Friday, May 22, 2009

Frequently asked questions, part 2

I'm using lacebacks on an extraction case. One question: when the lacebacks are tied in, with the wire on top, is there enough room around the brackets for elastic ties or would you have to use the ligature ties to tie everything in place?

I use elastic ties when engaging the wire. There is plenty of room on the bracket tie wings for both the laceback and the elastic tie.

What kind of burs do you use for IPR?

I use Essix burs. Find them here- http://www.essix.com/orstore/default.aspx . The specific burs I like are the 55000 for anterior reduction and the 699LC and 848MD for posterior teeth.

An issue that I am struggling with is re-bracketing. In the first scenario, a patient breaks a bracket, say in the 020 or rect wire stage. Some tooth movement seems to have occurred since the break. How far do we have to go back in wire progression to catch up? I have found that I'm often using 016 Niti to get the new bracket and tooth in line. But what then? Second, after repositioning for second order movement in mid-course, I'm going to 016 Niti, but then can't seem to get right to the rect niti next month because it won't fit that tooth position. Is there a certain way to reposition brackets that will speed the process? What if a patient is breaking brackets every other appointment? Biting fingernails?

The first rule in re-bracketing or repositioning is to be efficient. In your 1st case, even if you were in .020, I would re bracket that tooth at the same time I repositioned. If I had time, I'd do it that day. If not, leave the tooth unbracketed and schedule a longer appt. for repositioning in a month. One of the beauties of ortho is you can delay or speed up things depending on your schedule at that particular time. This is not the case with most other dental procedures.
To answer your 2nd question, if you can't go directly to 019x025 niti from 016 niti, use an 016 st steel wire for a month. Again, not all patient's teeth move exactly the same way, so sometimes we have to adjust on the fly. Position the brackets correctly (there is no magic here) and use the wires you need.

Breaking brackets is a whole different issue. Poor coop takes all the fun out of ortho. Look in my "policies" handout which I gave out in the last course. We charge the pt $20 per bracket after they have broken off 10 (most orthodontists start charging after 5). You will be surprised how quickly the situation improves after the parents get a few extra bills.

1) The bracket on LR4 has come off between just about every adjustment; however no other bracket has come off! FYI, I do have a few ortho cases going and haven't had problems with brackets coming off...this is starting to frustrate me! Any troubleshooting advice? (I have even placed a NEW bracket, just to be sure)

2) Do you have any info on how to place koby hooks?

3) According to USDI guidelines, the consolidate stage is to close posterior spacing, so if it's a non-extraction case, do you generally skip this stage? And are lacebacks your preferred method of closing space? I have heard of k-modules, chain elastics, etc. Which ones work best in which situations?

Brackets consistently coming off is a frustrating problem. It's usually related to occlusion. When you re bracket, make sure it is not interfering. You can relieve interferences by adjusting the bracket (usually a tie-wing is the culprit) and by also doing a minor adjustment on the opposing tooth.
I usually place Koby hooks under the archwire. Then you don't have to remove them on every wire change. Just tie it in like you would a steel tie. Be sure to pull tightly on the pigtail as you twist. After tightening, deflect the hook to where you want it to go by using a ligature director. Then tie the wire in as usual over the hook. The Koby hook gains stability when the wire is tied in.
Lacebacks are used early in extraction cases to control anchorage (that is initial retraction of cuspids into the extraction site without any forward molar movement) so, technically, they are not a method of space closure. Any elastic force can be used to close space. Power chains, k-modules, elastics, open coil springs, etc. all work. Use what works best in your hands. Personally, I use elastics (1/4" or 3/16" medium ) until the space is about 2 mm. Then I use power chain. I think the archwire used is more important than the type of force. To maintain good torque control, I like to use heavy rectangular wire during space closure.
Finally, if there is no space to close, consolidation is essentially complete, so, yes, you technically skip this stage in those situations.

What are the things to look for in the prefinishing check list?


Prefinishing Checklist

Name _________________________ Date ___________

Initial bracketing date ____________

1. Goals of treatment
a. _________________________ accomplished yes ___ no ___
b. _________________________ accomplished yes ___ no ___
c. _________________________ accomplished yes ___ no ___
d. _________________________ accomplished yes ___ no ___

Explanation of no answers
__________________________________
__________________________________
__________________________________

2. Static Occlusion – 6 keys
a. molar relationship......acceptable yes ___ no ___
b. tip.....................acceptable yes ___ no ___
c. torque..................acceptable yes ___ no ___
d. rotations...............acceptable yes ___ no ___
e. spaces..................acceptable yes ___ no ___
f. curve of Spee...........acceptable yes ___ no ___

Explanation of no answers
__________________________________
__________________________________
__________________________________

3. Functional occlusion
a. Left lateral working ______ balancing interferences ___________
b. Right lateral working _____ balancing interferences ___________
c. Protrusive ______________ interferences ___________________

Is functional occlusion acceptable yes ___ no ___ CR = CO? yes ___ no ___
Equilibration required yes ___ no ___
If unacceptable, why? _____________________________________________
________________________________________________________________

Ready for de-banding? Yes ___ no ___
If no, how long? ______________
Fee paid yes ___ no ___
If not, how much is owed? ____________



I have some anterior open bite cases I'm treating. In some of these cases the bite closes by just going through the wire progression while others require 019x025 nitinol rocking chair curve (RCS wire) coupled with heavy elastics from upper to lower canines. The problem with this is patient cooperation; patients will not apply the heavy anterior elastics because they hurt and instead of closing anterior bite we now have more bite opening. So, I'm wondering instead of using the RCS wire maybe I can use just a regular 19x25 nitinol with lighter anterior elastics (1 or 2 elastics instead of 3) . So, if the patient doesn’t wear the elastics the open bite won’t worsen. Would this work? What do you think?

Welcome to the wonderful world of ortho. One of the advantages of GP ortho is you get to pick the cases you want (and don't want) to treat. With diagnostic experience comes the ability to pick out these tougher cases before you begin treatment. You can then either charge more or refer.
If you have an open bite in the bicuspid area as well as in the anterior, a flat wire will not easily solve the entire open bite problem. In these cases, there is no way around the difficult mechanics of RCS plus heavy elastics. However, if the bite is closed (or nearly closed) in the bicuspid area, then lighter anterior elastics on a wire without curve should do the job.

Remember, a little (1 to 1.5mm) lateral open bite may respond to differential bracket position. Get those bis bracketed gingivally, and eruption (and hence lateral open bite closure) may occur. That being said, RCS plus heavy elastics is still one of the most reliable methods of open bite closure.

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