McLaughlin Manual View

The Top Ten Lessons
Presented by :
Richard P. McLaughlin, D.D.S.
Ciudad de México, México

13 de Abril del 2018
Top Ten Lessons I Have Learned
In Orthodontics
Richard P. McLaughlin, D.D.S.
TOP TEN LESSONS I HAVE LEARNED IN ORTHODONTICS
1. DIAGNOSIS AND TREATMENT PLANNING
2. IMPORTANCE OF STAFF
3. PLACING BRACKETS IS NOT SO EASY
4. ARCH FORM
5. NON-EXTRACTION CASES
6. FIRST BICUSPID EXTRACTION CASES
7 SECOND BICUSPID EXTRACTION CASES
8. SURGICAL CONSIDERATIONS
9. FINISHING
10.RETENTION
The greatest challenges in

orthodontics are in the area of
diagnosis and treatment planning
1
1
This can include:
1) Incorrect diagnosis and/or treatment

planning
2) Lack of acceptance by the patient
DIAGNOSIS AND TREATMENT

PLANNING CHALLENGES
• Presentation of surgical cases
• Presentation of extraction cases
• Presentation of IPR cases
Build our story before

you tell the story
2
2
The initial exam and
consultation are times to
educate the patient
DIAGNOSIS AND TREATMENT PLANNING
History Clinical Exam Records
CHECK LIST • TMJ’S and Musculature PROBLEM LIST
• Airway
• Perio Status and Soft Tissue
• Habits
• Facial and Skeletal Pattern
• Dentition
77
__
74
3
40
31
31
121
0
10
-4
102 9
96 -7
3
3
CONVENTIONAL CRANIAL BASED CEPHALOMETRICS
SN-GoGn° 32 82 SNA°
80 SNB°
2 ANB°
F-Mand° 26
U1-Palatal plane°
Pal-Mand° 28
110 -1 A-Na Perp mm
U1 APO°
5
0 Wits mm
2
Occlusal Plane Angle L1 APO°
L1-Mand plane° 95 -4 Pg-Na Perp mm
TMJs Skeletal,
And Dental &
Muscles Soft Tissue
Position of
Anterior
Airway Segments
Perio Status Transverse

Dimension
Habits
Remaining
Dentition-
Facial & Canines,
Skeletal Pattern Premolars,
Molars
Dental Status
N.D. 77
INITIAL __
74
12.8 yrs 3
40
31
“ I DON’T USE CEPHALOMETRICS
ANY MORE”
31
121
0
10
-4
102 9
96 -7
4
4
2014 JCO Study of Orthodontic Diagnosis
and Treatment Procedures-Part 1
Table 3
Cephalometric Diagnostic Records
Percentage of the time a routine pre-treatment cephalometric X-ray taken
 1986 - 90%
 1996 - 90%
 2008 - 74%
 2014 - 64%
Michigan Growth
Studies
90°
A point
Nasion
Perpendicular
Pogonion
Steiner Analysis 77 SNA

74 SNB
3 SNB
5
5
The “Wits” appraisal of
jaw disharmony
Alex Jacobson, MDS, MS, PhD
AJO-DO
November 2003 - Volume 124 Issue 5
Pages 470-479
or www.ajodo.org
84
__
79
30 5 ANB
27
27
112
‐1
6
1 3 WITS
94
84
__
79
30 5 ANB
27
27
112
‐1
6
101 1 3 WITS
94 ‐12
OCCLUSAL PLANE ANGLE = 101
6
6
G.B.
BEGINNING 87
__
86
52.8 yrs 1 ANB
20
14
111
23 6
5
5 WITS
86 4
94 +8
OCCLUSAL PLANE ANGLE = 86
With Class I occlusions,

the occlusal plane can vary
from 80° to 110°,
or a total 30°
This can effect the

position of pogonion
by 1.5 to 2 cm
N.S.
BEGINNING
73
17.0 yrs __
66
7
50
42
104
49 -3
POSITIONALLY SENSITIVE
13
3
DENTALLY8 SENSITIVE
Po can vary 1.5 to 2 cm
94
-22
7
7
N.B.
BEGINNING 86
20.8 yrs 28
95
__
-9
29
25
122
-2
-1
122
-15
-4 62 8
-15
29 85 88
66
66 16
A.H.
BEGINNING 85
__
81
12.6 yrs 4
37
29
35 107
7
1
107 -4
1
59 105
13 -4
22 78
80
80 9
Orthodontic Case
Surgical Case
8
8
Orthodontists need to
dentally compensate incisors
in many cases
Mx 1
Occlusal Plane WITS
Md 1
CLASS I
Mx1-PP
115
POP
Mx1-OP
8 57 0 Wits
20 65
Md1-OP
OMP
95
Md1-MP
9
9
J.C.
75
75
__
0
43
35
38 113
High Angle -4
113 8
11 56 -3 -3
27 80 3
72
-8
72
81
__
78
3
27
21
21
117 0
Low Angle 6
117 3
3
5 58
3
16 65
100 -6
100
79
75
__
4
24
20
104
Class II 6
-2
21
104
4
8 69 3
4
13 66
101
101 -11
10
10
78
82
__
26 -4
24
23
120
-6
Class III 3
-8
2
120
6 54
-8
17 81
82 -1
82
N.D. 77
INITIAL __
74
12.8 yrs 3
40
31
31
121
0
10
-4
121 102 9
12 47
-4
19 66
96 96 -7
Bruce Epker and Larry Wolford
90°
Subnasale
11
11
ARNETT
SOFT TISSUE
CEPHALOMETRIC ANALYSIS
• NATURAL HEAD POSITION

True Vertical
• WAX BITE IN CR Line
• RELAXED LIPS
SUBNASALE
AJO, SEPT. 1999
N.D.
INITIAL 77
74
__
12.8 yrs 3
40
31
121
31
10 -0
121
12 47 9
-4 -5
19 66
96
96 -7
12
12
NATURAL HEAD POSTURE
LITERATURE
• Moorrees-Am J Phys Anthropol, 1958
• Cooke-AJO, March 1988
• Lundstrom and Lundstrom-AJO, March 1992
• Arnett and Bergman-AJO, April and May 1993
LUNDSTROM AND LUNDSTROM

- NATURAL HEAD POSTURE AS BASIS FOR
CEPHALOMETRIC ANALYSIS,
AJO, MARCH 1992
• Sella-Nasion 5.3 sd
• Basion-Nasion 4.7 sd
• Porion-Orbitale 5.0 sd
• Natural Head Position 1.8 sd
• NHP is the most reproducible and accurate
ARNETT
SOFT TISSUE -8
CEPHALOMETRIC ANALYSIS
170
7
5
-19
-22
17 -15
15 15
-13
3 100
4 -1
26 8 21
115 3
96 57 -9 12 3
8 57 2 3 5 2
0
20 65 65 3 13 1
8
95
4 -5
2 51 47
59 -3
12
7 73 125
13
13
Conventional Ceph
82 SNA°
SN-GoGn° 32 80 SNB°
2 ANB°
F-Mand° 26 U1-Palatal plane°

110 ‐1
A-Na Perp mm
U1 APO°
5
Pal-Mand° 28 Wits mm
0
2
L1 APO°
L1-Mand plane° 95 Pg-Na Perp mm

‐4
14
14
ARNETT NORMS AND STANDARD DEVIATIONS
UPPER ANTERIOR SEGMENT-HORIZONTAL

Female STCA research values and (means)
Incisor torque to occl. plane 54.3° to 59.3° (57°)
K
Incisor tip to TVL -11.4 mm to -7.0 mm (-9)
K
Lip thickness 10.8 to 14.4 mm (12)
K
Lip to TVL 2.5 mm to 4.9 mm (3)
K
UPPER ANTERIOR SEGMENT-VERTICAL

Max. anterior height 23.6 mm to 27.8 mm (26)
KLip length 19.1 mm to 22.9 mm (21)
KIncisor exposure 3.1 mm to 6.3 mm mean (5)
Inter-labial gap 2.0 mm to 4.0 mm (2)
LOWER ANTERIOR SEGMENT

Occlusal plane to TVL 93.8° to 97.4° (96°)
L
L
Lip to TVL -0.5 mm to 3.3 mm (1)
L
Soft tissue ‘B’ point -6.8 mm to -3.8 mm (-5)
Soft tissue pogonion -4.5 mm to -0.7 mm (-3)

UPPER ANTERIOR SEGMENT-HORIZONTAL
Male STCA research values and (means)
K
Incisor tip to TVL -13.9 mm to -10.3 mm (-12)
K
K
Lip to TVL 1.6 mm to 5.0 mm (3)
K

UPPER ANTERIOR SEGMENT-VERTICAL
Max. anterior height 25.2 mm to 31.6 mm (28)
KLip length 21.9 mm to 26.9 mm (24)
KIncisor exposure 2.7 to 5.1 mm mean (4)
Inter-labial gap 1.3 mm to 3.5 mm (2)

LOWER ANTERIOR SEGMENT
Occlusal plane to TVL 93.6° to 96.4° (95°)
Incisor torque to occl. plane 60.0° to 68.0° (64)
L
L
Lip to TVL -1.6 mm to 3.2 mm (1)
L
Soft tissue ‘B’ point -8.7 mm to -5.5 mm (-7)
Soft tissue pogonion -5.3 mm to -1.7 mm (-3)
15
15
Upper Anterior Segment – Horizontal Numbers
Upper Incisor Tip Projection
Mx 1 ‐ TVL
Upper Incisor Inclination
Mx1 – Mx OP
16
Upper Lip Thickness
Mx1 Labial ‐ ULA
12 3
57 ‐9
‐ Upper Lip Anterior
ULA ‐ TVL
16
Upper Anterior Segment – Vertical Numbers
Mx Anterior Height
Sn’ – Mx1 Tip
Upper Lip Length
Sn’ – ULI
17
26 21
Upper Incisor Exposure
UL1 – Mx 1 Tip
‐
5 2
Inner Labial Gap
UL1 – LLS
17
Lower Anterior Segment Numbers
18
Lower Lip Thickness
LL Inside – LLOutside
96 Lower Lip Anterior
Mx Occlusal Plane 65 13 1 LLA
Mx OP ‐ TVL
‐5 Soft Tissue B Point
Lower Incisor Inclination
B’
Md1 – Md OP
Soft Tissue Pogonion
‐3 Pog’ ‐ TVL
18
ARNETT SOFT TISSUE CEPHALOMETRIC ANALYSIS
Anterior Segment – Numbers
Mx Anterior Height
Upper Incisor Inclination Upper Lip Length
19
21
Upper Lip Thickness
Upper Lip Anterior
26
12 Upper Incisor Exposure
57 ‐9 3
96 Inner Labial Gap
Mx Occlusal Plane
5 2
Lower Lip Anterior
65 13 1
Lower Lip Thickness
Lower Incisor inclination ‐5 Soft Tissue B Point
‐3
AJO, SEPT. 1999
19
57
-
AJO, SEPT. 1999
CLASS I
Mx1-PP
115
POP
Mx1-OP
8 57 0 Wits
20 65
Md1-OP
OMP
95
Md1-MP

57 -9
-
AJO, SEPT. 1999
20
20
Upper Lip Thickness
12
57 -9
-
AJO, SEPT. 1999

Upper Lip Thickness
12
57 -9 3
- Upper Lip Anterior
AJO, SEPT. 1999
N.D.
INITIAL
12.8 yrs
9
47 -4 13
21
21
Mx Anterior Height
26
AJO, SEPT. 1999

Mx Anterior Height
Upper Lip Length
21
26
AJO, SEPT. 1999

Mx Anterior Height
Upper Lip Length
21
AJO, SEPT. 1999
22
22
Mx Anterior Height
Upper Lip Length
21
5 2
Inner Labial Gap
AJO, SEPT. 1999
N.D.
INITIAL
12.8 yrs
29 25
3 5

Lower Anterior Segment – Numbers
96
Mx Occlusal Plane
AJO, SEPT. 1999
23
23
96
Mx Occlusal Plane 65
Lower Incisor inclination
AJO, SEPT. 1999
CLASS I
Mx1‐PP
115
POP
Mx1‐OP
8 57 0
Wits
20 65
Md1‐OP
OMP
95
Md1‐MP

Lower Lip Thickness
96
Mx Occlusal Plane 65 13
AJO, SEPT. 1999
24
24
Lower Lip Thickness

Mx Occlusal Plane 65 13 1
AJO, SEPT. 1999

Lower Lip Thickness

-5 Soft Tissue B Point
AJO, SEPT. 1999

Lower Lip Thickness

-5 Soft Tissue B Point

-3
AJO, SEPT. 1999
25
25
N.D.
INITIAL
12.8 yrs
102
66
15 7
-4
-6
N.D.
INITIAL
12.8 yrs
29 25
102 9
47 -4 13
3 5
66
15 7
-4
-6
N.D. BEG/PREDICTION
SN AT S
26
26
The Transverse Dimensions is about
Four Factors:
Midline, Cant, Yaw and Widths
27
27
N.D.
N.D.
N.D.
28
28
4. ARCH FORM
7. SECOND BICUSPID EXTRACTION CASES
9. FINISHING
10.RETENTION
Written
Treatment Plan
ARCHWIRE SEQUENCE
1st BICUSPID
EXT.
.015 multistrand .016 round heat activated
.0175 multistrand
.016 x .022 rectangular
heat activated
.014 round stainless steel
heat activated
.020 round ss heat treated
.019 x .025 & .017 x .025 .019 x.025 & .017 x .025
rectangular ss heat treated rectangular ss heat treated
29
29
ARCHWIRE SEQUENCE
1ST BICUSPID
EXT.
.0175 multistrand
heat activated
heat activated
.019 x .025 & .017 x .025 .019 x.025 & .017 x.025
ARCHWIRE SEQUENCE
2nd BICUSPID
EXT.
.0175 multistrand
heat activated
heat activated
.019 x .025 & .017 x .025 .019 x.025 & .017 x.025
ARCHWIRE SEQUENCE
2nd BICUSPID
EXT.
.0175 multistrand
heat activated
heat activated
.019 x .025 & .017 x .025 .019 x.025 & .017 x.025
30
30
4. ARCH FORM
9. FINISHING
10.RETENTION
THE GOAL
Efficient and User Friendly
Intra-arch Mechanics
and
60%-70%
To American Board Standards
THE STAFF
• Extra eyes and ears in the practice
• Experienced staff can train new staff
31
31
4. ARCH FORM
9. FINISHING
10.RETENTION
BRACKET PLACEMENT
Number One Mechanical
Procedure in Orthodontics
BRACKET POSITIONING
REFERENCES
• Andrews References
• Bracket Placement Chart
• Marginal Ridge References
• Incisal Edges
32
32
VERTICAL BRACKET
POSTIONING ERRORS
• Gingival concerns
• Lack of eruption - short clinical crown
• Lingual root positions - short clinical crown
• Gingival inflammation - short clinical crown
• Labial root position - recession - long clinical crown
• Incisal or occlusal concerns
• Tooth wear
• Tooth fracture
• Long or short clinical crowns
33
33
1) Draw the long axis of the clinical crown and the mesial
buccal cusp of the second molars.
2) Measure the clinical crown of the anterior teeth, divide in

half, and determine the row on the bracket placement guide.
Mark the incisors accordingly.
3) Draw the first molar bracket height established from

the row on the bracket placement guide.
34
34
4) Mark the marginal ridge height on the first molars.
5) Note the mm difference between the two.
6) Mark the marginal ridges on bicuspids. Do not mark

the second molars.
35
35
7) Use the same mm difference that was established on the
first molar to locate the bracket height.
8) Mark the bracket height for the second molars, keeping

it as occlusal as possible.
14) Use the same mm difference to locate the bicuspids

and second molar bracket height.
36
36
EFFICIENT
BRACKET REPOSITIONING
• Prior to placement of rectangular SS wires
• Whenever it is necessary to return to light

wires
• Bracketing previously unerupted teeth
• Bracketing previously blocked out teeth
ARCHWIRE SEQUENCE
.015 multistrand
.0175 multistrand

.019 x .025 & .017 x .025

rectangular ss heat treated
37
37
ARCHWIRE SEQUENCE

.0175 multistrand
heat activated
heat activated
.019 x .025 & .017 x .025 .019 x.025 & .017 x.025
ARCHWIRE SEQUENCE
NON EXT.
.0175 multistrand
heat activated
heat activated
.019 x .025 & .017 x .025 .019 x .025 & .017 x .025
ARCHWIRE SEQUENCE
NON EXT.
.0175 multistrand
heat activated
heat activated
.019 x .025 & .017 x .025 .019 x .025 & .017 x .025
38
38
CLEAN-UP TIME
• Progress ceph, if necessary

• Panorex x-ray, if needed
• Reposition brackets as needed
• Accurately construct the rectangular
stainless steel wires
4. ARCH FORM
9. FINISHING
10.RETENTION
Arch Form Efficiency andAccuracy

-A Two Part System
• Three shape templates for early round wires

and flexible rectangular wires
• Custom shaping for rectangular steel wires
39
39
Tapered Ovoid Square
Tapered Ovoid Square
40
40
Patient Name
Copy of Patient's Lower

Arch Form
41
41
Lower .019 x .025 Arch Wire
Shaped to Arch Template
Upper .019 x .025 Coordinated

to Lower Arch Wire
4. ARCH FORM
9. FINISHING
10.RETENTION
42
42
Class I Cases
SPACE GAINING PROCEDURES FOR

NON-EXTRACTION TREATMENT
IN THE LOWER ARCH
• Anterior movement of lower incisors
• Interproximal reduction
• Expansion
• Uprighting and distalizing of molars
A META-ANALYSIS OF MANDIBULAR
INTERCANINE WIDTH IN TREATMENT
AND IN POST-RETENTION
BURKE, S.P., ANGLE ORTH., 68:53-60, 1998
• Review of 26 previous studies on intercanine width

stability
• Use of meta-analysis technique of literature review
• Regardless of diagnosis and treatment modalities,
intercanine width expands 1-2mm during treatment
and returns to its original dimension post-retention
43
43
SHAPIRO, P.A., MANDIBULAR ARCH
FORM AND DIMENSION,
AJO, 66:58-70, 1974
• Mandibular arch length decreased substantially

in all groups during the post-retention period
• Arch length reduction was less in Class II,
division 2 cases than in Class II, division 1 and
Class I cases
EXPANSION OF THE LOWER ARCH

CONCURRENT WITH RAPID
MAXILLARY EXPANSION
SANDSTROM, ET. AL., AJO, OCT. 1988
• Studied 17 cases for intercanine change and 22

nonextraction cases for intermolar change
• Mean expansion of 1.1 mm of intercanine width
• Mean expansion of 2.8 mm of intermolar width
Space gained with lower arch expansion,

that is stable:
2 millimeters
44
44
1 mm 1 mm 1 mm 1 mm
1.5 mm 1.5 mm 2 mm 2 mm
.5 mm .5 mm 1 mm 1 mm
3 mm 3 mm 4 mm 4 mm
HOW MUCH ENAMAEL CAN BE

REMOVED FROM A PROXIMAL
SURFACE
There are no randomized clinical trials on how

much enamel can be removed.
Yet there are no reports on damage with IPR
DENTAL HEALTH ASSESSED MORE THAN 10

YEARS AFTER INTERPORXIMAL REDUCTION
OF MANDIBULAR ANTERIOR TEETH,
ZACHRISSON, BJÖRN
AJO, FEBRUARY 2007
•61 consecutive patients who had received mesiodistal

IPR of all 6 mandibular incisors were reviewed after
10 years
•IPR resulted in no iatrogenic damage (no caries,
gingival problems or alveolar bone loss)
45
45
Predictors of Variation in Mandibular
Incisor Enamel Thickness
Journal of the American Dental Asso., June 2007;
138(6); pg 809-815
N.E. Hall, S.J. Lindauer, E. Tüfekçi , B. Shroff
ARCHWIRE SEQUENCE
NON EXT.
.0175 multistrand
heat activated
heat activated
.019 x .025 & .017 x .025 .019 x .025 & .017 x .025
4. ARCH FORM
9. FINISHING
10.RETENTION
46
46
Class II Cases
N.M.
BEGINNING
11.6 yrs
1
3
2
4 19
105 25
58 5
-11 15
65 6 6
13 -1
5
-13
-9
J.H.
BEGINNING
11.4 yrs
1 3
2 4 21 19
95 56 -9 13 4
2 2
60 11 -3
5 -11
-7
47
47
TECHNIQUES FOR
INTER-ARCH CORRECTION
• HG and Class II Elastics
• Bionator
• Teuscher Appliance
• Twin Block
• Herbst
• Jasper Jumper
• Eureka Springs
• Mara
• Forsus
• Esprit
HORIZONTAL SKELETAL
APPLIANCE CHANGES
• “Wits” Change 4-5 mm

• Maxillary Retraction 2 mm
• Mandibular Advancement 3 mm
MAXILLARY MOLAR
DISTALIZATION
• Headgear
• HG, sliding jigs, Cl II elastics
• Cetlin retainer
• Double Nance jig
• Distal jet
• Pendulum
48
48
4. ARCH FORM
9. FINISHING
10.RETENTION
Class III Cases
A.Y.
BEGINNING
6.11 yrs 82
__
84
-2
22
19 116
19 1 -1
1 -6
116
7 58
-6
12 85
2
83
83
49
49
115-120
115-120
80-85
80-85
120
120
80
80
Early Treatment of Class III Malocclusion

Ngan, Peter
Seminars in Orthodontics 11:140-145
Growth Treatment Response Vector (GTRV)

Analysis
The GTVR ratio was calculated by using the
following formula:
GTVR = Horizontal growth changes of the maxilla

Horizontal growth changes of the mand.
50
50
ORTHOPEDIC TRACTION OF THE
MAXILLA WITH MINIPLATES: A NEW
PERSPECTIVE FOR TREATMENT OF
MIDFACE DEFICIENCY
Hugo J. De Clerck, DDS, PhD, et al.
Journal of Oral and Maxillofacial Surgery

Vol. 67, Issue 10, Pages 2123-2129
"Bollard" Skeletal Anchorage in

Orthodontics
Prof Dr. H. De Clerck
4. ARCH FORM
9. FINISHING
10.RETENTION
51
51
DIAGNOSIS AND TREATMENT
PLANNING CHALLENGES
• Presentation of Surgical Cases
• Presentation of Extraction Cases
• Presentation of IPR Cases
• Extrudes incisors-deepens bite

• Extrudes posterior teeth
• Causes anchorage loss
• Moves apices in wrong direction
• Takes 20-30% longer overall
• Doesn’t extrude incisors

• Doesn’t extrude posterior teeth
• Causes much less anchorage loss
• Moves apices in the right direction
• Takes 20-30% less overall time
52
52
Critical Appraisal of in Vitro Steady-
State Frictional Resistance Studies
Samuel J. Burrow III
Seminars in Orthodontics
2010: 16
pages 244-248
Elsevier 2010
• The abstract summary - Very little useful information, from

a clinical perspective, can be interpolated from these in
vitro investigations.
• Clinical tooth movement - A binding release process (based

on biology), not frictional resistance, is the major
determinant of how well a bracketed tooth moves down an
arch wire.
• Rate of tooth movement - It seems clear that once a level of

force sufficient to produce a biological response is present,
the rate of tooth movement is a function of biology.
Rapid canine retraction through

distraction of the periodontal ligament
Eric Liou, DDS, MS
C. Shing Huang, DDS, PhD
AJO-DO
October 1998 - Volume 114 Issue 4
Pages 372-382
53
53
Vertical undermining grooves
Oblique undermining grooves
Buccal View Occlusal View
• The process of osteogenesis in the periodontal ligament

during orthodontic tooth movement is similar to the
osteogenesis in the midpalatal suture during rapid palatal
expansion.
• Fifteen orthodontic patients who needed canine retraction

and first molar extraction were included.
• The upper and lower canines were distracted bodily 6.5 mm

in 3 weeks.
• During distraction, 73° of the first molars did not move

mesially and 27° of them moved less than .5mm mesially
with 3 weeks.
Conclusion:
• The periodontal ligament could be rapidly

distracted without complications.
54
54
R.O.
R.O.
55
55
R.O.
ARCHWIRE SEQUENCE

.0175 multistrand
heat activated
heat activated
.019 x .025 & .017 x .025 .019 x.025 & .017 x.025
ARCHWIRE SEQUENCE
NON EXT.
.0175 multistrand
heat activated
heat activated
.019 x .025 & .017 x .025 .019 x .025 & .017 x .025
56
56
ARCHWIRE SEQUENCE
1st BICUSPID
EXT.
.0175 multistrand
heat activated
heat activated
.019 x .025 & .017 x .025 .019 x.025 & .017 x .025
ARCHWIRE SEQUENCE
1ST BICUSPID
EXT.
.0175 multistrand
heat activated
heat activated
.019 x .025 & .017 x .025 .019 x.025 & .017 x.025
4. ARCH FORM
9. FINISHING
10.RETENTION
57
57
N.H.
N.H.
N.H.
58
58
1/2 1/2
.017X.025 sectional arch-wire
59
59
minimal tipping
ARCHWIRE SEQUENCE
2nd BICUSPID
EXT.
.0175 multistrand
heat activated
heat activated
.019 x .025 & .017 x .025 .019 x.025 & .017 x.025
60
60
ARCHWIRE SEQUENCE
2nd BICUSPID
EXT.
.0175 multistrand
heat activated
heat activated
.019 x .025 & .017 x .025 .019 x.025 & .017 x.025
ASYMMETRIES
•Dentoalveolar
•Anterior
•Posterior
•Anterior posterior
•Functional
•CR/CO shifts
•Structural/Skeletal
•Mandible
•Maxilla
ORTHODONTIC PROGRAMS
• Orthodontic Treatment Mechanics and the
Pre-adjusted Orthodontic Appliance
• Diagnosis, Treatment Planning and Treatment

Mechanics
• Inter-Arch Treatment Mechanics-Class II Cases
• Inter-Arch Treatment Mechanics-Class III and
Asymmetrical Cases
• Management of the Dentition
• Occlusion and the TMJ in Orthodontics
• Surgical Orthodontic Treatment
61
61
ASYMMETRIES
•Dentoalveolar
•Anterior
•Posterior
•Anterior posterior
•Functional
•CR/CO shifts
•Structural/Skeletal
•Mandible
•Maxilla
4. ARCH FORM
9. FINISHING
10.RETENTION
Upper Bicuspid Extraction

Criteria
• Occlusal Plane Angle

• Molar Relationship
• Upper Canine Crowding
• Upper 2nd Molar Crowding
62
62
CLASS II TREATMENT OPTIONS
• Non-extraction
• Upper second molar extraction
• Upper second bicuspid extraction
• Upper first bicuspid extraction
• Upper first or second bicuspid and lower incisor
extraction
• Upper first bicuspid and lower second
bicuspid extraction
• Upper and lower first bicuspid extraction
MAXILLARY MOLAR
DISTALIZATION
• Headgear
• HG, sliding jigs, Cl II elastics
• Cetlin retainer
• Double Nance jig
• Distal jet
• Pendulum
Class III Treatment Options

• Non-extraction
• Upper second bicuspid and lower first bicuspid
• Lower incisor extraction?
• Lower first bicuspid extraction
• Lower second bicuspid extraction
• Lower second molar extraction
• Lower second and upper second molar extraction
63
63

Mechanics
Asymmetrical Cases
Management of the Dentition
• Incisors
• Cuspids
• First bicuspids
• Second bicuspids
• First molars
• Second molars
• Retention
Management of the Dentition
• Incisors
• Cuspids
• First bicuspids
• Second bicuspids
• First molars
• Second molars
• Retention
64
64
Decoronation- a conservative
method to treat ankylosed teeth for
preservation of alveolar ridge prior
to permanent prosthetic
reconstruction
Dental Traumatology
2007
Vol 23
Pages 87-94
CDA Journal
Vol 28, No
11
Pages 846-
854
November,
2000
Decoronation of Lower Second

Primary Molars in Cases with
Agenesis of a Successional Second
Premolar
Dr. Richard McLaughlin
Dr. John Bennett
Dr. Peter Nordland
Dr. James Munce
65
65
THE NUTS AND BOLTS OF
HEMISECTION TREATMENT:
MANAGING CONGENITALLY MISSING
MANDIBULAR SECOND PREMOLARS
William Northway, D.D.S.
American Journal of Orthodontics & Dentofacial Orthopedics

May 2005
INCISOR TORQUE
Incisor Torque
Upper Upper Lower Lower
Central Lateral Central Lateral
Avex ™ 17º 10º -6º -6º
Original SWA 7º 3º -1º -1º
66
66
4. ARCH FORM
9. FINISHING
10.RETENTION
DIAGNOSIS AND TREATMENT PLANNING
History Clinical Exam Records
CHECK LIST • TMJ’S and Musculature PROBLEM LIST
• Airway
• Perio Status and Soft Tissue
• Habits
• Facial and Skeletal Pattern
• Dentition
TMJs Soft Tissue

And &
Muscles Incisors-
Anterior
Segments
Airway
Perio Status
Transverse
Dimension
Habits
Facial &
Skeletal Pattern Remaining
Dentition-
Canines,
Dental Status
Premolars,
Molars
67
67
CEPHALOMETRIC
TREATMENT PLANNING
DR. G. WILLIAM ARNETT
1.Correct Mx incisor inclination
2.Correct Md incisor inclination
3.Correct overbite
4.Correct overjet and molar overbite
a.Reposture lower lip
5.Set Mx incisor position
6.Set occlusal plane
7.Set ideal chin projection

Mechanics
Asymmetrical Cases
IF YOU TREAT THE FACE
YOU TREAT THE AIRWAY
68
68
MECHANICAL AND MEDICAL
STABILIZATION OF THE TMJ
• Full coverage upper splint
• Medications
PATHOPHYSIOLOGY AND
PHARMACOLOGIC CONTROL OF OSSEOUS
MANDIBULAR CONDYLAR RESORPTION
Michael J. Gunson, DDS MD, G. William Arnett, DDS

and Stephen B. Milam, DDS, PhD
Journal of Oral Maxillofacial Surgery, Oct. 2012
PATHOPHYSIOLOGY AND PHARMACOLOGIC

CONTROL OF
OSSEOSIS MANDIBULAR CONDYLAR RESORPTION
Etiology
• Inflammatory arthritis
• Rheumatoid arthritis
• Osteoarthritis
• TMJ compression
• Trauma
• Hormonal imbalance
• Individual patient susceptibility
• Gender
• Nutritional status
• Genetic back drop
• Oral habits
• Iatrogenic factors
69
69
CONTROL OF
Common cellular events are associated with condylar resorption:
• Osteoblasts are activated by cytokines (secreted by local

Inflammatory cells), free radicals, hormonal imbalances and/or
potent phospholipids catabolites.
• Osteoblasts then activate the recruitment of osteoclasts.
• Osteoclasts secrete matrix degrading enzymes (matrix metallo-

proteanases-mmps) that cause the breakdown of hydroxyapetite and
collagen.

CONTROL OF
PATHOGENISIS OF CONDYLAR RESORPTION

• Free radicals
• Cytokine signaling
• Phospholipid catabolites
• Hormonal imbalances
• Matrix metaloproteases
70
70
Medical Management Protocol
• Daily Multivitamin – Vitamin C & E
• Omega 3 (Fish Oil) 2-4 grams per day
• Vitamin D 2,000-4,000 IU per day/ per lab results
• Calcium 600 mg twice a day

CONTROL OF
• FREE RADICALS:
• Free radicals are molecules that contain one or more

unpaired electrons.
• They are very unstable, and they initiate

oxidation reactions to acquire paired electrons.
• The etiology of free radicals is increased by

mechanical loading (trauma), leading to inflammation.
ORAL CONTRACEPTIVE PILL USE AND

ABNORMAL MENSTRUAL CYCLES IN WOMEN
WITH SEVERE CONDYLAR RESORPTION: A
CASE FOR LOW SERUM 17β-ESTRADIOL AS A
MAJOR FACTOR IN PROGRESSIVE
CONDYLAR RESORPTION
AJODO, Volume 136, Number 6, Dec 2009
Drs. Michael Gunson and G. William Arnett, et al.
71
71
CONTROL OF
MATRIX METALOPROTEINASES (MMPS)
• MMPS are endopeptides that degrade collagen and elastin found in

articular tissue. Thus, they play a role in the degradation of bone and
cartilage in the TMJ.
• Evidence supports the presence of 6 of the 28 known MMPS

in the TMJ.
• Production of MMPS by such resident cells as osteoclasts can

be induced by TNF-ALFA, IL:-6 and RANKL 9 (cytokines).
Medical Management Protocol
•Doxycycline 100 mg once a day
• Feldene 20 mg once a day
• Simvastatin 20 mg once a day, if patient cannot
tolerate Feldene
• Amytriptiline 10 mg at night for bruxism
• Colanazepam .5 mg at night also for bruxism
MANY NSAIDS (NONSTEROIDAL ANTI-INFLAMMATORY

DRUGS) INACTIVATE CHONDROCYTES
CHONDROCYTES ARE THE ONLY CELLS FOUND IN

HEALTHY CARTILAGE-THEY PRODUCE AND MAINTAIN
THE COLAGENOUS MATRIX, WHICH CONSISTS MAINLY OF
COLLAGEN AND PROTEOGLYCANS
FELDENE AND SIMVISTATIN DO NOT INACTIVATE

CHONDROCYTES
72
72
CYTOKINES (FOR EXAMPLE, TUMOR NECROSIS
FACTOR ALPHA) ARE INVOLVED IN VARIOUS
TYPES OF INFLAMMATORY ARTHRITIS.
THEY ARE ALSO PRESENT IN JOINTS OF
NON-RHUEMATOID PATIENTS.

CONTROL OF
CYTOKINE SIGNALING:
• Cytokines are potent molecules involved in cell signaling. They are

produced by a variety of cells in the TMJ, including osteoblasts and
synoviocytes (during inflammation).
• Major cytokines involved in condylar resorption include tumor necrosis
factor alpha (TNF-A), interleukin 6 (IL-6) and receptor activator nuclear
factor kappa-betta ligand (RANKL).
•A common pathway for condylar resorption is the secretion of
cytokines, which prompt the activation of osteoclasts by osteoblasts.
•Osteoclasts in turn produce proteanases (MMPS) that break down
condylar surfaces.
ENBREL, HUMIRA
• USED TO TREAT A VARIETY OF INFLAMMATORY

DISEASES, INCLUDING ARTHRITIC PATIENTS
• BIOLOGIC RESPONSE MODIFIERS -

THEY WORK ON THE IMMUNE SYSTEM BY
BLOCKING PROTEINS
THAT LEAD TO THE DISEASE PROCESS
• BUT THEY ALSO WORK TO HELP HEAL

CONDYLAR RESORPTION
73
73
2015 joint stabilizing medications
 multi-vitamin o antioxidants
 omega 3 fatty acid 2-4G o potent antioxidant
 feldene 20mg o anti-inflammatory
 celebrex 50-100mg o anti-inflammatory
 simvastatin 20mg o anti-inflammatory
 methotrexate o potent anti-inflammatory
 17 beta estradiol o potent anti-inflammatory
 amitriptyline 5-10mg o antibruxism?, mm relax
 klonopin .5-1mg o antibruxism
 botox injection 25-50u o antibruxism
 buspirone 5mg tid o counters SSRI bruxism
 doxycycline 50-100mg o MMP control
 simvastatin o auto immune control
 enbrel (etanercept) o binds tumor necrosis factor
 humira o binds tumor necrosis factor
 Vit D and Ca++ o anabolic bone promoter
 17 beta estridiol o anabolic bone promoter
medication publications
 Gunson MJ and Arnett GW. Condylar
Resorption, Matrix Metalloproteinases, and think of TMJ
Tetracyclines. RWISO Journal, September medications in the
2010; Vol. 2, No. 1: 37‐44 same fashion as a
 Gunson MJ , Arnett GW, Milam SB. rheumatologist
Pathophysiology and Pharmacologic Control stabilizing multiple
of Osseous Mandibular Condylar Resorption. joints involved in
JOMS, August 2012, 70(8):1918‐34. collagen vascular
 Arnett GW, Gunson MJ. Risk Factors in the diseases i.e.
Initiation of Progressive Condylar rheumatoid
Resorption. Seminars in Orthodontics, Guest arthritis
Editors: Handelman CS, Green CS. VOL 19,
NO 2, June, 2013.

Mechanics
Asymmetrical Cases
74
74
4. ARCH FORM
9. FINISHING
10.RETENTION
DEFINITION OF FINISHING
• Correcting errors prior to finishing
• Over-correction
• Settling
SETTLING SUMMARY
Lower Arch
• .016 HA – good alignment
• 1-2 weeks settling needed
• .014 SS – some detail bends needed
• Molar offset, if chain required
• .019 x .025 SS
• 2 + weeks settling needed
75
75
SETTLING SUMMARY
Upper Arch
• .014 SS - 2 x 2 sectional wire
• No elastics needed, or triangle elastics
on canines, and/or posterior teeth
• .014 SS – 3 x 3 sectional wire
• Cuspid to cuspid well aligned
• Keep a 2x2 space closed
• .014 SS full wire
• Chain to keep spaces closed - use molar offsets
76
76
ARCHWIRE SEQUENCE

.0175 multistrand
heat activated
heat activated
.019 x .025 & .017 x .025 .019 x.025 & .017 x.025
ARCHWIRE SEQUENCE
NON EXT.
.0175 multistrand
heat activated
heat activated
.019 x .025 & .017 x .025 .019 x .025 & .017 x .025
ARCHWIRE SEQUENCE
1st BICUSPID
EXT.
.0175 multistrand
heat activated
heat activated
.019 x .025 & .017 x .025 .019 x.025 & .017 x .025
77
77
ARCHWIRE SEQUENCE
1ST BICUSPID
EXT.
.0175 multistrand
heat activated
heat activated
.019 x .025 & .017 x .025 .019 x.025 & .017 x.025
ARCHWIRE SEQUENCE
2nd BICUSPID
EXT.
.0175 multistrand
heat activated
heat activated
.019 x .025 & .017 x .025 .019 x.025 & .017 x.025
ARCHWIRE SEQUENCE
2nd BICUSPID
EXT.
.0175 multistrand
heat activated
heat activated
.019 x .025 & .017 x .025 .019 x.025 & .017 x.025
78
78
ORTHODONTIC VTO
Name: _____________________
MIDLINE MOLAR POSITION
Right 1st molar Midline Left 1st molar
Overjet ____mm Overbite____mm Crossbite
LOWER ARCH DISCREPANCY

3x3 7x7
Right Left Right Left
Crowding/Spacing-Anteriors
C/S-Bicuspids (E-L space)
C/S-Molars
Curve of Spee
Midline
Incisor Position
Initial Discrepancy
Stripping
Expansion
Distalizing 6 6
Extraction
Remaining Discrepancy
THE DENTAL VTO

Right 1st Midline Left 1st
molar molar
( ) cuspid cuspid ( )
( ) ( )
79
79
SURGICAL ORTHODONTIC VTO
Name: _____________________
MIDLINE MOLAR POSITION
Right 1st molar Midline Left 1st molar
Overjet ____mm Overbite____mm Crossbite
LOWER ARCH DISCREPANCY

3x3 7x7
C/S-Molars
Curve of Spee
Midline
Incisor Position
Initial Discrepancy
Stripping
Expansion
Distalizing 6 6
Extraction
DENTAL PRE-SURGICAL VTO – LOWER ARCH
( ) ( )
Right 1st Molar Cuspid Midline Cuspid Left 1st Molar
80
80
SURGICAL ORTHODONTIC VTO
UPPER ARCH DISCREPANCY

3x3 7x7
C/S-Molars
Curve of Spee
Midline
Incisor Position
Initial Discrepancy
Stripping
Expansion
Distalizing 6 6
Extraction
DENTAL PRE-SURGICAL VTO - UPPER ARCH
Right 1st Midline Left 1st

molar molar
( ) cuspid cuspid ( )
81
81
McLaughlin
Brackets and tubes Bennett
with Forestadent
Mini Sprint® Brackets McLaughlin Bennett 5.0

The occlusal gingival height has been reduced by 20% which ensures a significant increase in patient comfort.
Despite the lower height, it is just as easy to use as the larger bracket and has the same mechanical advantages.
The Mini Sprint® brackets feature deep tie wings for easy and secure double ligation and the use of elastic
bands. Maintaining the mesio-distal dimension ensures identical rotation control. The bracket base is characte-
rised by a geometry which fits perfectly to the natural contour of the tooth. Our patented hook-base ensures
excellent hold.
Maxillary Slot .022“

Order-no.
Tooth Torque Angulation In/Out Rotation
Right Left
1 Centrals +17˚ +4˚ 1.0 – 780T0101 779T0101
2 Laterals +10˚ +8˚ 1.5 – 780T0201 779T0201
3 Cuspids + hook -7˚ +8˚ 0.9 – 780T0301 779T0301
4 Bicuspids -7˚ 0˚ 0.9 – 780T0411 779T0411
5 Bicuspids -7˚ 0˚ 1.3 – 780T0511 779T0511
Mandibular Slot .022“

Order-no.
Tooth Torque Angulation In/Out Rotation
Right Left
1 Centrals -6˚ 0˚ 1.5 – 780T1201 780T1201
2 Laterals -6˚ 0˚ 1.5 – 780T1201 780T1201
3 Cuspids + hook -6˚ +3˚ 0.9 – 780T1401 779T1401
4 Bicuspids -12˚ +2˚ 0.7 – 780T1511 779T1511
5 Bicuspids -17˚ +2˚ 0.7 – 780T1611 779T1611
Tulip buccal tubes McLaughlin Bennett 5.0

The extremely flat design of Forestadent’s tulip buccal tubes ensures highest patient comfort.The tubes owe their name
to the tulip-shaped entrance funnel. It has been dimensioned especially large to allow quick and easy insertion of the
archwires. Tulip buccal tubes are made from stainless steel.
on Large Pad
Maxillary tooth Torque Angulation distal offset Slot
right left
76 67 -14° – 10° 743T0742 742T0742
.022"
on Large Pad
Mandibular tooth Torque Angulation distal offset Slot
right left
6 6 -20° – 0° .022" 743T1712 742T1712
-10° – 0° .022" 742T0722 743T0722

7 7
82
82
- 12 -
NOTES
NOTES
NOTES
Ciudad de México, México
13 de Abril del 2018

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The Top Ten Lessons

Richard P. McLaughlin, D.D.S.

Ciudad de México, México

Richard P. McLaughlin, D.D.S.

TOP TEN LESSONS I HAVE LEARNED IN ORTHODONTICS

1. DIAGNOSIS AND TREATMENT PLANNING

3. PLACING BRACKETS IS NOT SO EASY

6. FIRST BICUSPID EXTRACTION CASES

7 SECOND BICUSPID EXTRACTION CASES

The greatest challenges in

1) Incorrect diagnosis and/or treatment

2) Lack of acceptance by the patient

DIAGNOSIS AND TREATMENT

• Presentation of surgical cases

• Presentation of extraction cases

• Presentation of IPR cases

Build our story before

DIAGNOSIS AND TREATMENT PLANNING

History Clinical Exam Records

CHECK LIST • TMJ’S and Musculature PROBLEM LIST

• Perio Status and Soft Tissue

• Facial and Skeletal Pattern

L1-Mand plane° 95 -4 Pg-Na Perp mm

Perio Status Transverse

Percentage of the time a routine pre-treatment cephalometric X-ray taken

Steiner Analysis 77 SNA

With Class I occlusions,

This can effect the

Occlusal Plane WITS

Bruce Epker and Larry Wolford

• NATURAL HEAD POSITION

AJO, SEPT. 1999

• Moorrees-Am J Phys Anthropol, 1958

• Cooke-AJO, March 1988

• Lundstrom and Lundstrom-AJO, March 1992

• Arnett and Bergman-AJO, April and May 1993

LUNDSTROM AND LUNDSTROM

• Natural Head Position 1.8 sd

• NHP is the most reproducible and accurate

F-Mand° 26 U1-Palatal plane°

L1-Mand plane° 95 Pg-Na Perp mm

UPPER ANTERIOR SEGMENT-HORIZONTAL

UPPER ANTERIOR SEGMENT-VERTICAL

LOWER ANTERIOR SEGMENT

Upper Incisor Inclination

AJO, SEPT. 1999

ARNETT SOFT TISSUE CEPHALOMETRIC ANALYSIS

Upper Incisor Tip Projection

Upper Incisor Inclination

AJO, SEPT. 1999

Upper Incisor Tip Projection

Upper Incisor Inclination

Upper Lip Thickness

AJO, SEPT. 1999

ARNETT SOFT TISSUE CEPHALOMETRIC ANALYSIS

Upper Incisor Tip Projection

Upper Incisor Inclination

Upper Lip Thickness

AJO, SEPT. 1999

AJO, SEPT. 1999

ARNETT SOFT TISSUE CEPHALOMETRIC ANALYSIS

Upper Lip Length

AJO, SEPT. 1999