ARTICLES ON

ORTHODONTICS
FROM INTERNET

CONTENTS

FROM INTERNET..........................................................................................................1 1. Alexander Spirit MB Appliance..................................................................................4 2. Amazing Brace Survey.................................................................................................5 3. American Academy of Implant Prosthodontics.........................................................6 4. Art and Science of Selling Orthodontics....................................................................6 5. Bite Turbos..................................................................................................................10 6. Bravo Brackets............................................................................................................11 7. Bruxism and Clenching ............................................................................................14 8. CBJ. .- .Armed For Efficiency..................................................................................15 8. Colorful Braces Make More Than Fashion Statement..........................................16 9. Computer Imaging ....................................................................................................17 10. Considering Orthodontics?......................................................................................18 11. Copper Ni-Ti - Creative Use ...................................................................................19 12. Copper Ni-Ti (tm) Dimpled Arches and 35 degree Square..................................20 13. Creating A Smile - That's Good For Life..............................................................20 14. Esthetic Recontouring of the Orthodontically Treated Occlusion......................21 15. GP Adult Limited Ortho, the Begg Bracket Advantage........................................23 16. GP Adult Limited Ortho, the Begg Bracket Advantage........................................26 17. Implants as an Alternative Treatment for Missing Maxillary Laterals..............28 19. Invasion crevical resorption(ICR)..........................................................................30 20. Lingual Orthodontics- The Inside Story................................................................31 21. Malocclusion.............................................................................................................32 22. Mini Diamond Gold Series Brackets (tm)..............................................................34 23. Modern Orthodontics Diagnosis, Treatment Planning and Therapy.................34 24. Molar-Moving Bite Jumper (MMBJ).....................................................................35 25. New Ultra-Lock mesh bonding pad ensures superior bond strength..................36 26. Now You See Them - Or Maybe You Don't...........................................................38 27. Orthodontic Case Report ........................................................................................38

28. Orthodontic diagnosis and treatment planning.....................................................40 29. Orthodontic treatment in England and Wales.......................................................42 30. Orthodontics Will Never Be The Same..................................................................42 31. Payment Plan Options For Dr. Trepp's Office......................................................43 32. Problem of Digit-Thumb Sucking..........................................................................43 33. Radical New Movement in Orthodontics ..............................................................44 34. Resurgence of Lingual Orthodontics.....................................................................45 35. Sooner Orthodontic Facts Are Faced, The Better.................................................48 36. STAR-TEC Piezo-Electric ultrasonic unit.............................................................49 37. Straighter Teeth Boost Self-Esteem........................................................................50 38. Timeless Design. Exceptional Performance. Lasting Results..............................51 39. Titanium Resolves Health Concerns About Braces..............................................51 40. Using the Help of Computer Science ....................................................................51 41. What are the results obtained in my office today?...............................................51 42. Wick Flat Bow Retainer Wire.................................................................................53

Orthodontics Orthodontics is the branch of dentistry that specializes in the diagnosis, prevention and treatment of dental and facial irregularities. The technical term for these problems is "malocclusion," which means "bad bite." Orthodontics practice requires the professional skill in the design, application and control of corrective appliances (braces) to bring teeth, lips and jaws into proper alignment and achieve facial balance American Association of Orthodontists is a professional association of educationally qualified orthodontic specialists dedicated to advancing the art and science of orthodontics and dento-facial orthopedics, improving the health of the public by promoting quality orthodontic care, and supporting the successful practice of orthodontics. The members must meet the educational requirements of the Council on Dental Education of the American Dental association for a specialist, which are currently at least two academic years of advanced education in an accredited program. WANT TO KNOW MORE ABOUT ORTHODONTICS? To find an orthodontist near you, ask your family dentist for a referral or call 1800-STRAIGHT (1-800-787-2444). A wealth of free information is available from the American Association of Orthodontists by calling, toll-free, or writing: AAO, 401 N. Lindbergh Blvd., St. Louis, MO 63141-7816. Anyone considering orthodontics for themselves or a child can take advantage of the "Smile Bank," the AAO's free computer-imaging program. Just send in a closeup photo with a natural, toothy smile and an orthodontist will prepare a computer-generated "after braces" picture. Mail your photo (and return address) to the AAO, c/o "SMILES," Dept. SE, and you'll receive a free photo showing how orthodontics could improve your smile. Orthodontists are the experts uniquely qualified to correct "bad bites." The American Dental Association requires orthodontists to have at least two years of post-doctoral, advanced specialty training in orthodontics in an accredited program, after graduation from college and then dental school.

1. Alexander Spirit MB Appliance The Alexander Spirit MB appliance, true to the principles of the Alexander Discipline, combines the prescription of Ormcos highly evolved Mini-Wick System with the aesthetic superiority of SpiritMB brackets. Superior Clinical Efficiency Single tie wing design for increased interbracket distance Metal rotation arms for fast, efficient rotational control (preadjusted) Ample undertie wing area for easy ligating Convenient and comfortable hooks on upper laterals and lower laterals Constructed For Durability Advanced composite material provides excellent strength and color stability Wedge design minimizes occlusal interference and bracket wear Clearly Superior Aesthetics Clear composite material blends with all tooth shades Wont stain or discolor Fast & Accurate Placement Exclusive Face-Paint (tm) enhances the Diamond shape to ensure fast and accurate bracket placement Excellent mechanical bond retention compatible with any adhesive without need for primers or conditioners Debonds easily with little or no patient discomfort Related Subjects: - Following extensive clinical testing, Dr. Wick Alexander has incorporated the proven prescription refinements of the Orthos (tm) appliance into the Alexander technique. - Combines features found in todays most popular designs with enhancements and additional improvements, resulting in numerous advantages. AOA Delivery Commitment We respect the demands placed on our clients offices throughout the country and recognize the importance of meeting the exact appointment date. Recognizing that each practice designs its own patient recall system, please contact our Customer Service Department, tollfree, at 1-800-262-5221 to review your office procedures in more detail. We encourage definitive placement dates on each prescription form and suggest that the date be two-tothree days before the actual appointment date. This allows protection in the event there are any delays with the mail when re- turning your appliance. The following indicates the typical in lab production time we appreciate having for all appliances we fabricate: Functional Appliances Retainers Fixed Appliances Positioners (with brackets still on teeth) (with brackets removed) As demand for non-extraction treatment continues to grow, the Herbst Appliance is an increasingly prescribed option for arch lengthening and the correction of Class II malocclusions One Arch Appliances are increasingly used as an early treatment appliance to generate lateral or mesial-distal correction in individual arches. Again, we can handle your needs for special modifications. The Pendulum Appliance has traditionally been used to correct Class II malocclusion by distalization of upper molars. The Pendex, designed in 1991 by Dr. James J. Hilgers, combines palatal expansion with molar distalization. Well set you up for finishing success with our precision positioners and set-ups. Ask for Flexiclear, our most versatile positioner material. RPEs expand your options for non- extraction therapy. Its an excellent early treatment choice to begin palatal expansion and may be banded, bonded or used with stainless steel crowns.

Spring Retainers are great for returning cases to the way you finished them. Patients like our custom choices. BIOS(tm)-Adding Scientifically-Derived Precision and Improved Clinical Practicality to Light Wire, Higher Torque Mechanics. "Bios is the light wire, higher torque version of the System. Just as tooth morphology and size help determine bracket placement and occlusion, wire technology and trends in biomechanics help forge the need for different torque values. Put simply, the Bios System allows for earlier torque control with lighter wires. This helps ensure torque control throughout treatment when needed, less dependence on full-size edgewise wires, and techniques that use function more and dominance mechanics less. The intent with Bios is that when more torque is desired, it is built into the system; when less torque is needed, wires are downsized to use bracket tolerances. Years of work tying specific torque values to biomechanical principles and physiologic response allow the clinician who opts for lighter wires to get the best of both worlds - Orthos technology refined in the Bios light-force system." -James J. Hilgers, D.D.S., M.S. The profession's widespread acceptance of a truly revolutionary coordinated appliance system, has created a demand from leading proponents of the Bioprogressive Technique for incorporation of Orthos' advantages into their discipline. In response, ORMCO now brings Orthos' precision and compensation for the mechanical inefficiencies of existing systems to light wire, high torque techniques. The Bios prescription differs from Orthos by virtue of its increased torque in upper incisors and in the mandibular posterior segment, as well as lingual root torque in upper and lower cuspids. Bios affords the following major preadjusted appliance improvements that are also essential to the System: Compensation is cut into the slot of the lower cuspid brackets and the shape of the archwire sweeps close to the tooth surface, reducing the profile of the lower anterior brackets and the frequent requirement of first order bends mesial to lower cuspid brackets. Progressive distal tip in all lower anterior brackets achieves uniformity in root spacing. Lower bicuspid brackets with distal root tip achieve balanced proximal contacts and correct root alignment. Molar tubes are designed so that molars occupy the least amount of arch space and molar interdigitation is improved. Distal root tip is incorporated into upper 2nd bicuspid brackets. Thicker 2nd bicuspid brackets better synchronize with 1st bicuspids and molars. Moderately increased buccal root torque on maxillary posterior segments prevents lingual cusps from dangling. Arch forms and brackets are computer-derived from skeletal analysis and are integrally designed to coordinate the dental arches. Orthos bicuspid brackets are available gingivally offset with occlusally extended pad to increase the bond area. The bracket is correctly positioned while the extended pad increases bond strength. As Dr. Hilgers indicates, Bios affords the clinician who prefers lighter wires the benefits of technology refined in a light-force system. Bios is also designed to fill an important role for System clinicians as an auxiliary appliance available for adult and deep bite cases as well as cases with strong musculature patterns for which higher torqued appliances are desired 2. Amazing Brace Survey How many people around the world have braces on their teeth right now? " What To Expect: Experiences similar to friends who have worn braces Mutual support from your true friends and your orthodontist's helpers Coordination of your care between your family dentist and orthodontist Special instruction on how to clean your teeth with braces and often a prescription for a fluoride mouth rinse to protect the tooth surfaces Adjustment of your braces approximately every 4-12 weeks. Mild tooth soreness during the first week in braces and after adjustment office visits. Soothing recipes can ease the transition A treatment time of 6-36 months depending on the complexity of treatment. A period of retainer wear will follow removal of your braces A discussion of the effect of wisdom teeth on the orthodontic result

 The degree of success is almost always a reflection of a person's cooperation during treatment and retention. Active patient participation is always essential for success. Techniques: Space age low force wires that remember their original shape allowing teeth to move faster without kinking Clear tooth colored braces and gold braces Braces glued to teeth with adhesives that contain cavity fighting fluoride Computer video imaging which allows you to see a video picture prediction of your possible treatment result Combined treatment of orthodontics and surgery for abnormalities that are beyond the capabilities of orthodontics alone. 3. American Academy of Implant Prosthodontics A Rich Academic Tradition The American Academy of Implant Prosthodontics was formed December 10, 1982, at the Medical College of Georgia, School of Dentistry, with the grateful assistance of the Dean, Faculty and Department Chairpersons. "An Introduction to Implant Dentistry", was the title of this historic meeting and participation course. The AAIP is chartered in the State of Georgia as a non-profit organization. A significant event that shaped the AAIP's destiny was the second meeting held at the American Dental Association Headquarters Building in Chicago, November 11,12,13, 1983, with the grateful cooperation of the ADA Headquarters Staff. The speakers at this meeting consisted of some of the most knowledgeable university professors and scientists involved in Implant Dentistry. A controversial subject in Implant Dentistry was presented, "The Dental Implant - Tissue Interface". "The Dental Implant - Clinical and Biological Response of Oral Tissues", a hardbound textbook, was subsequently published, sponsored by the AAIP. After this book's release, international sales figures were beyond expectations, resulting in an unprecedented second printing for a book of this kind. Subsequent Annual Meetings were held around the country. Fellowship and Mastership Convocations and meetings were held in cooperation with dental schools such as the University of Pittsburgh and Louisiana Sate University. To this day, the American Academy of Implant Prosthodontics is the only implant organization that holds its meetings jointly with a University or Dental School. In 1990, a second textbook was published, entitled, "Implant Prosthodontics - Surgical and Prosthetic Techniques". Again, this textbook proved to be a best seller in Implant Dentistry.

4. Art and Science of Selling Orthodontics by B. Keith Black, D.D.S., M.S. Asheville, North Carolina Building Relationships That Last a Lifetime Dr. Keith Black received his M.S. and certificate in orthodontics from the University of North Carolina, Chapel Hill. He has been in private practice since 1986, lectures at UNC and is a sought-after speaker on practice management and efficient clinical systems. Active in local community affairs, Dr. Black has been awarded Employer of the Year as well as Small Business Leader of the Year by the Asheville Chamber of Commerce. He and his wife Susan have two daughters, Michelle and Kathryn, and are expecting their third child in September. Darnn it, Jim, Im a doctor, not a salesman." As an original Star Trek fan, I hope you recognize the paraphrased rebuff from Dr. McCoy to Captain James T. Kirk. As the only doctor on a deep space military vessel, Dr. McCoy enjoyed job security. He may have had to put up with scary alien encounters, Spocks Vulcan anatomy and Kirks impetuous nature, but he needed only to concern himself with being a clinician-nothing compared with running the business of an orthodontic practice today. Our roles, on the other hand, are numerous and varied. Besides clinician, were coach, psychologist and director of marketing and sales.

Having determined the title of this article, Im still uneasy with it. Why? Because it clearly indicates that I am a salesman. When I went to school, I know I went there to become a doctor of dental surgery, a dentist. I then received an advanced certificate in orthodontics as well as a masters degree in orthodontics from the University of North Carolina at Chapel Hill. There are courses in sales in business schools across the country, but I didnt take any of them. Why would I? Im a doctor. When I discuss selling at lectures around the country, many orthodontists are, at first, themselves uneasy. This article will attempt to aid you in a paradigm shift about selling. It contains some basic business facts and a discussion of a model of selling that is patient centered. I will share my thoughts about what the patient is really buying and offer some ideas for positioning the practice for you to consider so that you, too, can enjoy Dr. McCoys feeling of job security. Why We Hate the "S-Word" The concept of selling conjures in my mind a man in a two-piece leisure suit in a used car lot trying to get me to buy something I dont want. This common image of the typical salesman explains why selling is a difficult role for us to assume as health care professionals. This image of selling is a manipulative one where the salesman forces products on people who neither want nor need them. The image is unwarranted in health care delivery. Think of how much you enjoy helping others get what they want or need. I truly find it satisfying to help others get what they want. In helping others get what they want, we are building relationships. Selling as an outgrowth of building relationships is a concept that I think most of us can find comfortable. Its an approach quite different from the traditional model of selling that we find so distasteful. The traditional model of selling (Figure 1) is 10 percent opening, 20 percent qualifying the individual, 30 percent presenting the product or service and 40 percent closing, closing and more closing-in other words, high pressure sales. In the model of Relationship or PatientCentered Selling, the pyramid is inverted (Figure 2). The majority of time is spent in building a relationship with the customer or patient-over 70 percent of the time in building trust and identifying the needs of the patient-with only 10 percent delegated to the close. This model of selling is excellent for orthodontics. If it is employed appropriately, youll spend most of your time ensuring that patients have the opportunity to express their wants and needs and understand why your practice is best suited to meet those needs. You simply will need to "sell" the opportunity to start. Raving Fans: Why a Patient-Centered Model? The Patient-Centered Model allows the doctor as consultant to share expertise about what would be best for the patient from a position of authority and respect. It is an excellent complement to optimum patient relations-a marketing strategy that has been highly regarded in our profession for years. To have existing patients offer the kind of testimonials that make prospective patients see the value in the investment they are making, we must create raving fans. In a survey done by the Forum Corporation of 2,374 customers from 14 organizations, more than 40 percent listed poor service as the #1 reason for switching to the competition. We are all familiar with the 3/11 rule of marketing, but let me paraphrase it. If three customers are satisfied with a product or service, they may tell other people about it, if the subject comes up. If customers experience an unpleasant service or product that did not meet their expectations, they will tell 11 other people. Since patient recommendations are critical to prospective patients perception of your practice, patient service then becomes a vital marketing strategy and is integral to incorporating the Patient-Centered Model into your practice. The final measure of quality customer service is simply how patients perceive it. Perceived service quality is the difference between the service they got and the service they expected. Perception is how we make sense out of what we experience. It is not the quality of the service you give, it is the quality of service patients perceive that causes them to be satisfied with you and offer glowing recommendations that solidify their own and their dentists referrals. In survey after survey of businesses around this country, it is poor service that accounts for the majority of customer dissatisfaction. A recent study published in U.S. News and World Report cited why customers stopped coming to a business: 1 percent died; 9 percent were drawn away for normal competitive reasons such as another office opening closer to home; 14 percent were dissatisfied with the product; and

68 percent were displeased with the attitude of indifference on the part of an office representative. Our goal for our practices, then, should have customer service as its highest priority. Paul Hawken, founder of Smith and Hawken and author of Growing a Business, states, "Our goal as a company is to have customer service that is not just the best but is legendary." Lewis Gerschener, CEO of American Express Travel Related Services, says, "Service is our most strategic weapon. It is the only way we can differentiate ourselves in the marketplace." The Patient-Centered Model in Action The first thing we did to incorporate the Patient-Centered Model was to go to the one-step exam/consultation. We have used it now for over seven years. The patients can be seen in a short period of time, have all their questions answered and concerns alleviated and be ready for braces in one 1-hour appointment. In most cases, the one-step approach serves patients needs best and is consistent with the Patient-Centered Model. Time is a precious commodity in todays dual-income, on-the-go world. The one-step approach takes into account patients busy schedules and is of tremendous value and benefit to them. I may have been rationalizing that my patients expected a separate consultation based on my own preestablished idea of what an orthodontist was supposed to do. Once I got past the idea that I was rushing patients (i.e., using high pressure sales tactics) and understood that their needs are more important than my need to show them what I know, I finally got comfortable with the approach. So lets talk about the 70 percent of the Patient-Centered Model that relates to building trust and satisfying patients needs. Roger Levin, a dental practice management consultant, counsels that everyone listens to a radio station with call letters WIIFM ("Whats In It For Me?"). If were not attuned to hearing and responding to each patients needs, we may be "selling" something different from what our patients want to purchase. Ill use an example from my own life. When I purchased a life and disability insurance policy, I was buying comfort and safety. The insurance salesman sold-helped me purchase-the ability to take care of my family in the event of my absence. If the salesperson had positioned the insurance as an investment and I was in the market for security, we might never have made a deal. I certainly would not have felt that he had "helped me purchase" anything.I think we as orthodontists get caught up in "selling" our clinical expertise. We prominently display our diplomas and list a string of professional affiliations in the biographies that dominate our brochures. We "sell" functional results. Patients "buy" an attractive smile and improved selfconfidence and self-esteem. We "sell" clinical expertise. Patients "buy" an enjoyable place for themselves or their children to come. On the whole, patients dont know the difference between average and excellent results. They dont know what a reasonable cost for quality care is. They cant judge the technical competence of a doctor, whether the diagnosis is correct or whether the treatment plan is optimum, given their particular circumstances. In fact, simply having a D.D.S. diploma on the wall gives most patients all the assurance they need of your clinical capability. To them, the diploma is the level playing field. To distinguish ourselves, we need to ensure excellence in everything with which our patients come in contact and create value in their experience with us.

So If Not Clinical Expertise, Then What? Because people cannot judge you based on objective clinical criteria, their decision to begin with your practice is based on things they can make judgments about and what they are told by others. The majority of dentists make noncommittal referrals, giving patients at least two names of local orthodontists. (I may get called first because my name is early in the alphabet. I hope a Dr. Adams never moves into the neighborhood.) Because so little distinction is made through such referrals, the image that we project becomes the first critical elements by which we are judged-the initial patient call, the literature we send (including whether they can follow the map or directions we give), the attractiveness of our signage, the neatness of the parking lot and building, how we greet them when they first walk into the office as well as the general appearance of the office and the staff. Given that 85 percent of what we remember comes through our eyes with only 11 percent through our ears, we need to view our practices through our patients eyes, taking a visual inventory from time to time to ensure that what our prospective patients perceive about our practice is the image we intend to give. We have a phrase we use around the office that sums up this idea: "People dont care how much you know until they know how much you care." Research from a variety of sources

would concur. The U.S. Office of Consumer Affairs determined that 55 percent of a persons decision to buy rests on how well one likes the seller. Research by the Carnegie Foundation for the Advancement of Teaching indicates that 15 percent of ones financial success is due to ones technical knowledge, while 85 percent is due to ones personality and influence. In other words, people do business with people they like and trust. So how do people get to like you and trust you? Juan Carlson, who revitalized an airline near bankruptcy through landmark customer service, might suggest it is through what he terms "moments of truth." Every time individuals come in contact with your company (in your case, your practice), they experience a moment of truth and thereby feel better, worse or the same about you. Every contact is a chance to meet an expectation, exceed an expectation or fail to meet an expectation. Our lowest acceptable standard is to meet a patients expectation. It is how each individual moment of truth is handled that will determine your success in the marketplace. The initial patient call as well as the initial examination are critical moments of truth because they are the foundation from which all other perceptions will flourish. One of the first things I teach new staff members who are taking initial patient calls is to use language that assumes that the individual is already a patient. Its simple phrases such as, "When Jimmy gets his braces . . ." or "When you bring Sally in, you can relax with some hot coffee," that imply that patients and parents are already included as members of our patient family. We script the new patient call in terms of what to ask as well as ways we can respond to help the prospective patient feel comfortable. For example, we look for ways to congratulate patients for the decision they have made about exploring the possibility of orthodontic care. Sometimes mothers who are making the call about a young child are uncertain about the validity of their concerns. In such a case, Sherry Rauschenplat, our receptionist, may compliment the woman on having the foresight to have her child seen early in order to take advantage of all that orthodontics has to offer. If the patient is an adult, she might mention that we have over 100 adult patients and that we provide a private adult treatment room so that theyre comfortable. We make these comments as a means of building rapport that we know will be reinforced over time as we get to know one another. Our most powerful visual aid is the practice itself and we maximize its impact with an office tour during the initial exam. Its our "infomercial," providing a limitless number of opportunities to create positive moments of truth. Through the tour, we focus on two things: demonstrating how we will satisfy needs the patient has specifically mentioned (or that we might surmise based on their profession, etc.) and suggesting at least five aspects of the practice that we have designed based on the feedback we continually solicit from patients. We might mention how the openness of the office reflects our philosophy of accessibility to both patients and parents and that through it we also create an active, fun atmosphere that theyll enjoy sharing. For mothers concerned that their children have an enjoyable experience, we point out what contest is running, the reward system for good hygiene and making appointments on-time, the Gameboys in the on-deck area and our reasons for providing these services and incentives. Do other practices around the community offer such services? Sure, some do. We make sure patients know we do. If the patient or parent is in the health profession, we may go into the sterilization procedures in more depth, with lead-in phrasing such as, "You might be more interested than others in our sterilization procedures since you know firsthand how important these precautions are." We might highlight the X-ray machine with intensifying screens that limit exposure to no more radiation than being in the sun for three hours or that everyone in the clinic is a certified dental or orthodontic assistant. These nuances of communication show patients that we regard them as individuals. Every time you respond to an expressed need or concern, especially one mentioned in an earlier conversation, you show that the caring aspect of your practice is as important as the clinical. Example: "I remember you mentioned that youre concerned that Susie not have teeth extracted as you did when you were young, so I wanted to clarify that Dr. Black is committed to doing everything possible to ensure that Susie keeps all of her teeth." Combining this care with a strong walkout package that includes video imaging of pictures and review of the appointment creates an impressive visit. This attention to listening, caring and acknowledging your patients needs through empathetic responses is integral to building strong relationships. What Are Patients Coming to Your Office For? When patients come into your office, what are they really coming to buy? Weve already established that while our clinical expertise is a given, it is not why people come to us.

Psychologists say that humans do everything for one of two reasons: 1) to gain pleasure; or 2) to avoid pain. Put another way, people purchase good feelings or solutions to problems good feelings and problems as they perceive them. Seventy-five percent of all buying decisions are based on subconscious wants and needs as related to the pleasure/pain dichotomy. People buy based on emotion; they justify the decision based on logic. Prestige, perceived value, comfort and security are the roots of these emotional needs. Buying a car provides a good example. We all need transportation. Some of us want the bright, showy sports car. With such a purchase, we may not only be buying transportation, we may also be buying prestige. Others are satisfied with a simpler means of getting from point A to point B, maybe in a Ford Taurus. Perhaps with such people, security needs rank higher than prestige needs, and keeping more of their savings in the bank satisfies those security needs. In much the same way, patients buy orthodontic services for their own reasons, not necessarily why we think they should. Discovering those reasons and focusing on what we provide to address them is the job of my two treatment coordinators, Vicki Kemper and Nicole Waycaster. If patients are looking for a bargain, they will usually know it through the response we get at the initial patient call about whether we can book time for initial records. Bargain hunters must be convinced of the value of the investment, so we amortize the cost over the life of the individual and help the patient get in touch with how an improved smile will enhance their self-esteem, self-confidence or maybe in getting a job or promotion. When challenged with the fee being too high, Vickie might ask (usually Dad) how much he paid for his car in a given year (based on when he might have been in his early 20s) and what he would pay for one today, and then show how orthodontic fees have not kept pace with inflation over the last 20 years. When Nicole picks up on the fact that the patient will make a decision based on being in a prestigious practice, in her arsenal of features to highlight are that I am a lecturer at the university, am asked to make presentations to orthodontists on a national level and was awarded Small Business Leader of the Year by the Asheville Chamber of Commerce. In dealing with a quiet father who feels overwhelmed by the process of early treatment, the women would probably empathize with him and relate personal experiences with their own children and how they helped them cope. People are persuaded far more by the depths of your beliefs, feelings and emotions than any logic or knowledge you exhibit. When you and your staff sincerely believe that you are offering the patient exceptional value, odds are the patient will see it as such. You and your staff should have an unshakable belief in the value of orthodontics and that the manner in which you deliver it is the best anywhere. Selling vs. Helping People Get What They Need There is a big difference between selling and helping people buy what they want. Find out prospective patients needs and wants, select what you mention to them about your services based on those needs and wants and inform them that you are doing it. In most cases, if you know your community, if you regularly solicit patient feedback through surveys and focus groups, you will have developed service standards that will match those needs. Helping to solve a problem gains loyalty and creates the basis for long-term relationships. Size up and respond to each patients problems in a way that makes them glad they have done business with you. Remember, we all take credit for purchases that we are proud of, such as a beautiful home. Were quick to place blame on the seller of purchases we dont like, such as that lemon of a car. People dont come to us to "buy" braces. Theyre buying a solution to a problem. When they are buying the solution, what they are really buying is the expectation of feeling good. You may have the best clinical results in the profession, but your success will depend on how your patients feel about those results and the environment in which those results were accomplished. If we employ the Patient-Centered Model, we have transformed our role from salesperson to consultant in their making a decision that will have a lifetime of rewards. 5. Bite Turbos Ormco Bite Turbos are modifications of lingual incisor brackets. Their bite planes are horizontal to the occlusal plane to avoid creating a distal force on the mandible. The flat surface and deeper anterior-posterior dimension of the bite plane generate faster bite opening while preventing dislodgment of lower anterior brackets. Since there are no slots or tie wings, Bite Turbos are easier to clean than conventional lingual brackets. Placement and removal

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are also simpler and quicker than with composites, splints or bite planes. No lab fee. No worries about fit or adaptation. Bite Turbos the simple, efficient, economical answer to deep bite problems. New Burstone Horizontal Tube Cuspid Bracket Dr. Charles J. Burstone has streamlined his popular Vertical Tube Cuspid Bracket with a small, more comfortable, more versatile design featuring a horizontal auxiliary tube. It facilitates frictionless retraction-loop space closure and affords reduced friction with sliding mechanics. The horizontal tube allows more precise centering and provides a more secure attachment for retraction loop and root springs. Unlike vertical slotted brackets, convenient labial access makes insertion, tying and removal quick and easy. Auxiliary torques are consistent with those of auxiliary tubes on Peerlessmolar attachments, allowing straight wire connections. Applications Continuous-arch space closure with power arms or loops. Cuspid retraction or en masse space closure with sectional and segmented arches. Accommodates cuspid uprighting and rotation springs. Leveling with an auxiliary wire. Unilateral and bilateral posterior distalization. Secures hooks for Class I, II, and III elastics. Developing lingual root torque with an auxiliary torqued wire. Uprighting molars with a molar root spring. Cuspid intrusion and extrusion. Availability Burstone Horizontal Tube Cuspid Brackets are available as Medium Diamond Twins in the Orthos(tm) prescription. Maxillary brackets provide +10 degree angulation and -7 degree torque in the incisal slot; lowers provide +6 degree angulation and -11 degree torque in the incisal slot. The auxiliary horizontal tube is .018 x .025. Available in rights and lefts in .018 and .022 (principal, incisal slot) brackets.

6. Bravo Brackets Bravo Brackets: designed for optimal patient comfort and safety The sales of Bravo(tm) brackets have doubled in the last year, and there are good reasons why. We believe that Bravo brackets are the best Roth prescription brackets on the market today. They are designed to make orthodontics as comfortable as possible for your patients. Bravos are cast, not machined or injection molded They have a low profile design and an extremely small size so they do not irritate your patients cheeks or lips The outer edges are rounded to help prevent trapping food and gingival irritation. There is 45 degree beveling on the anteriors to prevent occlusal interference and bracket popoffs They have smooth low profile ball hooks. The hooks are rounded on the lip side and flat toward the tooth to prevent gingival inflammation The torque is in the base, not in the face Rounded mesial and distal tips on all tiewings, for improved hygiene. Raised gingival tiewings on the bicuspids to make cleaning easier and to prevent gingival overgrowth or irritation Available in gold or metallic-silver color Other key features include: Trapezoidal shape that matches the contours of a tooth - goes on easily, stays on the teeth Extra strong tie wings Contoured mesh base for secure bonds that will not pop-off Vertical scribe lines to insure proper bracket placement Hooks built in to the castings for greater strength

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 Specially designed stepup channel to allow wires to slide freely without popping out. Interchangeable maxillary biscupids - the ball hook can be put either on the mesial or the distal of the tooth to increase force levels when using intraoral elastics. Color coded to prevent mixups A wide selection of buccal tubes available to complete the bracket system: Singles, Doubles, Triples, Convertibles Frequently Asked Questions About Bravo Brackets Why have the sales of Bravo Brackets been increasing so quickly? As we have said above, sales of Bravo brackets have more than doubled in the last year. People like them. Orthodontists like them because the brackets are really easy to put on, and they work great. Patients like them because they are more comfortable than a conventional bracket and easier to keep clean. Both patients and doctors appreciate the reduced treatment time that comes with a Roth prescription. Most doctors who have tried Bravo brackets like them. Our sales have gone up accordingly Where are the Bravo's made? All of the Bravo's are made in our plant in Bristol Pa. Why do you cast your brackets? A cast bracket is inherently more comfortable than a machined or injection molded bracket. When you cast a bracket you force molten metal into a pattern. Unlike a machined bracket, there is never a sharp edge or burr to cut a patients lips or cheeks. The bracket slot is always clean and burr free. With a clean bracket slot, the archwire can slide more freely and with less friction. Another advantage of a cast bracket is that unlike an injected molded bracket, there is never a weak spot in a tie wing to break in a patient's mouth. Casting is a slightly more expensive manufacturing technique than machining or injection molding, but we believe that the additional patient comfort is worth the extra cost. Do you charge more since your brackets are cast? No! The additional manufacturing cost was only about a dime a bracket; we decided to adsorb the additional manufacturing cost Why are your brackets so small? In our testing we found that smaller brackets were more comfortable for patients. There were fewer reports of irritated lips or gums, and fewer problems keeping the brackets clean. We have made our brackets as small as we could, consistent with their working well, because the small size is what patients like the best. If your brackets are so small do they still work? Of Course! Our mini-brackets work just like a full sized bracket. The torque and the tip are just the same as in a full sized bracket. We use a precision casting process so that the brackets provide the same forces as in a full sized bracket. We have carefully designed the base of the bracket to prevent popoffs under normal use. Why do you round the mesial and distal edges of the tie wings? Again that is to make the bracket more comfortable for your patients. The curved edges have no abrupt ridges. Consequently, food is less likely to get caught under a tie wing. Gingival irritation is minimized, and oral hygiene improves. That makes the bracket more comfortable for your patients. Why do you raise the gingival tiewing on the bicuspids? In our testing we found that with a conventional tiewing, food would get caught under a bicuspid and irritate a patients gums. When we raised the tiewing, food rarely got caught so irritation was minimized, and oral hygiene improves. A second advantage was that the raised gingival tiewings made the brackets easier to ligate which saves chair time. Can I use an uprighting spring with a Bravo bracket?

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Of course! The center slot on the Bravo's is specially designed so you can slide an uprighting spring directly under the archwire. One can use the uprighting spring to move the tooth, and since the uprighting spring connects directly to the archwire, there is no extra force torquing the tooth. You say that your sales have doubled in a year. Have you been able to keep up with the demand? Yes, at least most of the time. When our sales started to jump, the people in our bracket production area worked overtime to try to meet the demand. We also hired some more people to keep up with the production, although that was a long process because we needed to hire the right people and train them well. There were a few times when we were not able to keep up with the demand so we built a waiting list and made sure that everyone got enough brackets to hold them over. The neat thing, though, is that customers have been willing to wait because the brackets are so good. Bravo bracket's are worth waiting for. Try them yourself to be sure. What else have you done to speed up deliveries? First we bought more equipment so that we could make more Bravos. We improved our process, to improve out yield. We also hired a contract manufacturer to help us mount the brackets on the bracket pads so that we can speed up our production (mounting brackets on pads is a slow step). All of these things were expensive and time consuming. However, our customers are worth it. When I look at the bravos under a microscope, they look unpolished. Is there a reason? Well, the Bravo's have all been polished before they leave our plant. Still, there are two reasons that they look unpolished. First we put little rounded dimples into the bracket slot to minimize the friction. When the bracket is wet, the archwire slides along the little dimples; salivia can get under the wire and act like a lubricant. The result is better sliding mechanics. A second issue is that we heat treat all of the Bravo's as part of our manufacturing process. During the heat treatment process, grains grow in the steel. This strengthens the steel so a tie wing never breaks. However, if you look under the microscope you can see the grains, so the Bravo's looks unpolished. Actually, the Bravo's are not unpolished. They only look unpolished because of the grains in the tiewings and the dimples in the bracket slot. What is the advantage of putting the torque in the base of the bracket? When the torque is in the base of the bracket, the force is more evenly distributed over the tooth. That gives the orthodontist more control of the tooth position. The treatment can be finished in less time and with less wire manipulation and less discomfort for the patient. Why do you use a trapezoidal shape? The trapezoidal shape conforms better to the contours of your patients teeth than a conventional rhomboid. That makes it easier to align the bracket with the tooth and leads to fewer popoffs and faster treatment. Why Roth prescription? Roth prescription is the most popular prescription in orthodontics today. Unlike some older prescriptions, teeth move without excessive friction, and with less wire manipulation. The result is a shorter less discomfort for the patient, and less work for the orthodontist. How are the Bravo's color coded? How should they be mounted? The Bravo's are color coded to facilitate proper placement. Generally, maxillary brackets have a red dot while mandibular brackets have a black dash. The bracket should be placed on the tooth with the dots or dashes on the gingival side facing in the distal direction. The hooks on the bicuspids and cuspids are also usually mounted on the gingival side with the hooks facing in the distal direction. However, the maxillary bicuspids can be switched so the hooks go in the mesial direction. Each of the brackets is designed to mounted on the center of the tooth. The scribe line down the center of the bracket should usually be aligned with the long axis of the tooth to facilitate optimal tooth movement.

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Are there any issues with allergies? Bravo brackets are made with a surgical grade stainless steel which is supposed to be hypoallergic; no one has told us about an allergic reaction to a Bravo bracket. Still, surgical grade stainless steel contains nickel and chromium. The literature indicates that some patients do get allergic reactions to nickel or chromium in dental devices. Consequently, we believe that it is better to be safe than sorry; We recommend that you NOT USE A BRAVO BRACKET IF YOUR PATIENT IS ALLERGIC TO NICKEL OR CHROMIUM. Use a composite bracket instead. Young people with pierced ears have about a 30 times larger chance of being allergic to nickel or chromium, than a person without pierced ears. Consequently, we recommend that a patient with pierced ears be tested for metals allergies before they get braces. What are the symptoms of allergic reactions? Generally allergic reactions produce inflamed gingivae, and soreness in a patients mouth. If a patient says that their mouth is sore all the time and the patients brush their teeth every day, there is reason to suspect that the patient is allergic to something in their appliances. This is specially true if the patient has pierced ears since metals allergies are 30 times more common in people with pierced ears than in the remainder of the population. Allergies to archwires and rubber bands are much more common than allergies to brackets. Still any patient complaining of soreness in their mouth between adjustments should be tested for metals allergies, and if the patient is allergic to stainless steel, the brackets, bands and buccal tubes should be replaced with a composite brackets and titanium bands and buccal tubes. 7. Bruxism and Clenching Unfortunately, due to the difficulties of developing an adequate laboratory model that can easily replicate bruxism and clenching, a successful investigate of these common human oral habits is almost impossible. For the patient these habits can be responsible for dental pain as they relate to the head and neck and not to mention the potential for biting stress mobility on the periodontium. Part of the problem deals with the infinite possibilities of positions that the mandible has with respect to the maxilla as these positions are influenced by the dentition, the anatomy and the musculature. They just can not be duplicated in an experimental environment. And to confound the matter even more is trying to cope with the habitual nature of the human psyche. One strong consistent finding for these parafunctional habits is that most patients will strongly deny that they are doing it. Parafunctional habits such as clamping, clenching and grinding are very subconscious habits. Bruxism is the grinding or gnashing of the teeth and can be easily diagnosed clinically by observing the attrition or wearing away of the incisal edge or cusps of the teeth. Clenching and clamping is a noiseless occlusal habit that does not affect the tooth surface per se but can be most destructive to the supporting periodontium and can create biting stress mobility. It would be very difficulty to separate these parafunctional habits in individuals as all of them can and could be on going simultaneously. These are the most common oral habits and probably affect easily 90% of the human population at varying time periods of our lives. Although the trauma due to occlusal forces have not been shown to directly cause bone loss, patients who are prone to periodontal disease certainly can be adversely affected by its presence. This can create various degrees of vertical bone loss and increase the potential for secondary as well as primary tooth mobility. Excessive parafunctional habits can increase the potential for muscle spasm and pain in the fibers of the temporomandibular muscles. This in turn induces more stress which causes more unconscious clenching and potential for headaches and more exacerbated pain with decrease mandibular movement affecting speaking and chewing. An occlusal appliance would not be necessarily beneficial for the following reasons: 1. When there is adequate function 2. When there appears to be no shifting of teeth 3. When there appears to be no mobility presence 4. When there appears to be no signs or symptoms of TMD(Temporomandibular Joint Dysfunction). An occlusal appliance would be necessary for the following reasons:

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1. Presence of occlusal wear and/or disturbing noise 2. Presence of primary and secondary occlusal trauma 3. TMD symptoms 4. Following extensive periodontal therapy, orthodontics(retainer), and reconstructive dentistry 5. Adjunct to occlusal adjustments A clear heat-processed hard acrylic occlusal appliance is usually made for the maxillary teeth covering all maxillary occlusal surfaces and incisal edges. It should be designed so that all opposing mandibular teeth contact the appliance in CR(centric relation). The anterior portion of the appliance is slightly ramped to create incisal pathways for the mandibular incisors and cuspids in protrusive movements as well as lateral excursions to the right and left. The bottom surface of the appliance should be smooth and flat as possible leaving no interferences or incumbrances for the mandibular teeth to come in contact.The occlusal appliance should have no movement or rocking when the patient closes in centric or when the patient moves their lower teeth into excursions on the appliance. These occlusal appliances reduces the force of any contact that might occur during bruxism and minimizes the effects of malocclusion, which allows the temporomandibular muscles to rest, reducing spasm-induced pain and allowing time for a damaged joint to repair itself. More often than not the effects of primary and secondary tooth mobility will disappear in association with successful periodontal treatment thus allowing the teeth to stabilize quicker. A reduction in tooth sensitivity is usually seen with the use of an occlusal appliance and especially noticeable with those patients that often complain about generalized sensitivity with little or no evidence of other problems. This makes the occlusal bite appliance a very important adjunct to restorative dentistry as well as orthodontics and periodontics. 8. CBJ. .- .Armed For Efficiency The new Preattached Cantilever Bite-Jumper (tm) (CBJ) is as strong, easily delivered and foolproof as could be designed and engineered. Itcan be delivered less expensively than by having a commercial lab fabricate the appliance. It can reduce the number of patient visits, while improving net profit during the correction of Class II malocclusions." The CBJ features . 022 tubes attached occlusal to the axles on the cantilever arms. This provides three distinct advantages: If minor lower anterior crowding is present, it can be corrected while wearing the CBJ. The tube allows the appliance to be adapted to Dr. Terry Dischingers Edgewise Bioprogressive Herbst Technique. If the tube is not needed, it can be ground away or ignored, and it will have no effect on therapy. We have found the single-appointment CBJ to be a boon to our treatment. Patients and parents dont have to make repeated trips to the office. Also, we can enroll patients into active treatment more easily and start them faster. In this manner, we routinely deliver a CBJ in 4560 minutes. Joe H. Mayes, D.D.S., M.S.D.From The Single-Appointment Preattached Cantilever Bite-Jumper, Clinical Impressions, Vol. 5, Number 2, 1996. Implementing the Cantilever Bite-Jumper The 20-patient CBJ Kit provides the essential components for the single-appointment Cantilever Bite Jumper. (tm) A complete size range of laser-marked first molar crowns (seven per quadrant) is provided 80 crowns distributed according to popular usage. Upper crowns are supplied complete with nickel-brazed axles, while all lower crowns come with nickelbrazed cantilever arms that are specifically designed for maximum strength and optimum patient comfort. Each cantilever arm has an axle with a .022 tube occlusal to it for use with bonded cases. All necessary components for 20 cases are also supplied, including rods, sleeves, Hex-Head screws and a Hex-Head Allen wrench.Hex-Head screws are used for all appliances to increase accessibility and improve performance over conventional slot-head screws. The CBJ saves the expense of additional chair time, doctor time and staff time, and costs significantly less than using a commercial lab. The CBJ Fit-Kit (tm) provides one loose crown in each of the 28 sizes for trial fitting in order to avoid having to trial fit (and possibly deform) the more expensive crowns with attachments. Prewelded Precision (tm) Lingual Hinge Caps are an option for the lower arch (and upper as well when TPAs or other auxiliaries are planned) to eliminate all soldering and lab work except for pouring models. If

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Hinge Caps are used, Snug Fit .032 x .032 wire (available in straight lengths or preformed lingual arches) is recommended for achieving an ideal fit with lingual or transpalatal arches. Peerless(R) M/P .022 buccal tubes are also available nickel-brazed to upper molar crowns for use in bonded cases. CBJ Technique Lingual Arch Using an impression of the lower arch, prefabricate a lower lingual arch (.032 x .032 Snug Fit is recommended) to fit precision lingual hinge caps or solder directly to the stainless steel crowns. An extra model is made when the patient is ready for the Cantilever Bite-Jumping Appliance. Extra model with adjusted .032 x .032 Snug Fit wire. Sizing Crowns The CBJ Crown Fit Kit contains loose stainless steel crowns for trial sizing,each crown has a permanent laser mark and can be reused after sterilization. The CBJ Crown Fit Kit protects the more expensive components. Loose stainless steel crowns are fitted in the mouth for size. Preparing Lingual Arch Using the original plaster model, trim around the lower first molar using a bur. This will allow the crowns to be fitted to the model; any up-down, in-out, or torque corrections to the cantilever arm should be made at this time. If using Precision Lingual Hinge caps, place the lower lingual arch, mark and make bayonet bends both mesially and distally to the hinge caps to prevent the lingual bar from moving in an anterior-posterior direction. Keep the anterior portion of the lower lingual bar on the cingulums of the lower anterior teeth and not on the soft tissue. Note: The lower lingual bar should be totally passive at this time; if not, make any necessary adjustments. To test, lay the arch in place with the hinge caps open. Trial Fit Once the appropriate size has been determined, trial fit all crowns. Measure the interaxial distance from the mesial of the upper casing to the distal edge of the lower on both left and right sides. These interoral measurements determine the distance the lower jaw will be moved forward. Cut to Length The untrimmed interaxial distance is 31mm, so the difference between the measured interaxial distance and this figure should be cut away. For example: interoral measurement = 27mm, cut away 4mm. A separate disk can be used to cut both rod and tube; remove any sharp edges with a rubber wheel. The tube should be routed at the opening so the rod doesnt have any restrictions and slides freely. To avoid soft tissue impingement, the rod should extend no more than 2-3mm past the axle on the upper crown. There may be a trade off as the rod should be as long as possible to prevent it coming out of the tube when opening wide, but short enough not to affect the cheek. Fitting Crowns Crimp both mesial and distal crown walls prior to cementation. Glass ionomer band cement (Protech) is recommended. Check the length of the precut rods and make corrections using shims on either or both sides. Recommendations Do not trim crowns unless absolutely necessary. To prevent screws coming loose, Ceka Bond* should be applied directly to the screws when fitted. *Ceka Bond is a registered trademark of Preatt Corporation 8. Colorful Braces Make More Than Fashion Statement ST. LOUIS- For orthodontic patients who choose to make fashion statements with their mouths, colors are really heating up. From soft pastels that coordinate with a wardrobe to bright hues for celebrating holidays or expressing school spirit, the colors appear mainly on

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the elastic ties that bind the wires to the brackets. These ties can be changed when the wires are changed. Colorful braces may contribute to treatment success While colors for braces are fun, the fun serves a serious purpose, notes Dr. William Mahon, a spokesman for the American Association of Orthodontists (AAO). Enthusiastic patients are more cooperative. And better cooperation can yield results that meet everyone's expectations. "When patients decide to become involved in their treatment, they usually take better care of their braces. The bottom line is, when patients follow our instructions, they can end up with better results," emphasizes Dr. Mahon. Patients have a splashy array of hues from which to choose for much of their orthodontic hardware. Even the replaceable rubber bands that many patients put in and take out daily come in about as many colors as you'd see at a fabric store. "Patients won't take the time to choose special colors unless they intend to use them," Dr. Mahon says. Colors have gone over very big with countless braces-wearers. "You wouldn't believe how enthusiastic my patients are about colors," says Dr. Mahon, with a laugh. Before leaving the house, males and females of all ages check the mirror to make sure their braces are properly attired. "Without my St. Patrick's green, I'd get pinched!" exclaims Jonathan Cobb, 12, during a checkup at Dr. Mahon's office in Bentonville, Ark. Braces add splash of color to all occasions St. Patrick's Day is only one of many holidays that orthodontic patients can brace themselves for. They can celebrate every time they smile, year-round: Orange and black for Halloween. Red and white for Valentine's Day-and on July 4, just add blue. Green and red for Christmasor blue and white for Chanukah, or black, red and green for Kwanzaa. Many adults also choose different colors whenever they need to have their braces adjusted. For a sports fanatic, it's a unique way to express loyalty to college or pro teams. Arch wires also are available in many striking colors-from metallic red and green to gold. Retainers can be fun, too Once the braces are off, retainers are another colorful means of personal expression. They aren't all roof-of-the-mouth pink nowadays. Some glow in the dark, and some are personalized with a photo of Fido or Cindy Crawford, or even the logo of a favorite sports team. Choices are limited only by the imagination. Young male patients, of whom many are into anything gross, may choose spiders, snakes or other creepy crawlers for their retainers. The AAO notes that more people than ever are bracing themselves. Colorful retainers and other orthodontic trappings, of course, are only part of the reason for this trend. Patients are finding that today's high-tech materials are more comfortable. The sophisticated engineering of the tooth-moving wires-developed through NASA and activated by body heat-has increased their tensile strength and flexibility, which makes orthodontic treatment more comfortable. (Some patients want braces that are nearly invisible-so they choose clear brackets through which their teeth can be seen, or lingual braces, which are applied to the backs of the teeth to move them from behind the scenes). Free information available from the AAO The AAO recommends that every child see an orthodontist no later than age 7. For "Good Beginnings," the AAO's free brochure on early orthodontic diagnosis, or for brochures on adult orthodontics and many other topics, call 1-800-STRAIGHT (1-800-787-2444). Anyone considering orthodontic treatment for themselves or for a loved one can take advantage of the "Smile Bank," the AAO's free computer-imaging program. Send a color picture of yourself with a big, toothy grin to the AAO, c/o "SMILES," and you'll receive a free photo showing how your smile might benefit from orthodontic treatment. AAO members are uniquely qualified to correct "bad bites." The American Dental Association requires orthodontists to have at least two years of advanced specialty training in orthodontics in an accredited program, after graduation from dental school. 9. Computer Imaging Sneaks A Peek At The Future

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It is now possible to literally "picture" yourself with a gorgeous smile. That's what potential orthodontic patients can do, thanks to a remarkable computer-imaging program. The American Association of Orthodontists (AAO) has already provided thousands of people with a free, computer-generated photograph showing how their teeth might look after successful orthodontic treatment. The centerpiece of this program is the "Smile Bank," a unique data bank of beautiful smiles created to help demonstrate how effective orthodontics can be. Hundreds of photographs of smiles, taken of actual patients after orthodontic treatment, have been programmed into the AAO's state-of-the-art Smile Bank.

Computer-imaging can provide benefits to potential patients If a person is thinking about getting braces, computer-imaging can provide-free of charge-a preview of what might be expected from orthodontic treatment. The opportunity to view a possible end-result prior to actual treatment offers a benefit to the patient, who will be making a commitment to obtain a beautiful, healthy smile. The process of computer-imaging is simple and quick. Via a video camera, the computer captures a person's image. An orthodontist then compares the person's smile to hundreds of beautiful smiles stored in the computer's memory. Within minutes, the computer can print out a side-by-side comparison of the current smile and a future one as it might appear after orthodontic treatment. While the resulting photograph is obviously an approximation of what orthodontics can accomplish, it can be useful in discerning the possible results of treatment. Individuals are encouraged to see an orthodontist to discuss how orthodontics could benefit their smiles and overall oral health. The computerized photograph can help motivate the patient who is contemplating undergoing orthodontic care. Plus, this "after" photo can provide a real incentive for the patient to cooperate with required orthodontic treatment. For example, the photos encourage patients as they change eating habits (not always required). And they receive support to faithfully use auxiliary devices, such as headgear and elastics, which are sometimes required. How to participate To receive a complimentary computer-generated photo of how you might look after orthodontic treatment, send a color photograph to the AAO. The photo should be a clear, close-up frontal shot, with a wide, "toothy" smile. Mail, with your name, address and phone number, to "SMILES," American Association of Orthodontists, 401 North Lindbergh Blvd., St. Louis, MO 63141-7816. To learn more, see an orthodontist or ask your family dentist for a referral. Or call toll-free, 1800-STRAIGHT (787-2444), for more information or the names of AAO-member orthodontists in your area. 10. Considering Orthodontics? Here are some things to think about. More than 4 million people in the United States and Canada are in the care of an orthodontist and looking forward to a beautiful, healthy smile that's good for life. The obvious potential reward is straighter teeth that are less prone to decay and injury. But just as important is the boost to self-confidence that a better smile can provide. As you prepare to make decisions about orthodontics, it's very important to be armed with the facts. Here's a checklist of what to keep in mind: Why is orthodontics important? Orthodontics can boost a person's self-image as the teeth, jaws and lips become properly aligned, but an attractive smile is just one of the benefits. Alleviating or preventing physical health problems is just as important. Without treatment, orthodontic problems may lead to tooth decay, gum disease, bone destruction and chewing and digestive difficulties. A "bad bite" can contribute to speech impairments, tooth loss, chipped teeth and other dental injuries. When should my child first see an orthodontist? The AAO recommends that every child should see an orthodontist no later than age 7. In some cases, this could be as young as 2 or 3.

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Many orthodontic problems are easier to correct if detected early rather than waiting until jaw growth has slowed. Early treatment may mean a patient will avoid surgery or other more serious corrections later in life. Is it ever too late for a person to get braces? No. Because healthy teeth can be moved at any age, an orthodontist can improve the smile of practically anyone-in fact, orthodontists regularly treat patients in their 50s, 60s and older! What makes an orthodontist different from a dentist? Orthodontists are the dental specialists who correct dental and facial irregularities, day in and day out. An orthodontist is expert at moving teeth, helping jaws develop properly and working with the patient to help make sure the teeth stay in their new positions. AAO members are uniquely qualified to correct "bad bites." The American Dental Association requires orthodontists to have at least two years of post-doctoral, advanced specialty training in orthodontics in an accredited program, after graduation from college and then dental school. What about costs? This will vary, of course, depending on the nature of the problem. Many orthodontic problems require only limited treatment. You may be surprised to discover that orthodontics is less expensive than you thought. Your orthodontist will be happy to discuss fees. He or she may offer payment plans to help meet individual financial needs. In addition, many dental insurance plans now include orthodontic benefits. Of course, it's important to keep in mind the lifetime value that orthodontics provides. Should I ask to talk to present and/or former patients? It is wise for a consumer to investigate the value of any product or service. Most orthodontic patients will give it to you straight -- orthodontics is one of the best investments they've ever made. Better self-esteem and better oral health are benefits that can last a lifetime. An AAO member will be glad to have you talk to current or former patients, who can tell you firsthand how braces have improved their lives. 11. Copper Ni-Ti - Creative Use Dr.Saul Burk received his D.D.S.from the University of Maryland and his M.S. and certificate in orthodontics from Georgetown University. He was an assistant professor of orthodontics at Georgetown University for 11 years. Dr. Burk is in private practice in Gaithersburg and Olney, Maryland. Copper Ni-Ti is a new quaternary alloy (nickel, titanium, copper and chromium) with distinct advantages: Constant force over long activation spans Near constant force guaranteed Resistant to deformation Less drop in unloading force A thermal treatment process that produces three different transformation temperatures: 27C, 35C and 40C. The low load-deflection characteristics in conjunction with resistance to permanent deformation provide a large range of activation. These properties allow creative use of Copper Ni-Ti. The illustrations show how Copper Ni-Ti can be placed above and below orthodontic brackets to institute intrusion or extrusion of teeth. The most common use is to level the mandibular plane of occlusion by placing the wire to the incisal of the mandibular anterior brackets or to the gingival of the first and second bicuspid brackets. If you are concerned with rotation of these teeth, place a sectional wire in the bypass segment. I have also used this technique to open bites by placing the Copper Ni-Ti wire to the incisal of the maxillary or mandibular anterior brackets. An anterior open bite can be closed by placing the wire to the gingival of the maxillary anterior brackets and/or the mandibular anterior brackets. Vertical elastics may be used but are generally not necessary. Another use is to weave this wire above or below an orthodontic bracket that could not be ideally placed initially. This technique will compensate for a bracket height discrepancy. I have found that an .016 35C or .016 x .022 35C wire works very efficiently over 10-12 weeks. I have used other wires, but our patients seem to prefer the gentle action and I am very pleased with the results obtained with Copper Ni-Ti.

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12. Copper Ni-Ti (tm) Dimpled Arches and 35 degree Square For even greater convenience and control, Copper Ni-Ti is now available in both upper and lower Orthos archform with dimples added. Now you can increase your appointment intervals without the added risk of an additional emergency visit. For those who prefer to start in round wires .018 x 27 degree Copper Ni-Ti is an ideal low force initial wire. The very popular .016 x .022 and .019 x .025 are offered where early torque control and one initial wire meet your needs. Square 35 degree Copper Ni-Ti is also now available in .017 x .017 and .020 x .020 in both Orthos and Broad archforms. Square wires allow you to easily engage your most severe rotations while maintaining torque control early in treatment. For unbeatable wire-to-wire consistency in an initial archwire, try our new Square Copper Ni-Ti. On-line Technique Guide Enlight Light Cure Adhesive 1. Arch before enamel preparation. 2. Dab conditioner* on teeth for 60 seconds 3. Rinse conditioner off teeth (5 seconds per tooth). 4. Air dry enamel until dull and frosty. 5. Apply FluoroBond XM sealant over conditioned enamel. 6. Syringe Enlight paste on bracket base. 7. Position bracket on tooth, clean excess and press firmly. 8. Using a light, cure the adhesive (10 sec. for clear, 30 sec. for metal brackets). 9. Place archwire immediately after curing. *Caution: Conditioner contains phosphoric acid, avoid contact with skin, eyes and soft tissue. In case of contact with skin or eyes, flush immediately with water, get medical attention for eyes. Do not take internally. 13. Creating A Smile - That's Good For Life Orthodontics Can Improve Oral Health, Boost Self-Image Braces don't just change looks-they can improve outlooks. The art and science of orthodontics has greatly enhanced the quality of life for many people of all ages. Patients say they no longer feel the urge to cover their mouths self-consciously whenever they laugh or smile. October is National Orthodontic Health Month. This observance spotlights the health benefits of braces, among them emotional well-being and improved oral health. It also presents an opportunity for orthodontic patients to tell how braces have changed their lives. Orthodontic patients come from all walks of life, and their personal stories are uniquely compelling. Some are strikingly attractive. But others are grateful they don't get a second glance on the street today-because before orthodontic treatment, people may have stared at them. Among these countless people is Amie Beth Dickinson of Birmingham, Ala., whose upper and lower front teeth protruded before treatment. Until she got braces in her teens, she may not have turned as many heads as she is likely to today. She was chosen Miss Alabama 1994. Most cases, of course, are not beauty-pageant winners, but everyday people: Youngsters whose playmates don't call them ugly names or make fun of them anymore. Parents who have decided to get braces themselves after they've witnessed the change in their children's smiles and attitudes. Or women and men who believe that opting for orthodontics means they won't have to think about dentures. "Changing people's lives is no small thing-and we do it every day," notes Dr. Terry McDonald, a Portland, Ore., orthodontist. "But the change isn't always immediate, and isn't always recognized." Joe Miller of Chicago is a case in point. He'd originally sought orthodontic treatment because his teeth didn't meet. Chewing was so uncomfortable that he felt fatigued after meals. After his braces came off, at first he didn't think he looked all that different. But Miller found that not only was he able to relax and enjoy a meal-he could see his teeth in snapshots. That is, he was all smiles, not looking down or away from the camera like he always had before.

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If some people gradually blossom and thus are unaware of how much they have changed over time, their before- and after-treatment photos often tell a dramatic story. Posture may have improved; the person may no longer slouch, but sits up straight. The smiles are less self-conscious-and more self-confident. And because the orthodontist's specialized training and expertise has helped to close up spaces between teeth or eliminate crowding, patients have found it's easier to keep them clean. Michael Smith of Lancaster, Pa., says he has fewer problems with tartar buildup since braces realigned his teeth and jaws. "I do believe my teeth will last a lot longer," says Smith, who got braces in his late 20s. But as has been the case with so many people, other benefits of braces have come as a very pleasant surprise. "Having braces really improved my attitude," Smith says. "I was reluctant to smile before I had them. I really didn't want to talk because I was afraid of the way people would perceive my teeth." In his enthusiasm about the process, and its gratifying results, Smith could be speaking for thousands of people whose lives have changed because of orthodontics: "Now I feel much better about myself. I have much more self-confidence." More about the AAO The American Association of Orthodontists is the dental specialty group that represents nearly all of the orthodontists practicing in the United States and Canada. A chief mission of the AAO is to educate the public about the benefits to oral health-and emotional well-being in general-that orthodontic treatment can provide. Also, the AAO offers a free service to anyone considering orthodontic treatment for themselves or for a loved one: the Smile Bank. Anyone can send a good, close-up color photograph showing a big, toothy grin to the AAO and receive a free computer-enhanced version of that photo showing what their smile might look like after orthodontic treatment. To find out more, call 1-800-STRAIGHT (1-800-787-2444). 14. Esthetic Recontouring of the Orthodontically Treated Occlusion Dr. Martin Epstein serves as assistant clinical professor at New York University College of Dentistry, Department of Orthodontics and on the attending orthodontic teaching staff at Staten Island University Hospital. He is engaged in the private practice of orthodontics in New York City and Staten Island, New York Dr. Theo Mantzikos is an assistant clinical professor at New York University College of Dentistry, Department of Orthodontics and Department of Oral Implantology. His private practice of orthodontics is located in New York City. Dr. Ilan Shamus is an assistant clinical professor at New York University College of Dentistry, Department of Orthodontics. His private practice of orthodontics is located in New York City. by Martin B. Epstein, D.D.S. New York, New York Theo Mantzikos, D.M.D. New York, New York Ilan L. Shamus, D.D.S. New York, New York The increasing demand for cosmetic orthodontics has led to advances in the art of esthetic recontouring. The presence of irregular incisal edges, a worn or abraded dentition and imbalances in tooth morphology may limit our ability to produce a cosmetic result. These features may detract from the well-treated orthodontic alignment. Esthetic Recontouring Recontouring of teeth by grinding may be indicated in conjunction with orthodontic treatment. Esthetic recontouring is the process of selectively remodeling teeth to affect their shape, position, length, contour and proximal relationship with adjacent teeth. Youthful, feminine smiles are typically characterized by rounded incisal edges, open incisal and facial embrasures and softened facial line angles. In a more masculine smile or one characteristic of an older individual, incisal embrasures are more closed and incisal angles more prominent. Significant generalized changes are possible when treating all anterior teeth visible in the patient's smile. The composition of the smile is primarily characterized by the architecture of the maxillary anterior teeth. The mandibular anterior teeth may also play a defining role . Cosmetic orthodontics is an art form and its treatment objectives necessitate specific guidelines in order to achieve the desired esthetic and functional result. The following eight considerations facilitate the decision process in the shaping and recontouring of enamel:

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Horizontal Components Smile form - The horizontal curvature of the outline of the maxillary incisal edges and lower lip . Gingival margin harmony - The maxillary central incisor gingival margins should be 1mm apical to those of the lateral incisors. The gingival margins of the canines and centrals should be at approximately the same level . Incisal edge balance - Maxillary central incisors and canines are positioned the same vertically and the lateral incisors are slightly shorter both cervically and incisally. Embrasure form - The form is influenced by the morphology of the teeth, their widths and their arrangement. Vertical Components Maxillary midline - A coincidence of dental and facial midlines establishes a vertical reference line for symmetry and balance between the two halves of the smile . Smile foundation - The maxillary central incisors serve as the key to the smile. A 3:4 width-to-length ratio is ideal. Axial alignment - Mesial inclination of anterior teeth tends to be pronounced from central incisor, to lateral incisor, to canine. Golden Proportion - The widths of maxillary anterior teeth correlate. From a frontal view, the curvature of the smile has each tooth displaying 60 percent of the size of the tooth immediately anterior to it . Technique Cosmetic Preview Initially, determine if the completed orthodontic result could be improved with recontouring. Anterior guidance, canine guidance and group function must be assessed and maintained prior to the initiation of conservative remodeling procedures. Patients with open-bite tendencies or vertical discrepancies must be treated carefully, especially if they have short, abraded teeth. Teeth that have been restored either by crowns or large fillings must be taken into account prior to esthetic recontouring. Periodontally compromised teeth and teeth with fixed prostheses pose difficult treatment limitations. Gingival inflammation and poor oral hygiene are also limiting factors. Preparation Design Esthetic recontouring is not meant to be a substitute for incomplete treatment. The prime tenet of recontouring is the preservation of tooth structure. Once the treatment plan is selected, the teeth must be adequately and conservatively prepared. The best preparation is determined on an individual basis for each given clinical situation. The shape and form of the teeth largely determine the esthetic appearance. It is imperative that natural, anatomic forms be achieved in order to obtain optimal results. Although exceptions to the guidelines presented will arise, the scheme is intended to provide the clinician with a working guide that can be considered in esthetic recontouring. The use of a high-speed handpiece, a generous water supply and light, intermittent brush strokes is recommended for recontouring. Step-by-Step Procedure Step One: Incisal Reduction - Starting with the maxillary central incisors, recontour the incisal surfaces to make them mirror images of one another . Next, prepare the maxillary lateral incisors and canines using similar procedures. Incisal surfaces should be prepared judiciously. Merely flattening the incisal surface results in excessive loss of tooth structure. Step Two: Distal Shaping - Starting with the maxillary central incisors, reshape the distoincisal corners of both teeth . This results in central incisors that are mirror images of one another. Prepare the lateral incisors using the same procedures . Step Three: Mesial Shaping - Reshape the mesio-incisal corners of both maxillary central incisors. This will result in two symmetrical teeth. Prepare the lateral incisors in similar fashion. Maneuver the fine-point diamond perpendicular to the mesio-incisal margins of the teeth. Step Four: Labiolingual Reduction - Contour any sharp corners or edges remaining as a result of incisal reduction and mesiodistal recontouring. Special attention must be paid to the lingual edges, labiolingual dimensions and incisal edge thicknesses. Use a football-shaped diamond bur for this procedure. Step Five: Canine Shaping - The preparation of the maxillary canines is determined by anterior esthetics and occlusal interrelationships. Incisal reduction of cusp height has

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previously been completed in relation to the central and lateral incisors (Step One). The mesial and distal incisal surfaces should be prepared with the mesial slope being the shorter of the two and corresponding to the natural anatomy of the tooth . This results in canines that are mirror images of one another. A football-shaped diamond bur is also used for this procedure. Step Six: Final Assessment - An evaluation of the esthetics and function should be done to critically determine if recontouring objectives have been met. Smooth and polish at the end of the adjustment to reduce heat and trauma to the teeth. Step Seven: Gross Polishing - Mounted white stones are used across the prepared surfaces . Start with coarse sandpaper discs and gradually work toward ultrafine discs. Step Eight: Fine Polishing - Add a final luster with fine pumice or polishing paste in a prophy cup. Step Nine: Fluoride Treatment - Following the recontouring, perform a topical fluoride treatment on the prepared surfaces. Case #1 A 30-year-old female is shown after having just completed orthodontic treatment for a Class I crowded malocclusion . The composition of her smile was not harmonious. Recontouring was recommended to provide a more esthetic appearance to the maxillary anterior teeth. Special consideration was given to the maxillary lateral incisors to benefit the final cosmetic result. Evaluating before-and-after photographs via the guidelines suggested, one visualizes the esthetic improvement Case #2 A 28-year-old male is shown after completing orthodontic treatment for a mutilated, Class II, division 1 malocclusion with significantly worn and abraded maxillary anterior teeth Discrepancies can be identified at the incisal edges of the central and lateral incisors. Furthermore, there is no continuity to the mesio-incisal and disto-incisal edges. The necessity for esthetic recontouring was justified after reviewing the esthetic guidelines. A more balanced smile has been achieved following the procedure, adding to the successful orthodontic treatment Case #3 Occasionally, reshaping of the mandibular incisors is recommended. Recontouring of jagged mesial and distal incisal angles may be required. The incisal surface should be prepared at a right angle to the long axis of the tooth. This patient presented with unesthetic incisors and a periodontal defect. Treatment planning included a periodontal grafting procedure and incisal recontouring . Conclusion Specific details of tooth positioning and intentional changes in tooth morphology by recontouring can significantly improve the final occlusal and esthetic result. The concepts and guidelines suggested to facilitate the decision to produce an esthetic orthodontic smile have been outlined and demonstrated through case presentations. Figure 1. Improving the smile by recontouring A. Smile form displaying incisal edges of maxillary anteriors B. Preexisting anterior teeth C. Completed recontouring of smile form D. Anteriors with esthetic recontouring completed

15. GP Adult Limited Ortho, the Begg Bracket Advantage In this age of cosmetic dentistry most general dentists should have some knowledge of orthodontic treatment. At least enough knowledge so they know what is possible orthodontically to enhance the restorative results for their adult patients. Actually, analysis of the orthodontic problem is the hardest part. If they have enough knowledge to assess the problem and the solution, the mechanics are fairly simple, especially when utilizing the Begg 256 bracket. I don't know what your dental school experience was in the orthodontic department. At my school one of our first projects was to take an .030 stainless steel wire and bend the wire from #18 to #31 around the buccal gingival necks of the teeth! I am convinced to this day the

23

project's sole purpose was to discourage all GP's from ever touching an orthodontic wire again. Don't panic! The orthodontic treatment I am about to describe isn't even nearly as tough as my initial dental school project. What are the advantages of the Begg bracket for limited orthodontic movement for the General Dentist? The biggest advantage is you only need one bracket! Yes, you can use the same bonded bracket on any tooth upper and lower from bicuspid to bicuspid. Actually, I would prefer two bases, one is curved slightly with mesh for bonding bi's and canines, the other is flat based for the incisors. Other techniques require a different bracket for each tooth. That means a possible inventory of 20 different brackets plus backups in case some brackets are lost or broken. Other types of brackets are also greater in cost than the typical Begg bracket. The third big advantage lies in anchorage control. Other brackets and techniques build torque into the bracket and don't allow free tipping. This means that teeth must move bodily. Bodily movements of teeth require greater anchorage to gain movement in the correct directions. Begg brackets allow free tipping and are ideal for segmental archwires. Many general dentists that do limited ortho struggle with removable appliances and sometimes fall short on results because of the removable appliance's limitations and/or lack of good patient cooperation. Many other general dentists know they are limited by removable appliances so they ship off the patient to a specialist. The specialist insists on ideal treatment. The patient really wants only their front teeth to be aligned. They don't want full treatment lasting 2 years or more. The end result, the patient receives no treatment. I find that I can achieve a reliable, excellent, and efficient results by bonding a few Begg brackets and placing a nitinol wire. I also find that I can achieve these good results in much less time, both my time and the patient's time when I use fixed Begg appliances. Two types of cases come to mind that lend themselves well to limited orthodontic treatment. The first type case is the adult with upper or lower crowded anteriors 5mm or less space needed to uncrowd the teeth. The second type of case is the anterior spaced patient, usually a large diastema. In the diastema case, if restorative dentistry is all you know, you will be tempted to place two porcelain veneers on the central incisors and be done with the case. Usually, in the larger diastema cases the esthetic result is much better if you first move the centrals together part of the distance and place four veneers on the teeth lateral to lateral. I will proceed to describe the steps necessary to treat both types of cases. Anterior Crowded Cases Take good records, photos, make sure you have X-rays of the teeth to be moved, and study models. After you have determined that you need 5mm or less space to uncrowd the anterior teeth and that the opposing arch doesn't have any teeth that will not allow the uppers to be aligned (crossbites, extruded and misplaced teeth etc.), you are ready to place your brackets. ( SEE Figure 1) Note: you do not need to use jigs to align brackets but you do need to understand placement differences on upper and lower teeth shown in the diagram. We typically prophy the teeth, etch, place unfilled resin on the tooth and the back of the bracket and then filled resin on the bracket. We then position the bracket on the tooth. We usually mix enough bonding material to place 3 brackets at a time. We are using a self cure resin. Allow the resin to set for about 5 minutes then you are ready to proceed with obtaining space and wire placement. You can gain some space, in some cases, by just rounding out the arch form. We usually obtain space by using ARS (air rotar stripping) as advocated by Dr. Sheridan. Sometimes you must wait for the teeth to align somewhat before you have good access to trim the contacts properly. I find two excellent ways to do this. For tight contacts that I don't want to remove more than a 1/2mm I will use a double sided diamond disc that fits in my straight low speed handpiece for contacts that I can trim a little more I will use a 699 carbide. In both cases you want to shape the contacts back to normal form and polish them. After I have provided for space (as I can and is necessary) I will fabricate the archwire. We use a pre-formed round nitinol .016 wire. I trim the gross excess from the distal ends and try the wire in the mouth. I mark the wire distal to the last bracket on each side. A laundry pencil will mark the wire . I take the wire out of the mouth and make 45 degree bends at those points toward the lingual side of the wire. These bends help keep the wire from moving from side to side through the brackets. I place the wire back into the brackets and pin the wire to place. We give the patient home care instructions, including flossing, and some utility wax(clear) to place on any resulting sore areas. I see them back in 4 weeks.

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At the four week visit I may use ARS to provide for some more space in areas that were malpositioned in such a way at the first visit that I couldn't shape the contacts properly. I probably would not change the wire just yet. Another 4 weeks and the teeth should be fairly well aligned. I may switch to hard wire, round austrailian .016, and make some minor bends to correct some minor rotations that the nitinol wire hasn't corrected. Also if a root is mesially or distally tipped I will place uprighting springs to correct that problem. The stiff .016 wire must be used if you are using uprighting springs. I would also recommend that you tie a ligature tie from the distal most tooth to the distal most tooth when the springs are used or you may open up space in the arch as you upright. Vary the visit timing according to how much uprighting you need. (You will have to develop a feel for this from your experience ) I would suggest 3 weeks until you develop some experience. When all teeth are aligned properly leave the wire in place for a few additional weeks without springs etc. to allow some stability before you remove the brackets. I remove the brackets with a bracket removal plier, polish the remaining cement off using a 1157 carbide in a dry field, medium grit Moores disc, then prophy paste. We take final records and include impressions for the retainers. The retainer of choice is the Essix, also advocated by Sheridan. A regular Hawley can be used if you wish. (Perhaps in a later article I can summarize how you can make an Essix retainer in your office). The patient is brought back within a week and instructed how to care for and wear the retainer (Full time 1 year then at night after the first year). Diastema Cases In cases of patients with large diastemas the initial visit is the same except you will not need to do any ARS work. If the teeth are fairly well aligned you may be able to place the hard wire at the first visit. The second visit you will need to place an .016 austrailian wire and show the patient how to place a rubber band from central to central bracket. They should change the rubber band daily. Use a size rubber band that will place about 21/2-3 ounces of force on the teeth. The next visit assess if the incisal portion of the tooth has moved enough. If it has, assess the root position. If you have to move the centrals more than a mm or so you probably will need to upright the roots toward the midline. Place uprighting springs with the arms toward the mesial and be sure to tie the centrals together with ligature wire or the springs will just move the crowns back distally. When the teeth are properly aligned remove braces and make a retainer. You may take the impression for the veneers at this visit also. Have the patient in as soon as possible for the retainer (you don't want those teeth to move---many times I will bond a wire (a braided wire works best) on the lingual of the centrals for extra insurance against movement). The next visit place the veneers and take a new impression for a new retainer (if you are using an Essix type) (if you are using a Hawley you may be able to adjust the labial wire to accommodate the veneers). I have included some other pictures that may be helpful including pictures of the major instruments you will need. I have also included before and after photos of models of two patients my associate Dr. Greg has completed. Case one was a flared anterior case with a large diastema between 9 and 10. No ARS was necessary in this case. Case two required the extraction of one lower incisor to allow enough room for the excellent result. Basically, that's what you need to know! Let me assure you realigning the anterior teeth for your adult patients is a highly satisfying procedure. This knowledge will allow you to be a much better dentist and assure that your restorative results will be better than ever before possible. Remember the saying: "If your only tool is a hammer, everything seems to be a nail". Don't be afraid to learn how to use a pair of pliers! Supplies Light wire plier Light wire wire cutters Bracket removal plier (could use wire cutters in a pinchno pun intended) Begg 256 brackets flat and curved base Nitinol .016 upper and lower preformed archwires Spool of .016 wilcox australian wire Hook pins Left and right uprighting spring pins Ligature wire

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 carbide high speed bur Double sided diamond disc for straight handpiece Rubber band sizes (could use power chains instead change every two weeks) Utility wax Composite bonding system (What you already have will probably do fine) 16. GP Adult Limited Ortho, the Begg Bracket Advantage In this age of cosmetic dentistry most general dentists should have some knowledge of orthodontic treatment. At least enough knowledge so they know what is possible orthodontically to enhance the restorative results for their adult patients. Actually, analysis of the orthodontic problem is the hardest part. If they have enough knowledge to assess the problem and the solution, the mechanics are fairly simple, especially when utilizing the Begg 256 bracket. I don't know what your dental school experience was in the orthodontic department. At my school one of our first projects was to take an .030 stainless steel wire and bend the wire from #18 to #31 around the buccal gingival necks of the teeth! I am convinced to this day the project's sole purpose was to discourage all GP's from ever touching an orthodontic wire again. Don't panic! The orthodontic treatment I am about to describe isn't even nearly as tough as my initial dental school project. What are the advantages of the Begg bracket for limited orthodontic movement for the General Dentist? The biggest advantage is you only need one bracket! Yes, you can use the same bonded bracket on any tooth upper and lower from bicuspid to bicuspid. Actually, I would prefer two bases, one is curved slightly with mesh for bonding bi's and canines, the other is flat based for the incisors. Other techniques require a different bracket for each tooth. That means a possible inventory of 20 different brackets plus backups in case some brackets are lost or broken. Other types of brackets are also greater in cost than the typical Begg bracket. The third big advantage lies in anchorage control. Other brackets and techniques build torque into the bracket and don't allow free tipping. This means that teeth must move bodily. Bodily movements of teeth require greater anchorage to gain movement in the correct directions. Begg brackets allow free tipping and are ideal for segmental archwires. Many general dentists that do limited ortho struggle with removable appliances and sometimes fall short on results because of the removable appliance's limitations and/or lack of good patient cooperation. Many other general dentists know they are limited by removable appliances so they ship off the patient to a specialist. The specialist insists on ideal treatment. The patient really wants only their front teeth to be aligned. They don't want full treatment lasting 2 years or more. The end result, the patient receives no treatment. I find that I can achieve a reliable, excellent, and efficient results by bonding a few Begg brackets and placing a nitinol wire. I also find that I can achieve these good results in much less time, both my time and the patient's time when I use fixed Begg appliances. Two types of cases come to mind that lend themselves well to limited orthodontic treatment. The first type case is the adult with upper or lower crowded anteriors 5mm or less space needed to uncrowd the teeth. The second type of case is the anterior spaced patient, usually a large diastema. In the diastema case, if restorative dentistry is all you know, you will be tempted to place two porcelain veneers on the central incisors and be done with the case. Usually, in the larger diastema cases the esthetic result is much better if you first move the centrals together part of the distance and place four veneers on the teeth lateral to lateral. I will proceed to describe the steps necessary to treat both types of cases. Anterior Crowded Cases Take good records, photos, make sure you have X-rays of the teeth to be moved, and study models. After you have determined that you need 5mm or less space to uncrowd the anterior teeth and that the opposing arch doesn't have any teeth that will not allow the uppers to be aligned (crossbites, extruded and misplaced teeth etc.), you are ready to place your brackets. ( SEE Figure 1) Note: you do not need to use jigs to align brackets but you do need to understand placement differences on upper and lower teeth shown in the diagram.

26

We typically prophy the teeth, etch, place unfilled resin on the tooth and the back of the bracket and then filled resin on the bracket. We then position the bracket on the tooth. We usually mix enough bonding material to place 3 brackets at a time. We are using a self cure resin. Allow the resin to set for about 5 minutes then you are ready to proceed with obtaining space and wire placement. You can gain some space, in some cases, by just rounding out the arch form. We usually obtain space by using ARS (air rotar stripping) as advocated by Dr. Sheridan. Sometimes you must wait for the teeth to align somewhat before you have good access to trim the contacts properly. I find two excellent ways to do this. For tight contacts that I don't want to remove more than a 1/2mm I will use a double sided diamond disc that fits in my straight low speed handpiece for contacts that I can trim a little more I will use a 699 carbide. In both cases you want to shape the contacts back to normal form and polish them. After I have provided for space (as I can and is necessary) I will fabricate the archwire. We use a pre-formed round nitinol .016 wire. I trim the gross excess from the distal ends and try the wire in the mouth. I mark the wire distal to the last bracket on each side. A laundry pencil will mark the wire . I take the wire out of the mouth and make 45 degree bends at those points toward the lingual side of the wire. These bends help keep the wire from moving from side to side through the brackets. I place the wire back into the brackets and pin the wire to place. We give the patient home care instructions, including flossing, and some utility wax(clear) to place on any resulting sore areas. I see them back in 4 weeks. At the four week visit I may use ARS to provide for some more space in areas that were malpositioned in such a way at the first visit that I couldn't shape the contacts properly. I probably would not change the wire just yet. Another 4 weeks and the teeth should be fairly well aligned. I may switch to hard wire, round austrailian .016, and make some minor bends to correct some minor rotations that the nitinol wire hasn't corrected. Also if a root is mesially or distally tipped I will place uprighting springs to correct that problem. The stiff .016 wire must be used if you are using uprighting springs. I would also recommend that you tie a ligature tie from the distal most tooth to the distal most tooth when the springs are used or you may open up space in the arch as you upright. Vary the visit timing according to how much uprighting you need. (You will have to develop a feel for this from your experience ) I would suggest 3 weeks until you develop some experience. When all teeth are aligned properly leave the wire in place for a few additional weeks without springs etc. to allow some stability before you remove the brackets. I remove the brackets with a bracket removal plier, polish the remaining cement off using a 1157 carbide in a dry field, medium grit Moores disc, then prophy paste. We take final records and include impressions for the retainers. The retainer of choice is the Essix, also advocated by Sheridan. A regular Hawley can be used if you wish. (Perhaps in a later article I can summarize how you can make an Essix retainer in your office). The patient is brought back within a week and instructed how to care for and wear the retainer (Full time 1 year then at night after the first year). Diastema Cases In cases of patients with large diastemas the initial visit is the same except you will not need to do any ARS work. If the teeth are fairly well aligned you may be able to place the hard wire at the first visit. The second visit you will need to place an .016 austrailian wire and show the patient how to place a rubber band from central to central bracket. They should change the rubber band daily. Use a size rubber band that will place about 21/2-3 ounces of force on the teeth. The next visit assess if the incisal portion of the tooth has moved enough. If it has, assess the root position. If you have to move the centrals more than a mm or so you probably will need to upright the roots toward the midline. Place uprighting springs with the arms toward the mesial and be sure to tie the centrals together with ligature wire or the springs will just move the crowns back distally. When the teeth are properly aligned remove braces and make a retainer. You may take the impression for the veneers at this visit also. Have the patient in as soon as possible for the retainer (you don't want those teeth to move---many times I will bond a wire (a braided wire works best) on the lingual of the centrals for extra insurance against movement). The next visit place the veneers and take a new impression for a new retainer (if you are using an Essix type) (if you are using a Hawley you may be able to adjust the labial wire to accommodate the veneers). I have included some other pictures that may be helpful including pictures of the major instruments you will need. I have also included before and after photos of models of two patients my associate Dr. Greg has completed. Case one was a flared anterior case with a

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large diastema between 9 and 10. No ARS was necessary in this case. Case two required the extraction of one lower incisor to allow enough room for the excellent result. Basically, that's what you need to know! Let me assure you realigning the anterior teeth for your adult patients is a highly satisfying procedure. This knowledge will allow you to be a much better dentist and assure that your restorative results will be better than ever before possible. Remember the saying: "If your only tool is a hammer, everything seems to be a nail". Don't be afraid to learn how to use a pair of pliers! Supplies Light wire plier Light wire wire cutters Bracket removal plier (could use wire cutters in a pinchno pun intended) Begg 256 brackets flat and curved base Nitinol .016 upper and lower preformed archwires Spool of .016 wilcox australian wire Hook pins Left and right uprighting spring pins Ligature wire carbide high speed bur Double sided diamond disc for straight handpiece Rubber band sizes (could use power chains instead change every two weeks) Utility wax Composite bonding system (What you already have will probably do fine) 17. Implants as an Alternative Treatment for Missing Maxillary Laterals Dr. Julia Harfin completed her dental and orthodontic training at the University of Buenos Aires, where she later received her doctorate in 1969. She serves as professor, Department of Orthodontics at Maimonides University. Dr. Harfin has spoken and published extensively domestically and internationally and belongs to numerous orthodontic and dental societies, including the and the Sociedad Argentina de Ortodoncia, where she has served as president from 1990 to the present time. She maintains her private practice of orthodontics in Buenos Aires, with a heavy emphasis on adult treatment. by Julia F. de Harfin, D.D.S., Ph.D. Buenos Aires, Argentina Introduction Dental agenesis occurs more and more frequently (as studied by Sinclair, McNeill, Joondeph, Thilander, Dolder, Grahnen, Meskin, etc.), especially missing maxillary lateral incisors, which represents a true challenge to an aesthetic solution. For a long time, moving the entire lateral segment mesially to place the cuspid in the lateral incisor position was suggested as an alternative treatment (Tuverson, Zachrisson, McNeill, etc.). Since the cuspid has a very different crown and root shape to that of the lateral incisor, as well as a darker shade, these solutions end with compromised results that do not fulfill the aesthetic requirements of good orthodontic treatment. Since lateral movements are made using bicuspids, which have shorter, thinner roots, functional requirements are not fulfilled either. On the other hand, replacing the missing lateral incisor by fixed prosthetic means requires reshaping neighboring teeth, with the consequent removal of varying amounts of enamel, depending on the type of restoration chosen (traditional fixed bridge or Maryland bridge), with the eventual risk of gingival recession, caries and the resulting aesthetic compromise. The osseointegrated implant is the most conservative and biological method, since a missing tooth can be replaced without damaging the neighboring teeth, provided the following factors are taken into account: Angulation and position of the roots of neighboring teeth. Smile-line height. Width of the interdental space. Amount of bone available.5. Length and width of the implant. Position of the implant with respect to the basal bone.

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 Remaining gingival thickness (and its transparency). Degree of patients commitment to future maintenance. Case Report Motive for the Consultation. The 23-year-old patient consulted to resolve her problem of congenitally missing maxillary laterals. She had been wearing a removable acrylic appliance to replace them and was experiencing the consequent phonetic and aesthetic problems. Patient presented a mesiofacial biotype, with a straight and harmonious profile. Dentally, she had Class II molar and cuspid relationships. The lower left 2nd primary molar was in infraocclusion, with a mesially inclined lower left 1st permanent molar and distalization of the lower left 1st bicuspid as well as the formation of a diastema due to its rotation . The inadequate inclination of the upper right cuspid, along with a very pronounced mesial inclination of its root (in the opposite direction to that required for an implant space), was another problem. On her radiographs (, we can see the almost horizontal position of the lower left 2nd bicuspid, with its fully formed root and its crown next to the middle third of the 1st molars mesial root. This represented a major challenge for its proper placement. Treatment Plan.With the placement of two osseointegrated implants to replace the missing laterals as our objective, we started treatment by placing preadjusted aesthetic brackets on the maxillary arch . As seen in this same figure, two acrylic teeth were added to the arch as a temporary solution to the patients aesthetic problem during active treatment. The maxillary central incisor and cuspid roots were uprighted, leaving adequate room for the implants. This space should not be less than 6.5 mm when the width of the implant is 3.75 - 4 mm, since a minimal 1 mm separation is necessary between each root and implant (. Simultaneously, the lower left 2nd primary molar was extracted and the clinical exposure of the 2nd bicuspid was accomplished by means of an osteotomy and gingival incision. Special consideration was given to preserving the periodontal structures of the neighboring teeth. A week later, a standard edgewise bracket was placed to begin relocation of the bicuspid, despite the patients age and the fact that the root of the tooth was already completely formed . This procedure was done using a sectional appliance with preadjusted brackets (. A Ni-Ti (R) coil spring was used to close the anterior diastema and compensatory bends were made to straighten the lower left 1st molar. Later, lingual buttons were used to finish rotating the bicuspid . reveals the excellent result obtained with this technique. Once the maxillary arch had been stabilized and proper spacing, root paralleling and adequate aesthetics of the anterior segment had been achieved, we proceeded to place the dental implants. In cases where the aesthetics are greatly compromised (as shown in this case report), the choice of implant system is important, since it should have the greatest range of prosthetic solutions. Furthermore, an evaluation should be made of the available connections between the implant and the final prosthetic restoration. To achieve the greatest aesthetic harmony, the crown-implant union should be at a subgingival level. Nevertheless, research has shown that the presence of a gingival sulcus deeper than 4 mm diminishes the oxygen pressure, creating the proper conditions for the development of highly aggressive, anaerobic subgingival flora. Balancing these two variables trying to achieve better aesthetics while diminishing the risk of peri-implantitis is accomplished by controlling the depth of the remaining peri-implant sulcus. To achieve this goal, type 31 implants were selected. Both implants were placed during the same surgical procedure. Even though the bone height and quality were good, alveolar collapse on the left side was considerable (such collapse is due to loss of the vestibular bone plate). It has been customary in such cases to flatten the bone until its buccolingual width is greater than the diameter of the implant. By following this procedure, the gingival limit of the implant would remain apical in relation to the cementoenamel junction of the neighboring teeth; in the case of a greater gingival thickness, we would have had a peri-implant sulcus much greater than 4 mm. Gingivectomy would have been necessary to avoid this situation, compromising the aesthetics even more. After all the facts were considered, we positioned the implant at the level of the existing bone crest, resulting in a slight gingival defect due to the presence of a small part of the implant that remained without a bone cover. The guided regeneration technique (highly predictable in implantology) was used and a nonreabsorbable membrane was placed (GorTex No. 6), its position fixed by means of the implant screw cap. The membrane was extracted 60 days later by a minor surgical procedure; then a four-month period was allowed for integration of the implant. For this technique to be successful, the implant must have primary or immediate immobility. Throughout the healing period, the orthodontic appliance remained in place .

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Another treatment option for patients with collapse of the alveolar process is to first achieve the bone regeneration of the collapsed zone with guided regeneration techniques and a bone graft. After adequate time for the bone to regenerate in the buccolingual dimension, the implants are placed in a second surgical procedure. Six months after the implants were placed, we uncovered them, verifying their immobility and monitoring the subsequent bone filling. Afterward, the gingival healing screws were placed, the flap was sutured and temporary crowns were placed . After the healing period, the screws were removed and the proper healthy condition of the internal epithelium within the periimplant sulcus was verified, as well as its depth . In any zone with significant aesthetic compromise, the temporary crowns should remain 10-60 days, enough time for the maturation of the gingival connective tissue; any alteration of the height of the gingival margin is thus prevented. In many cases, placement of the temporary crowns helps us reassess the aesthetics and determine if gingival plastic surgery is indicated.Construction of the permanent crowns is similar to that used with natural teeth, depending on the prosthetic choice. On this particular patient, threaded UCLA-type crown supports were selected ( and metal-ceramic restorations were placed and cemented . Its very important that this type of single-tooth implant restoration be diagnosed with the greatest possible accuracy in order to place the implant at the most adequate height and to determine the resulting gingival contour that would achieve the greatest gingival harmony. The excellent aesthetic result can be observed. Results. The predetermined objectives were achieved within a period of 16 months for the maxilla (eight months for orthodontic correction and eight months for osseointegration and prosthetic restoration) and 18 months for the mandible (complete relocation of the lower left 2nd bicuspid, despite the age of the patient and the fact that the root was completely formed). The functional and aesthetic results are shown , as well as the reaction of the gingival tissue six months later , where a highly acceptable aesthetic result can be observed. The texture, color and form of the gingival papilla, as well as its adaptation to the implants, are excellent. Conclusion Osseointegration as an alternative in the treatment of missing lateral incisors is highly recommended, based on current knowledge. The orthodontist plays a key role in preparing the occlusion prior to placement of the implants. Keep in mind that the proper location of neighboring teeth and their roots is fundamental in reaching the proposed aesthetic objectives. Osseointegration is recommended for patients who have completed their active growth periods. From the biological point of view, this is the most conservative restorative treatment, making it possible to maintain a functional occlusion in both anterior and posterior segments. Once the proper age is reached, the disadvantages are minimal (only one surgical procedure in two phases) and there is a high predictability of clinical success (>90%) whenever the indications are correctly considered and each patient is evaluated individually. 19. Invasion crevical resorption(ICR) Invasion crevical resorption(ICR) has unknown etiology. It has been linked with orthodontic movement of involved teeth, internal bleaching, and occlusal trauma. IRC is seen most often at the cemento-enamel junction(CEJ) and is usually first recognized radiographically as it is hard to detect with a casual clinical examination. Radiographically is may mimic decay at the CEJ but the pulp chamber and canal is most frequently not involved. Sections of extracted teeth have shown ICR to almost completely surround the root canal without actually invading it with resorption. Treatment of IRC involves complete debridement of the area. If the source for the resorptive cells(periodontal ligament) can be severed then further destruction will be halted and then it is simply a matter of proper restoration. The problem is that ICR has finger-like projections extending into dentine which are impossible to address with simple curettage. Leaving these areas unattended will lead to failure as resorption continues into these projections. In addition, multiple passages to the PDL are notable on histological examination. This demonstrates that there are usually more than one portal of entry for cells originating from the periodontal ligament. Many of these portals enter below the bony crest. These types of findings relate to a very difficult clinical situation. The difficulty of removing all labyrinths of canals below the bony interface through simple curettage is thought to contribute to failure of the treatment. Trichloroacetic acid(TCA) has been used in the treatment and management of IRC. TCA is used in short repeated applications of 20-30

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seconds on the exposed defect. It is also applied to the resorptive tissue until the defect has been debrided of all visible connecting channels. The coagulative effect of the TCA on these residual channels has been proposed to be the foundation for its clinical success. After curettage and debridement with TCA the resulting defect caused by IRC is repaired using a glass ionomer cement restoration. Numerous case studies have shown that the further apically the defect extends the poorer the prognosis. Large defects extending apically may be managed by a combined orthodontic extrusion approach to try and move the defect above the invading periodontal tissue level. ICR is a common dental finding that presents as a very challenging dental condition. Understanding the etiology and anatomy of the process and thorough knowledge of its treatment and restoration are a must for the best clinical success. Reference: Heithersay G: Invasive cervical resorption. Presented at the 1994 AAE 51st annual session. 20. Lingual Orthodontics- The Inside Story The "hidden agenda" of lingual orthodontics extends beyond "invisible braces" themselves to the prevailing unawareness in the profession of the current worldwide growth of the technique and its potential for increasing practice profit-ability. In these days of encroaching MSO's and discounters, lingual orthodontics affords a unique approach to positioning your practice on the inside track and offering your patients a truly aesthetic alternative well worth a premium fee. Today's improved bonding, archwires and lingual mechanics greatly facilitate the discipline. Perhaps of even greater benefit has been the development of a seasoned cadre of lingual practitioners with excellent teaching skills to guide your entry into or accelerate your mastery of the technique. Take a step up in orthodontics and take advantage of the learning opportunities provided by these distinguished clinicians. Additional course information is provided on the Course Schedule on the back cover. Dr. Didier Fillion has practiced lingual orthodontics exclusively in Paris since 1987. He holds quarterly in-office courses in French and English and has lectured and presented seminars throughout the world. Dr. Fillion has served in highest positions in French and international lingual orthodontic societies and congresses. For the first time, he is bringing the Fillion Lingual Orthodontic Seminars to the United States - New Orleans, October 13-15 and San Diego, October 16-18. "Lingual-friendly" case selection, "patient-friendly" mechanics and "orthodontist-friendly" technique will be thoroughly drilled, and many progress cases with adjustments will be presented. For additional information or to register, contact: Fillion Lingual Orthodontic Seminars, 3500 Behrman Place, New Orleans, Louisiana 70114; phone (800) 474-3633; fax (504) 362-1104. For courses in Paris or other locations, call 33-147042793 or fax 33-1-47551833. Dr. Courtney Gorman maintains his private practice in Marion, Indiana, and serves as associate professor, Department of Orthodontics, Indiana School of Dentistry, where he directs the lingual training program and also conducts an annual typodont workshop on lingual orthodontics for the Continuing Education Department. The next Indiana workshop will be held January 30-31, 1998. Included are an introductory session, diagnosis and treatment planning, comprehensive typodont exercises, laboratory procedures, bonding techniques and marketing. Practicing orthodontists as well as students from all graduate orthodontic programs are encouraged to attend. Last year's workshop filled quickly, so register early. For additional information or registration, contact: Continuing Education Department, Indiana University School of Dentistry, 1121 W. Michigan Street, Indianapolis, IN 46202; phone (317) 274-7782. To handle the heavy demand, Ormco is sponsoring a similar workshop in Orange, California, on October 24-25, 1997. Call Ormco at (800) 854-1741, Ext. 7575. Dr. Mario Paz maintains a large lingual practice in an area of high cosmetic consciousness and expectations. He conducts semiannual in-office courses that enable orthodontists new to lingual therapy to start treating lingual cases and that also advance the skills and knowledge of those familiar with the technique. A wide range of patients at all stages of treatment is seen, evaluated and discussed (course is limited to six participants). The course includes lectures, lingual prescription writing, new lingual archwire sequence and mechanics, enamel reproximation techniques, typodont practice and marketing. The next course is scheduled October 9-11, 1997. For details, contact Shelly at Dr. Paz's office: 9735 Wilshire Blvd., #308, Beverly Hills, CA 90212; phone (310) 278-1681; fax (310) 274-5286.

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Dr. Giuseppe Scuzzo enjoys a heavily lingual orthodontic practice in Rome and serves as visiting professor in lingual orthodontics at the University of Ferrara. Dr. Scuzzo founded and served as president of the Italian Lingual Orthodontic Association and now holds the positions of president of the European Society of Lingual Orthodontics and scientific secretary for the forthcoming Third European Lingual Orthodontic Congress to be held June 18-20, 1998, in Rome. He invites his colleagues to take advantage of this exciting opportunity to hone skills, share experiences and explore the latest advances in lingual technique and appliances. Dr. Scuzzo has published and lectured extensively in the field and conducts many courses jointly with Dr. Kyoto Takemoto. To contact Dr. Scuzzo, call 39-6-5685852 or fax 396-68592443. Dr. Kyoto Takemoto starts over 200 lingual cases each year in his Matsudo City office and in his lingual-oriented satellite office in Tokyo. He presents hands-on typodont courses in lingual orthodontics in-office, throughout Japan and around the world. He demonstrates the unlimited applicability of lingual mechanics to orthodontic treatment, including open- bite and extraction cases. A prolific writer and speaker, Dr. Takemoto has years of experience teaching orthodontists at beginning to expert levels of lingual orthodontic proficiency. Every phase of lingual treatment is covered extensively in his courses. Information and registration for Dr. Takemoto's Japanese courses are handled by Roy Kishi (Ormco, phone 81 3 3432 0065; fax 81 3 3432 1255). Contact Dr. Scuzzo regarding Takemoto/ Scuzzo courses. 21. Malocclusion Andre Ruest, B.Sc., D.M.D., Cert. Ortho. According to the Burlington Orthodontic Research Project (University of Toronto, Faculty of Dentistry, Report #3, 1957), 89 percent of 12 year-old children have some form of malocclusion. Of this 89 percent, 55 percent have a Class I malocclusion, 32 percent have a Class II malocclusion, and 2 percent have a Class III malocclusion. The classic Class I crowding case with no skeletal discrepancies more than likely represent only 10 to 15 percent of all Class I malocclusions. What is Class I malocclusion? Early on, orthodontics was strictly an "antero-posterior" specialty. Malocclusions were defined based on the anteroposterior position of the upper first molar. If the mesiobuccal cusp of the upper first molar occluded in the buccal groove of the lower first molar, then the occlusal scheme was described as Class I. Furhtermore, if there were no rotations or crowding of the teeth, the occlsion was then described as "normal". Thus a Class I malocclussion was one where the molar relationship was Class I, but was also accompanied by rotated and/or crowded teeth. The concept of the Class I occlusion was later extended to include a description of the canine relationship. A Class I canine relationship is one where the upper canine central lingual surface occludes in the embrasure between the lower canine and the lower first premolar. But the teeth were not the only structures responsible for dental esthetics and facial harmony. The jaw forms and positions are also influencial. Thus a concept of skeletal relationship was developed with the advent of cephalometrics as a clinical tool. Again, cephalometrics was strictly an antero-posterior discipline early on. Most of our concepts of skeletal malocclusion are thus rooted in this thinking. An angle can be measured between point A, nasion, and point B as they appear on a lateral cephalograph. If that angle is 2 degrees(+-) 1 degree then the skeletal relationship is said to be Class I. Point A is defined as the deepest point of the curved outline from anterior nasal spine to the junction of the alveolar process with the maxillary central incisors. The nasion is defined as the most anterior point of the frontonasal suture. Finally point B can be defined as the deepest point of the concavity that runs from the junction of the mandibular alveolar process with the mandibular central incisors to the most prominent point of the chin. Thus the concept of skeletal malrelationship introduced another variable in the diagnosis of malocclusion. Another variable to consider is the anteroposterior position of the jaw themselves. Thus the AP position of maxilla can be measured in a number of ways cephalometrically. The same holds true for the mandible. The most common and best known maxillary measurement is the SNA angle. Point S is the center of the sella turcia. An SNA angle of 82 degrees (+-) 2 degrees is considered the norm in the caucasian population. The corresponding mandibular measurement is the SNB angle where the norm for the caucasian population is 80 degrees (+-) 2 degrees.

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Yet another variable is the angulation and position of the incisors as seen on the lateral cephalograph. One can draw a line from the apex to the incisal tip of both the maxillary and the mandibular central incisors. The angle formed between this line for the upper incisors and a line drawn from point A to the nasion should yield a value of 22 degrees (+-) 2 degrees in the caucasian population. The incisal tip should be 4mm (+-) 1 mm forward from line NA. For the lower incisors, the value of the angle between the incisal line and the line from point B to point N (nasion) should be 25 degrees (+-) 2 degrees and the incisal tip should be 4mm (+-) 1 mm forward from line NB. The clinical findings of the classic Class I malocclusion case are thus as follows: A Class I molar relationship A Class I canine relationship Crowding and/or rotations A Class I skeletal relationship (ANB at 2 degrees (+-) 1 degree) A normal maxillary A-P position (SNA at 82 degrees (+-) 2 degrees) A normal mandibular A-P positon (SNB at 80 degrees (+-) 2 degrees) A normal angulation and position of the upper incisor A normal angulation and position of the lower incisor No vertical skeletal discrepancy No transverse skeletal discrepancy Such a case is essentially a dental problem where there is a tooth-size/arch-size discrepency. Either the teeth are too big for the normal size of the arches or the arches are too small for the normal-sized teeth. Depending on facial esthetics the treatment of choice in such a situation is four premolar extractions to create enough space to align the teeth and maintain the molar, canine, skeletal, and incisor relationships. Variations on a Theme From this basic clinical picture, one can add variations. The first can be described as a dentoalveolar protrusion where the angulation and position of the incisors will be forward of the norm. Such cases usually respond well to premolar extractions. The second would be the converse or dentoalveolar retrusion. In such cases it is recommended not to extract if possible for one risks creating a dished-in profile. A third variation is bimaxillary protrusion where both the upper and the lower jaws are forward of their norm. Extractions may not always be indicated in such a situation because the protrusion of the jaws may be compensated by other facial features which end up creating an esthetic facial pattern overall. However if the bimaxillary protrusion is accompanied by dentoalveolar protrusion, then extractions might be indicated. A rare occurence would be the combination of a bimaxillary protrusion and dentoalveolar retrusion. A fourth variation is bimaxillary retrusion where both the uper and lower jaws are behind of their norm. This condition rarely produces an esthetic profile and extractions might exacerbate an already unfavorable situation. Such a condition accompanied by dentoalveolar retrusion or protrusion is very difficult to treat. However, it is not enough to only consider the antero-posterior relationships. The orofacial complex is a three-dimensional structure with length, height and width. Skeletal and dental vertical and transverse discrepancies can modify the above clinical descriptions in significant ways. Two Other Dimensions The vertical dimension can have very disrupting effects on a malocclusion. Generally the skeletal vertical excess (hyperdivergent pattern, open bite) can be recognized by a steep mandibular plane. The mandibular plane can be measured on a cephalograph by extending a line from the lower border of the mandible to cross the Frankfort horizontal plane. The norm in caucasians is 25 degrees (+-) 4 degrees. Anything above that norm will be regarded as hyperdivergent. This hyperdivergence generally positions point B further back in the face making the ANB reading questionable. Generally, such cases can be helped by extractions and some growth modification to conteract the vertical growing tendency. If the patient is an adult, then one might consider surgery as part of the treatment plan to bring the patient closer to an ideal Class I skeletal relationship. If there is an open bite but no corresponding skeletal measurements then the open bite is probably caused by a habit and correction or control of said habit will help in the treatment of the condition. But if the habit accompanies an already excessive vertical skeletal pattern, treatment even in combination with surgery becomes very difficult.

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When the pattern is one of hypodivergence extractions are rarely a good solution because the strong musculature exhibited by such patients make it quite difficult to close extraction spaces. The habits usually associated with such patterns are bruxism resulting in early abrasion of teeth. Finally, the transverse dimension also has to be considered. In the transverse dimension, the width of the maxilla and mandible can be measured through the use of a postero-anterior cephalograph. Again there are several possible combinations. Both upper and lower jaws are correct width as are the dental arches Both upper and lower jaws are correct width but the dental arches are collapsed lingually (ususally not an extraction case) Both upper and lower jaws are correct width but the dental arches are tipped buccaly (one might consider extractions depending on the other spatial variables) The upper jaw is too wide and the lower jaw normal width. If the dental arches have compensated extractions might not be the answer The upper jaw is normal width and the lower jaw is too narrow. (Usually a difficult case) The upper jaw is normal but the lower is too wide. (Might consider expanding the upper jaw to meet the width of the lower jaw) The upper jaw is narrow and the lower jaw is normal. (Quite common. Usually rapid palatal expansion) In summary the Class I malocclusion can take varied aspects. Thus treating all Class I's with the same therapeutic regimen is too simplistic and can lead to disaster. Each case must be analysed on its own and in all three spatial dimensions. Furthermore, one must take into account the direction of growth in children and the evolution of the malocclusion in adults. Getting Started: Your initial consultation will include a complete review of your past medical and dental history. You will be asked what you want to change about your smile and what questions do you have about braces. Your orthodontist will do a detailed examination of your face, jaws and teeth. Your orthodontist will explain any tests (x-rays, photos and impressions of the teeth) necessary to plan treatment. Your orthodontist will try to answer the following questions: Can the problem be corrected? How much will it cost? How long will it take? When should it begin? What kind of appliance or device will be used? What does the patient do for treatment to succeed? What are the pros and cons of orthodontic care? Your orthodontist will tailor treatment for you. Your orthodontist will indicate any other dental care necessary before starting braces treatment. 22. Mini Diamond Gold Series Brackets (tm) Skillfully crafted gold cups and jewelry made as early as 3500 B.C. have been dug up in Mesopotamia (now Iraq), and even the early cave man was aware of gold. Man's fascination with gold is still going strong, stronger than we realized. Sales of our recently-released Mini DiamondGold Series(tm) Brackets far exceeded our forecast, so we're working this rich vein a bit harder to further spread the word about the benefits our gold plated brackets can bring to your practice. Gold-plated brackets have been around for a number of years, but never in the patented Mini Diamond design, the most popular bracket in the world. The quest for gold has historically entailed sacrifice, be it dying of thirst in the Superstition Mountains, freezing to death in the Klondike or even having to compromise on bracket design. The Mini Diamond Gold Bracket, however, affords gain without pain, the right shape and a precisely measured layer of 24karat gold plating that provides the glamour of gold throughout treatment. Mini Diamond Gold Series Brackets are available 5 to 5, upper and lower, .018 and .022, cuspids w/hooks and bicuspids w/o hooks, in the Level Arch(tm) Modern Technique (modified Roth). 23. Modern Orthodontics Diagnosis, Treatment Planning and Therapy by Larry W. White, D.D.S., M.S.D.

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This well-illustrated 121-page book is replete with useful information for the orthodontist who believes in individualized therapy that conforms to a patient's specific needs rather than relying on cookbook recipes. In addition, a 35-page appendix includes two articles on Class II interarch therapies reprinted from the Journal of Clinical Orthodontics that amplify Dr. White's highly evolved approach to treating Class II malocclusions. Chapter I on diagnosis and treatment planning includes a detailed explanation of the use of Holdaway's soft-tissue measurements and visualized treatment objective as part of a tridimensional treatment plan, plus a simplified step-by-step technique for making occlusograms. Chapter II presents an extensive view of Class II diagnoses and therapies that is balanced with respect to the controversies regarding extraction and nonextraction philosophies. Chapter III defines proper diagnosis as the key to successful treatment of the Class III patient in determining where to focus therapy. Chapter IV describes the most recent advance in preadjusted bracket systems and provides helpful information and techniques to reduce bonding and banding failures. Chapter V introduces a new and realistic paradigm of patient motivation and includes a description of some of the common dental behaviors of difficult patients and strategies for designing treatment for them. In Chapter VI, Dr. White presents his philosophy of retention and the techniques he employs. Quoting Dr. White, "from the inception I intended no more than to enlighten readers about a few diagnostic and therapeutic concepts I have learned from others through the years. Nevertheless, I hope it offers some ideas unavailable from other orthodontic sources." And indeed it does! You'll find Modern Orthodontic Diagnosis, Treatment Planning and Therapy to be a font of practical ideas that can benefit your practice. 24. Molar-Moving Bite Jumper (MMBJ) A native of Crane, Texas, Dr. Joe H. Mayes received his B.S. from Texas Tech University, followed by his D.D.S., M.S.D. and certificate in orthodontics from Baylor College of Dentistry. Dr. Mayes is engaged in the private practice of orthodontics in Lubbock, Texas, and has been actively involved in new product development. by Joe H. Mayes, D.D.S., M.S.D. Lubbock, Texas The MMBJ was developed to assist with the correction of dental and skeletal problems. The appliance works exceptionally well correcting skeletal Class IIs and closing missing lower 2nd bicuspid space. We have used the appliance unilaterally, bilaterally and with asymmetric cases. The appliance works equally well with all these dental and skeletal problems and is a valuable adjunct to our skeletal Class II corrections. As the molars are moved forward by the appliance , mesial crown tip is totally eliminated by the use of .045 lingual molar tubes with an .045 lingual bar. There are two types of MMBJ. One employs stainless steel crowns on the D/4s bilaterally. The .045 lingual bar extends distally through an .045 tube soldered to the lingual of the bands, unilaterally or bilaterally (prior tack welding facilitates the soldering procedure) . Most of the second type of appliance can be pre-made with Ormco Cantilever Bite Jumper (CBJ) components to simplify and speed the lab procedures . Both appliances use CBJ upper molar crowns with pre- attached axles, but the second one uses the lower CBJ with preattached cantilever on the side opposite the one with the missing lower 2nd bicuspid. This opens the bite slightly, allowing the other lower 1st molar to move mesially more rapidly. In either case, the D/4 bands are reinforced "a la Jim Hilgers." In other words, bulk up the band with solder when soldering the axle to the band . The solder goes completely around the band to make a very rigid anchor of the lower arch. Since many Class II malocclusions require widening of the upper jaw, take an extra upper impression at the first visit so that the upper expander can be fabricated prior to the patient visit. When the patient returns for the expander, take a lower impression, pour in lab plaster and separate the lower. If an E is still present in the missing 2nd bicuspid site, refer the patient for extraction so that the molar can be moved mesially. Trim the upper and lower models around the 1st molars as well as the D/4 on the side of the lower arch with the missing 2nd bicuspid . Cut the upper model down the midpalatal suture line with a die saw . This allows the two halves of the model to be positioned after the desired expansion has occurred. When the patient returns for the third visit, remove the lower spacers and the upper expander. Fit a band on the lower 1st molar and on the D/4 on the side with the missing bicuspid, and fit a CBJ crown on the opposite molar. Use CBJ Fit Kit crowns for trial fitting to avoid damaging the more expensive crowns with attached cantilevers. Then place the CBJ crown with

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attachment. Follow the same procedure to fit crowns on the upper 1st molars. Remove the band on the D/4 and tack weld an axle to it. Also, tack weld an .036 hook in place before soldering. Ni-Ti springs can be attached to the hook to connect the D/4 and 1st molar in order to bring the molar forward. Flow solder around the axle base and the band. Place the band back on the tooth . Measure the interaxle distance with the lower jaw pushed forward in an edge-to-edge position. This enables the lab personnel to cut the rods and tubes to the correct length before cementation. The bands and crowns that were fitted in the mouth are taken to the lab, along with the removed upper expander. The upper expander is placed on the two halves of the upper lab model, and the two halves are then sticky waxed in place to hold the separation (I sticky wax the halves on a tile used for soldering) . Place the upper CBJ crowns (previously fitted in the mouth) on the model after the expander is removed. Fabricate an .045 stainless steel transpalatal bar and solder and polish . It can be removed at the next visit, approximately 12 weeks away. Next fabricate the lower part of the appliance. Tack weld a 4.5 mm length .045 tube to the lingual of the lower molar band for ease of soldering; or you can use an .045 inconel Ormco tube tack welded to the band . Soldering is essential for sufficient strength of the attachment. Fit the CBJ crown on the model as well as the molar and bicuspid bands. Place the .045 lingual bar (that was premade on this model) into the molar tube. Make any necessary adjustments to the bar and make a mark approximately 3 mm distal to the D. This will allow the attachment of a stop on the lingual bar to prevent the molar from completely closing the space of the missing E. Remember, an E is 10 mm mesiodistally and the lower 5 is 7 mm mesiodistally. Therefore, we need to leave a little space when closing. This is not necessary if the cuspid and 1st bicuspid are present. Hold the lingual bar in place with sticky wax and solder to place on the lingual of the CBJ crown and the lingual of the D/4 . Since the molar will move forward on the .045 lingual bar, the bar must not be bent distal to the D/4, or the molar will bind. Check the fit of the upper and lower parts of the appliance in the mouth. Microetch the inside of the bands and crowns if this was not done previously. Crimp the mesial and distal of the crowns, attach the tubes (already cut to correct length) to the upper crowns and cement the appliance with glass ionomer cement . Attach a 9 mm 150 gm Ni-Ti spring to the hooks on the labial of the D/4 and the 6 . Check the rods to see if shims are needed for midline correction or lower jaw advancement and then attach the screws with Ceka Bond. Now give the patient instructions on possible problems and how to care for the appliance. Also advise the patient that as the molar comes forward, the lower lingual bar may impinge on the tongue. The bar will be trimmed at regular visits with a handpiece unless required more often. If an in-house lab is not available, an excellent alternative would be Allesee Orthodontic Appliances, Inc., (AOA). I have worked very closely with them on the designs of all the appliances I use. However, this is a rather simple appliance and can be done in a lab in the office with minimal equipment. As a variation of the CBJ, the MMBJ has proved itself a reliable and easy solution for the correction of a skeletal Class II with the dental deformity of a missing unilateral or bilateral lower 2nd bicuspid. The appliance helps with our overall goal of having braces on our patients for the shortest possible time. Take Advantage of MMBJ Mechanics in Your Practice Perhaps the best way to get started with the MMBJ is to rely upon the expertise of (AOA), P.O. Box 725, Sturtevant, WI 53177, phone (800) 262-5221. AOA can provide either of the two types of MMBJ described by Dr. Mayes. Or they can just size lower Ds or 1st bicuspid crowns with presoldered axles to your model. If you prefer to use your own lab, you can order the essentials from Ormco: Kits, CBJ Fit-Kits, CBJ components, spacers, .045 inconel tubes, lower D and 1st bicuspid ss crowns, and 9 mm .010 x .030 light force Ni-Ti closed coil springs. 25. New Ultra-Lock mesh bonding pad ensures superior bond strength. We think Rematitan titanium brackets are a great way for you to give your patients a happy and healthy smile. Independent studies have shown that approximately 32% of women and 20% of men have shown a positive reaction to nickel. These reactions can be as slight as inflamed gingival tissue to burning, itching or skin irritation. It should also be pointed out that when given the choice, patients have preferred titanium over stainless steel. According to Dr.

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Wayne Hickory of Ellicott City, MD, "Especially in medicine, people like to know they're getting the latest technology. Titanium is identified as a proven high tech product, and our patients appreciate what we're bringing to the treatment." In short, it enhances your practice's image. We will send you some samples of titanium marketing tools. As an introductory offer, if you purchase 10 cases of Rematitan you will receive FREE PATIENT LITERATURE PAMPHLETS ADDITIONAL POSTERS TO DISPLAY IN YOUR OFFICES A FREE TITANIUM CONSULTATION MODEL A ONE YEAR LISTING ON OUR INTERNET WEB SITE We register hundreds of "hits" on our web site every day and have taken calls from people seeking referrals for doctors using titanium. This listing will post your name, address, phone, fax and e-mail address (if available) on our web page. Therefore, a prospective patient has your information instantly. If you would like to place your order or need more information, please call us at 1-800-523-3946, fax us at 1-800-553-6389 Two studies were completed in 1996 which demonstrate the superior efficiency of the "A" Company Straight-Wire Appliance. Study #1: Straight-Wire Appliance Efficiency Study This study compares non-Straight-Wire Appliances to the "A" Company Straight-Wire Systems to determine which provides clinicians with greater economies in office and patient treatment procedures and to quantify performance measures of the appliances. Six doctors randomly selected 10 non-Straight-Wire appliance and 10 Straight-Wire Appliance patients for a study total of 120 patients. Doctors were asked to track specific patient data and to provide open-ended responses which summarized their findings. The findings indicated: Treatment time reduction on average of 7 months The number of appointments decreased on average by 6 appointments Chair time savings were 3.6 hours per patient The percentage of cases which finished on time climbed 50% Results are based on findings of study conducted by "A" Company. Your actual results may vary. "A" Company considers the doctors who participated in the study to be high quality orthodontists who clearly understand the concept of the Straight-Wire appliance and the importance of correct bracket placement and treatment planning. Study #2: Archwire Compensating Bend Comparative Study "One cannot help noticing that the manufacturer that started it all, "A" Company, still stands as a front runner in appearing to respond most clearly to the concepts of the Straight-Wire Appliance." Dr. R. Angelakis This study analyzed approximately 55,000 final archwires from twelve manufacturers to evaluate routine end of treatment practices using straight-wire brackets. Archwires were sorted according to size and compensating bends and analyzed by brand, slot size, prescription and line of the bracket. A differential analysis was performed to assess the proportion of compensating bends for each company. This study was conducted by Dr. R. Angelakis, New York University College of Dentistry, New York. Results indicate: Only "A" Company gives you all of these advantages: a fully programmed Straight-Wire System with a built in prescription for level slot lineup, proof of dramatically reduced treatment and chair times based on evidence from ongoing studies, and the latest product innovations designed by world leading practitioners. No matter how many imitators claim to be like us, only "A" Company has the last word on Straight-Wire efficiency: Start with us and you'll Finish First. For precision indirect lingual bonding, the T.A.R.G. is used by Dr. Didier Fillion in conjunction with his tooth-thickness measurement system that compensates for thickness differences with the addition of composite pads. Specialty Appliances also uses the T.A.R.G. indirect bonding system, with or without thickness variation compensations. The T.A.R.G. is a precision bracket placement device used in indirect bonding for either labial or lingual brackets. It will accurately and consistently establish technician- or doctor-specified torques, tips and bracket heights for each tooth with settings providing up to 0.5 and 0.01" precision. An instruction booklet is included with each T.A.R.G.

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T.A.R.G. (Torque Angulation Reference Guide) Related Subjects: -Clincal Impressions Vol 7 (1998) No. 1 26. Now You See Them - Or Maybe You Don't ST. LOUIS- Who says braces are just for kids? Certainly not the estimated 1 million adults in the United States and Canada who have chosen orthodontic treatment as the route to better oral health and emotional well-being. According to the American Association of Orthodontists, which has its headquarters in St. Louis, there are about 4 million U.S. and Canadian orthodontic patients; of that number, the AAO estimates that one out of four of these patients are over the age of 18. Which means you probably know an adult who is wearing braces-but doesn't necessarily mean you know they are. For instance, actress Mary Stuart Masterson, who has starred in films including "Chances Are," "Fried Green Tomatoes" and "Bad Girls," chose to undergo treatment via lingual braces, which are attached to the backs of the teeth and, therefore, are less visible. Though lingual braces aren't for everybody-they don't solve all orthodontic problems, and they generally prolong treatment time somewhat-they represent one of the treatment options now available to adults considering braces. Behind the scenes Masterson isn't the only celebrity who has benefited from orthodontics. Braces have helped shape other famous faces, including Cher, basketball star David Robinson, golf great Hale Irwin and Dr. Joyce Brothers, all of whom underwent orthodontic treatment as adults. But, whether in the glare of the cameras or just everyday people conscious of their appearance, many adults who decide to take the plunge and opt for braces find the only real challenge with treatment is working regular visits to the orthodontist into a busy schedule. As is the case with younger patients, successful completion of treatment for adults involves cooperating with the orthodontist's instructions. And, because of their extensive training and knowledge, orthodontists can select cost-effective methods and materials for correcting individual problems. "Teeth can be moved at any age," says Dr. Numa W. Cobb Jr., an AAO spokesman and orthodontist practicing in Greensboro, N.C. "Adults understand the investment in a beautiful and healthy smile. And, since they're generally footing the bill for treatment-often with the assistance of their employers' dental coverage-they're more likely to keep their braces clean, as well as wear elastics and retainers as instructed." Less metal Adults are discovering that today's high-tech materials are light-years away from the "metal mouth" look they may have been familiar with as teen-agers. Some recent innovations include clear or tooth-colored brackets and the sophisticated engineering of the tooth-moving wires, which has increased their tensile strength and flexibility. As a result, treatment times may be reduced in some cases, meaning less time spent in braces. Dr. Cobb emphasizes, however, that adult patients may choose to flaunt their orthodontic treatment, taking the attitude of "if you've gotta have 'em-you might as well flaunt 'em." Some adults have chosen gold-colored braces and wires to coordinate with their jewelry and other fashion accessories. What's more, today's retainers also come in patterns and colors other than the traditional roof-of-the-mouth pink. So, even a mild-mannered executive could, unbeknownst to most observers, be sporting a wild paisley or plaid-or the crest of an alma mater-behind that great smile that's soon to be good for life.

27. Orthodontic Case Report Dr. Gabriele Floria

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The impaction of maxillary permanent canines is a delicate problem for both its functional and aesthetic implications. It requires the coollaboration of the oral surgeon, the ort hodontist and the periodontist. When there is a palatal bilateral impaction and the patient is an adult, various factors which influence our clinical decisions must be considered. A good clinical and radiographic examinations are essential to reach an accurate diagnosis. Clinical Evaluation: Signs and symptoms Signs(1): 1. Delayed eruption of the permanent canine with or without prolonged retention of decidous canine 2. Absence of a normal canine bulge to the intraoral palpation 3. Presence of a palatal bulge noted to the intraoral palpation 4. Distal migration of lateral incisors, distal tipping spaces between the incisors, rotations and deviation of interincisive line if unilateral impaction. The absence of the canine bulge at earlier ages should not be consider indicative of canine impaction (2). Symptoms Shafer et al.(3) also consider canine impaction to be responsible for: 1. Dentigerous cyst formation 2. External root resorption of impacted tooth, as well as the neighbouring teeth 3. Referred pain 4. Internal resorption These sequelae may generate pain, but usually impaction of maxillary canine is completely asymptomatic. Radiographic evaluation The purpouse of a radiographic examination is: 1.To verify the presence of impacted teeth 2.To check the morphology and structure of the impacted teeth 3.To make sure there are no obstacles to orthodontic disimpaction 4.To locate the impacted teeth exactly Various radiographic exposures, occlusal films, panoramic views, lateral cephalograms, periapical films and tomography can be used. The first examination should be the orthopantomograpy because it gives us the most information. Moreover putting the orthopantomogram on the diaphanoscope, making a slide of the area involved, and transferring it on photo CD (Kodak system) a digitized high resolution computer image can be obtained. The computer also help us in comparing the dimensions of the impacted tooth with the corresponding one should it be present, in order to establish whether the impacted tooth is lingual or buccal. Since the X-ray moves in a straight line, if the impacted tooth is buccal its image will be bigger than the controlateral canine. The enlargement of the radiological image is also important to verify the absence of ankylosis, in which case the orthodontic treatment may be very difficult or impossible. Radiographically the ankylosis can be defined as the absence of a periodontal ligament (radiolucent line) which is a sign of the fusion of cement with alveolar bone (4). If the panoramic view doesn't give us sufficient information about the tooth location a periapical films following Clark's rule (tube shift) can be used. In this technique the orizontal angulation of the cone is changed when the second film is taken. If the tooth moves in the same direction as the cone, it is lingually positioned, otherwise it is buccally located. Treatment plan There are several treatment options: 1. No orthodontic treatment:especially when we have removed the obstacles to a spontaneous eruption (like a dentigerous cyst) or a sovrannumerary tooth. 2. Extraction of the impacted canine and movement of the first premolars into this position 3. Prosthetic replacement 4. Surgical exposure and orthodontic treatment to disimpact the canine and align it in the arch.

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This last option is obviosly the most desirable situation. Case Report A 30 year-old male, heavy smoker,(fig.1) was referred to the orthodontist by his family dentist. The clinical examination showed the presence of the left deciduos canine, and distal migration of lateral and central incisors. The absence of a canine bulge and the presence of a bilateral palatal bulge were noted upon intraoral palpation. There were no symptoms. Panoramic radiographs showed the presence of two impacted canines (fig.2). Considering the good morphology of the teeth, the position and the absence of ankylosis, (fig.3) in agreement with the oral surgeon the surgical-orthodontic disimpaction was decided. A fixed superior appliance (fig.4) was applied. The oral surgeon performed the surgical exposure (fig.5) of the impacted teeth and the orthodontist attached an auxilliary button directly to the crown's enamel on the palatal side. This one-step approach is preferable, and to assure good bonding to the enamel the exposure should be the least traumatic possible. A fibrine sponge is useful to reduce the bleeding around the crown, and a pariodontal curette can be used to remove the primary cuticle from the enamel. An orthophosphoric acid (37 %) was used for 40 second and the button was bonded. A ligature with several holes was prepared and attached to the button before bonding (fig.6). The surgical exposure was very conservative. Only the bony tissue over the crown was excised and the flap completely sutured. We consider this light surgical exposure to be beneficial to the future periodontal health. After a week the suture and the surgical dressing were removed, and light orthodontic force (no more 60 grams/2 ounces) with elastic ligatures was started (fig.6). Concurrently sufficient space was created in the arch thus reducing the diastema. A preformed round arch wire 0.020 was used to provide sufficient stiffness. During the treatment two endoral radiographs were made on each side to ensure that the movement of canine was not damaging the roots of the neighbouring teeth. When the crowns were erupted a metallic canine bracket was bonded, and the remaining movements were made with sectional (fig.7-8), later repositioning the bracket twice. A Flexiloy tm (Unitek) * 0.021 X 0.025 was the finishing arch and an Essix reteiner was used for retention (fig.9-10-11-12). The active treatment lasted 2 years and 2 months long. Both the canines at the end of treatment had good periodontal conditions (fig 13-14). References: 1) Samir Bishara: Impacted maxillary canines: A review. Am.J.Orthod. Dentofac. Orthop. 101;2:159-171,1992. 2) Ericson S,Kurol J. Longitudinal study and analysis of clinical supervision of maxillary canine eruption. Comunity Dent. Oral Epidemiol. 14:112-6, 1986. 3) Shafer W.G.; Hine M.K.; Levy B.M.; A textbook of oral patology 2nd ed. W.B. Saunders Co.,Philadelphia, 2-75:1963. 4) Moyers R E. Handbook of orthodontics, Second Ed., Chicago: Year Book Medical, 83-88,1963.

28. Orthodontic diagnosis and treatment planning Submitted by Dr Andre Ruest, Orthodontist We saw in this series on orthodontic diagnosis and treatment planning how to identify orthodontic problems with a quick screening process. The present article will deal with generating an orthodontic problem list from the observations gathered through the screening process.

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Listing the different problems observed allows the practitioner to focus on individual problems and hence determine what needs to be done and in which sequence. The following example will allow the reader to understand this process. A 21 year-old male presents to the office with a chief complaint of not being able to chew his food with his front teeth. Upon examination you notice that the mandibular plane angle is severely open, that the profile is straight and that the lower face height is long. A very basic problem list at this point would be: Problems 1. Open Mandibular Angle 2. Straight Profile 3. Long Lower Facial Height For each item on the problem list it is possible to generate a treatment objective (i.e. what is it that the practitioner plans to accomplish in regards to the particular problem: Correct the problem completely, reduce the severity of the problem, or leave the situation as is). In the above example then a possible objective list would be: Once an objectives list has been constructed from the problem list, the next step is to devise a treatment plan based on the data in the different lists. The individual objectives point to specific interventions that need to be done. Furthermore, the practitioner must also decide how the objectives will be met. In the above example a possible treatment plan would be: The next step is to decide how each item in the treatment plan will be accomplished. Because the patient has finished growth, the treatment plan involves surgical intervention to bring the skeletal parameters within normal limits. If the patient had been younger, then it might have been possible to harness growth to accomplish the same objectives. so in the above example, instead of surgically impacting the maxilla and setting back the mandible, the use of extra-oral traction to control maxillary vertical growth and mandibular anterior growth might be considered if growth is still present and the patient is will motivated. Once the mechanics of how each step will be accomplished have been established, then one must decide when they will be accomplished. Again in the above example, since the patient will be undergoing a surgical procedure combined with orthodontic therapy, dental decompensation must first be achieved to set up the case for surgery. This might take a minimum of 12 months before the patient can be scheduled for surgery. To visualize the chronological sequence of treatment let us take a look at the complete data concerning this particular patient.
Problems 1. Open mandibular angle 2. Straight profile 3. Long lower facial height 4. No labial seal 5. Tongue thrust 6. Gingivitis 7. Mutilated dentition 8. Cl III molar & canine relationships 9. Dental open bite (-4 mm) 10. Bilateral posterior X-bite 11. Retroclined lower incisors 12. Mesially-tipped lower 2nd molars Objectives 1. Close the mandibular angle 2. Maintain straight profile 3. Shorten lower facial height 4. Provide labial seal 5. Stop anterior tongue thrust 6. Control gingivitis 7. Replace missing teeth 8. Provide Cl I molar & canine relationship 9. Provide adequate dental overbite (2 mm) 10. Correct posterior X-bite 11. Upright lower incisors 12. Upright lower second molars

Chronological sequence 1. Control gingivitis (Objective 6) 2. Upright the lower teeth to decompensate (Objectives 11, 12) 3. Correct posterior X-bite to new lower width (Objective 10) 4. Correct sagittal, vertical and transverse skeletal components (Objectives 10, 8, 9, 1, 2, 3, 4, 5) 5. Fine-tune the occlusion (Objectives 8, 9) 6. Replace missing teeth (Objective 7)

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As can be seen in the above list the chronology for achieving each objective is just as important as the elaboration of the objectives themselves. In general, one must correct the transverse dimension before the antero-posterior or the vertical. We will elaborate, in the next part of this series, on determining the chronology of events in an orthodontic treatment plan. 29. Orthodontic treatment in England and Wales Discontinued orthodontic treatment in the general dental service and community dental service in England and Wales during the summer of 1991 Training dental nurses in the use of the PAR Index: A pilot study Assessment of general dental services orthodontic standards: the dental practice board's gradings compared to PAR and IOTN. Index of oral cleanliness (I.O.C.). A new oral hygiene index for use in clinical audit Orthodontic treatment planning by general dental practitioners Late lower arch crowding in relation to skeletal and dental morphology and growth changes A critical assessment of orthodontic standards in England and Wales (1990-1991) in relation to changes in prior approval Orthodontic management of root-filled teeth Orthodontic products update. Aligning archwires, the shape of things to come? - A fourth and fifth phase of force delivery Factors influencing the uptake of orthodontic treatment Distal movement without headgear: the use of an upper removable appliance for the retraction of upper first molars Consultant orthodontic services for cleft patients in England and Wales A new approach to incisor retention - the lingual spur retainer A clinical and laboratory evaluation of three types of operating gloves for use in orthodontic practice. In vitro measurement of enamel demineralization in the assessment of fluoride-leaching orthodontic bonding agents Practice management forum. Insights into business of orthodontics Clinical section. Prader-Willi syndrome - a case report of the multidisciplinary management of the orofacial problems The prevalence of temporomandibular disorder in patients referred for orthodontic assessment Scientific section. Obstructive sleep apnoea: fact not fiction Use of a modified twin block appliance following partial maxillectomy: case report The effect of static loading in orthodontic bonding Factors associated with the standard and duration of orthodontic treatment The effects of extracting upper second permanent molars on lower second permanent molar position An analysis of the papers published in the British and European journals of orthodontics Practical application of the PAR index: an illustrative comparison of the outcome of treatment using two fixed appliance techniques The assessment of crowding without the need to record arch perimeter. Part II: crowded and irregular arches Accuracy of orthodontic force and tooth movement measurements The assessment of crowding without the need to record arch perimeter. Part I: Arches with acceptable alignment. 30. Orthodontics Will Never Be The Same Now orthodontists and their patients have an alternative to traditional stainless steel for braces. Titanium is the new metal of choice... destined to make stainless steel obsolete... and able to rid patients of potential health problems.Call us for this story about the most significant and newest development in orthodontics to arrive in decades.

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As a worldwide orthodontic company our goal is to bring a happier healthier smile to your family. With this in mind Dentaurum is pioneering the use of titanium in dentistry. We would like to know your comments and suggestions. Please contact us for more information on our innovative products.

31. Payment Plan Options For Dr. Trepp's Office Orthodontic treatment is an excellent investment in the overall dental, medical and psychological well being of children and adults, and financial considerations should not be an obstacle to obtaining this important health service. Being sensitive to the fact that different people have different needs in fulfilling their financial obligations, we provide several payment options. OPTION A: Cash Courtesy Total treatment fee less 5% cash courtesy paid directly to our office when treatment begins. The savings in clerical costs are passed on directly to you. This option cannot be combined with any other option. OPTION B: Orthodontist Fee Plan (OFP) 800-637-3393 * No initial down payment. * 48 month payment plan available. * Fast, confidential service by phone. Interest rate is 9.9%. OPTION C: Office Payment Plan Please be aware that our office is unable to extend the same type of credit as OFP. We believe that OFP is the best way to finance your orthodontic fee. However, if you are not comfortable with that option, our office will extend you credit in this manner: * An initial payment is due when treatment begins, and the balance paid in less than 24 monthly payments. * No finance charge. Past due balances are subject to a late payment fee. OPTION D: Pre-authorized Checking * An initial payment is due when treatment begins, and the balance paid in payments to be drafted monthly from your checking account. * No interest or late payment fee. OPTION E: Credit Card Pre-Authorization (Visa-MasterCard- Discover) * Initial payment and each recurring monthly payment are automatically placed on your credit card with a single authorizing signature. * Repay credit card at your convenience. 32. Problem of Digit-Thumb Sucking Many a parent has come to my office concerned with the persistent thumb or digit sucking habit of their child. Both parent and child are frustrated with attempts to stop the habit. The parent is aware of the damage continued sucking habits can cause to the developing permanent teeth. Actual deformities can result if the habit is continued after age 6. Our office has always had a few suggestions to help tame the habit. We have come upon an aid to quitting the habit that shows much promise. This aid (book and glove) called "My Thumb and I" was developed by Carol A. Mayer, a certified Speech pathologist and Certified Orofacial Myologist and Barbara E. Brown. Barbara Brown's daughter, Ashley, at age 8, wanted to stop sucking her thumb but was unable to stop on her own. Her orthodontist recommended that she work with Carol Mayer. Ashley's struggle prompted this program. Her input and cooperation were invaluable to the creation of the program. "My Thumb and I" is a ten step behavior modification program designed to stop the habit of digit sucking. It is for children 6-10 years old who have been unable to stop thumb or finger sucking on their own. Each step is abundantly illustrated and includes motivational activities which reinforce the concepts stated. The program also includes a glove, parent guidelines, and worksheets for children. This program is designed to empower the child and to increase his or her self-esteem. It is a positive, holistic approach which will enable parent and child to

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work together to gain control of a negative response/habit. "My Thumb and I" will increase the emotional as well as the dental health of the child. My Thumb and I is.. Effective-- Teaches and motivates through behavior modification and rewards children to stop digit sucking. Healthful-- Promotes proper development of mouth, teeth, face, and speech. Positive-- Builds self-esteem, confidence, and gives a sense of accomplishment. Wholesome-- Encourages communication and understanding between parent and child as they work together. Fun-- Fascinates and involves children in entertaining activities. Relaxed-- Helps children progress at a personally meaningful pace. Appealing-- Easy to read large type, spiral bound, for easy use. Complete-- Includes a glove, progress charts, and a parent's guide. Below are some examples of what others are saying about "My Thumb and I". I liked the rewards and the idea of picturing myself with a pretty smile. Amy Hughes age 8 I am shocked! I didn't think Joey, age 9, could quit so easily. The glove really helped. He liked the stickers as well as the rewards. Mrs. Vetri, Naperville, IL The philosophy behind this book is relevant in today's health care climate. It's holistic, preventative, and conservative in its approach. Winifred Booker, Pediatric Dentist, Baltimore, MD My Thumb and I presents a positive approach. Amanda, age 9, developed a strong sense of "I can". I had no idea she could stop so easily. Her sense of accomplishment meant so much to her. Mrs. Raymond Perkins, Wheaton. IL "My Thumb and I" is the first of its kind in a field devoid of other specific how-to literature. Children need this product. Parents need this product. Dentists, orthodontists, pediatricians, speech pathologists, and other professionals need this product. The complete program and glove sell for $29.95 plus shipping. 33. Radical New Movement in Orthodontics The Damon SL System was designed and developed through a team effort of Dr. Dwight Damon and "A" Company. The Damon SL Bracket is a self-ligating bracket that enhances quality treatment while maximizing efficiency. Optimal tooth movement and patient comfort are built into the Damon SL System. A unique, integral ligating slide allows the archwire to move freely, dramatically reducing friction. Reduced friction enables the use of lighter forces to move your patient's teeth more comfortably.

Faster treatment by design The Damon SL System was designed to achieve specific efficiency goals for fast, controlled treatment. These include an integral ligating slide for quicker archwire changes, and a reduced friction bracket that moves teeth into rapid alignment with optimal sliding mechanics. A Straight-Wire Appliance with a twin-style design, the Damon SL bracket provides clinical control and allows you to finish a case using your current treatment mechanics. Together these features work to produce the desired effects: reduced chair time, shorter treatment time, and happier patients - all of which add up to a radically improved appliance for the orthodontic practice of the future. Availability: To purchase the Damon SL System, orthodontists must attend a prior to placing an order. For seminar dates and times see or contact your local sales territory manager. To begin using the appliance we recommend a Customer Starter Kit which includes: 20 cases of Damon SL brackets, an opening and closing instrument, a Damon SL "Cool Tool," an archwire seating instrument, an educational video and manual. The Customer Starter Kit also includes a two-tone study model for doctors and staff to use to practice bracket placement and usage.

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The Damon SL System is available in the Damon, Roth, or Andrews prescriptions, with or without hooks, in the .022 slot size. It is packaged in units of 10. Second bicuspids are available on bands. The Damon SL System will be available for .018 slot users of the Roth prescription in early 1997. For more information on all "A" Company new products call your local sales territory manager or call our Customer Service Department at (800) 524-3407. Designed by Dr. Ron Roth, the Tru-Roth appliance meets his stringent qualifications for Straight-Wire quality and performance with outstanding aesthetics. The Tru-Roth appliance is designed to reduce stress by offering a unique against debonding. Premature debonding creates inefficiency and scheduling nightmares. The Tru-Roth appliance has a specially roughened mesh base which increases bond strength by 70-80% compared to the standard mini-twin appliance - so we guarantee it will stay put. Bracket Unique features: Fits the tooth... this bracket provides outstanding fit on cuspids and bicuspids Deeper tie wing area for quicker ligation Easy bracket placement due to scribe line and rectangular shape. 34. Resurgence of Lingual Orthodontics Dr. Didier Fillion has practiced lingual orthodontics exclusively in Paris since 1987. He has published extensively and lectured and presented seminars on the subject throughout the world. His affiliations include the AAO, French Orthodontic Society, French Lingual Orthodontic Society (which he founded and serves as president) and the European Society of Lingual Orthodontics (as a founding member and honorary secretary). He also serves as course director of the two-year program in lingual orthodontics at Rene Descartes Paris V University. by Didier Fillion, D.D.S. Paris, France Introduction "Toto, I have a feeling were not in Kansas anymore." Todays orthodontist can readily relate to Dorothys apprehension as our specialty competes in an increasingly Oz-like arena. Its not the Wicked Witch of the West and her minions. Its the harsh, ever-changing marketplace realities that have disturbed the relative tranquillity enjoyed by orthodontists in past decades. And nowhere are these changing conditions more in evidence than in the USA, where MSOs, dental managed care plans, blatant advertising, and increased competition from nonspecialists are exacting a heavy toll on traditional practices. Changes are going on throughout the world and they will intensify. Whats the answer? Improved management, marketing and clinical techniques are helping many cope with the increased competition. And what better way to set yourself above the competitive mass than to capitalize on your training as a specialist and provide lingual orthodontics? What better way to distinguish your practice than to offer your patients the only truly esthetic appliance? My experience and that of orthodontists around the world are proving the value of lingual orthodontics to practice growth. This is reflected in the approximately 200 percent growth of lingual orthodontics worldwide in the last six years. In the early eighties, lingual orthodontics went through a more severe boom and bust in the United States than in the rest of the world. Consequently, American specialists are just starting to recognize the subsequent advances in lingual orthodontic technique, appliances, instruments, laboratory procedures and training. With this article, I would like to share my experiences and make you aware of what lingual orthodontics can do for your practice. In 1978, I started my orthodontic practice in Saumur, a small town located 300 kilometers from Paris. My first exposure to lingual orthodontics occurred in 1982 when I read the JCO article by the orthodontists comprising the Ormco task force. I was excited by the fact that this team of pioneers was affording us the opportunity to use "invisible" brackets. With a plier in my right hand and the journal in my left, I immediately started three cases, all with extractions; only the case with a lower incisor extraction could be finished with lingual brackets! An inauspicious beginning. In 1984, I decided to take a course given by Drs. Craven Kurz, Bob Smith and the late Jack Gorman, following which I attended all their European courses from 1984 to 1989. Wanting to

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extend my lingual practice, I left Saumur for Paris, where I made the decision to practice lingual orthodontics exclusively. I had been attracted by esthetics at each level of my life, so I could appreciate the fact that adults are becoming more desirous of a better appearance and, more specifically, a nicer smile. Therefore, I was delighted to be able to offer them a perfect esthetic appliance. By 1987, the era of unaesthetic appliances for adults was definitely over for me. The American lingual orthodontic experience in the early eighties was a failure for most orthodontists (mediocre results, a threefold or more increase in chairside time, longer treatment). By 1987, few American orthodontists were practicing the lingual technique, so my decision to use lingual appliances exclusively was a challenge. It proved to be an even greater challenge than I had anticipated, and I knew that for a while I would have to solve many problems in order not to regret my chosen path. First of all, I had to define how I would work and what would be my lingual practice characteristics. I set up five basic objectives, essential ones that I still pursue: Use the most esthetic and comfortable appliance. Treat all kinds of malocclusions. Reduce treatment time. Avoid extractions. Obtain the same results as with the labial technique. How Can These Objectives Be reached? Using Seventh-Generation Ormco Brackets Bonded to Both Arches For All Patients I have found these brackets to have three principal advantages: The bite plane of the bracket represents an incomparable advantage for correcting a great number of malocclusions, especially deep-bite and crossbite cases, with immediate bite opening obtained by lower incisor contact with the biting surface of the lingual bracket. Gingival hooks facilitate quick ligation. Sufficiently wide bracket slots allow for correction of rotations. The adaptation phase following lingual bracket placement takes 8 to 20 days. The use of lightcured protection paste around molar and bicuspid brackets and having patients wear thermoplastic splints that provide coverage of the teeth and brackets make this adaptation process much easier. For better esthetics and greater comfort, I finally stopped using auxiliaries such as labial buttons, labial brackets and transpalatal arches. Nothing is visible on the labial surfaces except white elastomeric chains around rotated teeth, the most rapid and efficient way to correct rotations. Using a Simple But Highly Accurate Laboratory Technique I prefer to bond lingual brackets directly to the initial model and to use the T.A.R.G. (Ormco) technique to position the teeth in space (virtual setup) and to be able to position brackets to specific heights. I added to it a tooth thickness measurement system in order to compensate for the differences in thickness with the addition of a composite pad. This resin pad is perfectly adapted to the lingual surface and forms part of each bracket base. Thus, each bracket becomes unique by virtue of its resin pad and its orientation to the labial surface of the tooth . The advantages of this indirect laboratory system are: The brackets are directly bonded to the malocclusion model with filled resins (Phase II, Paste A and B, Reliance products), allowing a tray for an entire arch to be prepared for precise bonding at one time . The tray is transferred directly to the patient. The transfer tray is made from a hard silicon-based material (Zetalabor [hardness: Shore A 85] from Zhermack, Ravigo, Italy) to ensure accuracy and permit bonding in the operatory with only unfilled resin. The rebonding procedure is accomplished either by cutting the initial transfer tray and setting the initial bracket in it or, if the bracket is lost or the transfer tray is damaged, by using a new unitary transfer tray made from a harder silicone material (Lutesil [hardness: Shore A 95] from Bisico, Bielefeld, Germany) to ensure tray stability during rebonding . A decrease in archwire bending throughout most of treatment results from the compensations for different thicknesses. Some esthetic bends are often necessary in the last three months of treatment.

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The CLASS system has been popular, but I have found the T.A.R.G. system to be more accurate and to work best in my practice. There is no scientific evidence that one system is better than the other, and clinically, excellent results can be obtained with both procedures. I selected the one that was easier to use in my practice. Using a Simple But Highly Efficient and Reliable Bonding Procedure Simple. Using a two-component ("A" and "B" liquids) unfilled resin, polymerization can be achieved in two different ways: by using a few drops of the A and B components (Maximum Cure, Reliance Orthodontic Products) and applying the mix to the lingual surfaces of the teeth and to the resin pads of the brackets that are positioned into the tray. by applying liquid A on the enamel of the lingual surfaces and liquid B on the resin pads, or vice versa (Custom 1-Q, Reliance Orthodontic Products), the polymerization takes place by contact of the two liquid components when the tray is inserted. Efficient. Three years ago we initiated systematic microblasting of the lingual tooth surfaces prior to etching. In vivo, we have noted not only an increase in bond strength (tested by voluntary debonding of brackets) but also a significant decrease in the number of bond failures during treatment. In vitro, a study performed in 1996 by Degrange, Altounian, Fillion and Themer at the Department of Biomaterials, University of Paris V, showed results comparable to the ones published by Reisner, Levitt and Mante in the AJO in 1997: In vitro, microblasting and etching of the perfectly cleaned enamel surface does not increase bond strength. In vivo, since the lingual surface is difficult to clean, microblasting seems to be the best way to prepare the bonding area and to enhance the etching process without gingival bleeding. Reliable. Our system has who dont practice the lingual technique and 29 percent by treated patients. Seventy-four percent of the patients are women and 26 percent are men (the male percentage twice that of five years ago). Most of these patients had wanted to improve their smile for many years but did not want visible appliances. Once treatment is accomplished, lingual orthodontic patients are really grateful for what you have done for them.

The Vital Role of Lingual Orthodontic Training I was very pleased with the attendance and response at the two lingual courses I conducted this past October in New Orleans and San Diego. I received my lingual education from three U.S. practitioners with wonderful clinical and teaching skills: Craven Kurz, Jack Gorman and Bob Smith. These pioneers started from scratch and established the foothold necessary for lingual orthodontics to overcome the many initial limiting factors and setbacks and to evolve into its current advanced and continuing-to-improve state. I am glad to follow in their footsteps and join other lingual orthodontic clinicians in accelerating the growth of this technique in the U.S. for the benefit of the public and specialty alike. The Eastman Dental Center at Rochester and Indiana University continue their vital roles as academic centers for the technique in the U.S. In October 1996, a lingual orthodontic program was created at the University Rene Descartes of Paris V by Dr. Alain Decker, chairman of the Department of Orthodontics. Dr. Gerard Altounian and I are coaching this two-year program. Six orthodontists (including three foreigners) participate in this didactic but essentially clinical program that will develop the necessary skills to conduct a large-volume lingual practice. With the increasing interest in lingual orthodontics, other schools around the world are taking note, and it is hoped that other resident and continuing education programs will be developed. Todays orthodontist need not reinvent the wheel or suffer through the extended learning curve our specialty confronted in the early years of lingual orthodontics. State-of-the-art training can be found throughout the world, and established lingual orthodontic societies and study clubs offer ongoing support. Conclusion Today, I do not regret my 1987 decision. By and large, I have reached the objectives that I set for myself, and my enthusiasm for the technique continues to grow. Many areas of lingual

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orthodontics have yet to be explored and a great number of improvements are at hand. Moreover, I am continuously elated and inspired by the happiness of my patients with their invisible braces. In 1991, I wrote in a French orthodontic journal that "this decade will make lingual orthodontics as easy to use as labial orthodontics," and we are close to reaching this goal. In fact, I am convinced that lingual orthodontics will someday replace labial orthodontics for adults. There is a need to learn and practice the lingual technique because: this intellectually stimulating technique, with some practice, is almost as easy to use as the labial one. it is a great way to uncover adults who are desperate for a nice smile but adverse to visible appliances, thus increasing ones potential number of patients. this technique makes it easier and faster to treat certain kinds of malocclusions than is possible labially. and last but not least, patients will soon have the awareness and rationale to criticize the orthodontist who does not offer this technique. The rewards that I enjoy everyday from practicing lingual orthodontics are such that I want to stay on the same road. I have come a long way and now I wish to share the road with others. Figure 1A. The mandibular anteriors are being intruded using an .016 x .022 35C Copper NiTi placed to the incisal of the anterior brackets. Figure 1B. The mandibular anteriors intruded after ten weeks. Figure 1C. An .019 x .025 Force 9(R) sectional is placed to level the anteriors Figure 2A. The mandibular anteriors are being intruded with an .016 35C Copper Ni-Ti placed to the incisal of the brackets. Notice that a bypass .016 x .022 35C Copper Ni-Ti is leveling the anteriors. Figure 2B. Ten weeks later, notice the intrusion of the mandibular anteriors and the leveling effects of the bypass sectional.

35. Sooner Orthodontic Facts Are Faced, The Better Age 7-a Year to Remember ST. LOUIS- When should a child get braces? Although individual problems determine the best time to start orthodontic treatment, the American Association of Orthodontists (AAO) recommends that every child see an orthodontist at an early age. This could be as young as 2 or 3, but should be no later than age 7. Many orthodontic problems are easier to correct if detected early rather than treating when jaw growth has slowed. Cases that demonstrate the advantages of early intervention can be found in most orthodontic practices. Unfortunately, many parents assume they must wait until a child has all of his or her permanent teeth, only to find out that treatment would have been much easier if started earlier. Dr. David Hamilton, president of the AAO, cites a 4-year-old boy whose teeth didn't meet properly. Also, his lower jaw was off-center. Early correction meant he didn't have to spend any time in braces as an adolescent. Early orthodontic treatment can have a tremendous impact on a young person's oral health and emotional well-being, says Dr. Hamilton, who practices near Pittsburgh. "We perform minor miracles every day," Dr. Hamilton says. "Parents tell me daily how much better their 7-, 8- or 9-year-old children feel about themselves because now they can smile, and classmates don't make fun of them. No child should wait until reaching the teens to feel good about his or her smile." Among the patients of Dr. Chris Carpenter, an AAO member in Denver, is a 6-year-old boy with a prominent lower jaw. Less than a year of early treatment means his case will be much easier to complete later on. Then there's Josh Miller, a 9-year-old who had a severe overbite. As an adult, Josh's father had needed to undergo jaw surgery to correct his bite. Josh didn't need to. His teeth are now straight and his jaws aligned, a result accomplished through orthodontics alone. Also, none of his teeth needed to be extracted, as had been the case for his dad.

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Kyle Miller is grateful his son didn't have to go through a similar ordeal. "There was no risk, but great rewards," he says of his ebullient 15-year-old, now out of braces and dutifully wearing his retainer per Dr. Carpenter's instructions. "We were optimistic throughout treatment, and of course are very pleased with the results." Early treatment can prevent serious problems down the road As the Miller case illustrates, early treatment can eliminate the need for more drastic measures. "Most bite problems are inherited, and therefore can't be prevented, but early diagnosis can help," Dr. Carpenter says. "Our primary goal is to correct severe problems that, if let go, will be much more difficult to correct later on in life." Orthodontists may use one of several orthodontic appliances designed to guide bone growth. In some patients, early treatment achieves results that may not be possible once the face and jaws have finished growing. "Teeth move more easily in younger kids," Dr. Hamilton says. Although many people associate orthodontic treatment with adolescence, orthodontists can spot subtle problems with jaw growth or with the teeth much earlier, while the primary or "baby" teeth are present. Some of the more readily apparent conditions that indicate the need for early examination include: early or late loss of teeth difficulty in chewing or biting mouth breathing thumb sucking crowding, misplaced or blocked-out teeth jaws that shift or make sounds speech difficulties biting the cheek or the roof of the mouth teeth that meet abnormally, or don't meet at all facial imbalance jaws that are too far forward or back grinding or clenching of the teeth. Early diagnosis can provide peace of mind Frequently, taking a child to the orthodontist results in a recommendation of "let's wait and see," notes Dr. Hamilton. "We may simply want to check your child periodically while the permanent teeth are coming in, and as the jaws and face continue to grow." Detecting an orthodontic problem early enables the orthodontist to determine the best time to begin treatment. And, as illustrated by the patients of Dr. Hamilton and Dr. Carpenter, early intervention can make the completion of treatment at a later age easier. Whatever the orthodontic diagnosis, the AAO emphasizes the importance of keeping in regular contact with the family dentist. 36. STAR-TEC Piezo-Electric ultrasonic unit This versatile dental instrument provides highly efficient scaling, endo filing and orthodontic bonding. THE STAR-TEC ULTRASONIC SCALER PIEZO ELECTRIC-BEST BUY $740.00 Operates at 40,000 cycles a second Gentle efficient prophylaxis Removes even the most obstinate tartar easily Removes tough adhesives, direct bonding cements, amalgam overhangs and even crowns Almost no heat is generated therefore, the unit can be used with very little water. THE STAR-TEC Multi Function Ultrasonic Unit Incorporates scaling mode, endodontic mode and debonding mode without having to adjust tuning! AUTOMATIC TUNING-is provided. No need to tune tips either. A specially designed circuit and transducer senses the load and captures the proper frequency for all modes. The STAR-TEC Piezo-Electric ultrasonic unit has all the power you need for efficient scaling. It will loosen crowns, bridges, and pins and it has endodontic capabilities built in! The tip of the STAR-TEC unit moves in a front to back direction, not in an elliptical pattern. This makes the procedure much more comfortable for the patient.

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USES LITTLE OR NO WATER-No water is necessary for the cooling of the handpiece. Water is used the way it should be, at the operator's discretion. ENDODONTIC FILING-The STAR-TEC unit needs nothing but our optional insert to provide ultrasonic power for your root canal work. Irrigation when necessary is also directed to the file. SMALL AND LIGHT WEIGHT-This solid state unit measuring 9" X 6" X 2 1/2" can be operated with its own foot switch or hooked directly to the delivery systems air foot control. ORDER RISK FREE! Each unit shipped from stock with three tips at our expense, and covered with a five-year warranty. Try this scaler in your office for 90 DAYS! Return it for a full refund, if you don't agree that it's the best you've ever used! *Ultrasonic devices are not recommended for use on anyone utilizing a cardiac pacemaker because of the possibility of interference. 37. Straighter Teeth Boost Self-Esteem ST. LOUIS-- When braces change looks, they change outlooks, too. Beautiful, healthy smiles are only the most obvious benefit of orthodontics. Another outcomeincreased self-confidence-may be less evident. But orthodontics can be credited for dramatic improvements in the careers and personal relationships of millions of people in the United States and Canada, according to the American Association of Orthodontists (AAO). Orthodontic patients come from all walks of life, and their personal stories are uniquely compelling. Today, many are grateful they don't get a second glance on the street- before orthodontic treatment, they drew stares. "These people didn't want to smile. They were very self-conscious," notes Dr. DeWayne McCamish, an AAO member in Chattanooga, Tenn.

BRACES CAN IMPROVE SELF-ESTEEM AT ANY AGE If patients begin treatment as children or adolescents, they may not have to endure years of embarrassment. Since adolescence, Juliet Sturnes of Chattanooga had automatically covered her mouth whenever she talked to someone. At age 47, she finally made up her mind to see an orthodontist. Her self-esteem was so low that she was afraid to waste the doctor's time. "It's a miracle," she says. "Today, I don't mind walking up to people and saying, 'Hi, how are you doing?' And I look them straight in the eye!" Today, her daughter also is in Dr. McCamish's care. The Rev. Randy Nabors, a minister in his mid 40s, is another of Dr. McCamish's patients. Much to his dismay, he realized that he wasn't as effective with his congregation as he would have wished. "I'm a public person, and people were looking at my mouth. Once, I heard some kids making fun of my teeth." After braces, that's not an obstacle anymore. "It has improved my smile," said Nabors, "but it doesn't bother me if people don't notice my teeth. That means they're normal." Ricki Ratliff, a 40-year-old patient of Dr. David Hime in Austin, Texas, is grateful for the same thing. She doesn't feel conspicuous anymore. And for the first time in her life, she feels attractive. A BETTER-LOOKING BITE USUALLY WORKS BETTER, TOO People whose bites are normal probably take eating for granted. For many who need braces, however, this can be an ordeal at least three times a day. Nabors' troubles with chewing were especially unpleasant: "I was choking on my food." Nowadays, thanks to the art and science of orthodontics, untold millions like Ratliff and Nabors can look forward to meals. "When I eat, my teeth meet soundly on both sides, each chomp bringing me a deep satisfaction," says Ratliff, who continues to "marvel" at the transformation in her attitude and appearance. Photos from a recent family reunion were a pleasant surprise. "I noticed an odd thing-in every picture I was smiling! I mean, a full smile like I had never seen on my face before," Ratliff says. "I really love those pictures. They're an end to 40 years of photos tainted by thoughts of whether my teeth showed or not. "Now I know. The teeth show, and I am proud of them. I finally feel pretty."

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38. Timeless Design. Exceptional Performance. Lasting Results. That's What Distinguishes a Classic. Classic Brackets This advanced system is genuine Straight-Wire through and through. Our exclusive design offers you the aesthetics of our Mini-Twin and the clinical control of our full-size Twin. For easy and secure ligation, the tie-wings are deeper and bracket placement is simplified by a familiar rectangular shape. Due to our exclusive Ultra-Lock TM mesh, "A" Company is able to offer a one-of-a-kind "No Bond Failure" guarantee on all Classic Brackets. For more information on all "A" Company new products call your local sales territory manager or call our Customer Service Department at (800) 524-3407. 39. Titanium Resolves Health Concerns About Braces While stainless steel has long been the workhorse material for braces worn by millions of people, increasing worries over exposure to nickel and other impurities have raised health concerns. Now a biocompatible line of titanium brackets for orthodonture has been introduced to replace stainless steel and eliminate any possible adverse reactions. Recent studies have documented that more than 30 percent of women and 20 percent of men show an undesired positive reaction to nickel sulfate, which is the same material found in stainless steel braces. Titanium brackets contain no nickel, so patients can put any fears of possible exposure to rest. The new patented Rematitan brackets from Dentaurum, Inc., also unlike the traditional stainless steel, are manufactured without using solder. They offer other clinically proven benefits such as greater comfort due to their lightweight design and better appearance due to a matted finish that absorbs light and actually becomes less noticeable in the mouth. Their unique features could even help reduce treatment time. Rematitan titanium brackets are predicted to make stainless steel obsolete and are now being used by orthodontists across the U.S. and Europe. For more information about this latest breakthrough in braces technology, contact your orthodontist. 40. Using the Help of Computer Science With digital imaging of brackets bonded to the malocclusion model and information such as bracket width and thickness noted for each tooth by the lab technician, it is possible to visualize the initial dental arch form in two dimensions on the screen and to simulate the tooth movement to an ideal position. For each treatment sequence, one can obtain a very accurate drawing of the specific archwires. The position of the first order bends between cuspids and bicuspids and between bicuspids and molars is perfectly predictable and reproducible for all archwires. Therefore, occlusal interferences can be avoided during treatment, an automatic coordination of the upper and lower arches can be obtained and treatment archwires can be prepared ahead of time by the practitioner or his staff. This software program called DALI (Dessin de lArc Lingual Informatise, computerized drawing of the lingual arch), used in my practice since 1989, is essential for me to reach the preplanned ideal tooth position and to decrease chairside treatment time . 41. What are the results obtained in my office today? Chairside Treatment Time Quite Similar to Labial Treatment Requirements How Is It Possible? In France, the dental hygienist profession does not exist and, furthermore, dental assistants cannot work in the patients mouth. Since Ive had to do all the treatment procedures myself, you can imagine the intensity of my motivation to improve swiftness and efficiency. Once again, necessity proved itself to be the mother of invention: One can place lingual archwires more quickly by using specifically-adapted instruments and by reducing the need for metal ligatures in the anterior region. The indirect bonding technique that I have developed is faster than direct labial bonding and equivalent to indirect labial bonding techniques. With the systematic use of microblasting, bond failures have decreased significantly. Moreover, by using a transfer tray made out of very rigid silicone material (85 Shore), one can reuse it for rebonding in 80 percent of the cases. The rebonding procedure is, therefore, very quick, taking only three to five minutes after archwire removal.

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Since the differences in tooth thickness are compensated for during the bonding procedures at the lab stage, archwire bending is reduced or even eliminated for most of the treatment (except for cuspid-bicuspid and bicuspid-molar bends), which saves a lot of time. With the use of shape-memory alloys (Copper Ni-Ti) at the first treatment stage, torque control can be achieved without having to change archwires. It was difficult to adapt the prior nickel titanium wires used in the labial technique to lingual orthodontics because of the first-order bends required and due to the narrow lingual arch form. It is now possible to treat the Copper Ni-Ti archwires to modify the shape memory designed by the manufacturer in order to create a new shape adapted to each arch form. At last, with DALI software, archwire design is facilitated and the archwires can be prepared ahead of time. Without a doubt, France is the country in which the restrictions to practice orthodontics are the most severe. In more favorable environments, where specially trained auxiliaries can perform most of the treatment tasks, the orthodontist should spend no more time treating lingual cases than he does treating labial ones. Lingual Treatment Duration Similar to Labial For the first half of the eighties, lingual orthodontic treatment was much longer than that required for labial. Why? Bracket positioning was not as accurate and there was no system to compensate for the different thicknesses of the teeth, making the finishing phase a very long one. Sliding mechanics side effects with lingual brackets were not well recognized or understood. Bonding quality was often inadequate. Orthodontists were insufficiently trained. Today laboratory steps and bonding procedures are greatly improved, and the most harmful sliding mechanics side effect, bowing, can easily be controlled. Also, the adaptation of shape-memory alloys to lingual orthodontics makes the alignment stage significantly shorter. It is essential to note that the quality of the final result and the amount of chairside time are directly dependent on the quality of the laboratory phase and on the precision of the bracket positioning on the plaster model. One must be aware that any system that tries to simplify the lab phase and does not pay due respect to these precision requirements will increase chairside time (to correct alignment or resolve torque problems), leading to regression of the lingual treatment progress. Discovery of an Easier Approach to Treating Some Malocclusions The bite plane of the seventh generation Ormco brackets causes an immediate posterior open bite, therapy routinely indicated for the deep-bite cases so frequently seen in the occidental population. Altounian, Fillion and Sorel made a study in 1994 of 30 cases showing an overbite greater than 4 mm that revealed results similar to those found in previous studies. Contact of the lower incisors with the upper incisor brackets causes the greatest tooth movement in the anterior region: 1.5 mm lower incisor intrusion, 0.9 mm upper incisor intrusion, 0.2 mm upper molar extrusion and 0.5 mm lower molar extrusion. As far as I know, there is no equivalent technique (labial or lingual) that can correct severe deep-bite cases as quickly (six months or less) as the lingual orthodontic technique with Ormco brackets. Ormcos recent highly successful introduction of Bite Turbos (modified slotless lingual brackets bonded to the lingual of upper incisors to open the bite for patients undergoing labial treatment) attests to the effectiveness of these mechanics . Moreover, there is no technique other than lingual to easily correct dental crossbite in the posterior region (because of the posterior open bite) as well as in the anterior region (a single tooth/bracket contact of one incisor or a lower cuspid is enough to open the bite) . Unlike their particular facility for opening deep bites, lingual brackets have no inherent advantage for correcting open bites. Nevertheless, one can obtain very good results with the appropriate mechanics: Modification of the bonding heights of the brackets in order to obtain a 3 to 4 mm differential between the anterior and posterior regions of both arches. Vertical intermaxillary elastic wear (spaghetti style); elastics attached to lingual brackets restrain tongue thrust, so their vertical effect is quicker . Increased Number of Patients Benefiting from experience, Ive been able to double the number of patients undergoing treatment in my practice five years ago, even though I have to handle all the clinical tasks personally. Like the situation in the United States, lingual orthodontics in France suffered

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from a bad reputation for many years. Many lectures and papers were necessary to prove that the technique was as efficient as labial orthodontics. Today 47 percent of my patients are referred by general practitioners, 24 percent by orthodontists 42. Wick Flat Bow Retainer Wire This new retainer wire created by Dr. Wick Alexander combines features found in todays most popular designs with enhancements and additional improvements, resulting in an easier-to-fabricate, easier-to-use retainer with numerous advantages: Wraparound design eliminates wires crossing and disturbing the occlusion. Flattened anterior lingual surface provides maximum tooth contact and control. Rounded anterior labial surface affords greater patient comfort (no edges) and better aesthetics (less refractive) than flattened designs. Proper wire temper prevents gingival slippage and makes appliance easier to wear. Correct contour requires little adaptation. Not an arch blank, but the most anatomically-correct arch form (Orthos/Alexander) available. Built-in lateral offsets. Smaller adjustment loops permit more distal placement and create less gingival impingement. Offered in three sizes (50, 54 and 58 mm between loop centers) that cover the range and minimize inventory requirements.

The Wick Flat Bow Retainer Wire is easier and faster to make and adapt, more comfortable and attractive, and, most importantly, it provides the arch shape, anatomical correctness and proper wire stiffness to maintain the orthodontic correction you worked so hard to achieve. The three preformed sizes are provided in packs of 10. Related Subjects: - Combines the prescription of Ormcos highly evolved Mini-Wick System with the aesthetic superiority of SpiritMB brackets. - Following extensive clinical testing, Dr. Wick Alexander has incorporated the proven prescription refinements of the Orthos (tm) appliance into the Alexander technique. proven itself in all cases. The oral floor anatomy and the size and position of the tongue can make the bonding procedure tough; nevertheless, use of the Dry Air System (NOLA) allows us to bond a full dental arch at a time in good working conditions, even the lower arch. This most efficient system includes a cheek retractor, an internal suction device for saliva and a tongue cage to isolate the dental area from the tongue. The bonding procedure as we do it, from microblasting to splint removal, should not take more than 15 minutes . Using Safe and Reliable Interproximal Enamel Reduction From the work of Sheridan, the classical interproximal enamel reduction has become a safe technique with a specific protocol that I have adapted to my practice with the following concepts: Safe and healthy final aspect of the reduced enamel surfaces and periodontal tissues, with anatomic reduction of the contact points, polishing of the reduced surfaces and protection of gingival tissues. No reduction of lower incisors. Complete awareness of the reduction effects of the selected instruments. These principles enable me to use this technique on a routine basis in my practice and allow me to safely extend the limit of enamel reduction and, therefore, decrease the percentage of extraction cases from 49 percent to 32 percent in the last five years. By using this technique, one can remove only what is needed; there is no tooth-profile flattening; and the rootresorption risk, usually high in adult cases, is decreased due to the reduced treatment time. Using Simple Sliding Mechanics For All Extraction Cases After testing many different mechanics, including segmented, I realized that even though all can be used successfully, the best way to retract anteriors and close extraction spaces is to

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use the sliding mechanics designed and taught by the Ormco task force in the early eighties. As with any sliding mechanics, this technique may produce undesirable side effects, such as slowed retraction caused by frictional forces and changes in the dental arch form in the cuspid-bicuspid area caused by the "bowing effect" (which is preventable). Nevertheless, sliding mechanics are the easiest lingual technique to implement and reactivate, as well as affording more comfort to the patient. Furthermore, it allows good control of the vertical and transverse dimensions if used with Ormco brackets with their incorporated bite planes. A study of my treated cases showed that only 10 percent (all with a dental Class II relationship before treatment) required total anchorage control. There are four treatment alternatives for this 10 percent: Avoid lower extraction as much as possible in order not to aggravate the initial dental relationship and because of the high risk of excessive lingual inclination of lower incisors. Plan anchorage preparation at the lab stage during bracket positioning. Use Class II elastics. Use a removable labial archwire (anchorage enhancer) at nighttime with Class II elastics The first two alternatives must be planned before beginning treatment, whereas the last two can be employed during the course of treatment.

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