SOUTHERN REGION

PRESENTATION
SUMMARIES

Treatment Efficiency
Protocols at UCSF
Presented by Gerald Nelson, DDS (February 23, 2007)

Dr. Gerald Nelson is Vice Chair at the UCSF

Orthodontic Program. His lecture reviewed some of the
strategies used to promote good outcome and efficiency
in the cases treated at UCSF.
TREATMENT GOALS
EFFECT OF SLOT PLAY
Efficiency of tooth movement is closely connected to
appliance prescription and archwire selection, especially
in the detailing phase of treatment. If slot play is large,
then much of the built in torque is lost. The clinician can

T
control this by being aware of the slot play in the bracket/
he lecture began with a review of ideal treatment archwire combination. Some examples:
goals, viewed as a necessary step to developing
efficiency protocols. The first
rst eight goals are 018 slot appliance
01
ndd 11
are described by the ABO in the 1 x 175- 7º
175
November 1998 AJO/DO. 1 x 25 - 6º
17
A further set of functional and
esthetic goals come from a 022 slot appliance
022
review of the literature and from 18 x 25 - 15º
experience in the clinic: 19 x 25 - 12º
21 x 21 - 6º
1. Mandibular arch form is
close to the pre-treatmentt An
Andrews advised that the ideal
arch form1 Figure 1: Incisor edges parallel to lower lip upp
Figure 1: Incisor edges parallel to lower lip upper incisor crown inclination
is 7
º. Consider your prescription
2. No lateral functional slides, a minimum sagittal in the upper central incisors. If your prescription is 17º
CO-CR slide such as in the MBT prescription, then you would want
a detailing wire that allows 10º of slot play in order to
3. Lack of posterior interferences during excursions achieve Andrew’s goal. In the 022 appliance, 21 x 21
would be very close. In the 018 appliance, the square wire
4. Maxillary gingival margins are symmetrical, — 175 x 175 — would be ideal.
and crowns are proportionally sized2
Different recommendations apply to ligature free brackets,
5. Upper incisor behind glabella – as described especially in passive brackets (those brackets where the
by Andrews clip does not force the archwire to the base of the bracket.
e.g. Smart Clip and Damon). In these brackets you will
experience too much rotational slot play if you use square
6. Maxillary incisors well displayed, plus 1-3mm
wires. Rectangular wires will help control this.
of gingival tissue and the upper lip smile line is
parallel to the upper incisal edge curve3
THREE PHASES OF TREATMENT
7. Incisor facial surfaces slightly protrusive in Jerry advocates organizing treatment events into three
relation to facial plane, and the cuspid facial phases. This not only helps you complete all necessary
tangents are slightly inclined toward midline goals in each phase, but standardizes procedures for the
at incisal staff, and helps when explaining progress to the patient’s
family.
8. The maxillary dental midline is within 2mm
of the facial midline • Alignment phase – Place the complete appliance,
correct all rotations, correct bracket any
misplaced
SUMMER 2007 • PCSO BULLETIN
SOUTHERN REGION
PRESENTATION
SUMMARIES
brackets, using a progress x-ray to ensure
parallel roots.
Suggested archwires in this phase:
022 slot: 016 super elastic followed by 021 x
021 heat activated. In ligature free passive
bracket, 18 x 25 SE wire for the second wire.
018 slot: 012 super elastic followed by 0175 x
0175 heat activated (3M)
The full sized wires can be continued through
any bracket resets. In ligature free passive
bracket, try 16 x 25 SE.
• Working phase –
Space closing, bite opening, arch
coordination, intermaxillary elastics, fixed bite
jumping devices, etc. This phase will need
archwires that are adjustable and stiff enough
to open bites or enable closing loops.
022 slot: 19 x 25 SS or Beta T.
018 slot: 175 x 175 SS or in ligature
free passive, 17 x 25 SS hybrid (3M)
• Detailing phase –
Small adjustments to gain good esthetics,
centric stops and functional occlusion. The
archwire should be fully adjustable and stiff
enough to minimize intra arch side effects
022 slot – 21 x 21 SS or in ligature free
passive, 19 x 25 SS hybrid
018 slot – 175 x 175 or in ligature free
passive, 17 x 25 SS hybrid
31
In edgewise brackets with ligatures, Dr. Nelson
promotes square wires over rectangular because you
will have
less slot play and lower forces per 1mm adjustment.
The hybrid archwire has more rounded corners,
reducing stiffness and making insertion easier at the
expense of a small amount of torque loss.
EFFICIENCY MARKERS
To measure treatment efficiency, count the number of
appointments needed to treat a comprehensive case. Set
an average goal of less than 25 visits from initial records
to and including two retention visits. To determine the
fee earned per visit, divide the number of visits into the
total fee. The treatment interval should be long enough
so the targeted movements are near completion. That
may be six to eight weeks for the alignment phase, and
three weeks for the detail phase. Intervals longer than
necessary for the tooth movement at hand do not
increase efficiency, and simply extend treatment time.
❖❖❖
NOTES
1
Housley, et. al. Stability of mandibular arch expansion,
Am J Orthod Dentofacial Orthop 2003;124:288-93
2
Kokich, V et. al. Comparing perceptions of dentists
and lay people; AJO/DO11:311-324 1999 or free
reprints at www.kokichorthodontics.com
3
Sarver, D, Principles of Cosmetic Dentistry,
AJO/DO 126:6:749-753
32 PCSO BULLETIN • SUMMER 2007