical, easy, useful, and effective— IF the operator
understands the various principles governing "force control". Although the range of force levels will
be broad, the entire range can be maintained at a very low level.
Article Text
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jan(53 - 57): Common Sense Mechanics Part 5
Fig. 61
Fig. 61 A. When the length of the diving board is doubled, only one-eighth the force is required to produce the same
amount of deflection. B. The same force acting at twice the length will produce eight times as much deflection.
Fig. 62
Fig. 62 Load (force) on diving board produces bending moments along the board, with the maximum moment being
located closest to the point of attachment.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jan(53 - 57): Common Sense Mechanics Part 5
Fig. 63
Fig. 63 The bending moments reduce as the distance from the load decreases.
Fig. 64
Fig. 64 As the load moves to the end of the diving board, the distance doubles and so does the critical moment.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jan(53 - 57): Common Sense Mechanics Part 5
Fig. 65
Fig. 65 Rectangular sectional arch with tipback bend.
Fig. 66
Fig. 66 A. With the sectional arch inserted in a molar tube on a typodont, measure the force necessary to raise the wire
to bracket level at the anterior end. B. Move the measuring device half the distance to the molar and note the force
measurement now needed.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jan(53 - 57): Common Sense Mechanics Part 5
Fig. 67
Fig. 67 To maintain the same force requires variation in archwire deflection.
Fig. 68
Fig. 68 Constant deflection creates variable loads.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jan(58 - 60): Cephalometric VTO
In the case of the Steiner Analysis it can be demonstrated with geometric principles that the sum
of the following four angles always equal 180 degrees: ANB, maxillary incisor to the NA plane (1 to
NA), mandibular incisor to the NB plane (1 to NB), and the interincisal angle (1 to 1) 1,2 (Fig. 1).
This is an invariable mathematical truth which can be utilized to enhance cephalometrics as a
clinical tool.
For example, in treatment planning it is difficult to estimate the desired finishing position of the
maxillary incisors, especially in orthognathic surgery cases where orthodontic therapy for removal
of dental compensations precedes surgery. Combining clinical judgment and the use of the above
mathematical truth, the visualization of the finished maxillary incisor position becomes much clearer.
The first step in obtaining the visual treatment objective involves a clinical judgment—
determination of the desired angulation of the mandibular incisor to the NB plane. Positioning of
lower incisors has been discussed extensively and norms and standard deviations for this angle have
been offered by many. 3-9 However, in actual planning of treatment, the desired angulation of the
lower incisor to the NB plane must be left to the judgment of the individual clinician.
The relationship of maxillary to mandibular incisors was proposed by Downs as the interincisal
angle.5 He suggested a normal value of 131°  3° to represent the ideal relationship of these two
teeth. Riedel, however, suggested that the relationship between maxillary and mandibular incisors is
best determined by functional and esthetic considerations. 10 From a functional standpoint the
relationship of maxillary lingual crown contour to mandibular incisal edge position is more
important than the interincisal angle. Considering esthetics, Riedel suggested that the upper and
lower incisor facial crown angle should approach 0 degrees or a straight line (Fig. 2).
Figure 3 shows three incisors with parallel axial orientations. The angle formed by the facial
surface of the crown and the long axis of the tooth differs in each example. Because of variations in
crown axis/root axis angulation as seen in dilaceration, an optimal facial crown angle of 0 degrees
does not always correlate to any single "ideal" interincisal angle. The interincisal angle most
appropriate to a particular case must be determined by drawing a cephalometric incisor "setup" with
a facial crown angle of 0 degrees. The resulting interincisal angle can be read from the drawing
(Fig. 4).
With a second clinical judgment— estimation of the ANB angle following treatment— it now
becomes a matter of simple mathematics to arrive at the angulation of the maxillary incisor to the
NA plane. Add the three angles: the 1 to NB, 1 to 1, and the ANB, and subtract the sum from 180
degrees to obtain the final 1 to NA measurement.
Thus, to apply this cephalometric VTO to a clinical case requires five simple steps:
Article Text
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jan(58 - 60): Cephalometric VTO
1. Determine the angulation of 1 to NB plane.
2. Set 1 to 1 at a facial crown angle of 0 degrees.
3. Measure the resulting interincisal angle.
4. Estimate the expected ANB angle following treatment.
5. Calculate the required 1 to NA angulation following treatment, using the formula: 180° - ( 1 to
NB) - (1 to 1) (ANB) = (1 to NA).
Using this simple VTO, it is possible to plan treatment finishing requirements and estimate the
necessary incisor torque, considering morphologic pattern, function, stability, and esthetics.
Assistant Professor, Department of Orthodontics and
Pedodontics, University of Pennsylvania School of Dental
Medicine, and Division of Dentistry, Children's Hospital of
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume Jan
Fig. 1
Fig. 1 The sum of the following 4 angles always equals 180°: ANB (A), 1 to NB (B), 1 to NA (C), and 1 to 1 (D).
Fig. 2
Fig. 2 (a) Facial crown angle of 11° Indicates the incisors are too proclined. (b) Facial crown angle of 0° (facial surfaces
are parallel) indicates Ideal Incisor esthetics. (c) Facial crown angle of -8° indicates the incisors are too upright.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jan(58 - 60): Cephalometric VTO
Fig. 3
Fig. 3 The angle formed between the face of the crown and the long axis of the Incisor differs in each of these three
Fig. 4
Fig. 4 These three examples show Incisors set to an ideal facial crown angle of 0°. Due to morphologic differences In
crown axis to root axis, the associated interincisal angle In each case Is different.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jan(58 - 60): Cephalometric VTO
1. Servoss, J.M.: Derivation of Acceptable Arrangements in the Steiner Analysis. Angle Orthod. 41:146-149, 1971.
2. Servoss, J.M.: The Acceptability of Steiner's Acceptable Compromises.Am. J. Orthod. 63:161-165, 1973.
3. Tweed, C.H.: Frankfort Mandibular Incisor Angle in Diagnosis, Treatment Planning, and Diagnosis, Angle
Orthod . 24:121 -169, 1954.
4. Ricketts, R.M.: Cephalometric Synthesis. Am. J. Orthod. 46: 647-673, 1960.
5. Downs, W.B.: Analysis of Dentofacial Profile. Angle Orthod. 26:191-212, 1956.
6. Steiner, C.C.: Cephalometrics for you and me. Am. J. Orthod 39:729-755, 1953.
7. Altemus, L.S.: A comparison of cephalofacial relationships. Angle Orthod. 30:223-240, 1960.
8. Garcia, Carlos J.: Cephalometric evaluation of Mexican Americans using the Downs and Steiner analysis. Am.
J. Orthod. 68:67-74, 1975.
9. Wei, S.: Craniofacial variations, sex differences, and the nature of prognathism in Chinese subjects. Angle
Orthod. 39:303-315, 1969.
10. Riedel, R.A.: In Graber, T.M., and Swain B.F., (eds.): Current Orthodontic Concepts and Techniques.
Philadelphia, Saunders, 1975. pp. 1111-1112.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jan(61 - 61): Technique Clinic - Preventing Decalcification on Banded Teeth
technique clinic
It is discouraging to find decalcified, white spot areas upon band removal. This complication is
noted most frequently on the buccal surfaces of mandibular molars. The following technique is
suggested as a means of reducing or eliminating this problem.
For a mandibular molar, the procedure would be:
Step 1 Fit the band and add the prescribed attachments.
Step 2 Complete a prophylaxis on the buccal surface of the tooth, using plain pumice.
Step 3 Isolate and dry the tooth and perform an acid-etch procedure for 30-40 seconds.
Step 4 Wash the acid off with water, dry the etched enamel surface, and paint on a sealant.
Step 5 Cement the band.
This procedure can be performed on any surface of any tooth. It is not restricted to the buccal
surface of mandibular molars.
New Jersey College of Dentistry 100 Bergen Street Newark,
N.J. 07103
FEBRUARY 1980, VOL. 14 / ISSUE 1
Common Sense Mechanics Part 6
The "Three-Cornered Space" Pitfall in Adult Treatment
Orthognathic Treatment in Patients With Temporomandibular Joint
Constructing the Gnathologic Setup and Positioner
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Feb(77 - 78): THE EDITOR'S CORNER
Prior to the advent of professional corporations, it was customary for orthodontists to count
income in excess of practice costs as profit, which represented the orthodontist's net income. Thus,
"profit" in 1978, in the average orthodontic practice was 52.3% of gross income. With the
proliferation of incorporation of orthodontic practices and with the blurring of professional and
commercial characteristics, this type of accounting will no longer do.
It is, and always has been, wrong to create the impression that orthodontic practice was that
"profitable". There is no business on earth that does not include the chief executive officer's salary
as a cost. The proper procedure is to allocate an annual salary for the orthodontist as a cost, along
with the salaries of the other employees of the corporation. In a practice that has a gross income that
is below average, it may well be that the doctor's salary will consume all of the net income after
other practice costs. In that category, he will need all the income he can get to support a reasonable
standard of living. However, once the practice income exceeds the average, then the net income
after costs, including the doctor's established salary, can become a fringe benefit and contingency
This fund permits adjustment of salaries at year-end, according to the amount of this net income,
through bonuses; and it allows for fringe benefits for the doctor and for the staff. These include
medical benefits, insurance benefits, auto benefits, uniform allowances, and retirement plan benefits.
Many orthodontists refuse the discipline of incorporation and salary, even though they know that
their salary is adjustable through bonuses at yearend and through retirement plan contributions and
other fringe benefits; and that the structure of corporations is such that the doctor is eligible for a
disproportionate share of the practice income. Many of these have merely had no advice or poor
advice. Many are simply unable to discipline their spending and, indeed, have their expenditures
exceed their income. They can even find solace in the often heard opinion that "a dollar saved is a
dollar lost" due to the rate of inflation and increased costs, and the difficulty in finding investments
which keep up with inflation after taxes.
It is precisely this difficulty with finding investments which keep up with inflation which
recommends a retirement plan in a professional corporation. You don't have to be a genius. You
don't even have to have any special knowledge about investment to come out better in your
retirement plan than the most knowledgeable and sophisticated of investors. With no risk. You come
out better, mind you. Not fantastic, but better.
Here's how. If you were to invest $10,000 a year in your retirement plan in a money market fund,
it presently yields better than 10% a year. Let's say 10% a year. That means that in seven years, by
the famous rule of 72, you would double your money. Now someone interrupts to say, "Yes, and
when you take it out, it is taxed at 60%". That is correct. So, if the fund terminated in seven years,
that first $10,000 would only be worth $14,000. If inflation during the seven years was 10% a year,
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Feb(77 - 78): THE EDITOR'S CORNER
you'd be left with only about $8400 in Year 1 purchasing power. That doesn't sound like a winner.
Maybe so, but everything is "compared to what". If you compare that to an investment yielding a
long term capital gain, which is taxed at only around 30%, you'd possibly expect the long term
capital gain to far exceed that measly retirement plan investment. Well, if my calculations are
correct, it would take a long term capital gain of about 37% a year for the same seven years to equal
the "measly" retirement plan. The reason is that the retirement plan investment is made in before-tax
dollars and the long term capital gain investment in after-tax dollars.
You might say, "I was right the first time. I'm better off spending it, in that case". Maybe so, but I
think it is a question of— Would you rather wind up at the bend in the road sorry that you had set
aside money in a retirement plan or wishing that you had?
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Feb(98 - 103): Common Sense Mechanics Part 6
Common Sense Mechanics
Clinical Application of the Diving Board Concept
If we wish to apply the cantilever principle and its modifications for practical use in clinical
orthodontics, we must understand its characteristics and possess some means of controlling the force
magnitude involved, as these equal and opposite forces, in the vertical plane of space, threaten our
treatment results in various ways. From the "Diving Board Concept", previously discussed, we
recognize that length affects load (force). If we double the length of wire, we reduce the force per
unit of deflection to one-eighth. Therefore, if we bypass bicuspids and cuspids during overbite
correction, and use a wire with tipback bends at the molars, we have in effect created a "diving
board", although certain modifications would be required in the anterior segment in order to provide
a true cantilever system. However, as we will see, the major advantages of force control can be
achieved in a practical manner by deviating from the true cantilever concept when desired, although
we remain free to use the cantilever approach if we wish.
If the tipback activation is constant, such as a 45° angle, then as the distance doubles, so does the
deflection (Fig. 69). Therefore, although the load per unit of deflection is reduced to one-eighth, the
unit of deflection is doubled, resulting in a net force of one-fourth (2 × 1/8 = ¼). However, it is quite
evident that the length of wire is increasing much more than "twice", and therefore the net intrusive
force on the anterior segment is dramatically reduced. With wire sizes of .016, the magnitudes at
times become so low, you wonder if "anything" will happen with the overbite. It is common to have
forces in the range of 20-30 grams and lower. I do not measure such forces because the entire range
remains low. If we apply a total force on an incisor segment of 30 grams (intrusion), for example,
we produce equal and opposite forces on the molars. But, one-half goes to each molar, meaning that
each molar in this example would incur only 7½ grams of force— enough to allow the molars to
erupt during vertical growth, but not enough to overcome the forces of occlusion.
Affect on Forces and Moments
Because the anterior-posterior arch length varies from patient to patient, when bicuspids and
cuspids are bypassed the length becomes a variable and, thus, so do the magnitudes of the intrusive
and extrusive forces at each end of the archwire, which we have already seen to be greatly affected
by changes in wire length. However, the entire range of force is so low that low magnitudes of force
may pose a greater problem than attaining higher levels of force. In fact, it may even require going
to archwires of greater diameter to produce a required force and desirable response.
The moment on the molars, however, cannot be ignored, as it is possible to tip back molars
undesirably, if not cautious. Be careful not to use too large a tipback bend (angle), as this in
combination with duration (time) of use can result in excessive tipback of the molar teeth. However,
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Feb(98 - 103): Common Sense Mechanics Part 6
if molars are tipped back without the use of forces that cause such teeth to "overerupt", I have yet to
see a case where such teeth have not readily uprighted during retention— usually within a period of
one year following appliance removal. If cervical headgear is being worn, this tends to prevent
much of the tipping in the upper arch. In many overbite cases, the correction is required in the upper
arch anyway, due to short lips and "gummy" smiles. In such cases, a tipback bend need not be
applied to the lower molars.
Pure Force
A pure force will not occur if the design of the archwires is improper. In a case where only the
molars and incisors are banded/bonded, direct insertion of the archwire into the incisor brackets,
following the placement of a tipback bend at the molar area, does not produce a pure intrusive force
to the incisor teeth. Initially, the wire will cross the lateral incisor brackets at a slight angle, resulting
in a more complex system in which forces and moments are introduced in combination. The exact
force is unknown and in certain cases might not even exist.
Remember the "Fallacy of Visual Inspection in Force Analysis"? In order to provide a pure and
known intrusive force, a wire segment can be placed into the incisor brackets and the archwire then
used as an "overlay" (Fig. 70). As a practical matter, I most often insert the archwire into the
bracket, but it should be emphasized that the term "cantilever" is no longer correct in the exact sense.
Notice in Figure 70 that the cantilever is in use with the lower arch. An anterior segment has been
placed with an archwire overlay containing a tipback bend. But the upper archwire has been inserted
directly into the incisor brackets and, as a result, a pure force is no longer introduced at the bracket
level . Instead, intrusive forces in combination with moments are introduced and the system is
therefore not a cantilever system. Notice the effect of the moments on the lateral incisors. This is
routinely seen when the archwire containing a tipback bend is inserted directly into the incisor
brackets. But it is practical, the forces remain light, and the lateral incisor inclination is easily
corrected following correction of the overbite.
The name of this series involves "Common Sense", and it is good to know what is technically
correct, but at the same time what is practical and works. There is nothing that says we must adhere
to a certain method derived from a given principle. We are free to modify any method in any way
that gives us the end result we seek. Each orthodontist may choose his preferred method. The
underlying principles offer him an intelligent choice. In any case, the force magnitudes in the
non-cantilever system remain light, and this is our primary concern.
Figure 71 shows a case which was treated with light forces using a noncantilever approach and
bypassing bicuspids and cuspids (Fig. 72). In addition to providing light forces, the bypassing
allows erupting teeth to adjust to their environment without direct interference from an appliance.
Again, the effect of the moments can be seen on the lateral incisors. Remember, it was pointed out
earlier that there is a large moment produced on the molar teeth from the tipback bend. When the
archwire is tied securely to the molar tubes, this moment tends to tip all of the teeth distally, as they
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Feb(98 - 103): Common Sense Mechanics Part 6
are forced to "follow" the molars. This "distalization" tendency is easy to check simply by observing
the unbanded cuspids and their change in axial inclination. The cuspid crowns tip distally as they are
forced back as a result of the thrust being received at the crown level.
Following treatment, with bands removed and removable retainers placed, note the improvement
occurring as the distobuccal cusps of the maxillary molars begin to "seat" themselves (Fig. 73). This
is a regular occurrence when molars have been tipped back without the use of excessive forces.
Nothing more than a 2×4 appliance (incisors and molars) was used in this case, and it can be seen
that the cuspids still have a distal crown inclination.
Headplates are taken regularly on all patients, but will purposely be avoided during this series, as
it is intended to introduce as many "common sense" approaches as possible into determining what is
happening and why, on a practical and clinical level.
Unbanded teeth frequently provide much information as to what is happening, as they do not
serve as reciprocal units. Such teeth (unbanded) are affected by directions of movement and often
permit us to verify clinically that what is happening is what we predicted should happen. If not the
case, something is wrong. But remember that "common sense" is a very necessary ingredient in this
matter of interpretation. For example, distal crown torque on an upper molar could turn out to be
mesial root torque or a combination of the two. If a deep overbite is present and the archwire tied
securely to the molar tubes, distal crown movement of the molars may become impossible with a
tipback bend, and instead the molar roots may come forward. If not inhibited by such interferences,
remember crown movement tends to precede root movement. So we do have an overall advantage if
we apply common sense. In fact, in most Class II malocclusions, the molars require some degree of
tipping (uprighting) .
Since overbite would normally be required with the use of a tipback bend, and since tipback
bends are sometimes desired in cases having little or no overbite for a number of reasons— many
yet to be discussed— the intrusive components of force can be eliminated by the use of "up and
down" elastics in the anterior of the mouth. These elastics do not erupt teeth— unless their
extrusive components exceed the intrusive components in the archwire. When balanced properly,
the extrusive components of force from the elastics simply cancel out the intrusive components of
force from the two archwires, upper and lower, when tipback bends are used in both arches. At the
same time, if it is desired to erupt anterior teeth in one arch, but not the other (certain types of
openbites), a tipback can be used in the arch where teeth are not to be erupted. The tipback produces
an anterior intrusive force which can be utilized in that arch, to offset the extrusive force, from the
up and down elastics.
Figure 74 shows a case with some interesting sidelights. Because of the large moment produced
at each molar, during overbite correction it is not uncommon to see "distalization" of an entire arch.
Non-banded teeth, as mentioned earlier, make useful reference points on a clinical level. When the
archwire is tied back at the molar tubes, the incisor segment is "forced" to follow the molars as they
tip back— if the molar crowns are allowed to tip back rather than the roots moving forward (some
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Feb(98 - 103): Common Sense Mechanics Part 6
combination would normally be expected). Note the position of the lower incisors relative to the
cuspids. Also note that the unbanded lower cuspids are tipping distally quite significantly during the
overbite correction. At the same time, teeth are erupting nicely.
The final case (Fig. 75) involves severe crowding. This patient was treated nonextraction. Only
the incisors and molars were banded until the very end of treatment when cuspid bands were added.
Using a minimal appliance for as long as possible and not letting the appliance do your thinking has
its benefits. The expression, "trade-off", may well apply, as the orthodontist is able to think more
and work less.
Fig. 69
Fig. 69 With a constant tipback angle, the deflection doubles as the wire length doubles.
Fig. 70
Fig. 70 Cantilevered "overlay" on lower anterior segment produces a pure intrusive force.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Feb(98 - 103): Common Sense Mechanics Part 6
Fig. 71
Fig. 71 Case before treatment
Fig. 72
Fig. 72 Treatment sequence of case shown in Figure 71, using light forces in a non-cantilevered approach.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Feb(98 - 103): Common Sense Mechanics Part 6
Fig. 73
Fig. 73 Case shown in Figure 71, after treatment.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Feb(98 - 103): Common Sense Mechanics Part 6
Fig. 74
Fig. 74 Treatment sequences of a case showing use of light forces with both a cantilevered and non-cantilevered
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Feb(98 - 103): Common Sense Mechanics Part 6
Fig. 75
Fig. 75 Case before and after treatment with minimal appliance.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Feb(104 - 105): The "Three-Cornered Space" Pitfall in Adult Treatment
The "Three-Cornered Space" Pitfall in
There are a number of pitfalls in adult orthodontic treatment. The "three-cornered space"
phenomenon ranks as one of the most important. Rather frequently, an adult patient will develop a
rather unsightly three-cornered space between maxillary or mandibular anterior teeth. Such a
development will usually elicit a prompt, negative, sometimes hysterical reaction from the patient. It
is important, that it be anticipated and mentioned during consultation. As an aid to selecting which
patients should be forewarned, it has been our observation that such space or gingival recession
occurs most frequently in three types of cases.
Overlapped Upper Anteriors
First, it can occur in cases with overlapped upper anterior teeth . When such teeth are aligned, the
gingiva is called upon to cover a wider area. This stretching can result in recession which reveals the
cementoenamel areas and creates a supraproximal space (Fig. 1). This phenomenon can be
aggravated by unfavorable tooth anatomy. When central incisors are paddle-shaped or much wider
at the incisal that the gingival (Fig. 2), only a small amount of recession can leave a large triangular
Upright Central Incisors
Second, this spacing tends to occur with upright central incisors, especially in deep bite cases. In
correcting the reverse curve that is usually present in the upper arch and in torquing the upper
incisors, the crowns frequently move labially somewhat. From a cephalometric and profile
standpoint, this movement may be desirable. However, in this type of adult, it frequently produces
"three-cornered space" in the anteriors (Fig. 3). It is wise to minimize such movement or at least go
slowly and monitor the gingival reaction closely.
Lastly, such spacing occurs rather frequently in mouthbreathing patients ( Fig. 4). As with any
mouthbreather, adults in this category tend to have vertical development and, consequently, open
bite problems. The use of anterior vertical elastics to correct the open bite, especially in a patient
whose functional pattern includes a slight "open mouth", tends to cause extrusion of the incisors.
When the incisors extrude, gingival recession and triangular spacing frequently result. Through the
use of headgear, this problem can usually be confined to the lower arch, where it is more tolerable to
the patient.
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Feb(104 - 105): The "Three-Cornered Space" Pitfall in Adult Treatment
Unfortunately, it is not possible to eliminate the "three-cornered space" pitfall from adult
treatment. All we can do is learn to reduce its psychological impact by anticipating it before it
occurs, and by minimizing its effect after it occurs. This can be done by reducing the affected teeth
interproximally and reconsolidating. In addition, sometimes, changing bracket angulations is
necessary to reduce root divergence. These changes will improve the situation and usually make it
Fig. 1
Fig. 1 Overlapping central incisors which developed "three-cornered space" after initial alignment.
Fig. 2
Fig. 2 Unfavorable paddle-shaped anatomy of central Incisors encourages development of "three-cornered space".
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Feb(104 - 105): The "Three-Cornered Space" Pitfall in Adult Treatment
Fig. 3
Fig. 3 Correction of upright central Incisors frequently produces "three-cornered space".
Fig. 4
Fig. 4 Open bite tendency associated with mouthbreathing Is a prime candidate for development of "three-cornered
space" In treatment.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Feb(108 - 120): Orthognathic Treatment in Patients With Temporomandibular Joint Pain-Dysfunctio
Orthognathic Treatment in Patients With
Temporomandibular Joint Pain-Dysfunction
In order to appreciate the role of surgery in the treatment of temporomandibular joint
dysfunctions, a descriptive classification may prove helpful.
A. Myofascial-Pain-Dysfunction
This category represents the great majority of patients seeking relief for temporomandibular joint
disorders. It is presently thought that emotional stress, destructive oral habits, and occlusal
deformities all may initiate this disorder. Evidence of intracapsular changes is either absent or found
to be reversible through various physical therapies. Admittedly, it is a fine line between MPD and
early arthritic changes.
B. Arthritides
There are various etiological factors known to result in arthritis, such as trauma, infection,
rheumatoid disease and degenerative joint disorders. While the temporomandibular joints, as with
other articulations in the body, have remarkable recuperative powers, ordinarily the classification of
arthritis is reserved for those instances where irreversible changes have occurred. The fine line
between physiologic adaptation and pathologic degeneration remains blurred.
C. Dislocations
Neuromuscular disharmonies as seen in MPD frequently are associated with dislocations and, if
so, respond quite nicely when treated accordingly. On rare occasions, anatomic configurations of the
joint predispose to dislocations and intracapsular surgical procedure may be required.
D. Fractures
Acute joint injuries with intracapsular fractures and/or dislocations may lead to significant
occlusal deformities and joint dysfunction. Treatment of the untoward sequelae may require surgery,
orthodontic alignment of teeth and restorative rehabilitation in the same manner as with
developmental jaw abnormalities.
E. Ankylosis
Fusion of one or both joints is usually the result of trauma and subsequent fibrosis and
calcification across the joint space. Surgical reconstruction of the joint is required to restore
mobility. The diagnostician also must be aware of false ankylosis where extracapsular restrictions of
mobility occur.
F. Developmental Deformities
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Hypo- and hyperplasias of the temporomandibular joint and masticatory musculature may be so
subtle as to not be recognized in casual clinical examination. Facial asymmetries and occlusal
disharmony seen in a patient should stimulate the clinician to obtain roentgenograms of the
temporomandibular joints along with cephalometric films.
G. Neoplasia
Tumors of the temporomandibular joint, fortunately, are rare. Progressive mandibular asymmetry,
malocclusion, and pain should alert the diagnostician to that possibility, however.
There are instances in each of the above disorders where treatment would require orthognathic
surgery. However, for the purpose of this paper, the surgical treatment of TMJ dysfunctions will be
limited to those problems where surgical realignment of the jaws is necessary to achieve the desired
When jaw relationships are such, that a stable occlusion can be achieved through dental
compensations alone and facial esthetics are acceptable, surgery is not indicated. However, when
compromise threatens the prognosis, then a coordinated treatment plan involving surgery,
orthodontics and restorative refinements offers a rational approach.
The adult or non-growing temporomandibular joint patient, most of the time, is accommodating
the mandibular posture to gain a tooth fit. These patients seem to have a somewhat lesser tolerance
level to occlusal interferences than many people in the general populace. Psychological stress tends
to trigger subconscious gnashing, clenching and bruxing of teeth. Many times the mandibular
musculature will go into severe contracture or spasm, thus stablizing the mandibular position so that
it becomes clinically impossible for the examining dentist to manipulate the mandible and get any
clear picture of the existing centric relation discrepancy. The use of the mandibular repositioning
appliance or splint has been quite successful in accomplishing the disclosure of the true discrepancy
in the occlusion that exists on most, if not the greater percentage of these patients. The repositioner
splint also allows the operator to test the patient's response to a change in the occlusion to see if the
patient responds favorably to a change in the bite relationship before embarking on a complex
course of treatment.
Cephalometric tomograms of the temporomandibular joints will reveal possible degenerative
joint changes prior to any type of treatment and should be used routinely for patients with
temporomandibular dysfunction symptoms.
Before accumulating orthodontic diagnostic records and determining a treatment plan, it is
necessary to:
1. Stabilize the mandibular position on a repositioner splint so that there has been no change in
mandibular position for a minimum time period of three months. (Any remodeling that may occur
would tend to show up within this time frame.)
2. Obtain a favorable response to the change in occlusion in terms of alleviation of symptoms to the
extent that the patient is comfortable enough that they are willing to accept that degree of comfort in
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a final result.
3. Obtain an accurate diagnostic mounting of study casts on an anatomical articulator to a true
hinge-axis and split cast verified centric relation lower cast mounting of at least two sets of casts for
diagnostic purposes.
4. Obtain a follow-up set of cephalometric tomograms of the joints.
Unless the above mentioned things are accomplished, there is not much percentage involved with
proceeding with treatment planning or treatment! Once these things have been accomplished, the
following orthodontic diagnostic records are recommended:
1. Frontal and lateral cephalometric headfilms taken in centric relation of the mandible with the lips
2. Panorex.
3. Full mouth dental x-rays.
4. Facial photographs showing full face at rest and smiling, profile (both sides if asymmetry is
marked), and intraoral photographs.
Since many adults or non-growing temporomandibular joint patients have a sizeable jaw
relationship discrepancy, they are usually beyond the possibility of correction either by alteration of
tooth morphology or orthodontics alone. However, it is generally not possible to detect the true
severity of the jaw relationship discrepancy until the patient has been comfortable and stable on a
repositioner splint for quite some period of time, during which the splint is constantly adjusted as
the mandible gradually repositions to seat the condyles in the fossae.
In developing a treatment plan for any particular temporomandibular joint patient, it must be
borne in mind that the occlusal result must be accomplished with unerring accuracy to a very high
degree of precision. Most approaches to orthognathic surgery seem to emphasize facial esthetic
improvement and although facial esthetics are of utmost importance, we must not forget that the
temporomandibular joint patient is primarily seeking treatment for a functional occlusion correction.
Thus, the occlusal result that is "close enough for government work", usually is not close enough for
the TMJ patient.
In many instances, surgery and orthodontics will only get the case to a point where it is now
possible to incorporate a very high degree of occlusal refinement through the use of gnathological
restorative procedures. However, it should be obvious that where a few restorations are present, the
goal of orthognathic treatment should be to achieve a degree of occlusal perfection so that future
procedures of the above mentioned kind may be obviated.
The splint therapy is a necessary test of the patient's response to occlusal treatment and degree of
motivation. We must find out if the patient will respond favorably to occlusal change, since
temporomandibular joint paindysfunction is a multifactorial problem. Occlusal change in itself does
not always eliminate the symptoms. The patient must also be more than a passive participant in his
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Feb(108 - 120): Orthognathic Treatment in Patients With Temporomandibular Joint Pain-Dysfunctio
or her treatment, and must be highly motivated if treatment is to succeed. It is also necessary to not
talk the patient into treatment or push him into treatment, but to guide him into making his own
intelligent and informed decision by giving him an understanding of the problem, the possible
solutions and his options with no guarantees!
The patient will know when he or she is psychologically ready to undergo orthognathic treatment
to eliminate the problem and get rid of the splint.
Once it has been determined that surgery will be required to satisfy the functional objectives,
attention should be focused on the site or sites of the skeletal deformity. The orthodontist, the
surgeon and when needed the restorative dentist should collaborate in assessing the occlusal needs
and the facial esthetics. While functional rehabilitation may have the highest priority, facial
appearance and long-term stability, surgical risks and costs must be considered by all parties
concerned. Since it is possible to realign in all planes of reference both the maxilla, the mandible,
and segments of each, a careful analysis of the cephalometric films, photographs and oriented dental
casts is mandatory. Anterior-posterior occlusal discrepancies often have vertical and transverse
components, also. The geometry of the facial skeleton along with the soft tissue drape must be
analyzed, predicted changes in facial appearance developed, and the projected results discussed
beforehand with the patient.
Communication between the orthodontist and oral surgeon is an absolute necessity. Each member
of the team must understand his area of responsibility and be willing to discuss opposing treatment
plans that are offered and resolve the differences to their mutual satisfaction. But most importantly,
they must assume a common treatment goal not only esthetically but functionally as well.
The patient should be seen by the surgeon with the orthodontist present prior to any preparatory
orthodontic treatment. This will allow the patient to hear his problem discussed by another person
from another viewpoint and give him the opportunity to understand his problem and the possible
solutions much better. It also allows the orthodontist and the oral surgeon to more freely discuss the
possible course of treatment before the case has been "painted into a corner" by what has already
been done orthodontically. The orthodontist must have a fair idea of what he can and cannot
accomplish orthodontically on a nongrowing patient in terms of tooth movement and he must also
know what surgical procedures are available to him, and the extent to which they can correct the
dental as well as the facial discrepancy. The oral surgeon must be aware of the orthodontist's
treatment goals and be able to guide the orthodontist in the selection of the surgical procedures that
will best apply to the case at hand.
Where an either/or situation exists in terms of the surgical procedure, the final decision should be
postponed until the presurgical tooth alignment has been accomplished. At this point in time a
second set of records including a frontal and lateral cephalometric headfilm, panorex, and set of
mounted study casts should be obtained and the appropriate tracings and surgical mock-ups should
be done. A second conference should then be held with the orthodontist and oral surgeon with the
patient present. At this point the final treatment plan will be selected and all parties involved will be
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fully informed.
It is all too common that the patient becomes the message runner between two busy doctors who
seem to have no time to speak with each other concerning the patient's fate, while the patient is the
conveyor of second-hand messages to each doctor, which usually results in misunderstandings and
total chaos, if not disaster!
From the orthodontic standpoint, the presurgical preparation of tooth positions entails aligning
upper and/or lower teeth in the most ideal arch form and positions possible in relation to the
respective jaws (e.g. the lower teeth are aligned ideally on the mandible and the upper teeth are
aligned ideally on the maxilla). No attempt is made to fit the teeth into occlusion normally at this
time. If anything, the discrepancy is made worse in anticipation of the surgical correction. The upper
and lower arch forms should be coordinated so that the teeth will occlude after the jaws are
surgically corrected. All too often, the orthodontist working by himself either attempts to avoid
surgery or attempts to help the surgeon by moving the teeth toward correction of the discrepancy.
This lessens the effectiveness of the facial correction that can be accomplished by the surgery and
should be avoided at all costs!
Patients with occlusion-related TMJ dysfunctions will usually respond and gain dramatic relief
through the use of an occlusal splint constructed and monitored according to gnathologic principles.
Ordinarily, concurrent with the relief of symptoms, a posterior repositioning of the mandible occurs.
When the discrepancy between maximum interdigitation of the teeth and physiologic mandibular
position is excessive, then surgery may be indicated. The question regarding the type of surgery
must be decided on an individual basis. Usually, the mandible is found to be in a retruded position
with premature contact in the molar regions. Surgical options include 1) mandibular lengthening and
rotation to close the anterior bite, or 2) maxillary intrusion with auto-rotation of the mandible to
close the bite. Segmental alveolar surgeries and combinations of both maxillary and mandibular
repositioning may be indicated in any individual case, but for purposes of this paper the more
common requirements will be discussed.
A. Mandibular Lengthening
Surgical lengthening is more commonly performed in the ramus of the mandible. Osteotomies
have been designed with the purpose of minimizing risk of the neurovascular structures and teeth,
maximizing bone healing and promoting stability. Whenever the mandible is lengthened and rotated
superiorly in the symphysis region, the suprahyoid muscles are stretched. If excessive tension is
evident at the time of surgery, then selective myotomies are required to achieve the desired
relationship. Even with detachment of essentially all of the muscle attachments to the body of the
mandible, lengthening of more than 15mm. often proves to be difficult.
The two most popular types of osteotomies used for mandibular lengthening are: 1. the saggital
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Feb(108 - 120): Orthognathic Treatment in Patients With Temporomandibular Joint Pain-Dysfunctio
split (Fig. 1), and 2. the "C" type (Fig. 2). The first is performed through an intraoral approach.
When successfully performed, it provides excellent overlap of bone in the lengthened position and,
of course, avoids an external scar. One disadvantage is increased risk to the inferior alveolar
neurovascular structures. With a "C" osteotomy, the risk to the inferior alveolar nerve is, perhaps
lessened, but facial nerve injury must be considered. Bone apposition is compromised in those cases
where lengthening is a centimeter or more. The external scar also may be objectionable for some
patients. In both approaches, the elevating masticatory muscles are detached from the body portion
of the mandible. Relapse tendency has proved to be a problem in patients with high mandibular
plane angles (short ramus— skeletal openbite facial patterns) regardless of the surgical approach
used. The higher the angle and the greater the distance of lengthening, the greater is the tendency for
skeletal relapse.
1. Overcorrect. An occlusal surgical splint is used to overcorrect the mandibular dentition in both an
anterior and vertical direction. The degree of overcorrection is proportional to the mandibular plane
angle and the distance the mandible is extended. In moderate extensions (7-12mm), the splint is
usually made to open the bite 3-4mm in the posterior and bring the anterior dentition into an
edge-to-edge relationship (see photograph). This degree of overcorrection allows for adjustment in
instances where skeletal relapse at the surgical site occurs. In those patients where little or no
relapse takes place, Class III and vertical elastic traction will guide the occlusion to place in a
relatively short period of time.
2. Seat the condyles in the glenoid fossa. Whether a saggital split or "C" type osteotomy is used to
lengthen the mandible, care must be taken to seat the condyles and hold them deep in the glenoid
fossae after placing the patient's teeth into the surgical splint and the mandible in the desired
occlusal relationship to the maxilla. Placement of the interosseous wire should be such that the
condyle is driven into the fossa as the wire is tightened. If this is neglected, the condyle may well
drift downward on the articular eminence. Posterior drift of the mandible then is assured after
release of the intermaxillary fixation. The entire purpose of the procedure, thus, is compromised.
3. Myotomy. The suprahyoid muscles, particularly the anterior digastrics and geniohyoid muscles
may be stretched to such a degree that tension prevents unrestricted positioning of the mandible. If
excessive tension is observed, detachment of the insertions of these muscles from the mandible is
4. Retention. In those patients with the skeletal open bite (high mandibular plane angle) type
configuration, skeletal relapse may be noted within a few days following surgery. Cervical retention
collars as used in stabilizing neck injuries have been found to be beneficial in retarding relapse. To
be effective, the collar must be worn fourteen hours per day or more for as long as six months
following surgery. The schedule and duration of wearing time is determined through monitoring
relapse tendency as viewed with headfilms. A lateral cephalometric film should be taken within the
first week following surgery. The films should be repeated at 3-4 week intervals until stability is
As long as intermaxillary fixation is in place, skeletal relapse cannot be accurately determined by
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clinical evaluation alone. Movement of the entire dentition within the alveolar bone may allow for
skeletal relapse to take place without relative change in the occlusal relationships.
B. Maxillary Repositioning
Intrusion and/or retrusion of the entire maxilla is frequently a more practical method of achieving
a stable occlusion. If facial esthetics can also be enhanced, then maxillary surgery is preferred.
Stability appears to be better than with most mandibular lengthening procedures. Intrusion of the
maxilla allows auto-rotation of the mandible. Not only is the vertical height of the face decreased,
but the mandible appears more prominent. The posterior premature contacts are removed by
elevation of the maxilla. A posterior open bite can be achieved also, if desired, by use of an occlusal
splint to achieve overcorrection during the period of intermaxillary fixation and during bone healing.
1. Surgical Method. Mobility of the maxillary fragment is of extreme importance. Following the
osteotomy, the maxilla is ligated to the mandible in the desired occlusal relationship. By rotating the
entire complex as a unit around the condylar heads positioned deep in the glenoid fossae, bone at the
osteotomy site can then be removed as needed to achieve the desired maxillary position. Fixation of
the complex is then accomplished with suspension wires from the zygomatic buttresses or
infraorbital rims. Occasionally, interosseous wires at the margins of the pyriform apertures are
useful. However, care must be taken to prevent tipping of the anterior portion of the maxilla
superiorly and displacing the condyles from the depths of the fossae.
2. Post-surgical Methods to Improve Position. Post-operative x-rays should be obtained within a
few days of surgery. If maxillary position is more extruded than was anticipated, then extraoral
traction can be used to retract and to retrude the maxillo-mandibular complex. A cervical collar or
high-pull headgear with two-three pounds of force or a combination of both a collar and headgear
has been found effective in postsurgical positional adjustments.
Once the treatment plan has been decided upon, the object of the orthodontic treatment is to align
and level both arches so that the lower incisors are in the most ideal relationship to the mandible and
the upper incisors are in the most ideal relationship to the midface anteroposteriorly, and the lip-line
vertically. The upper incisors must also have an ideal labio-axial inclination. The curve of Spee
should be level so that when the mandible is brought forward into an ideal overbite-overjet
relationship, the buccal segments will fall into an ideal Class I occlusion and the arch forms will be
coordinated so that there is no buccolingual width discrepancy. This is more difficult to accomplish
on a four bicuspid extraction case than it is on a nonextraction case. Closure of the bicuspid
extraction sites and retraction of the anterior teeth usually results in a deepening of the curve of Spee
in the lower arch and produces a reverse compensating curve in the upper arch. This results in too
deep an overbite and insufficient labio-axial inclination of the maxillary incisors to that when the
mandible is advanced the buccal segments fall into an end-on Class II relationship. In my opinion,
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Feb(108 - 120): Orthognathic Treatment in Patients With Temporomandibular Joint Pain-Dysfunctio
the four bicuspid extraction case in not ready for surgery until such time as the curve of Spee and
the compensating curve are completely levelled, roots paralleled adjacent to extraction sites, arches
coordinated and the maxillary incisors placed at the proper labial inclination.
This may require a considerably longer preparatory time on the adult than one might expect.
Nevertheless, without meeting the above mentioned criteria a good Class I occlusion will not be
obtained in the final result! I have not found it possible to correct the above mentioned situation
adequately after the surgery has been performed.
Construction of the surgical splint should be done on an anatomical articulator to insure that:
1. The mandible is advanced equally in length on both sides.
2. That the vertical increase is equal on both sides; and
3. To insure that the posterior teeth are centered properly over each other and their respective arches.
Hand holding the models or using a Galetti articulator may cause the splint to be built in violation
of the above mentioned objectives. This can result in the creation of a mandibular asymmetry, thus
causing the patient to go into a laterally accommodated bite. This will usually result in failure to
alleviate the temporomandibular joint or pain-dysfunction problem.
The surgical splint can be set up on the Whip-Mix articulator as shown in the accompanying
The splint is made so that the cusp tip imprints fit into the acrylic and the material around the
embrasures is removed so that the patient can get air and liquids through the spaces when the jaws
are wired together. At the time of surgery, after the saggital split has been completed and the wires
placed loosely through the proximal and distal segments, the teeth are wired into the splint by
placing the heavy gauge surgical wire over the orthodontic archwires which are at least .021 × .025
in dimension. Then the proximal segments are seated into the fossae and the interosseous wires are
tightened. Intermaxillary fixation is provided for a period of six to eight weeks. The intermaxillary
fixation is discontinued and the patient is allowed to wear the surgical splint with some light rubber
bands, except to eat, for another four to six weeks. After this the upper rectangular archwire is
replaced with a lighter round wire (.018) and short Class III elastics are worn full time ( 1/8", 6 oz.)
to gain intercuspation from the overcorrected position. This is accomplished with the elastics by a
combination of rolling forward of the maxillary teeth, lingual movement of the mandibular teeth,
extrusion of the bicuspids and a hinging closed of the mandible as the case is brought into a Class I
buccal segment relationship and the slight anterior cross-bite is corrected. This usually brings the
teeth into occlusion in a period of one to three weeks and very rapidly establishes posterior support
to the surgical fracture.
The occlusion is then allowed to settle on its own by employing the use of .021 × .025 braided
rectangular archwires which provide rectangular wire control, but have enough give to allow
individual cusp seating.
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Feb(108 - 120): Orthognathic Treatment in Patients With Temporomandibular Joint Pain-Dysfunctio
After appliance removal, a gnathological tooth positioner constructed from an anatomical
articulator mounting is utilized to control the final settling and seating of the occlusion toward
centric relation while band space closure is effected. The accompanying photographs of an actual
case history will serve to illustrate the technical aspects of these procedures. (See pictures A-V).
The same basic principles apply to setting the case up for maxillary as does for mandibular
surgery. The case must be levelled and extraction sites closed and arches coordinated to gain a Class
I interdigitation of the hand-held models.
A true hinge-axis articulator mounting is utilized to simulate autorotation of the mandible as the
maxilla is intruded. The autorotation is done first on a current cephalometric tracing by positioning a
template of the maxilla to the desired anterior and posterior degree of intrusion (Fig. 3). A template
of the mandible is then auto-rotated around the center of the condyle. The amount of intrusion of the
maxilla is measured both anteriorly and posteriorly and then the mock surgery is done on the
mounted models on the articulator (Fig. 4). A posterior open bite of 3-4mm is built into the surgical
splint as an overcorrection safety factor to be sure that the offending premature contacts are
eliminated with the surgical procedure. The case is levelled to .021 × .025 rectangular wires prior to
After intermaxillary fixation is removed the use of the surgical splint is discontinued. After
removal of the zygomatic buttress wires, the arch wires are changed to braided rectangular wires and
the posterior open bite is allowed to settle closed. The use of elastics to accomplish this is
discouraged. It is rare that the posterior open bite does not close on its own within a week or two.
After the removal of the orthodontic appliances, a gnathological positioner is used to settle the
case to centric and close band spaces (Fig. 5).
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Orthognathic case.
A-B. Before treatment. C. Patient in centric relation prior to surgery, after the tooth positions
are adjusted for the surgical advancement of the mandible. D. In centric occlusion prior to
repositioner splint wear. E. After stabilization on repositioner splint, showing distal
repositioning of mandible. F. Centric mounting on estimated hinge-axis prior to surgery. G.
Mounted models set for overcorrection antero-posteriorly and vertically for surgical splint
construction. H. Surgical splint of clear, heat-processed acrylic. I. Intraoral view with
appliance prior to surgery. J. Surgical splint being worn after removal of intermaxillary
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Feb(108 - 120): Orthognathic Treatment in Patients With Temporomandibular Joint Pain-Dysfunctio
K. Cephalogram in centric relation prior
to surgery. L. Post-surgical cephalogram. M. Finished centric relation cephalogram. N.
Gnathological positioner in place after appliance removal. O-P. Centric relation mounting of
finished case. Q-S. Finished occlusion. T-V. Finished facial photographs.
Successful treatment of many temporomandibular joint cases has been accomplished in the above
described fashion and a large majority of the mandibular advancement surgical cases have required
no further occlusal treatment. However, if discomfort should occur after completion of orthognathic
treatment, the patient has already been forewarned that further refinement of the occlusion may be
necessary and that he or she will be required to wear a repositioner splint once again to establish a
stable craniomandibular relationship that can be used for occlusal adjustment or gnathological
Bear in mind that occlusal adjustment or restorative procedures represent a further refinement in
the occlusion above and beyond the orthognathic correction. However, the restorative approach to
correction of occlusal function would not have even been feasible without first getting "in the ball
park" with orthognathic surgical treatment.
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Feb(108 - 120): Orthognathic Treatment in Patients With Temporomandibular Joint Pain-Dysfunctio
The need for precision orthodontics cannot be overemphasized in the treatment or the
temporomandibular joint patient. It is well to remember that although facial esthetics are important
and that we do not wish to treat the occlusion at the expense of the face, we must achieve a
functional occlusion in which centric relation and centric occlusion are extremely close, if not
coincidental, as well as achieving pleasing facial balance.
When other modalities cannot achieve these objectives, then orthognathic surgical procedures
have found to be a practical method of managing gross occlusal and facial disharmonies. This type
of surgery as with all surgery, is not without risk: therefore, it should be used with discrimination.
Fig. 1
Fig. 1 Saggital split osteotomy.
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Fig. 2
Fig. 2 "C" osteotomy.
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Fig. 3
Fig. 3 Maxillary intrusion and retrusion and mandibular autorotation on centrically related cephalometric tracing. Dotted
lines show anticipated post-treatment result.
Fig. 4
Fig. 4 A. Facebow transfer of true hinge-axis prior to surgery and construction of surgical splint. B. Presurgical
mounted models in centric relation. C. Mounted casts showing mock surgery workup. D. Mock surgery on mounted
casts showing vertical overcorrection of posterior segment. The surgical splint is constructed from these models.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Feb(108 - 120): Orthognathic Treatment in Patients With Temporomandibular Joint Pain-Dysfunctio
Fig. 5
Fig. 5 Finished occlusion in centric relation.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Feb(121 - 133): Constructing the Gnathologic Setup and Positioner
Constructing the Gnathologic Setup and
In previous JCO articles, I described the importance of a gnathologic tooth positioner (July,
1975), adult orthodontics and how knowledge of occlusion can effect adult treatment (July, 1976),
and lastly the DMR (Denar Mini-Recorder) that allows us to obtain gnathologic recordings on our
patient without doing a full pantograph (October, 1977). This article describes the steps that the
laboratory person takes in the construction of the gnathologic setup and the positioner.
In order for the lab person to make a gnathologic setup, certain information must be given him by
the orthodontist. The models must be mounted on a semi-adjustable or fully adjustable articulator,
which must be able to receive settings of protrusive path, the orbiting condyles, and the immediate
Bennett side shift. This information is extremely important in determining the torque of the upper
central, lateral, and cuspid complex; whether or not the case will have cuspid interference or cuspid
protection; the torque of the lower cuspids; and the angulation of the lower central and lateral
The orthodontist can deliver this information in one of several ways. he can use:
1. A fully instrumented pantograph, which I feel is now outmoded with the advent of the DMR.
2. The DMR, which might be described as a "mini-pantograph", since it allows us to analyze the
pertinent posterior determinants of the patient required to do a gnathologic setup (Fig. 1 ) .
3. The check-bite technique, whereby check-bites can be taken of the patient in lateral and
protrusive excursions.
The check-bite technique is the least accurate of the three, since it utilizes averages. The
immediate side shift is not measured accurately but, rather, interpolations must be made. The
pantograph and the DMR are by far the most accurate. The only problem with the pantograph is that
it takes so much time in the setting of the articulator. The DMR, which I use, gives us the wanted
angulations precisely and there really is no setting involved. The numbers are read right off the
DMR and transferred onto the articulator.
The technique being presented here also assumes the following:
The orthodontist must have treated his case into centric relation occlusion. The positioner will not
act like a functional appliance, seating the condyles and straightening the teeth at that position.
Rather, the positioner will only maintain whatever centric relation the patient already has, or it will
destroy centric relation occlusion achieved, if a hinge-axis is not done by the orthodontist in
mounting the models. An average hinge-axis can be used, but this normally means more
equilibration by the orthodontist after positioner wear.
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These steps can be used with any articulator that can accept a hinge-axis and can be adjusted to
the immediate Bennett side shift, the progressive Bennett side shift, and the protrusive path. The
articulator used in my office is either the Denar Mark II or D5A ( Fig. 2).
When the technician receives his mounted casts, he proceeds to cut off the teeth in such a way
that he does not destroy the occlusal plane as it relates in space to the condyles of the articulator. To
do this, all the teeth cannot be cut off at one time. The lower teeth are cut off first and then set back
to the existing upper arch.
Setting the Lower Arch
I need not go into an exhaustive history of the many norms used to set the lower anteriors. Many
fine orthodontic investigators have made their contributions here. All of the cephalometric evidence
seems to point to the fact that the average location of the lower anteriors is somewhere near 90° to
the mandibular plane. Some investigators find it 90 degrees plus or minus 3 degrees, and so on. All
of these cephalometric studies give us averages. These investigators took large samples of either
naturally occurring normal occlusions, or treated occlusions that were stable. From many hundreds
of cases that they studied, they arrived at average measurements. But, rather than use the average,
how about using something that comes directly from each individual patient?
It has been suggested to us by certain gnathologists that the proper angulation of the lower
anteriors be 90 degrees to a tangent coming off of the hinge-axis (Fig. 3). This will allow the lower
anteriors to be set in a position that will make the forces of occlusion truly distributed down their
long axis.
Angulation of the Lower Cuspids
The lower cuspid on the right side is to be set 90 degrees to the hinge-axis on the left side, and
vice versa for the left cuspid (Fig. 4). The rest of the lower arch can be set to ideal arch form that
comes from the patient's mouth, with the angulations of each tooth to be refined after the "dynamic
spiral" of the upper arch has been set, thereby establishing the proper curves, etc.
Setting the Upper Teeth
The upper teeth are now cut off and set to the already cut and set lower teeth. What we are trying
to accomplish by this first step is to simply get the teeth in wax so that they can be moved without
destroying the relationship to the condyles.
Setting the Upper Anteriors
What should be the torque of the upper anteriors? Again, pick a cephalometric source. But, all
these sources give us averages that have been derived after looking at literally hundreds or
thousands of head films. I say again, let us not be concerned with averages when we come to finding
the individual patient (these averages are an invaluable help to get us close), but rather let's see what
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Feb(121 - 133): Constructing the Gnathologic Setup and Positioner
the patient can bring to us, so that an average can be translated into an absolute for the individual
(Fig. 5).
As we consider torque of the upper anteriors, should we be concerned with the labial surface of
the upper anteriors as certain observers would have us do? Or should we be concerned with the long
axis of the upper anteriors as certain other observers would have us do?
I think as we answer the following question, it will become clear to us what part of the upper
anterior should be our reference point in setting the torque. The question is this: Is it the labial
surface or the long axis of the upper anterior that is functional? Neither. It is the lingual surface of
the upper central and laterals that functions with the lower central/lateral complex. Since it is the
lingual surface that functions, let us derive the information that the patient brings to us and apply it
to the lingual surface of the central/lateral complex in setting our torque.
Our goal in setting the upper anterior is to allow it to function in protrusive without violating the
protrusive path that the patient has in the glenoid fossa (Fig. 6). The protrusive path then is
extremely critical in setting these upper anterior teeth. It gives us not only the torque of the lingual
surfaces of the upper anteriors, but also gives us the proper overjet/overbite relationship as it relates
to the occlusal plane. For example, if the protrusive path of the articulator is at 40 degrees (of
course, this was read off the patient in the DMR procedure at debanding), then the torque of the
lingual surface of the upper central/lateral is set at between 42 and 45 degrees. And, if the protrusive
path in its relation to the occlusal plane varies greatly away from it, then the overbite might be a
very shallow one. If, however, the protrusive path comes close to paralleling the occlusal plane, then
the overbite of the upper central/lateral need almost be in the deep bite category.
Setting the Posterior Teeth
(I will be discussing the setting of the upper cuspids later since these are normally done after the
posterior teeth are set.)
In the setting of the upper posterior teeth, it is extremely important to remember that there is a
spiral that occurs when looking down from first bicuspid to second molar. The buccal and lingual
cusps of the first bicuspids are about equal in length, the lingual cusp of the second bicuspid is
slightly longer, the lingual cusp of the first molar is longer than the lingual cusp of the bicuspid
ahead of it, and the lingual cusp of the second molar is longer than the lingual cusp of the first molar
and also longer than its own buccal cusps. This has been described as the "dynamic spiral". Many
observers through the years have been warning orthodontists not to leave those lingual cusps
hanging too low, as these will eventually cause balancing and protrusive interferences. However,
there is equal danger in placing these cusps too high, out of centric occlusion. They will soon
supraerupt and cause the interferences that you were trying to eliminate in the first place.
If the upper dynamic spiral has been properly placed, then as it occludes in centric relation
occlusion with the lower arch, the proper curve of Wilson is restored in the lower arch.
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Feb(121 - 133): Constructing the Gnathologic Setup and Positioner
Once these refinements of the lower teeth and the upper posterior teeth have been accomplished,
and the case closes into a proper centric relation occlusion with no slip or slide of any kind, the case
is then ready to be run through the eccentric movements to make sure that there are not protrusive
working or balancing interferences. This is done without the upper cuspids in place.
Refinements of the Setup with the Upper Cuspids Out
The reason that the upper cuspids are removed, is that they are the ultimate agent for the lift-off
(cuspid protection in lateral excursions). We want to refine our setup with the upper cuspids out, so
that when they are placed in, their lift-off can be very gentle, in order to accomplish the desired
With the cuspids out, the case is first pulled into protrusive. What we are looking for is that none
of the posterior teeth will hit at this time. The lift-off is to be with the upper centrals and laterals
gliding over the lower centrals and laterals. It is to be gentle though definite. The protrusive
measurement is set into the articulator.
Setting the Length of the Upper Laterals
If the marginal ridges of the lower centrals, laterals and cuspids are properly placed, then one can
adjust the length of the upper lateral incisors relative to the central incisors at this time. The case is
pulled into full edge-on protrusive (Fig. 7) . Now the length of the lateral incisors is set so that they
hit the lower laterals and cuspids. Most of the time this will occur, making the upper lateral incisors
just slightly shorter than the upper central incisors. However, it is not uncommon to have them both
the same length.
In going into protrusive, the lingual slope of the upper central/lateral complex (since it is nearly
parallel to the protrusive path of the fossa) allows the case to very easily slip into protrusive and
back again, without placing any "bang" affect on the upper central/lateral complex. It has been my
observation that, many times, a diastema will establish itself after treatment when there never was
one before treatment, only because the angulation of the upper central/laterals was too severe for
that which was dictated by the fossa of the patient.
The amount of overbite is now rechecked. If, when the case goes into protrusive, all the posterior
teeth clear, then the amount of overbite that was set is adequate. If the clearance is too abrupt or too
heavy, then the overbite can be lessened. And, of course, if there is protrusive interferences of any
of the posterior teeth, then the overbite must be increased.
The protrusive measurement is now replaced by the orbiting condyle measurement.
The Lateral Excursions
The articulator is now allowed to go into first a right lateral excursion and then a left lateral
excursion (Fig. 8). We would like to have on the working side of the articulator (if the lower part of
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Feb(121 - 133): Constructing the Gnathologic Setup and Positioner
the articulator was moved to the right then the working side is the right side) all of the buccal cusps
of the bicuspids and molars lifting off equally in what might truly be called a group working
Normally, what will be found is that a bicuspid will be lifting off earlier. The bicuspid that is the
offender (that is lifting the case off before the other buccal cusps on that side) should be moved so
that as to not destroy the centric contact of its lingual cusp on the opposing buccal cusp of the lower
tooth, and at the same time removing lift-off. If the teeth cannot be moved in the wax so as to
accommodate this while not destroying the centric relation occlusion, then an equilibration of the
distal aspect of the buccal cusp of the lower bicuspid might have to be done. This is commonly
called a PKT notch (Fig. 9).
This is accomplished as the articulator is moved both into a right and left lateral excursion. The
working side should have a group working. (Remember the upper cuspids are not in the setup.) The
other side of the articulator— that is known as the balancing side— should have absolutely no
contact of any of these teeth whatsoever. If an upper lingual cusp should contact a lower buccal cusp
on this balancing side, then again the technician should rotate, tip or move these teeth in such a way
as to remove this balancing contact, while at the same time, not destroying the centric relation
occlusion contacts. Sometimes, refinement of the teeth on the working side may be needed.
Refining the Upper Cuspids
We are now ready to refine the positioner setup with the upper cuspids in their place. If the
technician is working with the Denar Mark II or D5A articulator, he must be sure the protrusive
measurement that he received from the patient and that he used in setting the upper central/laterals is
out and that the orbiting condyle measurement is in the articulator. This path is normally 5 to 10
degrees steeper than the protrusive path, and it is that path that the left condyle tracks in the fossa
while the patient is going into a right lateral excursion and vice versa. This orbiting path is to the
cuspid on its opposite side as the protrusive path was to the upper anteriors as far as setting the
torque is concerned. The technician is now ready to set the torque of the upper cuspid (and I'll let the
reader guess if we are talking about the labial torque, the long axis torque or lingual torque) and is
ready to set the upper cuspid either tight or loose depending on the amount of the immediate Bennett
movement (Fig. 10).
The cuspid has two condylar elements that will control its placement: 1) the orbiting condylar
path, and 2) the immediate Bennett movement.
Have you ever wondered what the difference was between cuspid protection and cuspid
interference? Why can some upper cuspids be placed very tight to the lower cuspid and not cause
any kind of trauma to the soft tissue of the upper cuspid nor cause the lower cuspid any excess
lingual movement; and why, in some cases, placing these upper cuspids too tight causes the kind of
pathology that the orthodontist is trying to eliminate with all of his treatment? The difference is the
amount of the immediate Bennett side shift.
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Feb(121 - 133): Constructing the Gnathologic Setup and Positioner
The lab technician will be asked to set the upper cuspid into such a position that the torque of the
lingual aspect, of the cuspid will be approximately 2 to 5 degrees steeper than the path of the
orbiting condyle on the opposite side. And if there is no immediate Bennett movement, then from
the centric relation contact of the lower cuspid, the liftoff will occur immediately. If, however, there
is some immediate Bennett movement, then there will need to be a slight hollow grinding of the
upper cuspid from its centric relation position, into the lift-off slope. It is hoped that this gentling of
the lift-off will not cause any trauma to an upper cuspid where there is looseness in the joint.
If there is any immediate Bennett movement where the upper cuspid must be hollow ground, care
must be taken to see that no working interferences occur from the buccal or lingual aspect of the
case. If there are, certain minor equilibrations will have to be done in the case in order to make sure
that we have cuspid lift-off, rather than a group function at the beginning of the lateral excursion.
Just one comment about group function: The way group function is used properly by the
Pankey-Mann people, I would have no argument against using it. In certain cases, it does work; and
it would seem to me it would be extremely easy to wax into a restorative case. However, in the
natural dentition with some possible settling that may occur, even though slight, I would suggest
that one stick with the simplicity of a cuspid lift-off.
The Finished Setup
The finished positioner setup should exhibit the following characteristics:
1. No slides or centric prematurities. The case should open and close with the maximum
intercuspation of all the posterior teeth and with no one tooth hitting prematurely, sliding or
skidding the mandible into an eccentric contact. In our setups we would like to have a five
ten-thousands thickness of articulating paper be able to slip through the central and lateral incisors,
drag through the cuspid area, and hold tightly on each and all of the posterior teeth.
2. Lateral Excursions. On the working side there should be no contact with the posterior teeth either
buccally or lingually. On the balancing side there should be absolutely no contact at all.
3. Protrusive Excursion. The upper central and laterals should slide evenly and gently against the
lower central and laterals, possibly picking up the mesial slope of the lower cuspids. There should
be not one of these teeth gliding any heavier than another. If easily obtainable, the distal aspect of
the upper cuspid may slide against the mesial aspect of the lower bicuspid. Often, this is an
impossible contact to get and there should be no extra effort placed in trying to obtain this.
The case now has been set in such a way that the patient's own determinants have been used to
determine the torque of the upper and lower anteriors, cuspids, and the overjet/overbite relationship.
The case is now fully contoured and ready for positioner construction (Fig. 11).
Questions to Consider
1. When the case goes into the protrusive or lateral excursion, how much clearance should there be
between the upper and lower posterior teeth?
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Feb(121 - 133): Constructing the Gnathologic Setup and Positioner
If the orthodontist was doing a waxup for a restorative case, then he could make the clearances
between the upper and lower posterior teeth extremely close, because these procedures are
extremely precise. However, when doing a positioner setup, you have to allow for such things as:
a. Settling of the dentition that might be occurring because the patient did not wear the positioner
b. The eruption of the twelve-year molars which might occur after the case is finished. For these and
other reasons, I am sure we must make the lift-off a little more severe, maybe a millimeter and a half
or two millimeters of separation of the posterior teeth. Almost all cases that are finished will have
more than a two-millimeter overbite. This is almost always necessary because of the lack of slope of
the protrusive path in the condyles.
Occasionally a patient will be found that has protrusive paths in the area of 25 degrees. If this is
the case, then the above rules will be violated. The torque of the upper anterior teeth will be much
steeper than will allow an even lift-off with the glenoid fossa. However, the determining factor must
be no posterior contact in eccentric movements above anything else.
2. If the case has a two-millimeter side shift, does one hollow grind two millimeters off the lingual
of the upper cuspid?
If the immediate side shift becomes more than .2 millimeters, then some discretion should be
used in the amount of hollow grinding of the upper cuspid. The rule is simply this: Make the cuspid
lift-off as gentle as possible, given the amount of the immediate Bennett, without destroying or
weakening the upper cuspid by hollowing grinding.
Let us discuss cuspid lift-off. Does a patient use it?
I think it is important to realize that we are trying to develop an occlusal scheme that the patient
will never use. If the patient used any occlusal scheme that we built in, he would destroy all of his
teeth. That is how strong the muscles of mastication are. We are trying to develop an occlusal
scheme that the patient will not use. Think of this example: If your wife comes home from the
market with her station wagon and starts to head into the garage, does she have to hit the left side of
the garage, then the right side of the garage, in order to glide her car into the garage itself?
Hopefully not. She knows where the garage posts are and she simply glides in between. Let's
suppose, however, her car is four feet in width and the garage posts are only three feet nine inches in
width. In this situation, there is no way that she can avoid hitting the garage. This might be an
analagous to setting the cuspids tight when there is an immediate side shift.
In our gnathologic setup, we are merely taking advantage of the proprioceptive nerve fibers to the
anterior teeth. The front teeth have proprioceptive nerve fibers, and if you put these teeth in the right
position, it allows the mouth to behave like radar— it knows where it is at all times, and will guide
the mandible into closure and out of closure in such a way that the back teeth will not clash.
To summarize then, we are trying to develop an occlusal scheme that will allow the patient not to
use his teeth, except in centric contact.
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Feb(121 - 133): Constructing the Gnathologic Setup and Positioner
The importance of the hinge-axis location is in the fabrication of the positioner. The most
important thing is that the wedge of material of the positioner between the upper and lower teeth be
of the proper width and size. It is imperative that when the patient closes on the positioner, the
second molar and the central incisors hit simultaneously (within reason, after all we might be doing
some selective extrusion of certain teeth).
If we are going to straighten teeth at an open vertical, that we hope to fit together at a more
closed vertical, then a hinge-axis must be taken. And, of course, in a positioner we are straightening
the upper and lower teeth at a vertical that may be open between two to four millimeters. As the
positioner is removed and the patient is allowed to close his teeth together, we hope that the teeth
will have maximum intercuspation at the centric relation vertical, with no skid or slide.
A complaint often heard in the early days was that a tooth positioner would automatically close
the bite. Of course, this may happen with any positioner that is made on either a Galetti-type
articulator or no articulator at all, but where the teeth are simply at all times held parallel, at the
open vertical or at the closed position (Fig. 12).
If the twelve-year molars are allowed to strike the positioner first, then two things will happen:
1. The front teeth are free to supraerupt— thereby closing the bite, and/or
2. the patient's condyles will be allowed to sublux around the first contact twelve-year molar area,
thereby causing Temporomandibular Joint Dysfunction symptoms somewhere along the line.
There are three ways of constructing the positioner so that the proper opening between the
maxillary and mandibular casts is not lost:
1. The first way is to make the positioner directly on the articulator to which the hinge-axis has been
transferred (Fig. 13).
In order to do this, both casts are removed from the articulator and a Vanguard-type blank is
drawn over each arch. Then the casts are placed back on the articulator and the blanks are ground so
that the articulator will close, allowing a total parallel contact between the upper and lower
Vanguard blanks. The vertical opening between the upper and lower casts will be such as to allow
approximately one and a half to two millimeters of positioner material between the twelve-year
2. The second way is to open the articulator to the vertical that you want; then take a wax bite at this
opening. The cast is then removed and flasked using this wax bite and the positioner is constructed.
3. The third method is also to take a wax bite at the vertical you wish to have your positioner made,
then use the Corrolator (manufactured by Denar).
Whatever the method used, it is extremely important that the wedge of material between the
upper and lower casts is at the proper thickness which is determined by the path of closure on the
patient's hinge-axis.
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Feb(121 - 133): Constructing the Gnathologic Setup and Positioner
Any time dentistry is going to be done at an open vertical— and, of course, with a positioner we
are straightening the teeth at a vertical that is much wider than the vertical where the teeth come
together— and then the teeth are expected to function in a much more closed vertical, the hinge-axis
must be taken to insure no centric slides.
Instructions to the Patient on Delivery of the Positioner
The patient is asked to wear the positioner continuously for the first three days, twenty-four hours
a day. He will only remove it for eating. Over the next two months, he will be asked to wear the
positioner six hours per day exercising, plus sleep wear. As the teeth begin to move into their final
position, the patient is then advised to wear the positioner less and less, until only nighttime wear is
required. At that point, the positioner is really acting as a retainer.
I do not go to retainers on the upper arch unless there is some specific reason to do so (i.e. cannot
breathe with the positioner in his mouth; upper twelve-year molars grow in after the case is finished
and will need teeth movement). However, after two months, a cemented four-to-four is placed on
the lower, and the positioner is ground out so that it will befit in place with this appliance as well
(Fig. 14).
In this article I have attempted to accomplish the following:
1. Give the laboratory procedures for the construction of a Hinge-Axis Gnathological positioner.
2. Give the formula whereby one can properly develop the torque on the upper and lower anterior
3. Give the rationale for hinge-axis location when using a positioner.
amount of the immediate Bennett side shift
There seems to be some evidence coming forth that an
immediate Bennett movement might be indicative of a
pathologic joint. Once the teeth and the condylar elements
are placed "in balance". over a period of time this immediate
Bennett movement will diminish. If this is as reported, then it
would seem that the Bennett movement is not a "border
movement" caused by hard tissue against hard tissue. but
rather a ligamentous position that hopefully, like a football
knee, will tighten if the trauma is removed. My advice in
finishing orthodontic cases where we find a large immediate
movement is to place the upper cuspids in a position that is
dictated by that immediate Bennett movement, rather than
hopefully waiting for the tightening of the ligaments, which
may or may not occur later on.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume Feb
Fig. 1
Fig. 1 DMR (Denar Mini-Recorder). Used to locate hinge axis, analyze immediate side shift, measure protrusive path
and orbiting condyle.
Fig. 2
Fig. 2 D5A Articulator. (Photo courtesy o Denar Corporatlon.)
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Feb(121 - 133): Constructing the Gnathologic Setup and Positioner
Fig. 3
Fig. 3 Front Tooth Analyzer developed by Dr. William McHorris setting lower incisors to hinge-axis target.
Fig. 4
Fig. 4 Front Tooth Analyzer setting lower cuspids 90° to opposite condyle. Setting lower incisors and cuspids properly
allows forces of occlusion to be directed down long axis of these teeth during mastication.
Fig. 5
Fig. 5 Front Tooth Analyzer setting torque of upper incisors so that lift-off during protrusive will insure no protrusive
interference and be as gentle as possible for the upper anteriors. Protrusive path is 45°. Incisor torque (as measured on
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Feb(121 - 133): Constructing the Gnathologic Setup and Positioner
the lingual functioning surface) is 50°.
Fig. 6
Fig. 6 Protrusive. Note lift-off with anteriors and no contact of posteriors.
Fig. 7
Fig. 7 Protrusive with upper cuspids out to set length of upper centrals and laterals.
Fig. 8
Fig. 8 A. Balancing side with upper cuspids out. No balancing interferences. B. Working side. Group working.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Feb(121 - 133): Constructing the Gnathologic Setup and Positioner
Fig. 9
Fig. 9 PKT notch. Distal slope of buccal cusp of lower bicuspids contoured to avoid working interferences.
Fig. 10
Fig. 10 A. Cuspid relationship with immediate Bennett side shift. B. Without immediate Bennett side shift.
Cuspids should have centric contact. The slope of the lingual surface of upper cuspids is dictated by the orbiting
condyle on the opposite side. How tight or loose is determined by the amount or presence of an immediate Bennett side
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Feb(121 - 133): Constructing the Gnathologic Setup and Positioner
Fig. 11
Fig. 11 Steps in setup.
A. Mounted debanded models.
B. Technician cuts off lower arch. Sets lower arch to upper arch. See Figure 3 for setting of lower incisors and cuspids.
C. Technician cuts off upper arch. Sets upper arch to lower. See Figure 5 for setting of upper anteriors.
D. Setup in working, with cuspids in. See Figure 7 for cuspids out.
E. Setup in balancing.
F. Finished setup in centric.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Feb(121 - 133): Constructing the Gnathologic Setup and Positioner
Fig. 12
Fig. 12 A. Skull with teeth in centric, with no occlusal stent. Note seating of condyles in fossa. B. Skull in Galetti stent.
Note how condyles no longer seat in glenoid fossa. C. Skull in Whip-Mix stent. Again note how condyles no longer seat
in glenoid fossa. D. Skull in hinge-axis stent. Note how condyles seat!
Fig. 13
Fig. 13 Positioner on setup.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Feb(121 - 133): Constructing the Gnathologic Setup and Positioner
Fig. 14
Fig. 14 Completed case. Centric (A-C). Right working with lift-off on cuspid (D). Left balancing with no balancing
interferences (E).
MARCH 1980, VOL. 14 / ISSUE 3
Orthodontic Office Design - Business Office
The Uncooperative Patient
Common Sense Mechanics Part 7
JCO/Interviews Mr. Martin L. Schulman on Fees
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Mar(149 -): 150 THE EDITOR'S CORNER
Whenever I get the chance, I speak with people I meet who are wearing orthodontic appliances to
find out what patients' and parents' attitudes are about orthodontics. I want to pass along my latest
such experience with the understanding that it does not contain universal doctrine, but is merely an
interesting incident— a conversation with the mother of two teen-age orthodontic patients I
happened to meet at the base lodge on a skiing trip.
The mother was a divorcee and her two teen-age daughters were living with her. Since I had been
giving some thought to the impact of divorce on children and especially with reference to its affect
on the cooperation of children in their orthodontic treatment, I said to her, "Divorce has many
traumatic ramifications and one which I am sure most people don't even think about is the effect that
divorce has on the cooperation of children in their orthodontic treatment. Orthodontists must have a
certain amount of cooperation from patients between office visits in carrying out instructions and
wearing their appliances properly and brushing their teeth, and in keeping their appointments on
time. Well, parents are involved in that process, supervising their children to see that they remember
to do what they are supposed to do and, often, in chauffeuring them to the orthodontic office for
their appointments. Frequently, divorce interferes with that process just because the family unit is
disrupted and the parents are unavailable or preoccupied; and, also, the very nature of the divorce of
parents has a devastating effect on many children causing them to feel alone, helpless, unloved.
Such children could care less about schoolwork or orthodontic treatment. They drop out. This leaves
the orthodontist with the frustration of not being able to accomplish what he knows could be
accomplished and greatly prolonging treatment time for no good purpose. How does this work in
your case? Do your girls cooperate with their orthodontist?"
"Yes, they do."
"Did you make any special effort to anticipate a possible problem such as I described? "
"I had two orthodontists recommended to me in our town and I took the girls to both of them.
They both did complete workups with all the records. Their diagnosis sounded just about the same
to me. But, I let the girls decide which one they wanted to go to."
"What was the basis of their decision?"
"One orthodontist was all business. He was very brief in his explanation. He gave the impression
of being very efficient, but the girls chose the second orthodontist, mainly because he was friendly
and spent some time explaining to them, not to me but to them, just what was wrong and what was
involved in fixing it and why it was important that it be done. He also told them that this was not
something that was being done to them or even for them, but with them. They were mighty
impressed with that."
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Mar(149 -): 150 THE EDITOR'S CORNER
"Now that the girls are under treatment, are you and they satisfied that you made a good choice
on that basis?"
"Oh yes, because he follows along in treatment in just that way. He never does anything but what
he explains in advance what it is going to be and why. And, if they have a problem or a question,
they feel free to call him themselves. I don't even get involved in that. He speaks directly with them
and they just have this comfortable, friendly relationship. They feel like he really cares how their
treatment is going to come out and he has them caring too."
"Does he ever communicate with you?"
"Oh yes. He calls me on the phone periodically and gives me progress reports on how the girls are
"Do you like for him to do that?"
"Do you like that method of communication as against say a letter or a report card of some kind?"
"Yes. I like the personal contact. Why, you know, when one of the girls had teeth extracted, it
was three weeks after our appointment with him, but somehow he kept track and he called us in the
evening after the extractions were done to find out how Cathy was feeling and whether she needed
any pain medicine. It's just a small thing to pick up the phone and call to give a progress report or to
find out how a patient is doing, but it means a lot to me and my girls. We know we made the right
choice. I wish he had been around our town when I was a youngster, but my parents never even
thought about orthodontic treatment for me. I wish they had."
"It's not too late. Why don't you talk over your own orthodontic problem with the girls' doctor.
You might be surprised to find out that you can still be treated. Make it a threesome."
"Hmm. I might just do that."
Sometimes I think that we are so busy getting our patients to be missionaries for orthodontics,
that we forget to be missionaries ourselves.
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Mar(171 - 175): Orthodontic Office Design - Business Office
business office
The nerve center of business activity in your office deserves proper space and planning. One of
the great weaknesses in many offices is that the business office barely has enough space for one
receptionist. When the practice grows, there is no place for a second girl. Even in a small office,
minimum business office area should be no less than 8 × 10, with an adjacent storage area if
possible and maximum countertop space. The business area should afford space to conduct
scheduling, accounting, etc., and also an area for semi-private conferences and phone conversations.
The business office should give the impression of efficiency by the use of modern equipment neatly
arranged. Orderliness creates a business-like atmosphere. Sloppiness in handling accounts, recalling
patients, and filing records, and general disorganization in this area can be costly to you.
In an effort to save space, some young orthodontists starting a practice will incorporate the
appointment area within or open to the operatory. While it cuts down on square footage
requirements, it is a costly mistake. Try as much as possible to plan eventually to have space enough
for two full-time girls working in the secretarial area comfortably. In observing the problems of
office design in growing practices, the lack of space and proper design of the business area is the
most common weakness.
A centrally located business office saves many steps for the secretary. This feature is more
important, perhaps, when the staff is small and the receptionist's duties are multiple and not
confined to the business area alone.
In a larger offices, one should consider a separate office for the executive secretary or office
The business office should be adjacent to the reception room, but not a part of it. It should be
located to allow maximum visibility of the reception area and, if possible, some proximity to the
treatment area. This becomes less important in large practices with a good intercommunication
system. Personal conversations, appointment problems, incoming calls, and the general conversation
in the business area should not be easily transmitted to the reception room or the operatory. These
extraneous conversations all day long can be annoying to the doctor and staff and break their
While we should reduce transmission of conversation and other sounds from this area, it should
not be done at the expense of completely enclosing or isolating the secretary. She should feel free
and uncluttered. A large glass window between the reception room and the business office space
affords visibility of the waiting room. Consider a glass door between the reception area and the
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Mar(171 - 175): Orthodontic Office Design - Business Office
business area. The cleaning or maintenance objection by some is overrated, and, it adds greatly to
the decor of the area. Properly fitted glass doors cut down sound transmission better than the
average wooden door and, in addition to giving a feeling of openness, it can be a functional
advantage for the receptionist to easily see all areas of the reception room.
The hall or area in front of the receptionist's desk should be extra wide, a minimum of 48"
(ideally 5') in small offices, so that incoming or outgoing patients can pass comfortably, even if a
parent is standing at the desk. Patients entering or leaving must pass by, but never through, the
business area. The ideal traffic pattern is one in which the patient enters one way and exits another,
passing by a centrally located business desk once. This type of circular patient traffic pattern can
also save the business secretary steps, since it is to her advantage to be close to the operatory.
However, it is primarily designed to create an efficient, uncluttered traffic pattern for the patient to
and from the operatory.
This circular traffic pattern has great merit. However, it is more applicable to larger offices with
greater square footage. In a cleverly designed office which employs a circular traffic pattern, it is
possible to minimize the loss of square footage in the halls or aisles bordering the central business
area, which sometimes is a criticism of circular traffic patterns.
Desk Area
The design of the reception desk should provide "appointment book protection". As the practice
grows, control of the appointment book means thousands of dollars to you and helps your daily
schedule run smoothly. An experienced receptionist guides a parent into accepting the appointment
that we want to give most of the time. She must have complete privacy of the appointment book to
do this. The biggest complaint I have heard from receptionists is their uneasiness in concealing the
scheduling book from the peering eyes of the aggressive parent. A properly designed desk and
countertop completely eliminates such confrontations and helps the secretary enjoy her task.
Countertop height should be 41''-43''. If it is much higher, the secretary will appear to be buried.
The countertop depth should be 16'' to 18''. Allow 4" of toe space on the patient's side of the counter.
The inside working surface height should be 30"-31" and depth 18"-20". Storage area between
working surface and countertop will be approximately 12", with removable slots in the shelf area for
versatility in storage. The two or three shelves within the 12" are in graduated depths for various
size forms, cards, and stationery. Make certain there is enough depth to the countertops in the main
desk area and the adjacent areas to allow for filing systems which afford fingertip control during
phone conversations. Countertops should be at least 18" in depth when drawers underneath them are
used for filing cards, which should be at least 4" - 5". Consider a hidden shelf under the counter area
for ledgers or for storage of materials, but don't encroach on knee space. We recommend adding a
4" splash board behind the counter top working surfaces to keep equipment and books from scuffing
the walls.
In small offices, where there is a problem of enough countertop or desk top area, consider a
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Mar(171 - 175): Orthodontic Office Design - Business Office
hinged shelf which swings up and occupies the wasted aisle to the side of the desk. This can also be
a protection against people coming around the desk into the private area.
A typing area or well should be off to one side and not take up valuable working space in the
desk area where business is conducted. To avoid distractions, do not design the typing area facing
directly toward the waiting room or window. Typing height is 26" - 27". Therefore a well in the
cabinet section can be at that level, keeping the rest of the counter at the 31"-32" level. if you use a
well, make it large enough, consider at least a three-foot width for the typewriter and dictating
machine. Drawers for storage of stationery items can be on either side of the well. The well should
not be sized just to fit the typewriter, because the width of a machine does not provide enough knee
room for comfort when typing. In addition, the smaller area is harder to keep clean and you might
purchase a typewriter later which is larger than your present one.
A basic rule of time and motion theory is that material should be close to the place of its use and
the people using it. With the great deal of paper flow and the need to keep and refer to records,
proper thought must be given to filing. The high priority items should be at arm's length to the
secretary while seated, or requiring only a slight turn. The three main filing vehicles are:
1. Floor mounted cabinets for patient charts and commercial materials.
2. Slide-out drawers with inserts for card filing.
3. Top of desk files, such as index card boxes and Rolodex.
For the centralized control of large patients folders, consider rotary floor mounted cabinets. When
placed between 2 office areas, filing can be conducted from both sides. When flush against a wail,
merely by pushing a foot pedal the files can be easily rotated for access to the file section that was in
the rear area against the wall.
These units are in modular designs, so one can add units as the record area grows. Rotary files
can house many types of material that are stored in the business area. There are many competitive
models on the market now. Times II distributed by Acme Visible is one that is quite suitable for this
type of record storage.
There is a trend to have the patient charts in the main operatory, but this should only be
considered in large operatories that are designed to handle the extra storage requirements. It is
important for you to analyze your system, its good and weak points, before making such a move.
The location of the patient charts often depends on where the treatment cards are stored, but if you
employ a traveling treatment card system, they need not be stored with the complete records. Some
doctor's work habits require complete records to be pulled at each appointment, so location of
patient records depends on who pulls the charts for the next day, who refiles them, and the time
when these jobs are done. With proper planning, the patient charts, can be placed adjacent to the
operatory within reach of the receptionist and also reasonably near the operatory.
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Mar(171 - 175): Orthodontic Office Design - Business Office
I recommend the patient treatment card not be in the patient record chart. It should be filed in an
area close to the main work area so that the receptionist on the phone is within easy reach, to refer to
or file the card. This is referred to as a traveling treatment card and seems to be the trend in most
Business Office Equipment
Since most people are right handed, the telephone should be located to the left of the
receptionist's main area of activity, so that she can control the phone with the left hand and write
with the other or do minor filing while on the phone. The minor extra cost of a push-button phone is
more than justified in time saved. A chime phone reduces the annoyance of a regular phone ringing
in your ears all day. Whether you go to a wall-mounted or free phone, it should be efficiently placed
for the receptionist, but yet have the ability for the patient to make calls. We do not want the
receptionist tied up with dialing duties. The phone should be located so that patients do not infringe
on the privacy of the secretary's side of the desk. A telephone answering machine is an aid when you
are understaffed due to sickness and in smaller practices where the staff is multidutied. It allows for
freer use of the secretary to assist in other areas. Your office is always covered for incoming calls.
Dictating and duplicating equipment is a must, even for the cost-conscious doctor starting a
practice. The dictating machine should be adjacent to the typing area. The duplicating machine need
not be located close to the key work area, because they often take up a good deal of room, but if
possible within the business office.
If you are considering a word processing typewriter, plan a special cove for it with sound
treatment, or a separate room that can be sound controlled.
Electrofiles are becoming quite common. If used, I recommend the larger units— a minimum of
three tiers. They are bulky and take up a great deal of a small secretarial area. Therefore, it makes
more sense in larger offices with large secretarial areas planned in advance for such equipment.
Lighting and Electrical Considerations
The business area should be well lighted. Ceiling lights should be fluorescents. Consider a
fluorescent fixture slightly behind and above the receptionist's work area. Too far behind will create
shadows on her work. Too far forward can create glare and eyestrain. The lighting should not be too
harsh, but adequate and comfortable for the detail work that has to be done in this area. Basically,
the foot candles of reflected light required in the business area (100-125) is more than in the
reception area (40-50) and less than in the operatory (150-250). A slimline single fluorescent under
the countertop is often used and can be incorporated into the desk design.
There should be ample wall outlets for the great amount of electrical equipment used in the
business area for typing, calculating, dictating, and duplicating. The sooner you can determine the
location of these items, the better. Outlets are needed both under and above the work surface. Proper
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Mar(171 - 175): Orthodontic Office Design - Business Office
planning will reduce the number of times you have to drill a hole in the top of a formica cabinet.
Strip electrical fixtures above the splash boards encircling the work area reduces the possibility of
being short on outlets in a key area, and the need to drill holes.
In selecting colors for the tops and sides of cabinets in an area where light is needed, any surface
that doesn't reflect 40% of the light which hits it should be avoided. Therefore, rule out such colors
as black, dark gray, dark blues and browns. Consider this problem also if you use a dark blotter in
the work area.
Miscellaneous Considerations
Since carpeting is recommended throughout the office, consider carpet casters on the secretary's
chair. Invest in a comfortable, good quality chair. A clear plastic mat under the secretary's chair has
its merits. Maneuvering is easier, and it extends the life of the carpet.
Some type of intercom is a must even in small offices and is indispensable in larger offices.
Executone is an established brand, but many new companies have entered the field and are
combinations of bell tones and telephone and light features. Communication centers should be
located at fingertip distance from the secretary. Private phone jacks are more expensive and have
special uses, but require the communicators to be at the station of origin. Light systems have special
uses, but have limitations as an originator of communication, without an accompanying sound, since
you must constantly be looking for it. Coordinated buzzers and lights are useful, but should not
replace the intercom which has speakers for communicating.
For those who are considering new offices and will be there at least 5 years, consider purchasing
your own telephones and hooking them up to the major phone company's equipment. Intercom
within the office is a feature of this equipment. The equipment can be written off as an investment
tax credit. It can be shown that over a ten-year period one can save approximately $4,000 and have
full ownership of your telephones.
Acoustical ceiling and as much acoustical treatment of walls as possible are recommended for the
business area which is the center of conversation and typing, and often has many hard formica
surfaces that encourage sound transmission.
President, Modern Orthodontic Designs, 1529 South Eighth
Street, Colorado Springs, CO 80906.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Mar(176 - 177): The Uncooperative Patient
Every orthodontist must confront the problem of the uncooperative patient. Many will use their
experiences as parents as their model for the management of the problem. Others may use their
recollection of their treatment by their parents and teachers as guiding principles, confirming, "This
is the way they treated me and look how I turned out".
These approaches include yelling, berating, threatening, and ridiculing the patient to improve his
performance. The parent may be called in for a conference or a note will be sent home, emulating
the teacher-child relationship.
Others, aware of some of the lessons of Haim Ginott (Between Parent and Child) and
Transactional Analysis (TA) recall that it's okay to criticize the deed, but not the child. In their
offices you can overhear statements like, "Jimmy, I get very angry when you chew ice and break
your braces". Or, "Judy, the bacterial plaque on your teeth is really growing. If you don't brush
better, it will cause a bad problem"
All of these approaches have one thing in common and that is they don't work. The TA
approaches have an advantage. They do not cause the patient as much discomfort and the
orthodontist doesn't get upset and transfer his frustration on employees and other patients.
Individual Responsibility
Recent writings on holistic health and wellness emphasize that everyone is responsible for his
own health; that what the doctor does is far less significant than what the patient does except in
certain crises. This concept can be an excellent guide in establishing a relationship with the
orthodontic patient that is based on the patient accepting responsibility for his treatment.
One orthodontist using this principle tells his patients, "You can have the finest physician in the
world, but if you smoke, overeat and do not get regular exercise, he cannot give you good health".
Obviously, infants must depend on adults to be their advocate for maintaining their health. The
infant can make only limited choices about diet and other activities.
By age eight to ten, the child can begin to accept some responsibility for his health practices.
During adolescence the transfer of responsibility to the emerging adult is one of the key occurrences
of that transitional period. The orthodontist can be an important catalyst in aiding the young patient
and parent to see their changing roles.
During the case presentation, the orthodontist should state clearly that he cannot straighten
Johnny's teeth. Only Johnny can do that, with the aid of the orthodontist. The key statement at the
case presentation may be, "Johnny, we have learned that everyone is responsible for his own health.
No doctor can give you good health, you must take it. Successful orthodontic treatment depends
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Mar(176 - 177): The Uncooperative Patient
more on what you do than what I do". After explaining to the patient what he must do; that is,
proper hygiene, proper food selection, and wearing of elastics and headgear, the patient is asked,
"Johnny, do you accept responsibility for your treatment?" Only if a confident "yes" is elicited
should treatment be undertaken.
This experience can be very important for the patient. It can help him achieve growth in areas
besides orthodontics. The parent is told not to nag the patient about brushing, etc., because it doesn't
work. It only keeps the patient dependent on the parent.
For many children this is the first time they are treated as the emerging person they are. It can be
a boost to their self-esteem that, so often, is under attack at home and in school.
Most important, it sets the stage for a mutually respectful relationship between orthodontist and
If, during treatment, the patient shows evidence of not meeting his agreement, it is not upsetting
or threatening to note, "Johnny, when we began your treatment, you told me you would accept your
responsibility. It appears that you haven't been doing so. Tell me if you've changed your mind, or if
you want to continue treatment".
Extent of Parental Involvement
If a parental conference is scheduled, the content can be far different than the traditional one
where the orthodontist and the parent would attack the child for his noncooperation. Now it's "Mrs.
Smith, Johnny hasn't been keeping his agreement to take responsibility for his treatment. I wonder if
you can help me understand what the problem is". If the parent responds that she will keep after
him, it is important to establish that that won't work. Only Johnny can do it. The orthodontist is
allied with the patient, even as the discussion is about the patient's failure to accept responsibility.
The placement of the responsibility for successful orthodontic treatment on the patient has
another advantage. It properly removes the guilt and frustrations of noncooperation from the
Using these principles, orthodontists report much higher levels of cooperation and, equally as
important, no more "bad days" because of breakage or delayed treatment. While breakage does
create extra work, continued poor cooperation justifies termination of treatment, because the patient
failed to take his responsibility. Continuing treatment, under this circumstance will not lead to
success, only prolonged treatment.
The orthodontic experience can have a profound influence on a child's life. Monthly visits over a
two-year period are significant. Not only can patients' occlusions be improved during this time, but
they can grow in self-esteem as they participate in a successful undertaking.
Progress in the behavioral sciences has lagged behind the technical breakthroughs of our
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Mar(176 - 177): The Uncooperative Patient
profession. The appreciation of holistic health concepts in orthodontics should close that gap.
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Mar(180 - 189): Common Sense Mechanics Part 7
Common Sense Mechanics
Distalization With Differential Torque
The tipback bend has been discussed and demonstrated and, since the tipback bend is used today
in a number of respected appliance techniques, it is in order to discuss it in greater detail. We know
that the tipback bend is an off-center bend and that the long segment and short segment indicate the
direction in which the forces act. We also know that the moments involved are unequal, thus
resulting in "differential torque". We have observed the "rowboat effect", which is the tendency for
the maxillary teeth to move forward during anterior lingual root torque (Fig. 76A). We have all
experienced this tendency for Class II relapse following headgear or Class II elastics when such
torque is applied. If we can simply understand WHY this occurs, then we can reverse the conditions
and create the opposite tendency, distalization ( Fig. 76B).
We already know that when we apply anterior lingual root torque, crown movement tends to
precede root movement. When the archwire is tied to the molar tubes, this "rowboat effect" is
transmitted to all of the teeth. Anterior lingual root torque can be applied in many ways. It makes
little difference whether we use a rectangular wire, or round wire with torquing loops, or whatever
other means one may choose. When a rectangular wire with anterior lingual root torque is engaged
into the molar tubes, anterior lingual root torque is produced (Fig. 77A). Therefore, we can produce
the opposite tendency for tooth movement by placing mesial root torque on the molars using a
tipback bend in a round wire (Fig. 77B).
Keep in mind that if the second bicuspid is engaged, the bend is no longer an off-center bend and
will result in, basically, equal and opposite torque on the molars and bicuspids. We are looking for
unequal or differential torque at the anterior and posterior ends of the archwire. An .016 wire in an
.022 × .028 slot is obviously a "loose" fit, but as you will see in time, the slots need not be filled.
Now, when this wire with tipbacks is inserted into the molar tubes and then engaged into the incisor
brackets, mesial root torque will be produced on the molars. But since crown movement tends to
precede root movement, there is a tendency for distal crown movement. If the archwire is tied to the
molar tubes, there is a distalization tendency for the entire upper arch, although teeth do not tend to
move distally with the same ease as they seem to move mesially or labially.
Remember that common sense prevails. If overbite interferes, at the time, with the distal crown
movement (tendency), mesial root movement of the molars will occur. These responses are highly
variable, as are many other responses such as headgear, etc. The most desirable responses occur
where teeth need uprighting, as these are tipping movements rather than bodily movements.
In general, the level of unerupted second molars does not pose the threat of impaction with the
use of a tipback bend (Fig. 78), except with techniques that use excessively high vertical force
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Mar(180 - 189): Common Sense Mechanics Part 7
levels. If the first molars are allowed to extrude as they tip back, they will literally be lifted and
tipped back over the second molar crowns. If the teeth are not permitted to extrude, they will tip
back and literally push the unerupted second molar even further back.
To give you an idea of how easy it is to increase extrusive forces without even realizing it, think
of this. The stiffness (load/deflection rate) of an .016 square wire is nearly twice that of an .016
round wire. Labial root torque increases anterior intrusive forces and therefore increases molar
extrusion. Remember that lingual root torque increases incisor eruption and molar intrusion? Labial
root torque is simply the opposite. This comparison is not intended to be critical of any technique,
but only to keep the orthodontist mindful at all times that many factors are responsible for vertical
force magnitudes, and knowledge of these factors allows steps to be taken to establish corrective or
preventive procedures.
Figure 79 shows the most serious tipback I have ever placed on molars— and recommend
strongly that you never do the same. But, as mentioned before, non-banded teeth can provide
excellent information as to what is happening. Note that the unerupted second molars not only were
not impacted, but were pushed back due to the large moment (distal crown torque) on the molars
and erupted in a tipped-back configuration. Also, note that the unbanded bicuspids and cuspids have
tipped back dramatically, relative to mandibular plane. This clearly indicates the direction of thrust
resulting from the differential torque. It is true that an intrusive force with round wire produces
labial crown torque (lingual root torque) on the incisors, but with the archwire tied back, the molar
moments are not only in control, but will cause the incisor crowns to maintain their
anterior-posterior position or retract. Instead of seeing flared incisors, the opposite effect is
experienced. In fact, more often than not, correction of a deep overbite in this manner (2 × 4) results
in a flattening of the incisors rather than flaring. In spite of an excessive tipback, Figure 80 shows
that the molars returned to a level position following appliance removal. I have not yet failed to see
this occur.
If you can think of how many cases you have treated nonextraction instead of extraction, simply
by starting treatment prior to loss of the second deciduous molars, think of how many more patients
can be included in nonextraction treatment if you could simply gain another 1½ to 2 millimeters of
space in each quadrant (Fig. 81). Since differential torque can do this, particularly where molars
require some uprighting, the combination of "E" space with that gained mechanically is significant.
My own feeling is that the tipped-back teeth, while uprighting, are continuing to erupt along a new
longitudinal axis, and thus give me a "net gain" when they finally attain their upright position. I like
to think I easily gain an extra 1-1½ millimeters. If you feel that any additional tipping of the molars
beyond a given point will simply be lost as the molars return to a level position, then don't include
such additional amount of arch length in your treatment planning. I credit my treatment planning
with additional arch, length on patients who are still growing vertically, while I credit additional
length with a big ZERO on nongrowers, such as adult patients.
In Figure 82 the same type of space gain is seen on a patient who transferred to my practice
following earlier extraction treatment and eventual relapse. In spite of the significant space opening
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Mar(180 - 189): Common Sense Mechanics Part 7
distal to the first molars, I consider this to be a "zero gain", as the patient is an adult and all
uprighting of the second molars will be accomplished by forward movement of the molar crowns.
Treatment is nothing more than overbite correction and expansion — but knowingly and purposely.
The only reason the second molars were banded instead of the first molars, is that the additional
length (Diving Board Concept) significantly reduced the stiffness (load/deflection rate) and thus
permitted use of a larger diameter wire (.020) and less breakage or deformation. Bypassing teeth
does result in more frequent deformation of wire but, in general, I do not consider this to be a real
problem, and can often move up to an .018. The tipback bend can always be reduced in order to
control the vertical forces. Again, common sense must be applied (cusp height, diet, etc.).
The space opening that was created with the tipback bend in the cases shown was accomplished
by gradually increasing the length of the archwires. As clinical evidence showed the tipback effects,
the 360° tie-back loops were gradually unrolled or unwound, which caused the archwire to become
longer and accommodate the additional arch length.
Class II Correction Without Headgear or Elastics
I would like to present a few cases to show some of the variations in response that occurred with
use of the tipback bend during overbite correction. It is important to understand that the Class II
correction is coincidental during overbite correction. This is not a means of eliminating headgear or
elastics. The simple fact is that where headgear is planned, you will be surprised, many times, to
find that the amount of headgear treatment originally planned is either reduced, some times
dramatically, or even eliminated.
The first case (Figure 83) is a girl who exhibited what I refer to as a "Super" Class II or "Double"
Class II malocclusion. Since the Class II malocclusion involves a significant degree of tipping and
the overbite is extremely deep, I consider this the ideal type of case to use differential torque with a
tipback bend. Headgear treatment was instituted prior to the conclusion of treatment, but substantial
progress was achieved prior to the use of any headgear or elastics (Fig. 84). You won't see this type
of case very frequently, but when much molar uprighting is required in such a case, be ready for a
welcome surprise. Also interesting is the fact that tipback bends were used in both arches, and still
Class II correction occurred (Fig. 85). Movement is usually more responsive in the maxillary arch,
although in this case much of the upper movement only required tipping (uprighting).
X-rays show the distal inclination of unbanded teeth, again giving evidence of the direction of
movement produced by differential torque when the large moment (relatively) is placed on the
molars (Fig. 86). For the benefit of the few remaining doubters, incisors can be intruded as
evidenced in Figure 87. The reciprocal teeth during incisor intrusion are the molars. Therefore, the
unbanded cuspids provide good clinical clues as to what is happening.
Figure 88 shows a girl with a mild Class II with only moderate overbite and upper anterior
crowding. There was decalcification present on lower molars, but no appliance was ever placed in
the lower arch. The lower arch was reasonably satisfactory, so only upper incisors and molars were
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Mar(180 - 189): Common Sense Mechanics Part 7
banded and the case treated with an .016 archwire with a tipback bend. Anterior alignment in itself
could be expected to result in overjet, but with no headgear or elastics ever utilized, and only a total
of six bands placed (Fig. 89), treatment was concluded successfully (Fig. 90). It is common, in this
type of case, to see this response.
In the next case (Fig. 91), no headgear or elastics were ever used, and you can see the need for
anterior lingual root torque following overbite correction (Fig. 92). The molars are tipped back at
the conclusion of treatment, but they upright during retention (Fig. 93), usually within one year
following appliance removal. Note the excellent facial esthetics post-treatment in this case (Fig. 94).
This case is shown to demonstrate, on a clinical level, the tipping back of incisor crowns with this
force system, as opposed to the labial flaring seen in the traditional full strapup with the use of an
archwire containing a reverse curve of Spee.
With a reverse curve of Spee, the incisors do flare, but the force system is not the same as that of
a tipback. There is no differential torque and, thus, the intrusive force acting through the incisor
brackets produces labial crown torque on the incisor segment with resultant flaring. With the
tipback, this anterior torque is "overwhelmed" by the molar moment, and the molars are favorites to
win the "Tug of War" that follows. If this mechanism is to be criticized, it should be because the
incisors are too often upright by the time the overbite is corrected and require anterior lingual root
torque to correct this. But, correction of overbites with a round wire (.016 or .018) need not result in
anterior flaring, as claimed by so many.
The tipback is not a substitute for headgear or elastics. However, because of the characteristics of
the force system, variations in correction will take place. Common sense helps to predict which
cases are most likely to be involved. Since the system works "with" the headgear and elastics and
not "against" them, progress is often made even with lack of cooperation. Also, because Class II
elastics tip an occlusal plane downward, use of a tipback in an upper arch only, does just the
opposite, and can permit the use of Class II elastics in such cases without affecting the upper
occlusal plane. As in any treatment with round wire, the other effects must be guarded against as
discussed earlier in this series.
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Mar(180 - 189): Common Sense Mechanics Part 7
Fig. 76
Fig. 76 A. "Rowboat effect". Maxillary teeth tend to move forward during anterior lingual root torque. B. Reversing the
mechanics results in distalization.
Fig. 77
Fig. 77 A. Rectangular wire with anterior lingual root torque will produce that movement when engaged in molar tube.
B. Round wire with molar tipback will reverse these mechanics.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Mar(180 - 189): Common Sense Mechanics Part 7
Fig. 78
Fig. 78 First molars (A,B) are tipped back (C,D) without impacting second molars.
Fig. 79
Fig. 79 Extreme tipback of first molars did not impact second molars.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Mar(180 - 189): Common Sense Mechanics Part 7
Fig. 80
Fig. 80 In spite of excessive first molar tipback (A), molars returned to level position following appliance removal (B).
Fig. 81
Fig. 81 Differential torque with molar tipback produces 1½ -2mm of space mesial to molars.
Fig. 82
Fig. 82 Space gain through differential torque in an adult.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Mar(180 - 189): Common Sense Mechanics Part 7
Fig. 83
Fig. 83 Case with "Super" Class II malocclusion.
Fig. 84
Fig. 84 Progress on case shown in Figure 83, prior to use of headgear or elastics.
Fig. 85
Fig. 85 Class II correction occurred using tipback bends in both arches.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Mar(180 - 189): Common Sense Mechanics Part 7
Fig. 86
Fig. 86 X-rays of case in Figures 83-85, showing that the unbanded teeth followed the distal inclination of the molars.
Fig. 87
Fig. 87 Incisor intrusion on case in Figures 83-86.
Fig. 88
Fig. 88 Case with mild Class II malocclusion.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Mar(180 - 189): Common Sense Mechanics Part 7
Fig. 89
Fig. 89 Case in Figure 88 treated with upper 2 x 4 appliance only.
Fig. 90
Fig. 90 Case in Figures 88 and 89, following treatment.
Fig. 91
Fig. 91 Case with Class II division 2 malocclusion.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Mar(180 - 189): Common Sense Mechanics Part 7
Fig. 92
Fig. 92 Case in Figure 91 following overbite correction.
Fig. 93
Fig. 93 Case in Figures 91 and 92 a year after appliance removal.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Mar(180 - 189): Common Sense Mechanics Part 7
Fig. 94
Fig. 94 Case in Figures 91-93 before (above) and after (below) treatment.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Mar(190 - 203): JCO/Interviews Mr. Martin L. Schulman on Fees
MARTIN L. SCHULMAN on Fee Management
GOTTLIEB Bud, orthodontists probably have more control over fees than they have over the
number of patient starts and costs in an orthodontic practice. Do you agree?
SCHULMAN Yes. I find that, in 1979, orthodontists are taking a more realistic view of fees and
their fees are increasing at a more reasonable rate than I have seen in the past. I am very pleased to
see that. Obviously, the orthodontic profession is faced with a reduced child population, with higher
costs and lower profit percentages and, most damaging of all, the money that is left doesn't buy as
much, due to inflation. There is no possible manner in which an orthodontist can continue to make
an adequate living, if he doesn't raise his fees substantially.
GOTTLIEB Many orthodontists hesitate to raise their fees, for fear of rejection.
SCHULMAN Just as the level of the salary for an employee is not the primary consideration for
employment, neither is fee the primary consideration for almost all patients in the selection of an
orthodontist. I feel it is really something other than that. The word, I believe, that is most important
is "confidence". If the doctor will convey a sense of confidence to the patient in his ability to deal
well with the patient, the patient really feels that fee is absolutely secondary. He doesn't much care
about the fee as long as he can afford it.
GOTTLIEB Do you think there should be a differential between a child fee and an adult fee?
SCHULMAN Several studies made in practices which treat lots of adults have determined that an
increased fee for treating adults is absolutely in order, and I completely agree with that conclusion.
The reason is that, although the adult patient's total treatment time is the same as a child's, and the
level of cooperation from the adult is as good or better than cooperation received from the child, the
time contributed by the doctor at each treatment procedure is greater with an adult than it is with a
child. The doctor must "stroke" the adult, where a chairside assistant can "stroke" a child. Stroking
the adult usually requires 20-40% more doctor time per treatment procedure. Therefore, that same
percentage of difference is appropriate for an adult treatment fee.
GOTTLIEB I've always felt that the fee for adults should be higher, but I think that most
orthodontists I know have no differential.
SCHULMAN I think that's changing, Gene. I think that now about 50% or more practices have a
differential and that the differential is growing. It was perhaps 5-10%, but now orthodontists who
are treating lots of adults are up to 25-30%, and some as high as 50%.
GOTTLIEB As nearly as I can tell, the increase in the number of adult patients in the average
orthodontic practice has been steady, but slow.
SCHULMAN I agree with you and I think that orthodontists have been just as remiss in pursuing
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Mar(190 - 203): JCO/Interviews Mr. Martin L. Schulman on Fees
the treatment of adults as most of them have been in pursuing the treatment of children. I'm
reminded of the doctor who came to me and said, "Bud, I can't understand why I have about 95%
acceptance of my consultations with children as the patient, but only about 60-65% acceptance when
adults are the prospective patient". We talked about it at some length and finally agreed that the
doctor was not conveying to the intended adult patient the level of confidence that the patient's
personal commitment would be worthwhile for the results that would be achieved; that, in the end, it
really wasn't worth the pain, the regimen of diet and hygiene, the visits on a regular basis, perhaps
peer comments and ridicule because of wearing appliances— it wasn't worth all that to get the kind
of dentition that the orthodontist was able to offer. So, essentially, the orthodontist was not
convincing the patient that the personal commitment was worthwhile. The doctor agreed with this
assessment and went home to work at preparing his consultation on a basis that would convince the
adult patient that the personal commitment was worthwhile. We both agreed that fee was incidental.
Fees related to adult treatment are almost never a cause for lack of acceptance.
GOTTLIEB Should not the same effort be made with children?
SCHULMAN When dealing with children, the parent usually makes the decision. So many children
have been treated that parents are well aware of the results and benefits of orthodontic treatment
with children. Even though the child may not be wild about entering into orthodontic treatment, the
parent convinces the child that it is worthwhile. The adult in this case is already convinced.
GOTTLIEB Some orthodontists do not want to encourage adult patients. How does the
orthodontist who is seeking more adult patients find them?
SCHULMAN It's a new area. It must be developed principally by increasing the awareness of the
general dentist. I find that a general dentist almost never looks for a malocclusion when examining
an adult. When he does see one, he almost never asks the patient if the malocclusion bothers them
and if they would be interested in talking to an orthodontist about having it corrected. Can you
imagine the number of adults who would be sent for treatment if general dentists would just ask
their adult patients if they are bothered by their malocclusions. The job that needs to be done is not
so much to educate the adults as it is to educate the general dental community, which should not be
difficult to do.
GOTTLIEB The general dentist happens to be dealing with the portion of the adult population that
seeks dental treatment and is concerned about teeth and health.
SCHULMAN That's right. Let me change the subject just a bit, still within the general area of fees.
Two aspects of fees really bother me and have for a long time. One of these concerns the diagnosis
and treatment plan, the most professional service an orthodontist renders; the one area that the
doctor never can delegate and, in fact, never does delegate. Yet, the overwhelming percentage of
orthodontists give away the diagnosis and treatment plan before they have even told the patient what
the fee is going to be. When they do tell the patient what the fee is, they don't even mention that the
fee covers the diagnosis and the treatment plan. Then they ask for the initial payment to be paid
when the bands are placed or before the bands are placed, which triggers the thought in the patient's
mind that the initial payment is for the bands. Then they ask that the balance of the fee be paid over
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Mar(190 - 203): JCO/Interviews Mr. Martin L. Schulman on Fees
a period of months, usually 24, which triggers the thought in the patient's mind that the monthly
visits cost whatever the monthly payments amount to. To complicate this condition even further,
doctors frequently say to the parent, "You can have Mary Jane bring the fee in when she comes in
each month for her monthly visit". Actually, they should discourage having the fee come in with the
monthly visit, because there isn't always a monthly visit; and, if the parent relates the monthly fee to
a monthly visit, there is no way in the world that it is a reasonable fee for a monthly visit. I believe
that this system for fees is one of the reasons that orthodontists have gotten the reputation among
dentists and patients that they charge a great deal and make a great deal of money. I think
orthodontists have brought it upon themselves by the way they conduct their consultations and by
the way in which they have their fees paid.
GOTTLIEB You would still advocate a substantial initial payment, wouldn't you?
SCHULMAN Yes, but I would much sooner see the initial payment related to the decision to
undertake treatment; and when a parent says, "I would like you to treat my child", the initial
payment would be due at that time. The fee payment would be related to the acceptance of
treatment. I would not relate any particular portion of it to bands and I would not relate the monthly
payments to any aspect of treatment. The fee really is to cover a diagnosis, a treatment plan, and a
series of treatments to correct a particular orthodontic problem. For many years, I have been trying
to get orthodontists to change the way in which consultations are conducted and the way that the fee
is presented. Those who do change are always pleased that they did.
Another area that bothers me is transfer patients. Transfer seems to be a universally unhappy
basis for undertaking treatment. Quite frequently, the doctor who is transferring the patient will tell
the patient that they should be able to have the treatment completed for the unpaid fee. The new
doctor, in order not to give the former doctor a bad name, will pretty much go along with
completing treatment for the unpaid fee. It's really quite unfair.
GOTTLIEB What do you propose?
SCHULMAN There is never a patient transferred for whom the new doctor does not do a new
diagnosis and treatment plan. He has to evaluate the patient's present condition and decide how he
wishes to best complete the treatment. I believe that there should always be a transfer fee for this
diagnosis and treatment plan; and I believe that the doctor who sends the patient to the new doctor
should always say, "You can expect the fee to be larger than the unpaid portion of the fee that we
originally arranged. There will be a fee for the new diagnosis and treatment plan".
Now, that's half the problem. The other half of the problem relates to an orthodontist undertaking
the care of a transfer patient at no fee, in most cases, for the entire retention period. I believe that the
new orthodontist is entitled to a fee for the retention period for transfer cases.
GOTTLIEB So, you would advocate at least a diagnostic fee and a retention fee on transfer cases?
SCHULMAN I'd like to see not less than a $200 diagnosis and treatment plan fee for every transfer
orthodontic patient and I'd also like to see an adequate fee to cover retention for every transfer case.
Together, they might perhaps amount to a minimum of $500-600 that any transfer case might have
to pay upon going to another office.
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GOTTLIEB A problem that often arises in transfer cases is that the appliance in place is not
suitable for the second orthodontist. In order to achieve his best result, he feels that the appliance
should be replaced. Should there be a fee for that?
SCHULMAN If the orthodontist feels that he would like to change the mechanics, I believe that
some compromise fee is in order. I don't believe that the doctor should undertake to do if for
nothing, as many do. One might add half of his strapup fee, which is essentially his cost, because the
average orthodontist has costs of 50% and profit of 50%. Charging 50% of his regular fee for
installing new mechanics means that he is donating his services for nothing for that phase, in order
to satisfy himself that he would be treating the case in the manner in which he felt he could secure
the best results.
I don't believe that he should give away his staff, his supplies, his rent and all his direct costs of
getting the new mechanics installed.
GOTTLIEB What is the obligation of Orthodontist A in regard to fee?
SCHULMAN I don't think that Orthodontist A generally prepares the patient for the fact that there
may be changes in mechanics and an added fee. I think too many orthodontists, in an effort to have
the patient like them when they leave, indicate that the treatment should be completed for pretty
much the unpaid fee, and that's a sad position to take. That's an improper position to take. It's wrong
not to prepare a patient at the time of transfer for a rather substantial additional fee.
GOTTLIEB Yes. I think it is part of the price of moving. Is a refund sometimes called for?
SCHULMAN By Doctor A? Oh yes, particularly if the fee is paid in advance. Doctor A
undoubtedly has an obligation to refund whatever portion of the fee has not been used.
GOTTLIEB Doctor A frequently may feel that lack of cooperation has prolonged treatment and he
may find justification not to make a refund, even if much treatment remains to be done.
SCHULMAN The orthodontist does not really know when he sets his fee whether he is going to
receive reasonable cooperation. Frequently, orthodontists will allow treatment to extend without
adding to the fee, primarily out of the goodness of their hearts. It is hard to be precise about
something that is an art. But, it makes it most difficult on transfer.
GOTTLIEB So, this is another aspect of fee — a contingency against noncooperation.
SCHULMAN Yes. I really believe that an open fee, which was common practice years ago, was
fairer to the doctor and to the patient. The problem with an open fee was that from the time the
anterior teeth got into alignment, the patient believed that the doctor was continuing treatment only
to increase the fee. Even though the patient sometimes overpays and sometimes underpays, patients
prefer the fixed fee and obviously most orthodontists agree, because 95% of all fees today are fixed
GOTTLIEB Do you think a fee range would be superior in any way to a fixed fee, and a
compromise between the two?
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SCHULMAN I don't think that patients would like it. I think you'd find it difficult to raise the stated
fee level merely because unexpected difficulties are encountered. I also feel that it is just as wrong
to give away part of a fee for finishing early. I think that, on the average, the fee should be about
where it is on a fixed fee basis. Some patients will undoubtedly finish early and will perhaps have
paid more on a per-hour basis. Others will take longer, and for that the doctor will receive no added
GOTTLIEB Do you not believe in a contingency that would extend the fee, by continuing monthly
payments, in the event of noncooperation?
SCHULMAN Well, I actually do believe in extending the fee in the event of noncooperation, but I
believe that you must arrange for it at the time of the initial consultation. If the patient has not been
told in advance that lack of cooperation may lead to a larger fee in the event of extended treatment
time, you really can't institute it a year or two later. The other aspect of extended treatment is the
most difficult case, such as a skeletal open bite, which I think many orthodontists handle wrongly at
the time of consultation. I believe that they should undertake to treat the patient for perhaps 24-30
months— whatever period they feel is appropriate— as a first step; and then do another diagnosis
and treatment plan and decide if they wish to go further. In many cases they may decide that they do
not recommend further treatment. If the doctor does decide that he would like to go further, feeling
that there could be further improvement, then the patient should be given an added fee to go into
another stage of treatment.
GOTTLIEB Patients will accept the idea that you have gone as far as you reasonably can go and
they are willing to terminate a case that is not corrected 100%, realizing a lot more readily than most
orthodontists believe that perfection is sometimes an elusive thing. If you set it up in advance that
this case is difficult and that we'll treat it for 30 months; do the best we can; and then reevaluate it at
that time; and you and I together will decide how much we have accomplished; and whether, for an
additional amount of time and fee, we feel that we would gain that much more by continuing; that
sounds pretty logical.
SCHULMAN I think it is reasonable. It is similar in some ways to two-stage treatment in children.
The doctor is always faced with the problem, if he states the fee just for the first stage, that he has to
receive acceptance again before he can begin the second stage. The other side of the coin is that, if a
fee is quoted for both first and second stages at the start of the first stage, the patient has no further
choice to make since they agreed to be treated for both stages; but, the problem is that this
arrangement discounts the effect of inflation over too many years to make it justified. I must say that
the difficulty with giving the patient a choice of whether or not they wish to proceed into a second
phase is that a fair number of patients decide not to do it, much to the chagrin of the orthodontist.
So, that is a problem.
GOTTLIEB Bud, let me take you through a sequence. A patient calls for a first appointment.
They've been referred by Dr. So-and-so. Is there going to be a fee for that first visit?
SCHULMAN My feeling is that there should not be a fee for that. It is similar to the first contact
with an accountant or a lawyer, at which time you are trying to decide whether to retain them. There
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is never a fee for the initial consultation.
GOTTLIEB So, you believe that the orthodontist should have an open door policy?
SCHULMAN Yes. In spite of the fact that I believe that the patient would be prepared to pay a fee,
I don't think one should be charged, because it is so valuable to be able to have a referring dentist
feel comfortable in sending a patient to you to see if that patient has an orthodontic problem.
GOTTLIEB Now this patient comes to see you and you determine that they have a problem, but it
is not ready for a diagnostic workup. You must see them again in 3 months or 6 months. Do you
recommend seeing them until they are ready for a diagnostic workup still at no fee?
SCHULMAN No, I don't believe that no fee is in order. Once the patient has entered the practice,
fees are in order. I believe that every appointment that the patient returns for an other examination
and evaluation justifies a fee. I have seen a development in recent years where the orthodontist will
establish a reasonable fee to cover the entire period of recall and observation until some final
disposition is made.
GOTTLIEB When the case is ready for diagnostic records, should the patient be informed what the
fee will be for diagnosis and treatment planning?
SCHULMAN A fee is definitely in order and, no matter what fee is charged, it is usually
inadequate because the orthodontist must do so much of the diagnosis and treatment planning
himself. He can't delegate that aspect of the program. The most he can delegate is some of the
record taking, but the decision-making must always be his. Most orthodontists don't talk about the
value of that particular visit, unless the patient does not accept treatment. Then they might present
the family with the bill for diagnosis and treatment planning in the area of $75 to $200.
GOTTLIEB Do you think it is preferable not to create a possible stumbling block at that point in
the relationship? Or, would it better to establish just what the financial obligation will be prior to
taking the diagnostic records?
SCHULMAN I think that most doctors say at the first visit, "I would like to take diagnostic records
of your child and do a diagnosis and treatment plan and present the results to you at our next
meeting. If you then enter my practice for treatment, assuming your child needs treatment, that will
become part of the overall fee. If you do not enter my practice for treatment, either because you
choose not to or because we find that your child does not need orthodontic treatment, there will be a
fee for the diagnosis and treatment plan of so-much money".
GOTTLIEB The word "shopper" enters my mind at this point and I wonder how you feel about
that. Do you feel that a person has a legitimate right to shop, and what can or should the orthodontist
do to protect himself against shoppers?
SCHULMAN That's an interesting point. I believe that most people are more prepared to undertake
treatment on their very first visit than they are at the second or third visit. If the doctor would be
prepared at that visit to make a commitment as to the need for orthodontic treatment and the type of
treatment indicated, in general a way without being specific about the exact treatment plan until one
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Mar(190 - 203): JCO/Interviews Mr. Martin L. Schulman on Fees
can be presented, that really thwarts the shopper, because he is presented with a total fee at that first
visit before a diagnosis and treatment plan has been presented. If the patient decides that the fee is
unreasonable, the patient leaves before the doctor has done any work on the case, other than an
initial and superficial examination and an estimate that is not binding as to the type of problem and
the general kind of treatment procedure to be followed.
I believe that the two-consultation technique was initially designed as a device to justify an $800
fee. It was felt that a doctor could not present a diagnosis and treatment plan that would run $800
without two visits to build the patient up to the level of confidence at which they would accept an
$800 fee. I maintain that the psychological approach today is quite unnecessary.
Patients today are quite prepared to undertake fees of several times that $800 fee without
multi-visit buildups.
GOTTLIEB How does the orthodontist starting out decide what the fee ought to be?
SCHULMAN I believe that the new orthodontist in an area almost always takes a fee that he
believes to be a little bit lower than the fee of established orthodontists in his area, and that is
probably a reasonable fee philosophy for him to follow.
GOTTLIEB When and how does he raise his fees?
SCHULMAN Raising fees involves a great emotional strain for most professionals. They really
hate to raise their fees. They have all kinds of mental anguish associated with raising fees. They
look for reasons not to raise their fees. The orthodontist nearby has not raised his fees and, therefore,
they are reluctant to raise their own. I maintain that fees only occupy third position in people's
decisions to undertake treatment. If I could convince doctors that the fee is not as important to the
patient as they believe it is, the whole professional would be better off. There is no question that
some people will shop fees. Those are the people who set up these doubts in doctor's minds, when
actually the doctors are probably better off without those patients anyway. But, orthodontists always
seem reluctant to raise their fees. They subject themselves to a terrible emotional stress whenever it
comes to fee-raising time.
GOTTLIEB Do you have any suggestion to relieve that stress?
SCHULMAN One device that may be helpful is for orthodontists to raise employees salaries once a
year and, at the same time, raise their fees by a relative percentage.
GOTTLIEB With annual increases in cost and with inflation, the orthodontist shouldn't have much
difficulty convincing himself that he must increase his fees, but there is a lot of pressure of
competition out there, in spite of the fact that the Federal Trade Commission doesn't think so — it's
one person against the world out there.
SCHULMAN Without an annual reevaluation of fees, the orthodontist stands to take an annual
income reduction.
GOTTLIEB What do you consider a preferable way to present a fee? Is it in one figure— "The fee
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will be $2000 to treat this case"?
SCHULMAN I believe so, Gene, and it should be part of a compound sentence, such as— "The fee
for treating Mary Jane's problem is $2000, and the time during which Mary Jane will be in active
tooth movement will probably be 24 months". Or the doctor might say," . . . and this kind of
problem can usually be corrected in about 24 months".
GOTTLIEB Does the doctor present the fee?
SCHULMAN I believe the doctor should mention the total fee, but not make the arrangements for
payment. As a matter of fact, if the patient were to say to the doctor at the same time the fee is
stated. "Doctor, how do I pay that fee?", the doctor should say, "Well, my secretary works
something out with everyone. She seems to be very good at that". With that, he dismisses himself
from further relationship to the money, which patients seem to prefer. I'm reminded of Marcus
Welby on television who is much loved by all of his patients. If you have ever watched the show, I
think you may realize that in all the years he has practiced medicine, he has never yet charged a
patient a fee.
GOTTLIEB No wonder he's loved!
SCHULMAN Psychologically, it is quite valid that the doctor should divorce himself from the
money. Patient's like it and I think that people other than the doctor can deal better with the money.
A trained secretary should present the different payment alternatives.
GOTTLIEB What alternatives do you favor?
SCHULMAN One of the alternatives should always be payment of the entire fee in advance. In that
case, the patient may use that payment as an income tax deduction as a medical expense. In my
observation, only a very small percentage of orthodontic practices offer that option.
GOTTLIEB Should there be a percentage discount inducement for payment in advance.
SCHULMAN In almost every case, a discount is illegal. If you state that there is no interest charge
for payment on an extended basis over a period of many months and then give a discount for
payment in advance, it really means that you are charging a premium or interest to people who do
not pay in advance, to the extent of the discount given. Therefore, your statement that you do not
charge interest is untrue and is in violation of the Truth in Lending Law.
GOTTLIEB That law is still in force?
GOTTLIEB And orthodontists should still be filling out those Truth in Lending forms?
SCHULMAN Oh yes. The contract for treatment should still be completed.
GOTTLIEB Since it is a contract, any fee contingencies, such as for lack of cooperation, should be
included, shouldn't they?
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SCHULMAN It is quite a valid contract. It should state whatever fees and contingencies there may
GOTTLIEB Do you suggest asking for a large initial payment?
SCHULMAN I think that the patient should be given a choice of initial fees, the smallest of which
is probably the amount the doctor is presently proposing and that there should be alternate choices
for initial payments, all calling for larger payments initially, with correspondingly smaller monthly
GOTTLIEB Do you still suggest the DCA formulas?
SCHULMAN Yes. Here is an updated version of that.
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GOTTLIEB How do you suggest handling delinquency?
SCHULMAN I feel somewhat differently about that than many people do. I believe that
nonpayment of the orthodontic fee is really related to expectations on the part of the patient as to
whether the fee must be paid promptly. If a patient believes that the practice is going to require
prompt payment of the fee, in almost every case the fee will be paid promptly. If the patient does not
believe that, or has been given no belief as to what the practice will require, many patients will test
the practice to see how far they can stray from prompt payment before the practice takes action. So,
it is really quite important at the time of the consultation that the secretary say to the family, "We
will expect you to meet these payments promptly". I think that should then be reinforced by a letter
that confirms treatment, so that the patient has a good understanding that the practice will require
prompt payment of the fee.
GOTTLIEB Do you have a limited number of months in mind?
SCHULMAN I believe that 24 months is about as many as most practices go.
GOTTLIEB How do you feel about handling the fee for retention?
SCHULMAN Many orthodontists have found that if they didn't have the fortitude to raise their
basic fee, they were able to institute a retention fee of $200 and really felt no resistance. Other
orthodontists in the area, with whom they felt they were competing, really weren't aware that they
had instituted that fee and, in fact, that their fee was increased by $200.
GOTTLIEB Is that arrangement set up in the beginning?
SCHULMAN It is covered in the letter confirming treatment, but it is not included in the contract
that the patient signs. The contract is for the period of active treatment only. At the end of active
treatment, the office calls to remind the family that there is a retention fee of so much that is to be
paid now, and asks how would they like to deal with it. Orthodontists who use this system tell me
that it works quite well.
GOTTLIEB Do you believe that anyone should receive free orthodontic treatment?
SCHULMAN Only the immediate families of general dentists who refer patients to the practice.
GOTTLIEB Do you have a certain number of referrals in mind to qualify a general dentist for free
SCHULMAN It is certainly unfair of many general dentists, who are not in a position to
reciprocate, to accept treatment on a no-fee basis, but many of them do. By and large, it is an
unhappy arrangement.
GOTTLIEB Is anyone entitled to a fee discount?
SCHULMAN I believe that a discount of 10% to your own staff and to the staff of the general
dental community is quite reasonable. I believe that chairside assistants in general dental offices are
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entitled to a discount of perhaps 50%, with the comment being made that treatment is being offered
at cost. I believe there is some advertising value in having a chairside assistant in a dental office
wearing your appliances.
GOTTLIEB There was a time when orthodontists did not raise their fees, because their case starts
were constantly increasing and their gross and net income kept increasing along with that. Do you
think this productivity approach to fees is valid?
SCHULMAN I really don't. I almost never encounter a practitioner who is not prepared to have a
higher level of income. Considering inflation, this is quite valid.
GOTTLIEB Of course, orthodontists do not really know how many patient starts next year will
bring. It makes planning difficult.
SCHULMAN It's interesting that people have asked me what their goals should be and I say that
they should really have two goals. One goal is to try to start more patients each year; and a second
goal is to maintain their level of gross income or perhaps have it exceed the previous year. That's a
minimum goal and, if they can't meet that goal, they should begin to think in terms of some radical
GOTTLIEB That's absolutely true, because if you stand still you are falling behind. Do you have a
concept similar to anticipatory pricing used in business to raise prices in anticipation of increased
costs and inflation?
SCHULMAN Gene, it's hard to do. All you can do is fight your battle year by year. You really can't
be that precise.
GOTTLIEB I have a feeling, though, that orthodontists would be more comfortable if they had
some formula basis to justify fee increases in their minds.
SCHULMAN It could be done as I suggested, by applying the same increase to fees annually as you
do to salaries of employees. It is a fairly logical approach to the problem.
GOTTLIEB And, I think that percent might cover both the kind of cost increases and inflation that
we have been experiencing, although it might be slightly low at this point.
SCHULMAN Well, orthodontics in general has not kept pace with inflation. The proof of that
statement is that the profit percentage has declined from 60% to 52% since 1970.
GOTTLIEB Is there a $2000 fee barrier?
SCHULMAN I don't think it is a barrier. I don't think doctors feel it is the barrier that the $1000 fee
was some years ago. This year, I am seeing a growing percentage of doctors coming right through
that barrier with no hesitancy at all. They are having no problem.
GOTTLIEB Are orthodontists controlling costs as well as they should?
SCHULMAN I've seen practices with a 75% profit percentage, but I think that on the average a
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Mar(190 - 203): JCO/Interviews Mr. Martin L. Schulman on Fees
profit percentage of 52% 55% 57% is reasonable. I have also encountered one 17-year-old practice
that had a 16% profit level. I was appalled by it and the doctor was scared to death by it.
GOTTLIEB Can you budget costs in an orthodontic practice? Can you say, "I'm going to have a
50-50 cost/profit percentage next year and it is going to be allocated in this percent for rent, this
percent for salaries, etc"?
SCHULMAN Well, I believe you can't. Many of your expenses are uncontrollable. The balance is
only controllable if you also can control the number of incoming patients, but that also is
GOTTLIEB Where can costs be cut?
SCHULMAN There are very few places you can cut.
GOTTLIEB Are orthodontists over-hiring, for example?
GOTTLIEB Are they permitting salaries to escalate automatically with annual increases without
regard to performance?
SCHULMAN Some do. Labor averages about 16% in most practices. In the practice I mentioned
with the 16% profit margin, his labor percentage was 30%. That's not too uncommon. But, there are
so many ways that employees' costs can be out of line, that it almost has to be approached on an
individual basis. It could be that the employee benefits are unreasonable. It could be that the wages
are too high. It could be that the performance standards are too low. It could be that there are too
many employees. There are all kinds of reasons.
GOTTLIEB Do you subscribe to an hourly wage?
SCHULMAN I much prefer that people be paid by the hour or by the day, than by the week or by
the month.
SCHULMAN Because it's more definitive. When employees are paid by the hour, it's less
expensive when the doctor is away. Where employees are paid by the week or month, the doctor's
absence usually results in the employees being paid without working, which to me seems
GOTTLIEB How close to the vest should the orthodontist think of operating with regard to costs?
SCHULMAN You must think of a practice as being similar to a business, with one primary
advantage. The average well-operated business will have a net profit percentage of 5-20%, whereas
the average profit in an orthodontic practice is in the area of 50%. The businessman must be terribly
careful in order not to have his costs become unreasonable and lose his profit. A professional in a
practice can be more relaxed, particularly if his gross income is at a satisfactory level. It isn't too
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Mar(190 - 203): JCO/Interviews Mr. Martin L. Schulman on Fees
painful if his profit percentage slips from 50% to 44% or 40%. He may not care to have a real tight
operation. If he doesn't care, it's perfectly all right. I find no fault with that, but I think he should be
aware of what he is faced with and, if he does care, he should look for better performance. If he
doesn't know how to make it better, he should find out.
GOTTLIEB To go from 60/40 to 50/50 would mean either reducing costs by one-sixth or 16 2/3%
or increasing gross income by 20%. Do you believe it would be easier to increase the gross under
those circumstances than cut the costs?
SCHULMAN Yes. I believe that it's easier to raise gross income that it is to reduce costs. Most
costs defy reduction, whereas income can always be increased through better practice building
performance. One advantage is that all added income normally carries only an increased cost of
perhaps 25%, which are the variable costs. That would be labor and materials.
GOTTLIEB That's an interesting point. Once you have established a practice, the cost of each
additional patient is an entirely different matter. It does not involve just dividing the number of
patients into the cost to get a unit cost.
SCHULMAN Yes, because costs are divided into two areas, fixed and variable. That is why doctors
have such a terrible time starting a practice. Once the practice is established, adding patients should
raise the profit percentage, because instead of making 50% on the additional patients, you should be
making 75% net profit, because all of your fixed costs— such as rent, utilities, repairs, dues and
subscriptions, insurance— are not variable and don't increase with more patients being treated.
GOTTLIEB That's right. After the break-even point on your fixed expenses, you are operating at a
different cost/profit level.
SCHULMAN Well, you see, businessmen are very aware of these differences, whereas doctors
never really pursued this level of sophistication in their practice operation, due to the nature of their
education and frequently to the absence of a need to know.
GOTTLIEB Do you think that doctors are going to have to pay more attention to this in the future?
SCHULMAN No, I don't. If they can maintain their practice gross incomes at a healthy level and
with a good rate of growth each year, they don't necessarily have to be any more aware of how their
costs are arrived at, as long as they are satisfied with the results. It's really a kind of personal thing.
GOTTLIEB You think that orthodontics is going to continue to be a happy and lucrative
SCHULMAN Oh, you bet. There are very few vocations in which people are as well off as medical
and dental practitioners. They control their own destiny, they earn good incomes, they have choices
in terms of investments, they can accumulate quite good amounts through pension and profit sharing
plans that enable them to retire quite comfortably. Most people don't have the choices that
practitioners do. Most people work for large companies; the company tells them what to do; they
retire, at best, on modest retirement programs; they don't have the choices of time commitment.
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Mar(190 - 203): JCO/Interviews Mr. Martin L. Schulman on Fees
Most doctors don't have to work the number of hours to generate their incomes that most people in
commerce and industry do. So, doctors really have all sorts of wonderful advantages. By the same
token, they are bright, committed people who devote their lives to their practices and their patients.
But, I think doctors are treated quite well, accordingly.
GOTTLIEB Do you think that the variety of alternative delivery systems — retail dentistry, clinics,
franchises, etc.— represent a threat to this way of life and will have an adverse affect in depriving
practitioners of their autonomy and their income?
SCHULMAN There are inroads being made. Whether the changes will have a profound effect or
not is hard to say. I think that the fee-for-service practice is the most desirable kind of practice there
is. If I were an orthodontist, that is the practice I would seek. In my judgment, I don't believe that
fee-for-service practices will ever fall below 65% of all orthodontic practices in the U.S.
GOTTLIEB Well, Bud, you have covered our subject in a broad and interesting manner, and I want
to thank you on behalf of the readers of JCO.
Mr. Schulman is Chairman of
the Board of the Dental Corporation of America, 1592
Rockville Pike, Rockville, MD 20852.
APRIL 1980, VOL. 14 / ISSUE 4
Financial Management of the Orthodontic Practice
JCO Interviews Dr. Brainerd F. Swain on Current Appliance Therapy
Common Sense Mechanics Part 8
A Simple, Economical Bonding Adhesive
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Apr(221 -): 222 THE EDITOR'S CORNER
Have you ever checked back to see how close to "on time" you finish your cases? Have you ever
compared the actual length of treatment to the estimated length of treatment? If you are consistently
off in your estimated treatment time, either the estimates are wrong or the treatment is inefficient or
the patient management is ineffective. It would be nice to find out which it is, because it is costing
you money. It is costing you money in a couple of different ways. If you estimate that a case will
take 18 months and it takes 24, in one way or another you have short-changed yourself to the tune of
one-third of the fee quoted. Either it should have been one-third higher, or you should have finished
the case one-third sooner. Not only were you not paid for the extra six months of treatment, if you
are on a fixed fee as the vast majority of orthodontists are, but you added a factor of 1/3 to your case
load during that period and your costs were elevated commensurately. If you are consistently
underestimating your finish by one-third, your entire case load would be one-third higher than it
should be. So, there is a great deal to be gained by finding out what your real experience is and
adjusting fees and fee arrangements and/or estimates of time and/or treatment procedures—
including intervals between visits— accordingly.
While the number of months actually involved in a case compared to the number of months
estimated is a rough measure, the number of visits is a better one. This study should be set up to
include the number of visits, the number of visits per month of active treatment, and the fee per
visit. The above chart will assist in organizing this information for you and it is suggested that you
fill it out for your last fifty completed cases.
While the number of months actually involved in a case compared to the number of months
estimated is a rough measure, the number of visits is a better one. This study should be set up to
include the number of visits, the number of visits per month of active treatment, and the fee per
visit. The above chart will assist in organizing this information for you and it is suggested that you
fill it out for your last fifty completed cases.
Estimated vs. Actual Treatment Time Analysis
# Mos.
# Mos.
# Mos.
Diff. as
a % of
# Visits
per Mo.
When I did this for fifty of my cases, I found that I had estimated 15% exactly. I had
overestimated 30% by up to 27% (in months), and I had underestimated 55% of the cases, with a
range from 4% to 70%. My average overestimation was 14%. My average underestimation was
36%. Overall, the group of fifty cases had been underestimated by 24%. This meant that my income
was 24% lower than it might have been, if I had estimated accurately; and that my case load was
24% higher than I had planned for. In analyzing the data, most of my problems stemmed from
underestimating short treatment cases, and in permitting a few cases to run too long. You can make
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Apr(221 -): 222 THE EDITOR'S CORNER
a bigger percentage error on smaller numbers, and it is amazing how much time can be allowed to
go by if you do not resolve to deal with long-term overdue cases that do not respond to your usual
technique and administrative remedies.
It was interesting, in my case, to find that the visits per month were almost identical for the cases
that were underestimated and for the cases that were overestimated, 1.5 versus 1.4 visits per month.
This was, in itself, a surprise. If someone had asked, I would have said that the time interval
between visits in my practice averaged four to five weeks. There were relatively more visits in the
short treatment cases and in the very prolonged cases.
It was also interesting to note that when the number of visits was divided into the amount of the
fee, the fee per visit in all "on time" cases tended to be the same. The fee per visit tended to be less
on the longer treatment cases estimated correctly, probably due to the additional dilution of the
front-end load built into the fee. It was substantially lower on prolonged treatment cases, due to my
shortening the interval between visits on prolonged cases.
I think we share a delusion in orthodontics about how fast our cases are treated. We would like to
think that our best time is our average time. We are also influenced by the fact that reported
treatment times tend to be low. It would seem wise to measure your actual performance on every
fifty completed cases, and to look to your method of estimating treatment time, of establishing fees
and fee arrangements; to your treatment management and to your monitoring of treatment progress;
to your contingency plans for treatment and fee if cases are unduly prolonged; and to your
communication of the whole concept of a control system of this kind to your patients.
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Apr(242 - 247): Financial Management of the Orthodontic Practice
Financial Management of the Orthodontic
Much has been written concerning the future of the private practice of orthodontics. As each
practitioner looks to his future, sound financial planning is advisable under any circumstances. In
the present practice environment, it is mandatory. Orthodontists concerned about their future cannot
maintain shoddy financial records. Sound practice decisions require an appropriate data base.
There are two broad areas of financial planning which should receive your attention:
1. Internal financial management.
2. Fees and financial arrangements.
The financial data necessary for internal financial management consists of two types of reports:
1. Profit and loss statement.
2. Statistical data.
In my opinion, these must be available on a monthly basis. Even if the data is not required each
month, it should be available and current, when needed. The information is critical in plotting the
relative growth or decline of a practice.
Profit and Loss Statement
The practice profit and loss statement is the most rudimentary financial report for any
practitioner. It is essential, not only for practice management, but also for income tax planning and
personal financial budgeting.
The profit and loss statement format which I prefer (Fig. 1) has several significant points:
1. Practice operating expenses are separate from Doctor compensation. Compensation paid to the
practitioner in various forms is considered profit in an unincorporated practice, but an expense in the
incorporated practice. Only by separating Doctor compensation from operating expenses will you
have the proper data base for overhead analysis. Also, this permits a more reliable comparison of
one practice to others.
2. All data is shown both for the month, for the year-to-date, and for the last year-to-date. This
provides an easy method of comparison of current charges to the previous year.
3. Expenses are in dollars and as percent of gross. This permits a quick appraisal of the comparative
weight of expenses currently and measured against the previous year.
As a supplement to the profit and loss statement, for practices with one or more branch offices, I
suggest a monthly report listing the income, new charges, and receivables for each branch office
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Apr(242 - 247): Financial Management of the Orthodontic Practice
(Fig. 2). This is important for the justification of each branch and to make the pertinent information
available should there be any consideration of selling or disposing of one or more of these locations.
Most often, the internal financial data should be prepared by your CPA or management
consultant. Seldom should it be developed by your office personnel. The accuracy of the
information is critical to the management of your practice.
Note that in Figure 1, "Net Profit From Practice" is shown at the bottom of the report. In most
instances, this is a temporary condition which is adjusted at year-end by bonuses and retirement plan
Statistical Data
In addition to the profit and loss statement, there are other items of information which are critical
and should be monitored in every practice on a monthly basis (Fig. 3). I simply cannot imagine a
practice that can be monitored properly without similar data.
The most sensitive area in most orthodontic practices today is the level of fees. There is a
justifiable concern of many practitioners for the "bargain" fees charged or to be charged by prepaid,
closed panel or retail practices, which Avrom King has labeled Tier 1 and Tier 2 dentistry. While
one must acknowledge that these types of services are expanding, I do not feel that they will erode
the well-managed Tier 3 practices. They may well make orthodontic care available to a segment of
our population which, in the past, could not or would not have access to it. My frame of reference is
only to practices not attempting to compete with Tier 1 and Tier 2 practices.
It is important to be aware of the fees being charged in your area by practices similar to your own.
These can be obtained in many ways, some of which are too devious to be noted here. Once you
have ascertained the level of fees charged by comparable practitioners in your area, you have three
obvious choices. Your fees can be below average, average, or above average. Most practitioners will
be at or near the average.
Fees that are higher than average, or at the highest level for the community, can provide a
competitive advantage, if the patient concludes that higher fees are accompanied by higher quality
care. The psychology of pricing is a whole subject in itself. Many years ago, the Shaefer Pen
Company attempted to bring out an extremely inexpensive ballpoint pen. No one would buy it,
assuming it was of inferior quality. Then they priced it many times more, and sold millions. In our
society, there is definitely the implication that quality is associated with cost. However, for the
practitioner to "carry off" the higher fee, his practice must be capable of delivering that type of
service and developing that higher quality environment.
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Apr(242 - 247): Financial Management of the Orthodontic Practice
Once the basic level of fees is established, they must be increased periodically to at least reflect
inflationary trends. Without these "cost of living" increases, the practitioner will experience a
decreasing net profit from his practice, while experiencing an increasing personal cost of living.
Financial Arrangements
During the case presentation, the orthodontist should gain the acceptance of the responsible party
not only for the treatment, but also for the fee. Once this acceptance has been accomplished, I
suggest that the specific financial arrangements be delegated to a member of your office staff.
Ideally, this would be the same person who will follow through on the payment schedule. In this
manner, the practitioner is removed from the dollar and cents aspect of the practice, leaving him free
to perform the professional tasks. Simultaneously, a relationship is established between a member of
your staff and a responsible party, which will be important should any financial problems or
questions arise in the future. The agreed-upon arrangement (following truth in lending regulations)
are made in writing, with copies to both your office and the responsible party. It is difficult for a
parent/patient to contend that the arrangements were not made in a certain manner, if these
procedures are followed.
The specific financial arrangements will differ according to the financial ability of the
responsible party. The orthodontist must establish the parameters, or the options available. I suggest
the following arrangement for the majority of situations:
1. A down payment should be received in all cases, of between 20 and 33%. The logic behind a
down payment is twofold. First of all, it should relate to the front-end work load at the onset of
treatment. Thereafter, if a patient transfers out or terminates for any reason, you've been paid
properly for the work performed. Also, the higher the initial payment, the lower the subsequent
monthly payments. In our experience, the people who have the most difficulty with a large down
payment always have a similar difficulty meeting larger monthly payments. Therefore, I recommend
that banding not commence until a down payment has been received. Simply postpone treatment
until that time.
2. The monthly payments should be scheduled to be completed two to four months prior to the
estimated time of completion of treatment. If the latter is 24 months, payments should be completed
within a 20-month schedule. The reason to establish a payment schedule shorter than the treatment
schedule is to allow for two variables— a shorter treatment time than anticipated and, if there are
overdue payments, hopefully they will have been paid by the time the case is completed.
3. The fee should be quoted to include a specific span of treatment, i.e., 20-28 months. At the time
of the financial arrangements, the responsible party should be told that, should treatment time extend
beyond 28 months either because of lack of patient cooperation or because of unusual difficulty of
treatment, the monthly payments will be reinstituted.
4. There must be a clear discussion of charges included and not included in the basic fee. For
example, is there to be an additional fee for records and retention? We favor a separate charge for
retention after the first twelve to eighteen months. This allows access to your practice for an
extended period and can be a source of income to you rather than a source of irritation.
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Apr(242 - 247): Financial Management of the Orthodontic Practice
5. I find all too frequently that practitioners do not remove the bands until the final payment has
been made, thus extending not only the amount of Doctor time, but also the amount of time the
patients are required to be banded. Both you and the patient benefit from good collection
procedures, rather than extended treatment.
Overdue Payments
Perhaps the most accurate barometer of the status of your accounts receivable is a tally of
overdue payments. These are simply payments that were due one or more months in the past. Your
system should clearly identify the amount of these overdue payments. Therefore, we suggest they be
tallied at the end of each month, list the total of 30, 60, 90 and over 90 day accounts— with the list
made available to you. These totals should be measured not only in the absolute, but also in relation
to the preceding period to determine if they are increasing or decreasing. We prefer not to see the
overdue payments exceed 4% to 5% of your annual gross income.
Followup on Overdue Accounts
Unquestionably, the best collection tool in your profession is the proper financial arrangement.
Establishing a sound basis originally, with a clear explanation of the fee and the due date of
payment, is a very strong deterrent to overdue payments. However, every practice experiences slow
or non-payers. We suggest the following sequential followup for overdue payments:
1. One overdue payment— a statement with a reminder indicating that one payment is now past due.
2. With the second overdue payment— a second written reminder with the statement, followed by a
telephone call to the responsible party to learn the nature of the problem.
3. For three or more overdue payments — we feel an in-person conference should be held between
the office staff member in charge of followup and the responsible party.
4. If that conference does not produce a satisfactory result— we suggest a conference between the
doctor and the responsible party. If satisfactory arrangements cannot be made, and the doctor does
not wish to write off or discount the amount due, treatment should be suspended and ultimately
terminated. The latter should be done only with the guidance of proper legal counsel and your
malpractice insurance carrier.
Your specialty has the unique ability to correlate the delivery of services with the payment for
those services without, in most cases, jeopardizing the patient's overall health. In my experience,
proper financial arrangements and a sound collection program need not jeopardize your public
relations or practice growth, while establishing a firm and effective manner of being properly paid
for your services. I feel these guidelines will complement and enhance a quality orthodontic practice.
The dynamic environment of orthodontics today requires of every successful practitioner a high
level of financial management. To ignore the principles noted herein is to encourage lesser financial
rewards from your practice.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume Apr
President Rocky Mountain Professional Consultants. Inc
10403 West Colfax Ave . Denver. CO 80215
Fig. 1
Fig. 1 Profit and Loss Statement
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Apr(242 - 247): Financial Management of the Orthodontic Practice
Fig. 2
Fig. 2 Branch Office Income Data.
Fig. 3
Fig. 3 Statistical Data.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Apr(250 - 264): JCO Interviews Dr. Brainerd F. Swain on Current Appliance Therapy
SIDNEY BRANDT, DDS, Interviews Editor
DR. BRANDT Barney, you were the originator of the Siamese bracket. How did that come about?
DR. SWAIN Well, I came out with it in 1949 after several years of experimenting with what was
then a relatively new problem in orthodontics, namely, paralleling roots when closing extraction
spaces. Let me explain that.
Up until the late 1930's, orthodontists were dominated by Angle's dictum that proper treatment
required a "full complement of teeth". In other words, orthodontic treatment meant nonextraction
treatment for all, except perhaps cases of severe crowding. There was a stigma surrounding
extraction treatment. In those days, the single bracket, used with a full-sized wire that had the proper
bends, was adequate to produce the three orders of tooth movement required with Angle's
nonextraction treatment. Then Tweed came along and changed all that. He did it in the following
manner. He recalled 150 of his treated nonextraction patients whose teeth and faces he didn't like,
and had four bicuspids removed. He retreated them (without charge, incidentally) and then
compared the results of each treatment. The improvement resulting from extraction treatment was so
dramatic and compelling that, for most of us who practiced in that era, Tweed— by this one stroke
alone — cut the Gordian knot and made extraction treatment acceptable.
However, closing extraction spaces meant moving teeth further, and orthodontists soon had
difficulty obtaining root parallelism when doing so. A lot of experimenting was done, including
changes in the archwire, in the positioning of brackets, and in the size and shape of the bracket
itself. For example, one ingenious archwire designed for paralleling was the gable roof arch
invented by Dr. Harry Bull and still in use today. It included a loop and not only paralleled the roots,
but maintained the crowns in contact while doing so.
In an effort to "build treatment into the brackets" and reduce or eliminate bends in the archwire,
orthodontists began to place brackets in positions that would offset the tendency of the roots to fall
behind during space closure, and also to compensate for some undesirable rotations occurring at the
same time. We came to realize that when closing an extraction space, the teeth on either side of the
space tend to tip and to rotate toward it. From this it was a simple step in the middle 1940's to devise
what I called a double offset technic, namely, placing brackets (these were molar or double width
brackets) on either side of the extraction space to offset undesired rotation and tipping. Then we
found it could be made more efficient, if short lengths of .030 or .040 wire were soldered on the
bands beside the brackets, either vertically or horizontally. The archwire rested against these when
tied into the bracket slot. They had the effect of increasing the distance between the bearing points
of the archwire, and that in turn permitted reducing the amount of offset in bracket positioning.
When these spurs or cleats were soldered on (most of us used gold in those days), they acted like
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Apr(250 - 264): JCO Interviews Dr. Brainerd F. Swain on Current Appliance Therapy
two walls of a bracket, so the obvious next step for many of us was simply to solder on another
bracket, particularly on molars. This introduced problems in getting the brackets properly alined,
especially on the curved surfaces of bicuspids and cuspids, and that led to my placing the two
brackets on a common base in order to assure alinement and facilitate attachment. Incidentally, as a
matter of interest in these times of high gold prices, the first Siamese Twin brackets were milled out
of solid bar stock, and this meant a lot of gold dust lost in the process.
DR. BRANDT Why did you call it the Siamese bracket?
DR. SWAIN Well, actually I call it the Siamese Twin bracket because of the famous circus twins
from Siam, who were joined together near the waist by a connecting tissue link. The analogy of two
brackets also joined at the waist by a connecting strip seemed logical enough, hence the Siamese
Twin bracket.
DR. BRANDT Have there been many refinements in the bracket since then?
DR. SWAIN Yes, many. Probably the most important are those that extend the principle of
"building treatment into the bracket": such as tip, torque, rotation, and the in/out feature, or variation
in labiolingual thickness of certain brackets, which reduces or eliminates inset or outset bends in the
archwire. In addition, the tie wings are taller and have been reshaped. The incisal wing of lower
incisor brackets has been chamfered to reduce occlusal interference. The gingival tie wing, on the
other hand, has been extended out labially, in order to improve access when ligating. Also, the tie
wing grooves are now deeper, and that helps in ligating or placing elastomeric thread or chain.
Accuracy in bracket placement got a boost when the edgewise slot was placed at an angle to the
sides of the bracket, so that when these sides are placed parallel to the sides of the crown, then the
edgewise slot will have the right amount of tip.
These changes are all helpful, but probably require a word of caution, which is that where the
original bracket was symmetrical from top to bottom and side to side, and the slot was parallel with
the upper and lower edges, the current brackets are so modified and so variable in shape that it is
important to keep in mind that the "bottom line" in bracket placement is the position of the slot
Don't let your eye be diverted by the orientation of other parts or by curved mesial and distal
surfaces or visual reference lines such as incisal edges. As Williamson puts it, "When you think of
placing brackets, think of placing slots".
DR. BRANDT How important is the placement of Siamese brackets in Straight Wire technic?
DR. SWAIN Sid, before answering that, may I repeat a point that has been emphasized by Andrews
and Roth, namely, that Straight Wire means an appliance, not a technic. Anybody's edgewise technic
can be used with the Straight Wire appliance. I use Roth's technic and his new hookup, which was
brought out in the fall of 1979. These brackets, which contain a new prescription for the amount and
direction of tip, torque and rotation force, are designed to provide not only for correction but for
overcorrection, which is Roth's "End of Appliance Therapy Goal". If you believe in overcorrecting,
and I have for a long time, then with all that good stuff built into those brackets, placing them
accurately is just more important and more rewarding than ever before.
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Apr(250 - 264): JCO Interviews Dr. Brainerd F. Swain on Current Appliance Therapy
DR. BRANDT Is bracket placement any more significant to Siamese brackets than others?
DR. SWAIN Yes. If you insert a wire that fills the slot on single, double width, and Siamese Twin
brackets, there will be greater control over the positioning of the crown and root. Logically, the
more accurate your bracket placement, the more accurate your leveling, alinement and rotation.
That's an advantage, not a handicap.
DR. BRANDT What is your feeling about the importance of interbracket distance?
DR. SWAIN Sid, interbracket distance is probably more important with treatment mechanics that
require archwire bends between brackets and where ample space is needed for them. Interbracket
space is much less important with a technic such as Ron Roth's, where you start out with either
looped or plain light wire arches and gradually level up to heavier flat archwires. Roth's bracket
prescription and recommendations for bracket placement build treatment, and indeed overtreatment,
into the brackets, so that, ideally, the objective is to produce all required final detailing movements
with a flat archwire. While that can be difficult, because errors of bracket placement, or occasional
variations in facial surfaces that affect placement may require some compensatory archwire bends,
the interspace between the Siamese Twin brackets is still ample.
Another factor that effectively reduces the need for wide interbracket space has been the
introduction of newer wires such as Nitinol and D-Rect, with their high resiliency and low
load/deflection rates. For example, when alining irregular anterior teeth and when there is little
interbracket space, these wires can be deflected considerably while ligating and yet not distort in the
process. Furthermore, they exert a light but relatively constant force. Even when crowding and
irregularity are severe and a looped archwire is used, if lack of interbracket space is a slight problem
while ligating, this clears up after one or two appointments. From that point on throughout
treatment, interbracket space is of little concern, except perhaps after finishing space closure and
other major tooth movements, and when preparing for final detailing. At that time, I relocate or
replace brackets that aren't positioned accurately, because although the brackets may look good at
the outset of treatment when the teeth are rotated and irregular, they often show need for
improvement when commencing final detailing. After relocating, brackets are often at a different
level from those mesial or distal, and it's usually necessary for one or two appointments to drop back
to a lighter archwire, such as Nitinol or D-Rect, in order to be in the slot while leveling. Also, these
wires are easier on the patient, and usually after one or two appointments a full-sized archwire can
be put in again.
DR. BRANDT When placing brackets, do you place them at the center of the crown or at some
measured distance from the incisal edge or buccal cusp?
DR. SWAIN I've done it both ways. In fact, I've switched back and forth several times. Angle and
his students, such as Strang, from whom I took my first Edgewise course, used the middle third of
the crown, so that's how I started out. Several years later, while at a Tweed Foundation meeting, I
heard about the use of a bracket gauge, and shortly after, at the recommendation of Dr. Harry Bull,
who invented the Bull loop and the gable roof arch, I standardized on bracket height, using a
measuring gauge and keying on the second bicuspid crown, which, as he'd noted, usually has the
shortest crown. I continued with this for both Edgewise and Light Wire strapups until I went into
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Straight Wire in 1976, and my first dozen cases had indirect bands done by "A" Company, with the
brackets located in the middle third of the crowns. That, of course, was where they were designed to
be, but revived some old problems such as the strong reverse curves needed for overbite correction
and some undesirable torque effects I hadn't seen for a while. Since then, I've gotten back to the
practice of measuring for bracket placement. Measurement is made from the incisal edge or tip of
the buccal cusp to the edgewise slot. If either the slot or incisal edge is tipped, I usually key on the
slot at the mesial half of the bracket. In both arches, the incisors, bicuspids and molars are set at
3½mm, except the upper second molar which is placed about 3mm. The lower cuspids are placed at
4 and the upper cuspids at 4½mm. These measurements may be increased slightly with large or tall
crowns. If so, the same increase is used for each tooth.
DR. BRANDT Why do you place the upper second molar tube at 3mm?
DR. SWAIN The practice of banding upper second molars at age twelve or early in the teens, and
then uprighting them into a full vertical adult position makes me uneasy. These recently erupted
teeth are often tipped both distally and buccally. In this age group, I'm going back to a policy I used
for many years (when soldering tubes on freehand), which was to place the upper second molar tube
slightly occlusally in relation to the first molar attachment, close to the occlusal edge of the band
and with the mesial end of the tube tipped up gingivally. This keeps the tooth slightly intruded and
tipped back distally, and it eliminates the need for an upward bend in the archwire, such as usually
placed in this region. In turn, that helps when placing the usual buccal root torque in these upper
molars, because it can be placed in a relatively straight, flat wire. To explain that, if the tube is at the
customary height and with the usual angulation, if buccal crown torque as well as an upward bend
are placed in the archwire, this creates a compound curve and the wire spirals outward as well as
It seems more in keeping with the concept of building treatment into the bracket and using a
straight wire for treatment, if the upper second molar tube is placed more occlusally on the tooth as
described, so as to produce slight intrusion and to maintain the distal inclination usual in this age
group. Finally, this slightly intruded or undererupted position is an advantage from a functional
standpoint, since the lingual cusp of the upper second molar is one of the most common causes of
occlusal interference during excursive movements. Furthermore, a slight extrusion of this tooth, for
example through failure to place enough of the usual upward or intrusive bend in the archwire to
keep it slightly intruded, can create what Roth calls a molar "fulcrum" and that can lead to occlusion
DR. BRANDT What does Roth mean by a molar "fulcrum"?
DR. SWAIN It refers to the effect on the occlusion or the temporomandibular joint when a molar is
extruded or overrupted. The consequences of this are illustrated in Figure 1. Figure 1A is taken from
the Broadbent-Bolton Atlas and represents the 12-year normal. Figure 1B shows the upper molar
extruded 2mm by, for example, cervical headgear. The jaws have been forced apart, the axis of jaw
rotation during closure is still at the condyle, but the anterior teeth are in open bite. Figure 1C shows
a different consequence of the same extrusion. The teeth are together in centric occlusion, but the
condyle is subluxated downward and backward, the axis of jaw rotation during final closure is at the
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extruded molar.
In the course of a panel discussion, Roth commented on the prevalence and significance of molar
extrusion or fulcrumming in TMJ dysfunction problems: "I have not yet seen a TMJ case that has
responded to occlusal therapy, in which there wasn't some degree of what I call a fulcrum, or
rocking, or inferior displacement of the condyles at the time the mandible was placed in a stable
position. This was a big revelation to me because initially, in my introduction to gnathology, a
centric slide was a deflection off the arc of closure and the mandible came forward and off to the
side a little bit. In my observations over the last 15 years, I would say the majority of TMJ cases I
treat and that I see are more vertical problems than anteroposterior problems. There is a share of
anteroposterior problems, but most of them are an inferior displacement of the condyle."
My experience with TMJ patients has been very limited, Sid, but as a teacher and practitioner I
have a special interest in the significance of these observations on molar fulcrumming in
orthodontics. I feel they should be of concern, because so much of what we do tends to extrude
molars. For example, a simple thing such as bracket placement. Let's say that a molar band (usually
a second, but possibly a first molar) is fitted too far to the gingival, so that the tooth is extruded.
Let's also assume it is held in this position long enough for bone to fill in beneath the root, so that it
is stabilized in this position. Will the intermittent forces of occlusion pound it back down again after
debanding? Not likely. Anyone who's experienced the discomfort of a "high" filling knows that
rarely happens. So, this molar fulcrum either results in an anterior open bite (Fig. 1B) or condylar
subluxation (Fig. 1C) and, unless the discrepancy is sufficiently mild or some very helpful condylar
growth and remodeling takes place, the patient may be predisposed to a TMJ problem because of a
bracket placement error.
Cervical headgear on upper molars and Class II elastics on lower molars also can extrude these
teeth. I realize that from the orthodontic viewpoint these mechanics have both defenders and critics.
I'm suggesting that from a jaw relation and functional occlusion standpoint, their use should be
reduced as much as possible or else avoided, especially among patients with a short ramus, short
posterior face height, or anterior open bite.
DR. BRANDT In view of the hazard of creating a molar fulcrum, how should the orthodontist treat
an open bite?
DR. SWAIN Sid, first let me say that the gnathologic approach to correction of an open bite is the
same in principle, whether it's being accomplished by orthodontics, equilibration, occlusal
restorations, surgery, or some combination of these four. That principle is to close the bite by
hinging the mandible shut, with the axis of rotation being at the condyle. This is in contrast to
conventional orthodontic mechanics, which use vertical elastics attached to the anterior teeth to
hinge the teeth shut, and where the axis of rotation is at the molars. The consequences of this
changed occlusion are again illustrated by comparing Figures 1B and 1C. First, let's assume that the
upper molar already occupied the position shown in Figure 1B when this open bite patient first
presented for treatment. In Figure 1C, the teeth are in centric occlusion, but the condyle has been
subluxated downward and backward out of the fossa. Depending somewhat upon the amount of
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subluxation and the patient's tolerance level or adaptive capacity, and in the absence of
compensatory growth and remodeling, this can give rise to a variety of problems, which may occur
promptly or appear years later. These include stretched or torn ligaments, muscle splinting, stiffness
and pain, clicking or popping, bruxism, accelerated enamel wear, headaches and neck aches.
If the orthodontist seeks to avoid these problems and to close the open bite by hinging the
mandible shut with rotation taking place at the condyles, then there are several options which alone
or in combination may accomplish the goal. One alternative is extraction treatment. If the
malocclusion is sufficiently mild that most of the extraction spaces can be closed by forward
movement of bicuspids and molars, this has the effect of pulling the teeth away from the condyle or
"out of the wedge", and this can result in a significant reduction of the open bite. Another option
would be to place a transpalatal bar and supplement this with a high pull headgear to the upper
molars. With good cooperation this might result in 1 or 2mm of intrusion, and that can mean 3 or
4mm closure at the anterior teeth. It may not be possible to entirely close the open bite
orthodontically, but if the cuspids can be brought into occlusal contact, this provides anterior
guidance during function, which is important in avoiding TMJ problems.
Aside from orthodontic movement, there are other options such as equilibration, extraction of
extruded teeth, rebuilding of occlusal surfaces, and surgery for more severe open bite problems,
especially those with associated TMJ problems.
One additional word, Sid, on open bites. It's good practice to x-ray the anterior teeth after four to
six months of treatment to check on root resorption. Open bite patients notoriously are prone to
considerable root resorption during orthodontic treatment. This also should be discussed beforehand
as one aspect of a full and fair disclosure of the possible consequences of treatment, when the
orthodontist is seeking the patient's informed consent.
DR. BRANDT How does the gnathologist's goal for anterior guidance correlate with the
orthodontist's goal of flattening the occlusal plane to obtain overbite correction? Doesn't that affect
the incisal guidance?
DR. SWAIN Most orthodontists find it necessary to flatten the occlusal plane during overbite
correction, especially in deep bite cases. At the end of appliance therapy, the curve of Spee is
leveled and overbite overcorrected. At that point, when the patient goes through mandibular
excursions, the anterior guidance will be not quite adequate, and it would not satisfy gnathological
goals. However, as the orthodontist is well aware, overbite seldom remains overcorrected. Almost
routinely after appliance removal, the curve of Spee gradually returns and overbite deepens
somewhat. That improves the anterior guidance, so that during excursive movements it will meet
gnathologic goals. An awareness of known postorthodontic relapse tendencies in this situation could
avoid possible misunderstanding between the orthodontist and the referring dentist, since with the
passage of time, and with no other input, the occlusion will improve and satisfy their mutual goals.
DR. BRANDT Do you believe that other appliances can be used to achieve gnathological goals?
DR. SWAIN Yes, I believe that while you could probably achieve gnathologic goals with other
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appliances, you'd have to work a lot harder than with Straight Wire. Keep in mind that a lot of the
elements we need in terms of tooth position were built in to Andrews' sample of nonorthodontic
normals. Since he measured this sample in order to build his appliance, it has in it a lot of the
elements we need to get a good functional occlusion.
DR. BRANDT Are Andrew's Six Keys to Normal Occlusion useful to you in treatment.?
DR. SWAIN Yes. All Six Keys were common characteristics among his 120 normals, but relatively
uncommon among the 1000-plus treated cases that he studied. To me this indicates that we had then,
and I suspect still have (speaking for myself), a ways to go before we match the fine detailing
reflected in these six characteristics. As a matter of personal interest, I have occasionally checked
my own patients and found this can be a humbling experience. It's tough to make all six. Reopening
of contacts at extraction spaces was the most common hangup for me.
DR. BRANDT Would you list the Six Keys for us?
DR. SWAIN The Six Keys are as follows:
1. Molar relationship. The distobuccal cusp of the upper first molar occludes with the mesiobuccal
cusp of the lower second molar.
2. Crown angulation or tip. The gingival portion of the crown is distal to the incisal portion in most
3. Crown inclination or torque. Anterior crowns have an anterior inclination; posterior crowns have
a lingual inclination.
4. Rotations. There are no rotations.
5. Spaces. There are no spaces; contacts are tight.
6. Occlusal plane. Varies between flat and a slight curve of Spee (1.5mm or less).
DR. BRANDT What's the concept behind the Straight Wire appliance? Does it actually mean a
straight wire?
DR. SWAIN Yes, Straight Wire means a flat edgewise wire that fills the slot and has idealized arch
form, but no other bends. The concept as I see it, is to provide (1) an individualized bracket at (2) a
prescribed position on each tooth, so that (3) a straight wire can be used to finish treatment for 95%
of patients.
Let me explain that statement as it applies to the Roth bracket setup and his mechanics:
(1) The individualized bracket used in this setup is designed to not only correct, but to overcorrect
each tooth position after a straight wire is inserted and sufficient time allowed for full expression to
take place. The rationale behind overcorrection is to acknowledge that teeth move aftert appliance
removal, and therefore one should leave each tooth in such position before debanding that it will
settle back into normal alinement and occlusion from the overcorrected position. The amount and
direction of overcorrection built into these brackets is the result of 3 to 4 years of clinical trial and
modification. As a long-time believer in overcorrection and its benefit to stability, Sid, I think this
advance is an idea whose time has come and come to stay. I know that two manufacturers have
either brought out or are working on their own versions of the new Roth setup.
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(2) The prescribed position. Sid, I believe accurate bracket placement is a prime weakness among
orthodontists, and I include myself in this group. Unfortunately, accurate placement is becoming
more important as more and more treatment is built into the bracket. That wasn't always so. When
Angle introduced his Edgewise appliance, there was one standard bracket and treatment was
accomplished with bends in the archwire assisted by auxiliaries. Bracket placement deficiencies
were compensated by altering the bends. However, with this new setup, the amount of treatment
built in has reached its logical conclusion. The torque, tip, rotation, overcorrection and final
detailing are all in the bracket provided three conditions are satisfied:
(a) a straight wire is placed,
(b) sufficient time is allowed for full expression of movement, and,
(c) the brackets are in the right place. If some are not, then bends will have to be placed and the
simplicity and efficiency of treatment will be reduced proportionately.
(3) To finish treatment. I did not say and don't want to imply that a straight wire is used from start to
finish. While that's been done, Roth's mechanics, like most others, use looped and plain round and
edgewise wires, plus auxiliary wires and headgear to accomplish movements such as leveling,
alining, rotating, retracting anteriors, closing extraction spaces, correcting Class II relationships and
overbites. Once these are accomplished, the straight wire is placed for overcorrection and the final
detailing which is Roth's "End of Appliance Therapy Goal."
DR. BRANDT Why does the upper cuspid have 13° of mesial tip?
DR. SWAIN In order for the upper cuspid to function properly, it has to have enough mesial tip so
that when a patient with a Class I occlusion goes into a lateral excursion, the tip of the upper cuspid
will function against the lower cuspid to give immediate separation or, disclusion of the posterior
teeth. Now, if the buccal segments are in Class I and the upper cuspid has little or no mesial
angulation, the incisal tip will pass through the embrasure between the lower cuspid and bicuspid
and there will be no cuspid rise. If there's no cuspid rise, there will be cuspal interferences on both
the working and nonworking sides and that often leads to bruxing, which adversely affects
postorthodontic stability. From the standpoint of functional occlusion, there may be harmful
consequences of this occlusal interference, including occlusal wear, periodontal disease (where local
or systemic predisposing factors are present) and temporomandibular joint dysfunction.
Now, having said that, I have to add that I'm a little uneasy with the 13° tip on the upper cuspid
bracket, because of the amount of tipping of roots in finished cases. I have a good panoramic x-ray,
one that provides an uninterrupted and continuous scan from third molar to third molar. When I take
an x-ray following treatment, I can see how every root relates to every other root, upper and lower as
well as right and left. Far too often, I see the cuspid roots, particularly the upper, too far back and
too close to the bicuspids. Of course, that's no surprise, because if the bicuspid bracket has 0° tip
and the cuspid bracket has 13°, even though allowance is made for differences in the root/crown
axis of each tooth, those roots are going to be pretty close. I know that sufficient mesial tip of the
cuspids is important from the standpoint of functional movements, but I'm concerned that 13° might
just be a couple of degrees too far.
DR. BRANDT How is the new Roth setup working out for you?
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DR. SWAIN Well, it's a bit early to be able to talk from experience, but I had seen the prototype
brackets undergoing trial in Roth's office, and liked what I saw. I haven't finished any cases with the
new setup, but expect it will provide the degree of overcorrection he seeks as his "End of Appliance
Therapy Goal' and will do that with a full-sized archwire containing few bends or, hopefully, none. I
also like the bracket placement he is now using with the setup, in part because it's so close to what I
was using with Edgewise years ago.
Three changes in the buccal segments are particularly important: (1) the upper bicuspids and
molars are tipped back slightly to 0°; the lower bicuspids and molars are tipped back slightly more
to -1°. That helps with anchorage control and has other benefits; (2), built-in upper buccal root
torque has been increased and is now progressive torque, upper bicuspids are -7° and molars are
-14°. That saves a lot of wire bending; and (3), the upper first and second molars now have 14°
rotation. This will overrotate these teeth and that will mean better occlusion in the buccal segments.
DR. BRANDT Did you say that overrotation of the upper first molar often aids Class I
interdigitation in the buccal segments?
DR. SWAIN Yes. For many years, when molar tubes were soldered on freehand, I made it a policy
to overrotate upper first molars, and did this by offsetting the molar tubes at the distal and using the
following guide: Bend a short piece of edgewise wire so that if forms two legs that meet at a right
angle. Using a model of the upper teeth, place one leg tangent to the mesial surface of the upper first
molar and the other leg extending back along the buccal surface. This leg will touch near the center
of the mesiobuccal cusp and will form an "offset" angle with the buccal surface, usually ranging
between 12° and 15°. That's kind of interesting, because the new Roth bracket is 14°. Now, if the
tube is on the band at this angle and a straight wire inserted, it will overrotate the upper molar
slightly, and that has a beneficial effect on occlusion, because the mesiolingual cusp, which fits into
the central fossa of the lower first molar, is moved forward by this rotation. In turn, patients usually
bite forward slightly, since the lower molar will fit better with the mesiolingual cusp of the upper at
that point, and most of us "tend to bite where our teeth fit best". The lower second molar also
occludes further forward, and the distobuccal cusp of the upper molar can more easily settle down
and back against the lower second molar in Andrews' key position. In addition, the tip of the upper
second bicuspid tucks neatly into the interspace between the lower second bicuspid and first molar,
and that intercuspation is hard to achieve with inadequate molar rotation.
Overrotation of upper first molars is also helpful where stubborn midline problems or
cusp-to-cusp relationships in the buccal segments seem to be responding slowly to treatment. From
my experience with the Straight Wire appliance in the past three years, I wasn't seeing enough
overrotation of molars with the brackets and bands as they were supplied. While this could be
remedied with a toe-in bend in the archwire, then it is difficult to engage the upper second molar.
However, with the increased rotation (14°) available in the new Roth upper molar brackets, I expect
to again see some of the improved intercuspation that occurs when these teeth are overrotated.
DR. BRANDT Does the Straight Wire appliance require a broader arch form?
DR. SWAIN I don't know that it requires a broader arch form, but it was certainly designed for one.
Andrews uses an arch form with the Straight Wire appliance obtained from measuring his 120
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untreated normals. Roth's arch form, the Tru-Arch, is based on observation of occlusal contacts and
functional movement patterns, posttreatment settling, and long term stability. Roth's arch form is
somewhat broader than Andrews'. Another broad arch form, the Penta-Morphic form, was brought
out by Ricketts in 1979. It was formulated from his research on normal occlusions, successfully
treated cases, and computer analysis of frontal, labial and vertical coordinate data. Incidentally,
Roth's Tru-Arch form and the "normal" form in Ricketts' series are just about identical except at the
second molars, where Roth's curves slightly to the lingual.
For orthodontists brought up to the Bonwill-Hawley form, or who believe that, insofar as
possible, the arch form of the malocclusion should be retained in treatment, these newer arches are
clearly broader. However, in each instance they are biologically based rather than, as in the case of
the Bonwill-Hawley chart, derived geometrically. Hopefully this will lead to greater posttreatment
DR. BRANDT What is unique about Roth's "End of Appliance Therapy Goal"?
DR. SWAIN It refers to his goal for positions teeth are to occupy when fixed appliances are
removed at the end of treatment. He believes that they should be overcorrected, in order to allow for
the anticipated posttreatment settling or rebound or relapse or whatever you choose to call it. Now
although overcorrection as a treatment strategy isn't new, I don't recall any previous
recommendation that it be done in all three planes of space in anticipation of relapse in all three
areas. And, I don't know anyone who has gone so far as to build that overcorrection into his brackets.
DR. BRANDT Do you foresee doing an entire treatment with a single straight wire for each arch?
DR. SWAIN Not right now, but continuing bracket modifications and improved physical properties
of wires are bringing us closer. These new brackets, which have not only treatment but
overtreatment built in, would probably serve, if given an archwire whose physical properties could
be changed during treatment. At the outset of treatment it should have high flexibility or low
stiffness, high resilience, and a low load/deflection or low spring rate. Nitinol (edgewise), for
example, has these properties and it certainly simplifies the alining, leveling and rotating usually
required at the beginning of treatment. However, when treatment gets into correcting overbite and
overjet, closing spaces and paralleling roots, establishing arch form, width and symmetry, these
require higher stiffness, while high resilience and a low spring rate are less important.
DR. BRANDT Barney, when you were in Light Wire, it was said that you never did pure Begg,
because you used the "chicken" bracket. What is the "chicken" bracket?
DR. SWAIN Sid, that refers to the combination bracket which provides for a free-pivoting gingival
slot and also has an edgewise slot. Years ago, to use something like that, or in fact anything but a
"pure Begg" bracket, was regarded as "chicken". Recently, however, there's been more interest
among light wire practitioners in combination brackets that do have an edgewise slot.
DR. BRANDT How do you feel about the current interest among Light Wire practitioners in these
brackets with pretorqued and preangulated slots?
DR. SWAIN The idea is to use the gingival slot for the usual three stages of Begg technic, and then
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go into a fourth stage, using the edgewise slot for more precise final detailing. One of the
manufacturers recently brought out such a "Four Stage Bracket". It looks interesting, but from my
own experience with the "chicken" bracket, I know that to make that edgewise slot work efficiently
without a lot of wire bending, it's going to require really accurate bracket placement Anyway, I
respect their attitude and interest and hope something comes from it, as there seem to be some
interesting possibilities. For example, one would be to place short segments of Nitinol edgewise
wire in the edgewise slots of cuspids and bicuspids during Third Stage paralleling. As already noted,
this wire has such high resiliency and such a low deflection rate that a full arch might serve for the
leveling, aligning, and rotating required in the Fourth Stage detailing.
DR. BRANDT Barney, you've always cautioned your students or listeners against the unilateral
Class II problem. Would you care to comment?
DR. SWAIN Sid, I believe you're referring to my statement that a unilateral Class II malocclusion
may be a tooth discrepancy case in disguise, and to be very careful in planning treatment. For
example, assume that a patient with a full Class II molar relationship on one side and Class I on the
other presents for treatment. Overbite and overjet are moderate (3 to 4mm) and there is no crowding
and no spacing. Given those six conditions, this has to be a tooth-size paradox. Measurement and
comparison of the upper and lower tooth widths in this case will usually show an unfavorably high
Bolton tooth-size ratio, probably 80% or above. Now, if models are made and a diagnostic setup
done with molars on both sides placed in Class I, there will not be room enough for the upper
anteriors to enclose the lowers properly.. Either an edge-to-edge bite or very slight overbite (1 to
2mm) will result. So, if the patient is treated and the Class I molar relationship holds, but the
edge-to-edge or slight overbite relationship does not, then the lower anterior teeth will probably
crowd up as overbite deepens, and the orthodontist is in a difficult spot explaining those crooked
teeth, because that's not just relapse. It's much worse than that. You have to explain, if you can, why
those lower front teeth are crooked after you treated them, when they were straight before you did so.
Treatment planning requires some kind of compensation, such as stripping or reproximation, or
else extraction of a lower incisor, to reduce the discrepancy enough to permit a realistically deeper
overbite and overjet, while still maintaining the Class I relationship on both sides. The diagnostic
setup is the best means for deciding between these alternative compensations, because it's a
three-dimensional resolution of a three-dimensional problem.
DR. BRANDT Are Class II elastics an integral part of your mechanics?
DR. SWAIN Yes, they are an integral part, but that doesn't mean that they're used steadily
throughout treatment. In fact, I prefer to avoid them whenever possible, except perhaps in the
skeletal deep bite case, for example, where some lower molar extrusion with Class II elastic force
would be of help with overbite correction. As a general rule, I prefer to rely on headgear force
attached directly to anterior teeth for purposes of retraction, unless Class II elastics at this time
would be of help for intentional forward movement of lower molars.
The Class II elastics are of two types, the short Class II and the conventional or long Class II. The
short Class II is attached from a power arm or loop in the upper cuspid area and extends to the
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power arm on the lower second bicuspid. In a nonextraction case, it might hook onto the lower first
bicuspid, and another short Class II might be attached from the upper first bicuspid to the lower
second bicuspid. The action of these elastics initially seems somewhat like a paradox, but is
understandable. Since they stretch in a more vertical than horizontal plane, the initial reaction is to
suspect that it would bring about quite a bit of extrusion among the lower teeth. However, it should
be recognized that the lower arch normally contains a heavy wire with a reverse curve, which
ordinarily tends to extrude bicuspids and hold molars and incisors down during flattening of the
occlusal plane. Cephalometric records taken before and after the use of short Class II elastics
indicate that there is little or no lower molar extrusion or tipping of the occlusal plane, certainly less
than that which frequently occurs with conventional or long Class II elastics stretched from the
upper cuspid area to the lower first molar. While this is an advantage with the short Class II elastics,
there is a disadvantage that occasionally arises, namely, insufficient correction in the buccal
occlusion, and that requires conventional Class II force to bring about.
DR. BRANDT You mentioned headgear for retraction of anteriors. Do you retract all six anteriors
simultaneously, or do you retract cuspids and then go back for the incisors?
DR. SWAIN I retract all the anteriors simultaneously, Frankly, that worried me back in 1976 when I
started with Straight Wire, because for the fourteen years I had used Edgewise in the 1940's and
'50's, retracting six anteriors at once was almost universally regarded as a great way to blow your
anchorage and end up with everything too far forward in the mouth. However, Andrews and Roth
were doing it routinely, and despite misgivings based on my earlier experience, I did also. It seems
to work, and when I checked a hundred finished cases recently. I came up with the following:
DR. BRANDT How do you correct the Class II relationship in a nonextraction case?
DR. SWAIN Through many years of both Edgewise and Light Wire technic, I've generally
preferred to correct the Class II relationship during the mixed dentition wherever possible. In the
permanent dentition, after growth is pretty well completed, correction of a Class II relationship
without extracting teeth would be unusual, unless the problem was quite mild and spacing is present
in the buccal segments so as to permit correction by tooth movement rather than jaw movement. In
severe problems, such as skeletal Class II with an open bite, where the use of Class II elastics might
result in lower molar extrusion and aggravate the open bite, I may extract only in the upper arch,
retract the upper anteriors, and leave the buccal segments in Class II. These patients usually have a
short posterior face height, and it's important to stay away from Class II elastics or other mechanics
that might subluxate the mandible and create TMJ symptoms for the patient.
DR. BRANDT Barney, orthodontists and other dentists have been at loggerheads regarding
occlusion for a long time. Do you see any signs of reconciliation of their views?
DR. SWAIN Yes, Sid. Occlusion problems, by their very nature are complex, and solutions more
often than not require the services and knowledge of people with skills in more than one area of
Article Text
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Apr(250 - 264): JCO Interviews Dr. Brainerd F. Swain on Current Appliance Therapy
practice. Small multidisciplinary study groups made up of dentists in various practice areas can help.
In addition, continuing education courses given by orthodontists and restorative dentists, for
example, and intended for both orthodontists and restorative dentists, can be superb. I think perhaps
the best opportunity is at the community level, where the orthodontist and the restorative dentist
collaborate in the diagnosis and planning and then in the ongoing treatment of patients with
occlusion problems. This kind of relationship is a special challenge to an orthodontist working with
a younger practitioner whose educational background included training in functional occlusion
concepts and goals.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume Apr
Fig. 1
Fig. 1 The molar fulcrum. A. 12-year normal (after Broadbent-Bolton). B. Molar extrusion resulting in anterior open bite.
C. Molar extrusion resulting in condylar subluxation.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Apr(265 - 272): Common Sense Mechanics Part 8
Common Sense Mechanics
Wire/Bracket Relationships
8 This discussion will appear to be academic at first, and of little use to the clinically oriented
orthodontist, but be patient. The content will increase your appreciation for the treatment procedures
that follow, which will utilize this information on a clinical level in an uncomplicated manner. The
relationship of the archwire to the brackets and tubes, prior to engagement, offers valuable and
interesting information. If a straight wire is placed over angulated brackets, a certain angular
relationship develops between the wire and the plane of the bracket slot (Fig. 95). The brackets
might be angulated as a result of the malocclusion or purposely angulated to permit overrotations,
etc. In any case, a straight wire overlying these brackets, prior to insertion of the wire into the
brackets, gives us clues regarding tooth movement. We cannot eliminate "common sense": however,
since identical force systems can produce different responses due to the biologic nature of the
environment. Teeth extrude more readily than they intrude. Certain rotations occur more easily than
others in different planes of space.
These force systems can become quite complex when more than two teeth are involved.
However, because we have thus far confined our mechanics to relatively simple situations involving
minimal placement of bands (brackets), and will soon be moving into extraction treatment involving
a greater number of bands, it seems appropriate at this time to go into a greater degree of
"exactness". For, if we can understand what is exact, we can then deviate from exactness and begin
to know the value of applying the same principles in "nonexact" terms, in order to achieve our
objectives in a practical way. In other words, we will avoid producing a complex appliance to satisfy
academic needs. Instead, we will keep the appliance simple and "read" the relationships involved
adjacent to the archwire bends as though only two teeth were involved. Disregarding the other teeth
will still allow us to get our results, as the forces transmitted to these "distant" teeth with relatively
light wires requires time, and we are more interested in the short-term movements.
Now that we know the emphasis will be on "practicality", let us not get lost with details that do
not pose a "clinical" threat. The following is presented only to create an awareness of what happens
when wire/bracket relationships change. As multiple brackets enter the picture, the system becomes
complex to apply, as it is then necessary to add the systems at the various brackets to determine the
net effect. This can be time-consuming, inexact, and impractical. If you will read an article titled,
"Force Systems from an Ideal Arch" by Burstone and Koenig (AJO, March 1974), you will
appreciate the true complexity of force systems in orthodontics. At the same time, I think you will
want to utilize what you can in an efficient and simple manner, even if it means sacrificing the
details involved in exactness, particularly since teeth seldom respond in an exact fashion.
Article Text
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Apr(265 - 272): Common Sense Mechanics Part 8
Basically, we deal with various wire/bracket relationships created by the malocclusion, archwire
bends, or both. For practical reasons, I prefer to attain bracket alignment regardless of the force
systems produced in the process. Once this is accomplished, desirable force systems can be attained
by placing bends at specific points along the archwire. In other words, we then determine what we
want by creating our own relationships. We have already seen this accomplished during our
discussion on vertical forces and tipback bends.
So, to get a further insight as to the force systems created by wire/bracket relationships, let us
consider the variations. If we begin by using a constant interbracket width (any width) and a center
bend, it can be seen in Figure 96 that the relationship can be created by the bend in the wire or by
the malocclusion. In either case, the force system is the same. As already said, I prefer aligning the
brackets and then determining my own systems by placing the bends where needed. If we now look
at Figure 97, we can see that the bend has been moved off center, but still remains identical to the
relationship created by the malocclusion. Again, in either case the force system is the same. Finally,
in Figure 98 we see that two off-center bends have been placed, the second being inverted, but
placed equidistant from the bracket. Yet the relationship is no different than the one produced by the
malocclusion and a straight wire, so the force systems are identical. Now, if we go back and look at
Figures 96, 97, and 98, and concentrate on the angulated brackets only, we can see what caused the
change in the wire/bracket relationships. The bracket on the left in each case remained constant in
angular relationship with the archwire, while the bracket on the right was slowly rotated clockwise.
Therefore, we can readily accomplish the same by placing bends instead, once the brackets have
been aligned.
Thus far, we have been talking about center and off-center bends only and, therefore, only need
be concerned with Figures 96 and 97. But, for the sake of discussion, and so that later we can prove
that the force systems we have so far discussed in these two bends are really the case, let us become
familiar with Figure 98. After all, everything that lies between the relationships in Figures 96 and 98
is merely a transitioning of force systems.
In my graduate school days, Dr.Charles Burstone referred to Figure 96 as a symmetric bend
relationship. I have adopted the term center bend or gable bend. He referred to Figure 97 as an
asymmetric bend and Figure 98 as a step relationship. I refer to the asymmetric bend as an off-center
bend. Since the step relationship has its place in mechanics, but because I seldom utilize it
(purposely), you will not hear me refer to this relationship in my discussion of Common Sense
Mechanics as it pertains to clinical treatment.
If we can see what forces and moments MUST exist in the two extremes under discussion (Figs.
96 and 98), then we can accept the systems that exist "in between". If you are really interested in
every detail, please refer to the published material I have mentioned.
Center Bend Force System
Let us begin to determine the forces and moments present in the two extremes of the wire/bracket
Article Text
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Apr(265 - 272): Common Sense Mechanics Part 8
relationships— the center bend and the step— by applying the requirements for static equilibrium.
Once we can prove these systems are present, by necessity, we can resume our discussion of
mechanics on a practical level. But it is only fair that you see, first, what occurs technically.
Looking at Figure 99, a center bend, we can see that forces must be applied at four separate
points for wire/bracket engagement. Since three requirements (previously discussed) MUST be met
and ARE met to establish the static equilibrium that will and DOES exist, we can go through each
step in order. Let us start by "assuming" all four forces are equal. We don't know, yet, if they are,
but we must start somewhere. Only when all three requirements of static equilibrium are met, will
we have discovered what the actual forces are. We are not interested in any actual figures, but only
relative magnitudes.
If all four forces (activational) are equal, then the first requirement for static equilibrium is
fulfilled. That is, the sum of the vertical forces must equal zero. Since there are no horizontal forces
necessary to engage the wire into the brackets, the second requirement is automatically fulfilled.
That is, the sum of the horizontal forces must equal zero. Since the third requirement says that the
sum of all the moments, measured from ANY point must also equal zero, let us choose the center
point for convenience (Fig. 99).
Now we will determine the moments produced around this point by each force (line of force)
acting at a perpendicular distance to such point. Force A produces a clockwise moment
(activational), equal and opposite to the magnitude of the counterclockwise moment produced by
Force D. Now, Force B produces a counterclockwise moment smaller in magnitude, because it acts
at a smaller distance from this point. Force C, acting at the same distance, produces the same
magnitude, but the moment is clockwise. When we add the four moments produced around this
point, the sum is zero. Therefore, we have met all three requirements for static equilibrium, and the
orginally "assumed" forces are proven to be correct. So, we can now determine the activational
force system at each bracket.
Since Forces A and B produce a couple (pure moment) which is clockwise, and since Forces C
and D produce a counterclockwise couple (Fig. 100A), we have now arrived at the net activational
force system— two moments, equal and opposite in magnitude. Tooth movement occurs as the
result of deactivation, as in Figure 100B. From now on we can refer to this system when we discuss
the center bend and know that it must exist in order to conform with the requirements of static
Step Bend Force System
Now, if we go to the step relationship, which is the other extreme under discussion, we will go
through the same analysis, again using aligned brackets with the bends placed in the wire (Fig.
101A). Since we must start somewhere, we will again "assume" that the four activational forces
shown are equal. If so, the sum of the vertical forces equals zero and the first requirement for static
equilibrium has been fulfilled. Next, the horizontal forces equal zero because there are none, so the
Article Text
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Apr(265 - 272): Common Sense Mechanics Part 8
second requirement is, likewise, fulfilled. All that remains now is to determine that all the moments
produced around a common point also equal zero, the third and final requirement. Using the same
center point, we can readily see that Force A produces a clockwise moment, the same as that
produced by Force D. Both are clockwise and both are equal in magnitude. However, although the
moments produced by Forces B and C are equal to each other and counterclockwise, they are
smaller in magnitude than Forces A and D, because they are produced at smaller distances.
Therefore, the sum of the moments does not equal zero. Since ALL THREE requirements are not
fulfilled, the original assumption that all activational forces were equal was incorrect.
Figure 101B shows the ONLY system that meets all three requirements. First, although Forces A
and D (equal) are smaller than Forces B and C (equal), the sum of the vertical forces can be seen to
equal zero. The horizontal sum remains zero, as there are no horizontal forces. But, the third
requirement is finally met, because Force A and Force D each produce clockwise moments equal in
magnitude and opposite in direction to the counterclockwise moments produced by Forces B and C.
In spite of the fact that Forces B and C act at smaller distances, balance is maintained due to their
greater magnitudes of force. The important thing to realize is that the net activational forces at each
bracket are unequal, unlike the center bend. If we now take the forces in Figure 101B, which have
been proven to be correct, we can analyze the individual brackets for the net activational force
system. Forces A and B produce a clockwise moment at the left bracket and a net force, as shown in
Fig. 102A. At the right bracket, Forces C and D form a clockwise moment also, with the magnitudes
being the same, as well as a net force equal and opposite to the force at the left bracket. Now that
the net activational system has been determined at each bracket, simple reversal (Fig. 102B) gives
the force system acting on the teeth (deactivation).
Variations between these two extremes were shown during the discussion of tipback bends and
will be shown in the next articles dealing with extraction mechanics. It will be seen that as the
wire/bracket relationship (between the center and step configurations) undergoes angular change
relative to the archwire, clockwise moments will transition to zero and, if the relationship change
continues beyond the zero point, finally become counterclockwise. All of this simply means that
there is "Law and Order" to all of this. It is my desire that this can be useful in an everyday practice.
Clinical Demonstrations
If you look ONLY at the two teeth mentioned, Figure 103 illustrates various center bend
relationships produced by the malocclusion itself. Anterior-posterior relationship must also be
considered, as demonstrated in Figure 103 with full wire/bracket engagement, such as with a
rectangular wire.
Figure 104 illustrates step relationships when applying the same approach. The single off-center
bend (as opposed to the step bend which actually contains two off-center bends) has already been
demonstrated many times. Figure 105 shows a rotated central incisor. A wire tied only into the two
central incisors would automatically create the off-center relationship. But, to keep matters simple,
all of the relationships mentioned and formed by the malocclusion are, for the most part, disregarded
Article Text
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Apr(265 - 272): Common Sense Mechanics Part 8
in obtaining INITIAL bracket alignment. In some cases, however, it would be foolish to disregard
The force system in the single off-center bend lies somewhere in between the center bend and
step relationships, depending on the EXACT wire/bracket angular relationship (Fig. 106). In spite of
the fact that using a constant bend, as already discussed, with variable interbracket distances
produces moments that vary, as seen in Figure 106B, the complication is taken out of it by utilizing
the differential in the system, as demonstrated with use of the tipback bend in overbite correction,
and as will be demonstrated in extraction treatment for anchorage control.
Do not let this portion of the series on Common Sense Mechanics drive you away. It was
presented to help you appreciate the need for deriving that which can be modified and made useful
in a busy practice. As you will see, the application will not be complex, but rather quite simple.
Article Text
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Apr(265 - 272): Common Sense Mechanics Part 8
Fig. 95
Fig. 95 Various angular wire/bracket relationships.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Apr(265 - 272): Common Sense Mechanics Part 8
Fig. 96
Fig. 96 The same wire/bracket relationship can be created by a bend in the wire or a straight wire in relation to a
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Apr(265 - 272): Common Sense Mechanics Part 8
Fig. 97
Fig. 97 Off-center bend produces same wire/bracket relationship as a straight wire in relation to a malocclusion.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Apr(265 - 272): Common Sense Mechanics Part 8
Fig. 98
Fig. 98 Step bend produces the same wire/bracket relationship as a straight wire In relation to a malocclusion.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Apr(265 - 272): Common Sense Mechanics Part 8
Fig. 99
Fig. 99 Center bend producing wire/bracket relationships that satisfy requirements of static equllibrlum.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Apr(265 - 272): Common Sense Mechanics Part 8
Fig. 100
Fig. 100 A. Forces A and B In Figure 99 produce a clockwise moment, Forces C and D produce a counterclockwise
moment. B. Tooth movement resulting from deactivatlon of the force systems is counterclockwise from Forces A and B
and clockwise from Forces C and D.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Apr(265 - 272): Common Sense Mechanics Part 8
Fig. 101
Fig. 101 A. Step bend force system with all four forces equal does not satisfy the requirements of static equlilbrium. B.
Step bend force system with Forces A and D less than Forces B and C doff satisfy the requirements of static
Fig. 102
Fig. 102 A. Forces A and B in Figure 101 B produce a clockwise moment; Forces C and D also produce a clockwise
moment. B. Clockwise moments result in counterclockwise tooth movement.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Apr(265 - 272): Common Sense Mechanics Part 8
Fig. 103
Fig. 103 Various center bend relationships produced by malocclusions.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Apr(265 - 272): Common Sense Mechanics Part 8
Fig. 104
Fig. 104 Various step bend relationships produced by malocclusions.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Apr(265 - 272): Common Sense Mechanics Part 8
Fig. 105
Fig. 105 A wire tied into rotated central Incisors would create off-center relationship.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Apr(265 - 272): Common Sense Mechanics Part 8
Fig. 106
Fig. 106 A. Center bend relationship. B. Off-center bend relationship. C. Step bend relationship.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Apr(273 - 277): A Simple, Economical Bonding Adhesive
A Simple, Economical Bonding Adhesive
Since the introduction of bonding to the orthodontic profession, adhesive systems have been
steadily improving in bond strength and simplicity of application. My original concept was to
develop an economically efficient adhesive system, in order to reduce chair and laboratory time and
to decrease office overhead, a particularly motivating factor in these inflationary times. I have
investigated commercially available adhesive systems and bonded with a great number of them; and
I have introduced others to the profession over the years, the most recent of which I have named
I still find EPAC, a liquid-powder acrylic adhesive system that I developed seventeen years ago,
to be an excellent adhesive. The sealant (Saga sealant) optionally employed with this system has
been reported by Zachrisson to be a superior sealant. I also develop Bondmor I(liquid-powder,
sealant), which is superior to paste-paste composite adhesives in terms of storage stability at
elevated temperatures; and Bondmor II (paste-paste, sealant), which is similar to Endur, Concise,
and 1-to-1 in chemical composition and bonding technique. However, in the past two years, I have
been bonding metal brackets more frequently with Contacto, a contact adhesive. Since the adhesive
does not polymerize until the paste contacts the primer on the bracket and tooth, maxillary and
mandibular teeth can be bonded with less "rushing" than with mixed paste-paste adhesives. While I
formulated Contacto to bond metal brackets, it can be used for plastic brackets with a bracket
conditioner for optimum adhesion. However, acrylic adhesive like EPAC are superior to Bis-GMA
composite type adhesives for bonding plastic brackets.
The Contacto kit contains a 40% phosphoric acid etching agent in a squeeze bottle (20 gms), a
primer (19 gms), a jar of paste (10 gms), spatulas, and foam pellets (Fig. 1). Its shelf life is
prolonged when the components are refrigerated.
Bonding Technique
The technique for direct bonding with Contacto is as follows:
Tooth Preparation
1. A careful and thorough prophylaxis of the tooth surfaces with pumice and water is essential.
Rinse and air dry. Care should be taken to prevent oil or moisture from depositing on the tooth
surfaces. Isolate the arch with lip/cheek retractors and cotton rolls (Fig. 2A)
2. Dispense the conditioning (etching) agent on a cotton pellet and etch the tooth surfaces for 1
minute (Fig. 2B).
3. Rinse thoroughly with water and air dry (Fig. 2C). The tooth surfaces should look frosty white
(Fig. 2D).
Application of Primer
Article Text
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Apr(273 - 277): A Simple, Economical Bonding Adhesive
4. Squeeze primer bottle and apply to foam pellet held with cotton pliers, or place 1 drop of primer
on a mixing pad and dip foam pellet into primer (Fig. 2E). Apply a coat of primer to the underside
of each bracket (Fig. 2F). A second cotton plier may be used to hold the bracket by the tie-wings.
Then, apply the primer coat to the etched surfaces (Fig. 2G). Do not rub primer on tooth surfaces,
but allow to flow. Discard the used pellet.
Application of Contacto
5. Using a toothpick, pick up a small amount of the paste and dab paste on the back of the primed
bracket (Fig. 2H). Avoid contamination. Do not allow primer to get into the paste.
6. Place the bracket onto the tooth immediately (Fig. 2I), pressing the bracket into the desired
position for 10 seconds with cotton pliers or similar holder. A bracket aligner can be used to align
the brackets and press the brackets against the teeth to assure a thin glue line (Fig. 2J). It is advisable
not to move the bracket during set, since this will break the bond. Do not use the same end of a
toothpick more than once. A warm air dryer is optional ( Fig. 2K).
Helpful Hints
This bonding procedure uses a minimal amount of adhesive and can be repeated on all the teeth.
Warm air accelerates polymerization. An archwire can be inserted 5 minutes after bonding ( Fig. 2L).
Debonding can be accomplished by squeezing a ligature cutter at the mesial and distal adhesive
joints or band removers and applying a peel force, followed by scaling, Cavitron, and pumicing.
One jar of paste can be used to bond 300 brackets. As with all the expoxy-acrylate adhesive
systems commercially available, one should wash his hands with soap and water after bonding, and
avoid skin or soft tissue contact with any of the bonding components.
Pressure of the bracket against the tooth for 10 seconds enhances bond strength by 1) decreasing
evaporation of the primer (monomer) during cure, 2) preventing air bubble formation, and 3)
producing flash around the edges of the bracket which reduces polymerization shrinkage under the
bracket and microleakage.
When bonding lower anteriors, excess flash should be removed to prevent gingival irritation.
Where there is excessive curvature or irregularity of premolar surfaces, it may be necessary to
adapt the bonding pads to conform more accurately to the bonding surface for maximum adhesion.
Additionally, it is advisable to put pressure and bond the bracket gingivo-occlusally, allowing the
adhesive flash to extrude occlusally. In this manner, the excess flash can be readily removed with a
cotton pledget or a scaler, and there is less chance of gingival irritation.
Failure rates of brackets bonded to premolars is greater than those of the anteriors. This may be
attributable to several factors. The premolars may not be fully erupted; there may be moisture
Article Text
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Apr(273 - 277): A Simple, Economical Bonding Adhesive
interference from the gingiva and the cervical internal enamel fluid; and SEM observations of
etched cervical enamel surfaces of premolars do not show the characteristic pitted prism and pattern
seen on anteriors, and tag formation is shorter and less numerous.
Molars can be readily bonded with Contacto. Mandibular second molars have less bond failures
than first molars. It is easier to bond molar tubes to partially erupted second molars than to cement
I have found that Contacto fosters greater efficiency in bonding and debonding than paste-paste
and liquid-powder adhesives, while producing clinically excellent bond strengths.
Dr Newman is President of General Orthodontic Labs.
General Orthodontic Labs, P.O. Box 298, West Orange, N.J.
Bondmor I
General Orthodontic Labs, P.O. Box 298, West Orange, N.J.
Bondmor II
General Orthodontic Labs, P.O. Box 298, West Orange, N.J.
General Orthodontic Labs, P.O. Box 298, West Orange, N.J.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume Apr
Fig. 1
Fig. 1 Contacto kit.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Apr(273 - 277): A Simple, Economical Bonding Adhesive
Fig. 2
Fig. 2 Bonding Technique. A. Isolate the arch and pumice teeth. B. Etch the tooth surface for 1 minute. C. Rinse
thoroughly and air dry. D. Tooth surface appears frosty white. E. Dispense primer. F. Apply primer coat to underside of
each bracket.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Apr(273 - 277): A Simple, Economical Bonding Adhesive
Fig. 2cont
G. Apply primer coat to etched tooth surface. H. Dab paste on back of primed bracket with toothpick. I. Immediately
place bracket onto tooth. J. Bracket aligner may be used. K. Warm air dryer is optional. L. Archwire can be inserted 5
minutes after bonding.
MAY 1980, VOL. 14 / ISSUE 5
Fee Payment in Advance
Orthodontic Fluoride Protection
Common Sense Mechanics Part 9
Surgical-Orthodontic Correction of Vertical Facial Excess
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 May(295 -): 298 THE EDITOR'S CORNER
The Greeks had a word for it and it was "holism". It seems fairly clear that it has remained Greek
to most people since that time. Every now and again, holism is revived, creates great excitement in a
variety of endeavors and fades away, only to show up again as a new generation rediscovers it. Jan
C. Smuts is sometimes given credit for the formulation of modern holistic theory. He said that the
determining factors in Nature are wholes, which are irreducible to the sum of their parts. Alternate
holistic doctrine has said that a whole cannot be analyzed without reduction to its individual parts.
In a similar manner, Gestalt psychology stated that perceptions and behavior were responses to
configurational wholes, while its counterpart— atomistic psychology— held that perceptions were
built from simple elements or atomistic parts. Atomistic theory predates Socrates and perhaps
holism was a philosophical response to it.
Chances are pretty fair that holism is violated whenever it is applied to a circumscribed activity.
Holism, after all, is a way of life, or a way of understanding life. It has been argued that the English
state was not a summation of the individuals who were members of it, but an organic structure with
a life of its own, a holistic life of its own. Perhaps so, but even the lordly English state was found
holistically wanting and the concept expired with the nineteenth century. As we speak today of
holistic health, holistic dentistry, and holistic orthodontics, we are contributing to the next demise of
holism by breaking it down to its parts.
The simple fact is that people, especially scientifically trained people, are better at deductive
reasoning than inductive reasoning. It would be unfortunate if, because of that, or because holism
and alternate holism are not scientifically provable, we were to reject both of them out of hand.
While we may identify a majority of orthodontic problems as having a genetic origin and believe
that they are a product of aberrations of growth and development of teeth, jaws, possibly muscles,
we also recognize the influence of airway and we are on the verge of implicating stress and its
relation to functional stress.
By the very nature of the influence that patient cooperation and patient motivation have on the
success of orthodontic treatment, orthodontics is especially well-suited to that aspect of holistic
health that would involve the patient in his diagnosis and in his treatment, and in his responsibility
for his own treatment. Also, the contribution that orthodontics can make to the individual's
appearance, comfort, sense of well-being and body wholeness, self esteem, success and happiness
are all rooted in concepts of holistic health.
The vast majority of orthodontists probably have a problem in accepting or even considering the
concept of positive imaging, which entertains the possibility that tooth movement might be
accomplished through mental imaging mobilizing some kind of force directed at a tooth or teeth. So
far, there is no reason that they should not be skeptical. Being skeptical, they need neither accept nor
reject the idea; merely suspend judgment. Which brings us full circle to the scientific habit of
Article Text
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 May(295 -): 298 THE EDITOR'S CORNER
It would be as harmful to reject science and the scientific method as it would be to reject holistic
concepts of health. There may well be an accommodation of the two in the practice of orthodontics.
Orthodontists have an opportunity to make a positive change in their philosophy and that of their
patients, in their expectations from orthodontic treatment and in their patients' expectations. That
change would involve a concept of orthodontics that is different from the traditional one of
straightening teeth as "the job". Orthodontists and patients together may view straightening of teeth
as a biomechanical procedure, which along with physiological and psychological goals evolves a
higher state of health and well-being.
The question for the moment is, apart from understanding what holism may be, whether it is
essential to "buy" the whole concept in one piece. Is holistic health an all or nothing concept? A
behaviorist might feel that way. It would be reasonable for a scientist to take what he can understand
and find good, and let the rest evolve if it will.
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 May(317 - 320): Fee Payment in Advance
Fee Payment in Advance
There is little difficulty in proving that the orthodontist benefits from payment of his entire fee in
advance of treatment. It is a great deal more problematic whether the patient benefits sufficiently
from payment in advance; and even greater doubt still, if he has to borrow in order to do so.
Potential Advantage to the Orthodontist
The benefit to the orthodontist is twofold. By receiving the entire payment in advance, it is not
subjected to the successive bites of inflation during the period over which it is paid; and the longer
the payment period, the greater the "taxation" of inflation and the smaller the total purchasing power
received. In addition, with the fee paid in advance, bookkeeping and billing on the account are
minimized. It could also be argued that the money received in . advance could be invested, even
conservatively, and grow to an extent. Whether the money is in the hands of the doctor or the
patient, it is subject to the same inflation rate. Therefore, the advantage to the doctor would be in
spending it before inflation can depreciate it further and before prices rise some more, or investing
it. Investments can both win and lose; and it can be shown that the difference in investment gain
between receiving the money all in advance or by a substantial initial payment plus the monthly
payments over a two-year period is demonstrable, but not crucial. This does not speak against
investment; merely that the difference would not be that great.
Before orthodontists become too involved in the promotion of payment of the entire fee in
advance in their practices, it would be well to examine the pros and cons.
It can be shown that at the 1979 inflation rate of 13.3%, the orthodontist would gain about 12½%
in purchasing power by receiving a $2000 fee in advance as against an arrangement for payment of
$800 initially and $50 a month for 24 months; about 15½% as against an arrangement of $560
initially and $60 a month for 24 months; almost 19% as against an arrangement $560 initially and
$40 a month for thirty-six months. The advantage diminishes with lower fees, and increases with
larger fees. It is interesting that the difference in purchasing power between payment of $560
initially and $60 a month for 24 months and $560 initially and $40 a month for 36 months is about
In an effort to persuade people to make payment in advance, some orthodontists are reported to
be offering the patient a 10% discount. It can be shown that a 10% discount wipes out the financial
advantage of receiving payment in advance compared to receiving payment over a two-year period,
with the exception of not having to keep the books and bill, and the fact that the money can be
invested. But, the investment advantage, which was small to start with is also negated by the lower
fee. In addition, the orthodontist who offers such a discount could run afoul of Regulation Z of the
Truth in Lending law, which is still on the books. He could not say that he does not charge interest,
because the government would interpret the discount to some as an interest charge to those who do
not receive it. That could get you back to keeping books again and writing end-of-year interest
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statements for patients. Also, one might question the offer of a discount on the amount that would
be the initial payment on an installment contract.
Potential Advantage to the Patient
There remains the question of the supposed tax advantage to patients who pay in advance.
Anyone who studies the tax aspects of payment of let us say a $2000 orthodontic fee in one taxable
year would have to conclude that it would take a very special case to make a substantial gain from
the transaction. Since there is a deductible on medical expenses of 3% of a person's adjusted gross
income, people in the very high income brackets — beginning around $70,000 — would have their
$2000 orthodontic payment eliminated by this 3% deductible. Most employed people these days
have medical insurance, which leaves them with relatively small out-of-pocket medical expenses per
year. With relatively small medical expenses, it is unlikely that most people with adjusted gross
incomes above $70,000 would have much left over to deduct, even with a $2000 orthodontic bill in
one year, after the 3% exclusion on medical expenses.
At the other end of the income scale, people in the $20,000 and $30,000 income range, although
the 3% medical deductible would be relatively small, are apt to have medical insurance. Therefore,
they, too, would not often reach the full 3% deductible with medical expenses other than
orthodontics. That would at the very best cut into the orthodontic fee to make up the 3%. However,
there is an additional problem. For a married couple filing a joint income tax return, there is a $3400
"standard deduction" built into the tax tables. Before the orthodontic fee would be eligible as an
"excess itemized deduction", first the 3% exclusion of medical expenses would have to be satisfied,
and then the remaining medical and other itemized deductions must exceed $3400. The chief
itemized deductions are real estate taxes, mortgage interest, other interest and finance charges, and
contributions. One would almost certainly have to own a fairly expensive home with a fairly good
sized mortgage and high real estate taxes to have the $3400 deduction. People earning $20,000 and
$30,000 a year are not likely to qualify.
Adjusted Gross Income (AGI)
Orthodontic Fee
Other Medical Expenses
Total Medical Expenses
Less 3% AGI
Qualifying Medical Deduction
Real Estate Tax
Mortgage Interest
Other Interest
Total Itemized
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Less Standard Deduction
Excess (deductible from
taxable income)
While there might be exceptions on both ends of the scale, it seems likely that the people who
might benefit taxwise from paying the orthodontist's fee in advance are in the $40,000 to $70,000
income range. The chief problem in that range is that the 3% deductible for medical expenses
becomes quite high and to the extent that it isn't covered by other medical expenses, would eat into
the orthodontic fee deduction and reduce the tax benefit accordingly.
Does it Pay the Patient to Borrow?
With the current cost of living and with the low levels of savings generally, who would have the
$2000 to put into the orthodontic fee in advance? Not too many people in any of the brackets
named. Would it pay them to borrow the $2000? If one were able to derive the maximum tax benefit
from the $2000, in the $20,000 bracket the tax saving would be $451; in the $30,000 bracket, $640;
in the $40,000 bracket, $828; in the $50,000 bracket $980; in the $60,000 and $70,000 bracket,
$1080. Since the cost, at today's interest rates of borrowing $2000 for 2 years would be about $400,
it would appear to be profitable for a patient to borrow the $2000 and pay the fee in advance,
provided that they have other medical deductions to equal 3% of their adjusted gross income and
$3400 in non-medical deductions in addition to the $2000 orthodontic fee, so that the entire
orthodontic fee would be deductible. Any reduction in the medical and non-medical deductions
below those levels, cuts into the orthodontic deduction and reduces the tax benefit. The patient who
does not have the mortgage interest and real estate taxes to deduct is out of this ballgame to start
Gross Income
Tax Saving
Now suppose that the patient only has $500 in other medical deductions, which is quite likely.
This results in a reduction of tax benefit in every category mentioned, because the 3% medical
deduction would exceed the $500. Thus, in the $20,000 bracket the tax benefit is reduced to $431; in
the $30,000 bracket, to $512; in the $40,000 bracket, to $559; in the $50,000 bracket, to $490; in the
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$60,000 bracket to $378; and in the $70,000 bracket to $206. It would not make good sense for the
people in the $60,000 and $70,000 bracket with other medical deductions of $500 or less to borrow
in order to pay the $2000 orthodontic fee in advance, because at present rates, the interest on $2000
for two years would be $400 or more. If loan interest is eventually reduced, to the extent that it is,
more people may benefit from borrowing to pay the orthodontist's fee in advance.
Adjusted Gross Income (AGI)
Orthodontic Fee
Other Medical Expenses
Total Medical Expenses
Less 3% AGI
Qualifying Medical Deduction
Tax Saving (no borrowing)
Tax Saving (with borrowing
@ current interest)
*Assuming $500 in "Other Medical Expenses" and $3400 in non-medical itemized deductions.
It seems clear that some people will derive a tax benefit from payment of the orthodontic fee in
advance and some will not. It will depend upon the size of the fee, the financial position of the
patient, the interest rate on borrowed money, and the tax laws at the time. One thing is for certain.
The orthodontist is not a tax expert and ought not assume that role, or become involved in the
patient's tax determination. Nor should he express or imply tax benefits that may not be realized.
The most that an orthodontist should do is to offer the option of payment of the entire fee in
advance, with the suggestion that this has some tax advantages for some people, and that it might be
well for the patient to consult his tax advisor to see if it would be suitable for him. Beyond that, the
orthodontist must be aware that it is not to his advantage to offer a discount for payment of the full
fee in advance.
ACKNOWLEDGEMENT — I wish to acknowledge the assistance of Jayne Barela in preparing
this paper.
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Orthodontic Fluoride Protection
The object of every topical application of fluoride is to achieve the maximum adsorption of
fluorine on the subsurface enamel layers. Hundreds of studies attest to the prophylactic activity of
fluorides against the development and extension of carious lesions. Topical fluoride applications are
the methods of choice among current preventive methods, mainly because they provide optimum
effectiveness with only limited application in a minimum of time.
Apart from fluoride rinses, which will be reserved for individual home treatment, the varnishes
and gels containing a fluoride element possess remarkable activity with very satisfactory flexibility
in use. Together with fluoride mouthrinses, they provide the best answer to the orthodontist's
prophylactic program.
Fluorine and Enamel Solubility
The presence of fluoride ions causes a disturbance in the bacterial enzyme systems. Fluoride
modifies the storage of intracellular polysaccharides and reduces their utilization outside the cell.
Salivary glycolysis is temporarily blocked, but the inhibition of acid synthesis is affected by the pH
of the environment in proportion to the concentration of the ambient fluoride ion.
Fluorine enables the enamel to resist dissolution in the presence of acids. The young enamel of a
tooth which has just erupted is still immature and permeable. It is particularly vulnerable to
physicochemical aggression. Prolonged contact with saliva gradually reduces its porosity by
superficially stabilizing the hydroxyapatite crystal. The incorporation of fluoride ion helps to
increase this stabilization and accelerates the process of surface glazing, without interfering with the
deeper hydroxyapatite lattice.
Another aspect of the correlation between fluorine and the reduction of enamel solubility
coincides with the concept that the caries lesion progresses from a resting pH of about 5.5 in
alternating phases of demineralization and remineralization. When the pH falls in the presence of
fluoride ions, the fluoride is integrated with the hydroxyapatite lattice of the surface. As soon as the
pH increases, the apatite precipitates preferentially. The repetition of such a process could lead to
the formation of stable fluorapatite. This fact is of importance, since demineralized enamel can
reduce its solubility from 60-70% merely by fluorine absorption. Under these conditions, the enamel
of young teeth is enriched mainly by fluorine deposits, repeated on the appearance of each new
group of teeth. The closer the contact of the fluorine with the receiving enamel surface, the more
effective the yield.
Fluorine and Remineralization of White Spots
The first sign of incipient disintegration is shown by a white halo, ill-defined but still smooth and
without loss of polish. The surface enamel soon loses its glazing and takes on a more and more
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chalky appearance as the lesion progresses and the surface layers of enamel become eroded. At this
stage, the white spot of demineralization, which forms the bed of the caries, markedly opacifies the
transparency of the enamel. This spot can become stabilized. In certain circumstances, it is even
Fluoride gels and, to a lesser extent, the saliva have a remineralizing power on white spots after
removal of acidogenous plaque. The rate of recuperation is increased severalfold in the presence of
fluoride ion, compared with synthetic calcifying fluids. Moreover, study of the kinetics of
remineralization has shown that the level of hardness recovery increases with the fall of pH values
and that, at a given pH, the rate varies linearly with the concentrations of salivary phosphates or
Saliva often arrests the process of recovery. At sufficient and continuous rates of recalcification,
an amorphous material is deposited in the softened areas, which plugs the intercrystalline spaces and
limits all possibility of further remineralization. If discovery of the lesions is recent,
remineralization is quickly obtained by intensive fluoride contact, after 24 to 48 hours. Most of the
time, apart from the loss of substance, which cannot be recovered by fluorine, complete restitution
of the original coloration occurs in two appointments, when gel is used along with fluoride varnish,
and hygiene instructions have been scrupulously followed. However, if unfavorable hygiene and
dietetic habits persist, the process of demineralization proceeds and the spot progresses inexorably
toward caries. The risks of demineralization and, therefore, of potential lesions, are substantially
increased in the presence of fixed or removable appliances to the extent that they limit the
maintenance of hygienic conditions.
Not only does the orthodontic patient have a reduction of self-cleaning due to salivary flow, but
fixed and removable appliances act as traps for food and materia alba, compelling him to exercise
more attention to oral hygiene. Orthodontic devices on the buccal and lingual surfaces of teeth upset
the deflective role of the gingivae. This increases the risk of caries with orthodontic bands, at their
periphery and under the bands because of the acidity of the sealing cement or the crumbling of the
cement; with bonded attachments, on the proximal tooth surfaces; and with removable appliances,
on the palatal surfaces at the tooth cervix. The incidence of more or less severe and extensive
demineralized areas are, therefore, singularly affected by the presence of orthodontic appliances on
the buccal and lingual surfaces of teeth.
At the Royal Dental School in Malmo, Sweden, Ingervall studied a group of children under
orthodontic treatment and a comparable untreated control group. The incidence of caries was
significantly higher in the treated group, and the distribution of the carious lesions followed the
location of the orthodontic devices exactly. Bands on incisors and canines protected the mesial and
distal surfaces, but encouraged cavitation in the cervical areas. Banded upper incisors had a high
incidence of carious cingulum areas. Ingervall recommended topical fluoride treatment before and
after orthodontic treatment and periodic checking of the cement seal.
Preventive approaches for the orthodontic patient must not only consider the enamel surface
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adjacent to the bands. Ideally, the whole enamel surface must be enriched with fluoride ion in
orthodontic patients. Even correctly fitted and sealed bands must be supervised, especially at the
gingival areas.
Protection will vary, depending on the behavior of the variety of fluoride deposited, its
concentration of free fluoride ion, the sequence of application, and the inherent retentive power of
the agent. With increased duration of fluoride contact, the superficial lattice can become saturated
with fluoride. Fluoride gels and varnishes can accomplish this better by providing a more intimate
and lasting contact of fluoride ion with the enamel surface.
Application of Gels
The semiliquid consistency of the gel gives it a unique plasticity of use. In addition to application
by means of trays, the gel is suitable for two other methods of application:
• Painting with cotton buds soaked in 2% sodium fluoride topical solution, using the method
described by Knutson. After polishing, the crowns of the teeth are isolated and dried with
compressed air. The gel is applied and, where necessary, it is pressed into the interproximal spaces
with silk thread. Individual moistening of the crowns is a long and tedious method of depositing
fluoride and, when fixed devices are present, it should be rejected.
• Brushing on the gel with a soft brush has the advantage that it doesn't require qualified staff or
specialized materials. Salivary dilution of the product affects its retention, and the long contact time
necessary for achieving adequate deposits of fluoride is a disadvantage.
Scrupulous cleaning of the enamel is recommended prior to the application of trays coated with
gel. Brushing is usually sufficient to remove a majority of the coating. Fluoride ion itself can
appreciably reduce interproximal plaque. To the progressive reduction of the volume of bacterial
coating is added the disappearance of some cariogenic strains, in particular streptococcus mutans.
Painting with fluoride varnish would produce a similar result by ensuring the constant availability of
fluoride ions captured by the plaque.
Composition of Fluoride Gels
Gels available on the market are composed of sodium fluoride (NaF), stannous fluoride (SnF 2),
sodium monofluorphosphate (MFP), acidulated phosphate-fluoride (APF), or aminofluoride (AmF).
Our preference is for the last two. AmF, APF, and SnF 2 have not been the subjects of
well-documented studies in orthodontics, but they have been fully tested in carioprophylactic
The aminofluorides contain 1% fluoride linked to aliphatic amines with long carbon chain. The
APFs are prepared by dissolving sodium fluoride in 0.1 molar orthophosphoric acid to produce a pH
of 3 and a fluoride concentration of 1.23%. The use of stannous fluoride has been considerably
restricted by its instability in an aqueous medium. This problem has just been resolved by adding a
glycerin solution to the fluoride gel. There still remains the problem of the unpleasant metallic taste
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of tin which is difficult to mask; whereas, the flavorings suggested for APF are able to hide the
acidity of the gel. Research is being conducted to produce other fluoride gels.
Effectiveness of Gel and Trays
The gel, laden with fluorides and contained in the tray, or the fluoride varnish applied by
painting, each has a double beneficial action. First, they promote reduction of enamel
demineralization in acids and reinforce remineralization of white spots; secondly, they inhibit the
production of acidogenic bacteria and also intrabacterial glycolysis of the plaque residues which
persist in the more inaccessible areas. These mechanisms require constant availability of ionized
In 1964, Englander and his coworkers evaluated the effects of daily applications of gels of 1.1%
neutral sodium fluoride and acidulated phosphate-fluoride on school children between ages of 11
and 14 living in a fluoride deficient community (Cheektowaga, N.Y.). The thermoplastic vinyl trays
carrying these gels were placed in the mouth for six minutes each school day, for a minimum of 200
applications. After 21 months, the group treated with NaF showed a 75% reduction of the incidence
of caries; the group receiving the APF showed an 80% reduction. More recently, the authors
reported that 23 months later an anticariogenic effect still persisted, reflected by 55% and 63%
fewer carious lesions respectively compared with the control group.
A more recent experiment by Horowitz et al, showed similar benefits which appear to be
maintained over a period of 2 to 3 years after discontinuance of twelve, six, or three monthly topical
The mechanism by which APF continues to provide cariostatic protection without further
application has not been completely elucidated. According to Horowitz, the high concentration
acquired by the enamel surface during application is responsible. It could serve as a reserve.
Silverstone sees this as a further advantage of gels.
It seems probable that the fluoride ions released by the APF of the gel may be trapped within the
superficial crystalline lattice for longer periods of time than occurs for other inorganic fluorides or
with the use of other forms of application. A significant increase in the fluoride content of the
surface enamel was found 4 to 60 days after the use of acidulated gels at the subsurface of the
enamel. This enrichment seems at least as effective, if not more so, and more stable than that
obtained by mouthrinsings using the same fluoride.
Types of Trays
Among the trays now available for carioprophylactic fluoride application, very few possess
hydrophobic properties or adequate water tightness (Fig. 1). Since the dilution of the topical fluoride
preparation results in a marked decrease in the initial concentration of the free fluoride ion, fluoride
adsorption is reduced by inadequate contact of the tray with the enamel surface. The fineness of
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adaptation of the splint directly affects the fluorine deposit. Interproximal spaces are likely to be
unprotected sites. This disadvantage helps explain the recent application of the new generation of
"thixotropic" vehicles. Viscous in a state of rest, the gel liquefies after shaking or as a result of
munching movements of the patient on his tray. It liquefies without difficulty and then quickly
regains its original gelatinous consistency. Close contact of the fluoride gel with the crown surfaces
must be sought in order to achieve optimum effectiveness; but only three types of trays (Fig. 2) and
positioner appliances (Fig. 3) achieve it:
• Preformed trays, made in three different sizes— for temporary, mixed, and permanent dentitions.
• Individual silastic splints of rigid or semi-rigid plastic, or rubber positioners. The preparation of
these trays requires deferred construction in the laboratory from the patient's casts, which makes
them of less practical value.
• Alginate impressions, complete or confined to the cervical contours of the teeth can take the place
of the best commercial trays, owing to the substantial saving in time. The precision of the alginate
compels the gel to impregnate the smallest irregularities. Along with positioners, they are the most
reliable trays. But the facility with which the fluoride ion forms complexes and bonds with the free
calcium ions present in the cellulose alginate could be a serious obstacle to this method of
application, since the fluoride ions lost would no longer be available for treatment of the enamel.
However, Silverstone feels that because of the high fluoride content of the gel — 10,000 to 20,000
parts per million — the fluoride ions captured by the alginate result in no significant reduction of
fluoride at the gel/enamel interface. Nevertheless, from our unpublished data, it appears that 3ml of
gel containing an average of 11,500 ppm produces only 56% of the initial fluoride concentration, i.e.
an average of 6,570 ppm for a 5-minute contact using normal commercial alginate; and 47% for an
average of 5,560 ppm after 15 minutes. This difference is too high to ignore. Added to the need for
careful elimination of the residues of gel adhering to the bottom of the impression, this represents a
major objection to the use of this method of applying fluoride gels.
Advantages of Trays
• Ease of use, since trays permit access to a complete dental arch at a time, if not to both arches
• Optimum ease of handling. 30 seconds suffice for application.
• Speed of deposit. 5 to 10 minutes of contact provide satisfactory temporary protection.
• Repetition is adaptable to the clinical case. 2 to 12 applications per year according to the
susceptibility of the patient to caries, the concentration and pH of the fluoride gel employed, and the
nature of the fluoride which it contains.
• Low cost.
• Safety. Regardless of the tightness of the tray, the amount of gel used does not exceed 2ml. There
is no danger in swallowing some or all of the product.
• Regularly reported effectiveness.
Excess Gel
While they enable the use of fluoride gel to be extended to the complete arch, trays often allow a
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tiny part of their contents to escape, although the consistency of the gel facilitates maximum delay in
its dilution in the saliva. However, despite their excellent retention and accentuated covering power,
both varnish and gel become diluted during application. From then on, they have the identical
activity on bacterial metabolism which characterizes other fluoride vehicles.
The taste of the gel tends to increase salivary secretion, particularly of submaxillary origin, when
a small amount of gel overflows the tray. The saliva containing gel must be aspirated by saliva
ejector or expelled during or upon completion of application. Most of the rare cases of nausea are
psychological. The combination of fluoride ions swallowed with hydrogen ions of the gastric juices
to form hydrofluoric acid is most exceptional. If it should occur, it can be neutralized by antacid gels
of the carbonate type. No other unfavorable reaction is reported in the literature. The use of fluoride
gels with either prefabricated trays or positioners offers the most safety.
Frequency of Application
The frequency of application generally recommended in the literature ranges from once a week to
once every three months. Less frequent application than that tends to produce uncertain results;
more frequent application scarcely improves the protection. A phenomenon which conditions the
frequency of application is that a substantial part of the fluorine applied may be lost in the form of
calcium fluoride. Marked variations in results may depend as much on the different experimental
conditions of the various reports as on the behavior of the different varieties of fluoride. However,
generally, too widely spaced treatments favor uncompensated losses.
Exposure Times
Frequency and time of exposure are linked, but both depend upon the pH of the gel and the initial
concentration of fluoride ion present. It can readily be seen that in order to obtain equal
effectiveness, weaker concentrations of gels must be given a greater frequency of deposit. The part
played by increase in concentration should not be minimized. Brudevold states that it is necessary to
use higher concentrations in order to obtain sufficient fixation in a short amount of time. Using
radioisotopes, Brudevold noted that the saturation of the enamel with fluoride is quick at first and
gradually slows, which justifies short exposure times. Under standard conditions of temperature and
pH, he found that after a 20-minute fluoride application, 28% of the fluoride ions are captured by
the mineral fraction of the tooth during the first minute, 41% during the first three minutes, and 93%
during the first 9 minutes.
Stearns claimed that maximum equilibrium concentration of fluoride is reached in the enamel
after 3 minutes. De Paola suggests exposure times between 5 and 15 minutes for children of 6 to 13
We favor bimaxillary application of the trays for 6 minutes, repeated every 3 months. The patient
is instructed to exert a slight intermittent pressure on the tray. The gel is thus pressed into the pits,
fissures, and interproximal surfaces and tends to impregnate areas with difficult access better ( Fig.
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Fluoride Varnishes
The studies which led to the introduction of fluoride varnishes were at first directed more at the
search for a maximum deposit of fluoride ion. Together with increased time of contact, they should
be capable of playing a curative and prophylactic role.
One of the methods for ensuring the increase in fluoride concentration in the enamel subsurface
consists of preventing all washing of the enamel surface for as long as possible. The practitioner has
everything to gain by instructing the patient to avoid drinking or rinsing during the half-hour
following the fluoride application. This precaution does not, however, make it possible to control
dilution by saliva.
Duraphat contains sodium fluoride suspended in an alcoholic solution of varnish. One ml of
varnish contains 50mg of sodium fluoride, equivalent to 22.6mg of fluoride ion.
One of the properties of Duraphat is to harden, even if it is contaminated by considerable salivary
flow. On moist teeth, it provides a yellowish adherent film coating, the complete disappearance of
which can be produced as soon as the contact time is considered adequate. It is as if the inert base no
longer fulfilled any other function, except that of an imperfect and unpleasant covering of the
coronary faces.
Clinical Tests of Activity
Due to the recent appearance of fluoride varnishes, only a small number of studies have been
devoted to long-term cariostatic effects. Schmidt and Riethe and Weinmann compared the
effectiveness of an aminofluoride gel with a concentration of 1.25% fluoride ion and Duraphat with
a concentration of 2.26% fluoride ion, and found that the activity of the varnish gave slightly more
positive results under identical experimental conditions. Hetzer and Irmisch found a caries reduction
rate varying between 18% and 45% after two annual applications of varnish for three years and that
the beneficial effects increase with the early eruption of the permanent teeth, up to 11 years of age.
Traces of varnish persisted 14 days after application. Maiwald and Geiger found a 45% reduction in
new caries in 179 schoolchildren after two applications of varnish. Koch and Peterson reported a
75% average reduction in new lesions in smooth coronal surfaces of 60 children after two
applications in one year. Burt et al recommend the intensive use of fluoride varnishes and suggest
that this measure should be strongly encouraged in group carioprophyiaxis.
Varnish Application
The procedure is similar to that of Knutson's technique for the painting of fluoride solutions.
Cleaning of the accessible smooth surfaces and natural sulci of the crown is indispensable to avoid
unfavorable retention of plaque residues, which could intervene between the product base and the
enamel surface. A fluoride paste should be employed, in preference to a standard paste, to provide
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an extra supply of fluoride ions before varnishing. Neither polishing nor drying of the enamel is
called for. They do, however, improve the application procedure. The dental surfaces are copiously
rinsed after polishing and then dried, if necessary. Opposing upper and lower quadrants are isolated
with cotton rolls.
One ml of varnish is expressed from the tube for the permanent dentition; 0.5ml is enough for the
mixed dentition; and 0.3ml is suitable for the deciduous dentition and banded arches. The varnish is
painted on the entire crown surface in less than a minute by means of a cotton bud, after which it is
not essential to maintain dryness, as the varnish spreads out and soon sets in characteristic patterns.
Application is facilitated by the color of the varnish, which disappears at the first brushing. The
adhesion of the material is appreciably reinforced by pretreatment with 50% orthophosphoric acid
for about twenty seconds. It is probable that better adhesion of the varnish is coupled with more
intensive fluoride deposits. Pretreatment produces moderate decalcification of the subsurface
enamel layers which increases retention due to widening the paths of access to the fluoride base of
the varnish and by increase in the total surface of enamel treated. This demineralization is not
desirable in the case of recent decalcification spots, where the enamel has already been strongly
Advantages and Disadvantages of Varnish
Among the disadvantages of this method of applying fluorine are the taste of glue which the
varnish leaves behind, and the delay after application until the patient is permitted to eat and drink.
It is recommended that intake of any nourishment should be postponed for 12 hours in order to
assure the maintenance of the applied film. This implies doing the painting at the end of the
afternoon. In the case of painting limited areas such as the incisor sector only, which represents the
majority of cases, the patient is permitted to take liquid nourishment and to chew on the untreated
teeth. Finally, ulcerous gingivitis and tendency to allergic reactions are contraindications to the use
of Duraphat.
Fortunately, the advantages of this method far outweigh the disadvantages. The advantages
• Speed of application. One minute is sufficient for both arches.
• Optimal handling of the product; a few seconds to prepare.
• Low cost.
• Excellent activity, requiring only one semiannual renewal of treatment.
• Outstanding effectiveness, giving speedy recuperation of white spots despite the presence of
The restitution in full of the color and gloss of the enamel in many cases leads us to think that
fluoride varnishes should be reserved only for treatment of white spots of demineralization resulting
from neglected hygiene or a carbohydrate-rich diet (Fig. 5). Fluoride rinsing solutions and gels will
suffice to provide significant carioprophylaxis throughout orthodontic treatment.
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Orthodontic Indications
In our view, the orthodontic indications for application of fluoride varnishes go far beyond the
prophylactic anticarious protection of newly erupted teeth. The occlusal surfaces of lower second
molars, which are particularly susceptible to the development of caries, would assuredly benefit
from this deposit.
Fluoride varnishes are indicated for the protection of cervical areas when removable or fixed
devices have been inserted (Fig. 6); for the recuperation of demineralized white spots (Fig. 7); and
for preventive remineralization of impacted teeth whose movement may require more or less
traumatic means of prehension (Fig. 7).
The case in Figure 7 illustrates the various indications in detail. In addition to alveolar and
skeletal dysplasias, the case had a follicular cyst on 22 which was pressing on 21 and 23, preventing
their eruption. Removal of the cyst was followed by eruption of 21 and then more slowly of 23, both
in ectopic position. Incomplete mineralization of their crowns was observed at this stage. Following
orthodontic treatment and band removal, the defects of mineralization were treated by two
applications of fluoride varnish a week apart. The color of these two teeth then quickly harmonized,
particularly on the canine where restitution is usually more difficult to achieve. Their lustre has
become entirely similar to that of the adjacent teeth. It is unlikely that a remineralization of salivary
origin alone could have occurred in such a short time; or that fluoride gels and fluoride mouth
rinsing solutions could have produced such quick and complete results.
Discussion and Conclusions
There is no doubt that the prevention of incipient carious lesions is one of the responsibilities of
the orthodontist who is concerned with high quality treatment. Topical fluoride gels and varnishes
provide a maximum of active element to the enamel in the minimum time. It is generally conceded
that this optimum accumulation must reach a critical concentration, which Muhlemann evaluated at
1000 ppm for the outer 30 microns of enamel. This hypothetical level is widely exceeded in the first
application of gel, but the aggressions which occur during orthodontic treatment are numerous, as
soon as strict rules of hygiene are not observed.
The fluorides which have given the best results so far in the form of gels are AmF, SnF 2 and
APF. NaF, which is reserved for mouthrinses, has a concentration markedly lower than that of gels.
Consequently, the daily home use of mouthrinses should be recommended during the entire period
of orthodontic treatment. In orthodontic practice, emphasis should be placed on brushing and the use
of trays coated with gel or the use of fluoride varnishes, in order to protect the enamel or to
recuperate white spots caused by incipient demineralization.
The principal advantages of trays is their ease of handling and the speed with which they can be
brought into use. In this respect, alginate impressions seem especially well-suited, except that the
results obtained by measuring the quantity of fluoride available after various contact times of the gel
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 May(321 - 335): Orthodontic Fluoride Protection
with the alginate must seriously moderate the enthusiasm for this method of applying fluoride.
Before bonding plastic or metal brackets, all contact of the enamel with fluorides should be
avoided and the fluoroprophylactic measures deferred. After band removal, applications of gel are
particularly indicated. The mesial and distal surfaces then become readily accessible by virtue of the
thickness of the two adjacent bands.
The enamel surface is better protected by more frequent fluoride application. One six-minute
application every three months is sufficient to provide excellent fluoride adsorption.
Because of their cariostatic efficiency and their large concentration of fluoride ion, the gels must
be reserved for professional use. The ease of application of trays makes this method preferable to
painting before the insertion and sealing of orthodontic appliances. The prevention program must be
followed during treatment and for the whole period of retention, when supervision is decreased by
the longer interval between appointments.
Professional applications of fluoride gels and the personal use of fluoride mouthrinses are among
the best techniques for administration of fluorides. They must constitute the basis of the preventive
program during orthodontic treatment. Because of their great effectiveness, fluoride varnishes
should be reserved for the protection of the retentive cervical areas, the remineralization of incipient
carious lesions, and the restoration of normal mineralization of impacted teeth moved into the arch.
ACKNOWLEDGEMENTS — The authors would like to thank E. Keiner for her kind assistance in
preparation of the manuscript. The constructive review of this article by Dr. F. Frindel is also greatly
NOTE— A full bibliography is available from the authors.
Dental Department, Research Center P. Fabre , Castres,
Dental Department, Research Center P. Fabre , Castres,
I.C N. Pharmaceuticals, Woelm Eschwege, West Germany.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume May
Fig. 1
Fig. 1 A. Prefabricated wax tray fitted to the arch. B. Synthetic foam tray with median split (MS). C. Soft vinyl tray.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 May(321 - 335): Orthodontic Fluoride Protection
Fig. 2
Fig. 2 A. Three sizes of polystyrene trays. B. Miniplast splint of rigid plastic with retainers (R) and soft resin periphery
(J). C. Alginate impression filled with fluoride gel (FG). D. Tray lined with plastic foam.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 May(321 - 335): Orthodontic Fluoride Protection
Fig. 3
Fig. 3 A. Positioner of semi-rigid plastic. B. Natural rubber positioner. C. Prefinisher (TP Laboratories). D. Ortho-tain
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 May(321 - 335): Orthodontic Fluoride Protection
Fig. 4
Fig. 4 Upper and lower trays (A), each carrying 1 ml of fluoride gel, are introduced simultaneously into the mouth (B)
following removal of ideal arches and premolar and cuspid bands. Patient makes light squeezing movements on trays.
Following removal of trays (C,D) the fluoride gel still covers coronal surfaces immediately after application, then is
diluted in expectorated saliva at the time of fitting of finishing arches (E,F).
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 May(321 - 335): Orthodontic Fluoride Protection
Fig. 5
Fig. 5 Orthodontic case in which poor hygiene left traces of decalcification (D,E,F). At the completion of treatment,
applications of acidulated phosphate fluoride gel (1.23% fluoride ion) along with daily mouthrinsing with sodium fluoride
(0.25% fluoride ion), in order to remineralize the white spots on the upper incisors. During retention, the white spots
were found to have disappeared (G,H,I), except on upper right lateral for which application of fluoride varnish is
Fig. 6
Fig. 6 Application of fluoride varnish by means of cotton buds. The deposited varnish remains in place (C) limited by the
gingiva above and the external limit of the band below.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 May(321 - 335): Orthodontic Fluoride Protection
Fig. 7
Fig. 7 Demineralization on impacted upper left central and canine require varnish for recuperation. At band removal,
the spots were treated with a double application of fluoride varnish (D,E,F). After one week, the recovery observed
(G,H,I) is representative of the effects of fluoride varnishes.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 May(336 - 342): Common Sense Mechanics Part 9
Common Sense Mechanics
Extraction Mechanics
Earlier, in the "Fallacy of Visual Inspection in Force Analysis", it was shown that a wire with a
bend off center is clearly different than one with a bend in the center, since one produces net forces
at the bracket, while the other does not. A center bend involves no net forces, but only equal and
opposite moments with full wire/bracket engagement in any plane of space.
The tipback bend is an off-center bend. The long segment indicates the direction of the force
produced, while the short segment points in the opposite direction to the force it produces (Fig.
107). In the tipback, two moments are also produced, but they are unequal. The larger moment lies
at the bracket or tube containing the short segment (Fig. 108). The smaller moment lies at the
bracket or tube containing the long segment. This smaller moment may, at times, be clockwise; and
at other times counterclockwise; and even disappear, producing the cantilever effect, because only a
pure force would exist at that bracket (Fig. 109). These various results are dependent on the angle at
which the wire crosses the bracket.
The important thing to remember is simply that regardless of the presence, absence, or direction
of the smaller moment the two moments are unequal and therefore, result in differential torque
dominated by the larger moment. Even if we do not recognize the smaller moment as being
clockwise, counterclockwise, or absent, it is still the larger moment that produces the net result. If,
for example, the larger moment is counterclockwise and the smaller moment is clockwise (Fig.
109A), the net effect is still counterclockwise. If the smaller moment is counterclockwise (Fig.
109B), the net effect is also counterclockwise, although more strongly so. If no moment is present
(Fig. 109C), the obvious net effect is, likewise, counterclockwise.
The resilient characteristics of the wire can complicate our interpretations, as archwire activation
often produces a different wire/bracket relationship, initially, than might be anticipated ( Fig. 110).
Practical Interpretation of Forces and Moments
Thus far, most examples used for center and off-center bends have involved only two teeth or two
units of teeth. Since we are going to be dealing with many teeth during the treatment of various
malocclusions, it might be wondered how complicated all of this is going to become. Well, it doesn't
have to become any more complicated than working with only two teeth.
There are techniques today that create a "single tooth" by segmenting a number of individual
teeth. In a sense, this was demonstrated when the cantilever principle was discussed. Four incisors
were treated as a single unit by the placement of an anterior segment of wire, and then an overlay
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 May(336 - 342): Common Sense Mechanics Part 9
archwire was used to apply the desired force. However, we are not going to be using segments for
treatment. As a practical measure, we will be treating the two teeth on either side of the bend, even
though we are using a continuous archwire and multiple banding/bonding. Often, we will be
discussing "segmented tooth movement", but on a continuous archwire. When dealing with multiple
teeth, the teeth adjacent to the bend will be discussed, while teeth farther away from such bend will
be temporarily ignored. Naturally, all of the teeth are ultimately affected, as the forces and moments
are transmitted along the wire. But, initially, the force system acts on the adjacent teeth most
effectively. Therefore, as a practical matter, we will not discuss the system in an unnecessarily
complex manner.
Please understand clearly — the technique shown in this discussion will depart from exactness;
but, in a practical sense, it works. It is simple, easy, orderly, hygienic, reduces the need for patient
cooperation, and will make your work more enjoyable, because you can think rather than follow a
"cookbook", and vary your procedures to fit your schedule — planned and unplanned. I am not
advocating this technique, but will simply be using one treatment approach to demonstrate the
application of principles of mechanics in a practical way. Naturally, you are free to apply such
principles in any way you feel will be better or enjoy doing more. The "fun" in orthodontics, I
believe, lies in treating common or similar problems in a variety of ways.
Cuspid Retraction
Figure 111 shows a crowded condition in which four first bicuspids were removed. We are not
discussing whether or not teeth should be removed, and we are not discussing cephalometrics. This
series will concentrate on a practical clinical approach in which principles of mechanics will help us
to predict and interpret tooth movement. Complete orthodontic records, including cephs are taken
and studied for all full treatment procedures, but we are attempting to discuss only the mechanics
following treatment decision and statement of objectives.
The typical extraction strapup involves the banding/bonding of cuspids, second bicuspids, and
first molars (Fig. 112). Many prefer to band second molars for anchorage purposes as well as for
gnathological considerations.
Others band second molars for alignment and control. As we move along, I will discuss some of
my reasons for not routinely banding second molars. Obviously, there are situations when they
MUST be banded. Remember, that as far as intraoral anchorage is concerned, we will be talking
about the effectiveness of differential torque as a means of control. Keep in mind, there is no such
thing as PERFECT intraoral anchorage, so we are seeking a method which offers the optimum for
Those who band second molars to increase anchorage are saying, in effect, that three teeth
(considering total root area, etc.) will tend to resist moving as much as a single opposing tooth will
tend to move, and therefore, during cuspid retraction, the cuspid will undergo the greatest
movement. However, experience has taught that this is not always reliable. Sometimes, the anchor
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 May(336 - 342): Common Sense Mechanics Part 9
unit serves well, while at other times it readily seems to move forward.
Since the forces during retraction are equal and opposite on the two units — anchor unit and
non-anchor unit — the multibanded unit actually receives the lesser amount of force per unit area
(stress) along the periodontal membrane while the non-anchor unit (cuspid) receives the greater.
This could be one of the causative factors in the variations that occurs. We will be discussing
moments (differential torque) as a means of controlling the anchor unit instead of purely by force
distribution. Again, this is not meant to imply that differential torque is an ideal means of anchorage
control. Extraoral means are always available, but not always desired.
In the cases being demonstrated, the appliance happens to be edgewise with .022 × .028 slots and
.045 headgear tubes. The initial wires are only .016 (occasionally .018). But this is not a discussion
of appliances, so mentally convert the various applications to the appliance and wire sizes of your
choice, but don't lose sight of the principles.
In Figure 112, you can see that anti-rotational ties are placed next to the extraction sites, unless
such rotations are indicated. The malocclusion usually results in initial archwire activation, due to
the fact the brackets are not yet aligned. The periodontal response that occurs is permitted to
improve bracket alignment and level, prior to placing any bends in the archwire. If total arch length
is to be reduced in the final result, the 360° tieback loops are placed "short" of the molar tubes as
shown. Also, anytime teeth are being retracted, there is a mesial force at the molar tubes. Toe-in
bends should be placed early, so as to initiate a counterrotation, so that we do not produce a
mesiolingual rotation of the molars when retraction is begun. Remember the "Cue Ball Concept". Of
course, many will offset this rotational tendency with lingual elastics. However, I do not use ANY
lingual attachments.
Next (Fig. 113), we see the placement of bends intraorally. If bends are placed intraorally, they
cannot .be placed against the brackets completely, due to the width of the Tweed loop plier that is
used. Therefore, the differential torque produced on the teeth adjacent to the extraction spaces is
reduced. This is because, as mentioned numerous times now, the closer a bend gets to the center, the
more equal become the moments; and when placed directly in the center, the moments are equal and
opposite. Again, these statements are not exactly precise, as the molars are included in the partial
strapup. But, as emphasized before, exactness is sacrificed so that we can utilize a "workable"
clinical approach. Likewise, regardless of how far we place bends off center, smaller interbracket
distances result in bends being relatively close to center. In fact, second bicuspids are sometimes
temporarily not banded to increase the distance and therefore the differential torque. Remember the
importance of the toe-in bends or lingual elastics to offset the tendency for mesiolingual rotation of
the molars.
Figure 114 shows the retracting elastics in place. I now utilize power chains and tie the cuspid
directly to the molar, while the second bicuspid is tied individually with an "O" Ring. This allows a
greater range of force. In order to evaluate the effectiveness of anchorage control, on a clinical
basis, observe the two units. The anchor unit should remain relatively upright, while the non-anchor
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 May(336 - 342): Common Sense Mechanics Part 9
unit should undergo tipping until archwire binding occurs. Once binding occurs, the roots will
respond to the moments produced by the archwire, until binding stops and crown movement is
resumed. Remember, the anchor side is located closest to the bend while the non-anchor side is
furthest from the bend. As cuspids continue to move distally, the bend automatically "approaches"
the center of the wire, until finally, when the extraction sites are closed, the bend is centered. So you
can see that as the off-center bend moves toward the center during space closure, the differential
torque begins to gradually disappear, and becomes equal and opposite torque when the bend is
finally centered. This is interesting, because we utilize the differential when we need it most and,
since tipping occurs with the non-anchor unit, the root parallelism begins to take effect as the bend
approaches center. By center, of course, we are not referring to the center of the entire archwire, but
to the center of the wire lying between the bicuspid and cuspid brackets. Do not expect to see the
anchor unit "tip back" as the mesial force on this unit from the retraction elastic will offset the distal
crown thrust that was observed in nonextraction treatment. However, the net force on the cuspid is
distal in direction.
Since we are considering differential torque rather than multibanded anchor units for "bulk", it
may be difficult to get used to the idea of banding LESS teeth for anchorage. For example, if the
second bicuspid is not banded (Fig. 115), the off-center bend can be placed more distant from
center. Remember that as we move away from center, the differential torque increases, whereas at
the center point the moments are equal and opposite and, therefore, there is no differential torque.
The clinical guide to effective anchor control is to look at the unbanded bicuspids and observe them
for mesial tipping. They will only tip mesially, if the molars come forward. Because of the mesial
root torque on the molars from the off-center bend, the molar itself will tend to move bodily, while
the cuspid is permitted to tip to a limited degree, as it experiences a smaller moment. Once the
spaces are closed, a centered bend will not be present, as the bend has been placed against the molar.
Therefore, to produce equal and opposite moments for root paralleling, it is not necessary to place a
new archwire and relocate the bend, as a bend can be placed immediately distal to the cuspid bracket
(Figure 116), and the moment becomes equal and opposite to the moment on the molar.
When the initial archwire is placed, the periodontal response will most often be initiated by the
malocclusion, which produces brackets that are angulated relative to a straight wire. When
reasonable alignment takes place, the bends may be placed. If anchorage is required, then the bend
is off-center. The tooth located closest to the bend indicates the anchor side. The opposite is the
non-anchor side. The anchor side requires a bodily type movement for displacement, whereas the
non-anchor side tips somewhat due to the lesser moment. As space closure occurs, the bend
becomes more and more centered, meaning the moments become more and more equal. When
finally centered, they are equal and opposite and root paralleling occurs. Toe-in bends or lingual
elastics should be in use for the duration of space closure and, in fact, should be placed prior to
initiating space closure, so that a countermoment is produced to prevent mesiolingual rotation of the
molars during space closure. Since round wire is being used, one must remain conscious of the "Cue
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 May(336 - 342): Common Sense Mechanics Part 9
Ball Concept", and not depend entirely on the concept of "rigidity for control".
Fig. 107
Fig. 107 Tipback bend is an off-center bend, with the long segment pointing In the direction of the force produced and
the short segment pointing In the opposite direction to the force produced.
Fig. 108
Fig. 108 The larger moment lies at the bracket or tube containing the short segment.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 May(336 - 342): Common Sense Mechanics Part 9
Fig. 109
Fig. 109 Depending on the angle at which the wire with an off-center bend crosses the bracket, and the length of the
long segment, the smaller moment (produced by the longer segment) can be clockwise (A), counterclockwise (B), or
nonexistent (C). In all three instances, the net effect is counterclockwise, dominated by the short segment
Fig. 110
Fig. 110 Engaging a tipback bend In the molar tube, initially produces a wire/bracket relationship different than the
ultimate mechanics.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 May(336 - 342): Common Sense Mechanics Part 9
Fig. 111
Fig. 111 Crowded case to be treated with tour-bicuspid extraction.
Fig. 112
Fig. 112 Typical extraction strapup, with cuspids, second bicuspids, and molars banded.
Fig. 113
Fig. 113 Bends placed intraorally with Tweed plier.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 May(336 - 342): Common Sense Mechanics Part 9
Fig. 114
Fig. 114 Retraction elastics in place. I now use an "O" Ring on the bicuspid and power chain from cuspid to molar.
Fig. 115
Fig. 115 If the second bicuspid is not banded, the off-center bend is further off-center.
Fig. 116
Fig. 116 When extraction space is closed, an intraoral bend can be made distal to the cuspid bracket, countering the
tipback bend at the molar and producing equal and opposite moments for root paralleling.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 May(336 - 342): Common Sense Mechanics Part 9
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 May(343 - 353): Surgical-Orthodontic Correction of Vertical Facial Excess
Surgical-Orthodontic Correction of Vertical
Facial Excess
The etiology and correction of vertical facial excess has been an enigma to dentistry for a long
time. Practitioners usually approached this multidimensional deformity with limited treatment
objectives. This, coupled with the treatment modalities previously available, precluded the degree of
success possible today. For instance, certain open bite cases were found to be resistant to all forms
of orthodontic therapy, while some were corrected only to relapse after treatment. In other cases,
orthodontics successfully managed the malocclusion with little appreciation for the facial
deformity. 1 Patients often looked worse after orthodontic treatment despite an improved occlusion.
During the past ten years, advances in the orthodontic and surgical approach to vertical facial
abnormalities have led to successful treatment. Surgical procedures to reposition the maxilla
superiorly have resulted in a stable decrease in vertical facial height. 2-5 Combined orthodontic and
surgical management has accomplished efficient treatment and predictable results. 6,7
It is the intent of this article to describe the esthetic, occlusal, and functional abnormalities often
encountered in patients with vertical facial excess (VFE). We will also discuss the treatment
considerations to obtain optimal facial esthetics, a functional occlusion and a stable result.
Esthetic Evaluation
Frontal esthetics: The most striking manifestation is an alteration in vertical facial proportion
resulting in a long narrow, tapering facial appearance. The vertical facial disproportion is usually
related to an increased length in the lower facial third (subnasale to menton). 8 Excessive exposure of
the maxillary anterior teeth and an increased interlabial gap are commonly noted. The patients may
show an excessive amount of gingiva when smiling.
Profile esthetics: Commonly, a clockwise rotation of the mandible has occurred and the chin is
retrodisplaced. The relationship of the nose, lips and chin is carefully assessed in order to integrate
correction of the horizontal and vertical disproportions.
Oral Evaluation
Mandibular position is assessed and the inter and intra-arch occlusal relationships are noted.
Excessive vertical dentoalveolar growth in the maxilla results in a high arched palate. An open bite
may or may not be present. Maxillary anterior arch constriction is noted by a narrow V-shaped arch
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 May(343 - 353): Surgical-Orthodontic Correction of Vertical Facial Excess
form and often results in crowding of the anterior teeth. Maxillary posterior arch constriction is
associated with bilateral crossbites. The occlusion is usually Class II.
Cephalometric Evaluation
Lateral cephalometric analysis reveals the following information regarding vertical facial excess.
The skeletal and soft tissue ratio of lower facial height to middle facial height is increased. This
disproportion is most often due to excessive maxillary alveolar growth. It is noted by the increased
distance of the root apices from the palatal plane and the excessive exposure of the maxillary
incisors to the upper lip. In certain cases, this vertical excess may also be due to excessive vertical
bony growth in the chin area. The maxilla is usually in a normal anteroposterior position. The
mandible is often retropositioned.
Functional Evaluation
These patients commonly have associated disorders involving airway, speech and tongue
function. The speech problem most frequently encountered are articulation errors related to
interdentalization of the tongue. Multiview videofluoroscopy studies in the lateral projection
demonstrate that the tongue tip to alveolar ridge sounds (apical phonomes) are generally
interdentalized with the tongue tip protruding past the maxillary central incisors. In the frontal
projection (AP), the tongue often sits low in the floor of the mouth and has a prominent groove in
the midline.9 Patients with VFE often present as mouthbreathers and have a decreased pharyngeal
airway diameter. Deformities of the nasal septum may aggravate an already narrow nasal airway.
Once the definitive diagnosis is made, a problem list is formulated from the esthetic, occlusal,
radiographic and functional evaluation. Treatment objectives are defined. The importance of
cephalometric prediction tracings, model surgery and the "two patient" concept in treatment
planning have been previously discussed (Figs. 1A and 1B).10 Correct sequencing prevents
unnecessary treatment and improves results. The following orthodontic, surgical and functional
considerations are pertinent to patients with VFE.
Orthodontic Considerations
The "two-patient" concept and cephalometric prediction planning aid in determining the
orthodontic tooth movements necessary to accomplish the surgical correction and to achieve the
treatment goals. Orthodontic treatment is divided into presurgical and postsurgical phases.
Presurgical orthodontic treatment is mainly concerned with intra-arch tooth movement, i.e.,
alignment and leveling. Postsurgical orthodontics is concerned with inter-arch treatment, i.e.
finishing and detailing the occlusion.
Presurgical: During this phase of treatment we do not direct our attention to inter-arch
discrepancies, but rather to intra-arch problems. In cases with openbite no attempt is made to correct
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 May(343 - 353): Surgical-Orthodontic Correction of Vertical Facial Excess
the bite depth. Mild transverse occlusal discrepancies, e.g. posterior crossbite, can be corrected with
orthodontics prior to surgery. In cases of moderate to marked maxillary constriction, it is best only
to align the teeth over the basal bone prior to surgery, and to surgically correct the remaining arch
width discrepancy.
Often, cases require alignment and leveling of the anterior teeth independent of the posterior
teeth. This is referred to as "segmental" orthodontic treatment (Fig. 2). If severe crowding of the
anterior teeth will not allow a satisfactory overbite-overjet relationship to be accomplished with
surgical correction, then extraction of teeth may be necessary to align the teeth. If segmental surgery
is planned in an extraction case, the teeth are aligned and space is preserved for interdental
osteotomies. In nonextraction cases that require interdental osteotomies, it is often helpful prior to
segmental surgery to diverge the roots of teeth adjacent to the osteotomy cuts. Periapical
radiographs are taken to determine if root positioning of teeth adjacent to projected interdental
osteotomy sites is correct. It is important that leveling procedures, interarch elastics and the majority
of space closure in extraction cases be completed prior to surgery to prevent increase in facial height
following surgery. With this approach the open bite may worsen prior to surgery. However, this
sequence of treatment assures a more stable vertical correction.
During the presurgical orthodontic phase, study models are taken periodically and model surgery
is performed to determine the correct timing for surgery.
Postsurgical: The objectives of postsurgical orthodontics are good functional and anatomical
occlusion with stable results. This phase involves completion of space closure in areas of interdental
osteotomies as well as leveling, finishing and detailing the occlusion. The corrected anterior bite
depth relationship is maintained or increased to promote a good functional occlusion . In cases with
marked surgical widening of the maxillary arch, the transverse or crossbite correction is maintained
with orthodontic appliances to aid bone remodeling and enhance stability. The posterior occlusion is
completed by eliminating cuspal interferences and establishing a good functional occlusion in all
excursive movements of the mandible.
Surgical Considerations
A variety of surgical techniques have been utilized for the correction of vertical facial
abnormalities. The most conservative and reliable surgical approach that achieves the desired result
should be chosen. In general, the vertical and transverse disproportions are best corrected through
maxillary surgery and associated anteroposterior disproportions with mandibular surgery. The
following surgical modalities are utilized.
Maxillary Surgery: The maxilla can be repositioned superiorly in one or several dentoalveolar
segments. During the surgical planning, attention is directed first to the anterior maxilla and the
relationship of the maxillary incisors to the upper lip. Excessive exposure of the maxillary incisors
will be decreased by superior repositioning of the anterior maxilla. In certain cases of VFE,
especially those with open bite, the relationship of the incisors to the upper lip is normal or even
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 May(343 - 353): Surgical-Orthodontic Correction of Vertical Facial Excess
decreased. In these cases, it is desirable to inferiorly reposition or not alter the anterior maxillary
segment. With intrusion of the posterior maxillary segments or the entire maxilla, the mandible
moves superiorly and anteriorly to occlude with the maxilla in its new position. This is referred to as
"autorotation" of the mandible. It produces a shortening of the lower third of the face (Fig. 1A). The
anterior and posterior maxilla can be moved differentially as indicated to achieve an improved upper
tooth to lip relationship, a normal bite depth relationship, and a good functional relationship of the
anterior and posterior teeth.
Mandibular Surgery: Anteroposterior disproportions not optimally corrected by maxillary surgery
are corrected by dentoalveolar, body or ramus osteotomies of the mandible. Cases having a Class II
malocclusion are often corrected to a Class I occlusion by autorotation of the mandible. Mandibular
autorotation will worsen a Class III malocclusion and create an anteroposterior disproportion in
cases having a Class I occlusion. The type of mandibular osteotomy chosen to correct these
discrepancies depends on the occlusal and esthetic considerations of the individual case. The
mandibular anterior dentoalveolar osteotomy is often beneficial in patients with VFE. It helps to
achieve a Class I cuspid relationship, an improved dentoskeletal relationship of the anterior
mandible, and a level mandibular arch. In patients who require additional reduction of vertical facial
height due to increased growth of the anterior mandible, a reduction genioplasty (chin procedure,
see Fig. 1A) is performed by a wedge resection of bone in this area.
It is significant to note that these maxillary, mandibular and chin procedures can be performed
intraorally and thus obviate facial incisions and facial scars.
Secondary Surgical Considerations: When the middle and lower facial structures are placed in
harmony, the appearance of the nose is altered. Superior movement of the maxilla causes widening
of the alar bases and upward movement of the nasal tip. Therefore, nasal surgery is best undertaken
after correction of the dentofacial deformity.
Functional Considerations
Speech and swallowing have been studied with pre- and post-operative multiview
videofluoroscopy. The results of these studies show essentially no change in function despite
alteration in facial arid oral morphology. Interdental articulation and forward tongue posture have
consistently persisted following correction of dentofacial deformities. 9 Therefore, we recommend in
cases of significant speech disorders that speech therapy be deferred until after surgical correction of
the deformity. Speech therapy in the presence of a structurally abnormal oral environment is
unnecessary if surgical alteration of the oral morphology is imminent. Therapy to change tongue
posture is deferred as well until completion of the surgical treatment.
The following two cases were selected to demonstrate evaluation and treatment of patients with
vertical facial excess.
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 May(343 - 353): Surgical-Orthodontic Correction of Vertical Facial Excess
Case 1
S.S., a 24-year-old male presented for correction of his open bite and speech articulation disorder.
When the patient was 13 years old, he had orthodontic treatment with extraction of upper first
bicuspids. One year prior to consultation with us he had a rhinoplasty.
Esthetic evaluation: In frontal view the patient exhibited a long, narrow, tapering face. This was
due to excessive vertical height of the lower facial third. The vertical relationship of the upper tooth
to upper lip was mildly increased, and an excessive interlabial distance was present. There was a
disproportion between the upper and lower lip length. The lower lip length was increased. He had a
narrowing of the middle and lower facial thirds. The upper lip showed a midline notch deformity
(Fig. 3).
Oral evaluation: Temporomandibular joint examination and mandibular function were normal.
Interarch analysis revealed severe constriction of the entire maxilla with bilateral crossbite,
severe anterior and posterior openbite and a Class II malocclusion with severe overjet. Tooth size
analysis indicated excessive tooth mass of the maxillary anterior teeth (Fig. 4).
Intra-arch examination revealed a high-arched palate. Crowding and malalignment problems
were noted in the upper and lower arches. Poorly contoured restorations were present (Fig. 4).
Cephalometric evaluation: Increased vertical height in the lower facial third was due to excessive
vertical growth of the maxillary dentoalveolus and chin area. Retroinclination of the mandibular
incisors was noted (Fig. 5)
Functional evaluation: The patient was a mouth breather with perioral muscle strain. The patient
also had a speech articulation disorder with interdental lisp. The tongue was low in posture.
Problem List
Esthetic: Long lower third of face, mild increase in exposure of upper incisors, lip incompetence,
increased lower lip height, narrowed mid and lower facial third, recessive chin.
Oral: Open bite, maxillary constriction, Class II malocclusion, retroinclination of the mandibular
incisors, crowding in the maxilla and mandible, poorly contoured restorations.
Functional: Mouthbreather, perioral muscle strain, interdental lisp.
Treatment Plan
Presurgical orthodontics: All the upper and lower teeth were bonded. Alignment and leveling of
mandibular teeth was completed with labial inclination of the incisors. The maxillary anterior
segment (cuspid to cuspid) and both posterior segments (second bicuspid to second molar) were
Article Text
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 May(343 - 353): Surgical-Orthodontic Correction of Vertical Facial Excess
segmentally aligned. The maxillary cuspid and second bicuspid roots were diverged to allow for
interdental osteotomies (Fig. 2).
Surgery: The maxilla was superiorly repositioned in four segments (Fig. 1B) . The anterior
maxilla was intruded and widened by sectioning between the central incisors. The posterior
dentoalveolar segments were intruded and moved laterally to widen the arch. This allowed the
mandibular autorotation to close the open bite and correct the Class II occlusion. A wedge resection
of bone from the chin allowed additional reduction in the vertical facial height. These procedures
also caused a widening of the middle and lower facial thirds. A V-Y advancement in the upper lip
corrected the midline notch deformity. All procedures were performed intraorally in one operation
(Fig. 3).
Postsurgical orthodontics: Orthodontic appliances have been removed in the lower arch and a
retention appliance has been placed. Orthodontic appliances are still present in the upper arch to
maintain the surgically widened maxilla and to aid bone remodeling. Uprighting of teeth, closure of
interdental osteotomy sites and detailing of the occlusion is being completed. Gnathological tooth
positioner is planned for retention.
General Dentistry: After orthodontic retention, recontouring and replacement of defective
restorations is planned.
Functional Therapy: Speech therapy initiated during the postsurgical orthodontic phase of
treatment was successful in correcting the interdental lisp. Surgical treatment eliminated the perioral
muscle strain by shortening the lower facial height and decreasing the interlabial distance.
Case 2
E.V., a 14-year-old female presented for correction of a severe malocclusion.
Esthetic evaluation: In frontal view the patient had a long narrow tapering face. This was due to
excessive vertical height in the lower facial third. She had excessive exposure of the maxillary
incisors with severe lip incompetence. The nasal tip was bulbous and the alar base was mildly
widened. The upper and lower lips were full. (Fig. 6).
The profile evaluation indicated mild flatness in the malar region. The nasolabial angle was acute
and the nasal tip had a drooping appearance. The upper and lower lips were everted. The chin was
retrodisplaced and poorly contoured.
Oral evaluation: Temporomandibular joint examination and mandibular function were normal.
Interarch analysis revealed a deep overbite, bilateral maxillary constriction and a Class II
malocclusion with severe overjet.
Intra-arch analysis revealed a high arched palate and a canted maxillary occlusal plane. There was
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 May(343 - 353): Surgical-Orthodontic Correction of Vertical Facial Excess
mandibular anterior crowding and an excessive curve of Spee. All the deciduous second molars
were over-retained and all the second bicuspids and third molars were congenitally absent ( Fig. 7).
Cephalometric evaluation: Lateral cephalometric analysis revealed an anteroposterior and
vertical maxillary excess. The mandible was retrodisplaced. The maxillary and mandibular incisors
were procumbent. The mandibular incisors were supraerupted and in a poor anteroposterior
relationship with the chin (Fig. 8A).
Functional evaluation: No airway or speech abnormalities were noted. The patient exhibited
perioral muscle strain due to a large interlabial gap.
Problem List
Esthetic: Long lower third of the face, excessive exposure of the upper incisors, increased
interlabial gap, bimaxillary protrusion, retrodisplaced mandible and contour deficient chin.
Oral: Deep overbite, Class II malocclusion, bilateral maxillary constriction, excessive curve of
Spee, and overretained deciduous 2nd molars.
Functional: Perioral muscle strain.
Treatment Plan
Presurgical orthodontics: After extraction of overretained mandibular deciduous second molars,
the upper and lower teeth were banded and bonded. Orthodontic mechanics in the lower arch
included segmental leveling and distalization of the mandibular cuspids and first bicuspids for
alignment of the lower anterior teeth. No attempt was made to intrude these teeth. In the upper arch
the anterior segment (bicuspid to bicuspid) and posterior segments (first and second molars) were
segmentally aligned. The arch width was slightly increased in the cuspid and bicuspid region. No
attempt was made to intrude the anterior teeth. Space in the extraction sites was preserved to allow
for interdental osteotomies.
Surgery: The maxilla was superiorly repositioned in three segments. The anterior maxillary
segment was intruded and moved posteriorly to correct the abnormal relationship of the upper teeth
to the upper lip. The posterior segments were intruded and moved laterally to correct the arch width
discrepancy. Mandibular autorotation corrected the Class II malocclusion, shortened the lower facial
third and improved chin position. A mandibular anterior dentoalveolar osteotomy was performed in
the second bicuspid area to intrude the extruded anterior teeth, to level the mandibular arch, and to
establish a normal overbite-overjet relationship. The chin was still deficient after autorotation of the
mandible and was augmented with Proplast. This improved the anteroposterior position and contour
of the chin (Figures 6 and 8B). All surgical procedures were performed intraorally in one operation.
Postsurgical orthodontics: Orthodontic finishing procedures included leveling of the mandibular
arch, space closure, and detailing the occlusion. Retention appliances were placed after completion
Article Text
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 May(343 - 353): Surgical-Orthodontic Correction of Vertical Facial Excess
of the orthodontic treatment. The stable result two years after completion of treatment is illustrated
(Fig. 7).
Patients with vertical facial excess often present with specific esthetic, occlusal and functional
abnormalities. Surgical procedures to superiorly reposition the maxilla have provided a stable means
of correcting this deformity. Combined orthodontic and surgical management has accomplished
efficient treatment and predictable results.
From the Department of Dentistry and Oral Surgery and
Center for Craniofacial Disorders, Montefiore Hospital and
Medical Center and Albert Einstein College of Medicine,
Bronx, New York.
From the Department of Dentistry and Oral Surgery and
Center for Craniofacial Disorders, Montefiore Hospital and
Medical Center and Albert Einstein College of Medicine,
Bronx, New York.
From the Department of Dentistry and Oral Surgery and
Center for Craniofacial Disorders, Montefiore Hospital and
Medical Center and Albert Einstein College of Medicine,
Bronx, New York.
From the Department of Dentistry and Oral Surgery and
Center for Craniofacial Disorders, Montefiore Hospital and
Medical Center and Albert Einstein College of Medicine,
Bronx, New York.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume May
From the Department of Dentistry and Oral Surgery and
Center for Craniofacial Disorders, Montefiore Hospital and
Medical Center and Albert Einstein College of Medicine,
Bronx, New York.
Wright/Dow Corning, Medical Products, Dept. A8547, Dow
Corning Corporation, Midland, Michigan 48640.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume May
Fig. 1
Fig. 1 Case 1. A. Cephalometric prediction tracing, pretreatment (unshaded teeth) and posttreatment (shaded teeth).
Note "autorotation" of the mandible and reduction of lower face height. B. Model surgery.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 May(343 - 353): Surgical-Orthodontic Correction of Vertical Facial Excess
Fig. 2
Fig. 2 Case 1. Presurgical orthodontics. Segmental treatment.
Fig. 3
Fig. 3 Case 1. Before (above) and after treatment.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 May(343 - 353): Surgical-Orthodontic Correction of Vertical Facial Excess
Fig. 4
Fig. 4 Case 1. Before (above) and after treatment.
Fig. 5
Fig. 5 Case 1. Pretreatment lateral cephalometric analysis. Note dental-skeletal-facial relationships. A. Middle facial
height. B. Lower facial height C. Upper tooth to lip relationship.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 May(343 - 353): Surgical-Orthodontic Correction of Vertical Facial Excess
Fig. 6
Fig. 6 Case 2. Before (above) and after treatment.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 May(343 - 353): Surgical-Orthodontic Correction of Vertical Facial Excess
Fig. 7
Fig. 7 Case 2. Before (above) and after treatment.
Fig. 8
Fig. 8 Case 2. Lateral cephalometric analysis. A. Pretreatment. B. Two years posttreatment. Dotted area represents
proplast chin augmentation.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 May(343 - 353): Surgical-Orthodontic Correction of Vertical Facial Excess
1. Anderson, B.O.: Multiple extraction patterns in severe discrepancy cases, Angle Orthodont 45: 291-303, 1975.
2. West, R.A., and Epker, B.N.: Posterior maxillary surgery: Its place in the treatment of dentofacial deformities, J. Oral
Surg. 30:562-71, 1972.
3. Wolford, L.M., and Epker, B.N.: The combined anterior and posterior maxillary osteotomy: A new technique. J. Oral
Surg. 33:842-51, 1975.
4. Bell, W.H.: Le Fort I osteotomy for correction of maxillary deformities, J. Oral Surg. 33:412-26, 1975.
5. Schendel, S.A., Eisenfeld, J.H., Bell, W. H., and Epker, B. N.: Superior repositioning of the maxilla: Stability and soft
tissue osseous relations, Am. J. Orthod. 70:663-74, 1976.
6. Fish, L.C., Wolford, L.M. and Epker, B.N.: Surgical-orthodontic correction of vertical maxillary excess, Am. J.
Orthod. 73:241-57, 1978.
7. Epker, B.N., and Fish, L.C.: Surgical-orthodontic correction of open-bite deformity, Am. J. Orthod. 71:278-99, 1977.
8. Schendel, S.A., Eisenfeld, J.H., Bell, W. H., Epker, B.N., and Mishelerich, D.: The long face syndrome — Vertical
maxillary excess, Am. J. Orthod. 70:398-408, 1976.
9. Goldsmith, D.H., Berkman, M.D., Shprintzen, F. J., Rothschild, D. and Trieger, N.: Functional adaptation of the
speech and swallowing mechanism following correction of dentofacial deformities. Abstract 145, Third International
Cleft Palate Congress, Toronto, Canada June 1977.
10. Berkman, M.D., Goldsmith, D., Rothschild, D., Trieger, N., Shprintzen, R.J.: Evaluation — Diagnosis — Planning,
The challenge in the correction of denotfacial deformities, Alpha Omega Journal V. 11 December 1978.
JUNE 1980, VOL. 14 / ISSUE 6
JCO Interviews Dr. Homer W. Phillips on Bonding Part 1
Common Sense Mechanics Part 10
Influencing Patient Cooperation
Orthodontic Scheduling and the Two-Income Family
Technique Clinic - Removing Bonded Begg Brackets
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jun(369 -): 370 THE EDITOR'S CORNER
There is a thesis that, for a variety of reasons — including the personality of people who make
good students, the selection of good students by professional schools, and the nature of the
professional training — professional people do not make good managers. Yet, management is not
an exact science nor an intuitive discipline. It can be learned. In that sense, for people as educable as
professionals, management is a subject which has been omitted from their education.
Orthodontic management can be divided into treatment management, office or business
management, and people management. Treatment management involves planning, organizing,
coordinating, directing, controlling and supervising treatment. Treatment results can be measured
following treatment, with a complete post-treatment analysis and with a system of grading results
(see Gottlieb, Grading Your Orthodontic Treatment Results, JCO March 1975). Treatment results
can also be monitored during treatment, manually or by computer, through a control system of
preprogrammed milestones in treatment. This is management by objectives (see Drucker, The
Practice of Management).
Office or business management is not basically different for an orthodontic practice than it is for
other enterprises. There are a few specialized records which are possibly unique to orthodontic
practice (see Gottlieb, Blueprint for Economic Survival in Orthodontics, JCO May 1976). Basically,
business management is concerned with productivity and profit and can be measured in those terms.
For an orthodontic practice, this can be measured in terms of referrals, case starts, net profit, and
purchasing power. Thus, it also lends itself to management by objectives.
When two significant functions are added, office or business management becomes less clear and
simple for most orthodontists. These are promotion and marketing; Orthodontists who can accept
"practice building" are uncomfortable with "practice promotion" and "marketing". Yet, the common
denominator of these is the solicitation of patient referrals. The words "promotion", "marketing",
and "solicitation" have acquired strong negative connotations in our society through abuse of their
basic intent. "Promotion" is only the advancement or furtherance of an enterprise. "Marketing" is the
performance of business activities that direct the flow of goods and services from producer to
consumer or user" (American Marketing Association). "Solicitation" is merely requesting or urging.
It is inaccurate to limit their definition to advertising, hard selling, or devious practices.
What has passed for practice building in the average orthodontic practice has not been successful.
The number of case starts in the average orthodontic practice has been declining for several years.
Orthodontists have not approached this crucial function in a purposeful, organized, managerial
manner. That must change, and practice building must also be managed by objectives and measured
by results. Management of referrers is measurable in terms of number of referrals. Patient
cooperation is measurable in terms of performance and "on time" finishing. It is possible to evaluate
the performance of oneself and one's staff on a productivity basis. But, practice building may be
more difficult to quantify than the other areas of practice to the extent that it may be even more
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jun(369 -): 370 THE EDITOR'S CORNER
concerned with people management.
There is more intuition involved in people management. There may be less difficulty for
orthodontists in inspiring others with a sense of professionalism, pride of excellence in
workmanship, and integrity, than with the interpersonal relationships involved in people getting
along with people, liking people, and helping people. The close personal contact and
interdependence of doctor and staff, and doctor and staff and patients, places more emphasis on
these intangible human qualities in a professional practice than in a business, and this is one of the
distinguishing features of the professional practice.
The basis for staff management is in selecting the right people, offering them excellent training
and support, giving them responsibility and authority equal to their capabilities, and providing
recognition and reward. The orthodontist who believes that no one can perform the technical tasks
as well as he can, will be amazed at how well and how quickly staff can do as well. What may have
become drudgery for him, becomes excitement and challenge for them. What is below his
capabilities, extends theirs. The orthodontist who is able to cut the cord— to the extent that he is
able to delegate technical tasks— may well find a rewarding practice fulfillment in management.
Someone said that you can't afford happiness any longer; it has gotten too expensive. Well, for
orthodontists, happiness will be the well-managed practice. Poor management or non-management
is becoming too expensive.
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jun(391 - 411): JCO Interviews Dr. Homer W. Phillips on Bonding Part 1
DR. HOMER W. PHILLIPS On Bonding (Part 1)
DR. GOTTLIEB Do you think that bonding has arrived as a substitute for orthodontic banding?
DR. PHILLIPS I definitely do. Many simple everyday things that we take for granted have evolved
because someone came up with a better idea. The same is true in the transition from bands and
brackets to bonded brackets. The bracket is the important part. The band is just something that is in
the way, in my opinion, and bonding is just the most recent improvement in the attachment of
DR. GOTTLIEB Do you think that it's important for orthodontists to know the differences among
the adhesives as far as their chemistry is concerned and how they are supposed to work?
DR. PHILLIPS I don't think they have to be able to write the formulas, but they definitely need to
know the chemical and physical properties associated with these products. They need to know the
difference between a thermoset and a thermoplastic adhesive; that GMA's are more rigid than
acrylics, have less water absorption, and are more subject to impact fracture. That sort of thing is
Important. You have to know the physical properties of the materials you are working with, or you
can't work with them intelligently.
DR. GOTTLIEB Do the physical properties vary enough so that they are going to be important for
an orthodontist in making his selection?
DR. PHILLIPS It isn't quite as important to know their properties as it was a few years ago when
the acrylic systems were a big part of the market. The majority of adhesives in use in the U.S. today
are the two-part Bis-GMA adhesives that are self-polymerizing when mixed, some of them with a
two-part unfilled resin sealant and some without. The ultraviolet systems are good systems, but are
not in wide use today. Clinicians seem to feel they don't need the extra timing that the ultraviolet
systems provide and, if they are using metal brackets, the UV light doesn't cure the adhesive under
the bracket pad. You really have to use transparent or translucent brackets for that.
DR. GOTTLIEB Are all Bis-GMA adhesives pretty much the same?
DR. PHILLIPS You can get a very acceptable adhesive from virtually any manufacturer. They do
vary in percentage of filler, and in composition and size of filler particles. These differences, plus
chemical modifiers, make for variable abrasion resistance, viscosity, and hardness.
DR. GOTTLIEB Is it the way that the operator handles the material that makes the difference in
DR. PHILLIPS Technique is all-important. Adhesives and bracket bases have improved so much in
recent years, that the weak link, without a doubt, is operator technique. These excellent materials
must be handled with greater care and greater precision in following directions than was necessary
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jun(391 - 411): JCO Interviews Dr. Homer W. Phillips on Bonding Part 1
in banding techniques. You just don't have the leeway, if you are going to achieve optimum bond
DR. GOTTLIEB What is the significance of the bond strengths of the various adhesives? Is the
least strong adhesive strong enough, under certain circumstances, to fill the bill and hold a bracket
on a tooth satisfactorily?
DR. PHILLIPS I would say that the bond strengths of present day Bis-GMA adhesives used with
proper technique far exceed the clinical requirements for keeping a bracket on a tooth for a typical
two-year treatment period. I think there is no question about that. What the minimum suitable bond
strength is, I think is an unanswered question.
DR.GOTTLIEB And requirements vary for different bonding sites.
DR. PHILLIPS There is no question that anterior teeth require less bonding strength than posterior
teeth and the chances are that the present materials are up to 50% stronger than they need to be. That
extra strength is worthwhile, however, because not every operator puts every bracket on in the most
optimal fashion. The extra strength allows for some sloppiness in technique. With proper technique,
there is no question that the maximum bond strength attainable with present materials is far stronger
than we need. But, bond strength alone is not the only factor in terms of clinical effectiveness. For
instance, any acrylic system absorbs water to a far greater degree than the denser Bis-GMA
molecule, and this will weaken an acrylic bond over a period of time in the oral environment. I don't
consider acrylic systems to be the state of the art at this time.
Guide lines drawn on model.
DR. GOTTLIEB How much guidance can be had from laboratory tests comparing various
DR. PHILLIPS There seems to be variation between conditions in the laboratory and in the mouth.
We don't really know if there is any one test that will show the superiority of one adhesive over
another. We don't really know whether it's water absorption or shear strength or peel strength that is
most important. You can compare different adhesives for different physical properties in the lab, but
I don't think you can correlate laboratory findings directly with what happens in the mouth, and
bond strength alone may not be the best guide anyway. Such properties as shelf life and ease of
manipulation have a bearing on clinical usefulness.
DR. GOTTLIEB Homer, you are a leading exponent of indirect bonding. I think our readers would
appreciate hearing from you the details of your indirect technique. Let's do the laboratory phase first.
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jun(391 - 411): JCO Interviews Dr. Homer W. Phillips on Bonding Part 1
DR. PHILLIPS First you need a recent model of the mouth. How recent depends on the age of the
patient and the condition of the mouth. For a young patient with erupting teeth, I would not want to
use a model that was over two weeks old. A model taken following extractions, which is a sequence
I don't prefer, I would want to use within one or two weeks at most. With a full, stable, adult arch, I
don't hesitate to use a model that's a month old. The first step on the model in the laboratory is to
draw the long axis of the clinical crown and extend that line onto the gingiva, well below the
gingival margin of the tooth. This gives us a bigger target to shoot at with the bracket. If you have a
tooth with a short clinical crown and draw a reference line only on the crown of the tooth, you lose
sight of the line as you approach the tooth with the bracket in a holding instrument. If you have
extended the line well onto the gingiva, then you can see it, and it gives you a landmark to parallel
DR. GOTTLIEB It is not always so easy to draw that line. Have you any suggestions about that?
DR. PHILLIPS It is true that we are dealing with a biologic system and that teeth are not regular
geometric objects. They are irregular and they are in various positions. So, it's not always easy to
decide where the long axis is. To aid in that, at least in the early stages of training our technicians,
we have them draw not only the long axis on the labial surface, but also draw the midline of the
occlusal surface and extend that line down the lingual. Once that is done, they may want to change
the labial long axis line. That's one reason I believe that the indirect method makes for more
precision; because, if it's hard to do in the lab, it's definitely harder to do in the mouth, where you
have much poorer access and can't draw lines the way you can on a model. After we have marked
the long axis on the teeth, we paint the models with a tin-foil substitute to facilitate bracket removal
later. Following that, we are ready to place the brackets on the model, with Concise.
Dispensing the composite from a syringe.
DR. GOTTLIEB How many brackets will you cement on the model at a time?
DR. PHILLIPS Only one bracket per mix. This material is so easy to mix, that it probably takes no
more than four seconds to mix it. So, we don't consider it to be a time penalty to mix separate
portions for each tooth.
DR. GOTTLIEB How do you dispense the ingredients?
DR. PHILLIPS We dispense the composite from syringes both in the clinic and in the lab. This
allows for a great saving in material and it is simply easier to dispense the amount you want where
you want it. It wouldn't think of going back to my original containers of A and B paste every time I
wanted to put a bracket on. In the same way, the chemist avoids contamination of his supply, by not
working out of his master reagent bottle.
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jun(391 - 411): JCO Interviews Dr. Homer W. Phillips on Bonding Part 1
DR. GOTTLIEB What's the life of the material in the syringes?
DR. PHILLIPS It's difficult to say, because, in normal use, it exceeds the amount we can put in a
syringe. Most of these materials at room temperature are probably good for at least a year.
Selecting the bracket.
DR. GOTTLIEB Do you refrigerate the material anyway?
DR. PHILLIPS Just a matter of good technique, we generally refrigerate the syringes overnight and
on weekends. One of the first things we do in the morning, like turning on the lights, is to take the
bonding materials out of the refrigerator. They stay out all day and are put back in at the end of day.
DR. GOTTLIEB So, the materials are dispensed out of the syringes until they are used up, and
until then you have no qualms about using them?
DR. PHILLIPS None whatsoever. It is just as if we were working out of the jars. Of course, the
materials are not mixed in the syringes. We have separate syringes. We usually keep 4 or 5 of each
component available at all times, wherever we want to use them.
DR. GOTTLIEB Do you use a bracket placing instrument?
DR. PHILLIPS The basic consideration is to be able to pick up a bracket, to be able to see most of
the bracket while it is held in the instrument, and to be able to let go of it without disturbing its
position on the tooth. I have yet to find an instrument that works better than a cotton plier for this
purpose. I do feel that improvements are possible, but it still needs to be basically that instrument.
We have developed an instrument that aids in placement mesiodistally and angularly for tip. You
have to decide where you want to place the bracket vertically. It becomes a matter of personal
preference whether you measure from cusp tip on posterior teeth and incisal edge on anterior teeth.
Mixing the composite.
DR. GOTTLIEB Do you follow a sequence in bracket placement?
DR. PHILLIPS If you are attempting to get as uniform a placement as possible, I feel you need to
start on a maxillary lateral incisor, proceed to central incisors and cuspids, and then bicuspids, going
by the tip of the cusp or by the marginal ridges. There are no absolutes, because you have worn
cusps and malposed and partially erupted teeth. I really think it gets down to clinical judgment on a
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jun(391 - 411): JCO Interviews Dr. Homer W. Phillips on Bonding Part 1
tooth-by-tooth basis. I don't see any totally mechanical way that you can place brackets a certain
number of millimeters from any landmark and always have them in a good spot.
Applying the composite to the bracket.
Positioning bracket on model.
DR. GOTTLIEB We probably should be lining up marginal ridges and adjusting cusps, rather than
measuring from cusp tips.
DR. PHILLIPS I would agree with that. It was somewhat easier to do with banding. More clinical
judgment is involved in the placement of the bracket alone to line up the marginal ridges. There is
no pat formula to get there. This is where being a knowledgeable clinician or technician enters into
appliance fabrication.
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jun(391 - 411): JCO Interviews Dr. Homer W. Phillips on Bonding Part 1
DR. GOTTLIEB You feel there is a greater potential for error in bracket placement with bonding
than with banding?
DR. PHILLIPS Although we have a greater potential for error in bracket placement with bonding,
we also have greater potential for putting it in an ideal position. If you are dealing with a bracket
prewelded to a band you are really pretty limited as to where you can put the bracket, so I think the
overall benefit is in favor of bonded attachments, where we have a greater capacity for proper
bracket placement.
After placement of the brackets on the model in the laboratory with Concise, our next step is to
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jun(391 - 411): JCO Interviews Dr. Homer W. Phillips on Bonding Part 1
construct a template to transfer the brackets from the model to the mouth.
DR. GOTTLIEB What material do you use for your template?
DR. PHILLIPS I want a very accurate impression material that is flexible and stable. The best
material I have found for this purpose is a silicone rubber. The particular one I use is Sir tray-type. It
is a paste/liquid system. We add more accelerator or catalyst than is called for, because we want it to
set faster. We don't want to spend several minutes in the lab waiting for the material to set. The
material is spatulated until it has a uniform color, and then it is placed on the model from the lingual
to avoid the possibility of knocking the brackets off with the spatula. Incidentally, if you are inclined
to prefabricate initial archwires, there is no better time than when the brackets are on the model and
before the tray is made.
Smoothing surface of the impression material.
DR. GOTTLIEB Do you engage the wire in the brackets?
DR. PHILLIPS You can't actually engage the wires in the brackets, because you may knock them
off the model, but you certainly can hold them right next to the brackets. If we are making a
multiloop archwire or a utility archwire, we will often make it in the laboratory before making the
tray, and have it ready at the initial bonding appointment.
DR. GOTTLIEB Do you have any tricks in handling or shaping the tray material?
DR. PHILLIPS In mixing the tray material, we use a dishwashing detergent to lubricate our fingers
so that we can shape the material without having it stick to our fingers. The rubber is very easy to
form and you can take your time. You can make the material set in seconds or minutes, depending
on how much accelerator you add and on the proficiency of the operator. It need not take more than
a minute.
DR. GOTTLIEB After the tray material has set, how do you remove it from the model?
DR. PHILLIPS The tray and brackets together can be removed from the model in two ways. You
can simply soak the entire model in water for about ten minutes and the tray will virtually float off;
or you can reach under the edge of the silicone rubber with a#7 spatula and pry each bracket off the
model. After you have removed the tray from the model, it is trimmed with scissors to the desired
shape. The final step is to lightly scour the surface of each bracket pad with a bur in a low speed
handpiece, to make sure that there are no contaminants of plaster or separating medium on the
bracket base. It has been shown by SEM photographs that if that surface is clean, you can't find the
interface between the composite set in the lab and the composite you add at the chair. If you have a
layer of plaster there, you are going to have a weak point.
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DR. GOTTLIEB Do you leave the brackets in the tray to clean the pads like that?
DR. PHILLIPS We leave them in. You can take them out to do it, but we don't feel we need to.
DR. GOTTLIEB Do you bond the full arch tray?
DR. PHILLIPS We do not ordinarily bond a full arch, but at this point the tray is left in one piece.
At chairside, I will section it with scissors into quadrants or other segments depending on the
occlusion and the patient.
DR. GOTTLIEB You make sectional templates as well as full arch ones?
DR. PHILLIPS At any one time in our laboratory there will be from a dozen to fifty sectional
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impressions with anywhere from one to three brackets each. Whenever we see a tooth that has
erupted sufficiently to warrant putting a bracket on it, we take a sectional impression and put the
bracket on at the next appointment, unless there is some overriding reason to do it immediately,
which is rare. This is easy appliance fabrication, in my view.
DR. GOTTLIEB The biggest bonding problem for many orthodontists is trying to work single
replacements into their schedule. Your procedure of taking a sectional impression and replacing the
bracket at the next visit doesn't upset your schedule at all.
DR. PHILLIPS Not at all. We do single replacements as easily as we do an archwire change. We
make no special time available to bond with one of these sectional trays. If we are adding a second
molar tube which necessitates an archwire change, we are much more concerned with time for the
new archwire than we are with time for bonding the attachment.
DR. GOTTLIEB We have covered the laboratory phase of your technique. Let's get into the
clinical phase.
DR. PHILLIPS We start with cleaning the tooth surface very carefully with a rotary prophylactic
instrument, using either a brush or a rubber cup with pumice. A prophy angle in a low speed
handpiece works very well, but in my practice we usually use a cordless prophy instrument that I
call a "Bond-Buddy". It is durable and has a lot of torque.
"Bond-Buddy" prophy instrument.
DR. GOTTLIEB Do you have a preference for brush or cup?
DR. PHILLIPS Not really. I know that Dr. Miura showed most excellent enlarged SEM
photographs to demonstrate that the brush did a better job. However, many practitioners who are
very successful with clinical bonding are using a rubber cup. In an initial bonding with healthy, tight
gingiva, a brush is probably the better way to go, based on Dr. Miura's work. If, on the other hand, it
is a rebonding or bonding in a mouth with hypertrophic gingiva and a lot of tissue fluid present, I
think you are more apt to cause bleeding with a brush than with a cup. In those cases, I would vote
for the cup. In any event, using pumice is very important. I have not found it necessary to use a dry
flour of pumice mixed only with water. We use a commercially available prophy paste, Zircate, and
have found it to be very effective.
DR. GOTTLIEB Removing the pellicle is an important consideration for bonding to teeth that have
already erupted.
DR. PHILLIPS Yes, for bonding directly or indirectly, thorough cleaning with a prophylaxis
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instrument and pumice,
prior to etching, is a most important step to remove not only the plaque and other surface debris, but
also the pellicle. The pellicle is anywhere from one to a few microns thick. You can't see it, but you
have to believe it's there, and that you must scrub it off in order to achieve maximum bond strength.
If you don't see a good etched surface, chances are that the problem started with not having the tooth
clean before you put the acid on it.
DR. GOTTLIEB At what point do you isolate the teeth?
DR. PHILLIPS Following the cleaning of the surface. It is really very simple, since we are working
only in quadrants.
DR. GOTTLIEB What is your procedure for isolating the teeth and keeping the field dry?
DR. PHILLIPS We don't use mouth props. We don't use chemical agents such as banthine or
probanthine. We simply use cotton rolls, high speed vacuum, and air. Following pumicing and
rinsing, we place a long cotton roll. For example, in the upper arch it extends from the molar area to
past the midline. We dry the teeth in that quadrant and place the etchant gel on the teeth from a
syringe, and we time it very precisely with a stopwatch. In the lower arch, we do the same thing,
with the addition of a lingual cotton roll along with the one on the buccal.
DR. GOTTLIEB There seems to be disagreement and confusion about etching concentrations.
DR. PHILLIPS Well, that's true. You do hear different opinions about etching concentrations, but
it has been shown that anything between 30% and 60% concentration of phosphoric acid will
provide a good etch within one minute. Less than 30% gives a less effective etched structure, and
80%-90% doesn't give a better etch pattern. You may, in fact, lose more enamel. Most commercial
etchants are in the neighborhood of 37% for liquids and 50% for gels, although there are gels that
are 35%.
DR. GOTTLIEB There seems to be an effective range. Does the quality of the etch vary within that
DR. PHILLIPS Yes, because the enamel varies within the same tooth. It is not uniformly blessed
with an equal number of enamel rods, equally parallel throughout. The etched surface can vary by
preferential etching of either the core or the periphery of the enamel rods. This is called differential
etching. In addition, one part of the tooth may be cleaned better before the etch; the surface might
not be uniformly dried; the acid concentration might not be kept uniform on the tooth surface; and
the acid may be diluted with saliva, resulting in a weaker solution. These technique variables, plus
the basic variability of the biological system you are dealing with, lead to variations in etching
DR. GOTTLIEB What is the significance of the amount of time that the etchant is permitted to
remain on the tooth?
DR. PHILLIPS The amount of time that the etchant remains on the tooth is a very important factor
in the creation of a porous enamel surface with optimum retentive qualities for bonding. Too short a
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time will not allow the differential etching to sufficiently increase the surface area. Too long a time
causes a greater loss of enamel structure and the honeycombed surface is not as deep or
well-defined as is desired for retention of the adhesive. What is needed is a time frame that is
clinically useful about 95% of the time.
One study recommends only a thirty-second etch time and one manufacturer recommends one
hundred and twenty seconds of etching. My experience is that thirty seconds is too brief for
routinely good etching. Usually, a sixty-second etch for adult teeth and ninety seconds for deciduous
teeth provides a clinically useful bonding surface. Teeth with a high fluoride content may require
ninety to one hundred and twenty seconds for etching, due to the increased resistance of the enamel
surface to acid dissolution.
DR. GOTTLIEB Can there be significant loss of enamel from the etching?
DR. PHILLIPS Silverstone has shown that, on the average, you'll lose about ten microns of the
enamel surface with a one-minute etch. The etching penetrates another 20-40 microns into the
enamel, although most published photographs show tags in the range of 15 microns. This is simply
because they are so fragile and are destroyed in making the specimens that are photographed. But,
even prophylaxis results in a loss of enamel surface. I suspect that drinking carbonated beverages
does the same thing. The dental profession has been quite comfortable for a hundred years, doing
procedures that take away much more enamel than we are talking about with etching. Enamel rods
average at least 2000 microns in depth and we are talking about removing 10 or 20. It is really not a
DR. GOTTLIEB The fragile etched surface is one potential source of technique breakdown.
DR. PHILLIPS The operator has to appreciate how fragile that etched surface is, and must be
careful not to break it down. Repeated application of liquid acid with a brush, for instance, stands a
good chance of breaking down some of that honeycomb structure you have built. I feel that a very
much better way to do this is to make a single application of the acid and not touch the tooth again,
except with wash water.
Applying etching gel with syringe.
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Stopwatch timer.
DR. GOTTLIEB And you prefer a gel for that.
DR. GOTTLIEB You do not agitate the gel?
DR. PHILLIPS Not at all. We dry the teeth thoroughly before placing the gel, to avoid diluting the
acid. Then we apply the gel from a syringe and don't touch it again. In fact, after one minute, which
we time with a stopwatch, we remove most of the gel with high speed vacuum before we even put
water there. Then we rinse off the rest of it and we never touch the tooth again until a sealant goes
Removing bulk of gel with suction.
Rinsing with water.
DR. GOTTLIEB Are you concerned about the gel getting on the gingival tissue?
DR. PHILLIPS No, we're really not, based on our clinical experience. We found that a 37% liquid
acid did cause discomfort and irritation to the gingiva. With the gel, we consider it improper
technique if we don't get it on the gingiva, because we want to have total coverage of the facial
aspect of the clinical crown. If we can see any of that tooth surface at all, we feel we haven't placed
gel everywhere it needs to be. We make a point of putting the tip of the syringe in the interproximal,
making sure we get the gel as far interproximal as we later will expect to get the sealant.
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DR. GOTTLIEB Of course, someone who was not using a sealant would not have to cover the
entire tooth surface with etchant gel or liquid.
DR. PHILLIPS That's quite true. You can place the gel quite accurately with the syringe only
where the bracket pad is going to be. That's one of the beauties of dispensing a gel from a syringe.
DR. GOTTLIEB How much time do you allow for etching?
DR. PHILLIPS For adult teeth, we etch routinely for 60 seconds. For deciduous teeth, we etch 90
seconds. Exceptions to this are for teeth that were formed in very high fluoride areas, which we have
to etch 90 or even 120 seconds.
DR. GOTTLIEB Which gel do you use?
DR. PHILLIPS It's TP's Direct-On gel. It is not only highly visible due to its color, but it stays
where you put it until you wash it off or take it off with a vacuum. We pull the gel off with a
vacuum tip and then rinse with water from a syringe, with most of the water going directly into the
vacuum tip. The next step is drying.
DR. GOTTLIEB Would you describe exactly how you dry the teeth, since dryness is one of the
most critical points in the process?
DR. PHILLIPS Yes. Drying the enamel is not as simple as it may seem. In my technique, we use
the high speed suction before we start drying the teeth with air; and the first thing we dry is not the
teeth, but the cotton roll. Cotton rolls are designed to absorb water and indeed they do. So, first we
dry the cotton roll with the vacuum and then we dry the teeth with the vacuum tip. This eliminates
most of the rinse water. Then we use a warm air drying instrument and we continue to use the
vacuum tip while we are using the tooth dryer. The vacuum aids in rapid drying.
DR. GOTTLIEB What precautions do you take to assure oil-free, moisture-free air?
DR. PHILLIPS If you have fairly modern equipment, you probably have a compressor that gives
relatively oil-free air and has a dryer and filter on it. If you do not, or if you live in a moist climate,
you may have moisture in the air line. For that reason and because warm air has more drying effect
per unit of time than room temperature air, I recommend the use of a dry, warm air source. We use a
unit developed for that purpose, the Penguin Tooth Dryer, with which we can dry each tooth
individually if we wish. It provides a temperature of about 115° F. and the volume of air is sufficient
for rapid drying, but without the harsh pressure of many air syringes.
Drying cotton roll with vacuum.
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Penguin Tooth Dryer.
Penguin dryer in action.
Etched tooth surfaces.
DR. GOTTLIEB Is that a great deal better than the hair dryer that many orthodontists use?
DR. PHILLIPS The hair dryer is effective for drying teeth, but it's not very comfortable for the
patient. We prefer a dryer that provides cooler air more accurately directed.
DR. GOTTLIEB When the surface is dried, you are now ready to apply the sealant?
DR. PHILLIPS Yes. We have etched the entire surface and we are ready to coat it with sealant. I
use the Concise system in the majority of cases. Either that or fastset Endur. These are similar
systems in that both have a two-part sealant and a two-part adhesive paste. We put down two drops
of resin, an A and a B, in two groups. We mix one A and B at a time and spread sealant over one
quadrant at a time with a little foam pellet. These are so light that, to prevent them from blowing
away, we set the foam pellet right in one of the liquid drops to anchor it down and be sure it is
available when we are ready. I feel that spreading the sealant on with the foam pellets is superior to
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doing it with brushes.
DR. GOTTLIEB Are those pellets generally available?
DR. PHILLIPS They come in the Concise kit, but any component of the kit, including the pellets,
can be bought separately.
DR. GOTTLIEB Do you put sealant on the bases, as well as on the tooth surfaces?
DR. PHILLIPS A very important step in indirect bonding is to reduce the surface tension of the
bases before you add adhesive to them. With the change to such small bases as we use these days,
you must use a very small amount of adhesive if you want to avoid a lot of flash. So, you put a dab
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of either the A or B half of the sealant system onto the base. It doesn't matter which one, since it is
not going to polymerize. It is just used to wet the surface so that when you add the new adhesive to
it, the adhesive flows better and does not leave voids. Working with a bare pad or mesh base, you
have to use a lot more material. Here we want just a minimum of material, but we want it spread
evenly, and we are reducing the surface tension to make that possible.
DR. GOTTLIEB Do you prefer these systems because you like the strength of the composite and
need the sealant to wet the surface?
DR. PHILLIPS To my knowledge, Concise is the only two-part self-polymerizing Bis-GMA
adhesive where the manufacturer's instructions allow varying the proportion of the A and B
components to vary the setting time. I prefer this method of timing and think it is a more positive
one than others which recommend that they be mixed only at a one-to-one ratio with the setting time
controlled by temperature. I can't really know what the temperature is, except that it is changing all
the time. For example, something brought out of the refrigerator is getting warmer all the time and
approaching room temperature. I like to time things precisely and to know precisely what working
time I have for the proportions I use. This is one reason I like the Concise system. Another reason is
that it is easier to mix than some of the others, and it is possible to vary the viscosity of the mix by
adding unfilled resin to it. You can add one part of A and one part of B paste and then add another
part of A liquid or B liquid and reduce the viscosity, if that is what you care to do.
DR. GOTTLIEB How do you decide that?
DR. PHILLIPS On an anterior tooth, I don't feel that I need the absolute maximum strength I can
get from the adhesive. So, I will dilute it, which gives a lower percentage of filler and a slightly
weaker system. This makes for a slightly easier debonding procedure. I also dilute it in order to have
the material flow very readily on the bracket pad in the chairside portion of the procedure. I like to
use a very small quantity of material that will flow evenly over the whole pad. A relatively viscous
or dense material will not spread out evenly. Those are the reasons that I use that particular system.
DR. GOTTLIEB If you control the viscosity, why use a sealant?
DR. PHILLIPS I feel that the lower viscosity sealant probably penetrates the enamel more readily
than the thicker material and this is why I use it. Also, perhaps there is some increased resistance—
albeit perhaps a minimal one— to decalcification if you cover the entire facial surface with sealant,
following etching the entire surface, of course.
DR. GOTTLIEB You have to use a relatively thick layer of sealant, don't you?
DR. PHILLIPS The Bis-GMA type sealants in self-polymerizing form that are available to us will
not cure in a continuous surface in thin layers in the presence of oxygen. It will simply wash off the
tooth surface after the bonding procedure is completed. There may be a little spot here or there, but
not a layer of sealant on the tooth. However, if you use a UV cured system, such as Nuva-seal, there
is a continuous layer of sealant. Of course, we all know that this layer abrades away with just normal
toothbrushing. However, there is no question that it affords protection to the tooth until it abrades
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DR. GOTTLIEB Does it last long enough to warrant using it?
DR. PHILLIPS Whether there is a continuous surface or not, there undoubtedly are tags of the
sealant in the enamel surface as inclusions, embedded in the enamel, and there is some evidence that
this does afford some increased resistance to enamel solubility. So, this is another reason that I use
DR. GOTTLIEB Do you envision better sealants in the future?
DR. PHILLIPS One of the great needs in orthodontics is to have a sealant that is highly abrasive
resistant, transparent, and will cure in very thin layers to afford greater protection against
decalcification. The lack of such a system is perhaps the major problem area remaining in bonding
today. I expect we will have such a material for clinical use in the near future. More than one group
is working on the problem.
DR. GOTTLIEB Once you apply the sealant with those foam pellets, you are ready to apply the
DR. PHILLIPS Yes. We dispense the A and B components of the paste system from disposable
syringes onto the mixing pad. Incidentally, we don't dispose of the syringes after one load. We reuse
them over and over again.
The mixed A and B is picked up in the disposable tip of a Clev-Dent composite placement
syringe, a CR syringe, and dispensed onto the bracket pads in the tray. This method is fast and
DR. GOTTLIEB How much adhesive do you use for each bracket?
DR. PHILLIPS We want just the correct amount of adhesive needed to flow over the whole bracket
base without any flash. That is a very small amount of material. But, for any mixed material, there
are just certain minimum quantities below which it is physically very difficult to work. The amount
actually needed is so little that it is awkward to handle. You have to accept the fact that you are
going to waste a little.
In the early days of bonding, as a holdover from banding mentality, we were using excess
adhesive, just as we used excess cement for bands, and we had a problem with flash. As we found
that we needed only a small amount of adhesive, the flash problem virtually disappeared. We still
occasionally get some flash. Immediately after removing the bonding template, we look carefully
around every base, using a four-power loupe. If there is any flash, it is removed with a carbide bur in
a high speed air rotor, but we don't have much to remove these days.
DR. GOTTLIEB Do you make any effort to spread the adhesive on the bracket base?
DR. PHILLIPS The CR syringe tip is placed directly on the bracket base and the material spreads
fairly evenly when expressed. When the template is pushed against the tooth surfaces, additional
spreading occurs.
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DR. GOTTLIEB Do you feel you get better pressure with the silicone rubber tray than others do
who use harder plastic materials?
DR. PHILLIPS Many of those who use an indirect bonding technique prefer a much stiffer tray
than I do. They feel that it gives a more positive seating of the appliance. But, I am concerned with
the path of insertion of the tray to avoid smearing the adhesive at the time of placement. You can do
everything else right— proper amounts of adhesive, properly placed on the pad, with bracket,
properly placed on the model— and still make a mess at the time of placement. We not only prefer
to use a flexible tray for that reason, but we also bond only in quadrants. We don't attempt to seat an
entire arch at one time. We are aware that this takes a bit more chair time, but we feel that the
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advantages outweigh the disadvantages. Another reason for using a flexible silicone rubber material
is that it is very easy to section the tray with a pair of scissors anywhere you want to. The first time I
see the tray is on a model at chairside and it is in one complete arch form at that time. At that point,
with the patient there, I make the decision of how I want to section the tray. In 90% of the cases or
more, I cut it in the middle and we bond in two quadrants.
DR. GOTTLIEB What considerations decide you to do otherwise?
DR. PHILLIPS With a very nervous patient or when a second molar is to be bonded or in the case
of a malposed upper second bicuspid— situations that are somewhat unusual— we don't hesitate to
cut the tray so that we may bond as few as one tooth at a time. Also, with the best technique we can
manage, we sometimes don't get the bracket exactly where we want it. If one bracket does not bond
properly, we can simply cut off that portion of the tray, take another bracket, pop it into the segment
of the overlay tray and rebond that one tooth indirectly. The material takes such an accurate
impression and is so flexible, I'm sure you could literally put a bracket in and out of it hundreds of
times very accurately. So, it's no problem to redo one if you need to. I feel that a template material
should take impressions accurately enough to make precision gold castings.
DR. GOTTLIEB Is it that accuracy that makes you confident that you are going to seat it correctly
each time and that you don't need a clear material to check the seating?
DR. PHILLIPS That's right. In my experience, the transparent vinyl materials are not really
adequate for bonding because of their hardness and their lack of stability. I think the only viable
reason for a transparent tray is if you are using a light-cured system. With a self-curing adhesive I
see no need for a transparent tray. There is no need to see the teeth through the tray, I see where the
tray fits on the model and where the cut surface is in relation to the central incisor, and that's where I
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put the tray in the mouth. I flex the tray to bring the bracket bases directly against the teeth without
smearing the adhesive. Then I personally hold the tray until the material sets, timing it with a
stopwatch. I hold it very carefully, using two hands, with one or more fingers along the occlusal and
two or three fingers on the facial, I can feel that it is place and I know that it stays in place until the
material sets; and you learn that if you have one tooth in the quadrant that is, say, a little malposed to
the lingual, you put a little extra finger pressure at that point to be sure that the bracket pad contacts
that tooth surface.
DR. GOTTLIEB You hold the tray yourself?
DR. PHILLIPS I feel that it is very important at the beginning stage of the doctor-patient
relationship, that the patient knows that I am involved. They are aware that I am sitting beside them
and holding something in their mouth, that I am involved in their treatment. So, I don't feel that it is
wasted time for me to spend the few minutes involved in positioning the trays and holding them in
place until they set, although I could delegate that responsibility.
DR. GOTTLIEB For how long is the tray held?
DR. PHILLIPS From the time that I begin mixing the material on the pad until I let go of the tray is
2½ minutes, timed with a stopwatch. We could do it much faster, but I am looking for a system that
works day in and day out, not just when everything is going exactly right. This method allows time
for all sorts of accidents and interruptions— if a spatula is dropped or a phone message is delivered.
I routinely have extra time available without making the bonding an unduly long procedure. It takes
about 50 seconds from the initial mix until I place the tray on the teeth. The rest is reserve time, so I
am almost never in a rush.
DR. GOTTLIEB How much time does it take all together to bond an attachment with your indirect
DR. PHILLIPS The entire procedure from seating the patient, through cleaning the tooth, etching,
and placing and removing the tray takes about ten minutes. My own involvement in the procedure is
closer to four minutes. Of course, dental practice acts vary from state to state. Since we have a fairly
stringent law in my state, I must do more of these procedures than many of my colleagues in some
other states where auxiliary personnel are authorized to do much more. I really don't mind doing
these things and, indeed, I shouldn't. I feel that I owe the patient a certain amount of my time. It is
very easy to do and we are not in a hurry.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume Jun
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jun(412 - 416): Common Sense Mechanics Part 10
Common Sense Mechanics
Extraction Mechanics
During the discussion on cuspid retraction, it was pointed out that : there are various anchorage
concepts, including multiple banding/bonding on the anchorage side of the extraction site.
Obviously, there are different types of extraoral anchorage, but we are discussing intraoral
anchorage, with the orthodontist choosing a method of control. In addition to the method of multiple
banding to form large resisting units, it was shown that anchorage can be instituted by banding a
lesser number of teeth and locating archwire bends in such a manner as to produce "differential
torque". When the bend is placed off center, the tooth (bracket or tube) located closest to the bend
contains the largest moment and, therefore, indicates the anchor side.
It was also shown earlier, that these unequal moments are important in terms of their "net
difference". The smaller moment can sometimes be in the same direction depending on the angular
relationships of the wire to the bracket. But, we are not concerned about determining exactly what
these specific relationships are, as it would unnecessarily complicate the approach to utilizing
differential torque. We simply know that if the unequal moments are in the same direction, their
additive effect increases the effectiveness of the anchorage (Fig. 117). In those cases where the
smaller moment is opposite in direction to the larger moment (Fig. 118), there is still a "net
difference" in favor of the anchorage side. However, as the interbracket distance becomes smaller,
the bend is closer to center and, therefore, the two moments are more nearly equal, which reduces
the effectiveness of the anchorage. By recognizing these factors, we can keep treatment simple and
Since differential torque considers the effectiveness of a net moment, total root area in the anchor
unit is not the primary consideration. As a result, bicuspid retraction can be considered in the same
way as cuspid retraction. Bicuspid retraction with severe anchorage requirements can be performed
on one side, while the same wire can be utilized to perform molar protraction on the opposite side of
the same arch. In fact, protraction is accomplished in the same manner— by locating the bend off
center. However, protraction will simply utilize the non-anchor side of the bend. In other words, the
bend is moved "away" from the teeth to be protracted as will be shown in the following case.
Bicuspid Retraction
In Figure 119, the malocclusion includes a deep overbite with a Class I molar relationship, but a
missing lower left second bicuspid with the second deciduous molars still in place. The lower left
first bicuspid is almost in contact with the mandibular lateral incisor and tissue blanching can be
seen as a result of the unerupted permanent cuspid lying labial to the lateral incisor and first
bicuspid. If the first bicuspid is not retracted following removal of the second deciduous molar, the
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patient is almost certainly faced with the need for a replacement, as well as the loss of the permanent
cuspid. In spite of the fact that I would normally like to wait a little longer before initiating
treatment, due to the lack of eruption in the upper arch, treatment was instituted with the removal of
the lower second deciduous molars, the lower right second bicuspid, and the upper first bicuspids.
Only a minimum appliance was placed and treatment began with an .016 archwire in the lower
arch. Because the molar was to serve as the anchor unit, a bend was placed mesial to the tube, thus
producing the largest moment on this tooth. An elastic was used to retract the first bicuspid ( Fig.
120). Clinically, the non-anchor tooth (first bicuspid) is observed tipping, while the molar remains
relatively upright. This verifies the anchorage and non-anchorage sides due to the unequal moments
present. As the bicuspid continues to move distally, it gradually approaches the off-center bend
lying mesial to the molar tube. As this happens, the two moments gradually become more and more
equal (decreasing differential), but opposite in direction. This gradual equalization provides the root
paralleling that is necessary due to the initial tipping. When the bicuspid is completely retracted, the
marginal ridge discrepancy, as a result of the tipping, is evident. This assumes, of course, correct
bracket and tube placement. As space closure is completed, the bend becomes a centered bend, and
the resulting equal and opposite moments will parallel the roots, as can be verified clinically by
levelling of the marginal ridges in time.
Molar Protraction
Next, the lower right cuspid and bicuspid are banded to begin molar protraction on the right side
(Fig. 121). All of this could have begun with the initial archwire, but I prefer keeping as many bands
off as many teeth for as long as is reasonable, and time is not critical in this case, because it will be
necessary to wait for upper tooth eruption. The upper wire, for overbite correction, was initially an
.016 followed by an .018. The intrusive and extrusive forces, are light due to the bypassing of teeth
(unerupted in this case) as discussed earlier. The lower archwire has been designed to serve as a
space maintainer on the lower left side for the unerupted cuspid by incorporating a "step-down", and
a center bend was placed between the retracted first bicuspid and molar to allow the roots to
continue to parallel themselves.
On the lower right side, there is no tieback loop mesial to the molar as this tooth is to be
protracted into the second bicuspid extraction site. The wire is usually an .018 followed by an .020
on occasion, as the tipping tendency for molars is too great with a lighter wire in an .022  .028 tube.
If mesiolingual molar rotation is desired— and most often it is not— no bend need be placed, as a
mesial force acting at the molar tube during protraction produces the rotation as a result of the "Cue
Ball" effect. If the opposite rotation is indicated, a sharp toe-in bend must not be placed, as it will
interfere with protraction by binding at the molar tube. A gentle curve can be placed instead. It will
produce the same required moment, as it still produces the same wire/tube relationship (Fig. 122).
In this case, since the molar is to be protracted, it belongs on the non-anchor side, and therefore,
furthest from the bend. The opposite side becomes the anchor side, so the bend is placed
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jun(412 - 416): Common Sense Mechanics Part 10
immediately distal to the first bicuspid bracket. Differential torque is again produced, just as
occurred on the left side, except the directions of movement are reversed because the locations of
the bends are reversed.
So, you can begin to see that all of this is not so complicated after all. No matter how fancy or
sophisticated an appliance, in the end teeth only move as a result of moments and forces, and we can
utilize principles of mechanics that will allow for use of a simple appliance in an acceptable and
efficient manner. But I do wish to emphasize again, that ultimately the teeth located distant from
these bends will encounter the effects of the TOTAL force system. It is a practical, but useful,
method to think in terms of "two units", even though we technically sacrifice preciseness.
In the case shown, the lower right first molar required a mesiolingual moment, and this was
automatically accomplished by the mesial force from the protracting elastic. A mesial force acting at
the molar tube produces a mesiolingual moment.
After space closure has been accomplished (Fig. 123), the bend located distal to the bicuspid
bracket is no longer an off-center bend. The centered position between molar tube and bicuspid
bracket, again, produces equal and opposite moments for root paralleling. In the meantime, the
space maintainer (step-down) on the left side has permitted cuspid eruption, while the first bicuspid
and molar roots were being paralleled at the same time.
Teeth continued to erupt in the maxillary arch ( Fig. 124) during lower tooth movement and
overbite correction. Admittedly, a case like this involves delay, but the need to get the lower left
cuspid into position dictated the starting time. At least the patient is subject only to a minimal
appliance for a long period of time.
A year following band removal (Fig. 125), the teeth have erupted except for the upper right
second bicuspid which is completing its eruption.
This is not an exceptionally difficult case, but is shown to emphasize that the concepts discussed
are not difficult to understand and apply. We can see that once we understand a given system, we
can learn to put it in reverse with no added complications. If we understand, for example, the force
system associated with lingual root torque, then under the same conditions, labial root torque will
result in a reversal of the system. We just saw that a bend located at the mesial side of an extraction
site produces a net movement in one direction, while locating the bend at the distal site reverses the
direction of this movement.
Now that cuspid retraction, bicuspid retraction, and molar protraction have been discussed, all
involving the application of differential torque applied by the simple location of a bend, it will be
shown that the same relatively simple concept can be applied to the simultaneous retraction of
bicuspids and cuspids using only single molars as anchorage units. Again, there is no such thing as
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jun(412 - 416): Common Sense Mechanics Part 10
perfect intraoral anchorage, but there is such a thing as providing maximal intraoral anchorage with
mechanical principles that provide greater reliability and consistency.
Fig. 117
Fig. 117 Unequal moments in the same direction increase the effectiveness of the anchorage.
Fig. 118
Fig. 118 Unequal moments in the opposite direction still favor the anchorage, if the molar moment is larger.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jun(412 - 416): Common Sense Mechanics Part 10
Fig. 119
Fig. 119 Malocclusion with missing lower left second bicuspid.
Fig. 120
Fig. 120 Bend mesial to the molar tube favors the molar anchorage as the first bicuspid is retracted with elastic.
Fig. 121
Fig. 121 Lower arch ready for molar protraction. Step-down on lower left maintains space.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jun(412 - 416): Common Sense Mechanics Part 10
Fig. 122
Fig. 122 Gentle curve (above) will produce the same rotation effect as the sharp bend (below) without Interfering with
molar protraction.
Fig. 123
Fig. 123 The case following space closure.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jun(412 - 416): Common Sense Mechanics Part 10
Fig. 124
Fig. 124 Teeth erupting in upper arch.
Fig. 125
Fig. 125 The case a year following band removal.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jun(417 - 421): Influencing Patient Cooperation
All of us have known the thrill of completing a patient who came to us with an extreme
malocclusion and then, on the day of band removal, has given us that grateful smile— and you know
he feels better about himself for our combined efforts. We also have known the miserable feeling
when another patient, who started with only a moderately severe orthodontic problem, looked only
fair on the day of appliance removal— the occlusion not intercuspated well, some overjet remaining,
and possibly some decalcification thrown in to make us feel worse. Why the difference? Since we
orthodontists are presumably a constant, I suggest that the most important unknown— and one we
can influence perhaps more than we do — is the cooperation we receive from our patients.
If I asked each of you to name five of your poorest patients (and I don't mean the ones who forget
to pay their bills), I would bet you could give them back quickly— and so, too, could any member of
your staff. You know the ones I mean— the ones that always catch your eye on a day sheet— whose
names look darker and larger, even though all were typed at the same time. All of us have these
kids, but what can we do about them?
Group Session Approach
In 1973, I decided to try to influence some of these children in my practice. I had had a
conversation with a psychiatrist, the father of one of my patients— first casually, and later in much
greater depth. Dr. E has a private practice, as well as serving as an attending psychiatrist at a family
and children's clinic, and works in group therapy with children. His background in children's work
was extensive, and, after several meetings, we proposed to have a series of group sessions with our
problem patients, with the objective of improving their cooperation. The problems were typical of
what we all live with— wearing of headgears, rubber bands, or removable appliances; brushing and
keeping appointments; or often a combination of these. Seven children were selected— and it was
easy to arrive at a consensus among our staff who should be included.
After obtaining parental permission, we arranged to meet with the children on a day the office
was closed. We planned four group sessions of ninety minutes each. Dr. E primarily led discussions
which flowed with a great degree of freedom and honesty. The various orthodontic problems were
extensively discussed and other problems spewed forth also— expected, to be sure, but a great
addition to our discussions.
Several conclusions were reached following these meetings. All these children had other
problems in many aspects of their lives. I am sure most of us have had the experience of discussing
orthodontic cooperation with a saddened mother, who counters with "I am hearing the same thing
from John's teacher and we're having trouble with him at home". When the parents inquired about
the results of our sessions, further individual therapy was recommended by Dr. E for several of these
young people. It was, in fact an answer for these families— a long awaited answer to many
heretofore unasked questions. The orthodontic cooperation of these children did not change at all—
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jun(417 - 421): Influencing Patient Cooperation
and each was completed as well as possible through my own efforts, with that characteristic ache in
my stomach on the day of band removal.
Subsequent followup showed a later maturity for some— but long beyond our sphere of
influence. In the same way that we cannot always pick the optimum period of growth in which to
treat orthodontically, we are not always able to wait for the onset of emotional maturity. We had no
effect on changing these poor cooperators— leading us to the conclusion that we usually must
accept this type of patient as is, continuing to try for improvement from them, but planning to do our
best with a minimum of their assistance.
Consider Andy H., who came to my office at the age of nine with a Class II division I
malocclusion. The overjet was 14 millimeters with an equally severe overbite. Early non-extraction
treatment was begun, with an anticipated time of treatment for Phase I of 15 months.
After 18 months of minimal improvement, Andy was part of our group therapy sessions, and later
received further private therapy. Phase I was discontinued and, upon the eruption of most of his
permanent teeth, Phase II was begun with the extraction of maxillary first bicuspids. Despite Andy's
assurances of help, his cooperation in every phase of his care was totally lacking throughout
treatment. Through no effort of his own, Andy was completed, changing a poor appearing
malocclusion to one that looks better. Today Andy is in college. He is functioning better, but has
had a poor orthodontic experience.
Oh for the opportunity to have been able to treat him with today's maturity— I'm sure we both
would have enjoyed it more and Andy probably would have a healthier, better looking mouth.
The Next Attempt
Following completion of our sessions with the psychiatrist, we sent letters to each of the patients
who participated. We asked two questions of each. First, "What could we have done before
treatment that might have given us an indication that you would find treatment difficult to accept?"
Second, "What could we have done at the beginning of treatment to make it easier to accept?" The
answers to the first question regarding their indication of negativism was primarily "nothing", other
than to discuss "pain" more fully prior to the onset of treatment. Perhaps we underestimate the pain
we are causing and I will discuss this later. The second question— regarding making treatment
easier to accept was also answered negatively (perhaps these were obviously negative children), and
nothing much was suggested to us here either. After these answers, we then devised a simple set of
questions to ask at the beginning of treatment, to try and develop insight into where we might expect
problems. Along with six questions, each child was asked to draw a "picture of a person", with the
eventual expectation that this might lead to some predictability of acceptance and cooperation
during our treatment, and perhaps be able to spot a problem sooner. Upon completion of the
orthodontic care of these patients, the pictures and questions were evaluated by the psychiatrist and
his predictions of cooperation were recorded. These were then compared to our estimates of the
cooperation actually received during treatment. The predictability was good at the high level of
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jun(417 - 421): Influencing Patient Cooperation
cooperation, but there was no reliable correlation beyond that level. Thus, we no longer use this!
Since we were unable to change this segment of our practice, I then began to look at the larger
overall group of patients, the ones we would consider to be our average patients. In reviewing my
completed records, it became obvious that some children sailed through treatment, while others took
much longer to treat a similar problem. Upon the removal of appliances, I asked each child to mark
himself based on how they actually had cooperated relative to our requests. These children were all
completed to our mutual satisfaction and the marks appeared quite honest, based on our own
treatment records and observations. Those who had gone from stage to stage without any obvious
problems gave themselves marks of 75 to 95 percent. Those where treatment was somewhat slower
offered their own evaluations of 45 to 65 percent. These were self-evaluations of the wearing of
headgears and elastics, the consistency of keeping appointments and, of course, brushing. The
patient scored himself with the theoretical number encompassing all of these aspects of treatment.
From these, we concluded that what we considered to be average cooperation is really mediocre that our so called "average" patient was really helping rather poorly.
We further found that many patients will not be as honest about their cooperation while active
treatment is underway as they are after the treatment goals were achieved and honesty no longer had
any risk. Further, when asked separately, parents often defended or lied about how much the child
was cooperating— even after the child told the truth about not doing as requested. In contrast,
frankness and candor on completion was astonishing from both parents and patient.
From this, I thought that if I could successfully increase the motivation of these patients, we
could probably achieve our results in considerably less treatment time, and certainly with less stress
to all involved. Our efforts were then turned toward this objective. I met with a clinical child
psychologist on several occasions to discuss improving overall cooperation. From these meetings,
and sessions between the doctor and our office staff, we began several different expanded
approaches to introducing our patient to his orthodontic care. Each child was specifically requested
to be at the consultation, which is our time devoted to describing his specific plan of treatment
following diagnostic records. In our consultation, the discussion is with the child, and the parents
also listen and learn. The child knows this visit is for and about him, and that his parents are there
for his benefit. He is encouraged to ask questions about his treatment and his parents are free to
discuss it as well.
Following this, and before treatment is begun, the patient is given an appointment with our
hygienist to discuss his participation in his treatment. This covers many aspects of care, from
keeping appointments to brushing— usually in a group with two or three others who are also about
to begin their care. Having a separate appointment for this has increased our time devoted to
cooperation, and our emphasis of this has made the patients more aware of the importance we place
on these aspects of their care and the necessity for their assistance.
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jun(417 - 421): Influencing Patient Cooperation
On the day of appliance placement, we allow sufficient time to describe fully what to expect. We
even tell them, for example, that we know how difficult it is to wear a headgear, that it really is a
strange thing, and not at all easy to wear. We further explain that it is the only thing we can give
them to accomplish that particular part of their treatment, and that the better it is worn, the sooner
we can discontinue its use. In all aspects, we are trying to anticipate how they will feel and what
they are likely to be unhappy about, and discuss it before it happens. Doing this, we have found it is
easier for the patient to accept his treatment and we can accentuate the reasons for using each
appliance, with all of us aware of the difficulties involved, which previously we were taking too
much for granted. What we do every day as a matter of course is a very hard experience to those not
accustomed to it. Our realization of this has made us better able to start our patients on the use of
their appliances. Most of our patients are in the difficult preadolescent or adolescent period of their
lives. This period is filled with many conflicts, and we are introducing further stresses.
Surely, we are obligated to do all we can to make this experience one that they can accept as
easily as possible, and anticipate as many of the feared unknowns as possible. Pain at any stage of
life is difficult— and there is no question that we create pain. During this period of life, the
discomfort is perhaps harder to take and gentle strokes have gone a long way to ease our patients
through this period. The more we are able to eliminate surprises and let the children know what to
expect, the less have been our surprises when the patients return for their regular visits.
Behavior Modification
Last year, I had a casual conversation with the mother of a patient about to start treatment. She is
a psychological therapist with a private practice treating family problems and also teaches behavior
modification to nursing students. From this conversation evolved my next step to improve patient
cooperation. A course in behavior modification was begun for our office staff.
When I originally suggested this program to our staff, their response was unenthusiastic. Despite
this, we planned the course— a series of four two-hour sessions— during office hours. After the
first week, I heard conversations amongst the staff about the program, and after the second week
there was almost unanimous interest. This feeling continued for all four weeks and the experience
was beneficial in many ways. These sessions allowed much give and take in the office
communication about these particular problems— and from them came a new enthusiasm and
sympathetic understanding when helping our patients during difficulties with treatment. Noticeable
changes were seen in the manner in which the girls spoke to the patients, their choice of words, and
the overall patience shown with the children. For those patients who did not give as much help as
desired, the behavior modification program dangles a carrot. The principle is one easily understood
in our society— the use of reward.
The program involves establishing a contract with the child. In the contract is outlined the
specific problem, the reward (or reinforcer), the desired change, as well as the check-in times and
finally the reward. The parent is also involved in the process, giving them some shared
responsibility for the success of treatment— and some welcome help for us. I have designed a
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jun(417 - 421): Influencing Patient Cooperation
contract, a copy of which is given to the patient and one of which is kept in our records. Any
member of the staff can make a contract and all children seem to understand the principle,
regardless of age.
Let's look at Richy C.— who had forgotten to brush his teeth for about three months despite all
our earlier efforts. In a conference with Richy and his mother, we talked about the problems,
discussed the use of the Water Pik as well as brushing— and set up a contract. Richy was to be
checked in four weeks and had to maintain good hygiene for the next two months before the reward
would be given. The reward was to be a record of Richy's choice provided by his mother. The
change was dramatic and has continued. The same idea has been utilized for headgear, elastic
wearing, keeping appointments, or any other desired result. The use of reward in our society is
common— wouldn't we be foolish not to utilize it in our behalf? Even our toy box is off limits when
our patient hasn't done his job. Its use is a reward for his good efforts. There have been periods
when desired changes have been accomplished, followed by some regression. In this instance, new
reinforcers must be used with varying intervals between rewards. The parents have been very
willing to assist in these efforts.
Each of these approaches has helped to improve the overall levels of cooperation in my office. As
a clinician, it has made my treatments run more smoothly, shared the responsibilities for problems
with the patient and his family, and allowed for more predictable and often shorter and less stressful
periods of treatment. Each new approach that involves our staff stimulates their interest and
participation far more than any technique changes.
One of the major differences between our private practices and commercial advertising
orthodontic clinics is the personal interest we can offer, and to do so has a reward for all. If we are
to survive in private practice as we know it, we must seek to provide excellent results for our
patients. However, neither the patients nor their parents are fully aware of our diagnostic and
biomechanical skills, nor the degree of technical excellence we are providing.
The behavioral aspects— the interest in the person as well as his case— address other needs of
the patient and his feelings, which can often provide a marked difference in what we are able to
accomplish .
Many years and much effort has passed since my day of graduation. During these years, the steps
ahead and the stumbles back have made me more certain than ever that I shall continue to strive to
better not only my orthodontic techniques, but also the ability of my entire office to make our
patients feel happy to be there and understand the importance they play in their own care. The
pleasures from these efforts to both patients and staff have been tremendous.
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jun(422 - 423): Orthodontic Scheduling and the Two-Income Family
Orthodontic Scheduling and the Two-Income
One of our colleagues wanted to find out what his patients and their parents thought of his
practice— what was right about it and, more importantly, what was wrong with it. So, he simply
asked them via a questionnaire. The results were enlightening. Their aggravation with his practice
was centered in two prime areas: (1) availability of appointments, and (2) no doctor contact after
consultation. Very simply, parents wanted to get the kids to the office when it did not destroy their
daily schedule, and they wanted to have some contact with the doctor to keep abreast of what was
going on.
Notice that these chief complaints fall under the broad title of service. They have nothing to do
with clinical acumen, patient cooperation, office decor, or the projection of professionalism. Our
colleague instituted procedures to correct the parents' chief complaints, and the results were
predictable. In his words, "I'm catching them faster than I can string them".
The orthodontist has associated the word "service" exclusively with the degree of excellence in
treatment, and this overall concept I endorse passionately. But, in today's professional climate, it is
getting tougher and tougher to compete for a limited supply of patients on a purely technical basis.
There are lots of competent orthodontists around and many more waiting in the wings. As it
becomes more difficult to maintain a position of professional isolationism, we have to think of
another way to augment concerned clinical treatment. That other way is service.
The Problem
The middle-class family has under-gone major change in the last nine years. The Census Bureau
tells us that about 50% of today's middle-class families combine two incomes with both father and
mother working. The working mother no longer has the time to get her kids to their routine
activities. She has to work in order for the family to survive economically. Her schedule is usually
tight. Any invasion on her delicately balanced timetable is a major obstacle.
A succinct example. Both parents of one of my patients worked— Mother for the telephone
company, Father as a construction supervisor. Mother had to bring the child to the office. She had to
take off from work, pick up the child, wait for the child, and return him from whence he came. This
was a two-hour expedition. Her pay was docked $22 while she was absent from work. Multiply this
dollar figure for all visits including retention, plus the fee for the case, and multiply the result by the
aggravation she caused on her job by being absent, and we get a general idea of the impact that
orthodontic treatment had on that particular family. When we realize that practically all adults and
one-half of the families we treat are more or less in the same boat, the situation becomes serious
enough until it is unconscionable to ignore it.
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jun(422 - 423): Orthodontic Scheduling and the Two-Income Family
The Solution
The problem has been stated, now what do we do about it? One answer is service. We can adjust
our time to the schedules of our working parents and adult patients. The day is gone, glorious as it
was, when the vast majority of our parents had the facility to adapt to our convenience. Our social
structure has dramatically changed, and we must offer our working parents and adult patients
appointments that are not unduly stressful to their livelihood. This means that we have to reevaluate
the traditional 8-4:30 schedule. What was conventional ten years ago is inconvenience today. I
suggest we work some evenings for our working parents and adult patients. Let's say we alter our
schedule two days a week to work from 1:00 p.m. to 9 p.m. The "after hours" portion would be set
aside exclusively for the patients who need to come at that time.
Can you imagine what would happen? Let me brief you. First, the parents would spread the word
like wildfire, because they usually associate with other two-income families. Second, your referral
base would be enthusiastically augmented by the employers of your working parents and adult
patients. You have done a magnificent thing for their absentee problem. And, finally, your
consideration for the plight of these patients will not go unnoticed. Your alteration of traditional
scheduling will be recognized for what it is— a sincere concern for people.
There is an easy way to test the accuracy of this. Ask your appointment secretary what time is
requested, or better yet, pleaded for by parents. The overwhelming favorite of coveted appointment
times will be the latest appointment in the afternoon or the earliest available in the morning.
You might justifiably say that these appointments have always been popular because parents were
concerned about their children missing school. A point well taken, but with the advent of the
American social phenomenon called the two-income family, the appetite for these choice
appointments becomes ravenous. It is important that the child not miss school, but it is imperative,
even essential, that the parent not miss work.
It would be naive to assume that the alteration of your conventional working day is easy. It is not.
The clinician and his staff must make adjustments in their work program. One can expect to work
through a period of awkward adjustment. But that's what service and practice building are all about.
It requires effort and readjustment to offer benefits to your patients that are extraordinary in your
community. If the inconvenience of change is too laborious to think about, then think about what
will happen to your practice when the orthodontist down the street decides to have a
service-oriented practice. After all, who would you go to if you were a working parent or a working
adult seeking an orthodontist? The answer is clear. The service-oriented practice takes no additional
time, simply readjustment of scheduling and attitudes that are rapidly becoming obsolete.
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jun(424 - 424): Technique Clinic - Removing Bonded Begg Brackets
technique clinic
In removing bonded Begg brackets, if the walls of the vertical slot are squeezed together (Fig. 1),
this action causes the base of the bracket to peel away from the bonding material, lifting the edges of
the base and breaking the adhesive bond. The bracket and base can then be peeled off the tooth ( Fig.
2), and any adhesive remaining on the tooth surface can be gently sanded and polished.
A plier with a sturdy tip should be used for this technique, to avoid breakage. The technique
works best on mini-based (3-4mm width) brackets. If the base is any wider, squeezing the slot does
not curl the edges of the base sufficiently. The same is true of curved bases. When this technique is
ineffectual, I revert to "base-squeezing". However, when applicable, the slot-squeezing technique
offers a more gentle approach to the removal of bonded Begg brackets.
I wish to acknowledge our assistant, Ann Lagattuta, for her part in developing this technique.
Fig. 1
Fig. 1 Squeezing the vertical slot.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jun(424 - 424): Technique Clinic - Removing Bonded Begg Brackets
Fig. 2
Fig. 2 Peeling bracket and base off the tooth.
JULY 1980, VOL. 14 / ISSUE 7
Orthodontic Economic Index — 1980
JCO Interviews Dr. Homer W. Phililps Part 2
Common Sense Mechanics Part 11
Technique Clinic - A Simplified Technique for Fabrication of Surgical
Orthodontic Economics - Population
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jul(441 -): 442 THE EDITOR'S CORNER
Dentists in many parts of the country are actively seeking to reverse a recent trend toward
permitting dental auxiliaries to perform expanded duties under various shades of supervision by a
dentist. The impetus for this action is apparently the fear that less well-trained people will assume
the tasks traditionally reserved for professionally trained people, especially in large closed-panel
clinics and in independently operated auxiliary practices. This is not an unreasonable fear,
considering the speed with which such facilities are coming to pass.
Various government agencies have expressed a similar thought— that the use of expanded duty
auxiliaries is part of the solution to the limited distribution of dental care; the limited availability of
dentists; the "high cost" of dentistry; the barriers to entry into the dental profession posed by
licensure laws which have high educational requirements and limit access to practice dentistry in
various states. These agencies have called for changes in state dental practice acts to greatly expand
the duties permitted to auxiliaries
Orthodontists were among the first to favor the use of expanded duty auxiliaries and, in many
states, sponsored changes in the dental practice acts to broaden the permissable duties of auxiliaries.
This action was taken in the face of large numbers of child patients and relatively small numbers of
orthodontists. It was a move that was aimed at increasing the orthodontist's productivity. It was
accompanied by a side effect which kept orthodontic fees at relatively low levels for a long period
of time. A consequence of this has been that, as the child population has declined and as the increase
in adult patients in the average orthodontic practice has been relatively slow, the size of orthodontic
fees plus reasonable fee increases have not been able to maintain the orthodontist's purchasing
Most orthodontists probably need the use of expanded duty auxiliaries, along with measures to
reverse the trend of decline of numbers of patient starts in the average practice, in order to maintain
or restore productivity. The consequence of limiting the use of auxiliaries in orthodontic practice,
either by law or by orthodontist inclination, is to limit the orthodontist's income or potential income.
One orthodontist with one pair of hands has limitations placed on the number of patient starts he can
handle, even if plenty of patients were available to him. This is demonstrated in practices in states
which still have very restrictive regulations with regard to dental auxiliaries and in which the
orthodontist observes the letter of the law. This may well have contributed to the figure that showed
up in the AAO survey of orthodontists, that the average orthodontist would feel comfortable starting
128 cases a year. If that is about the limit that one lightly aided orthodontist could start, it is not
strictly relevant to the question, that the average orthodontist is not now starting that many cases.
The problem for orthodontists lies in the fixing of the limit at any relatively low level. That
means that the orthodontist has only two mechanisms with which to try to keep up with growing
inflation and increasing costs and that would be in raising fees and lowering practice costs. Since
lowering practice costs is not, on the average, an effective way to cope with the problem and since
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jul(441 -): 442 THE EDITOR'S CORNER
most orthodontists cannot raise fees annually to keep up with the level of inflation and increased
costs that we have been experiencing, somewhere along the line, sooner or later, it has to catch up
with him.
The Department of Health, Education, and Welfare (now divided into the Department of Health
and Human Services and the Department of Education) has had a problem estimating the future use
of dental auxiliaries. In one report it is predicted that there will be less use of auxiliaries, for
economic reasons, and that dentists will be doing more of the tasks and working longer hours. On
the other hand, HEW has expressed the expectation and supported the concept that there will have to
be greatly expanded use of dental auxiliaries. No doubt we will see both of these happening,
depending on location and the nature of individual practices. It would be surprising if there were an
about-face on the question of expanded duty auxiliaries and measures taken to reverse the recent
liberalizing trend and revert to severe limitation of auxiliary duties.
While continuation of expanded duty auxiliaries is presently favorable for most orthodontic
practices, it would be unwise to ignore the possibility that, somewhere down the road, we may be
faced with intrusion into the traditional structure of orthodontic practice of a call for independent
orthodontic auxiliary practice, as we are now seeing the implementation of independent auxiliary
practice changing the nature of general dental practices with independent practice by denturists, by
hygienists and expanded duty auxiliaries in preventive practice, and a call for the independent
practice of EDDAs inoperative dentistry.
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Orthodontic Economic Index
The orthodontic economic index presented here was derived from an analysis of over 200
orthodontic practices established for five years or longer. No new practices were included, and high
and low extremes were eliminated in an effort to present a true picture of the average orthodontic
practice from 1970 through 1979. Indexing Year 1 (1970) as 100 permits an easy assessment of the
relative movement of the characteristics analyzed. Succeeding numbers are percentages of change,
increase or decrease.
Gross Income
Average Fee
Average # Case
Costs in $
Costs as a % of
Profit as a % of
Profit in $
Profit in 1970 $
Consumer Price
• Chairman of the Board, Dental Corporation of America, 1592 Rockville Pike, Rockville, Maryland
& Exp.
Chairside Labor
Prof. Supplies & Lab
Explanation of Cost Areas
Occupancy Cost: The total cost of the practice facility. Rent, utilities (heat, light, power, water),
repairs, depreciation of equipment, amortization of leasehold improvements, rental cost of
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equipment (if equipment is leased).
Clerical Wages: Wages, payroll taxes, medical reimbursement or other medical benefits, insurance
for employees (does not include Keogh, pension and/or profit sharing plan contributions, which are
considered to be profit).
Non-Operating Supplies and Expense: Office supplies, office expense, dues and subscriptions, auto
expense, general taxes, general practice insurance, telephone, travel, entertainment, legal and
accounting, continuing education, collection expense, other miscellaneous expenses. Interest
expense is considered to be profit in order to consider all practices equally. It must be assumed that
all practices are "paid for".
Chairside Wages: Same as Clerical Wages.
Professional Supplies: All supplies used in treatment of patients, laboratory purchases, wages for
internal laboratory employees (plus employee benefits), other costs of operating internal laboratory.
What is past is prologue. With inflation and other influences ravaging business, it behooves
everyone to analyze his past performance to plan future strategy. We were surprised this year to
learn that all of dentistry enjoyed its very best year in 1979. The growth in both gross income and
net profit was substantial. This was particularly surprising in view of the increased fears expressed
by most professionals about the future of their profession.
The gross incomes we reported as average from our analysis may be higher than average in the
United States, because dentists working with our office tend to be the more aggressive practitioners
who are seeking advice and help to build and operate a practice at a higher level. There is no way
for us to know the figures of practices not reviewed by us.
The largest growth came in pedodontics, which grew from $130,000, according to our reporting
practices a year ago, to $197,000 during the current year. Our reporting includes mostly the same
practices that reported a year ago, so even though this is somewhat shocking, we believe it to be
accurate. The next largest growth shown was in general dentistry. The average general dental
practice grew from $152,000 in 1978 to $189,000 in 1979. Well over half of the contributing
practices are the same practices that reported to us in 1978. Therefore, we believe that figure to be
Orthodontics showed an average gross income of $165,000 in 1978 and enjoyed a substantial
growth to $204,000. Some practices reported income reductions. Many practices reported a
reduction in the number of patients entering the practice. Virtually all practices in orthodontics
reported substantial fee increases, which is a principal reason for this rather large increase in gross
The profit in orthodontics went up from 52.3% to 53.4%, while not a single one of the costs of
operating an orthodontic practice varied by as much as one percent from a year ago. Orthodontists
had the lowest cost for chairside assistants for 1979.
We started rating the dental profession for its progress in management in 1978, when we gave the
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profession a grade of B for the year. A very considered grade for 1979 would be A minus. It is our
conclusion that dentistry has never improved more. Practices grew in a most healthy fashion. Profits
for the most part increased slightly, and costs were held reasonably in line.
We are more concerned about 1980. If present trends continue, the year could be far worse than
1979. It is going to require some extra special effort by the practitioner to maintain and continue a
healthy practice gross income in 1980, and to keep costs in line. Doubtless the clinics and capitation
programs will make inroads. There is no question the coming decade will see the failure and
disappearance of a substantial percentage of dental practices. We hope that our readers will not be
among them.
Chairman of the Board, Dental Corporation of America, 1592
Rockville Pike, Rockville, Maryland 20852
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jul(462 - 480): JCO Interviews Dr. Homer W. Phililps Part 2
DR. HOMER W. PHILLIPS on Bonding (Part 2)
DR. GOTTLIEB How often do you experience bond failure?
DR. PHILLIPS Today it's pretty rare. We had a horrendous failure rate in the early years of
bonding when techniques and materials weren't as good. For the last three years, we have had an
exceptionally low failure rate, but one that any orthodontist could equal. It's simply a matter of
following the proper procedures and, perhaps, knowing where not to bond.
DR. GOTTLIEB What are situations that shouldn't be bonded?
DR. PHILLIPS Any place where the bracket is going to be in traumatic occlusion. If we can't place
a bracket so that it will be out of occlusion, either by contouring the bracket or by positioning it
farther gingivally than usual, we simply don't put a bracket on until conditions will permit it to be
out of occlusion.
DR. GOTTLIEB What do you do if you put a bracket on and then find that it is in traumatic
DR. PHILLIPS The first thing we do after removing the transfer tray is to see if there is
interference anywhere. If there is, we use a diamond wheel in a high speed air rotor and equilibrate
the bracket or tube, but not the tooth, to get the bracket out of occlusion.
DR. GOTTLIEB Is it a problem in this regard that you do not have occluding models in the
laboratory phase?
DR. PHILLIPS If it is a full bonding, we do have an opposing model and we do use the models to
check for occlusal interferences. When we take a sectional impression, we look in the mouth with
the teeth in occlusion to see if a bracket can be placed in the customary position, which is basically
the middle third of the clinical crown. If it can be placed there without interfering with the
occlusion, we send the impression to the lab with instructions to bond to such and such a tooth. If,
on the other hand, we feel there is a real need to have a particular bracket on and we see that we
can't put it I n the usual place, we will put a note on our prescription to our laboratory technician to
place this bracket farther gingivally or toward the distal; and we always have the ability to grind
away part of the bracket if it still interferes. If we have to grind away too much, we simply remove it
and place a new one in a different position.
DR. GOTTLIEB Apart from traumatic occlusion, you feel that the bonding adhesives available
today are quite adequate for all normal chewing requirements?
DR. PHILLIPS We have instances, due to the forces of occlusion, when a patient will come in with
a bracket pad still firmly attached to the tooth, but with the bracket or tube gone. The weld has
failed, rather than the attachment of the base to the tooth. With present adhesives and proper
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technique, we don't need more bond strength. We've got all we want.
DR. GOTTLIEB What do you consider to be the latest and best in bracket bases?
DR. PHILLIPS As adhesives have become better, the base has been able to be made smaller, since
you don't need as much surface for adequate clinical bond strength. The base in widest use today is
the solid foilbacked bracket with mesh attached to it, either welded or soldered. GAC's photoetched
bases are an excellent surface, too. Smallness is helpful cosmetically, and in avoiding occlusal
interferences. But, perhaps the most significant feature of small bases is their potential for more
precise contouring to the enamel surface. The adhesives we use are more apt to contain voids, if
they are applied in thick layers. The closer fitting the bracket pad, the less chance for voids in the
adhesive that tend to cause it to fracture more easily. So, there is good reason to contour the bracket
pad for close adaptation to the tooth surface.
Another point is that if you don't have a deep thickness of material at the edge of the pad, such as
occurs using too flat a base on a convex tooth, there is going to be less area for plaque
accumulation. Beyond that, if you are using Lee's Unique or Ormco's System I, that rely on a
co-mingling of components— an A,B,A sandwich— you simply will not get as uniform a
polymerization if there is a great thickness of material. So, contouring is important and very easy to
achieve with the small present-day bases.
Setup showing small bracket bases.
DR. GOTTLIEB Do you feel that adaptation of bases is more precise using an indirect technique?
DR. PHILLIPS Yes, because in bonding indirectly, it is much easier to see if the base is well
contoured before you put adhesive on it.
DR. GOTTLIEB Is there room for more improvement in bases?
DR. PHILLIPS Ideally, a base would offer as much retention for the adhesive per surface area as
the enamel does. That is not the case right now, and the weak link in the bonding system is the
interface between the adhesive and the bracket base. Yet, something has to be the weakest link. I
don't think it is a special problem that orthodontists and the industry have to address particularly,
because the bases we have now will definitely hold up to the usual orthodontic force, with the
possible exception of headgear therapy.
DR. GOTTLIEB Do plastic brackets have a place in your practice?
DR. PHILLIPS Unless they are reinforced, in my view, plastic brackets are unacceptable for
routine edgewise orthodontics. They are satisfactory for short term orthodontics or in situations
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where tooth movement is limited or where both patient and doctor agree that they don't mind
changing brackets every three to five months due to wear and tear and discoloration. Unless there is
a metal slot, such as the Tella--Tech bracket has, plastic brackets are just not satisfactory, in my
view, because the bracket slot wears and distorts.
DR. GOTTLIEB What do you think of the cosmetic potential of plastic brackets?
DR. PHILLIPS That is their one reason for being, as far as I am concerned, and they are excellent
for a few months.
DR. GOTTLIEB Do you find that patients favor them on occasion?
DR. PHILLIPS Many adult patients definitely favor them. When I start an adult patient, if they ask
about "invisible" braces, we show them what they are and point out the drawbacks. If they insist on
it, I will use plastic brackets, but I also tell them that we may have to change to metal brackets for
part of their treatment. In fact, they may want us to do so, because when they discolor enough, many
adults in my practice come to feel that they really don't look nice after all and they are happy to
settle for metal brackets. I have very few patients in my practice with other than metal brackets, but
this is not to say what we are doing now is what we will be doing a year or two from now.
DR. GOTTLIEB Do you ever use bands?
DR. PHILLIPS We use bands routinely on upper and lower first molars. We routinely bond second
molars. Other than some transfer cases, I have no patients with bands other than on the four first
molars. I would modify that to say that I do have a few patients with porcelain jacket crowns and I
use bands for them. It is possible to bond to porcelain with such materials as Den-Mat, but this can
present a problem at debonding, unless the jacket is to be replaced.
DR. GOTTLIEB Are the first molars banded because you use headgear?
DR. PHILLIPS That's correct as far as the upper molars are concerned. I have not found it practical
to use bonded attachments with headgear, because you can't depend clinically on the patient being
sufficiently careful. With everyday orthodontics, you are going to have attachments come off with
headgear to bonded tubes.
DR. GOTTLIEB The leverage is great.
DR. PHILLIPS That's right. So, we see no reason to try. We think we are going to come out far
ahead in time-saving with less breakage, if we use molar bands with headgear.
DR. GOTTLIEB Why do you use molar bands on the lower arch?
DR. PHILLIPS We use first molar bands in the lower arch simply because, for most of my patients,
the first molar attachment is the last one in the arch during most of their treatment. The most distal
attachment in the mouth is the one that is closest to the fulcrum of the temporomandibular joint and
is going to receive the strongest occlusal forces. If anything is apt to come off, it's the one farthest
back, due to heavy chewing forces. Another consideration is that if a patient comes in with any
attachment loose other than a molar tube, we may elect not to replace it at that appointment. If it is a
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molar tube, I nearly always feel that it must be replaced immediately. I just can't live with anything
more than a very minimal breakage rate. Later in treatment when we include second molars, we
always bond them. I can't tell you how many years it has been since I have banded a second molar.
DR. GOTTLIEB In part is that because of the ease of access with bonds as opposed to bands?
DR. PHILLIPS Yes. It is so easy to bond a second molar, particularly with an indirect technique,
that I really can't think of a good reason for doing it any other way. Precise positioning is very easy
to achieve with a one-tooth template. You can put a tube on a tooth when perhaps only a third to a
half of the buccal surface is available. In years past, we used to defer putting attachments on second
molars because they had not erupted enough, but we just don't think about that any more. We take a
sectional alginate impression and the next time we see the patient, we put on a tube or four tubes—
whatever the case happens to need— without a special appointment.
DR. GOTTLIEB Is access to the template a problem in bonding second molars?
DR. PHILLIPS No. Looking at the template on the model tells me exactly what it should look like
when I have it in the right place in the mouth. For convenience in reaching back to the second molar
area, we simply stick a scaler into the silicone tray to facilitate placing it that far back in the mouth.
Holding one finger on the tray, the scaler is removed, and we continue to hold the tray with the one
finger until the adhesive has set, timing it with a stopwatch.
DR. GOTTLIEB How much eruption is enough to bond to, on a second molar for example?
DR. PHILLIPS On some second molars there may not be much buccal surface available. I use an
American Orthodontics tube that is only 2mm long on teeth that are not erupted enough to
accommodate a standard buccal tube. This allows us to get the tooth into pretty good position very
early in treatment. Incidentally, because we know that we are going to put attachments on virtually
all second molars, we use only convertible tubes on the first molars, so that we can convert them to
brackets, both upper and lower.
Taking the impression.
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The impression.
Tray in place.
Second molar attachment bonded.
DR. GOTTLIEB Do you ever do any direct bonding?
DR. PHILLIPS We do some direct bonding. We bond all lingual attachments directly and we will
occasionally — maybe three times a month— bond an incisor or cuspid bracket directly on a tooth
that was not fully erupted, or is in such a position that we did not want to bond it initially, or if we
are replacing a bonding failure.
DR. GOTTLIEB What decides you to go direct in those instances?
DR. PHILLIPS If the tooth is very easily accessible and not particularly malshaped or
malpositioned, we'll bond directly. It is generally in a situation where we consider the precise
positioning of the attachment to be the least critical part of the whole operation, such as with a
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lingual button or hook. In unusual places, such as the occlusal surface of an impacted tooth, we
bond directly.
DR. GOTTLIEB Do you place labial and lingual attachments in the same tray at the same time?
DR. PHILLIPS We do it occasionally, but not routinely. When we do it, we score the tray down the
middle to make it even more flexible labiolingually to avoid smearing the adhesive. When it is
smeared, we have to clean it off, and I'd just as soon not have to. We routinely bond lingual
attachments directly.
Tray scored for bonding labially and lingually.
Figure-8 hook.
DR. GOTTLIEB What kind of lingual attachments do you use?
DR. PHILLIPS Any place where we formerly placed a lingual button to attach an elastic thread or
ligature wire, we now make a little figure-8 hook of .016 wire and bond that. The two loops of the
figure-8 are at right angles to each other. If there is not room on the lingual of a rotated tooth to
bond a button or hook, we place the hook on the mesial, rotate the tooth, remove the hook, and close
the space. We do not hesitate to place the hook anywhere the occlusion will permit. We can form it
in a minute or less and custom-fit it. The hook fits in places where a commercially made button
would not fit or not fit well.
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Figure-8 hook in action.
DR. GOTTLIEB Do you routinely bond to all impacted teeth?
DR. PHILLIPS Yes, and direct bonding has a strong application with impacted teeth. We routinely
bond to impacted teeth that have been exposed. We have not ligated or pinned an impacted tooth for
several years. Bonding allows a more conservative surgical procedure in most cases.
DR. GOTTLIEB How do you handle the prophy preparation of the impacted tooth surface?
DR. PHILLIPS The impacted tooth has never been in the oral environment and does not have a
pellicle, which is formed from the salivary proteins. So, you don't need to scrub the tooth surface.
We don't even clean off the debris particularly well.
Impacted tooth exposed.
Gel applied.
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Gel rinsed off.
DR. GOTTLIEB Could you describe the bonding technique you use for an impacted cuspid?
DR.PHILLIPS In the first place, I try to be present at the surgery, to see the location of the tooth
and to see that tissue is removed to my satisfaction. I generally have the patient come to the office
about a week after surgery, with the periodontal pack in place. I remove the pack, place the acid gel,
wash it off, and go through our sealant and adhesive system procedures. The etching gel is much
preferable to a liquid in this area, because these teeth are pretty well in a hole. The gel can be placed
exactly where you want it on the tooth surface and not onto the soft tissue, particularly if you use a
syringe to dispense the gel. We get such an excellent etch on these teeth, because they have not been
exposed to the oral environment. Also, we don't worry about flash in such cases until later, when we
have moved the tooth to a more accessible position. We are very careful during the air-drying step to
avoid pressure that could cause hemorrhage.
DR. GOTTLIEB What other uses do you make of bonding?
DR. PHILLIPS I use it for retention of removable appliances. If the nature of the spring or clasp
and the shape of the teeth would tend to dislodge a removable appliance, we build a bulge of
adhesive on the tooth surface to create an undercut for the clasp or spring to make the appliance firm
and comfortable for the patient. We use a similar device to position an elastic over a flared incisor
and also to rotate teeth. We place a little adhesive on the tooth where we want a little extra pressure.
Etched surface dried.
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Sealant applied.
Attachment placed.
Bonded attachment tied In.
DR. GOTTLIEB The appliance is made from an impression of the untreated surface and then the
bulge is added?
DR. PHILLIPS That's correct. It puts a little extra push at that point. We also use the adhesive to
build out the contour of small teeth to close diastemas due to tooth size discrepancy. For example,
for a small lateral incisor that will be built out with a jacket following treatment, we build out during
treatment with adhesive to close the space. It stabilizes the area and looks somewhat better than the
gap between the teeth.
If a headgear patient has a band come off more than once, we bond it.
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Retention ledge of adhesive.
Retention bulge of adhesive.
Elastic engaged on retention ledge.
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Retainer clasp engaging retention bulge.
Diastema closed with adhesive.
DR. GOTTLIEB What is your technique for that?
DR. PHILLIPS We make as many holes as we have room for all around the band with a half-round
carbide bur in a high speed handpiece; carefully, because it is a slippery surface and you can hurt
your finger. We etch the tooth surfaces we can reach and bond by conventional technique directly.
We don't try to do this indirectly. There is no need.
Etching selected tooth areas.
Adhesive bulges applied.
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Positioner exerts pressure on adhesive bulges.
Band prepared for bonding.
DR. GOTTLIEB You perforate the interproximal part of the band?
DR. PHILLIPS Yes, because the perforations are for the mechanical interlocking of the adhesive to
the band. We're not concerned with whether or not we have etched the interproximal tooth surface.
The basic retention is from the buccal and lingual etched surfaces as far as attachment to the tooth is
concerned, but we want to interlock the band mechanically all around. This is a very effective way
of keeping headgear bands on.
DR. GOTTLIEB Are these bonded bands trouble to remove?
DR. PHILLIPS In most cases, you can remove them with conventional band removing plier
technique. If one is particularly stubborn, you can section it with a bur and remove it that way.
DR. GOTTLIEB Do you bond lower 3-3 lingual retainers?
DR. PHILLIPS Yes, and we do it indirectly. We fit the wire to the teeth on the model, make a
small bend in each end of the wire where it will overlay the lingual aspect of the cuspid teeth, make
a mound of adhesive that completely covers the lingual surface, then make an overlay tray and
transfer the whole thing to the mouth, bonding indirectly, as we routinely do. We bond 6-6
transpalatal arches in the same manner.
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Bonded lower lingual retainer.
Bonded transpalatal arch.
DR. GOTTLIEB Do you bond retainers for maxillary teeth?
DR. PHILLIPS We make a maxillary lingual bonded retainer with braided wire. You have to be
careful that the composite does not extend across the interproximal. These materials have an
extremely high compressive strength, but pretty low shear strength. If you bond across the
interproximal areas, the material will fracture. You also have to be aware of the occlusion. You can't
do this if the lower incisors are going to bite against it. An alternative way we do this is with
separate pieces of wire, one piece holding the centrals together and another for the central-to-lateral
on each side.
DR. GOTTLIEB Do you go to the labial side if you can't bond the lingual?
DR. PHILLIPS You can. Of course, it is not as esthetic.
DR. GOTTLIEB Do you bond an expansion appliance?
DR. PHILLIPS Yes. I think there are significant advantages to doing it in this fashion, and we have
been doing these for at least five years. The advantages include the fact that they are simple to
fabricate and no tooth separation or band fitting is required. Beyond that, the entire buccal segment
can be firmly encased in the acrylic, which I feel results in less alveolar bending and gives you as
stable an attachment as you could possibly have. Another advantage is that the appliance can be
placed at a very early age.
DR. GOTTLIEB How early an age would you consider?
DR. PHILLIPS My philosophy for expansion appliances is that if there is a skeletal crossbite that
requires palatal expansion, you can't do it too early. The patient has to be emotionally able to handle
it. No matter how short the clinical crowns, you can bond this appliance. You make it from one
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impression, with no further contact with the patient until the day you put it on. So, this is a very
atraumatic way to construct and place an expansion appliance.
Upper lingual bonded retainer.
Alternate upper lingual bonded retainer.
Upper labial bonded retainer.
DR. GOTTLIEB Does the fact that the entire posterior occlusal surfaces are covered create any
special problems?
DR. PHILLIPS I don't think so. No matter how expansion appliances are constructed, within a day
or two the occlusion is destroyed anyway. The appliance is only in place 3 to 5 weeks at most, and
in that length of time I'm not concerned with any permanent bite opening. It just doesn't seem to be a
DR. GOTTLIEB What kind of spring do you prefer in the expansion appliance?
DR. PHILLIPS We use a spring-loaded expander called a Minne Expander. We adapt the bars on
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each end of the spring to the lingual surfaces of the teeth, as if we were going to solder them to
bands. Then you can make the acrylic tray that covers all the posterior teeth, either by a pepper and
salt technique or with a Biostar machine or vacuum-forming machine. After removing the appliance
from the model, we perforate the acrylic trays because we are only looking for mechanical retention
here. We're not concerned with whether there is any chemical bonding between the adhesive and the
DR. GOTTLIEB How much etching do you do?
DR. PHILLIPS You have to be careful not to have more bonding retention than you want. These
appliances have tremendous retention on deciduous and adult teeth. In fact, with fully erupted adult
teeth, we etch only the buccal and lingual surfaces. If you etch the entire crown, you would simply
have to carve the entire appliance off with a bur. If you only etch the buccal and lingual, you can
generally break the appliance off in pieces, using posterior band removing pliers.
Minne Expander on model.
Finished expansion appliance.
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Bonded expansion appliance.
DR. GOTTLIEB On deciduous teeth you do etch the occlusal?
DR. PHILLIPS Yes. On deciduous teeth or any teeth with extremely short clinical crowns, say a
crown height of only 1mm, we do etch the occlusal surface.
DR. GOTTLIEB In such cases, do you use the same adhesive, or a more lightly filled one?
DR. PHILLIPS We use Concise, but in this case, we mix it in a proportion that gives us 3 to 4
minutes setting time, so that we have plenty of time to fill both halves of the appliance and seat it
DR. GOTTLIEB How soon after the adhesive has set can you make your first adjustment in the
DR. PHILLIPS We rarely wait more than 10 minutes. We hold the appliance in place for 5 minutes
and then we let the patient get up and stretch a bit and rinse their mouth. By that time, we are ready
to wind the spring. The spring of the Ormco Minne Expander is set by the operator. The patient does
not adjust this spring. The patient comes to the office once a week and the doctor winds the spring. I
prefer it, because I have control and it also gives me an opportunity to observe the patient at weekly
DR. GOTTLIEB What is you opinion about recycling and reusing metal brackets?
DR. PHILLIPS Probably 25% or 30% of metal brackets can be reused. The majority of brackets
are damaged either during treatment or during the debonding procedure; so most of them are not
usable more than one time. If, under strong magnification, the bracket slot appears undistorted and
the bracket base and mesh are still in good shape, I see no reason not to use them at least one more
DR. GOTTLIEB What is your procedure for recycling brackets?
DR. PHILLIPS First of all, we put the brackets in separate containers at the time of debonding, to
avoid having to sort them later. Following removal from the mouth, we burn off the composite in
the Esmadent Big Jane unit. Then we clean the bracket in the ultrasonic cleaner solution and place
them in the polishing part of the Big Jane unit. The brackets that we do recycle appear to be very
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jul(462 - 480): JCO Interviews Dr. Homer W. Phililps Part 2
"Big Jane" reconditioner and polisher.
DR. GOTTLIEB Many orthodontists tell me that bonding attachments isn't the problem, but that
debonding is. Do you feel the same way about debonding?
DR. PHILLIPS I don't consider debonding to be a problem. There is ample instrumentation in the
form of diamond or carbide burs in a high speed air rotor, to remove composite from the tooth. Of
course, this must be done with care to avoid marring the tooth surface. Debonding involves getting
the bracket and the bulk of adhesive off the teeth and then polishing the tooth surfaces following
DR. GOTTLIEB What do you use to accomplish the first part?
DR. PHILLIPS In the early days of debonding, we still had a debanding mentality and tried using
typical band removing pliers, which didn't work so well. We were putting tremendous stresses on
the teeth in that way. Although I never saw it happen, I was concerned about fracturing a cusp or an
incisal edge. We now know that the simplest way to get brackets off is to use a shearing type of
instrument, such as a ligature cutter, with the blades held flat against the tooth surface. As a rule,
this causes fracture within the adhesive and the bracket comes off very easily. I feel that good
debonding starts with proper bonding. If the bonding adhesive has been put on only in the required
amount, there simply isn't as much to take off and the problem is simplified to begin with.
DR. GOTTLIEB After popping the bracket off as you described, how do you handle the adhesive
that still remains on the tooth?
DR. PHILLIPS Much of the remainder can be removed with the same shearing type instrument.
These are made with blades at various angles to facilitate removal in various quadrants. Depending
on the type of adhesive and the quantity, some of it can be removed with a hand scaler, but this is
quite difficult with the harder materials. My preference, following the use of the ligature cutter, is a
straight fissure carbide bur in a high speed handpiece, turned rather slowly at 100,000 to 150,000
rpm. The specific bur that I prefer is a #1157 which has a rounded tip rather than a truncated tip and
no sharp edges at the end of the cylinder which might scratch the teeth.
DR. GOTTLIEB Do you use the bur in a wet field or a dry field?
DR. PHILLIPS We generally do this in a dry field. We place a cotton roll in the area where we are
working and dry the teeth. We prefer to use air directed at the working site as a coolant, rather than
using a water spray. A water spray would be more effective as a coolant, but would obscure the
view. So, we work with a dry field. This requires using a high speed vacuum, because the bur
turning at that speed turns the composite into dust, which the vacuum takes away.
DR. GOTTLIEB Does the carbide bur work better in a dry field?
DR. PHILLIPS I'm not sure of that. My reason for working in a dry field is strictly for visibility. I
want to see precisely what I am doing.
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jul(462 - 480): JCO Interviews Dr. Homer W. Phililps Part 2
Carbide bur used In debonding.
Pumicing following debonding.
DR. GOTTLIEB Do you use loupes at this stage?
DR. PHILLIPS I do. I find that I can see things with loupes that I can't see any other way. The
nearest thing to it is when you enlarge slides with a projector. You see things that you simply do not
see clinically. With loupes, you find what you thought was good bonding with no flash, actually
does have flash. And, you can remove composite with a bur more carefully. There is no bur that
cannot scar tooth enamel, but if you do this step carefully, there is a minimum of scarring and it
removes the material quite rapidly.
DR. GOTTLIEB And then you polish?
DR. PHILLIPS Right. Following removal of the composite adhesive with the carbide bur, the tooth
surfaces are pumiced thoroughly with a prophylactic instrument. This is a most important and
necessary step if you are trying to end with a very smooth tooth surface. My object is to leave the
surface at least as good as it was to begin with.
DR. GOTTLIEB Is that evaluation of the finished surface with a loupe or with the naked eye?
DR. PHILLIPS With a loupe.
Soflex discs used following pumicing.
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jul(462 - 480): JCO Interviews Dr. Homer W. Phililps Part 2
DR. GOTTLIEB Does the pumicing conclude the debonding process?
DR. PHILLIPS The teeth generally look pretty good following the pumicing, but a step beyond that
must be taken if you are looking for the most highly polished tooth surface you can get, especially
on flat incisor teeth. That step is to use a series of finishing discs in a low speed contrangle
DR. GOTTLIEB Which discs do you use?
DR. PHILLIPS The ones we have found most effective for this purpose are the 3M Soflex Disc
Series which comes in 4 grits— coarse, medium, fine, and superfine. If you are looking for the best
surface, you can't take shortcuts here. You must use all four discs. You have to program yourself to
the fact that you are going to have to take these steps, if you want the best surface you can make. It
almost takes more time talking about it than it does to do it. It takes about three minutes for the four
upper incisors and I think I owe it to the patient to spend those three minutes. The teeth will look
nicer and will be more plaque free.
DR. GOTTLIEB These discs are too fine to take the place of the pumice, I would gather.
DR. PHILLIPS Well, yes and no. The pumicing does things that a disc can't do because of better
access of a prophy cup versus a disc. You can't do the interproximal surfaces as well with the discs
alone as you can with the pumice followed by the discs. We have tried many combinations and find
that pumicing followed by the full four-disc series results in the best surface. We've used various
polishing pastes. We've used rubber wheels. We've used mounted points. We always come back to
the method I described. It will leave a very highly polished surface in a very short period of time.
Following debonding procedures.
DR. GOTTLIEB Do you consider decalcification to be much of a problem with bonding?
DR. PHILLIPS As far as I am concerned, the only significant problem that remains in bonding is
decalcification around the bracket pad. The key to avoiding it is good oral hygiene, but not all
patient are excellent brushers. The next best thing to routine good home care is office fluoride
treatments. At our bonding appointments, we routinely give a fluoride treatment immediately
following bracket placement, and we urge the use of a fluoride gel as part of home care. I am
looking for a system that will protect even the poor brusher from decalcification. I am working with
such a system at present, which shows promise of greatly reducing the amount of decalcification
suffered by poor brushers.
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jul(462 - 480): JCO Interviews Dr. Homer W. Phililps Part 2
DR. GOTTLIEB Are you much concerned about decalcification under the bracket, due to voids or
DR. PHILLIPS No. We don't have that as a rule. The sealant isn't exposed to air under the bracket,
so it does polymerize totally there. Beyond that, it's a matter of knowing how much adhesive to put
on and examining it carefully after we've bonded. If there is a gap somewhere, we've got a mistake
we can correct right then.
DR. GOTTLIEB A question was raised whether removing the interproximal protection of bands
resulted in increased- interproximal caries. Is that still an issue?
DR. PHILLIPS I don't consider it an issue. In my own practice and in other bonding practices that
I'm familiar with, we simply do not see an increase in interproximal decay compared to banded
cases. There is an extremely low incidence in my practice. The fact that it is easier to brush is one
part of it, and another is that we don't have loose bands or bands with cement partially washed out
being left on a tooth for a period of time.
DR. GOTTLIEB I think that the fundamental advantages of bonding over banding have been
glossed over. It isn't only that it may be easier and look better. To my mind it's the matter of patient
comfort, and getting rid of separation, band fitting, and the thickness of interproximal band material.
To me, these alone would justify bonding, without any of the other factors involved.
DR. PHILLIPS They would indeed, and we could add not having to be concerned about closing
band spaces and the ability to take bite wing x-rays at any time during treatment to check for
interproximal decay without removing the appliance. There are many advantages to the patient and
the orthodontist, but the main one would have to be patient comfort.
DR. GOTTLIEB Most orthodontists who bond favor a direct technique over an indirect one. They
say that indirect takes more time and is no more accurate.
DR. PHILLIPS Certainly the overall time is greater using an indirect technique, but chair time for
the patient and the doctor is much reduced. In addition to saving chair time during bonding itself, an
important consideration is time saved by having the brackets in the right place on the teeth. This
means that there are fewer bends to be made in every archwire throughout treatment, and this is
where you really save time. At least for myself, using the indirect technique that I have described, I
cannot place brackets as accurately by any other method.
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jul(481 - 488): Common Sense Mechanics Part 11
Common Sense Mechanics
Simultaneous Cuspid and Bicuspid Retraction
During the discussions on cuspid retraction, bicuspid retraction, and molar protraction, it was
seen that location of the bend in the extraction site determined the anchorage side. It was also
emphasized that as the interbracket distances become smaller, the bend in effect becomes located
closer to center, even if placed immediately against either bracket (tube) adjacent to the extraction
site. The closer the bend is to the center, the lesser the differential torque. If the bend is placed in the
center, the moments are equal and opposite. So, the more critical the anchorage, the more distant the
bend should be from center. Even temporarily avoiding banding of the second bicuspids, during
cuspid retraction, was discussed and demonstrated.
The case in Figure 126 presented in my practice following removal of the upper first bicuspids
only. She had a Class II malocclusion with lower anterior crowding. I had the lower second
bicuspids removed and planned on maximizing lower intraoral anchorage until sufficient space was
gained following cuspid and bicuspid retraction, at which time I would align the lower anteriors. In
the upper arch, there were no anchorage problems, so the plan was to retract the cuspids only
enough to break the contacts between the anterior teeth for alignment and space closure in the
extraction site.
A minimal appliance was placed (Fig. 127), involving only the first molars, bicuspids, and
cuspids. An .016 archwire was placed, and it can be seen that wire/bracket engagement resulted in
activation due to the malocclusion itself. This automatically produces the initial periodontal
response for tooth movement. It can also be seen that the bracket ties were not placed next to the
extraction sites on the lower first bicuspids, as rotation during space closure was desired.
Figure 128 shows placement of the bends intraorally. Note in the upper arch that the bends were
placed in the center, because this produces equal and opposite moments with no effective
anchorage. Some deformation can be seen. This deformation will tend to occur if the archwire bends
are placed prior to attaining reasonable bracket alignment. When this does occur, the Tweed loop
pliers can be placed over such bend at the following visit, and the bend reactivated.
In the lower arch, notice that the bends are located toward the molar tubes, indicating that this is
the anchor side of the extraction site. If desired, the bend can be placed in the archwire outside of
the mouth, thereby permitting closer placement to the molar tubes and thus a greater distance from
the center of the wire lying across the extraction sites. You might notice and wonder why the 360°
tieback loops are bent in the direction shown, since good spring design calls for a wire to continue
bending in the same direction as formed, when it is activated by wire/bracket engagement. The
answer simply is that this is not the ideal design. But it is easy, practical, and works. It can be any
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jul(481 - 488): Common Sense Mechanics Part 11
loop you wish, made in any manner you choose.
The occlusal views (Fig. 129) show the minimal strap-up in this case. I would like to again
emphasize the importance of putting in toe-in bends at this point to create a counterrotation for
space closure, as the terminal teeth (molars) will attempt to undergo a mesiolingual rotation. For a
long time, I was guilty of this error, and I can assure you it is a lot nicer not to produce an
undesirable molar rotation than it is to correct one with the archwire only, especially since I use no
lingual attachments and therefore no lingual elastics. If you use lingual elastics, you are not faced
with the same problem. I used to place my toe-in bends after beginning space closure, but strongly
recommend placement prior to this time. It is not necessary to worry about overrotation, as this
situation can easily be corrected— simply by engaging an elastic from the molar tube to the bicuspid
bracket at the end of treatment. The archwire, in such case, would be fully engaged in the bicuspid
bracket and would also terminate at this point. Simply cut off the wire distal to the bracket.
In Figure 129, notice that the lower crowding occurs all the way from bicuspid to bicuspid. It
probably SEEMS ridiculous to even consider the idea of retracting cuspids and bicuspids against
first molars, but it will be done. This is in direct contrast to those who guard anchorage so closely,
that only a single tooth is retracted at a time. Also note that the bicuspids are rotated, as any distal
force applied at the bicuspid brackets will cause such teeth to rotate— in this case, desirably. Since
the "Cue Ball Concept" can be applied here, it makes sense to retract the bicuspids first, thus
obtaining needed space and accomplishing the rotations at the same time.
As we follow the lower progress (Fig. 130), we can see that retraction elastics are placed from the
bicuspids to the first molars. I no longer use an elastic thread, but a power chain instead. Whatever
provides the necessary force is fine and the choice is yours. The cue ball concept tells us that since
the force (distal) is being applied at the bracket which is located off center (buccal) from the crowns,
the bicuspids ("cue balls") should rotate and move in a line distally. Figure 131 shows that this
occurs. Now that the bicuspids have been partially retracted and rotated, the bicuspids and cuspids
will be retracted simultaneously to gain further space for the incisors. Note the crowding that existed
from the start, so that we can CLINICALLY evaluate the response. In Figure 132, the elastics are
attached from the molars to the cuspids.
As the maxillary cuspids are retracted, using only a center bend, it can be observed that the
contact areas are separating (Fig. 133). No attempt is made to conserve anchorage.
Observe in Figure 134 that the upper extraction spaces have been almost closed. The center bend
continues to produce equal and opposite torque for root paralleling, and the space closing elastics
prevent the extraction spaces from reopening. Remember, the equal and opposite moments from the
archwire tend to bring roots "together" and crowns "apart". If you will look at the original
malocclusion (Fig. 126), you will note basically the same molar relationship. Remember, no attempt
was made to restrain maxillary molars from moving forward some. But, since we are analyzing
movement by clinical observation, we must apply "common sense". The lower molars COULD be
moving forward and thus be deceiving our clinical interpretation. You can see that the lower first
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jul(481 - 488): Common Sense Mechanics Part 11
molars are maintaining a reasonably upright condition, while the lower bicuspids and cuspids are
Today, at this point, since the cuspid relationship is now Class I, I would normally bond the
incisors and begin lower molar protraction. But, I decided for photographic purposes to continue
retracting the bicuspids and cuspids. This means that since the upper extraction spaces are closed,
further change in cusp relationships will tell us clinically what is taking place in the lower arch. We
can also relate these changes to the remaining spaces and the original crowding and arrive at further
supportive conclusions.
Next (Fig. 135), further retraction is observed and significant lower anterior spacing has
occurred. The molar relationship remains pretty much the same, but the lower cuspids have now
been retracted into a Class II relationship. When the molar starts to exhibit tipping, as seen on the
lower right side, too much force is being used. The tooth should be allowed to upright before
continuing further space closure.
In Figure 136 there remains significant extraction space on the patient's lower left side in spite of
all the space gained in the anterior. The lower left molar is a good example of what I mean when I
say it is necessary to place an early toe-in bend for counterrotation. Lingual elastics could prevent
this mesiolingual molar rotation, but I do not use lingual attachments for reasons I will later discuss.
Keep in mind that we started with differential torque, and this differential is gradually diminishing
as the interbracket distance continues to become smaller.
After space closure was completed, the incisors were banded and the anterior spaces closed (Fig.
137), and then the mechanics were reversed with Class II elastics. This was not the original plan,
remember. It was first planned to protract lower molars after retracting the cuspids into a Class I
relationship, and the plan was altered for photographic purposes. But, at the same time, you can see
that a "cookbook" routine does not have to be followed.
The occlusal views at this stage (Fig. 138), show that toe-in bends are still being used for
rotation, and for the FIRST TIME, spaces are observed distal to the lower first molars as a result of
reversing mechanics with Class II elastics.
Following appliance removal and during night retention (Fig. 139), the anchorage effects can still
be observed. On completion of space closure, the anchor bend (off-center) became a center bend
and resulted in equal and opposite moments producing root parallelism between first molars and
first bicuspids. The lower cuspid roots, however, did not receive the "direct" effects of these
moments as evidenced by their inclination. This is why I say we can be "practical" when we think of
only the teeth adjacent to the extraction site, as the force system has its most direct effect here.
Eventually, other teeth are affected, but I think the effect of the molar moment, here is quite
obvious. Since the anterior-posterior position of the maxillary incisors remained unchanged, zero
overjet before and after treatment is additional clinical evidence of the net movement in the lower
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jul(481 - 488): Common Sense Mechanics Part 11
I realize the word "clinical" has been used frequently. This is in no way intended to be opposed to
the taking of routine progress headfilms, etc. Because there are many ways to treat cases, and many
variations in interpretation of headfilms, it seems only logical to me that we should have the
additional tool of "clinical judgment". Some seem to possess this attribute from birth, but it can be
learned if one possesses the important tool of "common sense". There are many changes occurring
each day before our very eyes as we treat our patients. Realistically, we are not going to take a
progress headfilm everytime a patient comes through the door. By the time the film is developed,
traced, and analyzed, the patient has usually left the office and the appliance is back at work. I think
we should be capable of deciding what the appliance should do BEFORE the patient leaves the
Fig. 126
Fig. 126 Case presented with upper first bicuspids extracted.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jul(481 - 488): Common Sense Mechanics Part 11
Fig. 127
Fig. 127 Minimal appliance placed.
Fig. 128
Fig. 128 Placement of intraoral bends in archwire.
Fig. 129
Fig. 129 Occlusal views of minimal appliance placed.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jul(481 - 488): Common Sense Mechanics Part 11
Fig. 130
Fig. 130 Retraction elastics placed from molars to bicuspids.
Fig. 131
Fig. 131 Cue ball effect results In rotation of bicuspids with retraction.
Fig. 132
Fig. 132 Retraction elastics placed from molars to cuspids.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jul(481 - 488): Common Sense Mechanics Part 11
Fig. 133
Fig. 133 Incisors space as cuspids retract.
Fig. 134
Fig. 134 Upper extraction spaces almost closed, with no apparent change in molar position.
Fig. 135
Fig. 135 Significant lower anterior spacing with further retraction.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jul(481 - 488): Common Sense Mechanics Part 11
Fig. 136
Fig. 136 Significant space both anteriorly and in the extraction site.
Fig. 137
Fig. 137 Anterior spaces closed.
Fig. 138
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jul(481 - 488): Common Sense Mechanics Part 11
Fig. 138 Occlusal views. Toe-ins still In place for molar rotation.
Fig. 139
Fig. 139 Case in retention.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jul(489 - 489): Technique Clinic - A Simplified Technique for Fabrication of Surgical Archwires
technique clinic
One of the final, important duties of the orthodontist prior to surgery in surgical-orthodontic cases
is the fabrication of heavy ideal archwires for jaw fixation after surgery and for elastic wear
postfixation. Traditionally, brass spurs are soldered to the wires at premarked locations. This
procedure is time-consuming and frustrating, as anyone who has soldered a spur at the wrong
location or angulation can attest. We have been using a procedure that we find easy and accurate.
Once the final surgical archwires have been fabricated and worn by the patient for a period of
two weeks, the patient is again seen for impressions for a splint and setup, and for placement of
surgical spurs. Without removing the archwire from the mouth, split sliding hooks ( Fig. 1), size to
correspond to archwire size, are placed in the interproximal area (Fig. 2) with the hooks bent, cut,
and adapted for the specific interproximal area. They are lightly crimped in position until all are
positioned ideally. Then, hardwire cutters are used to crimp the spurs securely in place ( Fig. 3). The
spurs should be tested to make sure that adequate crimping has been done.
Aside from the ease of fabrication, an advantage of this technique is that the final archwire can be
left in the mouth, avoiding the introduction of any new tooth movement once the surgical splint and
surgical models have been fabricated.
Fig. 1
Fig. 1 Split sliding hook.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jul(489 - 489): Technique Clinic - A Simplified Technique for Fabrication of Surgical Archwires
Fig. 2
Fig. 2 Hook placed and lightly crimped.
Fig. 3
Fig. 3 Hook crimped securely with hardwire cutter.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jul(490 - 499): Orthodontic Economics - Population
Demography is the statistical study of population size, growth, distribution, and migration; the
relationship of these to other vital statistics; and their affect on social and economic conditions.
Demography and the application of its data is made difficult by the uncertain nature of the data
itself. Even the actual decennial census "counts" are admittedly inaccurate. From them and estimates
and projections made from them, and from interim samples, an enormous amount of more or less
inaccurate data is compiled and published by the Bureau of the Census. It is probable that
comparing figures supposedly drawn from the same assumptions and methods should be approached
guardedly, but it is almost certain that charts from two different sets of assumptions and methods are
not comparable. In addition, the data are subject to both sampling and non-sampling errors, and
there is no calculation of the non-sampling errors. This does not mean that the data is useless. It
does mean that one must be very careful to understand how the numbers were derived, what they
really mean, and how accurate they really are.
Population Movement
Recent population estimates (Census Bureau Series P-25, No. 876, February 1980) reflect
changes in the period from 1970 to 1979 (Table 1) largely due to population movement. The leading
states to gain in numbers from this process have been California, Texas, and Florida, followed by
Arizona, Colorado, Virginia, Georgia, North Carolina, and Washington. However, in the last half of
the decade growth rates of the retirement states of Arizona and Florida markedly slackened. Nevada
had the largest percentage rise (43.6%) in this period.
Three states— New York, Pennsylvania, and Rhode Island— and the District of Columbia lost
population between 1970 and 1979. District of Columbia showed the largest percentage fall
(13.3%). Most the states in the Northeast (with the exception of New Hampshire, Maine and
Vermont) and in the North Central regions had only limited growth. The Northeast had almost no
net population change; North Central States grew less than half as fast as the nation as a whole. The
West (18.1% increase) and the South (13.9% increase) grew much faster than the national average.
Florida (30.5% increase) and Texas (19.5% increase) grew several times faster than the national
average. Nine of the thirteen western states (Pacific and Mountain) grew by more than 20%.
Montana (13.2% increase), California (13.6% increase), and Washington (15% increase) were the
only states in the West which did not grow at least twice the national average rate.
The Series II-B data are use in Table 1, because this series is based on an assumption that
population migration in the future will be more likely to resemble the immediate past than the
distant past or a model with no migration at all.
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jul(490 - 499): Orthodontic Economics - Population
Changes In Age Structure
Changes in the age structure of the population between 1970 and 1979 are shown in Table 2.
Significantly for orthodontists, the population under 5 dropped almost 9% and the 5-13 age group
declined by 16.4%. These are the only two groups to decline in the period, but they are the youngest
level of population . Their decline will be carried through the older age groups as years go by, and
be reflected there. The 14-17 group showed a slight increase (2.7%). The largest increase was in the
18-24 (19.7%) and 25-34 (39.3%) groupings.
In the next ten years, the 25-34 age group can be projected to grow, but at a slower pace, because
the 15-24 age group which will be moving into the 25-34 age category has grown at a lesser rate,
even though their numbers are somewhat larger than the present 25-34 group. The projection is that
the growth of the 25-34 age group should slow to about 16.67% in the next ten years, while the
14-17 age group will show a decline and the 5-13 age group will continue to decline, but not as
sharply as in the recent past.
In the next ten years, the 7-17 age group, which is generally considered to be the orthodontic
child population, will show an annual decline (Table 3) until 1986. This will be a decreasing rate of
decline, but the real question is, as far as the future of the orthodontic child population is
concerned— What will happen to "Live Births" in the years ahead?
Birth Rate
The period from 1946 to 1961 is called the Post World War II "Baby Boom". In that period there
was a 50% increase in births. 1961 to 1976 is referred to as the "Baby Bust". In that period there was
a 25% decline in births. This was followed by a "turnaround" in births in 1977 and in 1978 (Table 4).
There is a belief in some quarters that the decline in the 7-17 age group will reach zero in 1986
and then increase to recover the 1961 level due to this "turnaround" in births. The basis for this
belief is that the sheer numbers of females of childbearing age from the Post World War II "Baby
Boom," even with a lowered fertility rate, will produce a steady increase in births, and that females
in the 30 to 34 age group are having late babies. Substance was given this idea by the fact that births
did increase 5% in the calendar year 1977 (Table 4), and by the birth data on females age 30-34
(Table 5). Many observers decided that this was going to be sustained annually for the foreseeable
future. Unfortunately, this has not happened. Births for calendar year 1978 were virtually the same
as 1977— almost no increase at all. Averaging the 5% increase in 1977 and an, at most, .6%
increase for 1978 may have been the basis for many to then believe that there would be an annual
increase of 3% to 5% in the next ten years.
It is in the nature of mathematics that it is much easier to decline than to increase. To recover
completely from a 25% decline in births would require a 33.33% increase in births. Even in the most
unlikely event that the optimism of the annual 3.0% increase in births were realized, it would take
about another 10 years to recover; and, while it would be increasing the number of children in the
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jul(490 - 499): Orthodontic Economics - Population
younger orthodontic age groups each year, it does take 7 years to reach minimum average
orthodontic age under present treatment modes. The best we could expect would be a recovery of
the 1961 birth rate by 1992, with the full impact of it in the orthodontic office by 1999. Beyond all
that, and beyond sheer optimism, there is no basis yet to believe that there will be an annual increase
in births of 3.0%, and there is some evidence that it may not be true.
The 18-29 female population is the most fertile age group (Table 5) . Table 6 shows that this
group increased 10.9% from 1973 to 1978 and will increase another 5.7% from 1978 to 1984. After
1984 this group will decline every year through 1997 (which is the farthest projection that can be
made at this time). The decline from 1984 to 1997 will be almost 25%.
The figures in Table 6 for numbers of 18-29-year-old females were obtained from the population
estimates by age, race and sex (Table 7), by a simple annual replacement of 29-year-olds with the
(Tables 1, 2, 3, 6, and 7 are on a July 1 to June 30 basis and are derived from population
estimates, Tables 4, 5 and 8 are based on actual counts on a calendar year basis.)
While the 18-29 female population was increasing 10.9% between 1973 and 1978, births were
increased only 5.7% in the same period (Table 4). It would seem unlikely that we are going to see a
significant increase in births during the 1978 to 1984 period in which there will be only a 5.7%
increase in the 18-29 female group. It would seem likely that we will see a decline in births after
1984, as this group declines in numbers, extending at least until 1997.
Just as there was variation for the various regions and various states with regard to movement of
population (Table 1), there are also differences by region and state for births (Table 8). The wide
variation of regions is shown on the chart. The variation for the states within a region is easily
Local Demographic Data
To the extent that national demographic data indicate prevailing trends, they are useful in calling
orthodontists' attention to the direction of flow of these numbers and their potential affect on social
and economic conditions within their own population environment. Almost no such environment is
average. Some are above average and some below. While some areas in the country are favored
demographically and may continue to be, even favored areas are subject to trends. They may be
starting at a more advantageous level. So, orthodontists disregard demographics at their peril.
Alerted to national trends by national demographics, each orthodontist ought to make a special
effort to pinpoint his own population statistics down to the significant population area, which is his
drawing area.
In Statistical Abstracts of the United States is a list of state sources of statistical data. If these do
not satisfy your local need, further inquiry may be made at various state offices (Secretary of State,
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jul(490 - 499): Orthodontic Economics - Population
Department of Commerce or Finance, state and municipal planning departments), university Schools
of Business, Chambers of Commerce, school administrators, police, telephone company, local
newspapers. Hopefully, these sources will be able to supply local data, and this market research will
add sophistication to your appraisal of an area in which you are located or to which you may plan to
move or install a satellite office.
Information that would be desirable includes data for as many years as are available and
projections into the future for total population, population by age groups, births, and interesting
related statistics such as average household income.
Two publications that will be useful to compare your area with national trends are the most recent
issue of Statistical Abstracts of the United States and Population Estimates and Projections.
A specific use for local demographic data might be found by applying it to the following formula:
Take the number of 7-17-year-olds in your area.
Divide by 11. This will give you the average number of children in your area available for
orthodontic treatment in any one year.
Divide this number by the number of orthodontists in the area, including yourself. This will give
you the average number of 7-17-year-olds available per orthodontist in any one year.
Multiply this number by 15%, which is an estimate of the percent of children treated by
orthodontists. This gives you the potential average number of child patient starts per orthodontist in
your area.
Multiply this figure by 15% (which is an estimate of the number of adult patients in the average
practice). This is 15% of the average number of child patients, 23% of the total number of patient
starts. This gives you a current figure for the potential number of patient starts, child and adult, per
orthodontist in the area under investigation.
Keep in mind that this merely isolates the population factor. There are other important
considerations such as utilization rate in the area. This might be high due to relative affluence of the
community, other social factors, and the presence of third party insurance programs. Another factor
is the difference among orthodontists in their ability to practice build and inspire referrals. Also,
differences due to location within a population area.
On the basis of the formula, you can also determine that, on the average, there are 6,250
7-17-year-olds per orthodontist in the United States.
The social influences that have resulted in a lowered fertility rate and a lowered birth rate will not
go away soon. Barring some overpowering event, the factors of women's lib, employment of
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jul(490 - 499): Orthodontic Economics - Population
women, less marriage, more divorce, less desire to accept the social and economic responsibility for
children, the "Me" generation, the pill, abortion, and homosexuality seem destined to overcome the
sheer numbers of Post World War II Baby Boom females; plus the fact that these females are
passing out of their traditionally most fertile childbearing years.
The best representation of the population of the United States to the year 2000 is still the graphic
in Figure 1. While the number of children is and will be a significant population entity and child
orthodontics is and will be a significant part of orthodontic practice, the number of adults—
especially in the 25 to 44 age category— is rising fastest. It will continue to do so until 1990 at
which time it will level off and the next age category— 45 to 64— being fed by the 25 to 44 group
as it ages, will in its turn assume the steepest rise.
The message for orthodontists from population statistics is that the sheer optimism of expecting a
turnaround in the birth rate is unfounded and the birth rate will probably decline, following a slight
turnaround from 1976 to 1981 or 1982. Thus, instead of expecting a significant increase in the
number of children, we are likely to see a slight near-term increase, followed by a long-term
leveling and decline. The biggest untapped potential orthodontic market in the next 20 years is the
25-44 age group and the growing, but neglected, 45-64 age group. Orthodontics is destined to
become increasingly a service for adults as well as for children.
If orthodontists in the future become interested in market research in an effort to add some
sophistication to their marketing choices, national population trends will be generally significant and
local population information more specifically significant. In using any population data, however, it
will be important to know when, how and by whom the data were recorded; to what extent the data
depend on estimates; and what the assumptions are on which a particular estimate is based.
Statistical Abstracts of the United States
Published annually by the Bureau of the Census. Obtainable
from Superintendent of Documents, Government Printing
Office, Washington, D.C. 20402 or from the bookstore of any
Department of Commerce district office. Price $9.
Population Estimates and Projections
Current Population Reports, Series P-25, Population
Estimates and Projections, published annually by the Bureau
of the Census. There is an annual subscription rate for series
packages. The January issue can be purchased separately
from the Superintendent of Documents (price— $1.75) and
is of special interest because it contains the most recent
national figures for population by age groups.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume Jul
Fig. 1
Fig. 1 Graphic projection of U.S. population to the year 2000(Artist - Francois Colos) (From Gotlieb, E.L.: Updating the
Economic Outlook in Orthodontics— 1978, JCO 12:496, 1978.)
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Jul(490 - 499): Orthodontic Economics - Population
Table 1
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Table 2
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Table 3
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Table 4
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Table 5
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Table 6
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Table 7
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Table 8
AUGUST 1980, VOL. 14 / ISSUE 8
Activators for the Fixed Appliance Orthodontist
Common Sense Mechanics Part 12
A Visualized Treatment Objective
Orthodontic Economics - Number of Orthodontists
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Aug(513 -): 513 THE EDITOR'S CORNER
Many orthodontists are expressing dissatisfaction with the advertising campaigns of their
professional organizations and a growing reluctance to support those efforts financially. It is an
error of the first magnitude to hold such a view and it would be extremely short-sighted if these
programs were allowed to wither away and die.
Whether we like it or not, whether we approve of it or not, whether we consider it to be
professional conduct of the highest level, it would be a mistake to live in the past. The world has
taken a turn. Orthodontics, along with all the other professions, ,has been thrust into the marketplace
through the legalization of professional advertising. To attempt to compete in the marketplace and to
consciously avoid using the tools of the marketplace to best advantage invites failure. We do not
know whether organizational advertising will prevent a burgeoning of individual advertising, but to
the extent that it might be successful enough to do that by increasing the utilization of orthodontics,
it deserves a decent try.
Many express the view that they are not seeing quick results from the advertising in terms of new
patients in their practices. It should be pointed out that an orthodontist could make an annual
contribution of $500 to such an endeavor and, since the amount is tax deductible, recover his
investment with one new case in ten years.
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Aug(529 - 545): Activators for the Fixed Appliance Orthodontist
Activators for the Fixed Appliance
Most American orthodontists feel that the treatment of most malocclusion is best done in the
early permanent dentition and with fixed appliances. There are times, however, when treatment in
the mixed dentition is more desirable and the appliance of choice is not the fixed appliance, but the
removable activator. Class II nonextraction cases, with either open or closed bites, fall into this
With fixed appliances, the usual approach to a Class II nonextraction case treated early is to use a
2×4 hookup and some type of headgear. So often, these cases do not respond well to this type of
treatment. The treatment usually becomes more involved than planned, and the intended two-phase
treatment plan ends up as one long continuous phase. Often, failure in this type of treatment seems
to be due to the type of oral environment in which the teeth function. Habits such as tongue posture,
mouthbreathing, lip biting and lip posture, which may be normal for a Class II jaw relationship, can
often successfully overpower the orthodontic corrective forces.
Activator Action
The activator is far more effective than fixed appliances when treating the Class II nonextraction
case in the mixed dentition. Its superiority lies in its ability to create a more desirable oral
environment. Because the mandible is positioned forward in the appliance, the denture is artificially
placed in a Class I relationship. The lower lip is forced in front of the upper incisors, rather than
behind them as so often is the case. The lateral and anterior lingual shields prevent poor tongue
posture and encourage nasal breathing. When normal oral environment is established, dental
discrepancies seem to almost correct themselves.
The mandible is positioned downward and forward in the appliance. This positioning tends to
redirect muscle pull in order to elicit a more favorable growth response. The muscle stretch tends to
inhibit the normal downward and forward growth of the maxilla. The vertical component of the
muscle stretch tends to inhibit the eruption of the teeth that are indexed in the appliance. With the
mandible forward, the condyle will be out of the fossa. Hopefully, this repositioning will encourage
the mandible to grow to its fullest potential.
Functional appliances can get very complicated and in some instances, require much more
expertise to master than the average fixed appliance orthodontist is willing to acquire. The
appliance, as it is used in my practice, is in its simplest form. Its purpose is not to move individual
teeth. This is usually carried out later with fixed appliances, if necessary. Its primary functions are to
establish a more desirable functional environment, to furnish a platform for applying orthopedic
forces to the denture, and to control the eruption of individual teeth. The appliance does not depend
on the muscle stretch for force application. The force needed is derived from directional headgear.
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Aug(529 - 545): Activators for the Fixed Appliance Orthodontist
Depending on headgear forces rather than muscle stretch allows for minimal opening when
designing the appliance. This makes the appliance more appealing to the patient (Fig. 1).
The activator has the ability to control the differential eruption of teeth. In the deep bite case ( Fig.
2), all teeth but the lower posteriors are indexed in the appliance (occlusal surfaces touch the
acrylic). Only the lower posterior teeth then are allowed to experience normal vertical development.
This difference in eruption of the lower teeth levels the curve of the Spee. Inhibiting the vertical
development of the upper and lower anterior teeth opens the bite.
If there is spacing in the upper anterior teeth, the lingual acrylic is relieved and the labial bow is
activated to close the space. In an open bite case (Fig. 3), all posterior teeth are indexed and the
anterior teeth are left free to erupt.
Directional Force Application
Directional force application is as important with activator therapy as it is with fixed appliance
therapy. In the low angle case two-thirds of the vertical is controlled by slowing the downward and
forward growth of the maxilla and the eruption of the upper posterior teeth. Controlling vertical will
allow any condylar growth to place the chin in a more forward position. In the high angle open bite
case, all three thirds of the vertical are control led by also slowing down the eruption of the lower
posterior teeth. Hopefully, the lower third of the face will be shorter and the chin will be even more
"J" hooks and directional headgear are used to obtain the necessary orthopedic forces (16+
ounces). The "J" hooks are attached to hooks that are soldered to the labial bow of the activator (Fig.
4). The force vector used depends on where the discrepancy lies. If the discrepancy is mostly in the
anterior-posterior dimension, as in a low angle deep bite case, then the force vector will be placed
about 15 degrees above the occlusal plane. If the discrepancy is more in the vertical dimension, then
the "J" hooks are moved further up on the headgear cheek plate. For the very high angle case, the
high pull headgear is used (Fig. 5). The appliance is very stable in the mouth, since all of the upper
posterior teeth are indexed .
For the high angle open bite case, all of the upper and lower posterior teeth are indexed into the
appliance, and the anteriors are free. As mentioned in our open bite high angle case, it is desirable to
apply a depressive force to the lower posterior teeth. This can be done in one of two ways. One way
is to increase the thickness of the construction bite and elicit more vertical force by stretching the
muscles (Fig. 6). The other way is to use a vertical headgear and a mandibular trough (Fig. 7). The
orthopedic force from the mandibular trough forces the patient's mouth closed at night and causes
the mandible to grow in a more counterclockwise direction (Case 5).
Treatment Plan
The more conventional method of treatment is to use the activator over a long period of time in
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Aug(529 - 545): Activators for the Fixed Appliance Orthodontist
order to take advantage of as much condylar growth as possible. A long treatment time, however,
has several disadvantages. The activator is worn only while the patient is home, since it is a bulky
appliance and does not allow for normal speech. This would mean that some of the correction
obtained would be lost during the day, due to the poor oral environment (tongue and lip posture,
mouthbreathing) which is associated with Class II malocclusions. The longer the treatment time, the
more time has to be spent recovering lost ground. A long treatment time can also cause the lower
incisors to be repositioned labially since the lower incisors help hold the mandible forward.
With orthopedic headgear forces, the overbite can be corrected rapidly, usually in about 10
months. Getting a more normal anterior tooth relationship early helps to establish a normal oral
environment early, even when the appliance is not in place. There is also less tendency for the lower
incisors to move forward, since the mandible is positioned forward only for a short period of time
during this ten-month period. The correction is obtained either by enmasse movement of the upper
arch, or by mandibular growth, or by a combination of both. Clinically, it is easy to tell which has
happened. If the upper incisors are lingually inclined, then the upper arch was distalized. If they are
not lingually inclined, then the mandible grew and the headgear was not required the full time.
The activator is then worn as a retainer with or without a headgear, as required, until the
permanent teeth have erupted. At this time, a determination is made for further treatment. Most
often when the initial overbite correction was obtained by distalizing the upper arch, the mandible
will continue to grow and the upper arch will be carried forward again, uprighting the upper incisors
(Case 1) . If this does not happen, fixed appliances will have to be utilized in order to torque the
upper incisors.
Treating cases this way utilizes the activator for artificially creating a more desirable oral
environment, while the dental discrepancy is corrected by orthopedic forces and growth. Correcting
the overbite rapidly with headgear does not fully utilize the effect that positioning the mandible
forward may have on condylar growth. What effect, if any, it has on increased mandibular growth is
widely debated. Case after case has shown me that after rapidly distalizing the upper arch, the
mandible grows well — well enough to bring the upper arch forward with it.
Class II Extraction Treatment
Most Class II extraction cases are best treated with fixed appliances after the loss of the last
deciduous tooth.
Usually a 2×4 setup is used until the overjet is corrected and then full appliances for final denture
alignment. This is a one-phase treatment. However, when the Class II relationship is due mainly to a
retrognathic mandible, then it is justifiable to start with an activator soon after the eruption of the
permanent incisors. This will be a two-phase treatment, with the second phase involving fixed
appliances. Even though, there is an additional effort for the orthodontist and the patient, the end
product should be a stronger chin.
Article Text
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Aug(529 - 545): Activators for the Fixed Appliance Orthodontist
Activators As Retainers
Many severe Class II cases are treated with fixed appliances to completion before jaw growth is
completed. The posttreatment growth pattern occasionally causes the case to relapse back into a
Class II relationship. The activator is very useful for retaining these cases, especially where there
was a deep bite involved. A strong relapse tendency will also require directional headgear.
Appliance Selection
A good percentage of the Class II cases have constricted upper arches. This can be demonstrated
initially by placing the original models in a Class I relationship and observing the buccal overjet.
Even when the buccal overjet is normal, both arches may be constricted. In either case, expansion is
indicated. Plastic, self-threading expansion screws are used. The threaded rod is not free-turning;
therefore, the possibility of slippage is diminished.
Appliance Construction
Figure 8 shows the waxing and wire placement for a typical Class II expansion activator. Notice
that the lingual of the lower posterior teeth is waxed out to allow expansion of the appliance without
expansion of these teeth. The occlusal surface is also waxed to allow for eruption of these teeth.
Figure 9 shows the models mounted on a verticulator. Self-curing acrylic is used. The upper model
is done first, using a salt and pepper technique. Both models are then placed on the verticulator and
premixed acrylic is applied to construct the remaining parts.
Case 1. This is the type of case that usually responds well to activator treatment. The denture is full
Class II, the bite is deep, and the mandibular plane angle is moderate. After nine months of
treatment with an activator and a directional headgear, a normal anterior relationship was obtained.
Clinically, it was noted that the upper incisors were lingually inclined. Superimposition shows that
most of the correction was obtained by distalizing the upper arch.
At this point the activator is used as a retainer, with the headgear used as needed. After
approximately two years, the upper incisors have a better inclination. Superimposition shows that
during this retention-treatment period the mandible grew forward, allowing the maxillary teeth to
rebound forward improving the inclination of the upper anterior teeth.
Case 2. This is another ideal case for the activator and directional headgear. Because the growth
response was good, the amount of headgear wearing was reduced and the case finished with good
upper incisal inclination. Treatment with fixed appliances would have been very difficult. Treatment
with the activator and directional headgear was simple and uneventful.
Case 3. Here is another case very similar to Case 2. Again, treatment was very easy with the
activator and directional headgear. In this case, also, the incisors finished with good inclination
because of adequate mandibular growth. This case, like the previous cases, required no further
Article Text
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Aug(529 - 545): Activators for the Fixed Appliance Orthodontist
Case 4. As mentioned above, the activator is a good appliance to use for interim treatment to see
really what growth potential is available. If the growth pattern in this case persists, a surgical
correction may be indicated. The activator was constructed so that the upper posterior teeth were
indexed in the acrylic and the lower posterior teeth were touching a flat occlusal plane. An expander
was incorporated into the appliance and the lingual flanges were standing away from the lower
posterior teeth. An adenoidectomy was recommended.
The vertical was controlled by using a vertical headcap and a mandibular trough (Fig. 7). This
vertical orthopedic force slowed the downward and forward growth of the maxilla, and slowed the
eruption of upper and lower posterior teeth. The overall result was a decrease in the Mandibular
Plane Angle. If the activator can maintain this pattern, surgery will not be indicated.
Case 5. This case was originally presented as having several possible treatment plans. It was
obviously a bimaxillary protrusion and would probably have to be treated as an extraction case later.
Regardless of what a computer diagnosis would have told me about the growth potential of this low
angle case, I would have had my reservations. I have seen several similar patterns end up with
retrognathic mandibles. So, even mandibular surgery was presented as a possibility.
The activator is a great appliance to use in cases like this. It will help the patient grow to his
maximum potential before a final decision is made about such things as extractions or surgery. After
five months of activator and directional headgear treatment, the case looks very different.
Obviously, it will not be a future surgery case. After another five months of treatment, it doesn't
even look like a bimaxillary protrusion. Further treatment has even distalized the lower incisors,
flattening the profile.
Activators do little to correct midlines. Usually, what you start with is what you finish with.
Because of midline discrepancy and a few other minor discrepancies, it was decided to fully band
the case.
Case 6. This case is a Class II division 2. The activator was constructed with springs lingual to the
upper incisors. The incisors were moved forward and the case was then treated like a Class II
division 1 case. Usually, no headgear is indicated. Actually in cases like this, where there is lower
incisor crowding, it is desirable to have the mandible positioned forward for as long as possible.
This forward positioning will tend to flare the lower incisors and the flaring action has aligned these
teeth. Acrylic is added to the appliance in the area of the lower incisors to accomplish this alignment.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume Aug
directional headgear
Dr. Hickham designed the directional headgear, available
from NOLA Orthodontic Specialties, 2001 25th St. (Suite A),
Kenner, LA 70062.
expansion screws
Great Lakes Orthodontic Products, 1550 Hertel Avenue,
Buffalo, NY 14216.
OIS, Box 274, Wilmington, DE 19899.
Case 1a
Case 1. Before treatment.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Aug(529 - 545): Activators for the Fixed Appliance Orthodontist
Case 1b
Case 1. Superimposition before (solid) and after 9 months treatment (broken).
Case 1c
Case 1. After 9 months treatment with activator and directional headgear.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Aug(529 - 545): Activators for the Fixed Appliance Orthodontist
Case 1d
Case 1. Superimposition before treatment (solid) and after 2 years of retention.
Case 1e
Case 1. After 2 years of retention.
Case 2a
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Aug(529 - 545): Activators for the Fixed Appliance Orthodontist
Case 2. Before treatment.
Case 2b
Case 2. After treatment.
Case 2c
Case 2. Superimposition before (solid) and after (broken) treatment.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Aug(529 - 545): Activators for the Fixed Appliance Orthodontist
Case 2d
Case 2. Photographs before (left) and after (right) treatment.
Case 3a
Case 3. Before treatment.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Aug(529 - 545): Activators for the Fixed Appliance Orthodontist
Case 3b
Case 3. After treatment.
Case 4a
Case 4. Before treatment.
Case 4b
Case 4. After treatment.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Aug(529 - 545): Activators for the Fixed Appliance Orthodontist
Case 4c
Case 4. Superimposition before (solid) and after (broken) treatment.
Case 5a
Case 5. Before treatment.
Case 5b
Case 5. After 5 months treatment.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Aug(529 - 545): Activators for the Fixed Appliance Orthodontist
Case 5c
Case 5. Superimposition before (solid) and after (broken) 10 months treatment.
Case 5d
Case 5. Cephalometric x-ray before treatment.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Aug(529 - 545): Activators for the Fixed Appliance Orthodontist
Case 5e
Case 5. After 10 months treatment.
Case 5f
Case 5. Superimposition before (solid) and after (broken) 5 months treatment.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Aug(529 - 545): Activators for the Fixed Appliance Orthodontist
Case 5g
Case 5. Photographs before (left) and after (right) treatment.
Case 6a
Case 6. Before treatment.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Aug(529 - 545): Activators for the Fixed Appliance Orthodontist
Case 6b
Case 6. After treatment.
Fig. 1
Fig. 1 Activator for a moderate Mandibular Plane Angle deep bite case, showing soldered hooks for attaching
directional headgear "J" hooks. Note minimal bite opening.
Fig. 2
Fig. 2 Cross section of an activator showing the eruption pattern of teeth for a Class II deep bite case. All teeth are
indexed in the acrylic, except the lower posterior teeth. Dotted lines show possible force vectors from a directional
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Aug(529 - 545): Activators for the Fixed Appliance Orthodontist
Fig. 3
Fig. 3 Cross section of an activator, showing eruption pattern on teeth for a Class II open bite case. All teeth are
indexed in the acrylic, except the anterior teeth. Dotted lines show application of a high pull headgear or a vertical
mandibular trough.
Fig. 4
Fig. 4 A variable straight pull directional headgear with "J" hooks approximately 15 degrees above occlusal plane.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Aug(529 - 545): Activators for the Fixed Appliance Orthodontist
Fig. 5
Fig. 5 Fully adjustable high pull headgear.
Fig. 6
Fig. 6 Activator for high Mandibular Plane Angle open bite cases showing soldered hooks and greater bite opening.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Aug(529 - 545): Activators for the Fixed Appliance Orthodontist
Fig. 7
Fig. 7 Vertical pull head Cap with mandibular trough.
Fig. 8
Fig. 8 Waxing and wiring the Class II expansion activator.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Aug(529 - 545): Activators for the Fixed Appliance Orthodontist
Fig. 9
Fig. 9 Activator models mounted on a verticulator.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Aug(546 - 553): Common Sense Mechanics Part 12
Common Sense Mechanics
Applying Principles to Total Treatment
Since extraction and nonextraction mechanics have been demonstrated, utilizing the various
principles discussed since the beginning of this series, I believe we can have a little fun at this point
by taking a few cases and observing treatment methods in an unconventional manner. That is, we
will avoid the "cookbook" approach of doing step-by-step procedures in each case and, instead,
institute any number of procedures already discussed, as the individual needs arise. Needless to say,
we must have a defined objective from the start, so that we know at all times where we are headed.
It is not the purpose of this series to define such objectives at any length or to present the diagnosis
and treatment planning for cases presented. As you are already aware, headplate tracings are not
being presented and discussed, as it is the purpose to keep this series as clinical as possible and to
present principles of mechanics only. There is nothing wrong with the so-called "cookbook"
approaches to orthodontic. treatment, but it can become quite routine and even boring at times.
Being able to vary procedures according to the time available and the tooth movement desired at the
time lends itself to more excitement, in my opinion, as well as ease of manipulation on the part of
the operator.
Class I Nonextraction
Let us begin by taking a Class I malocclusion with considerable crowding in the mandibular arch
and moderate overbite with linguoversion of the lower right bicuspids (Fig. 140). I feel much
information can be derived from the occlusal views of the malocclusion. When I observe the need
for change in posterior arch width, I feel that observation of lingual cusp height on the molars offers
significant clues as to which teeth should be moved buccally and which should be moved lingually.
Looking at the maxillary molars, it can be seen that all of the lingual cusps are high (occlusal)
relative to the general maxillary plane of occlusion. Looking at the mandibular first molars, it can be
seen that both molars are buccal to the second molars and also exhibit "high" lingual cusps. You
might argue that the second molars are lingual, but I believe the vertical height of the lingual cusps
indicates which teeth are tipped from their normal position in the arch and in which direction they
are tipped. Some orthodontists feel they can best obtain such information from a frontal headfilm. I
don't argue the point, but am simply saying that there are other means available for consideration.
Since the first molars are in a Class I relationship in the original malocclusion and since I have
determined, correctly or incorrectly, that the molars require lingual movement, then correction in the
lower arch will result in temporary "buccoversion" of the maxillary molars, until they are
constricted. Also, it can be observed that the lower right bicuspids do not require rotation, but only
simple buccal forces at the crown level. Remember that torque is a product of force times distance,
as described earlier.
Article Text
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Aug(546 - 553): Common Sense Mechanics Part 12
If we apply a simple lingual force at the molar tube level, we have created lingual crown torque.
Therefore, to provide a molar with lingual crown torque, a rectangular wire may be used, but is not
absolutely necessary in many cases. A simple lingual force passing through the tube and crown of
the tooth (line of force) lies occlusal to the center of resistance of the tooth, so that the force times
distance results in lingual crown torque. To go even a step further, we can provide lingual crown
torque for the second molar without even placing a band on the tooth, if nothing more is required. A
simple distal extension of the archwire through the first molar tube can be utilized to provide a point
force through the second molar crown and thus also produce lingual crown torque. So, it simply is
not necessary to band/bond teeth all of the time to obtain a given type of movement.
Based on profile requirements, it was decided to treat this boy on a nonextraction basis, in spite
of the amount of crowding in the mandibular arch. You do not have to agree or disagree on the
treatment plan, as we are only concerned in this discussion with the mechanics instituted to obtain
the end result. We have already discussed mechanics that will enable us to obtain some additional
lower arch length without anterior expansion. This means we can avoid expansion altogether, in
many cases, while keeping expansion to a minimum in others. Looking at the occlusal view of the
lower arch, I think you would agree that simply gaining arch length by pure expansion would result
in flaring of the incisors that would be clinically obvious.
For the reasons mentioned before, only a minimal appliance need was anticipated. Upper and
lower 2×4 (incisors and molars) were placed, with initial .016 archwires (Fig. 141), and tipback
bends in the lower arch. The tipback produced light intrusive forces on the incisors, while the
eruptive forces were shared by the molars resulting in each molar receiving only one-half of an
already light force. The eruptive force acting through the molar tube produced lingual crown torque,
as explained earlier in this series. The resulting lingual movement produced a temporary
buccoversion of the upper molars.
If you desire second molar movement lingually, distal extensions can be provided to the archwire
passing through the first molar tubes, and can be cut off when no longer needed. The large molar
moments, producing distal crown thrust as a result of the tipback bends, are allowed to thrust the
molar crowns distally, permitting a gain in lower arch length as the 360° tieback loops are gradually
unwound to permit this effect to occur. Since the archwire is tied to the molar tubes, the incisor
segment is not allowed to move forward, unless, of course, we exceed reasonable limits. We cannot
tip a molar crown indefinitely or unwind a 360° loop too quickly and beyond reason. That is, it can
only be unwound to the extent that a millimeter or so of arch length can be gained at a time as the
molar crowns "upright" and then tip back. You alone can decide on how far to tip back a molar, but
I don't think it is wise to try to be too heroic, as I have done in the past. I, personally, would be
satisfied with a gain of maybe two millimeters per side, but even this amount can be dramatically
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Aug(546 - 553): Common Sense Mechanics Part 12
increased, if the molars are tipped forward from the start, which has already been demonstrated.
In Figure 142, the lower right bicuspids, which were in linguoversion and required only a buccal
force at the crown level, have been ligated to the archwire. At the same time, this causes an
additional lingual force on the molar crown, resulting in more lingual crown torque. Do not be
fooled by overbite "correction". It is necessary to recognize temporary cuspal interferences from
tipback movements that produce this illusion.
Figure 143 would lead one to believe that everything is out of control, if one were not aware of
the force systems and predictable responses. The temporary buccoversion of the upper molars is
increasing, particularly on the right side, as the lower right first molar responds to both the tipback
bend and reciprocal movement resulting from the buccal forces on the bicuspids. This view shows
the lingual cusp height of the maxillary molars, whose arch width up to this point has remained
unaffected. However, the upper tipback bends provide anterior intrusion with reciprocal extrusive
forces on the molar tubes, producing lingual crown torque on these teeth, just as occurred with the
lower molars. Granted, the case does not look pretty at this stage, but presents no problem if one
remains aware of what is happening. One of the problems encountered, however, is the sudden
transfer of a patient at such a stage. The new orthodontist is likely to wonder what is happening and
why, and arrive at conclusions that might be unwarranted.
Figure 144 shows the space gained in the lower arch. The archwire was removed, as is frequently
done, to allow the teeth to seek their natural position in an environment whose function has been
altered. One of the variations that may occur is buccal movement of a molar crown. As explained in
an earlier part of this series, an anterior intrusive force actually produces an extrusive molar force on
the lingual side of the tooth. Therefore, whenever a rigid wire or binding occurs in the tube, the
crown actually undergoes buccal crown torque. But most of the time, with round wire, the crown
will move lingually, as the wire makes contact with the molar tube on activation, but "slips" and,
therefore results in a net force at the tube.
In Figure 145, a heavier wire has been placed in the lower arch, usually an .020. Note the amount
of molar uprighting that occurred with the archwire left out. This enables the orthodontist to see
what is happening and to note how much of the space gained in the arch is lost, and in what manner.
Simply stated, the teeth have been free to respond as they wish.
Earlier we discussed .036 overlays and demonstrated their use in the upper arch for expansion. It
was pointed out that the .036 overlay can be used for either expansion or constriction of arch width.
In this case, the upper first molars are now ready for an .036 overlay constriction arch, designed
with an anterior vertical loop and then constricted (Fig. 146). Since only equal and opposite forces
can occur, don't be led into thin king such an overlay can be used to produce a one-sided force. In
Fig. 147, the overlay is inserted into the molar tubes and the loop placed lingual to the archwire. The
archwire bend labial to the cuspids produces a "long arm" indicating lingual forces on the molars.
These bends are not necessary, as the forces produced from the overlay will easily overcome the
archwire resiliency. However, it keeps the operator conscious of what is being attempted in terms of
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Aug(546 - 553): Common Sense Mechanics Part 12
tooth movement and direction. When the patient arrives at the following visit, the bends indicate
what is being attempted and thus serve as a "treatment card" reference.
When the maxillary molars have been constricted, all wires are removed (Fig. 148), to allow
function to perform its role. Wires are reinserted, when indicated, to control or produce additional
rotations (Fig. 149).
Following appliance removal (Fig. 150), the molars upright, and normal function is established.
Adjustments for minor rotations can be made with a removable appliance (Fig. 151 ) by applying the
cue ball concept. By applying a force at a given point, the response can be predicted. A distolingual
rotation can be accomplished by applying a lingual force at the distobuccal cusp and relieving the
distolingual portion of the retainer to permit the rotation to occur. Obviously, the most effective
rotations can be accomplished with the fixed appliance still in place.
The facial profile picture (Fig. 152), taken later during retention, justifies the nonextraction
approach to treatment in my opinion.
The case discussed would not be considered a difficult case for any orthodontist, and treatment
might be approached in a number of ways. The approach described is not meant to be one of choice,
but, rather, it illustrates the fact that different concepts may be introduced into our treatment
procedures. Each orthodontist must decide which approach is preferred and proceed from that point
to treat the case. But, no one should feel forced to have all teeth banded/bonded at every stage of
treatment, regardless of the type of problem. There are advantages and disadvantages, and it is
entirely up to the operator to choose an approach which offers the greatest advantages, after such
considerations as skill, knowledge, and experience are taken into account.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume Aug
Fig. 140
Fig. 140 Class I malocclusion, before treatment.
Fig. 141
Fig. 141 Appliance placed. Note lower molar tipbacks.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Aug(546 - 553): Common Sense Mechanics Part 12
Fig. 142
Fig. 142 Lower right bicuspids ligated to archwire.
Fig. 143
Fig. 143 Combined actions exaggerate buccoversion of upper molars.
Fig. 144
Fig. 144 Note space gained In lower arch.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Aug(546 - 553): Common Sense Mechanics Part 12
Fig. 145
Fig. 145 Heavier archwire (.020) placed on lower arch.
Fig. 146
Fig. 146 Overlay arch (.036).
Fig. 147
Fig. 147 Overlay arch in place.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Aug(546 - 553): Common Sense Mechanics Part 12
Fig. 148
Fig. 148 Archwires removed following constriction of upper arch.
Fig. 149
Fig. 149 Lower archwire replaced for minor additional adjustments.
Fig. 150
Fig. 150 Case following appliance removal.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Aug(546 - 553): Common Sense Mechanics Part 12
Fig. 151
Fig. 151 Removable appliance adjusted for minor rotations.
Fig. 152
Fig. 152 Photographs before (left) and after treatment.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Aug(554 - 571): A Visualized Treatment Objective
A Visualized Treatment Objective
The Visualized Treatment Objective (V.T.O.) in use at the University of Alabama in Birmingham
Department of Orthodontics was devised by Dr. Reed A. Holdaway as a treatment planning method
based upon prediction and the desired treatment objectives. It is a procedure based primarily on
cephalometrics, the purpose of which is to establish a balanced profile and pleasing facial aesthetics
and to evaluate the orthodontic correction necessary to achieve this goal. The Holdaway V.T.O.
emphasizes soft tissue profile balance. This is in contrast to most other cephalometric analyses and
treatment planning methods which reposition the dental structures first, thereby permitting the lips
to drape over the teeth.
Growth of the craniofacial skeleton is predicted for the estimated treatment time, and the soft
tissue profile between the nose and the chin arranged to create an "ideal" facial profile for the
individual patient. Having established the soft tissue profile, the maxillary and mandibular incisor
teeth are repositioned to eliminate lip strain. Allowance is made for probable post-treatment "incisor
Guidelines are provided whereby the lips are graphically repositioned. A template may be used to
facilitate drawing the soft tissue of the lips. This is followed by location of the maxillary incisor
teeth. Finally, the lower incisors are repositioned to be in harmony with the upper incisors.
Following upon the repositioning of the mandibular incisor, the resultant arch length discrepancy
may be calculated to determine whether or not teeth should be extracted prior to orthodontic
correction. Should the computed information suggest that teeth be extracted, the V.T.O. will yield
information based on anchorage requirements as to whether first or second bicuspids should be
removed, or whether the proposed treatment plan is feasible or desirable.
The V.T.O. is thus a dynamic cephalometric analysis which takes into account both growth and
biomechanics, thus achieving its aim of being a Visualized Treatment Objective. It outlines a goal
from the inception of treatment and may be usefully employed in monitoring growth and treatment
In sum, therefore the V.T.O. accomplishes the following:
1. Predicts growth over an estimated treatment time, based on the individual morphogenetic
2. Analyzes the soft tissue facial profile.
3. Graphically plans the best soft tissue facial profile for the particular patient.
4. Determines favourable incisor repositioning, based on an "ideal" projected soft tissue facial
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Aug(554 - 571): A Visualized Treatment Objective
5. Assists in determining total arch length discrepancy when taking into account "cephalometric
6. Aids in determining between extraction and nonextraction treatment.
7. Aids in deciding which teeth to extract, if extractions are indicated.
8. Assists in planning treatment mechanics.
9. Assists in deciding which cases are more suited to surgical and/or surgical-orthodontic
10. It provides a visual goal or objective for which to strive during treatment.
General Concepts
The V.T.O. procedure described is based on concepts of growth prediction which relate facial
skeletal structural changes to the Basion-Nasion line, viz. to the base of the craniofacial complex.
Orthodontic diagnosis and treatment planning in growing children must of necessity involve growth
prediction. Growth responses are generally predictable within certain limits and can be measured.
The V.T.O. as described here is based on this philosophy. Newer studies, however, have indicated
quite clearly that one cannot rely completely on the constancy of growth pattern, since increments of
facial growth are not necessarily uniform in either direction or rate. It is recognized that precise
prediction of skeletal or soft tissue growth in amount or direction is beyond our present knowledge.
However, until the stage is reached whereby orthodontists and/or scientific investigators are able to
accurately predict or determine direction and rates of growth we have no alternative but to avail
ourselves of our present knowledge of growth based on average increments.
Growth of the mandible is predicted by using the facial axis which extends from the foramen
rotundum to Gnathion (cf. R. M. Ricketts). Using the facial axis as a growth parameter positions the
mandible in a downward and forward direction as related to the Basion-Nasion line. This establishes
total vertical facial height and forward positioning of the mandible.
The vertical position of the maxilla is established by using line NA and arbitrarily dividing the
face from Nasion to Menton into thirds. Studies have revealed that one-third of the total facial
height is expressed between Nasion and the hard palate or palatal plane of the maxilla. The
remaining two-thirds of vertical facial height is expressed between the maxilla and Menton. The
occlusal plane is located midway between the maxilla and mandible. These are the general theories
regarding vertical skeletal growth around which the Holdaway V.T.O. is based.
Extensive studies of soft tissue characteristics and changes due to treatment have enabled Dr.
Holdaway to record certain observations. Among these is his concern of tissue thickness anterior to
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Aug(554 - 571): A Visualized Treatment Objective
the maxillary incisor teeth in a strained and unstrained position. Lip strain may be reduced by
moving upper incisor teeth lingually. Having eliminated lip strain, the lips then follow any further
lingual movement of the incisors in a specific ratio.
An appreciation of the above philosophies makes it easy to understand the rationale of the V.T.O.
All cephalometric headfilms to be taken in the lips closed position even if the lips are strained to
The following to be traced:
I. The anterior and posterior cranial bases to include Basion (Ba) and Sella Turcica (S).
2. The pterygomaxillary fissure. Use the "Lip Contour Template" to locate foramen rotundum.
3. Lateral and inferior border of the orbits.
4. Anterior outline of the frontal bone.
5. Nasal bone and Nasion (N).
6. ANS and PNS and hard palate, also point A (Subspinale) .
7. Upper central incisor tooth and its alveolar process.
8. Mandible, including condyle if possible and symphysis (anterior and posterior border).
9. Lower central incisor tooth.
10. Maxillary and mandibular first molar teeth.
11. Anatomical external auditory meatus— to locate, "Lip Contour Template" may be employed.
12. Soft tissue profile to include forehead, nose, lips and chin.
The following lines are constructed on the cephalometric tracing:
1. Basion-Nasion line (BaN).
2. Line Nasion to point A (NA).
3. The Frankfort horizontal from Porion to Orbitale (Por-Or).
4. The Occlusal plane.
5. Downs mandibular plane.
6. The facial axis (foramen rotundum opening to Gnathion GN), (c.f. Ricketts).
7. Holdaway'S line (soft tissue chin to tip upper lip).
8. The facial plane (NPo).
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Aug(554 - 571): A Visualized Treatment Objective
(The reader is invited to perform this exercise by placing a sheet of tracing paper over the figure on
the previous page and following the step-by-step instructions.)
OBJECTIVE: To draw frontonasal area, line BaN and line NA.
a) Place a clean sheet of acetate paper over the original cephalometric tracing and copy the
frontonasal area both hard and soft tissue, tracing through the bridge of the nose.
b) Copy the line BaN.
d) Copy the line NA.
OBJECTIVE: To express growth in the frontonasal area over a two-year period (or estimated
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Aug(554 - 571): A Visualized Treatment Objective
treatment time).
a) Superimpose on line BaN and move the VTO. tracing until there is 1.5mm of growth expressed in
the frontonasal area (Dr Holdaway S studies reveal that there is approximately 36mm of growth per
year in this frontonasal area.)
b) Holding the VTO. tracing in the position as in a) above copy the Ricketts facial axis (foramen
rotundum to Gnathion).
NOTE: It should be appreciated that the predicted growth at Nasion along the BaN line is in effect
an overall prediction of all midfacial structures which include the nasal bone, maxilla and soft
tissues in this area.
OBJECTIVE: To express growth in a vertical direction in the mandible, and to draw the anterior
portion of the mandible, soft tissue chin and the mandibular plane of Downs.
a) Superimpose the V.T.0. facial axis along the original facial axis. Move the V.T.0 tracing upwards
so that the V.T.0 BaN line is above the original BaN line, the distance between these lines should be
three times the amount of growth expressed previously in the frontonasal area. Therefore. in this
instance the V.T.O. would be moved up approximately 4.5mm.
b) Holding this position, copy the anterior portion of the mandible to include the symphysis anterior
1/3 of lower border of the mandible and Downs' mandibular plane c) Draw soft tissue chin from its
anteriormost point, extending this line posteriorly. Eliminate any evident hypertonicity (mentalis
action} by rounding out this area.
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Aug(554 - 571): A Visualized Treatment Objective
OBJECTIVE: To express growth in a horizontal direction in the mandible (or lower face) and
draw the posterior border of the mandible
a) Superimpose on mandibular plane and move the V.T.O. forward until the original and V.T.O.
foramina rotundae are vertically aligned.
b) With the tracing in this position the posterior border and ramus of the mandible is drawn.
NOTE: Total vertical facial height as well as forward location of the chin have now been
established. The amount of forward growth at the chin point will be much the same as that at Nasion.
OBJECTIVE: To locate and draw the maxilla, and lower half of nose.
a) Superimpose the V.T.0. NA line on the original NA line and move the V.T.0. up until the vertical
growth expressed above the BaN line and below the mandibular plane is in the ratio of 40:60. I n
other words, there is 40% of total vertical growth above the BaN line and 60% below the
mandibular plane.
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Aug(554 - 571): A Visualized Treatment Objective
b) With the V.T.0. tracing in this position copy the maxilla to include posterior 2/3 of hard palate,
PNS to ANS to 2mm below the ANS.
c) With the V.T.0. in the same position, draw the new nose up to the middle of the inferior surface
of the nose. Estimated growth usually parallels the contour of the old nose in this area. Average nose
growth is 1mm per year
OBJECTIVE: To locate and draw the occlusal plane.
a) With the V.T.0. superimposed on line NA move the V.T.0. tracing so that the vertical growth
between the maxilla and the mandible is expressed as being 50% above the maxilla and 50% below
the mandible.
b) With the tracing in this position copy the occlusal plane.
Generally the occlusal plane is located 3mm below the lip embrasure This permits the lower lip to
envelope the lower one-third of the upper central incisor teeth. If the cant of the occlusal plane in
the original tracing is correct. then this should be maintained. However should adjustments be
indicated, then alter accordingly at this stage.
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Aug(554 - 571): A Visualized Treatment Objective
OBJECTIVE: To determine the soft tissue lip contour using the "new" Holdaway line (H-Line).
Dr Holdaway's vast experience enables him to accurately assess the desired soft tissue profile by
drawing the H-Line (judged from clinical experience) and then drawing the soft tissue lip profile to
fit within the framework of this line. The H-line extends from the soft tissue chin to the lower
border of the nose but touches the tip of the upper lip.
To assist the less experienced, the "Lip Contour Template" may be usefully employed as an aid in
the location of the H-line.
Dr Holdaway's studies have shown that in "ideal" profiles, the distance between the depth of the
upper lip contour and the H-line is between 3 and 7 millimeters.
Clinically judge the length of the upper lip. For short lips, use a 3 mm sulcus depth and a 7 mm
sulcus depth for long lips. In lips of AVERAGE length a sulcus depth of 5mm is used. Having
judged the lip length, use the "Lip Contour Template" to locate the H-line.
a) Judge the upper lip length to determine the most suitable lip contour profile for the patient.
b) With the lower end of the H-line tangent to the chin soft tissue contour, slide the template up or
down until the lip embrasure is located 3mm above the occlusal plane.
c) Maintaining the lower end of the H-line tangent to the chin contour, move the upper end of the
template forward or backward until a desirable, balanced and aesthetically "ideal" soft tissue profile
contour is obtained.
d) Pencil a point in the centers of the circles at the top and bottom ends of selected template H-line.
e) Joining the pencilled points will provide the location of the H-line.
Having determined the location of the H-line, the position of the lip embrasure and the upper lip
sulcus depth, we are now in a position to artistically draw the upper and lower lip contours.
The upper lip should just touch the H-line, whereas the lower lip should lie approximately ½mm
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Aug(554 - 571): A Visualized Treatment Objective
anterior to this line.
OBJECTIVE: To relocate maxillary central incisor
1) Lip strain— Dr Holdaway contends that in well-balanced soft tissue profiles the distance along a
horizontal line extending between a point 3mm below the original point A to the point where the
line crosses the upper lip is within 1mm of the distance between the labial surface of the maxillary
incisor to the tip of the upper lip. Should the lower measurement be less than within 1mm of the
upper measurement, then lip strain is said to exist. To eliminate lip strain where it exists the upper
incisor is moved back to allow the aforementioned readings to be within 1mm of each other
2) Where no lip strain exists retraction of the maxillary incisors allows the upper lip to move
backwards an equal amount, i.e. lip and incisors maintain a 1:1 ratio.
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Aug(554 - 571): A Visualized Treatment Objective
3) Maxillary Incisor Rebound— Generally, during posttreatment maxillary incisors tend to move
labially 0.5mm in Class I cases and 1.5mm in Class 11 cases. This is referred to as "Incisor
In this particular patient, the calculations would be as
a) Elimination of lip strain
4 mm
b) Distal movement of upper lip
c) Maxillary incisor rebound 1.5mm
Superimpose theV.T.0. tracing on the NA line and the maxilla and trace in the maxillary incisor,
taking cognisance of the amount it is to be repositioned. (viz 9.5mm in this instance). The axial
inclination of this tooth is judged and the occlusal plane is used to locate it vertically. The tip of the
maxillary incisor touches the occlusal plane.
OBJECTIVE: To reposition lower incisor and calculate resultant arch length change. 1) Having
located the position of the upper incisor, judge the position and axial inclination of the lower incisor
2) To calculate lower arch length change, superimpose tracing on mandibular plane and register on
symphysis. Measure the distance between old and new incisor position and double this measurement
to determine total arch length discrepancy.
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Aug(554 - 571): A Visualized Treatment Objective
OBJECTIVE: To reposition lower first molar, use the plaster casts to determine arch length
discrepancy due to crowding and/or rotation. In this case the discrepancy is 4mm.
Superimpose tracing on mandibular plane and register on symphysis.
Incisor repositioning was 2mm lingually, thus effectively decreasing lower arch length 4mm. The
total arch length discrepancy is now 4 + 4 mm = 8mm.
Due to mild lingual repositioning of lower incisors and total arch length discrepancy of 8mm, it is
apparent that second bicuspids should be removed.
If two first bicuspids were extracted this would create 15mm of space whereas only 8mm are
required. Due to anchorage consideration, the extraction of first bicuspids is contraindicated.
In this case, therefore, the mandibular first molar was positioned 3½mm forward on either side.
Space due to the extraction of two second bicuspids = l5mm Space required was 8mm. Thus, to
close residual space, molars were advanced 3½mm on either side.
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Aug(554 - 571): A Visualized Treatment Objective
OBJECTIVE: To reposition maxillary first molar
Using the occlusal plane and lower first molar as a guide, draw the maxillary first molar in good
Class I occlusion with the lower first molar
OBJECTIVE: To complete artwork
1) ANS to upper incisor
2) Anterior portion of hard palate.
3) Lower alveolus lingually and labially.
Patient L.A.W., a 14-year-old female. Because of the premature physiologic development in
this patient, the amount of predicted growth over a two-year period was minimal (.75mm in
the region from Sella to Nasion). Superimposing pretreatment and V.T.O. tracings suggested
retraction of maxillary incisors and leaving the mandibular incisors in their present position.
To effect this required the extraction of upper first bicuspids and lower second bicuspids.
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Aug(554 - 571): A Visualized Treatment Objective
Superimposing-the V.T.O. and posttreatment tracings shows the results achieved relative to
the prediction. The lips were retracted a little more than anticipated, the tip of the nose grew a
little less than anticipated, and vertical growth was a little less than predicted.
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Aug(554 - 571): A Visualized Treatment Objective
Professor and Chairman, Department of
Orthodontics, School of Dentistry, The University of Alabama
in Birmingham.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume Aug
Department of Orthodontics, School of
Dentistry, The University of Alabama in Birmingham.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Aug(572 - 574): Orthodontic Economics - Number of Orthodontists
Number of Orthodontists
In the past, when orthodontists have been asked to list the factors that they felt contributed most
to an economic decline in orthodontics, Number One on the list was "Too many orthodontists". It
was felt that the schools were graduating too many orthodontists each year.
All efforts to estimate the number of practicing orthodontists there would be through the Eighties
were doomed to failure by the inadequacy of the data. Such estimates would have to be made by
taking a current figure for the number of practicing orthodontists, diminishing it by the number who
were expected to retire and die, and increasing it by the number of graduating orthodontists. The
process would be repeated for successive years. The problem was that accurate data was not
available in any of these categories and the estimates were the result of compounding errors. We do
have better information today, but not good enough to validate using it for making estimates of the
future. Nevertheless, the information is interesting and may have some application.
Number of Practicing Orthodontists
As of June 25, 1980 there were reported to be 6,550 active, practicing members of the American
Association of Orthodontists. One can only estimate how many active, practicing orthodontists are
not members of MO. A reasonable estimate seems to place the total number of active, practicing
orthodontists as of July 1, 1980 around 7500. This cross checks with another model of the number
of orthodontists.
Number of "Retired and Died"
Previous estimates have used a figure of 1% for "Retired and Died". This seemed low compared
to about 1 at 2% for the general dental population, but it turns out that the actual numbers are lower
than that (Table 1).
As can be seen from the table, there is no pattern to the number who retire and die annually. The
number of AAO members who retire has been in the thirties with the exception of the numbers
reported in 1976 and in 1980. There is not a pattern of more orthodontists retiring because the
specialty may be aging or because of economic conditions. Nor is there a pattern of fewer retirees,
as yet discernible, because of economic conditions. The number of deceased active members is
extraordinarily low and a case could be made that it has decreased instead of increased. The
longevity of orthodontists must be outstanding.
Number of Orthodontic Graduates
The American Dental Association has been keeping dental education statistics for some time
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Aug(572 - 574): Orthodontic Economics - Number of Orthodontists
(Table 2). In making past estimates, full use was not made of this material. Furthermore, at JCO's
request, the ADA began in 1978 to break out figures for the number of foreign students and foreign
graduates included in the orthodontic reports. If one wishes to estimate the current and future
number of practicing orthodontists in the United States, foreign graduates, who may be expected for
the most part to return to their country of origin, must be subtracted from the total number of
graduates. Until we know exactly how many return and how many stay in the U.S., we still have a
lingering source of error.
As can be seen in Table 2, the total number of orthodontic graduates reached a high-water mark
in 1974 at 360, and has been declining annually. In fact, there has been at least a 25% decline in the
n umber of U.S. graduates and the percentage of decline is probably more like 30% when the
increasing number of foreign students is taken into consideration. We do not have figures for
foreign graduates back to 1974, but the number can be presumed to be relatively fewer than in 1979.
Thus, there has been a substantial attrition in the number of new orthodontists just because of the
working of the marketplace and the law of supply and demand. With the first year enrollment being
currently static, one might expect that the fall-off in graduates will continue to be slowed or cease.
In fact, it would not be surprising to see the number start to increase again in the mid-Eighties with a
renewed interest in orthodontics. With the number of foreign students enrolled also fairly static, one
would not expect a large increase in the number of foreign graduates in the near term. This should
presage a slowing of the decline in the net number of U.S. graduates or even a leveling off in the
near term. At any rate, subtracting the 48 foreign graduates in 1979 from the total of 277 means that
about 230 new orthodontists were eligible to enter practice in 1979. That number must be reduced
by those who enter teaching, the armed forces, public health service, and general practice. An
additional number of graduates will find employment, rather than open their own practices. From a
dilution point of view, new graduates cannot be counted as a full unit of competition, either. Thus,
the actual dilution of the approximate 7500 active, practicing U.S. orthodontists is probably well
under 200 for 1979.
It can be concluded from a study of available data with regard to numbers of active, practicing
orthodontists, the number of orthodontists who retired and died and from the net number of new
orthodontists, that while the number of orthodontists is certainly a factor in the economics of
orthodontics it does not appear to be the major factor that many orthodontists have thought it to be
in the past.
ACKNOWLEDGEMENTS — I wish to express my gratitude to the American Association of
Orthodontists and the American Dental Association, Division of Educational Measurements for
their help with the statistics used.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume Aug
Table 1
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Aug(572 - 574): Orthodontic Economics - Number of Orthodontists
Table 2
New Treatment Dimensions - With First Phase Sectional and Progressive
Edgewise Mechanics
Hypnosis in Orthodontic Treatment
Handling Characteristics and Bond Strength of Eight Direct Bonding
Orthodontic Cements
Common Sense Mechanics Part 13
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Sep(589 -): 590 THE EDITOR'S CORNER
The ADA has recently recognized over-the-counter fluoride mouthrinses as a therapeutic
category and given its Seal of Approval to two products— StanCare (0.1% stannous fluoride),
Block Drug Company; and Fluoriguard (0.05% sodium fluoride), Colgate-Palmolive Company.
Considering the undoubted merit of this form of fluoride therapy, there is evidence that it is
underutilized in orthodontics. The most direct evidence was presented in Dr. Leonard Gorelick's
Survey of Bonding (JCO, January 1979) in which only 31% of the respondents reported routinely
prescribing fluoride mouthrinses.
It has not been for lack of published information. Over the past thirty-five years a considerable
literature has been produced with regard to fluoride therapy in dentistry. More recently, numerous
articles have appeared in the orthodontic literature specifically relating fluoride therapy to caries and
decalcification prevention in orthodontic practice. Zachrisson (Angle Orthodontist, January 1975)
recommended, in addition to adequate brushing with a fluoride toothpaste, tray application of
fluoride gel prior to appliance placement, supplemented by daily fluoride mouthrinses. Zachrisson
repeated this advice (JCO, February 1978) and added an additional therapeutic aspect to daily
fluoride mouthrinsing in the interference by the fluoride with the growth of plaque. This plaque
inhibitory effect was also mentioned by Gwinnett (JCO, April 1979) while he, too, recommended
daily home fluoride mouthrinsing as an adjunct in a program of prevention of caries and
decalcification. Thomas (JCO, October 1978) also recommended semi-annual application of
fluoride gel in the office, supplemented by daily fluoride mouthrinses.
Recently, Bounoure and Vezin (JCO, May 1980) published a thoroughgoing analysis of fluorides
and concluded with the recommendation of a combination approach with adequate toothbrushing,
professional application of fluoride gels, and personal home fluoride mouthrinsing daily as the basis
for a preventive program during orthodontic treatment; with fluoride varnishes reserved for
protection of cervical areas and for remineralization of white spots. The idea of trying to
remineralize unbroken white spot lesions has been mentioned by various investigators in connection
with the use of somewhat stronger rinse solutions.
Physical protection with adhesives and sealants has also been reported. Lee, et al (JCO, April
1973) reported success with the use of Enamelite, a composite adhesive, for both preventive and
restorative purposes. Other coverings (copal varnishes, polyurethanes) have been tried by other
investigators (Myers, Horowitz) with inconclusive results. Zachrisson (AJO, February 1977)
indicated that a sealant coating added protection to the enamel surface and reiterated this (JCO,
November 1978) but with a call for improved sealants. Gorelick and Thomas concurred in this
thought. Phillips (JCO, July 1980) alluded to the development of improved sealants for enamel
Since there is evidence in all these preventive measures that caries and decalcification during
orthodontic treatment can be substantially avoided, it is to be hoped that Dr. Gorelick's next Survey
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Sep(589 -): 590 THE EDITOR'S CORNER
of Bonding will show a substantial improvement in the percentage of orthodontists who are using
these measures to the fullest extent possible, including routine daily fluoride mouthrinsing.
Avoidable decay and decalcification is so upsetting to both patient and orthodontist, and
noticeable lesions are so detracting from however perfect an orthodontic result, a maximum fluoride
effort is called for. The patient's future health, happiness, self-esteem, and appreciation of
orthodontic treatment are involved. The orthodontist's happiness, self-esteem, and source of referral
are also involved.
A recently published report about complaints might put this in practical context. It was said that
2% of people who have a complaint actually complain; meaning that for every complaint, there may
be forty-nine others who do not complain. However, every one who has a complaint tells his tale of
woe to eleven other people; meaning that for every complaint, 550 other people have heard about it.
That is something to avoid.
While it is not easy to motivate patients to undertake a daily routine of fluoride mouthrinses, the
effort should routinely be made. And if prevention fails, for the well-being of the patient and
themselves, orthodontists should be prepared to institute recuperative or restorative measures to try
to abolish the blemish on their work.
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Sep(607 - 627): New Treatment Dimensions - With First Phase Sectional and Progressive Edgewise
New Treatment Dimensions With First Phase
Sectional and Progressive Edgewise
This paper describes a proven procedure for distalizing maxillary buccal segments and arch
leveling. In first phase treatment, sectional modules are inserted to produce unequaled first order
mechanics, distalizing maxillary buccal segments in a matter of weeks. Bite opening and arch
leveling are effected with no molar tipback. New dimensions are added to mandibular anchorage
with no daytime headgear. The modules are used to control or bypass the edgewise appliance
countermoments and are designed with low friction and high force dissipation for maximum
treatment response. They are standardized for convenience with plug-in or overlay insertion without
interfering with progressive bracketing of the edgewise appliance.
The maxillary first molar is key to all quadrant arch length analysis, diagnosis and treatment
planning. The possibility of distalizing first molars a few millimeters, plus minimal incisor
advancement and slight expansion, if indicated, in addition to the use of bonded brackets, produces
an entirely new set of parameters for arch length evaluation and treatment planning. Extractions
thereby are reduced drastically, in precisely those marginal areas where extraction treatment
becomes difficult and complicated. This eliminates a whole spectrum of edgewise problem cases
needing excessive space management, leveling, and root torquing. Freed from these unnecessary
demands, edgewise treatment can function at its greatest efficiency with superior results.
Baumrind, et al (AJO, June 1979) found bodily movement of the upper first molars was possible
with heavy continuous extraoral forces, which was not observed with the intraoral appliances
examined. The most common methods for attempting to distalize buccal segments utilize extraoral
force either against buccal tubes on banded first molars prior to full banding, or against the tubes
with full edgewise bracket tie-in. In either instance, as the maxillary molar is moved distally,
rotation occurs around an axis near the center of the root (Fig. 1). The arrangement of periodontal
fibers of the distal portion of the roots resists intrusion. There is little resistance to the balance of
rotation, forcing rearrangement of the mesial periodontal fibers. This causes extrusion of the mesial
cusps and tipback of the distal cusps as part of the rotation process.
The superiority of gingival placement of the headgear tube over occlusal placement is clearly
demonstrated (Fig. 2), with a marked difference in the degree of molar tipping with distal force.
When distal movement of the upper first molar is attempted with the archwire tied into full-arch
bracketing, the rotation moment and molar tipping introduce a whole series of variable moments and
countermoments (Fig. 3). The direction of these is unimportant, but the induced friction and binding
introduce extraordinary resistance, which makes en masse distalization of the buccal segments
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Sep(607 - 627): New Treatment Dimensions - With First Phase Sectional and Progressive Edgewise
extremely difficult. This requires heavy extraoral forces, which is the difficulty that produced the
theory that distalizing of buccal segments was not orthodontically possible.
Immediate full edgewise bracketing reduces efficiency and prolongs treatment, due to the
countermoments and friction factor. Early bicuspid and second molar bracketing must be avoided.
Progressive bracketing permits a first phase of treatment with partial bracketing and sectional
mechanics prior to full bracketing. Delayed bracketing minimizes friction and allows occlusal forces
to operate during treatment as a functional inclined plane, to settle the occlusion within
gnathological parameters of the natural TMJ morphology.
Initial treatment functions must observe a sequential order (Fig. 4). Maxillary arch length
modification is integrated with sectional first phase treatment. Mandibular arch modification defines
first molar position. Minimal corrections are made to reduce Class II treatment interferences. Early
cuspid buccal uprighting must be delayed to avoid cusp interference with Class II mechanics.
During first phase treatment, the three engineering principles of lever deflection, bypass
mechanics, and load reduction are utilized. As a byproduct of these principles, first year edgewise
and straight wire treatment goals can be completed well ahead of normal schedules. Utilizing
sectional first phase with sectional progression to full bracketing, a 50% reduction in chair time can
be demonstrated in 75% of treated cases. This group includes Class II division 1, Class II division 2,
and Class I cases with moderate arch length deficiency. In about 25% of cases, extraction or high
angle, the process has variable but modified application.
The sectional first phase utilizes light force input with high force delivery during progression to
full edgewise bracketing. The sectional modules are phased out and discarded as progressive to full
bracketing phases in for the second and third order edgewise mechanics. Progressive edgewise
bracketing facilitates the first phase; full edgewise bracketing completes the second phase of
aligning, torquing, and finishing. While progressive bracketing in this article is with Triple Control
Edgewise, the process is equally efficient with any edgewise or straight wire brackets and molar
rectangular tubes with .045 headgear tubes.
Distalizing Maxillary Molars
Internal arch preparation for the distalizing function is minimal but important. Essential to the
treatment is prewelding of 3D lingual tubes to all four first molars and bonding of DBS lingual
buttons on the lingual of the first bicuspids (Fig. 5A).
The Rocky Mountain Bimetric Arch is a multipurpose unit, combining two sections. The anterior
arch (.022 Truchrome) provides an unusual balance of formability, low deformation and resilience
for multiple functions. The posterior .040 end section with intermaxillary hooks has Omega
Adjustable Stops attached. This combination unit inserts into the .045 headgear tube, having no
interference with edgewise bracketing and acts as both an arch length control and a multidirectional
arch modifier for controlled distal movement of the molar. Initial edgewise bracketing of the
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Sep(607 - 627): New Treatment Dimensions - With First Phase Sectional and Progressive Edgewise
anterior teeth is limited to the central incisors in Class II division 2 cases and the lateral incisors in
Class II division 1 cases. The .022 brackets permit the engagement of the .022 anterior wire into the
slot. With any slot size other than .022, the wire is ligated beneath the gingival wing ( Fig. 5B).
Distalizing molars, either bilaterally or unilaterally is a positive yet simple procedure. An .010 
.045 coil spring, 5mm in length, is inserted between the Omega Stop and the buccal tube. The coil
spring is compressed to 3mm to produce a 2mm activation and movement. This is supported by an
intermaxillary elastic system to be described later. The patient is seen at three-week intervals, during
which time there is a 2mm distalization of the first molar. It is not necessary to remove the archwire.
The Omega Stop is now reactivated 2mm more by compression with a Tweed plier, applying the
concave beak to the inner concave surface of the Omega Stop. This reactivation is simple, precise
and positive. It requires but a few moments of chair time.
Enmasse movement of buccal quadrants compounds friction and anchorage loads which are
counterproductive. It is important, therefore, during the sectional phase of treatment, to isolate teeth
or groups of teeth for sectional activation (Fig. 6). Anchorage loads become minimal and low forces
produce a high degree of biologic performance, sharply reducing treatment time during this first
One of the gross misconceptions in orthodontics has been the overestimation of anchorage value
of maxillary second molars and their resistance to distal movement. It is important that second
molars must not be banded at this point. The distalizing force applied to the first molar transmits
through the contact point to the second molar with little additional force required. Such distalizing
must be avoided until the second molar has erupted into contact, or if unerupted there should be
radiographic evidence of spacing between the molars. Distalizing should rarely be done before age
eleven, at which time the tuberosity enters a period of rapid growth to accommodate the second
molar in a more distal position. Bilateral and unilateral distalizing are equally simple.
Once the molars are in Class I position, the coil spring is removed and the Omega Stop is
adjusted to sustain the molar with minimal elastics. The bicuspids, cuspids and incisors are
sequentially distalized.
Figure 7A shows a Class II transitional case, age eleven years. The deciduous teeth were removed
to await some eruption. Following this the molars were distalized. The coil springs were removed
and the molars sustained with minimal elastics during the eruption of the bicuspids and cuspids into
a Class I alignment. The distalizing phase was completed in eight weeks (Fig. 7B). Following the
eruption of the permanent teeth, the Bimetric Arch is adjusted for intrusive action (to be described
later). Superimposition (Fig. 7C) shows distalization of the maxillary molar with positive apex
displacement. Stability of the mandibular molar and incisor is shown. The distalization was
achieved with minimal mandibular rotation and lower molar extrusion. Growth is not a factor within
this short time frame.
Distalizing Maxillary Bicuspids
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The sequential retraction of the bicuspids is a simple procedure with the 3D resistor, which is a
multipurpose plug-in module with the following functions:
• Resistor of molar tip with incisor depression.
• Resistor of 2nd molar extrusion.
• Posterior resistor for anterior advancement.
• Bicuspid retractor.
• Sectional expander.
This is an adaptation of a Rocky Mountain 3D sectional unit (Fig. 8A). The friction locks are
contoured in two designs, one to plug in upper right and lower left and the other upper left and
lower right. The activator has a 5-degree lingual offset for mucosal clearance. The .025 adaptor and
extender provide an excellent combination of resiliency and low deformation for multiple
adaptations. The 3D resistor is plugged into the prewelded 3D tubes, and adapted to the mesial of
the bicuspid and to the occlusal of the second molar (Fig. 8B).
Case D.C. (Fig. 9) demonstrates the sequential distalizing of first the maxillary molars, followed
by the bicuspids. This case with the missing tooth was chosen because it permits clearer visibility of
the positioning of the 3D resistor. The buccal quadrant distalized after six visits. The gingival
placement of the bicuspid retractor permits a high degree of bodily movement. The point of force
application places the center of rotation nearer the apex of the root, in contrast to a lower center of
rotation if force were applied at the level of the bicuspid brackets.
The transeptal fibers between the first molar and second bicuspid are extremely reactive to
tension. Once the molar is in position, these act to facilitate orthodontic distal movement of the
second bicuspid. Distal physiologic drift of the first bicuspid is completed with controlled retraction
by the 3D resistor. This procedure is effective bilaterally at the same time and is completed in a few
visits. Since no intrusion is required in this case, there is no needfor second molar control and the
distal extender is cut off. Activator adjustment with light wire pliers is simple (Fig. 10).
First phase distalizing is demonstrated in Case J .Y. a twenty-two-year-old patient with a Class II
division 2 problem (Fig. 11). The correction is shown (Fig. 11B) following the retraction of the
bicuspids. The cuspid is in the process of eruption. Class II elastics have been stopped and intrusion
of the incisors has now started. Superimposition (Fig. 12) shows no visible growth changes in the
six months of treatment. Distalization of the maxillary molar with apex displacement is evident.
Mandibular molar position is relatively stable with minimal mandibular rotation. The mandibular
incisors were advanced for arch alignment.
Maxillary Anterior Intrusion
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Sep(607 - 627): New Treatment Dimensions - With First Phase Sectional and Progressive Edgewise
Incisor intrusion is not attempted until the Class II relationship is corrected. The function of
incisor intrusion has been problem ridden because of the resistance common to the rectangular wire
in the anterior brackets and the reciprocal countermoments resulting in molar tipback. Complex
efforts toward molar control utilizing sectional or full edgewise bracketing, with a short interbracket
space, minimizes the lever deflection possibilities and produces low force delivery. The 3D resistor
which has previously been inserted for retraction of the bicuspids, is left untouched and now serves
a second purpose as a cantilever resistor (Fig. 13). The occlusal bearing of the anterior lever arm and
the apical vector of the second molar lever arm prevent molar rotation and tipback. Experience has
shown that the second bicuspid needs no attachment. It remains stable in the four-tooth posterior
anchorage unit, which secures molar position and prevents tipback. This diverts the reactor force
ordinarily acting against the molar into an anterior component to further maximize the intrusion of
the incisors and minimize the force needed for intrusion.
Maxillary intrusion, like distalizing, is a simple procedure. The key is avoidance of enmasse
intrusion with heavy forces, producing resistances and slow progress. As with distalizing, the key to
the process is the isolation of units permitting leveling sequences (Fig. 14). This produces a low
force, maximum response and in no way can overtax the posterior 3D resistance to the molar tipback
countermoment. This in turn reflects the low force input and the high magnitude of force anteriorly.
The result is a most efficient intrusion in a short time.
The internal 3D cantilever resistor once in place needs little or no attention and frees the buccal
teeth for activation of the same Bimetric Arch, previously used for distalizing and now adapted as a
bypass intrusive arch. The tipback bend is made on the .040 end section within the Omega Stop
(Fig. 15A). Because of the resistance in the Bimetric Arch, the tipback is far less than is ordinarily
used with an .018 tipback arch. The anterior .022 wire is inserted in the brackets or beneath the
incisor wings of the brackets depending on the bracket size being used (Fig. 15B). Note that the
Omega Stop is free of the buccal tube, since intrusion of the incisors only and no torque is
programmed in this instance. The engagement of the round wire permits a flow of the roots through
the medullary trough, avoiding cortical bone. This is free-flowing and rarely needs any further
activation. The results are as rapid as one could hope for. The bilateral 3D resistors make rapid
incisor intrusion possible with no molar tipback and round trips involved (Fig. 15C). No high pull
headgear has ever been found necessary and root resorption is avoided.
Once the central incisors are intruded, the lateral incisors are bracketed and the same procedure
followed. Cuspid bracketing permits utilization of elastic thread to the Bimetric Arch to intrude. If
the intrusion needs are excessive, an edgewise section with a helix and with the wire rounded as it
enters the edgewise bracket will intrude the cuspid to the level of the incisors (Fig. 16).
Maxillary Expansion
Coincident with intrusion, with the 3D resistor still in position, minimal expansion needs are
carried out through expansion of the Bimetric Arch (Fig. 17), which shows an excellent balance of
properties with adequate integrity and resilience to support the arch for expansion needs. The 3D
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Sep(607 - 627): New Treatment Dimensions - With First Phase Sectional and Progressive Edgewise
resistors can be removed and adjusted against any bicuspid that needs further buccal uprighting.
They likewise serve as internal mechanisms for midline sutural expansion, which is effective at a
rate in keeping with proliferation of new bone at the midline suture. This process shows no rebound
common to some palate splitting procedures.
There is a common error in orthodontics to expand arches and then attempt distalization. As
arches are expanded, there is some impingement on the buccal cortical plate, which produces an
unnecessary anatomical resistance to distalizing. Expansion should never be attempted until the
distalizing is completed, however much the need or severe the crossbite. By observing the proper
sequence with these treatment functions, treatment time can be drastically reduced.
Following the completion of the first phase, the Bimetric Arch is removed and progressive
bracketing is continued on to full bracketing as needed. Triflex wire is used initially for aligning
(Fig. 18), followed by a sequential series of round wires or rectangular wires, depending upon the
choice of the individual orthodontist for torquing and finishing. Distal movement of buccal
segments produces an increase in buccal arch width as the teeth continue posteriorly within the
medullary trough. Clinically this arch increase is stable. Although the increments may be significant,
this is not to be considered as orthodontic expansion.
Mandibular Anchorage Modification
There is a wide variation in anchorage values. In Class II division 2 cases with a closed bite,
mandibular anchorage values are high. Likewise, where molars have heavy widely diverging roots
and a tight restrictive lower lip, such values are always high. In contrast, anchorage values are low
when molars have short conical roots and a binding lingual frenum causes the tongue to override the
lower incisors (Fig. 19).
Mandibular anchorage is modified and increased to meet the need when necessary. The 3D
lingual archwire with twin vertical posts provides positive molar control as well as buccal root
torque. The diamond-shaped activator permits adjustment for positive geometric controls of the
positioning of the anterior archwire. The archwire should be in contact with the cingulum of the
anterior teeth (Fig. 20A). The .028 Truchrome archwire permits unequaled activation and yet is
resistant to distortion. Careful and precise adaptation will suffice for most anchorage needs.
Further increments are possible through cortical anchorage for which the 3D lingual archwire is
uniquely adapted. Buccal torque in the 3D posts is a most simple and precise adjustment. If further
anchorage is needed, an .018 round wire or bracket-filling edgewise adaptation from the molar
secured to the four anterior teeth would produce a degree of anchorage which far exceeds any
conceivable requirements (Fig. 20B) . The last two factors of molar buccal root torque and incisor
tie-in are rarely required when the 3D lingual arch anchorage is properly set up.
It is essential that unnecessarily excessive elastic loads be avoided. The sequentially designed
maxillary bimetric distalizing process is coordinated with elastic load reduction, which greatly
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Sep(607 - 627): New Treatment Dimensions - With First Phase Sectional and Progressive Edgewise
minimizes the taxation on mandibular anchorage and yet provides the full necessary force for the
individual sequential functions.
There is a potential source of error with improper timing. When the buccal teeth have not yet
erupted, the anchorage setup throws stress on the anterior teeth. Second deciduous molars, when
present and firm, provide favorable increments of resistance. When the deciduous molars are lost, it
is usually advisable to wait for the eruption of the bicuspids and the determination of molar position.
Any 3D lingual arch adjustments for arch modification, should be carried out either before or after
elastic traction and not during this function. Such adjustments do introduce variable torsions within
the wire, which would temporarily minimize anchorage values.
A common error in treatment is to apply too heavy elastics continuously over too long a period of
time, which destroys anchorage. The principle of elastic load reduction is one which delivers an
adequate force magnitude with minimal anchorage taxation. 5/16 (2oz) Rocky Mountain elastics are
used. Three are applied for the first five days, following which one is removed and two are
continued for five days. Then another is removed, leaving one continuous light elastic for the
balance of the treatment interval (Fig. 21). This is coordinated with the reduction of elastic needs for
the bimetric distalization process. During the first five days, with 6 ounces of elastics, one
millimeter of compression of the coil spring is dissipated, eliminating the necessity for 6 ounces. A
reduction to 4 ounces is adequate for the dissipation of the remaining coil spring activation. 2
ounces are then sufficient to sustain the bimetric mechanism during the balance of the treatment
interval. This is a fine tuning of Class II elastics and represents a coordinated program of maximum
response with decreasing anchorage taxation. This stands in contrast with the common prolonged
use of heavy elastics, which destroys mandibular anchorage stability.
Mandibular Arch Leveling
A sequential procedure is used likewise with mandibular intrusion and leveling ( Fig. 22).
Progressive bracketing involves the mandibular incisors, first, which are intruded with an .018
intrusive arch. The 3D lingual arch with distal extenders to the occlusal of the second molars (Fig.
23) provides more than adequate posterior anchorage for intrusion of the four incisors.
When intrusion of incisors is planned as a part of treatment, the initial 3D anchorage setup,
needed for the first phase distalizing, includes an adaptation of the .025 distal extender to the
occlusal of the second molar. This permits continuation of use of the same 3D arch for both
functions. The bilateral molar anchorage controls the countermoments for first molar tipback. The
sequential intrusion of units, in contrast to enmasse intrusion, further assures control of the
countermoments and maximizes the intrusion. The intrusive arch is an .018 Truchrome wire with
helix activated into the four incisor brackets (Fig. 24). Sufficient clearance of the .018 helix anterior
to the buccal tube permits a flow of the incisor roots into the medullary trough, which in turn allows
rapid intrusion without root resorption. Incisor labial root torque when needed to avoid root
resorption is a simple modular procedure. Following intrusion of the incisors, the cuspids are
bracketed and these are ligated to the archwire with elastic thread until engagement becomes
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Sep(607 - 627): New Treatment Dimensions - With First Phase Sectional and Progressive Edgewise
possible. After first phase mandibular anchorage and arch leveling have been completed,
progression to full bracketing permits arch alignment, torque and finishing as needed. These may be
carried out with round or rectangular wires of choice.
Arch Length Modification
The Bimetric Arch-coil spring modality is adapted to arch length modification, primarily as it
relates to regaining second bicuspid or cuspid space which has been lost due to premature deciduous
exfoliation. Case S.A. (Fig. 25) shows unilateral molar mesial drift having completely closed the
space for the second bicuspid. Figure 26 shows the space regained after distalization of the molar,
followed by mesial movement of the first bicuspid with a variation of the 3D resistor. Figure 27
shows the light wire plier adjustment of the activator as indicated.
Superimposition shows normal forward growth of SN over an eighteen month period, along with
a normal downward and forward growth of the mandible (Fig. 28). Distalization of the maxillary
first molar with positive apex displacement, lower molar and incisor stability with little mandibular
rotation are demonstrated.
Bilateral molar distalization with Bimetric Arch-coil spring module and first bicuspid mesial
movement with a modified 3D resistor can be carried on simultaneously, with controlled
countermoments and preservation of mandibular anchorage.
The Bimetric Arch-coil spring module is equally effective in arch length modification regaining
space for maxillary cuspids (Fig. 29). The buccal segments are distalized into Class I position. Then
the anterior .022 bow is reshaped to desired anterior arch form and the coil spring is allowed to
express itself without Class II elastics. In this instance the same 3D resistor acts as a posterior
resistor and provides anchorage for coil spring action anteriorly. The incisors are aligned and
intruded and the cuspid space regained (Fig. 29B).
The Bimetric-coil spring module is equally effective in Class II division 1 problems (Fig. 30).
The decidous teeth were removed and the molars were distalized coincident with a reforming of the
anterior .022 bow to desired arch form. Figure 30B shows the case after 14 weeks of treatment,
stabilized with minimum elastics, while awaiting eruption of the buccal teeth.
In Class II division 1 cases with a severe maxillary protrusion, reduction of the protrusion has
first priority. The coil spring is removed and Class II elastics permit a retraction of the anterior teeth
to a degree determined by the Omega Stop (Fig. 31). This reduction of protrusion is temporarily
terminated as cuspid position is approached. Classical Bimetric Arch-coil spring treatment is then
initiated for distalizing of the molar and retraction of the buccal segments with the 3D resistor. The
anterior teeth are retracted into final position in contact with the lower incisors (Fig. 32).
Superimpositions (Fig. 33), before and after five and one-quarter months of treatment, show
distalization of the maxillary molars with positive apex displacement and the reduction of anterior
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Sep(607 - 627): New Treatment Dimensions - With First Phase Sectional and Progressive Edgewise
protrusion. There was a slight mandibular rotation to be anticipated during the period of rapid
distalization. No adverse upper incisor root movement or round tripping is shown. Figure 33B
shows minimal lower molar changes and minimal anterior advancement of the lower incisor.
Functional Treatment Considerations
The current interest in removable functional appliances with buccal shields has caused criticism
of edgewise and full-banded treatment for being restrictive of natural arch width increase. The
Bimetric Arch modality design, with its 2 2 or 24 first phase sectional edgewise bracketing,
specifically maximizes natural arch width increase more efficiently than is possible with removable
The bypass of early bicuspid banding, to maximize efficiency in the controlled functions of
distalizing and intrusion, liberates the buccal teeth for functional improvement. Further, the heavier
.040 posterior arch is designed to bypass contact with the bicuspids. This inhibits the restrictive
forces of the buccinator muscle against the buccal teeth as is commonly evidenced by buccal
appliance compression on the cheeks.
It is common clinical experience to find buccal movement of bicuspids by as much as to 2 to
5mm away from the internal 3D resistors. As with functional appliances, this phenomenon occurs in
some cases and definitely not in others. It is proven to be independent of any orthodontic force, but
unmistakably it does occur. This results from altered parameters of muscle pressure as restrained by
the Bimetric Arch during sectional first phase treatment. Unlike functional appliances, which are
removable and completely dependent on patient cooperation, the Bimetric Arch modality is not.
This fact alone assures more successful results. Whereas functional appliances have severe
limitations relating to the three orders of tooth control and completion of treatment, the Bimetric
Arch modality as a first phase of progressive edgewise mechanotherapy does not.
This modality not only serves natural buccal arch width increase, but it is adaptable to maintain
and selectively modify the increase. This is accomplished with the 3D resistor already present.
Further positive and variable arch length modifications, as described, are possible without appliance
changes. Continued progression to full edgewise bracketing, where needed, adds the whole
spectrum of tooth control functions that are common to fixed appliances and not possible with
removable appliances.
First phase treatment does not require bicuspid and cuspid bracketing. Treatment can be initiated
prior to the eruption of the buccal teeth. During the late stages of mixed dentition, Class II
mechanics seem to release any given potential for condylar growth. This results in a degree of Class
II correction, which is less commonly seen in later full edgewise treatment. This is not consistently
predictable nor is it a mistaken dual bite. It does simulate functional appliance results. When it does
occur, it is accepted as a byproduct of the Class II distalizing mechanics during the transitional
period of active growth. The Class II distalizing function remains, however, as the viable central
premise of first phase sectional and progressive edgewise mechanics.
Article Text
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Sep(607 - 627): New Treatment Dimensions - With First Phase Sectional and Progressive Edgewise
First phase sectional treatment with progressive bracketing completes sequential distalizing and
leveling with low force and high biologic performance. Cortical resistance is avoided and tooth
movement through the medullary trough is maximized. The three engineering principles of lever
deflection, bypass mechanics and load reduction avoid the time-consuming problem with
countermoments, friction factors, resistance, heavy forces, and round trips, which are common to
full bracketing during this phase.
The first phase is adaptable to any rectangular arch system. Progression to any preferred full
rectangular bracketing as needed, permits the most precise aligning, torquing, and case finishing
free of the above problems which have been bypassed. Most important, multidirectional treatment
becomes a reality, eliminating the otherwise unidirectional excesses with their iatrogenic sequellae.
Finally, previously impossible treatment time reductions are realized.
Bracket and Tube Placement
1. Band 6| 6 with double rectangular tubes of choice, including .045 headgear tube preferably
gingival. 3D lingual tubes.
2. Band
6| 6
3. Bracket
with buccal rectangular tube of choice with hook, 3D lingual tubes.
with rectangular bracket of choice, as an initial part of progression to full bracketing.
4. IMPORTANT. Avoid any bicuspid or second molar bracketing during first phase to maximize
treatment efficiency and treatment chair time reduction.
Mandibular Anchorage Modification
1. Adjust Rocky Mountain 3D lingual arch for anterior control.
2. Adapt 3D distal extender to
7| 7
to control
6| 6
3. Add supplementary 3D anchorage if needed.
4. Utilize the elastic load reduction principle.
Distalizing the Upper Molars
1. Adjust and insert Rocky Mountain Bimetric Arch into .045 tube, contact Omega Stop with tube.
Article Text
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Sep(607 - 627): New Treatment Dimensions - With First Phase Sectional and Progressive Edgewise
2. Insert .045 coil spring 5mm in length. Activate 2mm.
3. Insert into headgear tubes for Class II treatment.
4. Ligate Bimetric Arch to 1 | 1 bracket. If other than .022, tie under gingival wing.
5. Activate with Class II elastics.
6. Repeat for Class I relationship.
Bicuspid Retraction
1. Adjust 3D resistor for retraction, bilaterally if needed.
2. Remove coil spring from Bimetric Arch and adjust Omega Stop to tube contact.
3. Remove 3D resistor, activate closing loop 1 to 2mm only. Insert with spring tension.
4. Support
6| 6
anchorage with minimal elastics.
5. Repeat 3, to close
7654 | 4567
54| 45
now in Class I occlusion.
Cuspid Retraction
1. Bond edgewise bracket on
3| 3
2. Ligate with elastic ligature
6| 6
3. Support
6| 6
anchorage with Bimetric Arch elastics.
4. Ignore any cuspid rotation and axial needs at this point.
Maxillary Arch Leveling
1. Tie in Bimetric Arch into
bracket. If other than .022, tie under occlusal wing.
2. Bond plastic lingual buttons on
3. Leave the 3D resistor undisturbed. It now serves another function as a cantilever resistor.
4. Molar stability is now assured with sectional resistance.
Article Text
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Sep(607 - 627): New Treatment Dimensions - With First Phase Sectional and Progressive Edgewise
5. Activate Bimetric Arch for 1 | 1 intrusion.
6. Bracket
2| 2
and intrude.
7. Intrude 3| 3 with edgewise sectional with helix, rounding the wire at the point of cuspid tie-in. If
intrusion needs are minimal, use elastic thread to Bimetric Arch.
Mandibular Arch Leveling
1. Continue 3D lingual arch with second molar extenders.
2. Bracket
21 | 12
for sequential intrusion.
3. Insert .018 Truchrome wire with helix and tipback bend or intrusive arch of choice.
4. Tie in edgewise brackets for activation.
5. 3D anchorage resists molar tipback and reflects force for anterior intrusion.
6. Bracket
3| 3
and tie to .018 arch for depression.
7. Bicuspids are free to erupt.
8. End of sectional phase treatment.
Maxillary Arch Alignment
1. Discard Bimetric Arch.
2. Complete edgewise bracketing as needed.
3. Use Triflex or light wire of choice to align.
4. Initiate sequential series of round wires to rectangular wires of choice.
Mandibular Arch Alignment
1. Complete full edgewise bracketing as needed.
2. Leave 3D lingual arch to prevent whiplash.
3. Insert Triflex or light wire of choice.
4. Align with round or rectangular wires of choice.
Article Text
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Sep(607 - 627): New Treatment Dimensions - With First Phase Sectional and Progressive Edgewise
Torquing and Finishing
1. Discard upper 3D sectionals and lower 3D lingual archwire.
2. Insert edgewise torquing arches of choice.
3. Complete finishing with brackets filled for full finishing control if needed.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume Sep
Fig. 1
Fig. 1 Distal force on molar producing reorientation of mesial poriodontal fibers, rotation and extrusion of mesial cusps.
Fig. 2
Fig. 2 Comparison ofocclusal and gingival placement of headgear tube with relation to molar rotation with distal force.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Sep(607 - 627): New Treatment Dimensions - With First Phase Sectional and Progressive Edgewise
Fig. 3
Fig. 3 Extraoral distal force on molar with full edgewise appliance causes friction binding.
Fig. 4
Fig. 4 Functions isolated and overlapping in sequence of progressive to full bracketing.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Sep(607 - 627): New Treatment Dimensions - With First Phase Sectional and Progressive Edgewise
Fig. 5
Fig. 5 A. Basic arch preparation with 3D lingual tubes on upper molars, DBS lingual buttons on first bicuspids, and
Bimetric Arch. B. Bimetric Arch with Omega Adjustable Stop and coil spring.
Fig. 6
Fig. 6 Sectional action in distalizing sequence.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Sep(607 - 627): New Treatment Dimensions - With First Phase Sectional and Progressive Edgewise
Fig. 7
Fig. 7 A. Class II transitional case prior to treatment. B. Distalizing completed in 8 weeks. C. Superimposition of
tracings before (solid) and after (broken) shows distalization with positive apex displacement.
Fig. 8
Fig. 8 A. 3D sectional arch. B. 3D resistor adaptation.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Sep(607 - 627): New Treatment Dimensions - With First Phase Sectional and Progressive Edgewise
Fig. 9
Fig. 9 A. Class II relationship. B,C. Distalization of molars and bicuspids completed in 3 visits for each a total of 18
weeks and 30 minutes of chair time. Note gingival placement of bicuspid retractor.
Fig. 10
Fig. 10 Activation of the bicuspid retractor.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Sep(607 - 627): New Treatment Dimensions - With First Phase Sectional and Progressive Edgewise
Fig. 11
Fig. 11 A. Class II division 2 case before treatment. B. After 6 months of treatment in 9 visits with 45 minutes of chair
time (after appliances).
Fig. 12
Fig. 12 Superimposition of tracings before (solid) and after (broken) treatment of case in Figure 11 showing distalization
with apex control.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Sep(607 - 627): New Treatment Dimensions - With First Phase Sectional and Progressive Edgewise
Fig. 13
Fig. 13 Moments (open arrows) and countermoments (solid arrows) with 3D resistor.
Fig. 14
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Sep(607 - 627): New Treatment Dimensions - With First Phase Sectional and Progressive Edgewise
Fig. 14 Maxillary leveling sequence.
Fig. 15
Fig. 15 A Tipback bend in end section for maxillary anterior intrusion. B. Bimetric arch engaged in anterior brackets. C.
Bilateral 3D resistors in place.
Fig. 16
Fig. 16 Edgewise section for intruding cuspids when needed. (Bimetric Arch removed for purposes of photography).
Fig. 17
Fig. 17 Adjustment of Bimetric Arch for expansion.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Sep(607 - 627): New Treatment Dimensions - With First Phase Sectional and Progressive Edgewise
Fig. 18
Fig. 18 Triflex arch for initial alignment with full bracketing.
Fig. 19
Fig. 19 3D anchorage considerations.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Sep(607 - 627): New Treatment Dimensions - With First Phase Sectional and Progressive Edgewise
Fig. 20
Fig. 20 A. 3D lingual arch contacts cingulums of lower incisors. B. Lower labial arch to provide additional anchorage
support when needed.
Fig. 21
Fig. 21 Elastic load reduction.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Sep(607 - 627): New Treatment Dimensions - With First Phase Sectional and Progressive Edgewise
Fig. 22
Fig. 22 Mandibular intrusion and leveling sequence.
Fig. 23
Fig. 23 3D lingual arch provides anchorage for intruslon of 4 incisors.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Sep(607 - 627): New Treatment Dimensions - With First Phase Sectional and Progressive Edgewise
Fig. 24
Fig. 24 Truchrome intrusive arch (.018).
Fig. 25
Fig. 25 Case with unilateral molar mesial drift before treatment.
Fig. 26
Fig. 26 Case in Figure 25 after correction requiring 9 months of treatment time and 9 months of eruption time for
second bicuspid.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Sep(607 - 627): New Treatment Dimensions - With First Phase Sectional and Progressive Edgewise
Fig. 27
Fig. 27 Adjustment of 3D activator.
Fig. 28
Fig. 28 Superimposition of tracing of case in Figures 25 and 26 before (solid) and after (broken) treatment.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Sep(607 - 627): New Treatment Dimensions - With First Phase Sectional and Progressive Edgewise
Fig. 29
Fig. 29 Bimetric Arch-coil spring module regained space for maxillary cuspid.
Fig. 30
Fig. 30 Class II division 1 case after 14 weeks of treatment (right) with Bimetric-coil spring module.
Fig. 31
Fig. 31 Coil spring removed for reduction of protrusion.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Sep(607 - 627): New Treatment Dimensions - With First Phase Sectional and Progressive Edgewise
Fig. 32
Fig. 32 A. Class II division 1 case before treatment. B. After 22 weeks of first phase treatment.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Sep(607 - 627): New Treatment Dimensions - With First Phase Sectional and Progressive Edgewise
Fig. 33
Fig. 33 Superimpositions of case in figure 32 before (solid) and after (broken) 22 weeks of treatment.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Sep(628 - 630): Hypnosis in Orthodontic Treatment
A Case Report
While the use of hypnosis in dental treatment has a long established and well-documented
history, there is little or no mention of its application in orthodontics. This is probably due to the fact
that orthodontists are not usually involved in dental procedures that call for frequent use of
hypnosis, viz. analgesia, pain control, etc. However, hypnosis has several other applications in
clinical practice that are often overlooked, and some of these have very definite applications in
This report deals with an orthodontic case that was treated with the help of hypnosis.
Case Report
C.K., a 21-year-old female, had a Class I malocclusion with Class III tendencies, a steep
mandibular plane angle, missing mandibular left first molar, maxillary lateral incisors in crossbite
and maxillary second molars in buccal crossbite. There was a severe midline discrepancy and the
case was by no means an easy one.
There was generalized hypocalcification and several of the anterior teeth bore stains. The patient
was due to undergo bleaching subsequent to her orthodontic treatment and it was felt that bonded
appliances were contraindicated. When banding was started, however, we encountered a severe
problem. The patient was unable to tolerate almost any pressure on her teeth, and the first few
sessions for banding and placement of initial archwires proved to be excruciatingly painful. C.K.
proved to be an extremely cooperative patient and followed all instructions given to her. So eager
was she to receive treatment that she kept struggling through each appointment. There is absolutely
no doubt that she was not "shamming" and that the pain and discomfort she felt, which lasted for
several days after each appointment, were very real. Things soon became impossible, however, and
the placement of a ligature tie would often bring tears to her eyes.
It was felt that it would be impractical, as well as undesirable, to use some form of analgesia or
anesthesia for each archwire adjustment. Unless some form of pain control was instituted, it was
obvious that treatment may have had to be terminated. The possibility of using hypnosis was
suggested, and the patient readily agreed to try it. She proved to be a good subject.
A hypnotic trance was induced and the depth of the trance enhanced through the use of visual
imagery (Fig. 1). When the patient was judged to have achieved adequate depth of trance, she was
asked to let her right hand "become numb" and to give a signal when this "numbness" was achieved.
Her ability to achieve this numbness was tested by inserting a sterile needle into the back of her
right hand (Fig. 2). The patient was then asked to place her "numb" right hand in the region of her
jaws and to transfer this numbness to her jaws, teeth, and the surrounding soft tissues (Fig. 3). The
Article Text
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Sep(628 - 630): Hypnosis in Orthodontic Treatment
entire session took approximately 30 minutes.
On subsequent visits, the patient was able to make her jaws and teeth numb on request, and it
rarely took her longer than a minute to achieve this state. She was also able to "lock" her jaws open
for prolonged periods of time without much discomfort (Fig. 4). Appliance adjustments for the
duration of her treatment were performed routinely and the patient rarely felt any discomfort. In
addition, the patient was given posthypnotic suggestions that greatly reduced the discomfort she had
normally felt after appliance adjustments. Treatment was successfully completed and the patient is
now in retention.
As far as the author is aware, this is the first report to describe the use of hypnosis for treatment.
There is very little doubt that treatment would have been all but impossible without the use of
hypnosis. Not only did treatment become possible, but the patient was able to virtually eliminate the
discomfort she felt. It is not unusual to hear orthodontists describe the occasional patients who
squirm in the chair every time an archwire is activated. The use of hypnosis for such cases ought to
be considered, since most orthodontic treatment lasts two years or more. Given the dozens of visits
each patient makes during the course of treatment, the extra few minutes of time would be well
ACKNOWLEDGEMENT — The author would like to acknowledge the contribution of Dr.
David K. Hennon, Professor of Pedodontics, Indiana University School of Dentistry.
Assistant Professor of Orthodontics,
Indiana University School of Dentistry, Indianapolis, IN.
Member, American Society of Clinical Hypnosis.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume Sep
Fig. 1
Fig. 1 Induction of the hypnotic trance.
Fig. 2
Fig. 2 Testing the numbness of the right hand. The arrow points to the needle in the back of the hand.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Sep(628 - 630): Hypnosis in Orthodontic Treatment
Fig. 3
Fig. 3 Patient transfers numbness from her hand to her jaws and teeth.
Fig. 4
Fig. 4 Patient locks her mouth open to allow operator to work.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Sep(631 - 636): Handling Characteristics and Bond Strength of Eight Direct Bonding Orthodontic C
Handling Characteristics and Bond Strength
of Eight Direct Bonding Orthodontic Cements
Q: Does composition affect the properties of direct bonding cements?
A: Yes. In general, acrylic cements tend to bond more strongly to plastic than metal brackets,
whereas diacrylate cements tend to bond better to metal brackets in vitro. In general, more highly
filled diacrylate cements bond better to metal brackets than less highly filled diacrylate cements.
Q: Explain why higher values of in vitro bond strength are reported for plastic brackets than
metal brackets with some cements.
A: Data from several in vitro studies indicate that acrylic and low-filled diacrylate resins form
stronger bonds with plastic than metal brackets. It is possible for these resins to bond chemically
with the plastic brackets, whereas only mechanical bonds are formed with metal brackets. The
addition of filler apparently interferes with chemical bonding, but enhances mechanical bonding.
Undoubtedly the nature of the bracket also affects bond strength.
Q: Where do bond failures occur during measurement of in vitro bond strength? A: Bond failures
in vitro generally occur at the bracket-cement interface with metal brackets. Failures with plastic
brackets occur within the bracket or at the bracket-cement interface. Bond failures seldom occur at
the cement-enamel interface in vitro, because under laboratory conditions the extracted tooth can be
prepared for bonding using an ideal technique. In vitro bond strength data suggest that the
cement-enamel bond is not the problem, whereas in vivo observations suggest the cement-enamel
bond is a problem. It would appear that the technique of bonding in vivo is extremely critical.
Q: Can a reason be given for the variation in strength and point of failure for materials which are
substantially the same, albeit different brands?
A: The cements tested vary considerably in composition, as Tables 1 and 2 indicate. Resin
composition, size, type, and amount of filler affect the bonding properties of the cements in a
complex way. Further, handling characteristics such as ease of mixing and working time may
contribute to variation in vitro and certainly in vivo.
Q: What variation in bond strength can be expected in vivo compared to in vitro?
A: The implication is that a cement that bonds better in vitro would bond better in vivo, if
preparation of tooth and bracket occurs under ideal conditions, as presumably occurs in vitro. One
operator made and tested all the samples in this report. Hopefully, the preparation and testing of the
samples were nearly ideal. Variations caused by a patient's saliva, by different operators, and by
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Sep(631 - 636): Handling Characteristics and Bond Strength of Eight Direct Bonding Orthodontic C
shear, rather than tensile, loading were eliminated or minimized.
Q: What is the Scheffe interval and what is its significance in the testing results shown?
A: The Scheffe interval accounts for experimental and random error, and allows two or more
means to be compared statistically. If mean A minus mean B is greater than the appropriate Scheffe
interval, then it can be concluded with 95% confidence that mean A is different than mean B.
Applied to the data in Table 3, for example, the Scheffe interval allows one to conclude that the
differences among the cements with metal brackets exist, but are not as dramatic as differences
among cements with plastic brackets.
Q: What is the clinical importance of in vitro bond strength data?
A: In vitro bond strength testing allows direct bonding cements to be ranked according to bond
strength under ideal conditions. The assumption is made that the in vitro ranking will agree with an
in vivo ranking. This assumption is difficult to test; but, if bond strength is the most important factor
in selecting a cement, then the data does allow the orthodontist a choice of weaker or stronger
cements, if other important factors such as cost and ease of handling are suitable.
Dr Guzman acknowledges the financial support of The
Universidad Central de Venezuela, Caracas, Venezuela.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume Sep
Table 1A
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Sep(631 - 636): Handling Characteristics and Bond Strength of Eight Direct Bonding Orthodontic C
Table 1B
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Sep(631 - 636): Handling Characteristics and Bond Strength of Eight Direct Bonding Orthodontic C
Table 2A
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Sep(631 - 636): Handling Characteristics and Bond Strength of Eight Direct Bonding Orthodontic C
Table 2B
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Sep(631 - 636): Handling Characteristics and Bond Strength of Eight Direct Bonding Orthodontic C
Table 3
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Sep(631 - 636): Handling Characteristics and Bond Strength of Eight Direct Bonding Orthodontic C
Table 4
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Sep(637 - 647): Common Sense Mechanics Part 13
Common Sense Mechanics
Part 13
Applying Principles to Total Treatment (Continued)
Thus far, we have observed treatment procedures involving various malocclusions, including
Class I extraction and nonextraction cases and a Class II extraction case. We have looked at Class I
and Class II extraction cases requiring good anchorage and have seen that it can be obtained in an
uncomplicated manner. Earlier, nonextraction cases were discussed that involved deep overbites.
Actually, regardless of the classification of the malocclusion, we should recognize at this point that
when we are dealing with "dental" malocclusions (versus "skeletal" malocclusions), there really are
little differences in treating one type as compared to another. We are trying to move teeth from one
specific point to another, and deciding which bends and which locations will encourage such
movements. As long as we have the means to control magnitudes, we really don't have to worry
about whether the mandibular plane is flat or steep. In fact, if anything, we might have to concern
ourselves with the forces being too light, particularly in a flat mandibular plane case. The easiest
thing in the world of orthodontics is to increase force levels. The more challenging aspect is to
minimize force magnitudes, and we really don't have a major problem, if we reflect on some of the
things that have been said regarding force control.
In the last article, it was explained that lingual crown torque can be produced on an unbanded
molar by applying a simple lingual force at the crown level. This may be accomplished by placing
an archwire with a distal extension through the molar tubes.
Class II, Dlvision 2 Malocclusion
I did not have the opportunity to finish the next case as planned. But, in spite of inadequate
lingual root torque in the "finished" result, there are lessons to be learned.
The patient is a young female adult with a serious Class II, division 2 malocclusion (Fig. 153). It
is very important that you take notice of the buccoversion of the maxillary second molars. The
lingual cusps contact the buccal surfaces of the mandibular molars. Complete correction will be
accomplished without banding these teeth. Also, note the "concave" bicuspid areas in the occlusal
view of the maxillary teeth, so as not to later interpret this as "collapse" due to the use of light wire
It is very interesting to look at a case Like this, as one might suspect that an intrusive force
through the incisor brackets would result in the line of force passing lingual to the center of
resistance, but the tracings (Fig. 154) show this not to be the case.
Upper first bicuspids have been extracted and treatment initiated with an .016 spiral arch and no
Article Text
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Sep(637 - 647): Common Sense Mechanics Part 13
extractions in the lower arch (Fig. 155). The case will, therefore, be treated to a Class II molar
relationship, and maxillary labial crown torque will be required to produce the necessary overjet to
permit alignment of the mandibular incisors. Note the buccoversion of the unbanded maxillary
second molars.
Intrusion in the upper arch only is accomplished, until such time as the lower incisor
bands/brackets can be placed (Fig. 156).
In Figure 157, you can see the off-center bend located mesial to the bicuspid brackets. This bend
provides the intrusive force to the incisors, while the distal crown thrust on the bicuspids enhances
the anchorage during space closure. The eruptive force acting on the bicuspids provides, in addition,
an "interlocking" tendency with the unbanded lower bicuspids.
In Figure 158, you can again see the upper second molars, which will require some lingual crown
torque. Note the high lingual cusps. The lower incisors are purposely being expanded, due to the
facial profile and cephalometric data.
Cuspid bands were placed and the cue ball concept applied (Fig. 159). In progress pictures (Fig.
160), again note the upper second molars. The space created by lower distal crown movement of the
molars "doesn't count". The patient is a non-grower, so any space created by distal molar crown
movement is not credited to arch length.
The lower archwire was segmented and the molars "set free" (Fig. 161). In Figure 162, the molars
have uprighted and the spaces have disappeared. Additional anterior intrusion was gained with an
.018 cantilever overlay (Fig. 163). The anterior segment does not have to be removed, unless desired
for some reason.
An .018 archwire, with distal extensions, was prepared for lingual crown movement of the
maxillary second molars (Fig. 164). The archwire was inserted (Fig. 165) with the extensions in
contact with the second molars. Choose the point of force application based on any rotation that
might be required on these teeth. Intraoral activation was obtained with a Tweed loop pliers ( Fig.
166). A center (gable) bend was placed intraorally in the extraction sites ( Fig. 167). Because of the
full strapup in the upper arch— excluding second molars — this center bend caused the archwire to
behave as a reverse curve of Spee and, therefore, intrusion occurred at both ends of the archwire,
unlike the tipback bend. Figure 168 shows the amount of overbite correction at this point in
The distal extensions were cut off after sufficient lingual crown movement of the maxillary
second molars occurred (Fig. 169), and function was permitted to accomplish the remainder.
A rectangular arch, .019 × .025, was fabricated ( Fig. 170) for the anterior lingual root torque and
placed (Fig. 171). Appliances were removed prematurely at the request of the patient who was
leaving the city (Fig. 172). Everything was satisfactory at this point, except for the needed lingual
Article Text
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Sep(637 - 647): Common Sense Mechanics Part 13
root torque. Six months later, the patient returned (Fig. 173).
The increase in overbite and inadequate lingual root torque are not happy components of the end
result. But, I hope that the various treatment procedures illustrated will justify presenting this case.
Obviously, under the right circumstances, treatment could be continued to a satisfactory conclusion,
as the most difficult aspects of treatment had already been accomplished. At any rate, it can be seen
that the maxillary second molars are successfully occluded with the lowers and that the lower
anterior expansion is justified, based on the patient's profile (Fig. 174). Rhinoplasty was
recommended to the patient following treatment, but not desired by patient or parents.
When teeth are banded throughout the arch, the force system is different than that presented in
overbite correction utilizing only a 2×4 appliance. Instead of extrusive forces on the terminal teeth
(molars), intrusive forces occur, as can be seen in the occlusal pictures. Keep in mind that the
second molars were not banded. The final headplate tracing established no growth during the period
of treatment, and absolutely zero increase in vertical dimension.
Something can be learned from almost any case, including those that do not meet the intended
objectives. Hopefully, that is the case here.
Class II Open Bite, Extraction
This might be a good time to discuss an open bite case requiring anchorage conservation, as it
will demonstrate that the concepts really don't change. We simply apply whatever concepts are
necessary to produce the desired force systems. I won't go into great length in this case, as much of
the discussion would prove to be repetitive.
This case presented with the right side in Class I and the left side in Class II (Fig. 175). As you
can see, the teeth were already decalcified, and in addition, she had had root canal therapy on the
upper right first molar. These are the cases that seem to so often work against your efforts, but I
believe such a case can offer a valid test for the mechanics, as the mechanics do not recognize the
problems mentioned— only application and response. Needless to say, the causative factor in an
open bite must be eliminated, if the result is to be satisfactory and stable.
Due to the midline discrepancy, asymmetrical extractions were done. The upper first bicuspids,
lower right first bicuspid, and lower left second bicuspid were extracted. Asymmetries have already
been demonstrated and corrected with asymmetrical mechanics, such as retraction on one side of an
arch with protraction occurring on the opposite side of the same arch at the same time.
Asymmetrical extractions, I find, present a very good means of correcting many asymmetries, and
such extractions, combined with asymmetrical mechanics, enhance such treatment even more, at
Figure 176 shows the amount of anterior space gained, using the same mechanics as described in
Article Text
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Sep(637 - 647): Common Sense Mechanics Part 13
the section on cuspid and bicuspid retraction, except that in this case, the cuspid and bicuspid on the
lower left side were retracted only part way and the molar protracted the remainder of the distance.
This is accomplished by use of a center bend in which neither side becomes the anchor side. The
other three cuspids were retracted individually.
The occlusal views (Fig. 177), again, point out the importance of placing toe-in bends early. This
case was treated at a time when I waited too long and had to make the correction toward the end of
treatment. It is much easier to maintain and even overrotate the molars than to have to correct the
mesiolingual rotations later. Figure 178 shows an extraction case with toe-in bends placed early to
provide the counterrotation needed by the molars. Notice in the lower occlusal view (Fig. 177) that
the right first and second molars are in contact, while on the left side space has developed between
the molars. Clinically, this verifies the effectiveness of the intended anchorage on the right side and
the intended first molar protraction (partial) on the left side.
Closing the Bite
In Figure 179, the anterior teeth have been banded and the spaces closed. In this case,
up-and-down anterior elastics were used to close the bite. They were used in a rectangular fashion.
For a short period of time, rectangular up-and-down elastics were used on the right side, but
triangular Class II elastics were used on the left side for some additional Class II correction, in
addition to the maxillary and mandibular teeth being brought together.
There are different methods of closing the bite, which have already been mentioned. In extraction
treatment involving open bites, the anterior segment can be purposely tipped back so that the
application of lingual root torque later will provide an intraoral vertical extrusive force, thus
eliminating or minimizing the use of any elastics. Also, when tipback bends are used, elastics can be
worn to erupt teeth in the arch of choice, while countering the intrusive force produced by the
tipback bend in the opposite arch. In other words, in spite of the fact that up-and-down elastics
produce extrusive forces in both arches, extrusion can be limited to the arch of choice.
The occlusal view (Fig. 180) shows the toe-in bend present on the maxillary molars. This should
not be required at this point, if placed early enough. Figure 181 shows the case two years following
treatment, and Figure 182 shows profile photographs before and after treatment.
Thus far, it can be seen that basically the same concepts have been applied to different
malocclusions, including open and closed bites and extraction and nonextraction cases. In the case
just described, no wires were ever used other than round wires. It is not the purpose in describing
the various types of treatment to suggest what should or should not be used, but rather to let the
individual choose for himself that which he feels will achieve his objective.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume Sep
Fig. 153
Fig. 153 Class II, division 2 malocclusion.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Sep(637 - 647): Common Sense Mechanics Part 13
Fig. 154
Fig. 155 First archwire - .016 spiral.
Fig. 155
Fig. 154 Direction of intrusive force on division 2 central incisor.
Fig. 156
Fig. 156 Upper incisors Intruded enough to band lower incisors.
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Fig. 157
Fig. 157 Off-center bend provides intrusive force on incisors.
Fig. 158
Fig. 158 Upper second molars will require lingual crown torque. Lower Incisors being expanded labially.
Fig. 159
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Fig. 159 Cuspid bands placed and tied for rotation.
Fig. 160
Fig. 160 Progress photos.
Fig. 161
Fig. 161 Lower archwire segmented distal to cuspids.
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Fig. 162
Fig. 162 Molars have uprighted closing spaces.
Fig. 163
Fig. 163 Cantilever overlay (.018) to intrude lower anteriors additionally.
Fig. 164
Fig. 164 Archwire (.018) wlth distal extensions.
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Fig. 165
Fig. 165 Archwire with extensions contacting second molars.
Fig. 166
Fig. 166 Intraoral activation of extensions with Tweed plier.
Fig. 167
Fig. 167 Center bend placed intraorally.
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Fig. 168
Fig. 168 Progress in overbite correction.
Fig. 169
Fig. 169 Distal extensions cut off after sufficient lingual movement of second molars.
Fig. 170
Fig. 170 Rectangular (.019 x .025) archwire.
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Fig. 171
Fig. 171 Rectangular archwire In place.
Fig. 172
Fig. 172 Case at premature band removal.
Fig. 173
Fig. 173 Case six months after band removal.
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Fig. 174
Fig. 174 Photographs before (left) and after treatment.
Fig. 175
Fig. 175 Class II open bite malocclusion.
Fig. 176
Fig. 176 Cuspid retraction with anterior spacing.
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Fig. 177
Fig. 177 Toe-in bends should have been placed.
Fig. 178
Fig. 178 Case showing correct early placement of toe-In bends.
Fig. 179
Fig. 179 Anterior teeth banded and spaces closed. Up-and-down elastics were used to close open bite.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Sep(637 - 647): Common Sense Mechanics Part 13
Fig. 180
Fig. 180 Late placement of toe-in bends.
Fig. 181
Fig. 181 The case two years after treatment.
Fig. 182
Fig. 182 Photographs before (left) and after treatment.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Sep(637 - 647): Common Sense Mechanics Part 13
OCTOBER 1980, VOL. 14 / ISSUE 10
JCO Interviews Dr. Charles M. Sorenson on The Behaviorally Oriented
Indelible latrogenic Staining of Enamel Following Debonding - A Case Report
Common Sense Mechanics Part 14
Orthodontic Office Design - Examination Room
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Oct(685 -): 686 THE EDITOR'S CORNER
A recent development in orthodontics has been the recognition by a number of non-orthodontists,
usually with some background in clinical psychology, that there has been a missing link in the
practice of orthodontics. While orthodontic technology has taken a quantum leap and our basic
biological science has improved, we have been slow to recognize and pursue the idea that
orthodontics is also a behavioral science. It simply has not been a part of our education. Considering
the close interpersonal relationships that exist in an orthodontic office between doctor and staff, and
between doctor and staff and patients; and considering the importance of patient cooperation,
motivation, and performance to the success of orthodontic treatment; it is remarkable that the
behavioral aspects of these relationships have been neglected.
Most orthodontists have understood the importance of patient cooperation and many have been
guided by a principle that they were doing something with the patient rather than for the patient or to
the patient. But, the efforts have generally not taken advantage of what is known in other fields
about human behavior and motivation. Fortunately, this is changing and we are likely to see the
behavioral aspects of orthodontic practice receive a great deal of attention, thanks to a great extent
to our friends in these other fields. Dr. Charles Sorenson is one of these and he gives us some idea
of the present capabilities and future potential in this field in an interview in this issue.
It is possible, with pencil and paper instruments, to profile the behavior characteristics of doctor,
staff, and patients and to guide them to more effective interrelationships. It is possible to know the
management style of the doctor and channel him to more effective management. "Know Thyself",
L.D. Pankey said, and he was right. It is probably the first step toward a behaviorally sensitive
practice. Another step is to choose and work with staff people who are behaviorally sensitive.
Doctor and staff must not only be technically proficient and provide excellent treatment, but they
must be reactive to the human element in their own relationship as a staff team and the relationship
of the staff team to the patients. Genuine caring for the individual as a human being goes beyond
straightening his teeth. This will be one of the characteristics of what Avrom King has described as
Tier 3 practice. It is not exclusive to Tier 3. It is as important in Tier 1 and Tier 2, since it is the
most important aspect of the human relationship in all forms of delivery of care. It will be essential
for Tier 3; highly desirable for Tiers 1 and 2.
It will require sensitive understanding on the part of orthodontists to recognize the need to
change, to know how to do it, and be able to accept it. To the extent that change may be stressful,
this may involve stress. If it is accompanied by an understanding vision of what the goal might be,
the stress may well be the stimulating kind that Hans Selye refers to, as opposed to distress.
Staff persons have to be selected with care, respected for what they are as human beings, and
appreciated for the contribution they make to the success of the enterprise and the success of the
human relationships in the practice. Doctor and staff with that feeling are co-workers in the service
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Oct(685 -): 686 THE EDITOR'S CORNER
of the patient. From that feeling, patients derive the vision that they, too, are co-workers.
A great deal of attention is going to have to be paid to a reallocation of priorities and duties. As
far as possible, those things that can be delegated to machines must be delegated to machines.
Repetitive paperwork and filing work must be delegated to computers. This includes patient
treatment records, financial records, scheduling, letter writing, many aspects of office
administration. Pulling and filing charts, and repetitive letter writing are examples of jobs that
should be eliminated for humans and turned over to machines. The human employees, as Dr. Sam
Callender pointed out years ago, will be freed to perform those tasks that they are uniquely equipped
to perform— the warm, caring, sensitive, human relationships on which a health care practice
should be based.
We have passed through a period when appliance therapy was most important and we have
learned how to move teeth with great proficiency. Appliance therapy will continue to be important,
but mastery of tooth movement is now a readily achievable goal. Orthodontists ought now be able to
turn their attention to the behavioral aspects of orthodontics and become as proficient in that.
Happiness will be more than a beautiful set of before and after models. The self esteem of a great
many people— doctor, staff, and patients— will be both a result of and a contribution to the
successful practice of the future.
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Oct(687 - 712): JCO Interviews Dr. Charles M. Sorenson on The Behaviorally Oriented Practice
on The Behaviorally Oriented Practice
DR. GOTTLIEB Chuck, I think our readers ought to know your background - that you have a
masters degrees in education, a masters in theology, a PhD in Management/Organization
Development and postdoctoral training in clinical psychology. That's an impressive amount of
education. Have you tied all that together now into one career?
DR. SORENSON I think that I have. I have tried to apply what I have learned to helping people
work together; specifically to make the helping professions more helpful and effective with the
persons they serve, by helping to improve the way that dentists and staff work together and the way
that dentists and staff work with patients; and, indeed, the way that patients work with dentists and
DR. GOTTLIEB A good deal of your work is with dentists?
DR.SORENSON I would say that 95% of my work now is with dentists and dental specialists.
DR. GOTTLIEB How did you get started working with dentists?
DR. SORENSON I have been interested in dentistry for a long time. In fact, I was admitted to the
University of lowa as a pre-dental student. I was drafted in World War II and when I returned, I
went into education. But I have been interested in dentistry for a long time. I became involved in my
present work with dentists because a dentist named Robert F. Barkley, whom many of your readers
will recognize I am sure, wanted to find out what he could about dentists who were effective in
working with staff and patients. That was the beginning of a research project we have been working
at for about eight years.
DR. GOTTLIEB How do you go about it?
DR. SORENSON We started simply meeting dentists that Dr. Barkley and his group pointed out to
us in response to our question, "Who are there among you that you would like us to study?" They
originally picked twelve. The idea was, if you want to discover what an outstanding or effective
health professional is like, start by studying people that other health professionals consider to be
outstanding or effective.
DR. GOTTLIEB Could you give us a thumbnail sketch of what you have found?
DR. SORENSON Outstanding dentists that we have profiled have three things going for them.
They are very good clinically. They love to work with their hands. They are quite perfectionistic.
They like things to turn out well. In that sense, dentistry continues to be a craft or an art. But,
beyond technical perfection, these dentists are thinking of their profession as being health oriented,
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Oct(687 - 712): JCO Interviews Dr. Charles M. Sorenson on The Behaviorally Oriented Practice
involved with things like nutrition and exercise. In addition to being technically and biologically
oriented, they are also behaviorally oriented. They are behaviorally sensitive. They enjoy people.
They help people grow. They can get people to take greater responsibility for their own health.
DR. GOTTLIEB How does this affect the way they practice?
DR. SORENSON The traditional clinically astute dental office tends to look backward and say
"What went wrong? What has happened that we need to repair?" You could call that a remedial
approach. A behaviorally sensitive office tends to look forward. They say, "What do we want to
achieve? What would be a preferred future?" and "Let's set some goals and clarify some values and
start to move toward a preferred future." That's distinctly different than waiting until something fails
and then fixing it or putting it back the way it once was.
DR. GOTTLIEB Are you describing a relationship between the dentist and the patient?
DR. SORENSON Yes, but I am also describing the relationship between the dentist and his staff.
Many dentists feel that staff meetings must be remedial, that their purpose is to iron out problems.
"What do we need to iron out today? Does anyone have any gripes?" If the staff says, "We're getting
along all right", he's tempted to say, "Well, then let's not meet". I don't think we can take a remedial
approach with our staff and in our management style and then make a switch and say that we are
going to be developmental with our patients. I have not found that to work.
DR. GOTTLIEB . Does this approach relate to orthodontists as well as to GPs?
DR. SORENSON It seems to me that there is even greater excitement among orthodontists for a
behaviorally sensitive practice. In the first place, orthodontics is largely discretionary. People will
live if they don't have it done and adults, particularly, are making choices between orthodontic
treatment and vacations, boats, houses, furniture, and cars. So, the orthodontist really becomes a
helper, helping people to adjust their values and place orthodontics higher on their value list.
DR. GOTTLIEB If you had a mission for an orthodontist as a helper, what would that be?
DR. SORENSON I've thought a lot about that. I believe the mission of an orthodontist is to help his
patient claim his or her self esteem.
DR. GOTTLIEB Not claim straight teeth and be happy with his appearance, function and so on,
but claim his self esteem?
DR. SORENSON Yes. Helping a person feel better about himself. To be glad to smile, to be able to
make friends, to get a better job, to be a better lover, a better parent, a better friend. The mouth is a
very basic social part of a person. In these ways the orthodontist is very much involved in helping
people claim their self esteem.
DR. GOTTLIEB Is there evidence that orthodontic patients lack self esteem?
DR. SORENSON Not really. Our data from patient interviews is not yet welldefined, but my hunch
is just the opposite — that the orthodontic patient values self esteem, values appearance, and,
therefore, wants to do something about his or her teeth. The person who doesn't care Just is not
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Oct(687 - 712): JCO Interviews Dr. Charles M. Sorenson on The Behaviorally Oriented Practice
going to Invest In straighter teeth.
DR. GOTTLIEB If orthodontics is a behavioral science, where do we start if we want to become
more behaviorally effective and a better helper?
DR. SORENSON We suggest, in fact insist, that we start by studying people. What is a person like
that is able to help other people? What kinds of things make an effective helper? Are these
characteristics innate? Are they learned? Can they be taught in dental school? Can they be changed?
DR. GOTTLIEB When you say, "We start by studying people", do you mean that you do and pass
the information on; or does the dentist and orthodontist do that?
DR. SORENSON Well, I think both. Our work is specifically geared to studying people. We
interview from 3,000 to 5,000 persons a month, and we've been doing this for 20 years or so. That's
40,000, 50,000, 60,000 people a year. We then help the practitioner learn to use the data we have
gathered, in working more effectively with his patients and staff.
DR. GOTTLIEB How do you manage to interview that many people?
DR. SORENSON There are many of us doing it. We have a moderate-sized firm that specializes in
interviewing and studying people. We also train many of our clients to interview and perceive talent
in persons. These clients also send us data for our research.
DR. GOTTLIEB Why are you continuing to build so large a sample?
DR. SORENSON When you do inductive research, as we do, your data base continues to grow. We
will likely continue this for years. In effect, every person interviewed using one of our instruments
becomes a part of our data base. The more people we study, the more help we can be to our clients.
DR. GOTTLIEB You are saying that the satisfactions to be gotten out of an orthodontic practice
derive from helping people become what they ought to become?
DR. SORENSON That's essentially true. The desire to help other people and to gain genuine
personal satisfaction from it is what we call a sense of mission.
DR. GOTTLIEB Yet, what we so often hear is that people are motivated to go into dentistry more
for reasons like being their own boss, making a good living, status in the community.
DR. SORENSON Yes. An altruistic sense of mission is one of the later things we develop. It would
not be unusual that a young man or woman would think of dentistry as being a good profession for
them personally. Give them a chance to be their own boss. To be a professional person. To make an
adequate living. But, as they get into it, if they have the potential to grow beyond being competent in
working with their hands, they soon discover that they like to help other people. In other words,
their mission emerges, and these are the people that really get a kick out of their work. It's the
person who has difficulty moving from being a fixer of things to a developer of people who
becomes bored and even angry. He's the one who wants to get out of dentistry.
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Oct(687 - 712): JCO Interviews Dr. Charles M. Sorenson on The Behaviorally Oriented Practice
I meet a lot of orthodontists who say they don't enjoy practice any longer. Perhaps
they ought to take a look at what you are saying and consider changing their point of view. What
you are saying is not going to interfere with their mechanical accomplishments.
DR. SORENSON Not at all. In fact, it will enhance their ability to do what they enjoy. As people
say, "Thank you. You've helped me a lot", those persons are missionaries. They refer patients, and
the orthodontist has more to do that he enjoys the most. Our research indicates that in virtually all
the helping professions, until the person discovers this mission or this joy and satisfaction that can
come from helping people, he or she becomes bored and loses some of the joy and personal
satisfaction from his or her career. We often ask orthodontists, "What gives you the greatest sense of
personal satisfaction?" It is not unusual for them to say something like, "When the child who has
been a patient of mine runs up to me in a supermarket and calls me by name, he's saying 'Here's my
orthodontist' and I get a kick out of that." When that orthodontist was a teenager or a young person
going into orthodontics, he didn't know that was going to happen, but he has discovered that this is
really fun and he likes it.
DR. GOTTLIEB On the other hand, an orthodontist in a supermarket may look across there and see
a patient of his, but he can't remember the name to save his soul and he avoids the contact. He
avoids this nice experience.
DR. SORENSON As a person is more comfortable with who he is, he is also comfortable at
extending himself to others; in other words, developing a relationship. And it would be entirely
appropriate for this orthodontist to walk right up to that person, extend his hand and say, "I know
that we have been working together. Can you help me out with your first name?" and not be
embarrassed at all.
Gene, I would like to go back to something we were talking about earlier, because I think it is
important. In studying people, most of the behavioral sciences have been oriented around studying
sick people. I went back to school full time about ten years ago to learn how to help people more
effectively. I found that virtually all of the literature and all of the research in our institutions of
higher learning have to do with the study of sick people— the institutionalized, the hospitalized, the
emotionally ill. I suppose that is easy to understand, because that was the approach of the
grandfather of this whole thing, Sigmund Freud. But, we've found that studying sick people doesn't
really help dentists or orthodontists or staff members or patients to feel better about themselves and
claim their own self esteem, because, these people are not institutionalized or emotionally ill. So, we
really had to start from scratch. We could not look to the literature and assume that an effective
orthodontist was one who was not schizophrenic, or depressed, or anxious, or obsessive. We really
had to start with a folk definition, as we did in 1973, and say to the dental profession, "Are there any
persons in your profession whom you believe are effective in working with people?" If they would
say back to us, "What do you mean by effective?", we would say, "Well, that's what we're going to
find out. How about just taking a folk definition. You define it and point them out. We will study
them and see what we come up with." We did study the people they pointed out and, as we had
expected, there were definite patterns, definite themes that run in these persons' lives, just as there
were themes in people who were emotionally ill, but they were different themes. We did not start
with dentists. We started with educators some 25 years ago, and went on to managers and
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Oct(687 - 712): JCO Interviews Dr. Charles M. Sorenson on The Behaviorally Oriented Practice
salespersons. We see selling as a helping profession. We have also worked with clergy. You know,
we are finding that a good, effective orthodontist is a combination of many of the best of these
DR. GOTTLIEB Are the themes for all the effective helping professionals pretty much the same?
DR. SORENSON No, they are not the same; but there is an overlap. That is, an effective teacher is
empathetic, and so is an effective orthodontist, and so is an effective staff member in an orthodontic
office. So, there is some overlap, but they are not the same. Let me give you an illustration. If you
ask a teacher how he feels when someone doubts what he has to say, a teacher says, "Thank God,
that's the best news I have had all day. I wish all of my students would disagree with me". We call
that ego drive. The teacher does not need to win in his or her point of view in order to feel OK about
what he or she is teaching. She wants the students to develop their own point of view. If you ask a
dentist or an orthodontist, "How do you feel when someone doubts what you have to say, they will
say, "I hurt, emotionally. I get depressed". So, there are some distinct differences between a dentist
and a teacher, but there is some overlap.
DR. GOTTLIEB The patient is a part of this relationship too, and I imagine that an empathetic
patient would be a superior patient.
DR. SORENSON Absolutely, and the patient knows almost immediately whether the dentist and
the staff are empathetic. I n fact, when there is anger in the dental office either within the staff or
within the dentist or between the dentist and the staff, the patient feels as though he or she is
imposing; that he or she is a part of the problem; that maybe he or she shouldn't have come into the
office. In this frame of mind, the patient doesn't look forward to coming and ultimately doesn't take
responsibility for his or her own health .
DR. GOTTLIEB Patients are very quick to sense the atmosphere in the office.
DR. SORENSON In our study of patients, we say to the patient, "How well do you think the dentist
and the staff get along together?" It is one of our basic interview questions in our Patient Attitude
Survey. Some patients say, "I think they get along well. They seem to like each other. They seem to
enjoy working together. I like the way they communicate. I like the way the dentist talks to his
staff". A few minutes later we ask, "What do you do on a regular basis to maintain your own
health?" There is a high correlation between the patients who say, "I think they get along well" and
"I do several things to maintain my own health. I floss. I exercise. I've changed my diet. I've given
up smoking or coffee with caffeine in it". But, when the patient says, "I don't think they get along
very well. There's high turnover. I see new faces every time I come in" and we ask, "What do you do
on a regular basis to maintain your own health", the patient says, "They've been after me to floss, to
give up sugar, to eat breakfast, I know I should, and one of these days I am going to, but I haven't".
DR. GOTTLIEB What you are saying is that when the dentist and his staff don't have a good
relationship, they also do not have a good relationship with the patient, and they aren't encouraging
the patient to take his part in this triad of responsibility.
DR. SORENSON Absolutely, and it goes deeper than that. The mission of an orthodontist is to help
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Oct(687 - 712): JCO Interviews Dr. Charles M. Sorenson on The Behaviorally Oriented Practice
the patient claim his or her self esteem. That process goes backward when the dentist and the staff
do not get along well together. Instead of claiming his own self esteem, the patient loses some of it
and feels less for having visited the office. He feels he has become part of the problem and will
avoid coming, if at all possible.
DR. GOTTLIEB Of course, there are some patients, especially children, who may be resistant to
having orthodontic treatment.
DR. SORENSON Yes, but underlying everything we have talking about are some basic
assumptions. One of those assumptions is that people want to feel better about themselves. They do
want to claim their self esteem. They would rather be whole emotionally, physically, and spiritually,
than compartmentalized or depressed or angry or ill. There may be exceptions, but we just make the
assumption that virtually all people, given a choice, would prefer to be whole. Once we make that
assumption, we then say, "How do we help people to become whole?" and we are faced with the
need to get our own selves together as helpers. We need to gather around us a staff that sees their
role as missional, who relate to people, and who are excited about their role as helpers. I'll even go a
step more than that. I believe we ought to view staff as a group of professional colleagues working
together, who feel that they benefit emotionally and economically from the growth of the practice.
Now we are into some hard core management decisions about how we select and compensate people
that choose to become professional helpers in a dental office.
DR. GOTTLIEB From the data you have gathered, do you believe there is a difference between
general dentists and orthodontists?
DR. SORENSON Yes, I do. Maybe it would be best to review the life themes that we find in
dentists in general, and then I will share with you my growing conviction that orthodontists are
unique. There are some things about orthodontists, I believe, that make them very unique.
DR. GOTTLIEB Would you define a life theme?
DR. SORENSON A life theme is a trait within an individual that we observe in his or her behavior.
We can observe a person who likes to help other people, for example. We don't have to guess at it.
We see it in person's behavior. We look upon an understanding of life themes as the key to helping
dentists, staff members, and patients become more effective.
DR. GOTTLIEB Would you please describe the life themes that you find in dentists?
DR. SORENSON The first we have already talked about is Mission— the desire to help other
people and the ability to get a kick out of it; to look forward to having people say. "It's been nice to
having a relationship with you, because you have helped me a lot". If you have a sense of mission,
you get a warm feeling that this profession is worthwhile. It is something you want to stay in,
because if you ever got out of it, how would you express your sense of mission? Another theme, that
is tied right into Mission, is Health. You would expect that persons in the health professions would
be concerned about holistic health, and they are. We find that dentists are very much concerned
about the many aspects of health and interested in their own health. They are joggers. They are
concerned about their diet. They work to improve themselves physically and emotionally, but also
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Oct(687 - 712): JCO Interviews Dr. Charles M. Sorenson on The Behaviorally Oriented Practice
spiritually. They say that there must be something even beyond what can be measured scientifically
that goes into being healthy in the holistic sense. They are talking about the spiritual dimensions of
health. So, we see dentists that we study as being very much health-oriented; being leaders in health,
as a matter of fact.
DR. GOTTLIEB Do you distinguish between the terms "holistic health" and "whole person health"?
DR. SORENSON No, I do not. I prefer "holistic", but if that is not well understood, I say "whole
person". I am not sure everyone knows what that means either. Many think that it is talking about
more than just straightening teeth. That's true, but we're still not holistic until we think body, mind,
and spirit.
DR. GOTTLIEB Should the orthodontist be holistic in his practice and become involved in
nutrition and other aspects of health?
DR. SORENSON "Should he" is a strong term. I would hope that the orthodontist would be a
healthy person in body, mind and spirit, because you can't help someone claim something for
themselves if you have not discovered it for yourself first. Whether the dental office should take
blood samples and hair samples and prescribe diet, I am really not one to say. I can say that, if a
dentist or orthodontist has not experienced a holistic approach to health, he cannot help a patient
claim his own self esteem. He can't be effective behaviorally without experiencing personal growth
in a holistic way first.
DR. GOTTLIEB Suppose we look at some more themes. You have spoken about Mission and
DR. SORENSON Dentists we have studied have a high sense of Ethics, which means the courage
to hold out for what they believe is right. When a patient says, "No thanks. I can't afford it", the
person with high ethics says, "But you need it. Let's see if we can work out a way for you to get
what you need. If it takes longer, then we will work it out over a period of time. But, I could not live
with myself if I did not do what I believe is right". Ethics is the courage to come on more strongly or
appropriately in the face of resistance.
DR. GOTTLIEB Would a person who is truly holistic totally disregard his own financial
well-being and that of his enterprise? If you say to me, " I just can't afford orthodontics", would I
say to you, "But you need it. Are you sure you can afford nothing?"; and you say, "I can afford
nothing", would I say, "In that case, I would feel part of my mission is to help you regardless of
whether you can pay me, and I will leave it to you whether you really can or can't or will be able to
in the future"? Can anyone operate that way?
DR. SORENSON In an entrepreneurial society, it would be foolhardy to do that to the extent of
going belly-up. Then you can't help anyone. To be ethical is to say, "I want to help you if I can and I
want you to have what we both agree would be best, to the extent that it is within our power to do
that. But, I do not want to bankrupt myself to do that, because there are many other people that I
could not serve if my practice went under". However, I think that by giving of ourselves, we also
receive and that, in all likelihood, we may well become more profitable as we learn to help people
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get what they need. That is another of those underlying assumptions we spoke about. In order to
benefit self as well as others, there is a certain amount of giving of self involved. All professionals
should be prepared to offer their services to some persons in need for little or no financial reward.
How much he or she can do this is really up to each professional.
DR. GOTTLIEB Let's get back to the life themes. We now have Mission, Health, and Ethics.
DR. SORENSON Another theme is Ego Drive, which is the desire to be seen as a significant
person. We find that it is very difficult to feel good about dentistry or orthodontics without it. But,
many professionals we study deny their ego drive and say, "I do not have to be seen as a significant
person. I do not feel badly when people doubt what I have to say. I don't have to be tops in what I
am doing". Actually, if they were honest, they would like to be seen as a significant person and, in
fact, selected dentistry because it was a position of status and importance in the community. One of
the things we have been able to help dentists most dramatically with is to help them own their
feelings about themselves and to claim their ego drive. When they deny it, they run out of gas about
mid-career, and they are not satisfied with their lives.
DR. GOTTLIEB Most orthodontists might be inclined to think they are doing the finest
orthodontics around.
DR. SORENSON Yes. That's the essence of what we are discovering. The real payoff does not
come from just craftsmanship. That's all right at one stage in life as we are learning to do what we
do. We call it the stage of industry versus inferiority. We need to feel we are competent. That
happens relatively early, until the mechanics of a profession become fairly routine. Then the reward
comes to a dentist from people saying that he has been able to help them. Without that, he becomes
bored and, perhaps, even angry.
DR. GOTTLIEB And that applies equally to staff?
DR. SORENSON Oh yes, absolutely. Many staff members talk about their work as being a dead
end. What they really mean is that they have learned to pass instruments or bend wires, but, "Where
do I go from here?" Like the dentist who is in the same boat, they become bored.
Well, Self-Actualization is another theme. The people we study like to be their own person and
call their own shots. They do not want to work for a large corporation. They do not want to punch a
time clock. They do not want to have someone telling them which two weeks in the year they could
have off for vacation. They are self-actualized. If they want to change the way in which they
practice, they do it. They are quite willing to make dramatic changes in their lives, personally and
DR. GOTTLIEB Still, some dentists and orthodontists will find their legitimate niche in what
Avrom King has called Tier 1 and Tier 2 dentistry.
DR. SORENSON The dentist who goes to work for a large corporate entity probably will find that
to be his or her way of self-actualizing. They are still free to choose and that is what they choose to
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Individualized Perception is another theme. People we study think about individuals and have a
way of understanding the uniqueness of staff members that they work with, as well as the
uniqueness of patients. If you ask these orthodontists to talk about their patients, they talk about
individuals by name. They think not of procedures, programs, numbers, or policies, but of
individuals, and they see each person as being unique. Each person actually is unique and, since the
dentist is able to perceive that uniqueness, he is able to help them.
Still another theme is Relator, meaning that these people get a kick out of relationships. They
work at it. They want to be liked. They extend themselves to others, as in the supermarket scene we
spoke about. In a social gathering, where there are some people they know and some they do not
know, they like to get around and meet as many people as possible. Not to be slick or sell
something, but because they like to meet people, to get to know people and build a relationship with
DR. GOTTLIEB If you aren't built that way, is it something that you ought to leave alone and let
other themes work for you? Or should you recognize that you are not the most outgoing person in
the world and that it would be better for you and for your practice if you were? Can that be worked
on? Can one change?
DR. SORENSON It's not a simple answer. I may have to deal with that three different ways and I
think I can briefly. We do need to be aware of who we are and, sometimes, it is helpful to say, "I'm
not comfortable doing that". Then we might ask, "What are you comfortable doing?" If it is the
technical aspects of your work, then build on that. On the other hand, more often we have learned to
defend ourselves against relationships and it is not a case of just saying, "Well, I ought to let it be,
because that's the way I am". If you dig deep enough, most people would say, "But I would like to
be liked. I like relationships. I like friends." Since we are social animals, so to speak, very few
people are happy dealing only with things. Often, we are able to help a person get in touch with
what is really important to him, and then he can manage relationships and feel more comfortable in
social relationships, if he chooses to. But, there is nothing wrong with a person saying, "I do not
choose to". However, there's the third aspect. If a dentist chooses not to relate to people, then it is
almost mandatory that he or she gather around him a staff which is people-oriented. If we do not, we
are depriving the patient of that relationship and the patient does not grow. We should not ask the
patient to pay the price for our inhibitions in relationships.
Another life theme is Activator. An activator likes to change people's attitudes and behavior.
They say, "Oral disease is pandemic and I am called to do something about that. People are apathetic
and make poor choices for themselves sometimes, and hurt themselves because of those choices. I
am a change agent. I would like to change that". They are always figuring out ways to be more
effective as a change agent.
Another life theme is Delegator. A delegator is a person who is effective in getting other people
to take responsibility. In our studies, we find that the patients who get healthier take responsibility
for their own situation. The effective dentist is effective in helping them to take greater
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responsibility. We call it Delegator.
DR. GOTTLIEB That's not just delegating tasks to staff, in other words. This is delegating
responsibility to patients.
DR. SORENSON Yes, but simply telling a person what you want him to do is often very poor
delegation, because it doesn't take into account what the other person is ready to do or wants to do
or is capable of doing. It doesn't take into consideration the person's goals or objectives or definition
of success. The effective delegator does very little telling but interacts with a person in such a way
that the person discovers and takes ownership of what's important to him, using the resources of the
dentist or orthodontist.
Conceptualization is another life theme. Conceptualization means the ability to describe in a
meaningful way what a person is about. For example, many dentists that we study conceptualize
holistics very well. They conceptualize prevention, they are able to communicate what they believe,
to help other people to conceptualize what better health would be like and how to get there. It's not
telling. Telling is not a good helping skill. Conceptualization goes beyond telling to understanding,
to relating, to communicating. Nonverbal language is helpful too. A grunt or a raised eyebrow may
help persons conceptualize or understand what is going on in the relationship. When relationships
are good, almost any attempt to communicate is successful.
Another life theme is Sophistication. It means being a chooser. The dentists we study make a lot
of choices about what is important to them. They choose the way they want to practice dentistry.
They choose continuing education. They are rather compulsive about picking out those things they
think will take them where they want to go, or that will enhance their ability. There is a reason for
them doing what they do. It shows up in their avocations; what they do with their spare time; their
hobbies; even their choice of food, music, esthetics, art. They know what they like and don't like.
DR. GOTTLIEB This must relate to their choices of staff and of friends.
DR. SORENSON That's right. Even in their relationships with people. They choose the people that
they feel they can relate with best. They even select their patients. That doesn't mean that they reject
all the others, but they do pick out the people they think they can help the most.
Another life theme we call Pre-Crisis. The traditional medical model diagnoses, treats, and cures
illness or disease. It is remedial in approach and looks backward. But, the persons that we study
don't think that way. They talk more about the future, more about achieving health than eliminating
disease, more about what can be done now to be of benefit later. Part of this is the ability to delay
gratification. An orthodontic patient may say, "These braces may be rather unattractive, hurt a bit,
feel funny when I chew certain foods, but it's worth it". They have a pre-crisis or futuristic view
about this. "I'll do something now that will help me later."
Technological is another life theme. These persons enjoy working with their hands; doing a fine
job and having others in the profession say of them, "Dr. So-and-so has a good set of hands. If I
were having my work done, I would choose him. He is a fine meticulous craftsman". These persons
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say of themselves, "I can do this better than anyone else. I'm the best in town". There is a bit of Ego
Drive involved there, but it is really claiming their ability to do things well and to be perfectionistic.
You know, we are taught in our formative years that it is wrong to be perfectionistic. Maybe sick.
We read in professional journals that dentists ought to be a little more relaxed. But, our research
doesn't indicate that to be true. The people that are pointed out to us by their colleagues as being
effective are quite perfectionistic. They are perfectionistic on behalf of their patients and-not to
bolster their own image of themselves.
DR. GOTTLIEB There is the satisfaction of creativity involved.
DR. SORENSON Yes, but they say that it then turns out well for the people they are trying to work
with. It will last longer. It will look better. It is better for the patient; and that attitude is a very
healthy thing. On the other hand, a compulsion to be perfect for the sake of being perfect may well
become a neurosis, and a liability instead of an asset.
There is one more theme and that is Empathy. This is the ability to put yourself in the place of the
person you are trying to serve. Empathetic persons can know what the other person may be thinking,
can feel what they may be feeling. They have been there themselves. They have struggled with the
same decisions regarding better health, for example. I believe that an other thing we have been
taught to our detriment is that dentists, orthodontists, physicians, clergymen, and teachers should not
be empathetic, that they should maintain a. professional distance. That is not what we find our
research. We find that the people who are most happy in their field are quite empathetic and can feel
what the other person is feeling, but they do not lose their identity in that other person. They become
more effective by being perfectionistic.
DR. GOTTLIEB This is different from sympathy, now.
DR. SORENSON Yes. Sympathy is sort of patronizing or almost looking down and saying, "I feel
sorry for that person. It's too bad about Mrs. Jones and all the pain she's suffering". Empathy is
being able to hurt when the patients hurts and, far from being detrimental to the orthodontist, we see
it as essential in order to be effective behaviorally.
DR. GOTTLIEB How does that relate to the concept that one shouldn't encourage people in their
DR. SORENSON To reinforce psychosomatic illness?
DR. GOTTLIEB Supposing an orthodontic patient says it hurts and gets a lot of attention and
warm fuzzies from the orthodontist and the staff and his parents, and he likes that; so now,
everything hurts.
DR. SORENSON Part of being empathetic is tuning in on your own feelings. If you say to me, "It
hurts", and I can find no physiological reason for the pain, I will say, " I 'm sorry that :it hurts. It
must be real to you. However, it does not seem to be physiologically related". Then I will begin to
examine other possibilities. I may even confront the person, if I believe he "needs" to be ill and say,
" I sometimes wonder if you need to hurt in order to win our sympathy". If you do that, however,
you better be tuned into their feelings as well as your own. A professional helper will rarely be taken
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advantage of because of h is or her empathy. Fear of this sort is largely an "old wives' tale".
DR. GOTTLIEB Well, we have covered the life themes, and now I would like to go back to the
question of how it is that you believe orthodontists are unique.
DR. SORENSON I do believe that orthodontists that I have come to know are unique. They don't
have a separate set of themes, but the configuration of themes may be slightly different or the
strength of these themes may be slightly different in an orthodontist. All dentists and orthodontists
:have all of these themes, but some are stronger than others. For example, orthodontists have a
strong sense of Mission. They literally want to help people claim their self esteem and feel better
about themselves. They do not get a real kick out of scraping something or tinkering with it. They
want to see you feel better about yourself. Because of that, the Relator theme is often strong in
orthodontists. They say, "I really must develop a relationship with people". In addition, they realize
that their practice is referred and for that reason they need to develop a strong relationship with
people— patients and dentists. As a rule, they are pretty good at relating to people. The Delegator
theme is strong in an orthodontist. He really does want to know if you are wearing your headgear;
and if not, why not. They don't just lay it on a person and say, "You ought to feel guilty about that".
They say, "What can I do to help you do what you need to do? It is your mouth and your teeth, and
soon we may not be seeing each other again. I'd like you to own what you are doing. I'd like it to be
important to you".
Orthodontists that we study tend to be in a Pre-Crisis orientation, because it takes a long time to
do orthodontics and they have to future-focus. There is one more theme that is different with
orthodontists and it is a strange one. I thought that we would find a strong Technological theme in
the orthodontist, as we do among general dentists who emphasize crown and bridge. But, the
orthodontists that I am coming in contact with have a moderate technological theme. They say, "I
have learned the technology and I can handle anything new that comes along. Now I get more of a
kick out of relationships with people." Many really enjoy children.
DR. GOTTLIEB It is important to relate all this to staff, and I guess that is the second part of the
DR. SORENSON Yes. We've studied more than 15,000 staff members in the same way. We go into
an office and say to the dentist and staff. "Who among you do you believe is the most effective?",
and we study that person. There are life themes in staff members, just as there are in dentists and
orthodontists, and I could share those themes with you.
DR. GOTTLIEB Please do.
DR. SORENSON One is Interaction. The staff members who are pointed out to us as being
effective like to interact with each other, with the dentist, with the patients. In fact, it's impossible to
help someone behaviorally to take greater responsibility for himself without being able to interact
with him. Interaction is the opposite of inhibition. Inhibited people are not very effective as helpers.
A second staff theme is Mission and it is a lot like the mission theme we described for the dentist.
It's the desire to help other people and the ability to get genuine personal satisfaction from seeing
other people grow. The Rapport theme is a little like Relator in the dentist, but rapport is the desire
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to be liked; figuring out what to do in order to get people to like you because, if you are liked by the
person you are trying to help, in all likelihood you are better at helping them. It is very difficult to
help someone who doesn't like you.
Gestalt is the only psychological word that we kept. We didn't know what else to call it. It means
being a bit of a fussbudget; being neat, well-organized, bothered when things are off-schedule;
being somewhat of a perfectionist. There are so many interruptions in a dental office in a day, that a
person without gestalt— without the ability to see that at the end of the day we're going to come out
somewhere— that person has difficulty in pulling it all together. One of the staff who needs gestalt
more than anyone else is the receptionist. She needs to know how to fill up the appintment schedule
and arrange for people to come in when she wants them to and keep the schedule flowing.
Self Concept is another staff theme. People who are able to help people in a dental office have a
realistic, positive self image. They are aware of their weaknesses, but essentially think well of
themselves. It is very difficult to help another person if we do not like ourselves. If we do not like
ourselves, we tend to manipulate the other person so that we feel better. That gets in the way of
being effective in a dental office.
Activator is similar to the Activator theme in a dentist. It means being a change agent, wanting
people to change and working at getting them to change. Empathy, as in a dentist, is being able to
put yourself in the place of the patient or other staff members or the dentist, and understand how the
other person is thinking and feeling. Organizational Relationships is a new theme, without a similar
theme for the dentist. This is the ability to derive genuine personal satisfaction from working within
a team, liking to work with these people, liking to be supervised, believing that one learns from the
dentist, liking to work in the office because of the opportunities to learn and to grow. We call it
Organizational Relationships. It's the opposite of being angry or isolated from the others in the
Continuity is a staff theme that means the tendency to think of one's work as a career. The patient
needs continuity, so that there isn't a new face every time he comes in; and, in order to help the
patient, we need staff members with continuity. The dentist needs to manage staff members so there
is continuity and tenure, and so that people do see it as a career and not a dead end job.
DR. GOTTLIEB Does that mean that a patient would prefer to establish a relationship with one
staff member and have continuity in that way?
DR. SORENSON We believe, behaviorally, that they would. We do ask patients, "Do you look
forward to seeing anyone in particular when you go to the office?" When they do mention that they
look forward to seeing Susan or Mary Ann or the dentist, and we say, "Do you do something on a
regular basis to maintain your own health?", they say, "I do and I learned it from Mary Ann. She has
been most helpful to me". So, we would say that seeing different people each time you come in gets
in the way of the behavioral responsibility we are seeking to engender.
The last staff theme is Performance. The people that work on a staff in a dental office like to turn
out the work. They are high performers, who are bored when they are not busy. They want to do
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quality work and they want to do a lot of it. They get a kick out of saying at the end of the day,
"Gee, we accomplished a lot today. It was a good day. We saw a lot of people, but we dealt with
them all effectively". They can take a lot of responsibility. They work fast with their hands. This is
like the Technology theme in the dentist. These people like to perform with their hands. They like to
learn new tasks and the challenge of learning new things. They are not intimidated by change. They
say, "If there is a better way to do it, we'd like to do it that way, because it's fun to be a high
performer". Well, those are the themes in staff members in an orthodontic office as well as in a
general dental office.
DR. GOTTLIEB Are some of these themes stronger in more effective staff people?
DR. SORENSON There are key themes. These are the themes that are so important that, if they are
missing, it is a handicap. One of them is Rapport, the desire to be liked. If we do not extend
ourselves to other people so that we are liked, we are handicapped. We could well be a machine
instead of a person. Gestalt is a key theme— knowing what to do, how to do it, what comes next and
being perfectionistic in that regard. Self Concept is a key theme. If we do not like ourselves, we
have a hard time helping other people to help themselves. Performance is the other key theme for
staff people. They need to enjoy the technical aspects of the job. This is particularly important in an
orthodontic office.
DR. GOTTLIEB And, do you use your knowledge of themes to select an effective staff?
DR. SORENSON Yes. However, selection alone is not enough. We've discovered that you can
have a very highly talented staff but, if they are not managed well by the orthodontist, these people
do not perform well. In fact, the more talent the staff members have, the quicker they leave unless
the orthodontist is ready to manage. And so, there is also a profile or a set of themes in a manager.
The key theme in a manager is the Developer theme. The manager who is a developer gets a real
sense of personal satisfaction from helping other people grow.
DR. GOTTLIEB Do the managerial themes overlap with the themes for the professional side of
DR. SORENSON There is some overlap. Delegator, for example, is one of the themes in a
manager. So is Activator and Individualized Perception. But, there are some themes unique to
managers and, as we work with dentists to help them become better managers, we profile them as
managers, looking primarily for this Developer theme. Do they really like to see other people
develop? Can they select the best talent and turn them on so that they can grow?
DR. GOTTLIEB Most orthodontists have not been trained in management, have not been
interested in management, and don't view orthodontics as a managerial profession.
DR. SORENSON Yes, that's right and we think it is unfortunate. There really is going to be little
alternative in the years ahead for an orthodontist, other than to become a manager or to hire a
manager who will gain genuine satisfaction from managing. Management means many things to
many people, and my guess would be, Gene, that some of the orthodontists reading this interview
will say, "I don't want to be a manager, because a manager is someone who directs and controls
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other people, and I wouldn't want to do that". But, that's not what we are talking about. We sort out
administration as dealing with things, and management as dealing with people effectively.
DR. GOTTLIEB What we call office management and business management, you put into
administration. That would include treatment management for those aspects that are administrative?
DR.SORENSON Scheduling appointments and that sort of thing. Yes. The role of the orthodontist
as manager is helping people to develop and grow.
DR. GOTTLIEB Having identified all those staff themes, how can we use the information?
DR. SORENSON One way is in selection. The other is in management.
DR. GOTTLIEB Is the sequence to profile the orthodontist first and match staff selection to him?
DR. SORENSON Quite the contrary. We like to go the other way around. We would like to help
the orthodontist to perceive outstanding talent of the kind that has proven to be effective, and then to
learn how to manage that kind of talent. It's really not a matching game. It is a matter or recognizing
who is outstanding.
DR. GOTTLIEB There is an interesting parallel. Professional football teams will frequently draft
the best athlete that is available.
DR. SORENSON Yes, they don't match him to the coach or to the ability of the coach.
DR. GOTTLIEB Or even to the position that he played previously. They find what they think is the
best athlete available at the time and they will work with that.
DR. SORENSON Yes. That's the concept that we're working on in the dental office. But, how do
you recognize talent? One way would be to hire them and try them for five years, but that can be
costly and ineffective. The way that we have found is to develop a structured interview around these
themes. That requires considerable expertise, and we have been refining such interviews for years.
You need to know what to ask and what to listen for. It is not done haphazardly. It is not a chat or
conversation. It is a highly developed instrument and a highly developed interviewing skill.
DR. GOTTLIEB And these would enable the orthodontist to classify an applicant in terms of the
staff themes?
DR. SORENSON Absolutely. Not just more or less, but in a highly predictive manner. We've tried
everything else— intelligence tests, multiple choice, true/false. We've worked with some of the
major psychometric people in the country and finally abandoned all paper and pencil instruments,
because we could not get predictive until we sat down with a person face-to-face and asked him a
series of questions. If we want to know if you are empathetic, we ask the question, "Let's say you are
watching a five-year-old who's hammering. He hits his thumb and cries and cries. What would you
do?" The empathetic person says, "I would pick up the child, kiss the thumb, run cold water on it,
put a band aid on it". That's an empathetic response. A non-empathetic response would be, "Don't
pick up the child or you'll make him a sissy. Teach the child to use the hammer". So, you need to
learn what to ask and what to listen for.
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DR. GOTTLIEB How did you determine that your Perceiver Instruments measure what they are
supposed to measure?
DR. SORENSON You are raising the question of validity. First of all, you will recall that Auxiliary
Perceiver was developed by studying staff members who are pointed out by others as being
effective. This results in concurrent validity. We also conduct ongoing studies to correlate results on
the Auxiliary Perceiver Interview with evaluation of on-the-job performance. From time to time, the
Perceiver Instrument is adjusted, based on the data received, to maintain predictive validity.
Properly administered and interpreted by a trained Perceiver, the structured interview can be quite
predictive of the behavior of an applicant on the job.
DR. GOTTLIEB You said that you have eliminated all the tests that orthodontists are accustomed
to using. Does that include manual dexterity tests?
DR. SORENSON Now I need to talk about predictors, non-predictors, and negative predictors. A
manual dexterity test would be a negative predictor. A low manual dexterity score for a person
applying for a job requiring considerable manual dexterity would indicate that the person might not
be able to perform. It would be a contraindication to hiring such a person and, therefore, a negative
predictor. However, you cannot assume the opposite. High manual dexterity does not correlate with
effectiveness in working with people, either negatively or positively. There is just no correlation. It
doesn't permit any prediction about helping people claim their self esteem. You might use it as an
extra indication, but not as a prime tool in selecting staff people. IQ is also a negative predictor. A
person with a low IQ might not be able to learn the complex tasks of an orthodontic office, and
would be a contraindication to hiring. But, just because a person has a high IQ doesn't indicate that
he or she will be effective. So, again, it is a negative predictor. There are some non-predictors, like
age and education. We simply have not been able to correlate age or education with performance.
DR. GOTTLIEB What about previous training?
DR. SORENSON We have found no correlation between previous training and effectiveness as a
DR. GOTTLIEB How does an office go about using the structured interview?
DR. SORENSON More and more, we've been involved in training two people in an office to learn
to be what we call Auxiliary Perceiver Specialists. They learn to give the interview, to interpret what
is said, and to make a predictive judgment on that person's behavior. That's a skill that takes a
minimum of three or four months to learn. A few people take a year to learn it, and some people
don't seem to be able to learn it.
DR. GOTTLIEB Is this something that staff members should be doing, rather than the orthodontist?
DR. SORENSON We like the orthodontist and one other person to learn this. The orthodontist may
or may not be doing the interviewing, but needs to learn the language and how to interpret what's
being said. If, for example, another staff member comes to him and says this applicant has
high-gestalt, average rapport, strong empathy, and a strong sense of mission, he must know what all
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that means, where that person would work best, and how well she would fit in with the other staff
members. He must be knowledgeable whether or not he actually conducts the interview. Some
orthodontists enjoy the actual interviewing, while others would rather delegate it.
DR. GOTTLIEB Does a procedure like this apply more to the large office, rather than the small
DR. SORENSON Not really. Both need talent, even if a small office might not need to find as
many talented persons as often as a larger office. Also, I see this process primarily as management
development for the orthodontist and whomever else in the office is involved in management. The
developmental manager needs to manage to the unique talents of each person in the office and the
best way I know of to understand these talents is to interview the person and to understand their life
themes. Then he can learn management techniques, what to do at staff meetings, how to motivate
people, how to manage conflict, how to communicate.
DR. GOTTLIEB How is the orthodontist going to learn all of those things?
DR. SORENSON Through experimental learning. It can't be learned by going to lectures, listening
to tapes, or watching films. It starts, I think, with the orthodontist understanding the people he
manages in terms of the models we have identified. He will need to interview each staff member to
do this. Then he says, "How can I help these particular people grow to be more like those people
that are pointed out as being effective?" Then you have a developmental program that is effective,
without wasting a lot of time on things that are not particularly germaine. For example, let us say
that, in a particular office, empathy may be moderate or even low as determined through profiling of
the staff. The appropriate developmental training for the staff would be listening skills. The people
could be helped considerably to learn how to listen, rather than telling or not interacting at all.
DR. GOTTLIEB Do you feel most orthodontists can become good managers?
DR. SORENSON I believe that most orthodontists can become better managers. You have probably
heard of the Peter Principle— that people tend to rise to their level of incompetence. I don't know if
that is true or not. We talk more about Paul's Principle— that poor managers tend to manage good
people poorly. And, there is a corollary— that poor managers manage mediocre people better than
good people. So, selection without management development, from our point of view, is rarely
effective; and we feel that the key to all this is the evolving of the orthodontist and others in the
office as developmental managers.
DR. GOTTLIEB Management in those-terms is a one-on-one proposition.
DR.SORENSON Yes. Management is a one-to-one process. It is the relationship that the
orthodontist establishes with each individual that he or she manages. This includes patients, and the
orthodontist needs to spend time one-on-one with them. We are currently involved in the
development of a Patient\Client Perceiver, which is a brief structured interview to be used with the
new patient in the intake process. Once the readiness of the patient to assume responsibility is
determined, appropriate interpersonal skills can be utilized by the staff.
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Oct(687 - 712): JCO Interviews Dr. Charles M. Sorenson on The Behaviorally Oriented Practice
DR. GOTTLIEB How is performance appraisal handled with the staff?
DR. SORENSON That's a one-on-one conversation, maybe once a year. Certain processes are
constructive in performance appraisal and others are not; and those skills can be learned as part of a
management development process. Outstanding people expect this kind of dialogue. They become
disappointed if they don't get feedback on their performance. They like to know how well they are
doing . Also, they have a part in developing their own job description. They don't like to be given a
job description. The job should be built around their talents and when you change a staff member,
the job ought to flow around that person's talents. If it can't, then we have the wrong staff member
and we need to pick someone with the particular configuration of themes that will suit the position
and enhance the overall team. We introduce performance appraisal along with Perceiver Training as
a part of management development.
DR. GOTTLIEB How does the orthodontist appraise his own performance?
DR. SORENSON In a behaviorally sensitive office, the staff would evaluate the performance of the
orthodontist; and patients do too. We conduct Patient Attitude Surveys in which patients are asked
to evaluate the performance of the whole staff, including the orthodontist. These surveys are
interviews with a random sample of patients, conducted by long distance telephone.
DR. GOTTLIEB It seems to me that the orthodontist is on both sides of the evaluation, which
almost requires that he be aware of his management style.
DR. SORENSON Yes, he does, but that is not difficult. There are some pencil and paper
instruments that can be used in determining what a person's management style is. We are all aware
of the authoritarian style, for example. That means that, "I'm right and you're wrong. Let me tell you
what you need to do to please me." There may be times when that is effective, but talented people
prefer a more participatory style. They like to know what is expected, but they like to have a hand in
shaping those expectations and in determining their own destiny.
DR. GOTTLIEB I think that a poorly utilized management tool is the staff meeting .
DR. SORENSON Yes. Common feedback that I get from orthodontists is, "I used to have staff
meetings, but I gave them up because nobody would talk". Our interpretation of that is that the staff
is angry if they won't talk and that there is something about the doctor's style that interferes with the
staff learning how to communicate and be open. If it happens in the staff meeting like that, you can
rest assured that the same thing is getting in the way of the patients taking greater initiative for their
own destiny. I don't believe that it's possible to have a staff that is effective in working with patients
behaviorally without good staff meetings. Staff meetings are a learning laboratory for discovering
how to work with patients effectively. We learn how to help each other in a staff meeting, and this
skill carries over to working with patients.
DR. GOTTLIEB How often should the staff meet?
DR. SORENSON I think that staff meetings need to be scheduled regularly, for an hour or two at
least every other week, during the working day.
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Oct(687 - 712): JCO Interviews Dr. Charles M. Sorenson on The Behaviorally Oriented Practice
DR. GOTTLIEB It shouldn't be with the dentist lecturing to the staff.
DR. SORENSON Unless he has something that needs to be lectured about, such as something he
has learned that he wishes to share with the staff. Otherwise, the dentist can learn to participate in
the staff meetings without having to be in charge. To line up a staff and say, "Here is an agenda that
I have developed and what you really need to do, staff, is to shape up", is a very ineffectual way of
working with the staff and, incidentally, a very ineffectual way of working with the patient, too.
DR. GOTTLIEB What would you say is an effective way of conducting staff meetings that will
DR. SORENSON I have some strong feelings about that, based on many years of experience. I
think that someone needs to serve as a facilitator or enabler. It need not be the dentist and doesn't
have to be the same person every time. Volunteers will do. The facilitator merely says, "What do we
need to talk about today?" As people volunteer things, the facilitator writes them on a blackboard or
on a piece of newsprint, so that everyone can see. Then the facilitator says, "Let's put them in the
order of their importance." They are building an agenda right there in the staff meeting. Then the
enabler says, "Whose item was the first one?" Someone says, "That's mine". And the enabler says,
"Go ahead and start us off. What were you thinking as you mentioned that item?" It gives the
initiative right back to the staff member. Then everyone pitches in and serves as helpers on that
issue; and we're finished with the item when the person whose item it was says, "Enough. I think
we've handled that satisfactorily. I feel good about it". Then we take the next item and say, "Whose
item was this?" It might be the orthodontist that has listed something important to him; and the
facilitator says, "Well, start us off. What do we need to know about that?" Without exception, this
process is more effective behaviorally than a cut and dried, highly structured staff meeting.
DR. GOTTLIEB What would be a good way for an orthodontist to introduce this kind of staff
meeting to his staff?
DR. SORENSON The orthodontist might say, "I would like to try a different way of doing a staff
meeting and see how we like it. I'd like for someone to be a facilitator. Maybe I will do it the first
time, just to model it. Instead of distributing an agenda that I have developed or that we have gotten
out of a suggestion box, why don't we just develop it right here? Let's go ahead and do it. What do
we need to talk about today?" So, they have a staff meeting along those lines. Then he might say,
"Let's evaluate the staff meeting we've just had. How do you feel about it?" Almost without
exception, people will say, "That's one of the best staff meetings we've ever had. I liked that. All of
a sudden somebody listened to me". There are only two reasons to have staff meetings. The primary
reason is to hear from the staff. The secondary reason is to generate enthusiasm, by allowing people
to enhance their own self esteem. They come out of such a staff meeting thinking, "Gee I'm pretty
effective. We just made a decision on something that I believe is important", and that enhances the
staff person's self esteem. This almost never happens with an authoritarian leader. People leave his
meeting thinking,"I don't know why I attend. I guess it's because I am getting paid, but those are bad
experiences and next time I'm not going to say anything. I'll knit or sharpen my instruments during
the staff meeting". I see a lot of that going on in staff meetings, instead of participating.
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Oct(687 - 712): JCO Interviews Dr. Charles M. Sorenson on The Behaviorally Oriented Practice
DR. GOTTLIEB And regular staff meetings should be held if you have two employees or twenty?
DR. SORENSON Absolutely! And the beauty of an orthodontic office is that, from a social
psychologist's point of view, it is a small group. It's like a family, and the processes work best in
small groups. A small group would be from two or three to twelve or fifteen. Since our personality
was determined in the first place in our family of origin, which is a small group, it can be shaped or
enhanced in another small group, which is a secondary group— our work group in a dental office.
DR. GOTTLIEB Is there ever an occasion to break up a large staff into small departmental groups?
DR. SORENSON Yes, there is, particularly in group practices. We like to see staffs meeting in
many small groups— the clinical staff, the clerical staff, a particular orthodontist and his support
team. There is quite a complex pattern of small group meetings in large practices.
DR. GOTTLIEB Earlier you said that we ought to view staff as colleagues who must feel that they
benefit emotionally and economically from the growth of the practice. What are your thoughts on
how staff should be compensated?
DR. SORENSON I think that we are in trouble in the way that we compensate people in a dental
office. The day is fast approaching when salaries will not be able to keep up with inflation. In
addition, salaries, and especially wages, imply a hierarchical struggle between boss and employee. If
we are going to attract and keep talented people in the decade ahead, I think we are going to have to
move toward some kind of profit sharing in addition to salary. That would be behaviorally
congruent with the kind of management and the kind of talented people we have been helping to
select in orthodontic offices— highly motivated, achievement oriented people. The kind of profit
sharing I am talking about is a formula for sharing in the economic growth of the practice. Such
growth, which is reflected in profit, is distributed monthly according to a rather complex formula. I
believe it is possible, and perhaps even desirable, to eliminate wages or salaries in favor of profit
sharing, though most offices prefer to maintain a base salary, with profit sharing in addition.
DR. GOTTLIEB Many believe that if you turn over your staff every three years that makes life
more interesting and, in addition, employees do not get included in retirement plans and that excess
compensation goes to the orthodontist.
DR. SORENSON There is a faulty assumption that the way to keep things together is to keep tight
control on what we pay employees, and that this is the best way to survive. That is a good way to
remain quite mediocre as a manager and as an entrepreneur, or even to fail. The sooner we
deemphasize salaries and emphasize some kind of economic sharing of growth, the better off we
will be. Salaries should be seen as a floor below which compensation will not fall, rather than as a
ceiling on income, as most salaries are.
DR. GOTTLIEB Do you adhere to Herzberg's ideas on management?
DR. SORENSON Yes. I think Herzberg's theories apply here. There are hygiene factors and
motivational factors, and salaries are hygiene factors. But, profit sharing is a broader idea. It is
reward for effectiveness and goes far beyond wages and salaries. In Herzberg's terms, profit sharing
might be seen as a motivational factor.
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Oct(687 - 712): JCO Interviews Dr. Charles M. Sorenson on The Behaviorally Oriented Practice
DR. GOTTLIEB What can we say to the orthodontist who feels that this is all idealistic stuff, but
has very little to do with the bottom line in the average orthodontic office?
DR. SORENSON I don't know of a more effective way of becoming profitable than to hire talented
staff, and to manage them for excellence. There are some underlying assumptions in what we have
been saying, and unless these assumptions make sense to the orthodontist, he very well may feel that
this is irrelevant. On the other hand, if an orthodontist subscribes to these assumptions, then all the
things we have been saying seem vital. The first assumption is that there are sufficient human
resources to provide the world with caring leadership. Now, many orthodontists don't believe that.
They say, "My community is different. We just don't have talent in this town. I run an ad and you
ought to see the people I get". In this case, we would want to see the ad, but our experience is that
talent is distributed proportionately throughout the country— in small towns, big towns, rural,
urban, and suburban— and there are sufficient human resources available everywhere.
DR. GOTTLIEB Humanistic talent is different from technical talent.
DR. SORENSON Yes. So, we need to be able to spot it, and here we come back to the profiling,
the themes, and the structured interviews. We have to know what we are looking for.
Second assumption. We live in an orderly universe in which there are consistent recurring
patterns of behavior which can be studied and understood. If we just find somebody who is effective
by accident, and there is not another person like him or her in the world, we're in trouble.
Fortunately, there are patterns in staff members who are effective in the dental office, and in dentists
and orthodontists. We called these patterns life themes. There are different patterns, but there are
patterns; and behavior can be predicted from these patterns. That makes staff selection more fun,
more scientific, and more manageable. We discover that we can select persons with talent for
helping others.
DR. GOTTLIEB Are the changing lifestyles that we are seeing in our general population
enhancing the opportunities for orthodontists to find this talent?
DR. SORENSON Ye, I think they are, particularly with women. Orthodontics is a masculine
dominated profession, with a predominantly feminine staff. Women in our society have traditionally
been taught to be passive and nonassertive. Some of the life themes we have been talking about—
Interaction, Rapport, Empathy— are more feminine or "right brain" characteristics. But, the modern
staff member is also becoming more assertive. Some of the more masculine, "left brain" themes are
Activator, Organizational Relationships, and Performance. I think this is to the orthodontist's
Another assumption. Each person is a unique expression of talent, and we must understand that
each configuration of themes or talents is unique. Thus, each person is unique. Positions are unique,
too. You do not need the same configuration of themes for a chairside technician as for a
receptionist, or for a health learning facilitator or a lab technician. So, there are unique profiles, and
each person has unique gifts. We want to build on the strengths and manage around the weaknesses.
That's just the opposite of conventional wisdom. Society teaches us to strive to strengthen our
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Oct(687 - 712): JCO Interviews Dr. Charles M. Sorenson on The Behaviorally Oriented Practice
weaknesses, and that is very difficult managerially. Maybe in therapy we can strengthen our
weaknesses, but managerially it is much more effective for the orthodontist to select talent and then
build on the strengths. Each person has a little different configuration of strengths, which must be
considered in light of the specific position.
The fourth assumption. A person's talents are best developed when that person is in relationship
with another person who cares. We call this management. If an orthodontist, as manager, is not a
person who cares, a person's talents do not grow; in fact they atrophy. Both staff and patients need a
relationship with somebody who cares. Generally that would be the orthodontist as manager. The
orthodontist also needs that relationship with someone who cares and he must get that from friends,
spouse, or patients and staff.
The fifth assumption. When each person is in relationship with someone who cares, human
resources are multiplied. We call this synergism. If we have five talented people in a relationship,
the total is not five times more than one. It might be 25 times more than one, because of the
interaction, because of the exchange of ideas, innovations, creativity, even confrontation. Talent
multiplies itself, like yeast in bread.
The sixth assumption is that the multiplication effect is more evident in positions where caring
makes a difference, such as in teaching, or dentistry, or orthodontics. Caring is the single most
important factor in all the helping professions.
DR. GOTTLIEB Supposing that you recognize that you have not selected people well, that if you
had it to do over again on the basis of the profiling that you are now able to do and on the
understanding that you now have, you never would have hired some of your staff in the first place.
Do you believe that, under those circumstances, the orthodontist should manage the weaknesses and
has an obligation to continue the relationships, or should he rather have a higher obligation to the
practice and patients and sever the relationships and start again with people who profile better?
DR. SORENSON I think it would be quite inappropriate to replace someone on the basis of our
profiling. Replacements need to be based on performance and performance appraisal. If a person is
not working out, it's quite evident to everyone concerned, and sometimes changes are made. But, not
because someone profiled you and said, "You know what? You haven't got it". The profile should
be used as a tool to assist personal growth, building on talents, and building the job around the
person to the extent that is possible. But, it is performance, or lack of it, that makes it not possible,
not the profile. Now then, if change is necessary and needs to be made, then the interview would be
used to select persons with the themes and the talent you believe would work out best. So, it is both
a developmental tool and a selection tool, but should not be used as an ax to chop someone out of
the organization.
DR. GOTTLIEB When you separated administration and management before and spoke of
developmental management, that does not preclude some fairly authoritarian decisions by the
orthodontist, does it? Some decisions do not benefit from a participatory approach.
DR. SORENSON Yes, there are some decisions that need to be made quite authoritatively.
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Oct(687 - 712): JCO Interviews Dr. Charles M. Sorenson on The Behaviorally Oriented Practice
Sometimes, the dentist or the orthodontist is the only one who can make them, and he makes them
unilaterally. Developmental management refers to the need to help each other g row, the need for
dialogue, for helping each other define the job and evaluate performance, the need to share in
compensation — all those things I have been talking about. But, yes, certain decisions are made in a
rather authoritarian style. If you believe a certain procedure would benefit the patient most, you do
it. You don't put it up for a group decision. It is important that the orthodontist be aware of his or her
style, and whether it is working. Then an evaluation can be made about changing that style, if
DR. GOTTLIEB The concept is so new and different, that many orthodontists might feel that
surrendering that much authority would throw the practice into chaos or anarchy.
DR. SORENSON It's not anarchy at all. It involves everyone taking psychological ownership and
responsibility. In reality, the orthodontist is giving up very little, with the possibility of gaining a
great deal.
DR. GOTTLIEB The orthodontist does not divest himself of all authority and just become one of
the staff.
DR. SORENSON Not at all. He may lose his facade, his fantasy of being all-powerful, and instead
become effective in activating people to do what he believes is best for everyone concerned.
DR. GOTTLIEB To what extent do you think some people really do want an authoritative figure to
tell them what to do?
DR. SORENSON Some persons do, but this does not mean that this approach is always best. The
perceptive orthodontist or manager will empathize with each person and, if necessary, say, "Yes. I
can tell you what I believe would be best and what you ought to do". He interacts at the level where
the patient is. But, very shortly, after a relationship has been established, he says, "I think it's time
that you being to share with me what you would like, and I would like you to be involved in
deciding for yourself. Ultimately, you need to decide". So, even the patient who is looking to the
orthodontist as a father or dictator or God can be encouraged to grow and take charge of his own
decisions. This would be true with staff members, too.
DR. GOTTLIEB Is it damaging to the doctor to give up his authoritarian image?
DR. SORENSON Not if he has something better to put in its place. Power is sometimes by virtue of
position. The doctor is in such a position, and we are learning more and more from our studies both
in sociology and psychology, that is the weakest kind of power there is. There is another kind of
power and that is earned authority. I earn my authority by how effective I am in interacting with you.
When people really respect you as a person who knows what he is talking about, then you can
influence the thinking of others by interacting appropriately with them, that's real power and
authority. I would hope that authority by virtue of position would give way to authority by virtue of
interpersonal competency.
DR. GOTTLIEB We have covered a lot of ground in our conversation. Could you pull all this
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Oct(687 - 712): JCO Interviews Dr. Charles M. Sorenson on The Behaviorally Oriented Practice
together so that our readers would know where to begin in developing a behaviorally sound
orthodontic practice?
DR. SORENSON I believe that the place to start is with a better understanding of the patients—
their needs, motives, values, and goals— and particularly with what they are saying about the office.
The Patient Attitude Survey is a good way to do this. I would then recommend developing an intake
process with new patients around the Patient/Client Perceiver.
The team can be developed by first profiling the staff as a part of Auxiliary Perceiver Training.
Developmental management processes can then be initiated such as constructive staff meetings,
effective performance appraisal, career development, and profit sharing.
Personal and professional growth of the orthodontist may begin by interviewing and preparing a
written Developmental Portrait of the orthodontist. The Portrait includes an evaluation of the life
themes we have been talking about, and recommendations for personal and professional growth.
We have recently begun conducting introductory and advanced developmental seminars at our
Colorado office in the San Juan Mountains of southwestern Colorado. Once a dentist or orthodontist
initiates one or more of the growth processes with us, he or she is invited to participate in these
seminars. We also work directly within many dental offices.
DR. GOTTLIEB Chuck, I want to thank you for these insights into a behavioral approach to
orthodontic practice. It could well be a new key to motivation and management in all aspects of
orthodontic practice.
Dr Sorenson is President of Charles M.
Sorenson, Associates, an affiliate of Selection Research,
Inc., P.O. Box 458, Wilmette, IL 60091.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Oct(713 - 715): Indelible latrogenic Staining of Enamel Following Debonding - A Case Report
Indelible latrogenic Staining of Enamel
Following Debonding
Bonding of metal orthodontic brackets has become increasingly accepted as a routine treatment
procedure. Thousands of cases are treated each year using various manufacturers' brackets and
bonding materials. Recently, the authors have seen an indelible staining of enamel upon debonding
which was not present at the onset of treatment. A survey of practicing orthodontists in the United
States and Canada has identified other cases of this type of enamel staining following debonding.
We believe this may not be an isolated phenomenon. This report presents one of these cases with a
possible explanation for its etiology.
The patient, a healthy 12-year-old female, was first seen in September 1975 by her orthodontist
for correction of a maxillary midline diastema. Conventional orthodontic bands were used during
treatment. The diastema was corrected and the banded teeth were ligated for retention. In March
1977, a second treatment phase was entered in which the metal bands on the incisors were replaced
with perforated metal brackets bonded directly to the incisors using an ultraviolet light cured sealant
composite resin system. In November 1978, the metal brackets were removed. Before debonding,
the referring clinician indicated that there was no external stain associated with either the brackets
or resin suggestive of a problem beneath the brackets. After debonding, the central portion of the
maxillary left central incisor appeared greenish-black (Fig. 1). Pumice failed to remove the area of
pigmentation. The patient was then referred for consultation to the School of Dental Medicine,
SUNY at Stony Brook.
Occupying the incisal half of the labial surface of the maxillary left central incisor was a
significant area of dark green discoloration. The periphery was irregular and the surface hard to the
tip of an explorer. Pretreatment photographs (Fig. 2) showed the presence of a diffuse white lesion
in the region of the acquired pigmentation. There were no dental symptoms and, with the exception
of white spots on other teeth, nothing abnormal was discovered during intra- and extraoral
The debonded brackets were available for examination. In the area of the bracket adjacent to the
site of enamel discoloration was an area of resin deficiency, probably lost during debonding.
Associated with the underlying intact resin was a region of dark green discoloration (Fig. 3). This
was visible to the unaided eye and was confirmed using a light stereomicroscope.
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Oct(713 - 715): Indelible latrogenic Staining of Enamel Following Debonding - A Case Report
The bracket and associated resin was prepared for examination in a scanning electron
microscope. In the discolored area were numerous pieces of material exhibiting conchoidal fracture
patterns (Fig. 4). In order to determine the elemental composition of the discolored resin material,
small fragments were dissected from the site under a stereomicroscope using a fine plastic
instrument. Isolating the fragments avoided bracket interference in the elemental analysis. The
fragments were bonded to a graphite stub, using colloidal carbon (Fig. 5) and coated with carbon to
render the sample conductive for further scanning microscopy and x-ray dispersive analysis.
An elemental analysis was conducted in an AMR 1000A scanning electron microscope equipped
with an x-ray analyzer. An off-sample scan is shown in Figure 6. Several elements are present
ranging from sodium to zinc. As the discolored particle enters the scan, two additional peaks appear
at the chromium site (Fig. 7). The scan was repeated several times to assure the accuracy of this
observation. Unpigmented resin did not show any chromium peaks.
The identification of chromium in the discolored material recovered from the bracket is highly
significant. Chromium salts in general are green-violet in color 1 and a possible source of chromium
is the bracket and/or the weld site between the perforated base and the wing. Oxides of chromium
are green and may form at weld sites. The following tentative explanation is offered. Kostlan and
Plackova showed that zones of developmental hypomineralization, appearing as subsurface white
spot lesions clinically, possess a relatively greater volume of space than normal enamel. 2 Studies by
Davila and his coworkers have shown that resin sealants will penetrate into white spot lesions
following acid etching.3 The latter facilitates resin penetration by opening up pathways into the
relatively more porous lesion. During bracket placement and prior to resin polymerization,
chromium salts could have become dispersed in the monomer of the bonding resin. In minute
amount and in such blind locations, discoloration would neither have been seen nor anticipated by
the clinician. The pigmented resin entered the enamel and polymerized. After bracket removal, that
portion of pigmented resin occupying the subsurface spaces within the developmental lesion
remains indelibly present.
Cooperative laboratory studies have begun in conjunction with Dr. Rolf Maijer at the University
of Toronto in an attempt to document this hypothesis. 4 Until all facets have been explored, and in
light of the occurrence of other clinical cases, it would be advisable to carefully weigh any decision
to bond metal brackets over sites showing existing developmental or pathological white spot lesions.
ACKNOWLEDGEMENT — The authors wish to thank Dr. John Warren of Brookhaven National
Laboratory, for this cooperation in conducting the elemental analysis.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume Oct
Associate Professor (Orthodontics) School of
Dental Medicine, State University of New York at Stony
Brook. Stony Brook, N.Y.
Professor of Oral Biology and Pathology,
School of Dental Medicine, State University of New York at
Stony Brook, Stony Brook, N.Y.
Fig. 1
Fig. 1 Photograph showing the indelibly pigmented maxillary left central incisor.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Oct(713 - 715): Indelible latrogenic Staining of Enamel Following Debonding - A Case Report
Fig. 2
Fig. 2 Arrow indicates site of existing developmental lesion prior to treatment.
Fig. 3
Fig. 3 Scanning micrograph showing site (arrows) of discolored material. ( 11)
Fig. 4
Fig. 4 Scanning micrograph showing conchoidal fracture patterns in discolored material— probably resin. ( 200)
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Oct(713 - 715): Indelible latrogenic Staining of Enamel Following Debonding - A Case Report
Fig. 5
Fig. 5 Scanning micrograph showing an example of discolored resin fragment (arrow) used in the elemental analysis.
( 50)
Fig. 6
Fig. 6 Elemental distribution in an off-sample scan.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Oct(713 - 715): Indelible latrogenic Staining of Enamel Following Debonding - A Case Report
Fig. 7
Fig. 7 Note the two chromium peaks (CR) present when the discolored fragment is scanned.
1. Handbook of Chemistry and Physics 45th Edition Published by Chemical Rubber Company 1964.
2. Kostlan J. and Plackova A: The histological investigation of the developmental hypomineralized areas of the enamel
and their comparison with the carious lesion Arch. Oral Biol. 7:317-326 1962.
3. Davila J.M., Buonocore M.G. Greeley C.B. and Provenza D.V.: Adhesive penetration in human artificial and natural
white spots J. Dent Res. 54:999-1O08, 1975.
4. Maijer R.; Personal Communication.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Oct(716 - 723): Common Sense Mechanics Part 14
Common Sense Mechanics
Applying Principles to Total Treatment (Continued)
There are basically three general types of Class III malocclusion, if we don't get too technical.
One would be purely dental, including mandibular displacements on closure, while the other two
would comprise dental/skeletal and purely skeletal problems. The latter requires surgical treatment,
whereas the first two can be treated orthodontically without surgery; although the dental/skeletal
type treated by orthodontics, without surgery, will involve compromise. There are many reasons for
accepting a non-surgical approach in the dental/skeletal types, including economic considerations.
Since orthodontic treatment alone is therefore applied in such cases, it is reasonable to include this
type of case in the discussion of "Common Sense Mechanics".
Class III (Atypical), Mandibular Displacement
We will begin by discussing a dental Class III malocclusion (atypical) involving a slight forward
displacement of the mandible during closure and a severe midline discrepancy. Obviously, such a
case looks worse than it really is (Fig. 183). The patient in this case was almost able to bite "end on"
with the incisors when asked, but not quite. Unlike most such cases in my practice, I elected to have
four first bicuspids removed. The purpose of this entire presentation, as mentioned, is to discuss
mechanics, not the reasons for electing to extract teeth— except as it might pertain directly to the
mechanics, such as gaining arch length with a tipback bend and thus converting a possible
extraction case to nonextraction treatment.
Maxillary cuspids were retracted until sufficient space was gained to align the six anterior teeth
(Fig. 184). An off-center bend is used to assure sufficient anchorage, but once the space has been
gained, the mechanics are reversed so as to produce buccal protraction of the maxillary molars. It
was intended, as part of the treatment plan, to maintain the anterior/posterior position of the
maxillary incisors and to retract the lower anterior segment sufficiently to eliminate the mandibular
shift and establish a Class I occlusion. Lower retraction is accomplished with an off-center bend to
maintain anchorage on the molar side of the extraction site. Such details have thus far been
described so frequently, that their description is not repeated. In most nonextraction cases, I find
myself expanding the upper anterior segment for such correction and frequently there is a good
lower arch in these cases. Notice the heavy lingual frenum. The patient disliked having these
occlusal pictures taken due to the discomfort, and yet refused any surgical correction. The lateral
views show root paralleling taking place with center (gable) bends. Figure 185 is an occlusal view
of the upper prior to appliance removal.
The case is shown in retention (Fig. 186) shortly after completing the treatment. The retainer has
been relieved to allow a distolingual rotation of the upper right first molar. The final pictures ( Figs.
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Oct(716 - 723): Common Sense Mechanics Part 14
187 and 188) were taken 4½ months later.
When dealing with tooth movement, there is not a whole lot of difference in treating the various
classifications of malocclusions, as has been seen. Understanding forces and moments, and how
they operate, as well as controlling magnitudes in the vertical plane of space, allows the orthodontist
to treat various problems with almost the same degree of ease.
Class III, Dental/Skeletal
Unlike the previous case, this girl presented a difficult Class III malocclusion. There was no
displacement on closure of the mandible, meaning the entire dental relationship would require
correction purely by tooth movement (Fig. 189). Ideal correction in a case such as this would require
surgery because of the skeletal contributions to the malocclusion. But this case was treated by
orthodontics alone, meaning that compromise must be part of the end result. In such cases, I
anticipate certain problems during retention, including partial Class III relapse and a tendency
toward open bite or lack of sufficient overbite.
Notice the crossbite in the buccal segments in addition to the anterior crossbite. Merely correcting
the crossbite in the buccal segments will worsen the Class III anterior relationship. There is also
lower anterior collapse present, meaning that correction in this area will worsen the anterior
relationship. The unerupted upper left cuspid is completely blocked out of the arch, but this really
isn't a problem, as the anterior teeth will purposely be moved forward to correct the malocclusion.
Note the facial profile and the typical "dished in" middle third (Fig. 190). I feel this type of case
requires certain compromises to be established beforehand, such as the willingness to leave "some"
lower rotations, which will encourage more overbite and overjet following treatment.
Nonextraction treatment was instituted, with the clear intent to expand the maxillary teeth and to
correct the molar relationship as much as possible with Class III elastics. In spite of the seriousness
of this malocclusion, you might find it interesting to observe the amount of dental correction
obtained using only 2×4 appliances in each arch. Nothing more than an .036 overlay was used to
correct the buccal segment crossbite.
After placing 24 appliances, a maxillary archwire was placed using coil springs to advance the
incisors (Fig. 191). Note that aligning the mandibular incisors at this time would make the problem
even worse. They are aligned later. There is no "shift" present in this case, so all changes shown are
due to tooth movement.
Six and one-half months later, a mild overbite has been established and space opened for the
upper left cuspid (Fig. 192). The molars have moved distally as a result of the prolonged distal
forces at the molar tubes. This seems to occur readily in a dental/skeletal Class III malocclusion.
The lower anterior segment is being aligned at this time.
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Oct(716 - 723): Common Sense Mechanics Part 14
In Figure 192, the upper left cuspid is making its appearance into the available space. An .036
overlay to correct the crossbite was used in the manner described earlier (Fig. 193). Class III elastics
are worn throughout this period to prevent Class III reoccurrence in the anterior segment during
expansion of the buccal segments. Note the correction observed two months later (Fig. 194) and
how much has been accomplished with only the use of 2 4 appliances and an overlay expansion
arch. Bends have been placed distal to the lateral incisors to produce lingual forces on the molars as
indicated by the long arms that are produced. Whenever forces on the molars are obtained in this
manner, it is wise to use a heavier wire such as an .020, as bypassing teeth reduces force magnitude
as has been demonstrated earlier in this series. I like light forces during vertical movement and
accept heavy forces during horizontal movement. The .036 overlay is certainly a heavy force and
should never be activated for any type of vertical movement. Figure 195 shows the case prior to
band removal, twenty-two months following the start of treatment. Bonding would have hurried the
eruption of the upper left cuspid, but I didn't bond at the time, although all of my cases are now
bonded. Figure 196 shows the profile at the time of appliance removal.
One year after appliance removal (Fig. 197), the expected type of relapse has taken place. The
occlusion is not ideal by any means and shows a Class III tendency. Frankly, I consider myself lucky
to be able to maintain this amount of overbite and feel that it might be a mistake to preserve lower
anterior alignment, if the overbite begins to disappear in a case of this nature. For this particular
patient, the overbite managed to maintain itself.
Minimal appliances are not the answer to all of our problems, quite obviously. But I think,
sometimes, full appliances can add to our problems. Reciprocal effects cannot be selective and
forces cannot be as reliably controlled. Often, it may be best to complete the vertical requirements in
treatment prior to placing the remainder of the appliance. Taking certain advantages of the use of
minimal appliances for some stages of orthodontic treatment does not deny the operator the
opportunity to finish treatment with a full appliance.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume Oct
Fig. 183
Fig. 183 Dental Class III with mandibular displacement, before treatment.
Fig. 184
Fig. 184 The case toward the end of alignment and space closure.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Oct(716 - 723): Common Sense Mechanics Part 14
Fig. 185
Fig. 185 The case prior to appliance removal.
Fig. 186
Fig. 186 Profile of case In Figs. 183-187 before (left) and after treatment.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Oct(716 - 723): Common Sense Mechanics Part 14
Fig. 187
Fig. 187 Final photos of case in Figs. 183-186.
Fig. 188
Fig. 188 Profile of case In Figs. 183-187 before (left) and after treatment.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Oct(716 - 723): Common Sense Mechanics Part 14
Fig. 189
Fig. 189 Dental/skeletal Class III before treatment.
Fig. 190
Fig. 190 Profile of case In Fig. 189, before treatment.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Oct(716 - 723): Common Sense Mechanics Part 14
Fig. 191
Fig. 191 First appliance in place.
Fig. 192
Fig. 192 The case 6½ months after placement of first appliance.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Oct(716 - 723): Common Sense Mechanics Part 14
Fig. 193
Fig. 193 Overlay arch to correct buccal crossbite.
Fig. 194
Fig. 194 The case after 2 months of overlay arch treatment.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Oct(716 - 723): Common Sense Mechanics Part 14
Fig. 195
Fig. 195 The case prior to appliance removal.
Fig. 196
Fig. 196 Profile at appliance removal.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Oct(716 - 723): Common Sense Mechanics Part 14
Fig. 197
Fig. 197 The case one year after appliance removal.
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Oct(724 - 726): Orthodontic Office Design - Examination Room
examination room
While some orthodontists do their initial examinations in the main operatory, this has many
drawbacks as the practice increases and patient volume is greater. To conduct an examination in an
open style operatory can be distracting, if other patients are present or if auxiliary personnel are
cleaning and preparing the work area. It also develops an attitude on the part of the parent that they
are welcome in the operatory, which may be undesirable to some orthodontists. Most orthodontists
attempt to have a separate examination room.
Another consideration favoring a separate examination room is that some adults, when exposed
to an open bay operatory, sometimes are shocked to see auxiliaries performing work that they
thought was done only by the orthodontist. Orthodontists have accepted the delegation of duties so
readily that we overlook that there are those who are not aware of this development in our practices.
Some adults make it a point to request that the doctor be the only one to do their orthodontic work.
While this is not the rule, it does occur; and indicates that, in some instances, it is wise to introduce
our routine of practice to the public gradually. The privacy of the working operatory area at the first
visit may be prudent.
I prefer and recommend that the examination room not be in the 8'  10' range, but rather in the
12'  12' range, so that the comfort area is not violated at that very important first meeting. Many
parents and patients are tense at the exam, and a crowded room tends to add to that feeling. Consider
the congestion of a 8'  10' room which is filled with the exam patient, mother and perhaps father
also, the dental assistant, and the doctor himself. Then add the dental chair (2'  6'), counterspace,
cabinets, etc. We know all too well the importance of the first impression, and that the case may be
won or lost at the first examination . Any contribution to a relaxed, competent, and comfortable
atmosphere will aid in securing the case.
The larger exam rooms allow the parents to be seated, if the doctor prefers that the parents be
present during the examination. If the doctor does not follow this routine, the extra seating space
allows for an excellent audiovisual room combined with the exam room area. If the assistant aids the
patient with the pre-examination paper work, this type of arrangement gives them a room to fill out
the necessary information in private. The preference of the handling of the patient and parent is up
to the doctor. However, a comfortable examination area requires planning and the larger rooms
afford flexibility and possibilities of dual function.
In smaller offices, it will be necessary to consider combining the examination room with other
uses. A common combination usage is the exam room and an x-ray or cephalometric room. In
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Oct(724 - 726): Orthodontic Office Design - Examination Room
determining the square footage of this type of combination, remember to provide space for the
possibility that you may want to add a panoramic x-ray machine some day. For larger practices, I
recommend separating the x-ray room from the area in which examinations are conducted, and
providing for a records room combined with x-ray. If possible, it is a good idea to have a window in
this room, especially if the square footage is on the short side. The use of mirrors can also be
effective in making a small exam room, or any room, feel more spacious.
In general, the ideal location depends on several factors, one of which is who is in charge of
seating the examination patient. Another important factor is whether or not your schedule enables an
assistant to aid the prospective patient in filling out the pre-examination material. I highly
recommend this procedure, as it is more personal than handing out a clipboard and pencil. If the
office is one with a large square footage, then the distance from the operatory to the exam room
must be a consideration. If the room is to be multipurpose, then the type of activity which is shared
there makes a difference as to location. For example, an examination room which also serves as an
audiovisual room may be located in several areas of the office.
Since the receptionist is usually the one who escorts the patient to this room, it should be located
near or adjacent to the business area. A secondary location could be directly off of the reception
room, but it should allow the parent and patient to have reasonable access to the business areas as
they leave. It is essential that parents and patients do not walk through the main operatory, but are
able to go directly to the examination room.
Since this room may be used as an overflow room, I strongly recommend that it be easily
accessible to the main operatory. It would be wise to have easy visibility into this room from the
main operatory, but still have the ability to make it very private when desired. A glass wall or large
window with drapes has been used effectively for this purpose. The draperies, when closed, create a
feeling of warmth as well as privacy. The exam room should have doors, to avoid interruptions
during the exam.
The general lighting in this room should be similar to that in the main operatory in foot
candlepower, when this room is used as an adult patient operatory or a general overflow room. The
lighting should not be harsh, but rather generalized in nature.
Consider a fluorescent fixture illuminating the wall, to provide a background for photography. A
built-in view box is useful in this room for short case presentations or progress reports. This is an
excellent use for this room and it keeps the parent out of the main operatory.
Other Considerations and Combinations
The uses of this room can be varied:
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Oct(724 - 726): Orthodontic Office Design - Examination Room
Initial examination.
Partial or full consultation.
Problem cases.
Instruction room (personal and audiovisual) .
Adult treatment room.
Recall or retention checks.
General overflow from main operatory.
Additional storage area adjacent to the operatory.
Since this room can have many functions, it must naturally be larger than the average individual
The decor in this room should help to relieve patients' apprehensions. Some patients are quite
young, and this is the first time they are meeting you. A decor which produces a feeling of warmth
and friendliness is indicated. A built-in model storage area is recommended for this room, since it
will often be used to show examples of treated cases similar to the problem of the child in the chair.
Procedural Variations
Some doctors have successfully employed a very casual and informal approach to their
examination appointments by intentionally conducting the exam in a room free of dental chairs and
dental equipment. In what might be physically considered a lounge with furnishings and decor
similar to a mini-waiting room, the doctor does a tongue-blade examination. If treatment is required,
an explanation of the problem and the need for records is explained. In this setting an audiovisual
film is also presented, introducing the parent and patient to what can be expected in the orthodontic
program and the need for cooperation for success.
In summary, the physical setup of the examination area depends on the routine the doctor wishes
to employ during his exam. The factors of size, location, and combination uses depend on the
procedures previously discussed, as well as the size of the practice and the square footage available.
President, Modern Orthodontic Designs, 1529
South Eighth Street, Colorado Springs, CO 80906
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume Oct
NOVEMBER 1980, VOL. 14 / ISSUE 11
JCO Interviews The Kesling & Rocke Group on Begg Technique
The Double Tooth
Common Sense Mechanics Part 15
First — and Lasting — Impressions
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Nov(755 -): 756 THE EDITOR'S CORNER
Dentists and orthodontists are under the impression that everyone else but dentists and
orthodontists has some rational way of determining a price for a product or a service. This has led to
the recent appearance of plans advocating cost accounting as an honest and equitable method of
establishing dental fees. The method usually involves adding a figure for desired dentist salary to
office costs and computing an hourly rate based on the number of hours the office is expected to
work. Further refinements break down the hourly rate into categories, depending on what staff
member at what salary performed the task or portion of the task.
This idea probably ranks high as a nail in the coffin of dentistry as a profession. It profiles
dentistry as a highly skilled piecework craft. It fractionates dental procedures. It plays into the hands
of those third parties— insurance companies, unions, government— who would like to install a
cost-plus system, with control of both the cost allowance and the plus. Beyond that, linking the
production of dentistry to time has been tried and found wanting. We have been through a period
fifty years ago when dentists had time clocks in the operatory; not to improve their efficiency by
finding out how long procedures took, but to make their fee charges based on time. Woe to the
dentist who spent any of the patient's time in idle chatter like, "Hello, how are you?" It is
paradoxical in this age of holistic health efforts toward whole person dentistry, that a mechanism
would be advanced that would fractionate dentistry; that in this age of recognition of the
consequences of stress, a mechanism would be advanced that enhances stress.
There are many potential sources of stress in a dental office— the demands of the work itself, the
difficulties of interpersonal relationships with patients and staff, and the dentists' hangups with the
infliction of pain and the drive for perfection. However, perhaps the greatest producer of stress is
time. Linking the fee to time can only result in greater stress in practice.
Cost accounting seems like an attempt to establish a standardized method of fee determination,
but time may not be the best way to do that, since there is quantitative time and qualitative time. It is
like asking Pablo Picasso to add up what he spent a year for paints, brushes, and canvas and adding
a unit fee for time spent on the canvas.
It is a tenet of pricing that so long as you cannot predict the demand side of the price equation,
you cannot decide in advance what your income ought to be and you can't use a cost-plus basis for
determining a unit price or fee. Monopolies and utilities, which have a much surer estimate of their
demand side, and which are price regulated, are more suitable for cost-plus price determination.
Even they have trouble making it work, and the rest of the business world does not use this system.
They are undoubtedly paying attention to their costs and their break even point, but when it comes to
pricing, they agonize as much as a dentist or orthodontist, and they establish prices by administrative
decision. If the price is set too high, not enough people will buy and the price will be lowered. If the
price is set too low, demand will indicate that and the price can be raised. Since orthodontists failed
to raise fees very much during the Fifties and Sixties, when practices were growing and incomes
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Nov(755 -): 756 THE EDITOR'S CORNER
were constantly increasing and inflation was not an important factor, orthodontic fees are in the
latter category.
There may be a number of rationales for cost accounting fees. One of the more frequent ones is
that it is "fair". However, this type of fee is no more automatically fair or equitable than fees
established in other ways. It might give the orthodontist the idea that he is being fair; or give the
patient the idea that the orthodontist is being fair. It becomes a device to make the orthodontist more
comfortable and the patient possibly more receptive, but fairness is not even relevant. The
orthodontist really does not know what is fair to somebody else. Even acceptance on the part of the
patient does not mean that they believe the fee is fair. There is evidence that 10-20% of patients do
not believe the fee is fair. Nevertheless, the vast majority of patients accept the present range of fees
and methods of fee determination as fair. Fairness on the part of the orthodontist exists on the other
side of the transaction— giving the patient the service that he needs and deserves and for which he
agreed to a fee which he perceived to be fair.
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Nov(758 - 778): JCO Interviews The Kesling & Rocke Group on Begg Technique
Robert A. Rocke(RAR)
Peter C. Kesling (PCK)
R. Thomas Rocke (RTR)
Paul A. Rocke(PAR)
Harry G. Barrer (HGB)— for JCO
HGB The Kesling & Rocke Group represents the mother lode of Begg philosophy and treatment in
the United States. Among you, you represent well over 50 years of Begg experience. Although the
basics of Begg philosophy and technique remain essentially unchanged, your innovations in
technical procedures and mechanics have improved Dr. Begg's original methods, and you have been
instrumental in spreading the use of this philosophy of treatment through the many classes of
orthodontists who have made the trek to the "Mecca of Begg Philosophy" at the Center in Westville
in order to-learn the technique or refresh themselves with new thought and procedure.
Bob, the Kesling & Rocke Group is one of the oldest orthodontic associations. What do you
believe is the reason for the long term success of your association with the late Dr. H.D. Kesling?
RAR Our relationship started during the depression, ripened with time, and eventually lasted over
45 years. In trying to analyze the success of any relationship, certainly hard work on the part of all
parties is most important, and there must be mutual admiration and respect. There is no place in a
successful partnership such as this for petty jealousy. And, the parties must have an understanding
before the association starts.
HGB Would you have a written contract right from the start?
RAR We definitely would have some written arrangement with any associate joining the practice.
There might be a trial period of three to six months, following this written arrangement and, if
things do not work out, the contract could be made null and void without any ill feelings.
PCK Each partner should have certain areas of responsibility. This helps assure the smooth daily
operation of the practice.
HGB Do you mean administrative or clinical responsibilities?
PCK I was thinking of administrative duties.
HGB On what basis do you divide up the duties?
PCK Duties are delegated, whenever possible, according to the individual's particular abilities,
preferences, and time available.
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Nov(758 - 778): JCO Interviews The Kesling & Rocke Group on Begg Technique
HGB Do you rotate duties through the partnership?
PCK From time to time; but in general, if it works well, we just keep going with the same
HGB What do you feel are the advantages of a group practice over a solo practice?
RAR The value of consultation with your associates makes a big difference in patient care.
Vacation times can be readily arranged, and patients are better taken care of in a group practice than
they are in a solo practice. I think that a group practice can grow more readily than a solo practice
because of the association of the various partners in the community.
PCK The patients benefit because a member of the group would think twice before compromising
an adjustment or a finish if one or two, or more, partners were going to judge his or her work. We
review the final results of each case among all the members of our group. At the completion of
treatment we evaluate each case, using a special grading sheet to assess the quality of treatment and
result achieved (Fig. 1).
Another advantage of a group practice is, of course, the economics of sharing overhead— items
that in a solo practice would have to be carried on one man's shoulders can be distributed. And, as
Bob mentioned, vacations, illnesses, and business trips can easily be covered in a group practice.
HGB How are the patients assigned to individual doctors?
RTR Basically, the patients are randomly assigned to doctors, unless they express a preference. It is
up to the receptionist to assign new patients in a fair manner, according to the percentage of
ownership each member has in the partnership.
HGB Who does the diagnosis, case presentation, and financial arrangements in your practice?
RTR Each doctor does his own diagnosis and case presentation. We do get together on those cases
where the diagnosis is difficult. The financial arrangements are presented by the doctor at the time
of each presentation. The secretary then makes the detailed arrangements after the consultation.
HGB Do you cross-treat patients, or does each of you maintain an "individual practice"?
RTR Generally speaking, we do not cross-treat. We try to see our own patients at each appointment.
Patients feel more comfortable seeing the same orthodontist. Also, when boards are being
considered, each doctor must treat his own patients to meet the requirements. I believe that is how
we got started seeing our own patients. Before that, we treated whoever came into the room.
RAR When we began to use the Begg Technique in 1957, we initiated cross-treating on all patients.
At that time the Technique was not clearly divided into three stages. We had to feel our way along
by trial and error. By cross-treating we could assess the effect of other partners' adjustments. As the
Technique developed into its present state, we stopped this practice. However, we certainly
cross-treat on emergency appointments, or if one is away from the practice for any length of time.
PCK Having done it both ways, I would say that everything else being considered, one can do a
better job if he sticks with the same patients. You get to know each patient personally, and have a
better chance of having them help you through maximum cooperation.
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Nov(758 - 778): JCO Interviews The Kesling & Rocke Group on Begg Technique
HGB What do you do if there isn't enough time to make the required adjustments at a given
RTR In general, we don't have that problem, perhaps because our practice is better organized than
most. However, I feel that if an adjustment is necessary, it should be made at that time, even though
it may create a backlog in the reception room. This would be particularly true if a problem were
developing for that particular patient. It is very important to correct any existing or developing
problem at the time it is noticed.
HGB What role do you assign to your auxiliaries?
PCK We don't have auxiliaries do as much work at the chair as I am sure is being done in other
offices. Our assistants mainly hand us the instruments. They do not place archwires in the patient's
RTR In Indiana, auxiliaries can take impressions for diagnostic purposes, but not for the fabrication
of appliances. They can also take x-rays, but cannot do irreversible procedures.
PCK Our practice is organized to take advantage of the efficiency of the Begg Technique. We only
see our patients every six to eight weeks. We don't have to run a lot of patients through here like a
mill. We have enough time set aside so that we can do whatever is necessary at each appointment.
We have had patients come to us from other practices where they were upset at having assistants
working on them most of the time.
HGB Do you use an open, or closed-end fee?
PCK We have a flat, closed-end fee for treatment, and that includes all the appliances we feel will
be necessary to complete treatment, including positioners. And it also includes retreatment, if
RTR That is a firm fee, regardless of inflation, and it can be paid over an extended period of time,
without interest charges. However, I am sometimes tempted to charge an additional fee if they
missed retention appointments, and all of a sudden a year or so later they come in complaining of
PCK We all have some patients come back ten years later, with a little lower anterior crowding. If
they want to go through corrective measures, there is no charge.
HGB Do you mean full appliance retreatment, or just corrections such as rotations or a slipped
PCK The degree of retreatment would, of course, depend on the degree of relapse. We would do
whatever is necessary to correct the situation, from full appliances on both arches to perhaps the
simple placement of a Spring Aligner to correct lower anterior crowding (Fig. 2).
Happily, there are very few cases such as this. If it got to be a high percentage, we would
probably have to reassess our approach. If you have diagnosed the case properly and treated it
properly, you shouldn't have much relapse. I feel relapse is usually caused by the orthodontist erring
in some way, before or during treatment. Perhaps the case was not diagnosed correctly at the start.
We can do better today with better procedures, and more thought to overcorrection.
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Nov(758 - 778): JCO Interviews The Kesling & Rocke Group on Begg Technique
HGB What posttreatment changes would you accept before saying the case has relapsed sufficiently
to require some active retreatment?
PCK Minor crowding of upper and lower anterior teeth, slight rotations of bicuspids, deepening of
the bite. A decision to retreat is usually not made by the orthodontist alone. The patient's degree of
satisfaction and wishes must be considered, also. It is sometimes surprising when we suggest
retreatment to patients and they don't want it. They are perfectly happy. On the other side of the
coin, one may have what he considers to be a beautiful result, and the patient (or "Mama") doesn't
like it.
HGB Have you given any consideration to inflation? Since we quote long-term fixed fees, do you
make any adjustment?
PCK We presently review our fees annually, and attempt to increase them to keep up with
cost-of-living increases. In the 1960's we were lax on this point, and I feel we let our fees stagnate to
relatively low levels. Of course, we don't adjust a patient's fee once it has been accepted. Once we
quote a fee, that's it.
HGB Now that we have a little overview of your administrative procedures, let's discuss some
treatment procedures. What is your position on extraoral force as it pertains to your treatment
RTR We haven't used extraoral force of any kind since 1959, and have documented thousands of
cases (Fig. 3) to illustrate the fact that we can accomplish all corrections without the use of headgear.
HGB Many orthodontists feel that by using headgear they can treat a case nonextraction that
otherwise might require extractions. They don't want to "doom" the patient to the extraction of
RTR We would probably have a higher percentage of nonextraction cases if we used headgear.
However, our feelings are that in "borderline" cases the results will be more stable if tooth substance
is reduced, rather than teeth held back temporarily during treatment with headgear.
PCK Orthodontists with ten, twenty or thirty years of experience in treating patients usually agree
that the results are more stable in those cases where no headgear was used and teeth were removed
when necessary.
HGB What about bumpers and activators?
RTR I don't think we can really comment on these appliances, since we have not had much
experience with them in our practice.
PCK I don't think there is any technique that can get things going as fast as the Begg Technique. If
the child is old enough, if you can band the upper and lower six anterior teeth and the first molars, I
think you ought to start the Begg Technique and forget about the lip bumpers.
HGB Would you discuss your use of early treatment in the mixed dentition?
RAR In certain cases such as:
Article Text
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1980 Nov(758 - 778): JCO Interviews The Kesling & Rocke Group on Begg Technique
(1) In Class III malocclusions, which may require one or two, or more periods of treatment until full
growth is reached.
(2) In cases with extreme overjet, to reduce the maxillary protrusion to help insure that the upper
anteriors will not be fractured, and assist the developing child psychologically. This is accomplished
with a removable palatal appliance having a circumferential wire or elastic across the anterior teeth (
Fig . 4) .
Other than that, we do no early treatment. In most cases our experience has shown that if cases
are started too early (in the developing dentition), the treatment time will run extremely long. If
partial treatment is completed before the permanent dentition has erupted, further treatment may be
required. This only wears the patient out, and we feel that it is not necessary.
PCK Early treatment might also be detrimental in that the limited amount of movement possible due
to the absence of many of the permanent teeth might only result in masking the true severity of the
malocclusion. The orthodontist could then be misled in the diagnosis, and not extract in a case
which required a reduction of tooth mass. The result could be a bimaxillary protrusion at the end of
treatment and/or relapse.
RTR We find that the Begg Technique is most efficient in treating cases when the appliances can be
placed on all permanent teeth at the beginning of treatment.
PCK With the Begg Technique success does not depend on how early one begins treatment, but to
what degree the teeth and even the arches are overcorrected, and that doesn't mean one has to get
started at a very early age.
HGB What is your view on serial extraction?