CDM D3

CONVENTIONAL ORTHO
 THIS PRESENTATION

THE BASICS OF BRACKET PLACEMENT

WIRE PLACEMENT and WIRE SEQUENCE

BRACKET REPAIRS

BASICS OF INVISALIGN TREATMENT

DELIVERY OF ALIGNERS

DELIVERY OF ATTACHMENTS

CHECKING IF CASE IS PROCEEDING AS PLANNED

*** RDA HELP WITH ORTHO/INVISALIGN?

 CDM

~70 Active Ortho Patients

~ 30 Active Invisalign Patients

 The “problem” List
CHIEF COMPLAINT?
1) Patient Interview? ETIOLOGY?
2) Skeletal? 1) Growth?
3) Dental?
4) Crossbites? A) Stage?
5) Crowding?
B) Direction?
2) Habits?
3) Airway?
SOLUTIONS? ACTION?
1) TX Timing/CVMS 1) Consent/Treat
2) Myofunctional TX 2) Establish FEE
3) Expansion? 3) Or Refer
4) Orthodontics? Invisalign?
Need for Orthodontic Treatment

Protruding, irregular, or maloccluded teeth

can cause 3 types of problems:

(1) Psychosocial/Self-esteem issues

(2)Problems with oral function, including difficulties in jaw

movement, TMJ disorders, and problems with chewing, swallowing, or
speech.

(3)Problems of accentuated periodontal disease and tooth

breakdown (assoc with parafunction)
ANGLE’S OCCLUSION & MALOCCLUSION

 Class I Occlusion

 Class I Malocclusion

 Class II Malocclusion
-Division 1

-Division 2

 Class III Malocclusion

CLASS I “normal” OCCLUSION
CLASS I MALOCCLUSION
CLASS II MALOCCLUSION
CLASS III MALOCCLUSION

Anterior cross bite

% of U.S. Individuals In Angle’s
4 Malocclusion Classifications
 25% Class I “Normal” (untreated) Occlusion

 50%-55% Class I Malocclusion

 15%-20% Class II Malocclusion

 1% Class III Malocclusion

 Normal Overbite

A vertical overlap of the incisors. 1-2 mm is normal.

 Normal Overjet

Horizontal overlap of teeth; 2-3mm is normal.

OPEN BITE
ANTERIOR CROSSBITE
 THE
“STRAIGHT – WIRE”
APPLIANCE

Or

Brackets and Wires

Palmer Notation
Dr. Larry Andrews
Dr. “Straight Wire”

“Father” of the
Straight wire philosophy
 NON-ORTHODONTIC
“NORMALS”

120 Cases evaluated that were “Perfect” by Nature

(No Orthodontic treatment needed) this led to the
development of the SIX KEYS to “normal” occlusion
THE SIX KEYS TO “NORMAL” OCCLUSION

Dr. Lawrence F. Andrews

The Study of 120 Non-Ortho Norms

1. Class I Occlusion (molar and cuspid)

2. Proper Crown Angulation (Distal root tip)
3. Proper Crown Inclination (Torque 105 90)
4. No Rotations
5. Tight Contacts (no spaces)
6. Flat Curve of Spee
1st Key: Molar/Canine Relationship

Upper mesial buccal cusp, lines up with lower buccal groove

 IMPROPER MOLAR TIP PROPER MOLAR TIP
IMPROPER RELATIONSHIP CORRECT RELATIONSHIP
2nd KEY: CROWN TIP (“LEANING TOWER”)

5°
Root Distal
ALL NORMAL ROOTS
TIP DISTALLY

90°

MESIAL DISTAL

UPPER LEFT CENTRAL

3rd KEY: CROWN TORQUE (“angulation”)
+18°

90°
ESTABLISH PROPER CROWN TORQUE

NOTE:

CROWN TORQUE BUCCAL =

ROOT TORQUE LINGUAL
 5° +19°

90° 90°

TIP TORQUE
PROPER TORQUE BUILT IN BRACKET RX

+18°
4th KEY: NO ROTATIONS

Dotted line
shows a mesially
rotated molar
taking up space,
which would
cause a class II
molar relation
 5TH KEY:

NO SPACES
6TH KEY: “FLAT” CURVE OF SPEE
6 KEYS ARE OUR ORTHODONTIC
treatment GOALS
1. Class I Occlusion (molar and cuspid)

2. Proper ROOT Angulations (Tip)

3. Proper Crown Inclination (Torque)

4. No Rotations

5. Tight Contacts (no spaces)

6. “Flat” Curve of Spee

 MOST IMPORTANT?

1. TREAT TO MAXIMUM FACIAL HARMONY

2. TREAT EARLY WHEN YOU SEE THE NEED

3. EXTRACT ONLY WHEN ABSOLUTELY NECESSARY

 SLOT TIP

“CROWN ANGULATION”
MESIO-DISTAL
PROGRAMMED INTO STRAIGHT WIRE APPLIANCE

10
SLOT TORQUE

CROWN ANGULATION
BUCCAL to LINGUAL
BASIC BRACKETING CONCEPTS
CLINICAL ANALYSIS of Malocclusion

PRE-TREATMENT SMILE Analysis

CEPHALOMETRIC ANALYSIS (Incisor angulation?)

MODEL ANALYSIS of Malocclusion

RADIOGRAPHIC ANALYSIS of root angulations

PROPER BRACKET PLACEMENT for Maximum correction

 BRACKETING 101

 EVAL MODELS and PANORAMIC

 EVAL ROOT ANGULATIONS VS MARGINAL

RIDGES

 EVAL ROTATED TEETH

 EVAL INCISOR RELATION? OB/OJ

 MODEL EVALUATION

for

BETTER BRACKET PLACEMENT =

MORE EFFECTIVE Treatment Outcome

Evaluate Pre-Tx ROOT angulations
Mark Long Axes
On Working Models
Pre-TX “Constricted Arch” Panoramic Rendition
 WHAT WE SEE BEFORE TX

Common areas of Root convergence

PROPERLY positioned brackets for CORRECTION
Post-TX “Corrected Arch” Panoramic Rendition
 WHAT WE WANT AFTER TX

Root Parallelism= Improved RETENTION

Another common area
Proper bracket placement=

“distal” Parallel roots

BRACKET PLACEMENT
 BRACKETING 1st APPOINTMENT

STUDENT DOCTOR STUDENT ASSISTANT

 ORTHO CASSETTE
 EXPLAIN PROCEDURE
 PUMICE U 5-5  SEAT PATIENT

 RETRACT, ETCH, PLACE OPAL  BRACKET SET-UP (UPPERS)

SEAL (DO NOT CURE)
 PLACE UR5-3 – DR G OK  MATERIALS, LIGHT, ETC

 PLACE UL 5-UR2 – DR G OK  ASSIST STUDENT DR AS NEEDED

 PLACE SEPARATORS ALL 6’S  REPLACE and ORGANIZE

INSTRUMENTS IN CASSETTE
(NO SHARP ENDS STICKING OUT)
 DISMISS PATIENT/SCHEDULE ONE
WEEK
PLACING SEPARATORS
 BRACKET/BANDS 2nd APPOINTMENT
STUDENT DOCTOR STUDENT ASSISTANT
 ORTHO CASSETTE
 EXPLAIN PROCEDURE

 SEAT PATIENT
 PUMICE U 6’s LOWER 6-6

 BRACKET SET-UP (LOWERS 5-5)

 TRY-IN BANDS (ONCE YOU FIND
THE CORRECT SIZE OTHER
MOLARS WILL BE ~THE SAME  BAND SET-UP
SIZE)
 CEMENT BANDS – FUJI BLUE  MATERIALS, LIGHT, ETC

 BRACKET LR 5-3, THEN LL5-LR2-  ASSIST STUDENT DR AS NEEDED

OK DR G
 REPLACE and ORGANIZE
INSTRUMENTS IN CASSETTE (NO
 CUT, TIE IN PLACE .014 NiTi SHARP ENDS STICKING OUT)
UPPER/LOWER
 Used to further seat the band by having the
patient bite
 Serrated tips for increased control
 3rd APPOINTMENT + others
STUDENT DOCTOR STUDENT DOCTOR
 EXPLAIN PROCEDURE
 ORTHO CASSETTE

 ASK/CHECK FOR ANY LOOSE

BRACKETS, BANDS, ETC  SEAT PATIENT

 ASK HOW PATIENT IS “RECEIVING  BRACKET REPAIR SET-UP

TREATMENT”

 MATERIALS, LIGHT, ETC

 REPAIR AS NEEDED

 CHANGE WIRES AS NEEDED:

 REPLACE and ORGANIZE
INSTRUMENTS IN CASSETTE
(NO SHARP ENDS STICKING
GENERAL WIRE SEQUENCE: .014 NiTi, OUT)
.016 NiTi, .016X.016 NiTi, .016X.016
STEEL, .016X.022 STEEL
GET BRACKET SET UP READY
ETCH ONLY AREAS

FOR BRACKETS

(AIR DRY & BOND)

PLACE SMALL “DROP” OF ADHESIVE
 PLACE BRACKETS AS
PRECISELY

AS POSSIBLE

for

BEAUTIFUL SMILE
CURVATURE
GENERAL DISTANCE
Cusp tip to “SLOT”

4.5
4.0 4.0
3.0 3.5
4.5
 4.5
4.5 4.0
4.0 4.5
4.5

3.0 3.0
3.0 3.0 3.0 3.0

PROPER BRACKET POSITION

IMPROVED SMILE CURVATURE
 BRACKETS “CENTERED” ON BUCCAL SURFACE

BRACKETS “LONG AXIS” LINE

to
TOOTH LONG AXIS
 TIPS

UPPER BRACKETS Placed to correct or maintain

Smile Curvature.

LOWER BRACKETS placed to correct Curve of

Spee:
Use lower SECOND MOLARS and CANINES as
ANCHOR UNITS (relative to DEPTH of Curve of Spee)
ALL lower anteriors (canines included) place them at
same height (4mm), Lower bicuspids and 1st Molars
1mm more gingival then place bracket on 2nd molar 1mm
more occlussal.
SAMPLE CASE
98*

STAGE 5
 “STREAMLINED” Analysis

ANB (º) 7 2

Wits (mm) 4 0
MP - SN (º) 35 33.0

U1 - SN (º) 96 103

LOWER INC to MP 98 90
 DX?
 SKELETAL? Class II ( ANB 7*, Wits 4mm)

 DENTAL? Class I (R), Class I molar (L), Class II

Canines

 FACIAL/HABITS? Dolicho, No habits

 PSYCH? Self esteem

 TX TIME: 18 months

 FEE? $4500
PLACING WIRES
SICKLE and HEMOSTAT
CORRECT

INCORRECT
TWO TYPES OF TIE CONFIGURATIONS:

1) REGULAR- circle around all cleats

2) “FIGURE 8”- MAXIMIZES EFFECT

To HELP tie DIFFICULT teeth
Make CUSTOM END
 TYPICAL WIRE SEQUENCE

 STAGE 1: LEVELING AND ALIGNING

 STAGE 2: OPEN THE BITE (PROPER INCISOR

RELATION), ORTHOPEDIC OR ORTHODONTIC

 STAGE 3: CORRECTION OF MIDLINES,

RETRACTION OF ANTERIOR TEETH, SPACE
CLOSURE

 STAGE 4: FINAL LEVELING, MAXIMIZE TIP

AND TORQUE
INDIVIDUAL WIRE “RACK”
 STAGE 1

 .014 NiTi wires

 (duration-1-3 months)

 LEVELING (marginal ridges)

 ALIGNING (misaligned roots)
 DEROTATING
Bracketing Gauge
Placing Retractor
Another Type of gauge
 STAGE 2
(In treatment 4-6 mo)

 .016x.016 NiTi wires (duration-2-3 months)

 Final LAR
 Take “Updated” Panoramic for final root
ANGULATION re-evaluation
 Perform necessary “Rebracketing”

 *** NOT RECOMMENDED to move to steel

wires until this step is confirmed
 STAGE 3

 .016x.016 STEEL wires (duration-3-6 months)

 .016x.022 STEEL wires (remainder of Tx)

 CORRECT MIDLINES (use of ELASTICS)

 RETRACT ANTERIOR TEETH
 SPACE CLOSURE
 FINAL CORRECTION OVERBITE and
OVERJET
 Elastic Mechanics

(INTERARCH FORCE)

Generally: Once in “square” wires

ELASTICS

LATEX 3/16” NON-LATEX ¼”

CLASS II MALOCCLUSION

What happens?
1) U Anteriors RETRACTED/RETROCLINED
2) L Anteriors PROTRACTED
CLASS III MALOCCLUSION

What happens?
1) U Anteriors PROTRACTED
2) L Anteriors RETRACTED
 STAGE 4 (FINAL)

 .016x.016 or .016x.022 STEEL wires (with

curves)
 (duration-3-6 months)

 FINAL “DETAILING”
 MAXIMIZE TIP/TORQUE
 FINAL SPACE CLOSURE

TOTAL TX TIME ? ~ 18 MONTHS (average

case)
WHEN CASE IS READY

TO FINISH….
CASE FINISHING
 GET PATIENT TO SIGN CONSENT

 REMOVE MOLAR BANDS (for

RETAINER impressions)

 TAKE UPPER AND LOWER ALGINATE IMPRESSIONS

 Replace “adjusted” same wires (steel lace to prevent

SPACES.

 RECOMMEND: UPPER HAWLEY and LOWER BONDED 3-3

BAND-REMOVER
BRACKET REMOVER
MORE PREDICTABLE

RESULTS
TWO YEARS LATER…
SUMMARY
“ORTHO CARTS” TOP DRAWER
2ND DRAWER
3RD DRAWER
4TH DRAWER
Bottom DRAWER
“ORTHO CASSETTE”
Be organized!
Opal Ortho
Cement
Every Cart

Valo Light
 ORTHO “workhorse” SET UP

Sickle

Ortho Hemostat
BRACKET PLACING TOOLS:

REGULAR AND MOLAR

STRAIGHT BRACKET
PLACING INSTRUMENT
Correct bracket hold
 CUTTING TOOLS

WIRES AND LIGATURES

Distal-end cutter

Ligature cutter
“CUTS and HOLDS” Distal-end
 OPAL
BRACKET
CEMENT

ETCH

SEAL

BOND
Conclusion
FOCUS ON “PRECISION”

 CORRECT BRACKETING

 LESS NEED TO “CHANGE” BRACKETS

 USE SIMPLE WIRE SEQUENCE

 LESS “HEADACHES”
 MID-TX RECORDS
“Pano-Repo”
“HALF-WAY” or ~6months into ESTIMATED TX

PHOTOS

PANO- $ NO charge

EVAL ROOT ANGULATIONS/”BRACKET REPO”

MODEL ANALYSIS: MOLAR-CUSPID-MIDLINE-MARGINAL

RIDGES

Discuss progress with your patient

 SIX KEYS TO OCCLUSION

(our TX GOALS)

1. Class I Molar/Canine relationship

2. Proper ROOT tip
3. Proper CROWN torque
4. No crown rotations
5. No interproximal spaces
6. Flat occlusal plane
(FLAT Curve of Spee)
 Basic Appointments

 Screening
 Records
 Treatment Plan presentation/case
acceptance/payment
 Case START (bracket Upper 5-5, Separators)
 Final Banding/brackets/bands
 Periodic (D8670) Ortho
 D8670 (Periodic Ortho)

 Bracket REPAIR
 Wire CHANGE

 EVERY APPOINTMENT (check):

 MOLAR-CANINE-MARGINAL RIDGES
 CORRECTION of ROTATIONS
 POSTERIOR ALIGNMENT
 ANTERIOR ALIGNMENT