The Vari-Simplex Discipline

An appliance has been designed to deliver excellent treatment results in a simple, organized way; this system is a combination of proven ideas from many practitioners. Patient cooperation is important in any treatment, and I find that complicated appliances make it more difficult for patients to succeed. Complicated systems with heavy wires, heavy elastics, auxiliaries, and complex wires and elastic placements make patient cooperation more difficult and greatly contribute to patient discomfort. Major goals are high-quality results, patient comfort, and reduced chair time. Simpler archwires afford fewer archwire changes, and easier ligation and activation. We rarely use multiloop arches, because they are timeconsuming, create food traps, and often impinge upon the gingival tissue and we rarely solder hooks to the archwire. Soldering is also time-consuming and can reduce archwire effectiveness. We use ligature hooks instead, when necessary. All this adds up to Simplex, Discipline was chosen, rather than Appliance, to reflect the idea that the orthodontist must be knowledgeable in edgewise mechanics and must play an active role in the application of the appliance to the individual patient. Diagnosis and Treatment Planning My case diagnosis is generally reduced to two steps: determine the desired position of the mandibular incisors, and then determine the treatment needed to position the maxilla and maxillary dentition over the desired 1

mandibular arch position. The object of treatment is to position the mandibular teeth within the mandibular trough, with four goals in mind: 1. Incisors upright over basal bone 2. Cuspids not expanded 3. Curve of Spee level 4. Nonextraction therapy whenever possible In discussing diagnosis and treatment planning, it is critical to understand that orthodontists come from a variety of backgrounds. Appliance design should not dictate treatment techniques, and no single system-of diagnosis is absolute. Many diagnostic procedures have been researched, developed, and used successfully by clinicians around the world. My approach to diagnosis attempts to be straightforward and simple. Certain factors influence my thinking. The first factor is age. The patient's age will determine whether we think in terms of mixed dentition early treatment, full treatment during adolescence, or adult treatment. The other factors can be categorized according to the diagnostic records taken to study the three tissues (facial, skeletal, dental) in their three dimensions (vertical, transverse, sagittal): 1. Intraoral and/or panoramic x-rays show: a. General dental condition. This must be healthy before appliances are placed.

b.

Missing teeth. A decision must be made to open, maintain, or close the spaces.

c.

Impacted teeth. A decision must be made to expose and attempt to bring into position or extract.

d.

Third molars. A decision must be made on their disposition.

2. Study models show the teeth in relation to each other and, in the transverse dimension, to the jaws: a. Overbite b. Overjet c. Dental discrepancy d. Molar and cuspid class e. Crossbites f. Curve of Spee g. Midline relationship h. Gingival health 3. Facial photographs show the soft tissue relationships: a. Prof I le- probably the single most important factor in my diagnosis b. Smile line-the relationship of the maxillary incisors to the upper lip

c. Facial symmetrydimensions

helpful in studying the vertical and transverse

4. Cephalometric appraisal determines the skeletal relationships in the vertical and sagittal positions, and the relationship of the teeth to the bones: a. General skeletal pattern - determines the position of the jaws in relation to the skull and to each other b. Tooth position-their relation to the jaws and to each other I have never felt that a cephalometric tracing alone should be the determining factor in diagnosis. Although it is helpful in making the final decision, too many other factors must be considered. Following a

predetermined triangle, computer analysis, or other specific diagnostic methods could be helpful, but should never be used as the sole determining factor for diagnosis. It has been said that orthodontics is still an art as well as a science. As diagnosticians, we must always back off and look at the total picture before making the final decision. Although I use more specific details, the following is how these principles are applied. Problems in the vertical dimension are generally evaluated by the relationship of the base of the skull to the mandibular plane. This can be measured by SN-MP, FMA, or other linear vertical measurements. On growing patients, the vertical is controlled by 1. Extraoral forces- high-pull or vertical-pull headgear

2. Chin cap 3. Transpalatal arch 4. Extractions 5. Vertical elastics The transverse dimension is measured by A-P cephalogram, facial photographs, and model analysis to determine if crossbites are present or if posterior buccal uprighting is needed. The transverse can be controlled by: 1. Rapid palatal expansion 2. Expansion or constriction with archwires 3. Crossbite elastics The sagittal dimension is evaluated by measuring the relationship of the maxilla to the mandible and to the skull. Cephalometric measurements that can be used include SNMP, FMA, OM, Y-axis, and ANB. Skeletally, the sagittal is controlled by extraoral forces. Sagittal position is also affected by tooth position. For years, this factor was thought of as the only way the orthodontist could have an effect on the face. Tooth position is still the area where the most predictable control can be achieved by the orthodontist. Dentally, the key to sagittal control is the position of the mandibular incisors. In our diagnosis, their position is determined by the 1-1-A-Po line, the Holdaway ratio, and IMPA (relationship of mandibular incisor to mandibular plane). The decision to extract or not to extract obviously affects 5

the position of these teeth. To me, it is the most important decision made by the orthodontist. No matter how many diagnostic records are taken, certain factors can only be observed in the patient himself. During the initial examination, the first procedure is the palpation of the temporomandibular joint while the patient is opening and closing his jaw. Next, the patient's gingival health is described in words from observation and, sometimes, from probing. Then, before the teeth are examined, the patient is asked to swallow so that any tongue thrust tendency can be observed. Laminagraphic x-rays are taken on every patient who exhibits abnormal TMJ function. If there is a question about the patient's gingival health, he is referred to his dentist or to a periodontist. Treatment of a tongue thrust is more difficult. Having cycled through myofunctional therapy, my approach today is to first make the patient and parent aware of the problem, then to give the patient simple instructions in proper swallowing. The Concept of the Vari-Simplex Discipline The most important factors in determining the design of the VariSimplex Discipline are the size and shape of the teeth, especially the mesiodistal width and curvature. These affect interbracket width, which, in turn, affects the ability to rotate the teeth and level the arch without using time-consuming vertical springs, multiloops, or extra archwires. Selecting the proper bracket to fit the size and shape of each tooth will also influence ease of ligation and the ability to obtain complete bracket engagement. Another major factor is the accessibility of the tooth and whether it is 6

located in a curved or straight area of the arch. Finally, the design must take into account patient comfort and the frequency of bracket wing breakage. The system evolved around five factors related to brackets: bracket selection, bracket height, bracket angulation, bracket torque, and bracket inout. Putting these considerations into brackets, as pioneered by Dr. Ivan Lee, Dr. Larry Andrews, and others, made us begin to think about the bracket rather than the archwire. I am totally convinced that a pretorqued appliance is superior for quality control. I am not saying that every case can be treated to an ideal result with my appliance without any additional wire bending. However, if the brackets are properly placed, archwire bending is kept to a minimum. I have found that the quality of my results is more predictable and consistent today than ever before. Bracket Selection Each tooth has a particular bracket that is most effective. Twin Brackets Twin brackets (Diamond brackets) are used on large, flat-surfaced teeth-maxillary central and lateral incisors. The Diamond bracket is designed so that all the horizontal lines are placed parallel to the incisal edge of the tooth, and the rhomboid design makes it possible to align the vertical lines parallel to the long axis of the tooth. The flat surfaces of maxillary centrals and laterals permit full archwire engagement in the twin brackets. The accessibility of these teeth negates the usual difficulty in tying twin brackets. Also, twin brackets on the incisors allow 5-6mm of interbracket 7

width, which is sufficient for flexibility, rotational control, and torquing ability. As the maxillary lateral incisors erupt, they frequently remain high relative to the normal position of the centrals, presenting a significant incisogingival interbracket discrepancy. Twin brackets on these teeth provided additional tie wings for easy initial wire placement, whereas the rotation wing of a single-width bracket might cause interference with the archwire. Twin brackets also allow additional handles for placing power Mains, ligating anterior teeth together, and placing hooks for elastics. A final factor is patient comfort. Twin brackets are smooth and minimize irritation of labial tissue. Lang Brackets Lang brackets were invented by Dr. Howard Lang. We use these brackets with the Diamond design on large, round-surfaced teeth at the corners of the arch-maxillary and mandibular cuspids. The pad is contoured so that this bracket fits beautifully on most cuspids. The straight wing of the Lang bracket eliminates interference with complete archwire engagement at this most curved position in the arch. The single bracket allows for easy ligation and increased interbracket width. The wing can easily be activated for rotational control. In extraction cases, the cuspids can be retracted on round wire with very little tipping or rotation. Why not use twin brackets on cuspids? Because they decrease interbracket width, making it more difficult to ligate and to control rotations. It is often impossible to get full bracket engagement with a twin bracket on a 8

round-surfaced tooth. Also, the distal wing of a twin bracket on a mandibular cuspid can interfere with the maxillary cuspid in occlusion, and sometimes causes attrition of the maxillary cuspid cusp tip. Lewis Brackets Lewis brackets on large, round surfaced teeth that are not at the curve of the arch-maxillary and mandibular bicuspids and on small, flat-surfaced teeth- mandibular incisors. We use the basic Lewis design with a wedge shape, which puts the tie wing close to the tooth occlusally and far out gingivally. This makes it easy to tie, to use as a hook for elastics, and to keep clean. I often use up-and-down elastics on posterior teeth, and this wedge shape is excellent for that purpose. The Lewis bracket is a fixed-wing single bracket, which produces sufficient interbracket width. The wings provide maximum rotational control and can be activated for additional rotation. Why not use a flexible Steiner wing instead of the fixed Lewis wing? First, the fixed wing is more capable of exerting additional force, especially on a rectangular wire. Second, the fixed wing saves adjustment time, since the archwire need not be removed to activate the wing. Third, the Lewis brackets are less sharp, so it is not necessary to tie in the archwire at the banding/bonding appointment, if, for example, we are doing indirect bonding. Finally, perhaps the biggest difference is that, by using the fixed wing, we never need to be concerned with breakage.

An additional benefit offered by the single bracket with wings is that, on a tooth that is badly rotated, the wing in the direction of the rotation can be removed. The bracket can then be positioned properly, with the remaining wing serving to rotate the tooth into proper position. Other Attachments Twin brackets with a convertible sheath are used on maxillary and mandibular first molars, which are usually banded. The convertible sheath is easily removed when second molars are banded, converting the attachment to a bracket. Headgear tubes are placed occlusally on the maxillary first molars. This position makes it easier to see and to use them; it minimizes food traps, oral hygiene problems, and gingival impingement; and it eliminates blockage when omega stops are used. Single buccal tubes are used on maxillary and mandibular second molars, and lingual hooks are placed on all molar bands. Since the appliance does not dictate treatment technique, it is easy to alter this system by changing the molar tubes to fit one's philosophy. Maxillary triple tubes and mandibular double tubes would change this concept into a bioprogressive approach and enable the practitioner to use utility arches. Bracket Height Bracket height is extremely important in the design of a fully activated appliance. Each bracket is placed at a predetermined position on each tooth relative to the other teeth. Placing a bracket higher or lower affects the 10

amount of torque and angulation, and the incisogingival position of the tooth. Obviously, bracket height will vary to fit the clinical crowns. Cusp tips vary, and that is a consideration. If incisors have chipped edges or mammelons, the teeth should be recontoured or the bracket height adjusted before bracket placement. Bicuspid bracket height is the key (X on the chart below) because its clinical crown height is so variable. Its normal height is 4.5mm. The other bracket heights are calculated in relation to X, as shown on the chart. An obvious deviation from these measurements would be in an open bite case. Since the treatment plan would be to intrude the posterior teeth and extrude the anterior teeth, we would increase the bracket height on anterior teeth by 0.5mm and decrease the bracket height on posterior teeth by 0.5mm. By planning ahead, we are building treatment into the appliance. Enough cannot be said about bracket positioning. You can spend years designing an appliance so that all the torques and offsets are just right, but if the brackets are not placed in their proper positions, the appliance just isn't going to work. If adequate time is spent placing the brackets on the teeth in their proper positions at the beginning of treatment, many problems will be avoided, and much time will be saved in finishing the case. It is important to position brackets in the center of the tooth mesiodistally, so that the rotating wings will be able to function properly. As mentioned earlier, on a severely rotated tooth, the interfering wing can be removed to enable the bracket to be placed in the center of the tooth, and to

11

build in some over rotation. Obviously, that wing will never need to be replaced during treatment. Bracket Angulation (Tip or Second-Order Bends) The objective is to position the teeth in the most ideal axial inclinations. This allows the roots to be parallel to each other and the crowns to be placed in their most esthetic and functional positions. I prefer the Diamond bracket with angulations measured to the long axis of the crown, because it simplifies bonding placement and assures accuracy. The horizontal incisal and gingival portions of the bracket are parallel to the incisal edge and the vertical portions are parallel to the long axis of the crown. There is nothing to measure but the height. When banding, the band is placed parallel to the incisal edge or occlusal plane of the tooth, and the bracket is angulated on the band. Two sets of measurements are shown on the angulation chart, depending on whether the incisal edge reference is used for banding or the long axis reference is used for bonding Diamond brackets. When banding bicuspids in extraction cases, the band is seated more gingivally on the side toward the extraction site, so I no longer find it necessary to angulate the bracket. This provides adequate tip of the bicuspid root into the extraction site, which, combined with the 6* tip in the cuspid, is sufficient to parallel the roots. The mandibular first molars have a - 6 0 tipback built in to promote leveling and to gain arch length. This will be 12

discussed in detail later. There is 00 angulation on the mandibular second molars, since I have found that these teeth rarely need to be uprighted excessively. If necessary, they can be uprighted by placing a tipback bend in the archwire when bending the omega stop. Bracket Torque (Third-Order Bends) I have been using the first three components-bracket selection, bracket height, and bracket angulation-in my practice since 1968. Only in 1978 did I move the torque from the archwire into the bracket. Other pretorqued appliances have determined their torque from measurements of the natural dentition. Our approach was to measure the torques in rectangular archwires used to finish well treated orthodontic cases. We took 5_0 finished results we liked and measured the torques in the final archwires used to obtain those results. My system is designed so that the best results are achieved when an.017" x.025" arch wire is used to fill the..018" bracket slots. This leaves enough play to permit easy archwire engagement to the base of the bracket slot, which increases patient comfort. The rule of thumb is that .001 " of play equals about 4 * of torque, so each of the torques listed below should be considered to be plus or minus 40 due to play. These measurements differ from commonly used torques in three major respects. The -30 torque on maxillary cuspids-compared to extremes of + 7 * to - 7 0 in other appliances-eliminates the need for adjusting the torque later 13

in treatment. I have found the - 3 ' to be just enough to prevent these teeth from tipping out. No torque is placed in the mandibular second molar tubes, because we always use omega stops. As the omega is bent out to avoid impingement on gingival tissue and to create less of a food trap, we've automatically placed the torque into the second molar. If we had torque built into the second molar attachment, when we bent the omega stop out away from the gingival tissue, we would have to detorque the wire end, Not having torque in the second molar attachment saves one small step. If the omega stop is not used, the second molar buccal tube should have the torque and the distal tip angulation built into it. The most important difference between the torques in my appliance and those of other appliances is that we put - 5 * of lingual crown torque or labial root torque in the mandibular incisors. This was validated in an unpublished thesis done by Dr. Dwayne Trammell as a graduate student at Baylor in 1980. He analyzed a number of my routine Class 11 nonextraction cases, first locating the most forward positioned mandibular incisor

cephalometrically. We then banded/bonded the mandibular arch, using the -5' torque on the mandibular incisor brackets, and inserted an .017"x.025" Direct multistranded archwire. We left that wire in for an average of three months to eliminate all rotations. There was no headgear or Class III elastics-just the archwire tied into the brackets. Cephalometric tracings made after the three months and superimposed on the originals showed that the incisal edge of the mandibular incisors changed less than 1mm, and to the lingual at that. The root tip moved labially an average of 1 mm. From this, I interpret clinically that the mandibular 14

incisor stayed just about where it was. If a round wire had been placed at the first appointment and left in place for three months, the mandibular incisors would have been expected to tip labially. So, the effect of the - 5 * torque and the rectangular D-Rect wire is to hold the mandibular incisors in their original position. They do not cause the teeth to tip lingually. How many cases are there in which the orthodontist says, "If I could just keep those mandibular incisors where they are, I could treat the case non extraction"? it is my belief that the negative torque on the mandibular incisor brackets, plus the flexible D-Rect wire to begin torquing control from the initial archwire, plus the space gained through bonding as opposed to banding, plus the ability to perform selective interproximal enamel reduction -all of these together mean that many more borderline cases can be treated nonextraction. In a few nonextraction cases, the mandibular incisors are tipped lingually before treatment. In these cases, the standard 0 0 torque should be substituted for the - 5 0 torque. In an extraction case, I still use the -50 torque, because I want the mandibular incisors to stay in the same basic location. In the same investigation, Dr. Trammell studied the reaction of the mandibular first molar when - 6 0 tip is placed in the bracket. Dr. Trammell took laminagraphic sections through the mandibular first molar at the beginning and after the three-month period of treatment with the .017"x.025" D-Rect archwire. Superimposition showed that the root tips moved anteriorly less than half a millimeter and the crowns tipped distally an average of 1mm. In other words, with only the archwire tied in and with no Class III elastics or headgear to the mandibular arch, the mandibular first molars uprighted 15

and 2mm of arch length was gained. I attribute this to the -6' tip on the molars and the anchorage effect of the -50 torque on the incisors. Actually, it seems like a reciprocal action. This reinforces Dr. Tweed's concept of upright mandibular incisors and first molars. Bracket In-Out (First-Order Bends) The fifth component of the Vari-Simplex Discipline is bracket in-out. The appliance incorporates a system of interrelated, compensating bracket base thicknesses to replace the usual first-order bends or offsets. I can't remember the last time I placed a lateral inset or cuspid offset bend in the maxillary archwire. In bending an omega stop, I bend in a slight offset and a gable bend to get additional rotation on the maxillary first molars. That's about all the wire bending done in the maxillary arch. In the mandibular arch, I have described how I place torque into the archwire for the second molar tubes, and occasionally-about one arch out of 50-1 might have to bend a slight cuspid offset or molar offset. But there is really very little wire bending for first-order bends with this system. Archwire Selection and Sequence It must be understood that the bracket is only a "handle" placed on the tooth. For this concept to produce the desired results, emphasis must also be placed on the force systems inserted into the bracket slots. Proper archwire selection and sequence will allow the Discipline to deliver the desired results. 16

The combination of greater interbracket width achieved with Lewis and Lang brackets, improved resiliency of archwires such as D-Rect and TMA, and the Vari-Simplex Discipline itself have all contributed to the reduction of time-consuming archwire changes. Before selecting the archwire to be used, its intended purpose must be identified. The first step, in most cases, is the elimination of rotations. This is best accomplished by the use of the newer, flexible, more resilient wires- multistranded round and rectangular TMA and Nitinol. Leveling and space closure are accomplished next, usually with rectangular wire-TMA or stainless steel, depending upon the specific need. The last step-final leveling and arch form-are always performed with stainless steel wire. The usual selection of archwires includes: A. Nonextraction 1. Multistrand .017" x .025" D-Rect (mandibular arch) and .0175" Respond (maxillary arch) 2. Occasionally, an .016" SS round or an .016" x .022" SS rectangular wire may be used to further eliminate rotations 3. .017" x .025" SS ideal finishing archwire It is important to remember with nonextraction treatment in the mandibular arch that every arch should be rectangular, if possible, so that anterior torque control can be achieved. B. Extraction 1. Maxillary Arch 17

a.

Multistrand .0175" Respond or .017" x .025" D-Rect (depending on the severity of the malpositions)

b. c.

.016" round SS wire for retracting cuspids .018" x .025" SS with closing loops to retract four anteriors (reduce archwire posteriorly)

d.

.017" x .025" SS finishing archwire

2. Mandibular Arch a. Multistrand .0175" Respond or .017" x .025" D-Rect b. .016" round SS archwire or .017" x.025" D-Rect c..016" x.022" SSclosing loop archwire d. .017" x .025" SS finishing archwire Direct Bonding The final component of my system is bonding. The benefits to the patient are overwhelming: less chair time, improved appearance, greater comfort, and much less trauma to the teeth and gingival tissue. There are also benefits to the doctor: it is easier and less time-consuming than banding, there are fewer hygiene problems (when a fluoride rinse or gel is prescribed), and it allows for interproximal enamel reduction in the borderline

nonextraction case. Also, bonding does not require an enormous inventory investment if a practitioner wants to evaluate a new appliance. RememberKeep It Simple, Sir. 18

One of the best learning experiences any practitioner can have is to photograph several different types of patients at every appointment from the beginning to the end of treatment, and then to go over the- charts and photographs. It will enable you to study your treatment plan and archwire sequences, the length of time each archwire is left in the mouth, the performance of each archwire, and the total time needed for the completion of treatment of each arch. The first tirne I did this, I realized that the total time needed to complete mandibular arch treatment is perhaps as little as six months in a nonextraction case. In addition, one of the big problems on a Class 11 case is moving a Class 11 canine to a Class I relationship when the mandibular arch is banded. Bracket interference can create canine attrition, loose bonds, and retardation of tooth movement. For these reasons, I rarely band the mandibular arch until I have a Class I canine relationship. Why start sooner? Maxillary Arch My typical nonextraction treatment, then, begins with the maxillary arch. The incisors, cuspids, and first bicuspids are banded, and the second bicuspids and first molars are banded. Second molars are banded near the end of treatment only if they are in poor position. After the appliances are in place, we usually insert a multistranded, spiral, round archwire. I prefer the round wire, because maxillary torque control is not critical at this stage. Two weeks after the bonding and banding appointment, the patient is given an extraoral appliance, which I call a retractor.

19

At the third appointment, usually four or five weeks later, rotations are tied, and the retractor is adjusted. It normally takes two appointments for the initial spiral wire to eliminate rotations in the maxillary arch. Multilooped archwires are never used for the elimination of rotations during the first stage of treatment. State-of-the-art archwire material and the proper bracket selection have made that time-consuming procedure unnecessary. The initial spiral archwire is generally removed at the next

appointment, and an.016" round wire with omega stops mesial to the terminal tubes is placed, so that the archwire can be tied back. This wire further eliminates rotations and continues leveling the arch. If the case involves a closed bite, enough excess curve of Spee is placed in the archwire to enhance the opening of the bite. It is extremely important to tie this archwire back. The orthopedic action of the retractor is beginning to take effect during this period, if the archwire is secured molar to molar. If it is not tied back, the molars begin to move independently and create space between the maxillary first molars and second premolars. Is it necessary to place omega stops in the archwire? In other words, why use tiebacks? There should be unanimous agreement about that, but there are many differing opinions. In my opinion: when in doubt, tie back. There are at least three ways of tying back-the traditional omega stop, power chain or ligature wire from molar to molar, and bending the archwire at an angle distal to the molar tube. My purpose in tying back the archwire is to consolidate the arch-to convert the arch from several units to a single unit. It is necessary for the 20

arch to be in one unit for the extraoral forces to act orthopedically instead of dentally; and intraoral elastic forces must act on the arch and not on individual teeth. The omega stop, placed 1-2mm mesial to the buccal tube, enables placement of an active tieback force on the arc6ire. This can close small spaces that could have developed if the elastic hook were placed on the bracket. A consolidated arch eliminates the need to ligate teeth together or to solder hooks to the archwire. All spaces should be closed while the .016" archwire is in place. In addition to tying back, power chains can be used from molar to molar to close all spaces. If a rectangular multistranded wire is used instead of the.016" wire to initiate torque control at the same time, it should be bent distal to the first molar tube (Fig. 13) or tied in, with power chains from molar to molar. One or two appointments later, after all the rotations have been eliminated, all spaces have been closed, and the arch is beginning to level, the round wire is removed and the third and final archwire-an .017" x .025" rectangular stainless steel finishing archwire-is placed. If the bite is still closed at this stage, a bite plate is used so that the mandibular anteriors occlude on the bite plate and free the occlusion (Fig. 14). This will improve the effectiveness of the maxillary archwire, and allow the posterior teeth to begin erupting into a more level position. The pressure of the mandibular anterior teeth on the bite plate will tend to depress them. This will begin to open the bite and level the mandibular arch before it is bonded and banded. Mandibular Arch 21

Sometime after the final archwire is placed in the maxillary arch, separators are inserted between the mandibular posterior teeth, and the mandibular arch is bonded and banded two weeks later. Again, the incisors, cuspids, and first bicuspids are bonded, while the second bicuspids and first molars are banded. We routinely band erupted mandibular second molars, except when the angle of SN to the mandibular plane is greater than 400. Bonding/banding the mandibular arch is delayed in a nonextraction case for the following reasons: 1. It will avoid interference of mandibular brackets with maxillary teeth. 2. As the maxillary arch improves, the mandibular curve of Spee improves naturally. 3. If a bite plate is needed, it fits better and is more comfortable after the maxillary arch has been properly aligned. 4. Total time needed to treat the mandibular arch is 6-9 months. 5. It allows more time for the mandibular second molars to erupt. The mandibular arch is the key to nonextraction treatment with the Vari-Simplex Discipline. There are five primary reasons for our ability to control the advancement of the mandibular anteriors: 1. 2. Bonding eliminates the need for interproximal band space. A -50 torque on the mandibular incisors resists anterior flaring of these teeth. 22

3.

The use of .017" x .025" D-Rect multistranded, braided archwire permits torque control in the anterior segment with the initial archwire.

4.

A -6* tip on the mandibular first molars allows distal movement of the molar crowns, which can create additional arch length.

5.

With bonding, selective interproximal enamel reduction is possible. Elimination of the band spaces through bonding and the initiation of

torque control with the initial flexible rectangular archwire in the negatively torqued brackets will provide the control in positioning the mandibular anterior teeth-the key to a nonextraction case. In cases in which nonextraction treatment is preferred, but crowding of the mandibular arch may prevent unraveling and uprighting of the lower anteriors-despite the five factors listed above-then Class III mechanics should be considered. If Class III elastics are used, they must be initiated at the time of the placement of the first wire. This wire must be round and multistranded because of the excessive anterior crowding. Without Class 11.1 mechanics, the mandibular anteriors will advance labially. A combination of the distal force from the Class III elastics and the uprighting tip on the mandibular first molars will control this advancement. The angulation of the -60 tip built into the first molars creates an uprighting force, serving the same purpose as a tipback bend. Together with Class III elastics, this allows the first molars to upright farther distally, creating additional arch length and allowing the anterior discrepancy to unravel with little or no advancement.

23

If Class III elastics are worn to the mandibular arch, the orthodontist must take into consideration the extrusive force of the elastics on the maxillary first molars. In a closed bite case, some molar extrusion may be desired to help open the bite. In the case of an open bite or a higher SN-MP angle, however, a high-pull force is added to the facebow during Class III mechanics to prevent molar extrusion. The high-pull force should be initiated before placement of the first mandibular wire. After bonding and archwire placement, the next appointment is used to tie rotations. In a severe discrepancy nonextraction case, we often remove the D-Rect mandibular archwire and slenderize (strip) the mandibular anterior teeth-another benefit. of bonding over banding. The term

"slenderizing" is used, rather than "stripping", for the selective interproximal reduction of enamel. This phrase was coined by my brother, Dr. Moody Alexander. It is important to leave the D-Rect wire in the mandibular arch until the anterior rotations have almost been eliminated. This will take 2-4 months. If all rotations cannot be eliminated, we sometimes follow the .017" x .025" DRect wire with an.016" x.022" TMA or stainless steel archwire. This wire can also be effective in leveling the mandibular arch. The next wire is an.017" x.025" stainless steel finishing archwire. If additional leveling is needed, a reverse curve of Spee is placed in this final archwire.

24

At this point in treatment, the final .017" x .025" archwires are in both arches. Extraoral forces have continued throughout, and a Class I molar relationship should have been achieved. We then proceed to final detailing. Class 11 elastics may be added, if necessary, until normal centric relation is achieved. Notice that Class 11 mechanics are not initiated until finishing archwires are in place. Premature use of Class 11 elastics can cause loss of torque control, bite closure, tipping of the occlusal plane, and a false bite. To correct a midline shift, a midline elastic with a Class 11 elastic on one side and/or a Class III elastic on the other will help shift the arches into their final positions. Up-and-down elastics may be used to correct any open bite, or for overcorrection. Occasionally, we will need crossbite elastics on the posterior teeth to achieve the normal buccal overiet. After this final detailing, the case is ready for bracket and band removal. The amount of time needed to detail the case is directly proportional to the quality of the initial bracket placement. If the brackets are properly placed, as described earlier, it will rarely be necessary to place any additional bends (first-, second-, or thirdorder) to finish the case. Extraoral Force Application Having used all types of extraoral appliances, I have concluded that the best results are achieved with a facebow attached to the maxillary first molars. Patient acceptance and cooperation are better. Therefore, successful orthopedic results are achieved. In addition, the facebow offers better control of the posterior transverse dimension, so that palatal arches are not necessary 25

in the normally growing patient. Dr. Fred Schudy taught me to call the extraoral appliance a "retractor" ratherthan a "headgear". "Retractors an appropriate term, while "headgear" sounds like a football helmet. I use the same length outer bow on all retractors. The bow stops anterior to the ears, so that it will not interfere with the ears when a highpull is used. The direction of pull depends on the cephalometric evaluation of the patient. With an angle of SN to mandibular plane of 35 0 or less, we use a cervical-pull neckstrap; 36-420, a combination-pull; and greater than 420, a high-pull. I seldom use high-pull retractors attached to the archwire because of lack of patient cooperation and loss of transverse control, and for eye safety. The exception to this rule is the adult patient who has a high smile line, with excessive gingiva showing. I prefer the outer bow to be parallel to the occlusal plane and to the inner bow. When the patient closes, the lips should seal just behind the junction of the two bows without impingement on the lips (Fig. 15). We often have to adjust the retractor on first insertion, because the first molars are tipped or rotated. Adjustment is made on the inner bow where the wire goes into the molar tubes. Further adjustments must be made as the molars level and rotate, which should occur in two or three months. A simple method of adjustment is to place one end of the inner bow in its tube. The inner bow on the opposite side should be parallel to the retractor tube, but about 5mm buccal to it. The only time I adjust the outer bow is to swing it superiorly in a closed bite, low angle case when I am attempting to extrude the maxillary molars. I never do this in any other case, 26

because this is what has given the facebow the reputation for extruding molars. It has been my observation that molar extrusion is controlled if the facebow is used with the correct pull (cervical, high, or combination) as determined by the diagnosis, if the maxillary archwire is engaged in a fully banded arch, and if the occlusion is counteracting any vertical force exerted on the molars. When the retractor is seated for the first time, the elastic strap is adjusted for 8-10 ounces of pressure per side, and we increase that to approximately a pound per side once the patient has adjusted to the force. Depending on the diagnosis, the patient will wear the retractor 8-14 hours per day. As a general rule, if the patient's ANB is 5* or more, the retractor is worn 14 or more hours a day. if the AN B is 3-5 0, retractor wear can be reduced to 12 hours. If the AN B is less than 3 0, the retractor is worn at night only, 8 hours a day. In my practice, retractor wear is probably the most important determinant of a patient's success or failure in treatment. Therefore, we particularly emphasize cooperation during the first six months of treatment, when the patient is usually enthusiastic. I don't make the patients keep charts, because I do not want to put them in the position of misrepresenting the truth about whether they have been wearing the retractor. If the patient has been wearing the retractor, the maxillary first molars will be somewhat mobile. Another indication is worn on the neckstrap. The patient brings the retractor to every appointment, and I check the wear and also adjust the neckstrap. 27

In my practice, we treat approximately three out of four cases nonextraction. The decision depends upon the patient's ability to cooperate, and on the orthodontist's ability to produce a result with an esthetically pleasing profile and with an excellent occlusion that will remain stable in the ensuing years. In some cases, we simply must remove teeth to ensure that good result. I will describe the typical treatment sequence for a Class 11 division 1 case with a 5-8mm discrepancy in the mandibular anterior arch. Maxillary Arch After the extraction of the four premolars, spacers are placed for the maxillary second premolars and first molars, which will be banded. It is important to leave the separators in place for two weeks to create adequate space and to allow initial discomfort and soreness of the teeth to dissipate. I Two weeks later, the maxillary arch is bonded from the canines forward, after the maxillary second premolars and first molars are banded. The initial archwire-.0175" Respond or.017" x.025" D-Rect braided wire- is then tied in as, well as possible, usually with 0-rings, depending on the severity of the discrepancy in the anterior teeth. Except in a Class III or bimaxillary protrusion maximum anchorage case, where the mandibular incisors are protrusive and the canines are Class 1, we will begin treatment in the maxillary arch and allow the mandibular arch to drift (driftodontics) for six to eight months. By the time the mandibular arch is ready for bonding and banding, the anteriors will have unraveled by themselves and the mandibular second molars will often have erupted enough for banding.

28

At the next appointment, two weeks after the placement of the initial archwire, rotations are tied with steel ligature wire and a cervical facebow is seated. We call the facebow a retractor, and the patient is instructed to bring it to every appointment. Four to five weeks later, the initial multistrand archwire is removed, and an.016" stainless steel round wire is placed, usually with omega stops 12mm anterior to the molar tubes. If this archwire cannot be fully engaged in one of the maxillary centrals or laterals, a note is made to tie that rotation at the next appointment, so that the rotations will be completely eliminated as early as possible. At this same appointment, canine retraction is initiated with a three-unit segment of Power Chain 11. One unit is wrapped around the double tubes on the first molar, and the second unit passes over and is not engaged in the Lewis brackets on the bicuspid. The third unit is stretched anteriorly to the canine bracket. The retractor is also adjusted, ensuring that there is adequate force to prevent mesial movement of the molars, and the instructions concerning patient cooperation in retractor wear are reinforced. At the next three to five appointments, spaced five weeks apart, the power chains retracting the canines are replaced and the retractor adjusted. Canine retraction normally takes three appointments. In a closed bite case (overbite greater than 3mm), we begin treatment of the mandibular arch as soon as the canines are Class 1, to help open the anterior bite. If the bite is not closed, canine retraction is completed (canines touching second

premolars) and incisor retraction is initiated prior to proceeding to the mandibular arch. 29

The canine may have a tendency to tip and rotate during retraction. The canine bracket should not become disengaged from the .016" round wire, because the teeth will then tip and rotate much faster. If this begins to occur during canine retraction, it is important to ligate the canine bracket completely to the .016" wire, to upright and rotate the canine back to its normal position before placing the power chains. If there is some tipping and rotation at the completion of canine retraction, it is a simple procedure to leave the.016" wire in for an extra appointment after ligating the canine to engage the archwire to the base of the bracket slot, and then to figure-eight that ligation to the premolar and molar. If necessary, the mesial wing of the Lang bracket can also be activated to complete the rotation (Fig. 23). One appointment should accomplish complete uprighting and elimination of the rotation without changing archwires. Why retract canines individually rather than retract all six anterior teeth as a unit? Since most cases we treat have a Class 11 canine tendency, I prefer to obtain a Class I canine relationship as soon as possible. By retracting the canines first, several benefits occur: 1) less posterior anchorage is lost because fewer teeth are being retracted, and, since it's early in treatment, the patient will be more cooperative in wearing his extraoral appliance; 2) by obtaining a Class I canine relationship before the mandibular arch is banded there is no concern for cuspal interference, loose bonds on the mandibular canine, or attrition of the maxillary canine cusp tip; and 3) after canines have been retracted, torque on the maxillary incisors is more easily controlled during their retraction.

30

After the maxillary canines have been retracted on the.016" round wire with the power chain, an .018" x.025" stainless steel closing loop archwire is placed. This archwire is bent in an ideal arch form with large, tear drop shaped loops just distal to the maxillary twin lateral bracket. Omega stops are not used, but the wire extends through the first molar tubes. Before placing the archwire in the mouth, the portion of the archwire distal to the closing loops is reduced approximately .001" in the anodic polisher, so that part of the wire can slide through the brackets easily during activation. It is activated by placing a #442 plier on the archwire distal to the molar tube, pushing it distally 1-2mm to open the closing loop, and bending the end 45 degrees gingivally to produce a stop. The patient is seen every four to five weeks, and the maxillary closing loops are activated Imm at each appointment. This method of retracting the four incisors as a unit allows more torque control than if all six anteriors were retracted together. Complete space closure should be accomplished in six to eight months. After all maxillary spaces are closed, the. fourth and final archwire is placed. This.017" x .025" stainless steel wire is bent with ideal arch form and omega stops and may or may not incorporate an accentuated curve of Spee, depending upon the overbite. Mandibular Arch Following the KISS Principle, I believe in allowing Nature to help attain treatment goals. For example, while diagnosis is made primarily to the 31

mandibular arch, my treatment usually begins in the maxilla and is not initiated in the mandible until six to eight months into active therapy. The advantages of delay in banding the mandibular arch in extraction cases are that: 1. it allows physiological drifting of crowded mandibular anterior teeth, 2. little posterior anchorage is lost since maxillary molars are being held distally, 3. while retracting maxillary canines there is no interference and/or attrition on the cusp tips from the mandibular canine brackets, 4. it allows additional time for the second molars to erupt more fully, and 5. total time needed to complete mandibular arch treatment is 9-12 months. As the maxiliary spaces are closed and the canines are in a Class I relationship, the mandibular arch is banded/ bonded and an .017" x .025" DRect rectangular braided archwire or an .0175" Respond multistranded wire is placed at the same appointment. This wire is kept in place until most of the rotations in the anterior teeth have been eliminated by tying them at subsequent appointments. The next mandibular archwire, which is used for one or two appointments for leveling and elimination of rotations, is usually an.016" round stainless steel wire with omega stops 1-2mm anterior to the second molar tubes. If there is some curve of Spee in the arch, the archwire is bent with a reverse curve and tied back. The omega stops are not used if only a 32

small amount of extraction space remains that can be closed with a power chain stretched from molar to molar. If there is too much space to close with a power chain, an .016" x .022" stainless steel rectangular closing-loop archwire is used. A Bull loop is placed in the extraction site, and omega stops are placed at the distal of the twin brackets on the first molars. Care must be taken to avoid overactivation of this closing loop, which will cause dumping of the mandibular arch. If the mandibular arch has a deep curve of Spee, a gable bend is placed at the closing loop. Space closure takes from two to six months, depending on the amount of space to be closed. During this period, the amount of extraoral force used depends on the molar relationship. In a severe Class 11, active headgear force for 14 or more hours a day is needed; in a Class 1, only night wear is required to hold the maxillary molars in position. After spaces have been closed in the mandibular arch, the fourth and final archwire is placed-an .017" x .025" stainless steel ideal arch with omega stops 1-2mm anterior to the second molar tubes. If the arch is not adequately level after one or two months, this archwire is removed, a reverse curve of Spee is placed, and the archwire is retied, being sure it is tied back. Detailed finishing takes three to six months. Rotations are tied and the wings on the Lang or Lewis brackets are activated to finalize rotations. Midline, Class 11, or Class III corrections are made with elastics. During this phase of treatment, it is critical to manipulate the patient's mandible at each appointment to ensure a centric relation bite is present. It may be necessary to adjust one or both archwires to expand or constrict the buccal segments so 33

that an ideal buccal overjet relationship is achieved. After this fine-tuning, the patient is ready for the removal of brackets and bands. A typical extraction case takes 20 to 24 months from initial maxillary bracket placement to removal of all brackets-depending on the severity of the case and the patient's cooperation. Elastic Wear Although each patient has individual requirements, some general statements can be made regarding the use of intraoral elastics. Class III elastics are often worn early in treatment either to correct an anterior crossbite or to prevent advancement of the mandibular incisors during the initial elimination of rotations in nonextraction treatment. Class 11 elastics are rarely worn until both arches have rectangular archwires. Early indiscriminate use of Class II can cause loss of anterior torque control, rotation of the occlusal plane, and a deepening of the bite. Normally, Class 11 elastics are worn during the last few months of treatment, when both arches have finishing archwires. During this period the difference in centric occlusion and centric relation is corrected. Midline correction is achieved after all spaces are closed and final archwires are in place. A midline elastic, connected from a maxillary lateral to the opposite mandibular lateral, is worn in conjunction with a Class 11 or Class III elastic to achieve the desired correction.

34

Crossbite elastics are worn as early as possible, so that the correction can be maintained during treatment. Lingual lugs are placed on all molar bands for this purpose. Special elastics are worn during the finishing stages of treatment. Anterior and posterior up-and-down elastics are worn to finalize the cuspal interdigitation and overbite. After appliances are removed a special elastic is worn to close band spaces and consolidate the arch. Palatal and Lingual Arches Control of the transverse dimension, especially in extraction cases, is usually obtained by use of the extraoral facebow to the first molars. Because of this, we do not routinely use palatal or lingual arches. On specific problems, however, these appliances are used. Palatally, two designs are preferred. The Nance palatal arch, designed with an acrylic button placed in the anterior center portion of the palate, is used in a case with an extreme discrepancy, a Class I molar relationship, and anterior teeth that are in normal positions. The purpose of the Nance is to hold the anterior and posterior teeth in place while the canines drift into their position. A transpalatal arch with a Goshgarian design is used on all high angle cases. In addition to maintaining the transverse dimension, the TPA can inhibit vertical alveolar growth, which is desperately needed in high angle cases. Often the patient will rest his tongue on the arch bar, which creates an impression of the arch bar on the tongue and places a vertical intrusive force on the molars. The arch bar is designed to be removable, so that it can be expanded, constricted, or adjusted to rotate the molars during treatment. 35

In the mandibular arch a lingual holding appliance is used to preserve the "E" space when needed. This occurs in nonextraction cases frequently. In extraction cases, it would be used in a maximum anchorage situation with crowding, while waiting for the remaining teeth to erupt. This lingual arch is used specifically as a holding appliance. I have not found it necessary to use this appliance to control the mandibular transverse dimension. Expansion Appliances Constricted maxillary arches are routinely corrected with a rapid palatal expander. This is an all-metal appliance with bands on the maxillary first molars. The jack screw is turned every 12 hours or every 24 hours, depending upon the case, for two to three weeks, until the crossbite is overcorrected. After being sealed with acrylic, the appliance stays in the mouth for approximately six months. Slow palatal expansion with a quadhelix appliance is sometimes used on younger patients. Arch Form Although the round multistranded initial archwire has no arch form, it is rarely left in the mouth more than two months. The next wire, .016" stainless steel, is contoured and placed in the mouth to see if it conforms to the patient's arch form, The buccal overjet is observed to determine if the posterior portion of the archwire should be expanded, constricted, or left the same. This procedure is followed until thefinishing.017" x.025" mandibular archwire is bent. This archwire is contoured to fit the patient's original study models, making sure the canines are not expanded. After this archwire has been in place for a time, the maxillary finishing archwire is contoured as 36

needed to fit the mandibular teeth. Although coordinating maxillary and mandibular archwires may be necessary, I find it more practical to contour each archwire individually as needed to solve the particular problem. In 1981, Dr. Garland McKelvain reported on the arch forms used, with the Vari-Simplex Discipline in an unpublished thesis written while he was a graduate student at Baylor. In this study he used 102 maxillary and mandibular finishing .017" x .025" archwires selected from cases in my practice that he thought were well-treated and had all the characteristics we believe in-upright teeth, non-expanded canines, and level arches. He made copies of the final archwire used on those cases, drew perpendicular lines down the middle of the arch forms, and measured across the arches at certain intervals. He put those measurements into a computer, and evolved a series of arch forms. The following conclusions were reached: 1. The average maxillary arch design had very little standard deviation from all those examined. 2. Of the mandibular arches studied, all could be related to one of the two mandibular designs with very little standard deviation (Fig. 26). 3. Compared to the subsample form according to sex, age group, teeth included in the appliance, and extraction versus nonextraction therapy, the arch forms appeared to be approximately the same as the master sample form. 4. Compared to the original pretreatment models with appliances placed, there appeared to be no great change in the shape.

37

5. Comparing arches to the Par, Brader, and Boone forms, there was a significant difference in shape. Quoting from Dr. McKelvain, "Arch'design has always been one of the most important parts of the successfully treated orthodontic case. The design used in the final stages with the finishing archwire molds the maxillary and mandibular dentitions to their final orthodontic results. The function, stability, and esthetic results have been determined in great part by the final shapes of the arches and should not be changed greatly from their original forms. This study demonstrated very little change between the pre and post orthodontic forms. Many preformed archwires and arch forming guides of various shapes and sizes have been used for many years in the practice of orthodontics. Some of these are similar to the arch forms suggested from the evidence of this study, and others are quite different. "In previous studies, arch form was either calculated mathematically, through the aid of mechanical devices, or from the study of 'normal' occlusions that had not been treated orthodontically. This study was areverse of previous studies in that the final product was examined and investigation was conducted to determine how that result was reached. Then the final result was compared to the initial malocclusion to check its validity. The purpose of this study was not to derive arch designs for the maxillary and mandibular dentitions to be used on absolutely every case treated orthodontically with any and every type of treatment mechanics and appliances. The study is aimed at suggesting the use of a set of arch designs that could be utilized with a specific straight wire orthodontic appliance 38

(Vari-Simplex

Discipline)

and

not

change

the

original

form

significantly while achieving good results. In a high percentage of the cases, these designs should need little or no modification." .. When I began private practice, I tried a number of band removal and retention procedures. My first approach included removal of canine and premolar bands, and retying the archwire in an attempt to close the resulting band spaces. These cases seemed to grow worse, because proper arch form and torque control were lost. Next, I tried removing all the bands in one appointment. This technique required many retainer adjustments because of band spaces, and conventional retainer wires interfered with the occlusion as the teeth settled. Even more significant, the cases seemed to slip forward, often approaching an end-on canine relation, and the bites closed

excessively. Another approach-using positioners-worked beautifully if the case had been overtreated; but the time, effort, expense, and patient cooperation required lessened my enthusiasm. After a year of struggling with retention, some clear goals came into focus: 1. Close band spaces (bonding greatly reduces this need) 2. Maintain proper anterior torque 3. Obtain correct interdigitation 4. Control overbite/overjet relationships 5. Maintain solid Class I molar relationships 6. Design retainers to maintain the interdigitation achieved in active treatment

39

After

discussing

these

problems

with

fellow

orthodontists

and

clinicians, I developed an accumulation of ideas that I call "Countdown to Retention". The countdown begins when the patient's teeth have been properly positioned, centric relation achieved, roots at extraction sites parallel, mandibular canine width not expanded, proper buccal and labial torque, normal overbite, overjet relationships, and Class I canine

relationships. Posterior Settling Technique When all these conditions have been achieved, the posterior teeth are sometimes not completely settled. To accomplish this, the archwire (usually mandibular) is cut between right and left canines and premolars. The posterior archwire segments are removed, leaving these teeth completely free. The anterior archwire remaining is bent distal to the canine brackets, leaving a 3-3 sectional archwire. The patient is then instructed to wear a series of elastics as follows: 1. In a Class 11 case, a 3/4", 2oz elastic is worn on both sides beginning with the maxillary lateral incisor, going to the mandibular canine, and continuing up and down until three teeth on both arches are involved. 2. If a Class III vector is needed, the elastic is first hooked to the mandibular canine, proceeds to the maxillary canine, and continues up and down until three teeth in both arches are included.

40

3. If additional overbite is desired, a 1/4", 6oz elastic can be worn as an anterior "box" Again, the elastic can be hooked up to give a Class 11 or

Class III vector depending upon the need. The patient is instructed to wear these elastics 24 hours per day for three weeks. In the normal case, when the teeth have settled properly, the patient is instructed to wear at night only and is scheduled for appliance removal in three to four weeks. In some instances, especially in open bite cases, the patient may be instructed to discontinue all elastic wear and be observed for several months, watching for relapse, before appliance removal. In some cases, the maxillary archwire is cut between the laterals and canines, freeing the maxillary canines from the archwire. Wearing the upand-down elastics will help position these teeth nicely (Fig. 40). Since I am concerned about tooth control when the maxillary arch is sectioned, that patient is seen more often. Bond/Band Removal First Appointment All bonds except on the four mandibular incisors are removed, and the premolar and second molar bands are removed, leaving only the four first molars banded. The teeth are then thoroughly cleaned; and an assistant reviews oral hygiene procedures, giving the patient a package of unwaxed dental floss and advising special attention to toothbrushing and flossing procedures to return edematous gingivae to normal. Mandibular canine bands are fitted and maxillary and mandibular impressions are taken. The 41

impressions are poured twice-first for the working models, and then for routine -final models. The mandibular archwire is then retied to maintain mandibular incisor position. Instructions to the patient are as follows: 1. Wear one 3/4", 2oz elastic only on the maxillary arch and only at night. 2. Wear a facebow to the maxillary first molars while sleeping, to maintain the proper molar relationships (unless the molars are in a superClass I relationship), even if a facebow was not used during treatment. 3. Chew sugarless gum during all waking hours, squeezing posterior teeth as hard as possible in centric relation. The patient should be in good centric relation at this time. To make sure, I manipulate the jaws to find centric relation. To teach the patient this position, I touch the junction of the hard and soft palates with a mirror handle and say, "Put the tip of your tongue right there and bite". Even if it doesn't feel exactly right, they are told to squeeze and be careful not to slide after they have closed. The teeth are extremely mobile at this stage, and squeezing forces them to settle quickly. I have been known to say, "If your teeth aren't settled by the time you come in next appointment, your braces may have to be put back on". Maxillary Retainer The buccal tubes on the maxillary permanent first molars are shaved off the plaster study model. An .036" wire is formed to fit closely to the anterior teeth. An adjusting loop is placed in each canine region and the wire is extended distally, touching each tooth, until it reaches past the terminal 42

molars and "wraps around" all maxillary teeth. "C" clasps (.036") are then formed around the maxillary terminal molars. As the wire passes the distal portion of the teeth, care is taken to bend it away from the lingual surface of the terminal molar. Occasionally, if they were not banded, the maxillary second molars are "kicked out" too far buccally at the end of treatment. If the mandibular second molars are in good position and the maxillary retainer does not inhibit the maxillary second molars, the pressure of the buccinator muscles and normal eruption will move these teeth into normal position. The "C" clasps are then soldered to the facial wire in the area of the distobuccal cusp of the maxillary second molar. Quick-cure acrylic is then sprinkled on the plaster model, incorporating a bite plane and full palatal coverage. Care is taken to achieve a constant thickness of acrylic, so the only area requiring adjustment by grinding will be around the lingual surfaces of the teeth. The acrylic is never polished, since the patient's tongue seems to adapt better to the rougher surface. The bite plane is adjusted when the retainer is delivered to the patient. A 3mmdiameter hole is placed in the center of the palatal area superior to the central incisors (Fig. 42) to help control tongue position. Mandibular Retainer For the mandibular canine-to-canine retainer, an .036" lingual wire is carefully adapted 1mm below the incisal edge of the anterior teeth and then soldered to the canine bands. It is important to position this wire high on the lingual surfaces. Since this is the flattest portion of these teeth, the wire will

43

engage the entire lingual surface, thus preventing rotations. Elastilugs are spot-welded to the distolabial surface of the canine bands. If rotations or spacing develop while wearing the banded 3-3, the problem can be solved by removing the banded 3-3 and reducing the interproximal enamel. The 3-3 is then recemented and a light elastic is worn, labially between the elastilugs placed on the canine bands, converting the 3-3 into an active appliance. In some cases, we may bond the mandibular retainer. The advantages of bonding are that no metal shows on the labial surface, oral hygiene and periodontal health are improved, and no band space is needed. The disadvantages of bonding are that bonding failure could result in the retainer being swallowed, rotation and space problems cannot be corrected, the technique must be much more precise, and the retainer is not removable. The bonded 3-3 is a passive appliance. Second Appointment Within the next one to five days, the remaining brackets and bands are removed, a panoramic x-ray is taken, and the retainers are delivered. The bite plate in the maxillary retainer is adjusted until it is just out of contact with the mandibular incisors upon closure. The lingual surface of the retainer is relieved 1-2mm adjacent to any posterior teeth that need more lingual settling (Fig. 44). Since no wires interfere with the occlusion, the teeth can continue to settle. Using the up-and-down elastics several weeks before appliance removal does such an excellent job in settling the teeth that the time between the first two appointments can be reduced. An advantage of 44

delivering retainers the next day is that they need much less adjustment in the mouth. Post-Treatment Review At this same appointment, patient and parents are invited to review the patient's results in a post-treatment conference. We use the panoramic x-ray to talk about the third molars, discuss possible relapse, and answer any questions. I always make sure to give credit to the patient for the successful result, and stress continued good oral hygiene. Full Band Removal First Appointment This technique was first developed in the late 1960s, when all patients were fully banded. Since 1978 all cases in my practice have had anterior teeth bonded, and therefore the technique has changed somewhat. We still receive many transfer patients with a fully banded strapup, however, so I will discuss the technique used on fully banded cases. For full band removal, mandibular second molar bands and all canine and premolar bands are removed at the first appointment with a posterior band-removing plier. The incisor bands are cut off with a band-slitting plier, leaving only the first molars banded. Band removal must be done carefully, since these teeth are extremely sensitive. To close the band spaces and tuck the teeth into better positions, the patient is given the following instructions: 45

1. Wear one 3/4 ", 2oz elastic 24 hours a day from the buccal tube of the maxillary first molar labially to the buccal tube of the opposite first molar. 2. Wear one 3/4", 2oz elastic at night only from the mesial bracket of the mandibular first molar labially to the mesial bracket of the opposite mandibular first molar. 3. Wear a facebow to the maxillary first molars while sleeping to maintain the proper molar relationships (unless the molars are in a superClass I relationship), even if a facebow was not used during treatment. 4- Chew sugarless gum during all waking hours, squeezing on the posterior teeth as hard as possible in centric relation. Second Appointment At the second appointment, about five days later, mandibular canine bands are fitted and impressions taken for the canine-to-canine retainer, and for the maxillary removable retainer. If all mandibular band spaces have closed, the patient is instructed to discontinue wearing the elastic around the mandibular arch. The other instructions remain in effect, and the patient is reappointed for insertion of the retainers three days later. Third Appointment Eight days after band removal, we schedule the third appointment. The first molar bands are removed, a panoramic x-ray is taken, and the two retainers are delivered. Subsequent Retainer Appointments 46

Four to six weeks later, the patient is seen for retainer adjustment and any artistic recontouring of the incisal edges of the maxillary anteriors that may be needed. At the next appointment, we take final records-lateral cephalogram, profile, front, and smiling photographs; and frontal and lateral intraoral photographs with the teeth in centric relation. We take additional final study models only in cases that may be used for teaching or for presentation at meetings. The next appointment is about four to five months after appliance removal. The patient is instructed to wear the retainer only while sleeping. We check for centric, working, and balancing prematurities, and perform an occlusal equilibration if necessary. The patient receives a retainer case and instructions for the following year, and then self-addresses a postcard to be sent for the next appointment in 12 months. The patient is then seen annually until a decision can be made on the future of the third molars. The mandibular canine-to-canine retainer is usually removed between the patient's 17th and 20th birthdays, after the third molars have either been extracted or erupted normally. Selective interproximal enamel reduction (slenderizing) is then performed to flatten the contact points of the mandibular incisors immediately after the fixed retainer is removed. In a case that was extremely crowded before treatment, the canine-to-canine retainer may be adjusted so that the patient can wear it while sleeping. The patient's final appointment is one year after removal of the fixed retainer. When released from the practice, the patient is told to wear the maxillary retainer at least once a week, indefinitely. 47

Variations in Procedure Mandibular Incisor Problems Some special problems require variations in retention procedure. In a nonextraction banded case, if there was a severe discrepancy or if the mandibular incisors had been slightly advanced, an impression for the canine-to-canine retainer is taken the same day bands are removed, and the lower retainer is seated at the maxillary impression appointment. If the mandibular incisors are slightly rotated or become crowded between appointments, the lingual of the mandibular incisors is shaved on the model to produce an idea canine-to-canine retainer. At the following appointment, the patient forces the appliance in place by biting down on a band-seating instrument positioned on the lingual wire of the canine-tocanine retainer. As the wire is seated, the mandibular incisors are forced forward into proper alignment, and the patient's bite holds the wire in place for several minutes. The canine-to-canine retainer is then cemented, with the patient continuing to bite, holding it in position as the cement hardens. If the mandibular incisors have rotated, but there is still interproximal spacing, the banded canine-to-canine retainer is designed to leave adequate space between the teeth and the wire. Small hooks are placed on the distolabial surface of the canine bands, and after the appliance is cemented, a 1/4 ", 2oz elastic is worn from hook to hook labially until the rotations have been eliminated and the spaces closed *

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If, after the retainer is cemented, the mandibular incisors become rotated, the following sequence is easily accomplished: 1) remove retainer, 2) slenderize incisors, 3) re-cement retainer, and 4) wear a 1/4 ", 2oz elastic from canine to canine attached to elastilugs until rotations are eliminated. Maxillary Incisor Problems Maxillary incisor problems may also necessitate variations in fully banded cases. If the band spaces are larger than anticipated, a 5/16", 31/2oz elastic can be worn around the involved anterior teeth near the incisal edges, in addition to the normal 3/4", 2oz elastic. The incisal placement helps artistic positioning, as well as space closure. Poor artistic positioning can be partially corrected by placing the 5116" elastic around two, three, or all four incisors, as close to the incisal edges as possible.

Open Extraction Sites If extraction sites are still open after band removal, as happens frequently with adults, a 5/16", 6oz elastic can be worn around the involved canine and premolar until the space closes, and only at night thereafter. In the mandibular arch, the first molar bands are not removed when the canineto-canine retainer is seated, and the patient continues wearing the 3/4", 2oz elastic from molar to molar until extraction sites are closed. Miscellaneous Problems

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In the case of a poorly positioned maxillary canine, its bracket is not removed at the first appointment. The 3/4", 2oz elastic is worn through the bracket slot of the canine, which moves the tooth lingually. For buccolingual relationship problems, 3/16", 6oz crossbite elastics can be worn on the first molars to increase or decrease the buccal overjet on one or both sides after the other bands have been removed. If the maxillary second molars are erupting buccally, the retainer is modified by placing the "C" clasp on the maxillary first molar; an .020" wire is soldered to the.036" labial wire in the first molar region, then bent to contour buccally around the maxillary second molar, where it can be activated to bring the tooth into position. If excessive labial torque remains in the maxillary incisors, as often happens in Class III cases, we alter the wraparound design of the retainer. Since the labial wire tends to slip gingivally in these cases, we solder small wires between the lateral incisors and canines, and incorporate them into the lingual acrylic. Because the elastics tend to upright the incisors, it is important that sufficient torque be established during treatment to avoid "ducking" problems during retention. If sufficient maxillary torque was not established, the elastic may slip off the teeth. This can be resolved by forming a "stop" with a small amount of cement on the central incisors, or by squeezing beading wax onto the elastic between the dried incisors. Summary 50

That's my countdown to retention. It's a fast and simple procedure, requiring very little chair time, but the teeth must be in reasonably good relationship at the time of band removal for it to work, The elastics close band spaces, improve arch form, and improve mandibular molar relationships by exerting force in a mesial direction. The facebow holds the maxillary molars while spaces are being closed, and prevents any mesial rotation from the elastics- The gum chewing and squeezing force the teeth to settle quickly within their own physiological limitations, but care must be taken that they do not traumatize the TMJ. Because of the appliance design, with no wires crossing the occlusal surfaces, retention does not interfere with normal occlusion and allows continued settling (Fig. 46). The retainer is a passive, holding appliance. Therefore, the final occlusion is dictated by function, not by the orthodontist. I am often asked whether there is any relapse after this retention procedure. My clinical observation has been that very little relapse occurs in the mandibular incisors. Most relapse occurs in the maxillary teeth. This seems to be a result of abnormal muscle function and/or teeth shifting toward their original malocclusion. Continuing to wear the retainer as instructed-calling the retainer "pajamas for your teeth"-will solve the latter problem. Abnormal muscle function is a different story. Mouth breathing and tongue thrusting can cause the bite to open after treatment on an open bite, high angle case. Conversely, the deep bite, low angle case that develops post treatment bruxism is destined to relapse, causing excessive overbite. 51

With these exceptions, it has been my experience that if the mandibular arch is properly positioned-the arch level with the incisors not tipped forward, the molars uprighted, and the canines not appreciably expanded-and the maxillary teeth interdigitate with the mandibular teeth in good centric relation, significant relapse is limited. Many orthodontists, because of their training or personal inclinations, believe they must develop an authoritarian environment to manage their practices. My opinion, however, is that to survive in today's culture, you must create a different kind of atmosphere. With the increased competition for the orthodontic patient, many new and different ideas regarding patient recruitment are emerging. Advertising in all forms is competing with the traditional forms of patient referral. It is not my purpose to comment on their validity, except to say that I hope our specialty will always remember its basic responsibility. Our patients come to us for "straight teeth" and facial esthetics. If, in addition to this service, the patient has had a positive experience during treatment, that patient and his or her parents will be the best possible source of patient referrals. Recently, a parent who had been in our office no more than five minutes told me, "I belong in this office". Since approximately half of the people who seek our services are pat lent- referred, it is especially important that our office personnel foster the type of environment in which people feel comfortable. . My goal has always been that patients walk out of our office with a smile, not with tears. If they're happy when they leave the office, they're going to tell their friends. I've had schoolteachers come because their 52

students recommended our office. Staff referrals are also important. Staff members live in different parts of town, socialize with different people, and can really recruit for you. Adult Room Another important source of referrals is adult patients. We cater to adults and don't treat them like children. Our standard procedure is that patients pick up their own charts upon entering the office. We have separate chart boxes for adults and children. When an adult patient enters, he or she takes the chart and goes straight to our "adult room", which is a mini-office just for adults. They have their own tooth brushing sink, their own miniwaiting room with a pot of coffee and the morning newspaper, and an operatory with two dental chairs and units. I remember being told in school not to seek out adult patients, but when I redesigned my office over six years ago I decided to include the adult area. I assigned a chairside assistant who was an excellent communicator to work with adults, and I had her ask every patient, "How do you like this compared to the old arrangement?" Almost every patient preferred our new environment, and a typical comment was, "This is the first time today I've had an opportunity to relax and collect my thoughts". After all, what adult would prefer to be treated in a room with a bunch of kids, loud music, and blinking lights? Children's Room In our children's "Rainbow Room", we play soft rock music on tapes and two FM stations. Each chair also has its own AM-FM stereo cassette

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portable player with earphones so the patient can select his own station or bring his personal tape. The office has a uniform schedule so that each day of the week the staff wears a different, colorful uniform. Once a week we all wear jeans and boots and listen to country western music. We also have flashing lights and mirrors on walls that are slanted so that the entire room and even the trees across the street are reflected. This helps create an open space environment. Orthographics Several years ago I decided to develop an organized system of forms and patient information to improve my practice management. I worked with Susan Gaylord Buxton, a professional artist, to develop a set of material called "Orthographics", which uses the idea of taking a trip in a car as a metaphor for orthodontic treatment. There's a line, representing a road, that runs at the top of the page throughout all the handout material, and it is all color-coordinated. The major component of this system is a booklet called "The Road to a Super Smile" (Fig. 48). The road that runs through the book is posted with highway signs -"Start" proper cleaning habits, "Stop" bad habits, "divided highway" for spacers, etc. We also hand out individual pages that have been reprinted from the book as reinforcers during various stages of treatment. Initial Exam When a patient comes in for the first appointment, he or she fills out our initial examinations card-yellow for children, blue for adults. The 54

receptionist then takes the patient and parents (if applicable) into our new patient room, where she gives them a "Welcome to Our Office" letter-blue for children, green for adults, red for transfers-containing sections on preliminary examinations, diagnostic records, consultation, oral hygiene, appointment policy, and fees. A letter on early treatment is also given at the new patient examination if the patient is approximately 9 years old or younger. The letter discusses advantages and disadvantages of early treatment and the possible necessity of later treatment. I define early treatment as first-phase treatment in the mixed dentition stage after the upper lateral incisors have erupted, using fixed appliances with a retractor or a functional appliance. Another way to describe early treatment is as correction of the jaw. Correction of the teeth comes later, in the second phase. We make it clear that early treatment does not necessarily preclude later treatment. Our typical early treatment patient is around 8 years old, and the usual treatment time with maxillary 2x4 and retractor is 12 to 15 months. The key that makes this approach successful is that we don't use the usual retainers after fixed appliances are removed, because of the constant adjustments required. We simply have the patient sleep with a loosened facebow. If a Class I molar relationship has been achieved, we only need about 6 ounces of force to hold that relationship. If the anterior space opens or if anterior rotations occur, the patient is instructed to wear a 1/4 " light elastic at night. These patients are then checked every four months until the second phase is initiated. 55

The new patient room, where the initial examination is conducted, is designed, to be as informal and as unlike the traditional dental office as possible (Fig. 49). The patient lies on a couch for the examination, the parent sits nearby, and my assistant takes preliminary notes. After I examine the patient, we sit and visit for awhile; I tell the parent in general terms how long the treatment will take, discuss the possibility of extraction or nonextraction, and quote a fee range. I then give the patient the "Super Smile" booklet and say something like, "We're getting ready to take a trip, to travel this road to a super smile. I want you to read this book and study what's in it, because it's very important that you understand what's going to be happening to you. You hear a lot of stories about braces, but if it is not in this book, don't believe it". Then I may add to the parent, "Now, Mom, I'd like you to read this, too, especially if you've never had any experience with orthodontics, because it will answer a lot of your questions". Appointment Card Next we schedule the appointments for diagnostic records and consultation. We have appointment cards of two designs. In my office, we use the Super Smile License, which is similar to a driver's license. There is also an appointment card that is like a ticket to a rock concert. On the card we check off "short trip" or "long trip" (or "short performance" or "long performance") to give the parents an idea of the appointment length. Records and Diagnosis In addition to taking cephalometric and panoramic x-rays, intraoral photographs, and impressions for study models, we thoroughly educate the 56

patient in oral hygiene procedures required while wearing braces. The patient and parent are shown a videotape I recently made on oral hygiene (available through the AAO audiovisual library) and receive personal instruction from our staff member. A kit is given to the patient that includes the reinforcer page on "Start those proper cleaning habits", a toothbrush, dental floss, perio-aid, and prescriptions for the Water Pik and Vitamin C. The prescriptions are not necessary, but allow these items to be tax-deductible to the parents. After diagnostic records are taken, the case is ready to be diagnosed. On our treatment sheet, I have a blank for every consideration in a case diagnosis; my partner or I mark every blank to show we have looked at every possibility, and we also write down our treatment plan and financial suggestions. This information is used for the consultation, which is held in the new patient room. Consultation When the patient and parents or spouse come in, we give them a short audiovisual presentation, and then the office manager talks to them about scheduling appointments and financial arrangements. Formerly, I came in first and discussed the case and quoted the fee, but I found that if she talked about financial arrangements before I made my presentation, the parents would be much more relaxed and able to communicate when I entered. Now, after my secretary discusses scheduling, she goes over the "Truth in Lending" contract (Fig. 51) with the parents. This new disclosure design is required as a result of an amended Act of Congress in March 1980. If they 57

are not sure how they want to pay, she doesn't fill it out until the next appointment. She also leaves them a Consent Form, which includes sections on patient cooperation, headgear, relapse, and so forth. When I come in to discuss the case, I first ask, "Are there any questions about the consent form?" Then, using the form, I emphasize any potential problem areas. If it's an unusual case, I may circle or star several of the sections on the form. Our consent form has the name of every orthodontist in Arlington printed at the top; we all agreed to do that so the patients would know that everyone in town uses the form. The patient, parents, and I all sign the consent form to show that we're making a commitment together. The Truth in Lending form and consent form are printed with yellow NCR copies. The parent or adult patient is given the copies, and we keep the originals. I spend 10 to 20 minutes in the consultation talking about treatment and tooth mechanics, but most of the time I am reinforcing the idea of cooperation. We use the formula "Effort Equals Result" to challenge the patients. Not only does this theme run throughout the Super Smile book, but it is also posted on the wall in the New Patient Room and above the exit door as patients leave the office (Fig. 52). 1 strongly believe in this "quality time" spent with the patient and parents. It helps develop a team spirit and will virtually eliminate communication problems in the future. Reinforcers At subsequent appointments, we add more positive reinforcement by giving the patients some of the individual pages printed separately from our 58

booklet. For example, at the spacers appointment we give them the page on spacers. When the braces are put on they are given the page identifying parts of the braces and what to do if they are damaged. When the retractor is first placed, the patient is given the page that describes it and discusses safety. After the braces are removed, the patient is given the page of instructions on retention as discussed in last month's article. The day the retainers are delivered, they are given the page on retainer care and replacement charges. Finally, after four months of full-time retainer wear, the instructions are given for night-only wear during the next year. Each page is a "reinforcer" taken out of "The Road to a Super Smile" to re-emphasize a certain stage of treatment. Super Smile Certificate One of the highlights of the treatment is the day the orthodontic appliances are removed. We are coming to the end of that "Road to a Super Smile", and to commemorate that experience, the patient is given his or her "Super Smile Certificate" (Fig. 53). This certificate is professionally lettered, and includes the patient's name and the date the appliances are removed. It is signed by my partner and me, and framed. When it is presented to patients, we congratulate them on their accomplishment and ask that the certificate be hung on their wall to always remind them that they have crossed the finish line a winner, It is a very happy time for all involved. Post-Treatment Review Some of the best quality time spent with the patient and parents is the post-treatment review. This is a time when they are shown the before-and59

after treatment records. Most of the review is performed by the staff member, and then the doctor comes in to answer any questions. The condition of the wisdom teeth and the need to continue wearing retainers is discussed. Finally the patient is given all the credit for putting forth the effort to achieve such nice results. The parents are also congratulated for their efforts, especially in bringing the patient promptly to each appointment. After wearing the maxillary retainer fulltime for approximately four months, the patient is given a retainer case and the reinforcer page on retention (Fig. 54), and asked to self address a postcard to be mailed next year. Shortly afterward, the parents are sent a "Smiling Memories" album (Pinehill Enterprises, Inc., Huntsville, Texas) (Fig. 55) showing the beforeand-after teeth and face. These prints are inexpensively made from the slides by using an Instant Slide Printer. Conclusion The development of the Veri-Simplex Discipline has enabled me to control the mechanical aspects of our orthodontic practice to such a degree that I now have more time to concentrate on personal motivation of the patient. Producing an excellent finished result is the primary responsibility, but producing a happy, self-assured patient is an added opportunity we have. Orthodontists today have an abundance of riches in available

techniques and appliances; indeed, a major problem Way is in selection and arrangement of these sources.

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