Download pdf - MASTER CLINICIAN · vs. self-ligation, Tweed vs. Bioprogressive, and so on), and I realized early in my education that such philosophies tended to restrict my intellectual de-velopment

273VOLUME LIII NUMBER 5 © 2019 JCO, Inc.

MASTER CLINICIAN

Associate Editor Peter Sinclair conceived this department devoted to recognizing the Master Clinicians who have made the orthodontic specialty what it is today. Every few months, Dr. Sinclair will delve into the career story and treatment principles of one of these seminal figures. We welcome your nominees for future Master Clinicians.

Dr. Sondhi is a former Professor, Department of Orthodontics and Oral Facial Genetics, Indiana University School of Dentistry, Indianap-olis, and has been in the private practice of orthodontics in Indianap-olis for 42 years. He continues to lecture nationally and internationally. Contact Dr. Sondhi at 620 Mayfair Lane, Carmel, IN 46032; e-mail: [email protected]. Dr. Sinclair is an Associate Editor of the Journal of Clinical Orthodontics and a Clinical Professor, Advanced Orthodontic Program, Division of Endodontics, Oral and Maxillofacial Surgery, and Orthodontics, School of Dentistry, University of Southern California, Los Angeles; e-mail: [email protected].

Dr. SinclairDr. Sondhi

orthodontists—Dr. Anoop Sondhi—in another of his Master Clinician series of interviews. I met Dr. Sondhi early in my career (which was also early in his career). It was obvious to me from the start that he was a dynamic and creative orthodontist, bound for professional greatness and fame. Dr. Sondhi has many orthodontic innovations to his cred-it, innovations from which we all benefit. He approaches everything he does with vigor, hard work, and enthusiasm. In fact, perhaps the greatest thing I have learned from him over the years is to always maintain a positive attitude and to accept nothing short of excellence in all aspects of life. He is one of the happiest people I have ever met, and the result of this attitude has been his incredible success in all areas of his life.

As we go through our profes-sional careers, we all come across various practitioners

whom we enjoy and benefit from knowing. This month, Dr. Peter Sin-clair introduces us to one of those

Anoop Sondhi, DDS, MS

@2019 JCO, Inc. May not be distributed without permission. www.jco-online.com

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I would be remiss if I did not mention that Dr. Sondhi and I share a common passion other than orthodontics: private aviation (Fig. 1). While I enjoy flying small private aircraft and let it go at that, he approaches flying with the same vigor he applies to everything else. He is a terrific pilot, and I believe he holds practically every certification in aviation. I am truly envious of his accomplish-ments in both orthodontics and aviation. I am sure that you will enjoy—and benefit from—reading this interview. RGK

DR. SINCLAIR Who were your mentors?

DR. SONDHI We all tend to experience small and cumulative influences from many of the teachers we encounter throughout our professional schooling. The first one who had a profound impact on me as an orthodontist was Dr. Tom Graber. He was a leg-end in orthodontics by the time I started my gradu-ate education at the University of Illinois, of course,

and he chaired the Department of Orthodontics at the University of Chicago. I had read his textbooks1 and felt all the excitement of a star-struck teenager when I first met him. It did not take long to realize his brilliance as an orthodontist, as a teacher, and as an author. His grasp of the orthodontic literature and vast reservoir of knowledge were evident to anyone who had even a brief conversation with him. More important, he was generous with his time and even more generous with his encouragement of young orthodontists. I was lucky that he noticed some of my early work when I made my first pre-sentation at the AAO conference in 1992, and he subsequently recommended me as a speaker at a number of national and international meetings.

What especially captivated me—both when I met him as an orthodontic resident and subse-quently as a young orthodontist who had an inter-est in doing research, publishing articles, and pre-senting seminars at national and international meetings—was his refusal to fall into any ortho-dontic “camp.” It is my opinion that such camps frequently stifle independent thought, and they definitely oppose anything that may challenge their own cherished philosophies and beliefs. Whether the subject involved TMJ treatment, fixed appliance mechanics, or interceptive treatment (some of the issues that were controversial then and continue to be controversial now!), I found Dr. Gra-ber to be a true agnostic. He was interested in the science and the evidence, and he struck me as be-ing a totally independent thinker. Although Dr. Graber had encouraged me when I was a young professor at Indiana University, he continued to encourage me after I left my faculty position and went into private practice. In fact, once when he was a scheduled speaker for the Great Lakes As-sociation of Orthodontists meeting in Indianapolis, he became quite ill and was unable to travel. He mailed me all his slides (this was before the days of PowerPoint) and the text of his entire lecture, and he instructed me to deliver it for him! I was honored that he trusted me with his material.

The other gentleman I would definitely men-tion is Dr. Robert M. Ricketts. He was also a legend in the profession of orthodontics,2,3 and I had the good fortune to learn from him, since we were both

Fig. 1 Dr. Sondhi in captain’s seat of his Cessna Cita-tion jet.

275VOLUME LIII NUMBER 5

ANOOP SONDHI, DDS, MS

DR. SONDHI There are a number of orthodontic philosophies (extraction vs. nonextraction, ligation vs. self-ligation, Tweed vs. Bioprogressive, and so on), and I realized early in my education that such philosophies tended to restrict my intellectual de-velopment as an orthodontist. They are simply too doctrinaire, and their approach is entirely precep-torial. There seems to be too much emphasis on “tooth details” and not enough on a comprehensive understanding that we are doctors at the chairside of our patients—and it is the patients we are treat-ing, not just their teeth. Now, that does not mean that orthodontic biomechanics are not important or that those details are not important. Quite the contrary. I am very aware of the level of skill that it takes to finish an orthodontic case properly, as well as the skill that it takes to achieve accurate appliance placement, archwire bending, and prop-er detailing. It’s just that my philosophical approach starts from a much more comprehensive level.

Let me give you a simple example: I had a patient who came in because she had noticed a progressive opening of her bite over a period of two to three years (Fig. 2). She had previously had orthodontic treatment. There were wear facets not-ed on the canines, so it was evident that these teeth had been in contact at some point. The patient was

alumni of the University of Illinois. Dr. Ricketts proved to be one of the most innovative thinkers of his generation, and it was partly because of his work that I developed an interest in the management of TMJ disorders. He was kind enough to encourage me as a young researcher, and I had the good for-tune to lecture on the same program with him a few times during the 1980s. I believe we are all the ben-eficiaries of some of the innovations he introduced into the science behind orthodontic treatment.

Lastly, I must mention that I have been men-tored in one form or another by a number of the colleagues whom I have had a chance to practice with over the years. I am afraid to give out individ-ual names because I am equally afraid that I am going to leave somebody out, but they know who they are. Some of the pediatric dentists, restorative dentists, periodontists, oral surgeons, and endodon-tists in our community whom I have had the priv-ilege of working with have been exemplary in their work and in their commitment to patient care. I don’t believe that my practice would have been quite as successful had I not had the opportunity to work with these incredibly talented clinicians.

DR. SINCLAIR What is your orthodontic philos-ophy, and how does it guide you?

Fig. 2 Case 1. 48-year-old female patient with significant open bite before treatment. Note wear facets on canines.

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48 years old, and I thought it necessary to under-stand why her occlusion had changed over a rela-tively short period of time at such an age. I asked to do a diagnostic work-up, and an assessment of the cephalometric x-ray showed a definite expan-sive lesion along the posterior aspect of the hy-pophyseal fossa (Fig. 3). I informed the patient that while I would be happy to correct her malocclusion later, she had other, more pressing issues that de-manded our attention. A quick consultation with an endocrinologist and a neurosurgeon confirmed the diagnosis of a pituitary adenoma, which of course explained the secondary changes in the mandible. The lesion had been detected in time, and the neurosurgeon specifically commented that he was grateful to be able to remove the tumor before it became inoperable.

The point is, we should remember that we are doctors entrusted with the patient’s treatment and well-being, and not just “tooth movers.” It frightens me to think about the number of doctors who are now willing to treat supposedly “simple” aligner cases without a proper work-up or radiographic analysis. That concern has increased exponential-ly with the recent advent of aligners being offered directly to the patients, without any examination by a doctor.

I gave that case example to underscore the fact that my philosophical approach is to be the patient’s doctor and to be their advocate. Before I am willing to examine their teeth, I really do try to take a very careful medical and dental history, conduct a thorough clinical examination, examine their TMJ function, check their periodontal status,

and have a good comprehensive understanding of the clinical problems that need to be addressed. If the patient has endodontic or periodontal lesions that should be addressed before we start anything, then that must become the priority. I sometimes like to tell my patients that I am appointing myself the quarterback for their dental team, and I find this is greatly appreciated.

DR. SINCLAIR What diagnostic principles do you follow?

DR. SONDHI It is a fundamental precept that no matter what aspect of clinical practice you are in-volved with, appropriate treatment is possible only after a good diagnosis. I like to follow an extremely structured process in developing the diagnostic data used to establish a definitive diagnosis and an in-formed treatment plan. We generally encourage patients to fill out their medical and dental histories and forward them to the office prior to the consul-tation appointment. That way, if there is information that needs to be explored further, we have the time to do so before the appointment. A common exam-ple is the frequent confusion about whether a patient with a heart murmur needs prophylactic antibiotics. Patients are frequently told that the heart murmur is not clinically significant, from a medical point of view, without being educated about the need for prophylactic antibiotics during certain dental pro-cedures. Receiving the history in advance also al-lows us to access other information we may need from their dentist, such as periodontal charting for adult patients or information about mixed dentition

Fig. 3 Case 1. A. Cephalogram shows expansive, erosive lesion in posterior wall of hypophyseal fossa. B. Fol-low-up radiograph after adenoma re-moval shows reossif ication of posterior wall.

A B

Reossification

Erosive lesion in posterior wall of fossa



Fig. 4 Static examination checklist for dentition and occlusion.

DATE __________________________ S T A T IC E XA M IN A T IO N

DATE OF BIRTH ________________________ NAME ____________________________________________________ 1. FACIAL SYMMETRY: SLIGHT GOOD ASYMMETRIC R L LOWER BORDER INFERIOR TO R L CHIN DEFLECTION: SLIGHT R L 2. PROFILE: STRAIGHT CONVEX CONCAVE 3. FACIAL FORM: MESOGNATHIC PROGNATHIC RETROGNATHIC 4. LIP POSTURE: TOGETHER RELAXED TOGETHER SLIGHT STRAIN TOGETHER EXCESSIVE STRAIN 5. LIP PROFILE: UPPER: NORMAL PROTRUSIVE RETRUSIVE SHORT

LOWER: NORMAL PROTRUSIVE RETRUSIVE EVERTED 6. NASO-LABIAL ANGLE: NORMAL ACUTE OBTUSE 7. CHIN BUTTON DEVELOPMENT: NORMAL STRONG RECESSIVE ELONGATED 8. PRIMARY TEETH PRESENT: NONE A B C D E F G H I J N/A T S R Q P O N M L K 9. MISSING TEETH: NONE R 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 L 32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 10. MOLAR OCCLUSION: RIGHT SIDE: CLASS I II III LEFT SIDE: CLASS I II III CL I WITH II III TENDENCY CL I WITH II III TENDENCY N/A END TO END CL II III N/A END TO END CL II III 11. CANINE OCCLUSION: RIGHT SIDE: CLASS I II III LEFT SIDE: CLASS I II III CL I WITH II III TENDENCY CL I WITH II III TENDENCY N/A END TO END CL II III N/A END TO END CL II III 12. ANGLE CLASSIFICATION: CL I CL II DIV 1 CL II DIV 2 CL III N/A 13. OVERJET/UNDERJET: ____________________mm OVERBITE/OPENBITE ____________________mm 14. CROSSBITE: NONE BILATERAL UNILATERAL ANTERIOR POSTERIOR R L TEETH NO.__________ 15. ARCH LENGTH: MAXILLA: EXCESS SPACE ADEQUATE SPACE MAJOR / MINOR / MODERATE CROWDING

MANDIBLE: EXCESS SPACE ADEQUATE SPACE MAJOR / MINOR / MODERATE CROWDING 16. CHRONOLOGICAL DENTAL DEVELOPMENT: EARLY NORMAL DELAYED N/A 17. OCCLUSAL WEAR: NORMAL EXCESSIVE WEAR FACETS: MILD SEVERE GENERALIZED R 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 L 32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 18. CURVE OF SPEE: NORMAL MODERATELY DEEP SEVERE REVERSE 19. DENTAL MIDLINES: MAXILLA: R __________mm L MANDIBLE: R __________mm L 20. ORAL HYGIENE: GOOD FAIR POOR 21. TONGUE POSTURE AND FUNCTION: NORMAL HYPERACTIVE ANTERIOR / LATERAL TONGUE THRUST 22. WIDTH ATTACHED GINGIVA: NORMAL / NARROW TEETH NO. R 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 L 32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 23. GINGIVAL RECESSION: NONE TEETH NO. R 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 L MILD 32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 GENERALIZED 24. ABNORMAL FRENUM: MAXILLA: NONE LABIAL BUCCAL MANDIBLE: NONE LABIAL BUCCAL LINGUAL 25. LIP MUSCLE TONE: NORMAL HYPOTONIC HYPERTONIC 26. MAXILLARY INCISOR VISIBILITY: REST_______________mm WIDE SMILE_______________mm 27. LIP LINE: NORMAL HIGH LOW 28. ADDITIONAL NOTES: 1. ______________________________________________________________________________________ _____________________________ 2. __________________________________________________________________________________ _________________________________

3. ___________________________________________________________________________________________________________________

4. __________________________________________________________________________________________________ _________________

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treatment that may have been completed in a pedi-atric dentist’s office. Once we have reviewed the history, I like to follow a systematic checklist in conducting the patient’s clinical examination (Fig.

4). This keeps the process focused, and there is less risk of overlooking a potentially significant detail.

I continue to be surprised by the number of my colleagues, especially some of the management

Fig. 5 Analysis of mandibular and TMJ function.

FU N C T IO N A L A N A LYS IS 29. INITIAL CONTACT: REPEATABLE R 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 L QUESTIONABLE 32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 30. MANDIBULAR SHIFT (I.C. TO M.I.C.): NOT MEASURABLE MESIAL / DISTAL _____mm RIGHT / LEFT _____mm VERTICAL _____mm LIMITED 31. PROTRUSIVE EXCURSION: _____mm COMPLETE DEFLECTION / DEVIATION: NONE LEFT RIGHT SIGMOID

POSTERIOR INTERFERENCES: R 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 L 32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17

N/A NONE

CLICK: NONE RIGHT LEFT PAIN: NONE RIGHT LEFT TMJ / MUSCLE _____________ 32. RIGHT LATERAL EXCURSION: WORKING SIDE GUIDANCE BALANCING INTERFERENCES _________mm NONE R 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 L NONE 32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17

CLICK: NONE RIGHT LEFT PAIN: NONE RIGHT LEFT TMJ / MUSCLE _____________ 33. LEFT LATERAL EXCURSION: BALANCING INTERFERENCES WORKING SIDE GUIDANCE _________mm NONE R 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 L NONE 32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17

CLICK: NONE RIGHT LEFT PAIN: NONE RIGHT LEFT TMJ / MUSCLE _____________ 34. MAXIMUM MANDIBULAR OPENING: _______mm WITHOUT PAIN _______mm WITH PAIN PAIN: NONE RIGHT LEFT TMJ MUSCLE _____________ DEFLECTION / DEVIATION: NONE RIGHT LEFT SIGMOID

END FEEL: N/A HARD SOFT _______mm WITH PAIN R L __________________________ 35. TMJ AUSCULTATION: RIGHT: NEGATIVE CONDYLAR SUBLUXATION CREPITUS MILD CLICK: RECIPROCAL OPENING CLOSING MODERATE ________mm ________mm SEVERE

LEFT: NEGATIVE CONDYLAR SUBLUXATION CREPITUS MILD CLICK: RECIPROCAL OPENING CLOSING MODERATE ________mm ________mm SEVERE

OTHER: ____________________________________________________________________________________________________________________________________ 36. JOINT LOADING: N/A RIGHT LOAD: PAIN R L NEGATIVE LEFT LOAD: PAIN R L NEGATIVE 37. MUSCLE PALPATION: NEGATIVE FALSE POSITIVES: YES NO

RIGHT: MASSETER TEMPORALIS LATERAL PTERYGOID MEDIAL PTERYGOID

LEFT: MASSETER TEMPORALIS LATERAL PTERYGOID MEDIAL PTERYGOID

OTHER: ______________________________________________________________________________________________________________________ __________________ 38. TMJ PALPATION: RIGHT: NEGATIVE EXTERNAL: CLOSED OPEN INTRAMEATAL

LEFT: NEGATIVE EXTERNAL: CLOSED OPEN INTRAMEATAL



planning checklist, which we designed to make sure that no details are overlooked.

In addition, we also do a complete TMJ func-tional analysis for every patient (Fig. 5), even on a child with a crossbite in the mixed dentition. The reason is that there are patients who have undetect-ed or incipient TMDs, and I prefer to identify those, educate the patients about my findings, and con-struct an informed consent that documents our findings. There have been a number of cases over the years in which my orthodontic treatment rec-ommendations were changed by my findings during the TMJ examination (Fig. 6). This is not to imply that we obtain radiographs of the TMJs for every patient. That said, there are a number of orthodon-tic patients who did not come in complaining of

consultants, who seem to think that immediately upon completion of the clinical examination, you should start giving the patient some information on how you plan to treat their problem. I am ex-tremely reluctant to do so until I have looked at the complete set of diagnostic records. So I generally inform the patients and parents that the purpose of the diagnostic work-up is to develop the specific treatment plan that is appropriate for them, and I encourage them to ask all their questions after we have studied the data. In fact, if one is willing to opine about the patient’s treatment following just the clinical examination, what justification would the doctor have for requesting diagnostic records after that? I really do sit down with the diagnostic records in front of me and follow a treatment-

Fig. 6 Case 2. A. Patient who re-quested treatment because of inability to bite her food. Incisal and cusp-tip wear indicates contact between ante-rior teeth at some point. B. TMJ ra-diographs show moderate to severe avascular necrosis in otherwise asymptomatic patient, which would be critical in diagnosis and treatment planning.

A

B

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any TMJ problems for whom we have elected to obtain radiographs based on our clinical findings.

DR. SINCLAIR What are your most important mechanical principles?

DR. SONDHI When I think about biomechanics, there are principles that fall under two categories. The first is a biological principle. We have known for a very long time that it takes very little force to move a tooth.4-21 That is true regardless of the di-mension in which the movement is planned. I think it is fair for us to acknowledge that for the longest time in orthodontics, the forces used have far ex-ceeded the forces actually required to accomplish the movements. Some of this was due to limitations in the appliances that we use. Because of inter-bracket distances and because we used primarily stainless steel archwires until the 1970s, there was

a limit to how much we could minimize the forces delivered to individual teeth. The advent of lighter archwires, such as nickel titanium and beta titani-um, increased our options exponentially. Further, with design modifications to increase interbracket distance, we now have the ability to reduce indi-vidual force delivery by a substantial amount. Re-grettably, some schools of thought continue to insist that you are not being a “real orthodontist” unless you finish cases with stiff stainless steel archwires. I disagree with that school of thought. I do not use stainless steel rectangular archwires as my finish-ing wires because I am able to achieve the same level of precision and control by using rectangular nickel titanium and beta titanium archwires.

Think about something that happens on a rather routine basis in many orthodontic practices (and something that used to happen in mine until about 20 years ago). Let’s assume a patient is in

Fig. 8 A. High-, medium-, and low-torque modules. B. Color-coded modules stored in separate drawers for ease of use and inventory management. If manufacturer cannot supply desired colors, containers can be marked with blue, green, and yellow highlighters.

Fig. 7 A. Class II, division 1 malocclu-sion with flared maxillary incisors. B. Class II, division 2 malocclusion with lingually inclined maxillary inci-sors.

A

A B

B



not take me too long after that, however, to realize that the application of a single prescription in treat-ment of patients with different malocclusions and craniofacial types simply defied a logical under-standing of the variation in human anatomy. If we think about it from a clinical perspective, we can quickly understand that no capable physician would limit themselves to using only one antibiot-ic or only one anti-inflammatory medication. The notion that we can somehow have a single ortho-dontic prescription that will meet the needs of pa-tients with diverse requirements strains one’s cre-dulity. Although there have been efforts to develop appliances that were “customized” for a patient, these do not appear to have gained much traction in orthodontic practice, possibly because of cost or other encumbrances.

Figure 7 shows digital illustrations of a Class II, division 1 malocclusion with flared maxillary incisors and a Class II, division 2 malocclusion with lingually inclined maxillary incisors. I believe most orthodontists would agree that we would use brackets with a high degree of lingual root torque for the Class II, division 2 case. If the next patient came in with a Class II, division 1 malocclusion, would we really want to put those high-torque brackets on those incisors? Obviously not! But that is exactly what we have been doing for a long time. Most orthodontists simply select a prescription and then use it on every patient they treat. For that rea-son, I proposed variable-prescription modules in the high-, medium-, and low-torque categories (Fig. 8A). When I plan treatment, I now specify which teeth should receive high-, medium-, or low-torque brackets; the brackets can be stored conveniently

treatment with an .022" × .028" appliance, into which the clinician has placed an .019" × .025" stainless steel archwire (a common finishing arch-wire in the .022" slot). Now this patient comes in with one lower incisor that is a millimeter higher than the adjacent tooth. I think it is reasonable to say that in the majority of such scenarios, the cli-nician would place a 1mm step in the .019" × .025" stainless steel archwire and then reinsert it to level the incisal edges. Except once you have placed the archwire back in the brackets and are now going to lift the segment with the step to engage the extrud-ed incisor, think about the amount of force placed on the tooth that has the smallest root in the human mouth. I don’t believe it is unreasonable to point out that the amount of force being delivered is prob-ably 40 or 50 times greater than the force actually required to intrude that tooth. With our knowledge of the physiology of tooth movement, we have be-come aware that the amount of force required is much lower than what we have been using, but many of us have not modified our treatment proto-cols to take advantage of that knowledge.4-21

The second biomechanical principle that has had a significant impact on my clinical manage-ment of patients is the recognition that we must use variable-prescription technology in our treatment. I understand how the original concept of a specif-ic prescription was developed during the earlier stages in the evolution of preadjusted appliances. Indeed, approximately 23 years ago, I published information touting specific torque and tip values in a hybrid prescription that combined what I thought were the stronger elements of the original Ricketts, Roth, and Alexander prescriptions. It did

Fig. 9 Low-torque maxillary brackets and high-torque mandibular brackets used to compensate for tooth-mass discrepancy, thus minimizing overjet often caused by closing missing lower incisor space. A. Before treat-ment. B. After treatment.

A B

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in three drawers for that purpose (Fig. 8B).Furthermore, I have found it extremely effec-

tive to sometimes use different torques on the op-posing arches. As an example, closing the space for a missing lower incisor routinely results in some residual overjet. It makes sense, therefore, to use a low-torque appliance in the maxillary arch and a high-torque appliance in the mandibular arch (Fig. 9). Similarly, in a Class II, division 2 patient, it is logical to argue that we should use high-torque brackets on the central incisors, but not on the lat-eral incisors, which are already flared (Fig. 10).

The resulting improvement in our quality control and the reduction in total treatment time have been excellent.

To facilitate variable-prescription treatment, I designed a treatment-planning sheet (Fig. 11). I also have a sheet of bracket settings for patients who require standard bracket placement, as well as variations in bracket placement for the correc-tion of open or deep bites (Fig. 12). Let’s assume we have a skeletal Class III patient with adaptive and compensatory changes in the axial inclinations of the maxillary and mandibular anterior segments (Fig. 13A). This case will require decompensation to facilitate a mandibular osteotomy. The variable prescription calls for low-torque brackets in the maxillary anterior segment and high-torque brack-ets in the mandibular anterior segment (Fig. 13B), so the treatment-planning sheet is filled out ac-cordingly (Fig. 13C). The variable prescription effectively decompensates the case for the man-dibular setback (Fig. 14).

Another patient has an atypical Class II, di-vision 2 malocclusion, with one maxillary incisor inclined lingually and the other flared labially (Fig. 15). It would be inherently illogical to place central incisor brackets with the same torque on both teeth.

There are so many different ways of using the variable-prescription concept, and we are obviously limited in how much discussion we can devote to

Fig. 10 Class II, division 2 malocclusion treated with high-torque brackets on maxillary central incisors, but not on remaining maxillary anterior teeth.

Fig. 11 Treatment-planning sheet used to select appropriate torques and bracket settings for direct or indirect bonding.



face today is largely the result of the advent of clear aligner treatment in orthodontics. Now, I don’t mean that I find treatment with clear aligners to be either undesirable or particularly difficult. In-deed, I think we are all starting to recognize that there are some cases that can be treated extremely well with clear aligners, and that clear aligners make possible certain movements that are actually

the concept here. I would, however, like to point out one last example. A patient presents with a decided asymmetry in her malocclusion: a crossbite on the right side and none on the left (Fig. 16). We should not use the same torque values on the brackets in the right buccal segment as we do in the left buccal segment, which is not in crossbite; instead, I would select high-torque brackets for the right side of the maxillary arch and low-torque brackets for the right side of the mandibular arch (Fig. 17). In this case, a slight overcorrection was considered necessary and desirable for long-term stability (Fig. 18).

DR. SINCLAIR What is your best clinical tip?

DR. SONDHI That is a challenging question. Over the years, I have found so many specific pointers that have had a significant impact on my ability to treat patients, and it is hard to pinpoint one that towers above the others. So I will wrap some of my favorite precepts into a single concep-tual plea. I implore my fellow orthodontists to re-frain from being in a hurry to get to large finishing archwires. There is so much that can be accom-plished with extremely light wires, which are physio logically better and obviously much more comfortable for the patients. Since I currently favor treatment with self-ligating appliances, I make it a point to do all incisal edge reshaping, virtually all interproximal reduction, and all bracket re-positioning while still in extremely light arch-wires—usually tandem archwires. I would submit that if any bracket repositioning is done after you are already in rectangular finishing archwires, it is essentially too late. And I say this with reference to my previous observation that using stainless steel rectangular wires is simply not necessary with the technology available to us today. In fact, when I have orthodontists visiting or observing in my office, they are quite frequently startled to see that I simply do not have any rectangular steel wires in the clinic anymore.

DR. SINCLAIR What is your greatest clinical challenge?

DR. SONDHI The greatest clinical challenge I

Fig. 12 Bracket settings for standard orthodontic correction, with appropriate modifications for open or deep bites.

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Fig. 13 Case 3. A. Patient with Class III malocclusion and need for decom-pensation prior to orthognathic sur-gery. B. Planned variable prescrip tion. C. Treatment-planning sheet calls for low-torque maxillary brackets and high-torque mandibular brackets.

A

A B

C



Fig. 14 Case 3. A. Different torque values applied in upper and lower arches to effect decompensation be-fore surgery. B. Patient after man-dibular setback surgery.

Fig. 15 Case 4. A. Atypical Class II, division 2 malocclusion with one up-per central incisor inclined lingually and one flared labially. B. Planned variable prescription.

A B

B

A

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more difficult with fixed appliances. Asymmetri-cal expansion is a perfectly good example.

The challenge, however, is that some of the direct-to-consumer advertising has created a patient population that does not have a good understanding of the limitations of clear aligner treatment. I find it somewhat challenging to try to educate patients about the pros and cons of clear aligners vs. fixed appliances and the difference in outcomes. In an effort to address the demand for esthetic treatment, I have started to treat quite a few patients with what I call a hybrid approach. Mostly for adult patients, we can now offer treatment with aligners in the maxillary arch—since most of them show only the upper teeth when they smile—and brackets in the mandibular arch (Fig. 19). This approach, however, requires us to understand how to manage some spe-cific issues. For example, because the aligner ma-terial crosses the occlusal surfaces of the maxillary teeth, I find that these cases do not finish quite as well in the posterior occlusion. As a consequence, I now find myself trimming the aligners to allow settling. I have developed other new approaches for treatment planning, bracket placement in the brack-eted arch, and finishing procedures.

DR. SINCLAIR What other challenges do you see in orthodontics today?

DR. SONDHI I think it is extremely important for orthodontists to understand the developing body of knowledge regarding the impact we can have in the management of sleep disorders caused by a nar-rowing of the nasal and nasopharyngeal airway. Clearly, the subject has raised enough interest that the AAO made it the sole topic of its winter con-ference in January 2019. My protocol has been to recognize that we are neither capable of nor com-petent to diagnose specific sleep disorders. We therefore require that the patient be diagnosed by a specialist in sleep disorders (usually a pulmon-ology specialist) and that the diagnostic work-up specify that the sleep apnea is secondary to a con-stricted nasal or nasopharyngeal airway. Once that diagnosis is made, we need to understand its appli-cation in two distinct categories. In children, we have a good body of evidence to indicate that rap-id maxillary expansion can increase the nasal air-way, simply because the palate also happens to be the floor of the nasal cavity. If the child happens to need expansion for dental reasons as well, then that is a classic opportunity to kill two birds with

Fig. 16 Case 5. Patient with unilateral posterior crossbite on right side. Treatment plan involved high-torque max-illary brackets and low-torque mandibular brackets on right side.

High Torque Maxillary Arch

Low Torque Mandibular Arch



one stone. The other area in which orthodontics becomes important is the management of adult sleep apnea. We are finding that many dentists use propulsive mandibular appliances to increase the airway without recognizing (and without informing the patient) that some patients are unable to re-establish a posterior occlusion after sleeping for several hours with the mandible in a protruded position. Apart from the fact that this is distressing to the patients, there is serious risk of damage to

the anterior dentition if it is left in end-to-end con-tact. There have been many such instances in which I had to do subsequent orthodontic treatment to reestablish the patient’s occlusion in this protruded position. In more severe cases, of course, the ortho-dontist will work with an oral surgeon, because orthognathic surgery would be required to correct mandibular retrognathia. Sometimes a combination of a maxillary Le Fort osteotomy and a mandibu-lar sagittal osteotomy may be needed to reposition

Fig. 17 Case 5. A. Progress photographs demonstrate partial correction being expressed by variable prescrip-tion. B. Patient in finishing archwires. Note amount of correction achieved by using different torque in each arch.

A

B

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the maxillary and mandibular complexes and fa-cilitate opening of the nasopharyngeal airway.

DR. SINCLAIR Are there any other topics you wish to mention?

DR SONDHI Yes, I would like to address the issue of interceptive treatment. Once again, terminology and semantics become important, because other-wise we end up confounding our own thought pro-cesses. I discourage the use of such terminology as “Phase I treatment” and “early treatment.” As the great Dr. Proffit used to say, “What is early treatment—something you do at 5 in the morn-ing?” I believe the specific focus ought to be on the concept of providing treatment before eruption of the permanent dentition only in those patients with developing problems that need to be ad-dressed. Of course, there are studies that have ex-amined the efficacy of what are referred to as “one-phase treatment” and “two-phase treatment.” That is unfortunate, because the proponents of one-phase treatment seem to imply that interceptive treatment during the mixed dentition is either re-dundant or totally unnecessary. I believe that is a dangerous way of looking at things, because it flies in the face of our own national campaign to en-courage orthodontic consultation at age 7. Consid-

erable evidence exists concerning the efficacy of interceptive treatment in specific circumstances, such as transverse deficiencies, canine impactions, or serial extractions. The problem is that there is no way for us to identify the children who would benefit from such interceptive measures unless we see them at an early age, which is something that the concept of one-phase treatment seems to dis-courage. Our profession needs to recognize that we should encourage an initial consultation be-tween the ages of 7 and 8, so that the children who would benefit from interceptive measures can be identified and treatment can be planned, while the others can continue under observation until the appropriate time for initiating comprehensive treat-ment. I tell the parents of my patients, as well as my referring dentists, that I am always happy to do a consultation that ends with my advising them that nothing needs to be done at this time, and that we will keep the child under observation to determine the appropriate time for instituting treatment. The consultations I don’t like doing are the ones where I am halfway through examining the child and the thought shooting through my brain is, “Darn, I wish I had seen this a year ago!”

DR. SINCLAIR Thank you for sharing your clin-ical experience and insights with our readers.

Fig. 18 Case 5. Patient after treat-ment.



REFERENCES

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Fig. 19 Case 6. A. Patient with minor maxillary arch-length deficiency and moderate mandibular arch-length de-ficiency who specifically requested treatment completion within six months because of her upcoming wedding. B. Aligners used in maxil-lary arch and esthetic brackets in mandibular arch, since aligner treat-ment alone was not likely to resolve this degree of crowding within limited time frame.

A B