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PUBLISHED BY ORMCO VOL. 9, NO. 2, 2000

CLINICAL

Impressions

Dr. Pitts on a

New Model ofEconomyPage2

Dr. Mayes onCuring LightsPage 15

Dr. Hilgers& Tracey onBioprogressivePrinciplesPage 18

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rthodontics is a won-derful profession andIm more excitedabout it now than Iveever been. Its morefun for me and mypatients and staff, andI see it continuing toget better and better.Much of my excite-ment is due to thetremendous strides

weve taken over thepast 15 years in developing appliancesystems and techniques that offer us theability to treat patients more efficientlyand with greater patient comfort andhigher quality (Case 1). This has led meto the development of a new philosophyof treatment a philosophy that hasevolved over the 30+ years that Ivebeen practicing.

When I began my orthodontic career in1968, my philosophy of treatment was

limited to a rather narrow definition,which included ideal Class I occlusionwith as much stability as possible (teethover basil bone, not expanding the cus-pids, etc.), exact tooth positioning, andgood periodontal health with parallelroots. Aesthetics was important but notas important as stability. Being trainedunder Dr. Dick Riedel at the Universityof Washington meant that stability wasparamount very similar to the Tweedphilosophy. I treated most Class II cases

with a headgear and a lot of extractions.We saw most patients on a 4-week sched-ule. Treatment took an average of 24 to40 months in 40 to 60 appointments.

By the 1980s my philosophy of treatmenthad broadened. I was doing more archdevelopment and less extraction.Dentofacial orthopedics was enhancedthrough fixed Herbst* and other noncom-pliance appliances. Aesthetics and lip line

were beginning to equal and even surpassstability in importance as we studied themidface and arch form. Developing andenhancing the midface and smile becameone of the more fun and challenging partsof orthodontics for me. Final tooth posi-tioning was extremely important and wetried our best to get great finishes. Bythen we were seeing most patients ona 6-week interval. Full treatment timehad dropped to 18 to 30 months in 25to 50 appointments.

What was happening during the 1980son the practice management front madeclear to me, perhaps for the first time, thesynergy between clinical and personalexcellence. By 1980, I had a huge staff of23 and we were seeing up to 110 patientsper day. My staff and I were continuallystressed and, by the end of most days,so exhausted that we were useless to ourfamilies. And we were starting fewer casesper month than we start today.

In the mid 1980s, I transitioned fromclinical practice in Reno, Nevada, to full-time practice management consulting.In evaluating hundreds of practicesthroughout the United States, I saw thatmy experience with a stressful, loadedschedule was a pattern that was beingrepeated in offices around the country.With this expanded scope, I could

clearly see the tremendous cost ofclinicalinefficiency on managing an orthodonticpractice and, in turn, on clinical andpersonal excellence. What I found wasthat clinical efficiency, or the lack thereof,dictates most of our management chal-lenges. The paradox was getting a high-quality finish in a reasonable number ofappointments.

Obviously, the more appointments it takesto treat each case, the more our workday

is jammed. Loading is a term I use to char-acterize this phenomenon. It refers to anyunnecessary or unplanned protocol thatadds time to an appointment or adds anadditional appointment to finish a case.But its the compounding effect that is sodevastating. When you load just a fewvisits per case, you add thousands ofappointments to your schedule each year.And it takes only a few unnecessary loadsper case to create chaos. Lets do the mathIts not uncommon for me to see doctorstoday add 6 to 10 unnecessary appoint-

ments per case. In a practice with 400active patients, that equates to 2,400 to4,000 more appointments that one shouldnot have to deal with. The load alonetakes a medium-sized practice and makesit a big practice, not in terms of revenuebut in terms of activity a practice muchharder to manage. We all talk about howmuch emergencies load the schedule, but

Orthodontic Finishing: A

O

by Thomas R. Pitts, DDSReno, Nevada

Dr. Tom Pitts received his undergraduate dental educa-tion from the University of the Pacific, School of Dentistryand his orthodontic specialty training from the Universityof Washington. He served in the Army Dental Corpsbetween 1966 and 1968 and began in private practicein Reno, Nevada, in 1970. Dr. Pitts is the founder of thewell-respected Progressive Study Club and did full-timeconsulting in orthodontic practices around the UnitedStates for many years, returning to private practice in1990. He lectures throughout the United States on clinicaland practice management efficacy.

* Herbst is a registered trademark of Dentaurum.

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New Model of Economy

case continued on page 5

Case 1 - Pretreatment Adult male, Class I crowded with narrow posterior arches.the real menace are dozens of little stepsthat doctors take each day that are neverthought of as extra. Oftentimes theseadditional steps are a result of things wedont do early in treatment that cost us alot of time later. Individually theyre justlittle things that we do; collectively theyrea capacity stopper, a growth blocker anda threat to our health and the health ofour practices.

Once the cycle begins, it is exacerbated

of its own accord. But if we dont load theschedule, we have more time for patientson each visit to create a better finish.When you are crazily seeing patients in arushed manner, you often cant do every-thing you want to do that day, so youappoint them to return in 2 to 3 weeks.This further jams the schedule. The snow-ball effect has begun. Additional appoint-ments require more staff, more space andresult in more stress. They require morepractice days and drive our receptionistsnuts trying to figure out a schedule that

works. Nearly all the practices I analyzeare seeing many more patients per daythan is necessary. Everybody suffers theconsequences, including the patient.

We all know that the less time braces areon a patients teeth, the better the peri-odontal response, the better the enamelhealth and the better it is psychologicallyfor the patient. With an appreciable num-ber of unnecessary appointments per case,we get into overtime treatment. If treat-ment is extended and the patient getstired, our chance of producing a beautifullyfinished case diminishes significantly.

By the time I transitioned back into ortho-dontic practice from consulting in 1990,my philosophy of treatment had broad-ened even more. This philosophy specifi-cally took into account the negativeimpact that clinical inefficiency was

continued on following page

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Dr. Pittscontinued from preceding page

4

having on our ability to achieve high-quality results. Efficiency, then, and evencomfort had taken a higher position in thehierarchy of elements that defined quality.Because of them, I felt compelled to startdoing my own research about how toincrease the percentage of high-qualityfinishes while decreasing the time andnumber of appointments, especially sincewe were now getting the tools to makeit a reality. Nickel titanium wires andsprings helped decrease treatment time

and increase comfort. We had the fixedHerbst therapy from Terry Dischinger(Lake Oswega, Oregon) to addressClass IIs. Dwight Damons (Spokane,Washington) passive self-ligating bracketwas now being developed and I couldsee a phenomenal difference in what thattechnology could provide, dramaticallydropping necessary appointments andoverall treatment times while improvingthe response in the periodontium.

During the five years we have been using

the Damon system in our practice, wehave systematically identified many proto-cols that could be combined with othersor eliminated altogether to reduce thenumber of appointments to finish a caseand finish with beautiful results. I referto this process as unloading. Throughthis re-engineering, we have reducedthe number of visits per case by 8 to 10,saving thousands of appointments eachyear. With the Damon appliance, we seeonly 45 to 55 patients a day with a man-

ageable staff of 9, starting approximately40 cases each month. We treat nonextrac-tion cases in 6 to 16 months in 6 to 14appointments. Moreover, I feel that myfinished tooth positioning is better thanits ever been. Each month we make treat-ment more economical in terms of savingappointments. Now, in the first decadeof this new millennium, we have thetools and the experience working withthese tools to create great finished results

and achieve the highest level of patientcare that includes efficiency and comfort.It has allowed me to put into effect ournew practice model (Figure 1). Its beensuch a wonderful experience using thefully programmed Damon SL bracket.I get full initial wire engagement andkeep it throughout treatment. This givesme wonderful control to finish accuratelyand efficiently.

The Damon System: The Foundation for our

New Practice ModelThe Damon System is the foundationfor putting our new model into practice.Dwight Damon and I had long talkedabout how a passive self-ligating bracketsystem could be highly instrumental inreducing treatment time and visits whileincreasing comfort as long as it did notgive up any of the benefits of Straight-Wire. In fact, I like the Straight-Wirecharacteristics in this bracket better thanany other Straight-Wire bracket Ive everused. I believe these characteristics are

enhanced by the archwire slot closingto form a complete tube on each tooth(Figure 2). As Ive observed other practicesusing the Damon technique, though, Ivenoticed certain ways that some practices,especially in the early stages of using theDamon system, load time and entireappointments, which we have eliminated.The most common mistakes that loadappointments are protocols that areeasily changed without changing overallmechanics (Figure 3). In fact, the best

news about the Damon system and thisnew model is that employing it doesntrequire any major change in the mechan-ics just refinements of technique refinements that can be used to get greatfinishes with enhanced patient comfortand in less time than conventionalsystems. Its some of these refinementsof technique that I will share with youin the remainder of this article.

Figure 1.

continued on page 6

Figure 2. The Damon bracket archwire slot closesto form a complete tube, enhancing its Straight-Wire characteristics.

Figure 3.

Our New Practice Model Exceptional, Economical Finishing Fewer Appointments per Case Less Time per Adjustment Fewer Appointments per Day Greater Patient Comfort More Communication with Patient per Visit More Energy for Doctor and Staff Less Distress Happier, More Cooperative Patients Less Decalcification Better Bone and Tissue Response Better Control of Teeth

(because wire is always engaged) Simplicity of Mechanics Better Periodontal Response Easy to Market (because patients love it)

Most Common Mistakes that LoadAppointments Starting Treatment Too Early Improper Bracket Placement Bond Failures

Not Bonding Each Tooth at the InitialAppointment, Especially Second Molars

Not Using Differential Torque on UpperAnteriors and Cuspid Brackets

Starting with an Initial Wire Heavierthan .014 Nickel Titanium

Lack of Cooperation with Finishing Elastics Not Using Stainless Steel Wire to Finish Inadequate Staff Training on

Opening/Closing Damon Brackets

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Case 1 - Midtreatment (continued from page 3)

10 Months into Treatment. The case is nearingits Class I finish in .019 x .025 Damon stainlesssteel wires and frontal and lateral finishingelastics.

4 Months into Treatment. The bite buttons on theupper centrals opened the posterior bite slightly.At this point, we repositioned 4 brackets.

Posttreatment Having reached a beautiful occlusion in only 7 appointments speaks to the unloading process.

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Unloading the Schedule:Appropriate Treatment TimingIt has been my experience that mostpatients attitudes about braces take a dipafter 12 to 14 months of treatment. Thisgives us a small window of patient coop-eration. If you waste appointment time,you have to work harder to keep enthusi-asm and compliance at a high level.Knowing that this window is small, Iprefer to start as many full-treatment casesas possible only after the second molars

erupt. I do so unless there is an unusualsituation such as an impacted tooth thatI want to assist. If you feel you must begintreatment early, start with a partial appli-ance such as an expansion appliance, a lipbumper or nighttime extraoral applianceand charge for it. With an impacted tooth,you can use a partial extension from apalatal arch or a bonded molar (again,charging for it) while you are waiting forthe second molars to erupt.

Accurate Bracket Placement & BondingIf you take only one idea from this article,let it be this: make bonding and precisionplacement of brackets your number onedoctor-time priority. There is no otheraspect more critical to a quality finish thanthe initial placement of brackets. You onlyget one chance at tooth preparation andbracket placement. I consider it the mostimportant doctor time spent in treatment.Inaccurate positioning is one of thebiggest loaders of extra visits how manydepends on the number of errors, but my

best guess would be a load of 2 to 10appointments.

I spend more time in the bonding processtoday than I ever did, but those extra fewminutes per case pay big dividends. Wedirect bond in our practice because I placesome bracket pads underneath the gingi-val tissue. (Indirect bonding works wellfor some doctors, but I have not found itto be advantageous in our practice.) Even

if I pumice, recontour, condition and sealthe arch myself, I can complete one fullarch in fewer than 10 minutes. If I dele-gate the preliminaries and only place thebrackets, it takes me 7 or fewer minutesper arch. If I take those critical 20 min-utes to do all the prep work myself, I amassured that each tooth is finely prepared.I realize that I am going against so-calledmodern convention by performing thisprotocol myself and in using 4- to 6-handed dentistry, but the results warrant

it, and losing bonds during treatment canload 4 to 5 appointments.

As Dwight Damon recommends, I uselong cotton rolls rather than cheek retrac-tors in the bonding process for greaterpatient comfort and to get a better visualfield (Figure 4). I have an assistant holdthe side opposite where Im working sothat no saliva touches the crown surfaceand I can get direct access (Figure 5). Toensure accuracy, I also recommend magni-fying glasses (Figure 6) and (at the sugges-tion of Dr. Louis Anderson in Katy, Texas)a large 2-inch front-surface mirror whilebonding (Figure 7). This mirror creates alarge picture of the occlusal view of eachtooth, which helps keep the occlusal partof the pad touching evenly on the labialsurface of the incisors as well as makingsure that the bracket is placed exactly atthe height of contour and/or parallel tothe central groove (Figure 8). Perfectingyour placement technique is a must.

Pearl.Its a common error to have themesial/incisal part of the bracket slightly

away from the tooth, which will rotate im-properly and cost appointments (Figure 9).

Direct Bond All Teeth at InitialBonding. Thanks to the encouragementof Dr. Mike Steffen, Edmund, Oklahoma,I bond every tooth at the initial bondingeven if Im not going to engage particular

Dr. Pittscontinued from page 4

Figure 4. Long cotton rolls offer greater patientcomfort and better visual field.

Figure 5. Assistant holds side opposite fromwhere I work for better access.

Figure 6. Magnifying glasses ensure greateraccuracy when placing brackets.continued on page 9

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Figure 9. A common error is placing the mesial/incisal part of the bracket pad slightly away fromthe tooth, which will rotate teeth improperly.

Figure 7. Comparison of large 2-inch mouthmirror versus smaller one.

The first thing I would recommendwhen youre just learning to use theDamon brackets is to be sure you cansee the bracket clearly. If you under-stand how its parts fit together, youcan tell the difference between thedoor of the bracket and the bracket

itself, which will help you consider-ably. If your doctor uses magnifyingglasses, borrow them when yourelearning how to open and close thebracket. You can also use a typodontto practice. Of course, you know thatyour experience with a typodont willbe a little different from what youllexperience when you open and closethe bracket in a patients mouth. Afteryou and other staff members practicewith a typodont for a while, the brack-ets will open and close quite easily.

The brackets that will be in a patientsmouth will be a little stiffer to openand close a good thing consideringocclusal forces. Another tip: when yourebond a bracket, be sure that there isno sand left from the microetching thatcould jam the door. Yes, the Damonbracket is a little more intricate thana regular tie bracket, but youll soonmaster it and be happy that you did.

Opening the Damon SL BracketThe Damon SL brackets open downward.

The upper brackets open toward the incisal/occlusal edge; the lower, toward the gingiva.To open, hold the Damon Opening/Closinginstrument with the tips of the plier at a slightupward angle (roughly 45) with a bottomnotch of the plier resting on the bottom ofthe door of the bracket. When the bracketis open, its door covers the bracket housingand the wings. By angling the plier, it catchesonly the door. If you hold the plier at a 90angle or straight on, the plier will catch thedoor and bracket housing and will notbudge. Using only a light finger action,pull the door down with the plier. No wristaction is necessary.

Closing the Damon SL BracketTo close the Damon SL, do the reverseof opening it. Hold the Damon Opening/Closing instrument with the tips of the plierat a slight downward angle (roughly 45)with a notch of the plier resting on the topof the door of the bracket. Using only alight finger action, lift the door up with the

plier. No wrist action is necessary.

If the door is jammed, move your plier to theoutside edge of the door, again tilting theplier downward so you dont catch the wing.Using only a light finger action, lift the doorup with the plier. No wrist action is neces-sary. I also find it advisable to open andclose the cuspid brackets at the outside edgesof the door. Move back and forth from oneside of the door to the other in a teeter-totteraction until the slide is completely openedor closed.

Patti York has been in the dental field for18 years, 2 years as a dental assistantand 16 years as a clinical orthodonticassistant. She also handlesall ordering, tracingcephalograms and

fabricating Herbstappliances forthe practice.

Figure 8. Large 2-inch surface mirror aidsprecision placement.

Staff Member Comments

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Case 2 - Pretreatment Adult female,Class II, division 2, with deep bite.

Midtreatment 11 Months into Treatment.The case was nearly finished at this point, butbecause I had initially bracketed the case 6 x 6,it took 3 more appointments and 6 more monthsto finish the case.

Dr. Pitts

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teeth at that time. Pick-up bonding costsvaluable appointment time and loads theschedule. (Remember: like things at liketimes.) Another thing that makes treat-ment more comfortable for the patientand saves time is direct bonding first andsecond molars instead of using bands.With no separators to place, no bandsto size and cement, no band spaces toaccount for at debanding and no

debanding, we unload 1 to 2 appoint-ments per case.

We dont extend the first wire to thesecond molar to preclude it from comingout of the second molar tube while thepatient is chewing. We go back to thesecond molar at the next appointmentwhen we get into the .016 x .025 heat-sensitive wire. If weve already bracketedthe second molar, weve saved time thatnext visit. In an extraction case, we endall wires at the first molar until spaces are

closed, then pick up the second molar-with an .018 x .025 heat-sensitive wire.The bracket is there ready for us whenwe need it. Ive found that by bondingsecond molars at the initial bonding, weunload at least 3 appointments overall.Case 2 demonstrates the additional timeit costs to leave second molars unbracketeduntil later in treatment.

Posttreatment

continued from page 6

I would encourage staff memberswhose doctors are considering a changeto the Damon system to learn as muchas they can about it, to get a real under-standing of its benefits and becomeeducated about the mechanics. Westaff members, too, get set in our ways.And, heck, change is scary, but youcouldnt pay our clinical staff enoughmoney to go back to conventionallytied brackets. And when you can treatpatients with less discomfort in shortertimes with fewer appointments, whywouldnt you want to offer yourpatients these advantages? Especiallywhen you experience what we havein not seeing the same number ofperiodontal problems, nor the samelevel of decalcification.

When youre first learning to open andclose the bracket and they pop off thetooth, you may have a tendency towant to blame the bracket. Patty Yorkalready shared her foolproof techniquesfor opening and closing the Damonbracket. What I suggest is to rememberhow long it took you to learn to tiebrackets. Believe me, learning to usethe Damon bracket is easier and quicker,

and when you consider what you andyour patient will gain in the long run,its well worth the effort.

Those of you involved with orderingfor the practice and staying within acertain budget may get hung up onthe cost of the bracket, but if you stepback and look at the bigger picture,factoring in the shorter treatment timesand fewer visits, it doesnt take a rocketscientist to see that the cheaperbracket is actually more expensivein the long run.

Joni Beedle has 30 years of experiencein orthodontics as aclinical assistantand treatmentcoordinator. She

has conductedpresentations onpractice manage-ment and clinicalefficiency to staffand doctors in theU.S. and Canada

for the past13 years.

continued on page 11

Staff Member Comments

This result took 18 months instead of 11 becauseI had not bracketed the 2nd molars initially.

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Dr. Pitts

Case 3 - Pretreatment Adult male witha slightly anterior open bite, very narrow upperarch and a crossbite on the right side.

Midtreatment I had bonded 2nd molarsfrom the beginning, used tongue remindersand posterior crossbite elastics for a short time.Repositioned 3 brackets after 4 months oftreatment.

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Posttreatment Finished case in 15 months and 10 appointments.

Bonding with a Tight CoronoidProcess. I can generally bond 7 x 7 atone time but we find that sometimes inthe upper arch, the coronoid process istight and the mouth small, so I bond6 x 6 and then bond the 7s separatelywith the jaw moved out to the side. Thepoint is, we get all the teeth bonded atthe bonding appointment.

Bonding in Deep Bites. For deep bites,using built-up composite bite buttons(usually on the upper anteriors) can

unload 2+ appointments because no

pick-up bonding is necessary and level-

ing occurs more quickly (Figure 10 onpage 12). We also use composite bitebuttons on asymmetrical cases and inopen bites. I attribute my introductionto bite buttons to Dr. Karl Nishimura,Tustin, California.

Ensure Bond Strength with Good Productsand TechniquesBond failures cost appointments and canload 2 to 6 appointments per case. Itsmy contention that many bond failuresoccur because assistants place brackets


continued from page 9

The most commonmistakes that loadappointments areprotocols that areeasily changed

without changing

overall mechanics.

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throughout an entire arch and then waitfor the doctor to reposition them beforelight curing. By that time, ambient lightalone has begun to cure the adhesive andrepositioning at that point breaks theinitial polymerization that can eventuallyresult in failure. Reclaiming the bondingprocedure eliminates this problem.

Im very excited about Ormcos newsealant and bond enhancer, Ortho Solo.Ormco has added all the right ingredients

to enhance bond strength, includingfluoride release and a proprietary materialfor quick drying. It also has glass fillerthat gives it structural properties andadded strength. I bond 5 x 5 withOrmcos light-cure adhesive, Enlight, andIm extremely pleased with its viscosity,strength and ease of clean up. I use aheavier light-cure adhesive (one of 3Msgeneral dental products P-50 universalpaste) on molars. Prior to placing theadhesive on the molars, I lightly paint amultipurpose bonding primer on the pad

so the adhesive can be squeezed into themesh. I feel that this procedure givesgreater bond strength to the molars, yetmakes it still relatively easy to debond.

Use Differential Torques to Compensate

for Treatment MechanicsI use differential torques on the upperand lower cuspid brackets, dependingon the starting tooth proclination andexpected treatment pressures. This keepsthe canine root from bumping up againstthe buccal plate, which will slow treat-ment and elastics correction. It also looksmore aesthetically pleasing to have up-right canines and not too much lingualcrown torque. If upper cuspids are flaredlabially, I use -7 torque; if toed-in, +7;if upright, 0. I use two torques for the

lower cuspids for the same reasons: iftoed-in, +7; if upright, 0. I do the samething with upper centrals and laterals.If proclined, I use +7 torque on centrals

and +3 torque on laterals. If retroclined,

I use +12 or +17 torque on centrals and+8 or +10 torque on laterals. For thesame reason, Ill use -10 torque onmandibular molars. A number of ourtreatment mechanics, including finishingelastics, negatively affects torque on thecuspids and upper anteriors. I like toovercompensate by using these differenttorques at the beginning of treatment,saving many appointments when finish-ing. I preselect torques when workingup the case so that an assistant can pullthe proper torques when setting up the

bonding tray. I will also add torque tothe first stainless steel wire to speedmovement and keep molars uprightagainst elastic pressure.

Figure 10. Using composite bite buttons in deep bite saves 2+ appointments. Figure 11. On a severely malaligned tooth, I place a single-wing bracket,Attract, tie in an .014 SE wire and use an active open-coil spring.

If you take only one idea from thisarticle, let it be this: make bonding andprecision placement of brackets your

number one doctor-time priority.

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Light Forces for Arch Form, PrecludesDumping, Aids ComfortWhen first using the Damon system,many doctors have a strong urge to startcases with larger archwires than is advan-tageous. They do so because theyre usedto tying in brackets with more friction.Because of the lack of friction in theDamon bracket, it is extremely importantto begin with very light forces. WhatDwight Damon and I found is thatpatients teeth actually move more quickly

with lighter wires (.012 or .014 nickeltitanium wire) in the beginning stages,probably as a result of leaving more oxy-gen in the PDL and not overpowering themusculature of the lips and face. We seeearly tooth movement with these forcesover the first 8 to 10 weeks and lessproclination of the lower incisors duringthe leveling process than with conven-tional brackets. We also get full bracketengagement on every tooth unless its anextremely crowded case where theres noroom for a full Damon bracket. In such

cases, I always bond severely malalignedteeth at the initial bonding using anAttract single-wing bracket. I then par-tially engage the wire into the bracketusing an ultra-light active, open-coilnickel titanium spring (Figure 11).It is my rule never to use an activeopen-coil spring on a light wire unlessthe malpositioned tooth is tied into thewire; otherwise it will move the otherteeth too far labially. I will then bond afull Damon bracket at the repositioning

appointment. See the Damon SL WireProgression chart (Figure 12) on page 14.

Noncompliance AppliancesI ascribe to Dr. Terry Dischingers philoso-phy of getting molars to a Class I occlu-sion through a fixed Herbst appliancebefore going into full braces. If usingelastics, its critical to get patients towear them 24/7. I instruct patients not

Clinical Impressions Live!Continuing Education Seminar Series

A Conservative ApproachTo Radical Change

It used to be that, by definition, good

orthodontics meant a lot of tweakingand a successful practice meant man-aging a large staff and seeing 100-120patients a day.

Whats so exciting about the Damonsystem is the opportunity it offers toestablish a new model by which wedefine success high-quality resultswith improved patient comfort infewer appointments and shorteroverall treatment times than withconventional brackets. And while it

requires only minimal adjustment totraditional treatment mechanics, itsadvantages are many. First, theres theconvenience of self-ligation thatmakes it a hit with staff no moretedious tie-ins. Archwire changes takeonly minutes. Second, theres the useof light-force wires in a virtually fric-tion-free system that Dr. Damon feels

allows low-force wires to operate

at peak expression, thereby stimulat-ing more biologically compatibletooth movement and promotinggreater efficiency and comfort.Third, doctors around the countrywho use this bracket all say the samething that it has reshaped theirreferral base from dentists to patients,an enviable position to be in.

If Dr. Pitts discussion of the Damonsystem has piqued your interest tolearn more about it, register now for

one of the three limited-attendanceseminars. In these seminars youllhave the opportunity to discuss face-to-face what the Damon self-ligationsystem can mean to your practice.For course details and to register on-line, go to www.ormco.com/seminarsor you may contact Meredith Brick at(800) 854-1741, Ext. 7573. 7 CEUs.


Drs. Tom Pitts & Dwight DamonSept. 15, 2000Newport Beach, CA

Dr. Dwight DamonNovember 10, 2000, Washington, D.C.& April 23, 2001, New Orleans, LA

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to remove their elastics even to eat,telling them that if they dont eat withtheir elastics in place, it will cost themat least six months in extended treat-ment. If youve unloaded the schedule,youll have additional motivational timewith each patient to work toward thatelastic-wear commitment.

In the final elastics stage, we turn owner-ship of the remaining treatment time topatients and tell them, Johnny, the time

you have remaining in braces is now upto you. Every hour that you dont wearyour elastics can prolong your treatmentindefinitely, so you now control howmuch longer youll be in braces. Sincewe measure overjet each appointment,we can demonstrate to the patient theirlack of compliance. If I see evidencethat the patient has not been wearingthe elastics, I place fixed springs(Figure 13) or a Bite Fixer as early as

the first return appointment after weveplaced the elastics.

ConclusionOur new model has given us more choicesin how we manage the practice. If wewant to grow the practice, we can use thetime weve gained through unloading tostart more patients with the existing staffand doctor time. We can choose to workfewer days and see fewer patients eachday. The point is that the choice is ours.

As word gets around, more and moreadults are seeking treatment to touch upmalpositioned teeth and create a beautifulsmile with our arch form. They are morewilling than ever to go into treatmentbecause we can get good results so quickly.We, of course, cant expedite every casethe way wed like to, but we are makinggiant strides in this process. Extractioncases in our practice take an average of3 more visits than nonextraction cases.Herbst therapy takes an additional 4appointments. Difficult impacted teethseem to take an additional 8 visits onaverage. Knowing this helps us chargefees accordingly.

I take my hat off to Dr. Dwight Damon forhis innovation of the Damon appliance.Quality comes first; economy second.In order to be economical, we must focuson the number of appointments to treateach case and keep tracking appoint-ments. We must go into each treatment

by beginning with the end in mind. Wemust visualize the beautiful finish andplan accordingly. We cant piddle around.

Also, we will not take the braces off untilweve got the best finish we can get forthat particular case. My hope for ourprofession is that case finishing is donemore quickly and gets better and thatpractitioners can lessen the chaos, stressand confusion in their everyday lives.

Figure 12.

Damon SL Wire ProgressionEXTRACTION

MAXILLARY MANDIBULARArchwireChange Size Type Size Type

1 .014 Align SE .014 Align SE

2 .016 x .025 Align SE .016 x .025 Align SE

3 .019 x .025 Damon SS .018/.019 x .025 Damon SS

NONEXTRACTION

MAXILLARY MANDIBULARArchwireChange Size Type Size Type

1 .014 Align SE .014 Align SE



4 .019 x .025 Damon SS .018/.019 x .025 Damon SS

Figure 13. Fixed springs work well when patientsare lax in elastics wear.

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Curing Lights: An Overviewby Joe H. Mayes, DDS, MSDLubbock, Texas

hen lasertechnologywas firstdevelopedfor the dentalfield, I wasimpressed bythe claims ofhow fast itwould curelight-curedadhesives.

Despite thecost, my payback analysis (given the time-savings) warranted my buying severallights, and I urged Ormco to considerexploring the possibility of distributinga laser light product. Since I was fairlycertain of the advantage of laser technologyover plasma arc technology (PAC) andconventional lights, I volunteered to testthree types of lights in my practice andreport my findings and recommendations.The units I tested were the LaserMedAccucure 3000, the Apollo 95E PAC

light from DMD and the DemetronOptilux 501 prototype curing light withthe special 80 watt tungsten/quartz/halogen OptiBulb. Interestingly, afterplacing hundreds of brackets using eachof the three types of lights in direct andindirect bonding, I can fully endorse theDemetron Optliux 501 conventionalcuring light. Compared with the other

options, it is reasonably priced, compatiblewith all light-cured adhesives, easy tomanipulate, highly portable and exhibitsnearly comparable curing times. SeeFigure 1 for my comparative analysis.

Features of Plasma Arc (PAC) LightsThe United States National Aeronauticsand Space Association (NASA) developedthe original plasma arc technology. Thislight source is fairly new to orthodontics.Two electrodes with a large voltage poten-tial ionize a gas (xenon plasma) that emitslight (Figure 2). The plasma arc bulb

W

Dr. Joe H. Mayes, a native of Crane, Texas,

received his B.S. from Texas Tech University,followed by his D.D.S., M.S.D. and certificatein orthodontics from Baylor College ofDentistry. Dr. Mayes is engaged in the privatepractice of orthodontics in Lubbock, Texas,and has been actively involved in new productdevelopment.

Figure 1.

Figure 2. The Apollo 95E plasma arc curing lighfrom DMD proves to be good for direct bondingbut ineffective for indirect. Its cost is also high,beginning at $3,500 U.S.

Curing Light ComparisonPAC Laser Optilux 501

Noise Yes Yes Some

Heat Yes Some None

Portability Low Low High

Hand Controls Extra $ Extra $ Yes

Refractory Period Yes No No

Ramp Mode for Indirect Ineffective No Yes

Aesthetic Curing (in seconds) 3 3 5

Metal Curing (in seconds) 5 5 8

Direct Bonding Excellent Excellent Excellent

Indirect Bonding Fair Excellent Excellent

Cost $3,500 U.S. $6,000 U.S. $1,500 U.S.(and up) (and up) (and less)


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generates considerable heat and thereforerequires a large fan to cool it during andafter each burst of light. This fan is, inpart, responsible for the noise and thecumbersome size of the unit. While thefan cools, there is a delay (refractoryperiod) before you are able to activate thelight again, making the PAC light ill-suitedfor indirect bonding where speed in mov-ing from bracket to bracket is paramount

to efficiency.

The PAC light produces a high-intensity,limited spectrum light that is filteredto blue light in the range of 460-490nanometers. While some PAC lights offera step-cure mode, the starting milli-wattage (mW) is too high at the initialburst of light (400+ mW), cancelingthe advantages of using a step-curingcycle. Most PAC lights use foot pedals

to operate, although hand controls arenow available for many units at an addi-tional cost. The hand controls require youto press a button with your index fingeras you point the pen tip from the incisal/occlusal edge to initiate the cure. The penis not as easy to operate as the gun designof conventional curing lights, but moreimportantly, it is difficult to sterilize. Youcan wipe it down with a glutaraldehydesolution, but it cannot be autoclaved andthere are no protective sleeves designed to

fit it. Covering it with standard protectiveproducts reduces its output. PAC lightscan burn soft tissue if the tissue is leftexposed to it for standard curing timesrecommended by adhesive manufacturers,so caution must be exhibited.

I have found that the curing time for PAClights is 5 seconds under metal bracketsand 3 seconds under clear brackets. Thecost of PAC lights starts at $3,500 U.S.

Features of Laser LightArgon ion lasers (light amplification bystimulated emission of radiation) emit amonochromatic coherent light in wavelengths that cover that blue light regionof the visible light spectrum (457-502nanometers) (Figure 3). Like PAC lights,laser lights require a large fan to cool theirbulbs and are therefore noisy, cumber-

some and less portable than conventionalcuring lights, but there is no refractorytime, making lasers an excellent choice forindirect bonding of multiple brackets inquick succession. In 10-second bursts,they have been shown to decrease thesolubility of enamel in acid while at thesame time increasing fluoride uptake.The mechanism is not clearly understood,but it could help reduce or eliminatedecalcification.

Lasers emit a highly collimated beam ofphotons that can travel long distanceswithout dispersing, so most lasers featurea dispersive tip to diffuse the light. The tipof the laser that comes in close contactwith the bracket and self-cured adhesiveis the size of a thin pen and cures byplacing the pen at the incisal edge of atooth in direct bonding. The pen and its

micro-fiber tip suffer from the samesterilization problems as the PAC light,although there is a small plastic steriliz-able extension available for an additionalprice (Figure 4). In addition, most lasercuring units are activated by a foot pedalthat, while effective, seems less intuitive tooperate than the familiar gun design ofconventional lights. Another disadvantageis that dental assistants may not beallowed to operate a laser in some states.

Figure 3. The LaserMed laser curing light provesto be good for both direct and indirect bonding,but the price starts at a hefty $6,000 U.S.

In the study I conducted on bond failures, Iused each of the lights for 20 cases of indirectbonding and 20 cases of direct bonding (400brackets per light). The three types of lights

compare favorably with one another in termsof bond failures.

Bond Failure ComparisonA 6-Month Trial

Number of Bond FailuresDirect Indirect

PAC 1 4Laser 0 2501 1 2

Dr. Mayescontinued from preceding page

The OptiBulb wasspecifically designed

for curing and,unlike other halogen

bulbs will notdegrade with time.

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I have found that the curing time for laserlights is 5 seconds under metal bracketsand 3 seconds under clear brackets. Thecost of laser units starts at $6,000 U.S.

Features of the Demetron Optilux 501 LightThe Demetron Optilux 501 curing lightwith its 8 mm Turbo+ light guide (Figure 5)is a conventional curing light equippedwith a special curing bulb. The OptiBulb

was specifically designed for curing and,unlike other quartz/halogen bulbs suchas youll find in standard 35 mm slideprojectors, will not degrade with time. Itis also optically focused by the light guide,providing uniformity of cure throughoutthe entire diameter of the tip. It emits afull-spectrum light that is filtered to a bluelight with a range of 400 to 505 nanome-ters. This specially designed filter preventsexcess heat buildup so that the unit canrun continuously. Its intensity at specific

wavelengths is increased for maximumabsorption of the photo initiator in mostlight-cured adhesives, which is the reasonOrmco can guarantee it to work with alllight-cured adhesives on the market. Itsfan is quiet and the unit quite portable no larger than its predessor design (theOptilux 500), which fits easily at eachchair. Its distinctive gun design makesit easy to use. It cures under metal brack-ets in 8 seconds and under clear brackets

in 5 seconds. Its cost is approximately$1,500 U.S. 40% of the cost of PAClights and 25% of the cost of laser lights.

Boost Mode for Direct Bonding andRebondingThe Optilux 501 offers a number of out-put modes, including Boost and Ramp.The Boost (B) mode outputs filtered lightin excess of 1,000 mW/cm2 in 10-secondcycles. This mode is ideal for both directand indirect bonding and for rebonding

loose brackets. I treat loose bracketsmuch like indirect bonding. We lightlymicroetch the bracket, treat it withReliance Plastic Conditioner, and rebondit to the tooth using the same adhesiveas in the initial bonding. We would, ofcourse, have first acid-etched the toothand used a sealant. Ormcos Ortho Solo

is an excellent combined product, consist-ing of a filled sealant andbond enhancer. Whenindirect bonding, I donot cure the sealant

before the tray is placed.In direct bonding, Icure the sealant beforeplacing the bracket.

Ramp Mode for IndirectBonding in the LabOne of the chiefadvantages of the 501is the Ramp (R) curemode that rampsexponentially from100 mW/cm2 to 1,000mW/cm2 in the first 10seconds and remains over1,000 mW/cm2 for thelast 10 seconds. Thelower output reducesthe number of and rateat which free radicals form(which initiates the polymerization), andthus slows the initial reaction rate. Thisallows the composite to flow for a longer

time to accommodate the 2-5% volumet-ric polymerization shrinkage in the pasteas it reaches the gel (hardened) state.The ramp mode is therefore ideal forcuring custom bases while doing indirectbonding in the lab, helping to reducethe microfractures that occur as the cureprogresses.

ConclusionThe Demetron Optilux 501 curing lightaddresses virtually all the problems asso-

ciated with the more expensive PAC andlaser curing lights. Unlike those lights,it has the mode for any curing assign-ment: traditional, ramp, boost or bleach.There is no need to change technique,

it cures all adhesives and the curingtimes are comparable. Given its priceversus other curing lights, I consider itan excellent value.

17

Figure 4. The LaserMed laser light is availablewith a sterilizable plastic extension for anadditional price.

Figure 5. The Demetron Optilux 501curing light proves excellent for bothdirect and indirect bonding and its priceis a reasonable $1,500 U.S. or lower.

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Hyperefficient Orthodontic Treatmeby James J. Hilgers, DDS, MS, Mission Viejo, Californiaand Stephen G. Tracey, DDS, MS, Upland, California

he term hyperefficientorthodontic treatmentdescribes a broad spec-trum of technology andtreatment advances thatresult in a highly profi-cient, predictable andnoncompliance approachto the correction of ClassII malocclusions. It reliesheavily on traditionalBioprogressive principles.

When developing theBioprogressive approach to orthodonticmechanotherapy, Dr. Robert Rickettsproposed a technique that embracescontinual change and evolution. To fosterunderstanding of this approach, Rickettswisely proffered a set of principles toguide clinicians in treatment decisions.He did this in preference to publishing atreatment cookbook, which connotes anunacceptably rigid approach to therapy.1

These principles are as profound andapplicable today as when first advocated.

The combined words bio andprogressiveembody his original intent that thisapproach not only adhere to biologicalprinciples but also be progressive andopen to scientific betterment. The maximtechniques change; principles remain con-stant is an apt description of the visionRicketts first endorsed for his flexibleapproach to orthodontic therapy. Thepurpose of this article is to demonstratehow the Principles of BioprogressiveTreatment (Figure 1) are called into play

in today's hyperefficient orthodontic treat-ment. These principles are demonstratedin two cases. See Case 1 on page 22 andCase 2 on page 24.

Principle: Any tooth can be moved in anydirection with the proper application of force.Many orthodontic disciplines focus moreon what orthodontists cannot or shouldnot do rather than on what is possible. Acase in point is the strong admonition

against attempting to distalize molars.The Pendulum appliance has proven tobe successful in distalizing molars inClass II malocclusion when case selectionis appropriate.2 In most Class II malocclu-sions there is also arch form incongruitybetween the upper and lower arches,necessitating expansion of the upper arch,ideally occurring prior to the Class IIcorrection.3 This is true for both nonex-traction and extraction Class II cases. ThePendulum appliances focus on this need

for creating arch form symmetry by distal-izing the molars and expanding the archwith one appliance. The latest iterationin this family of appliances is the Ph.D.appliance, a Pendulum Hyrax distalizer,that has been used to expand the upperarch and effect rapid distal movementof the upper molars, using the upperdentition for anchorage.

Dr. Jim Hilgers focuses on ideas that can beused in any practice, regardless of size or ther-apeutic bias. He holds numerous patents withinventions on display at the Smithsonian andreceived a gold medal for an educational CDfrom the New York Film Festival. He receivedhis D.D.S. from Loyola and his M.S.D. andcertificate in orthodontics from Northwestern.He has been in private practice in MissionViejo, California, for 30 years, written over80 journal articles and lectures internationally.

Dr. Steve Tracey combines innovative yetprudent orthodontic mechanics with a belief inthe limitlessness of our potential to create suc-cess. He has a practice in Upland, California,and serves as assistant professor at LomaLinda, where he earned his D.D.S. and M.S. inorthodontics and was named instructor of theyear in 1995. He has published several arti-cles and lectured in 13 countries all whilecompeting in the Ironman Triathlon, climbingMt. Rainier and trekking in the Amazon.

TFigure 1.

Principles of Bioprogressive Treatment

Any tooth can be moved in any directionwith the proper application of force.

Use new technology within the boundsof time and based on proven scientificprinciples to further simplify and improveBioprogressive therapy.

Use segmental mechanics where indicatedto sequentially unlock the malocclusion.

Unlock the malocclusion in sequences that

aid rather than inhibit treatment. Apply differential torque control

throughout treatment.

Treat overbite before treating overjet.

Employ overcorrection in both mechanicsand appliance design.

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The Ph.D. (Figure 2) is a hybrid appliancethat uses an occlusally bonded Hyraxexpander and .027 TMA PendulumSprings with full bracketing of the upperarch. Lingual sheaths are welded on thepalatal side of a Leone Hyrax expanderto attach the Pendulum Springs. Thesprings are activated to the midline beforecementing and placed into lingual sheathson the molars to deliver approximately175 grams of distal pressure. The upperarch is stabilized with sectional archwiresthat extend from the second bicuspidto the midline, allowing the maxilla tounlock. The Hyrax jack-screw is activatedslowly (1 activation per day) until ade-quate arch width is achieved. The amountof expansion needed can be reevaluated

and adjusted as the upper molars movedistally. Although there is some forwardmovement of the upper arch during themolar distalizing process, that movementis negligible and is a good tradeoff foreasier hygiene maintenance and the rapid-ity of molar distalization. It is also easilyoffset by the use of Class II elastics duringthe retraction process.

Principle: Use new technology withinthe bounds of time and based on proven

scientific principles to further simplifyand improve Bioprogressive therapy.Ongoing evaluation of the latest pread-justed bracket and terminal tube designsis fundamental to Bioprogressive princi-ples. Researchers continue to improve andsimplify bracket prescriptions. One thinghas become abundantly clear: the specificbracket prescription a clinician chooseshas as much to do with the philosophybehind the mechanics used as with theanalysis of static (untreated) ideal occlu-sions.4 The types and sizes of archwires

used, how the malocclusion is correctedand the importance of overcorrection allplay into the formula. A bracket prescrip-tion that is right for one clinician may betotally inappropriate for another.

The Bios prescription, developed byHilgers et al.,5 is the light-wire versionof Orthos* and is the result of the appli-cation of computer-assisted engineering(CAE) technology6 to a light-wire,high-torque technique. It represents theoutcome of a total reevaluation of oldassumptions about what constitutes bio-logically advantageous tooth movement.It reconciles the need for early torque con-trol with the use of light-force wires thatare more comfortable for the patient andelicit healthy and efficient periodontal re-sponse. With appropriate torque controlthroughout treatment and less depen-dence on full-size wires, we can relymore on function and less on dominance

mechanics to effect high-quality results.When more torque is required, it is avail-able in the bracket system; when lesstorque is needed, use of smaller dimen-sion archwires allow more play betweenthe walls of the bracket slots and thearchwires.

Terminal tubes, important to a fully coor-dinated bracket system, have had a ten-dency to be complex, oversized and cum-bersome. With the advent of Accent first

and second molar tubes, these issues havebeen resolved.7Accent buccal tubes areas small as casting technology allows andfunneled (six times normal wire entrysize) for easy wire placement (Figure 3).These small, nonconvertible tubesintegrate placement of buccal-segmentbrackets (and bands, if used) with secondmolars. In combination with super-flexiblewire alloys (e.g., Ni-Ti, Copper Ni-Ti),these tubes permit early engagement ofall the teeth, including second molars,regardless of the extent of malalignment

(Figure 4). Nonconvertibility eliminatespremature cap conversion, the need totie in the lower first molars with steelligatures, and the vertical tie-wings thata convertible tube automatically implies.

It is contrarian to suggest that noncon-vertible tubes be used on first molars, butthey do have certain advantages. They donot attract as much plaque, rarely causeocclusal interference and, being funneled,are easy to use in conjunction with resilientarchwires. For the practitioner whoprefers to use double archwires, Accentsauxiliary (gingival) tube has also beengreatly reduced in size. It has no torque orrotation (which can be set by the clinicianin the archwire) and is shorter than themain archwire slot. The overslung mesialportion of the tube thereby protects theauxiliary archwire from being deformedby the forces of occlusion.

19

Employing Bioprogressive Principles

Figure 2. Ph.D. immediately after cementationwith .027 TMA Pendulum Springs preactivated to

the palatal midline. Upper arch is fully bonded atplacement.

Figure 3. Accent tubes on both molars. Even an.0175 x .0175 TMA archwire can be extended tothe second molar due to wire flexibility and largetube entries.

* Orthos is distributed in Europe as Ortho-CIS.


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Drs. Hilgers & Traceycontinued from preceding page

Principle: Use segmental mechanicswhere indicated to sequentially unlockthe malocclusion.After using the Ph.D. appliance to distal-ize the molars into a slightly overcorrectedClass I occlusion, an .016 x .016 upperutility archwire used in conjunction withClass II elastics can provide the segment-ed mechanics to sequentially unlock themalocclusion. This archwire serves severalpurposes: (1) The step-up in its armsholds the distalized molar position, using

the anterior segment for anchorage. (2) Itfrees the upper buccal segments to beretracted to the distalized upper molars.(3) It offers a catch-point for Class II elas-tics that translate force back to the uppermolars through the buccal arm on theutility archwire. This protocol is funda-mental segmental mechanics: the upperincisors, upper buccal segments andupper molars are all being moved orstabilized as separate components.

Principle: Unlock the malocclusion insequences that aid rather than inhibittreatment.The first step in the sequence of protocolsto unlock the malocclusion is employingthe Ph.D. appliance to distalize themolars. To close the resulting space, elas-tomeric chain (rather than an archwire)is used to free-float the upper buccalteeth back to the distalized molars. Lightforces will retract these teeth up to 7 mmwith adequate control and withoutexcessive tipping, rotation or unduly

straining the anchorage. Free-floatingavoids archwire friction, saves anchorage,provides rapid movement of the teethand places posterior teeth in a Class Irelationship early in treatment. Class IIelastics worn to a Z bend in the upperutility archwire provide the neededanchorage. The alignment process in theupper arch actually begins when theupper buccal segments are in a solidClass I occlusion.

Figure 4. Each generation of cast molar tubes increased functionality without increasing size.Bioprogressive designs (1997 left, 1985 center) and Accent (1994 right).

Figure 5. Note the vertical deflection of an.017 x .017 35C Copper Ni-Ti wire ina high cuspid.

Figure 7. Computerized scan of upper arch usedto digitize the Orthos arch form that coordinatesanatomically based arch shape with Bios brack-ets and tube geometry.

Figure 6. After 6 weeks, the cuspid has beenerupted considerably, even with an edgewisewire.

Figure 8. A schematic analysis of the positioninglogic used for each tooth in developing the Biosbracket system and arch-form shapes.

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Principle: Apply differential torque controlthroughout treatment.Superelastic archwires have changed theface of modern orthodontics, offeringtools to deliver differential torque controlas needed. Traditional orthodontic doc-trine dictates beginning with round wiresand finishing with edgewise wires. In cer-tain cases, round wire leveling of the low-er arch often results in a forward tippingof the lower incisors and arch expansionby lifting lower lingual cusps upward and

outward. This practice has been replacedby using square or rectangular archwiresthat achieve torque control and yet areso flexible and have memory so constantthat they can almost always be engagedat the outset of treatment, regardless ofbracket placement irregularity. The arch-wire that typifies these characteristics isCopper Ni-Ti.8 The ones most commonlyused at the beginning of treatment areeither .017 x .017 35C Copper Ni-Tior .016 x .022 35C Copper Ni-Ti(Figures 5-6). Since these archwires areactivated by heat (by body temperature@35C) and rendered flexible by beingchilled before placement, individualproblem areas of engagement can beresolved by chilling the wire locally withEndo-Ice. The net result: stability of thelower arch by virtue of immediate torquecontrol and leveling with forces that aregentle, yet effective. Use of these wiresreduces the need for a utility archwirein many cases and results in longerappointment intervals, more simplicity

in treatment and fewer emergencies.

Another critical component of this systemis its coordinated archwires in the Orthosarch form that integrate with the bracketsystem, encouraging better results. Priorto the development of this arch form,most commercially available archwireswere based on various clinicians arbitraryconcepts of the ideal arch form. Due to theinfluence of the brackets, the shape of the

dental arch that results from treatmentwith these arch forms often differs fromthe archwire shape that produced it. Whatneeded to be done was to begin with ananatomically derived dental arch formand reverse engineer the brackets andarchwires to produce the desired dentalshape. The engineers of Orthos did justthat. The Orthos arch form is unique inhaving been derived from skeletal andanatomical norms (Figures 7-8). Its formis constructed via CAE software (Figure 9)

from those norms factoring in the geome-try of the Bios brackets and terminaltubes.9 The result creates a harmonybetween anatomy, function, appliancedesign and arch form that was heretoforeunachievable (Figures 10-11).

Principle: Treat overbite before treatingoverjet.The space created by distalizing the uppermolars and retracting (free-floating) thebuccal segments is mesial to the uppercuspids. Upper incisors cannot typically

be retracted to an ideal overbite/overjetrelationship without further bite opening,especially if the lower arch is already level.A single archwire the preformed .016 x.022 TMA asymmetrical reverse curve TLoop10 allows retraction, torque controland intrusion of the upper incisors. If theupper incisors are retracted without thisbite opening, there is either (1) trauma tothe lower incisors, (2) forward movementof the upper buccal segments or (3) aninability to entirely close the space betweenthe cuspid and lateral incisors. The TMAT Loop creates a step-up between thecuspids and laterals by opening the distal(longer) portion of the loop and closing itsmesial (shorter) extension. This step-upcan be from 0 to 5 mm, depending onindividual need. In addition, accentuatedcurve of Spee built into the archwire aidsin the bite-opening process and verticallyseats the buccal segments.

Figure 9. Computer-generated Orthos archwireproduction. Consistent use of the same ideal

arch form throughout treatment aids in earlyarch-form integrity.

Figure 10. Individually cut bracket slot in eachBios bracket produces exacting tolerances andbuilds rotation in slot where indicated, reducingheight and bringing the archwire closer to thecentral contacts of the arch.

Figure 11. Individual torque is determined byfacial type. To coordinate with growth, the longaxis of the upper incisor should be parallel tothe growth axis of the face. For example, brachyfacial types would have a more acute interincisalangle and dolichofacial types would have a moreobtuse interincisal angle. The individual growthpattern is taken into account when determiningactive or passive torque.continued on page 27

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Drs. Hilgers & Tracey

Case 1 - Pretreatment Treatment Based on Bioprogressive PrinciplesEleven-year-old female patient brachyfacial-type exhibits a mild Class IIdeep bite with no crowding.

Midtreatment Segmental Mechanics to Unlock Malocclusion Sequentially.

Upper arch with .016 x .022 Force 9 archwire. Lower arch with.016 x .022 TMA ideal archwire. Note step-ups maintained.

Upper arch with .016 round flexion archwire. Lower arch .016 x .022 TMAideal archwire.

At placement of asymmetrical reverse curve T Loop closing wire to closespace mesial to upper cuspids, which resulted from retracting buccal segment.

After closing with TMA asymmetrical reverse curve T Loop archwirefor 6 weeks.

After 3 months of molar distaliza-tion with Ph.D. appliance.

Upper utility wire being used for anchorage while free-floating buccal seg-ments with elastomeric chain closes space resulting from molar distalization.

Immediately following Ph.D. removaland placement of upper utility arch-wire to stabilize molars.

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Upper arch with flattened, dead-soft .016 x .022 Bond-a-Braid

(Reliance Orthodontics) 2-2permanent retainer.

Lower arch .027 TMA 3-3 retainer

Posttreatment

Superimposition showing mandible (orthopedic)change: Ba-Na at crossing of facial axis.

Superimposition showing maxillary dental change:superimposed at ANSPNS at incisive canal.

Superimposition showing mandibular dentalchange: corpus axis at pogonion.

Superimposition showing maxilla (orthopedic)change: Ba-Na line at nasion.

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Drs. Hilgers & Tracey

Case 2 - Pretreatment Treatment Based on Bioprogressive PrinciplesFifteen-year-old female patient with brachyfacial-type face exhibits a mildClass II, division 2, deep bite with mild crowding.

Midtreatment Segmental Mechanics to Unlock Malocclusion Sequentially.

Using .016 x .022 Ni-Ti archwire to level and align upper arch afterretracting (free-floating) buccal segments. Using .016 x .022 TMA ideal

archwire in lower arch.

At placement of .016 x .022 TMA asymmetrical reverse curve T Loopclosing archwire to close space mesial to upper cuspids, which resulted

from retracting (free-floating) buccal segment.

After 3 months of molar distalizationwith the Pendulum appliance.

Upper utility archwire being used for anchorage while retracting (free-float-ing) buccal segments with Class II elastics to close space resulting from moladistalization.

Molar position after distalization.

Using .0175 x .0175 TMA ideal archwire in upper arch and .016 x .022TMA lower ideal archwires with detailing bends.

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Posttreatment

Superimposition showing mandible (orthopedic)change: Ba-Na at crossing of facial axis.

Superimposition showing maxilla (orthopedic)change: Ba-Na at crossing of facial axis.

Superimposition showing mandibular dentalchange: corpus axis at pogonion.

Superimposition showing maxillary dental change:ANSPNS at incisive canal.

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Be Afraid. Be Very Afraidto miss out on one of the greatest orthodontic learning experiences in which youll ever participate.Leave your inhibitions behind. Pack your steamer trunk. Prepare for a journeythat will change your orthodontic life.

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Get your passport by calling Suzie Gleasonat (949) 830-4101. Shell be happyto send you additional cargoto make your perilous journeya safe and prosperous one.Fee: $2,740. Sign-ups are limited.

Let the Adventure BeginWith Your Guides

Drs. Jim Hilgers & Steve Tracey

Imagine Exploring mechanics thatvirtually guarantee quality andon-time results.

Imagine Discovering the true power ofmarketing and persuasion usingrich, sensory experiences that will

drive your patients wild withenthusiasm.

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Drs. Hilgers & Traceycontinued from page 21

Principle: Employ overcorrection in bothmechanics and appliance design.Techniques that use the natural occlusalforces of the teeth without overridingfunction have definite merit. Most casesfinish a little more easily when thepatient's individual muscular pattern isharnessed, augmented and utilized to seatand detail the occlusion. The principleof torque control throughout treatmentproposes that in most cases it is beneficialto have a torque control wire (square or

rectangular) engaged during most of treat-ment. Flexible rectangular or round wireshave a distinct advantage in finishing,however. They allow the teeth to settlevertically while maintaining arch formand other first-order adjustments. Thisprotocol is contrary to the traditionalorthodontic doctrine that dictates begin-ning with round wires and finishing withedgewise wires. Functional finishingwould propose just the opposite in manycases; that is, begin with edgewise, finishwith round or flexible archwires. It isbeneficial to maintain strict torque controlin one arch (usually the lower), somewhatfreeing the opposite arch (usually theupper) to seat against it. This conceptimplies an ideal archwire (usually an.016 x .022 TMA) in the stabilizing archand a yielding archwire (usually an.016 x .022 Force 9, an .016 x .022Titanium Niobium FA [finishing archwire]or a light, bendable round wire) in theopposing (or moving) arch.11 Functionalfinishing slowly and consciously turns

over control of the occlusion to themuscular pattern, enhancing on it withvertical seating elastics and accommodat-ing the overcorrection needed to finishmost cases (Figure 12).

ConclusionRicketts' basic philosophy for treatment,described as his Principles of Biopro-gressive Therapy, creates a solid founda-tion upon which clinicians of this and

future eras can continue to grow andchange. Two cases demonstrating theseprinciples were shown to further eluci-date how improvements in both tech-nique and materials allow the clinicianto adhere to these original principleswith highly efficient mechanics. Changesin technology are the driving forces tofurther simplify and improve this tech-nique. The principles that are the corner-stone of this technique are alive and well,thanks to the vision of its innovator.

References1. Ricketts, R.M.: Bioprogressive therapy as an answer

to orthodontic needs. Part I. Am. J. Orthod. Dentofac.

Orthop., 70:241-268, 1969.

2. Bussick, T.J.: A cephalometric evaluation of skeletal

and dentoalveolar changes associated with maxillary

molar distalization with the Pendulum appliance.

Unpublished Masters Thesis. University of Michigan.

Ann Arbor, MI, 1997.

3. Moore, A.W.: Orthodontic treatment factors in

Class II malocclusion. Am. J. Orthod. Dentofac. Orthop.,

45:323, 1959.

4. Vardimon, A.D. & Lambertz, W.: Statistical evaluation

of torque angles in reference to straight wire (SWA)

theories. Am. J. Orthod. Dentofac. Orthop., 86:56-66,1986.

5. Hilgers, J.J.: BiosA bracket evolution, a systems

revolution. Clinical Impressions, Vol. 5, No. 4,

pp. 8-14+, 1996.

6. Andreiko, C. & Payne, M.: The arches are like a

hat box Clinical Impressions, Vol. 4, No. 1,

pp. 2-5+, 1995.

7. Hilgers, J.J.: State-of-the-art simplicity in bucal tube

design: Twelve reasons to take a giant step backward.

Clinical Impressions, Vol. 5, No. 1, pp. 12-14, 1996.

8. Sachdeva, R.: Variable transformation temperature

orthodonticsCopper Ni-Ti makes it a reality. Clinical

Impressions, Vol. 3, No. 1,

pp. 2-5+, 1994.

9. Hilgers, loc. cit.

10. Farzin-Nia, F. & Hilgers, J.J.: The asymmetrical T

archwire. J. Clin. Orthod., 101:81-86, 1992.

11. Hilgers, J.J.: Functional finishing: The concept,

the tools, the techniques. Clinical Impressions, Vol. 5,

No. 3, 8-13+, 1996.

Figure 12. Class II vertical elastics foster contin-ued Class II correction while aiding seating final

occlusion. Vertical component of the elasticsholds teeth in occlusion, assisting in functionalsettling.

Ricketts' basicphilosophy for

treatment,described as his

Principles ofBioprogressive

Therapy, createsa solid foundation

upon whichclinicians of this

and future eras cancontinue to grow

and change.

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1717 West Collins AvenueOrange, CA 92867

(800) 854-1741(714) 516-7400www.ormco.com

Date Lecturer Location Sponsor, Contact and Subject

6/1-2 J.M. Bonvarlet & J. Bogey Reunion Isle AOSM; Josiane Koskas 33 1 48 59 16 17 ; Adding Some Strings to Your Arches6/1-3 B. Durand & M. Jeantet Montpel lier, France AOSM; Josiane Koskas 33 1 48 59 16 17; TMJ Art iculat ion Level 26/1-3 Jean-Francois LeClerc Brussels, Belgium Fourth European Lingual Orthodontic Congress; ECCO 32-2-647-8780; The Balance of the Smile6/5-7 Wick Alexander St. Petersburg, Russia Dental-Kompleks; Raissa Veronina 7 812 311 01 77; Principles of the Alexander Discipline6/8 Wick Alexander St. Petersburg, Russia Dental-Kompleks; Raissa Veron ina 7 812 311 01 77; Alexander Typodont Course6/9 M. Swartz & R . Bray Las Vegas, NV Ormco; Meredith Brick (800) 854-1741, Ext. 7573 ; Bonding The Bracket Kind & The People Kind6/9-10 Wick Alexander St. Petersburg, Russia Dental-Kompleks; Raissa Veronina 7 812 311 01 77; A lexander Study Club

6/12-16 Jerry Clark San Sabastian, Spain Span ish Orthodontic Society; Dr. Martin Fax 34943 42 3710 ; Increasing Your Profit Realization6/15-17 Multiple Speakers Szczecin, Poland Pol ish Jaw-Orthopedic Society ; Pommeranian Medical Academy 48 91 4820 453; 26th Symposium6/15-17 Wick Alexander Kyoto, Japan Ormco Japan; Roy Kishi 81-3-3945-0065; Principles of the Alexander Discipline6/16 Joe Mayes Rockport, ME Maine Orthod. Society; Dr. Zeleniak (207) 626-3550; Lean-Thinking Orthodontics6/18-19 Wick Alexander Tokyo, Japan Japan Assoc. of Adult Ortho.; Roy Kish i 81 3 3945 0065 ; Orthodontics Using the Alexander Discipline6/20-21 Wick Alexander Tokyo, Japan Ormco Japan; Roy Kishi 81-3-3945-0065; Steps in Interdisciplinary Treatment6/22-24 L. Hutta & J. Mayes Worthington, OH Ormco; Paula Allen-Noble (800) 990-3485; In-Office Comprehensive Hands-On Herbst Training*6/23 R. Bennett & J. Garbo Chicago, IL Ormco; Meredith Brick (800) 854-1741, Ext. 7573; Peak Performance and Prosperity6/29-30 Didier Fil lion St. Petersburg, Russia Dental-Kompleks; Raissa Veronina 7 812 311 01 77; Lingual Ortho Typodont Course*7/1 J.M.Bonvarlet & F. Bassigny Paris, France AOSM; Josiane Koskas 33 1 48 59 16 17; Breaking Barriers Level 27/3-7 Didier Fillion Paris, France Didier Fillion 33 1 47 04 27 93; 2nd Session of the One-Year Program (2000)7/4-5 Didier Fillion Paris, France Didier Fillion 33 1 47 04 27 93; Advanced Lingual Ortho Course7/8-9 Dirk Wiechmann Munich, Germany Ormco Europe; Dirk Wiechmann 49 5 472 5062; ECO Lingual Therapy7/21 Giuseppe Scuzzo Berlin, Germany Ormco Europe & Dr. Loidl; Michle Marinesco 31 33 453 6154; Lingual for Lab Technicians

7/22-23 Giuseppe Scuzzo Berlin , Germany Ormco Europe & Dr. Loidl; Michle Marinesco 31 33 453 6154; Advanced Lingual Course7/21-22 Joe Mayes Myrtle Beach , SC Charlene White Progressive Concepts; Jana Whitley (800) 445-7805; 15th Annual E. Coast Convention7/22-24 Stuart McCrostie Sydney, Australia Dr. McCrostie; Maree 61-2-9489 6000; Successful Lingual Orthodontics8/1-7 Larry & Will Andrews San Diego, CA Andrews Foundation (619) 224-0866 ; 7 Consecutive Independent Morn ing-Only Courses8/4-6 Jerry Clark Ann Arbor, MI GORP; Dr. McNamara (734) 668-8288; Orthodontic Residents Presentation8/25-26 Wick Alexander Puebla, M exico Centro Mexicano en Estomato log ia; Dr. To ledo 52 22 40 1448 ; Prin . of the Alex. Discipline8/28-29 Didier Fillion Santiago, Chili Dr. Mller 56 2 217 1239; Lingual Ortho Typodont Course*9/1 Terry Dischinger Louisville, KY KY Orthodontic Association; Dr. Johnson (502) 852-1324; Full-Face Orthopedics9/1-2 Dirk Wiechmann Osnabruck, Germany Ormco Europe; Top Service 49 5 472 5062; Lingual Therapy9/7 Terry Dischinger Honolulu, Hawaii Hawaiian State Orthod. Meeting; Mike Bailey (808) 245-1818; Full-Face Orthopedics9/14-16 Wick Alexander Arlington, TX Ormco; Brenda Horton (817) 275-3233; Principles of the Alexander Discipline9/15 Didier Fillion Basel, Switzerland Dr. Oberholzer 41 61 331 3110; Lingual Ortho Course9/15 D. Damon & T. Pit ts Newport Beach, CA Ormco; Meredi th Brick (800) 854-1741, Ext. 7573; A Conservative Approach to Radical Change9/15-16 Jim Hilgers Dublin, Ireland OISM; P. Dowling 353 1 6127303; Hyperefficient Treatment Mechanics9/21-24 Jerry Clark Boca Raton, FL Southern Assoc. of Orthodontists; Sharon Hunt (800) 261-5528; SAYOS Practice Issues9/22-24 Didier Fillion Berlin, Germany Dr. Neumann 49 177 2298 551; Advanced Lingual Ortho Course9/29-10/1 Wick Alexander Munich, Germany Ormco Europe; Andy Barte lt 49 89 922 99190; Vert ical Defic iency and Vertica l Excess

*Typodonts and/or Participation

For additional information on any course, please call the contact number shown or (international doctors) Ormco distributor

Lecture/Course Schedule at a Glance

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